Swimmer’s Ear

Not all ear infections are created equally. Swimmer’s ear differs from a middle ear infection. It is an inflammation of the skin lining the ear canal and is most common in older children and teens. Middle ear infections (otitis media) are caused by pus behind the eardrum and are most common in infants and younger children.

What is swimmer’s ear?

Swimmer’s ear (AKA otitis externa) gets its name because it is commonly caused by water in the ear canal making a good environment for bacteria to grow, causing an infection of the skin.

Water can come from many sources, including lakes, pools, bath tubs, and even sweat, so not only swimmers get swimmer’s ear.

Increasing the risk of swimmer’s ear:

Anything that damages the skin lining the ear canal can predispose to a secondary infection, much like having a scraped knee can lead to an infection of the skin on your knee. Avoid putting anything in your ears, since it can scratch the skin of the ear canal. This includes anything solid to clean wax out of the ear.

Excess earwax can trap water, so cleaning with a safe method can help prevent infection. A little wax is good though — it actually helps prevent bacterial growth. For more on earwax, please see Ear Wax: Good and Bad.

Yes, it sometimes hurts!

Swimmer’s ear can cause intense pain. Sometimes it starts as a mild irritation or itch, but pain worsens if untreated. It typically hurts more if the ear is pulled back or if the little bump at the front of the ear canal is pushed down toward the canal.

Ear buds (for a music player) or hearing aides can be very uncomfortable (and increase the risk of getting swimmer’s ear due to canal irritation).

Other symptoms:

Sometimes there is drainage of clear fluid or pus from the canal.

If the canal swells significantly or if pus fills the canal, hearing will be affected.

More severe cases can cause redness extending to the outer ear, fever, and swollen lymph nodes (glands) in the neck.

Swimmer’s ear can lead to dizziness or ringing in the ear.

Prevention of swimmer’s ear:

Controlling wax

If your child has excessive wax buildup, talk with his doctor about how often to clean the wax. Wax does help keep your ears clean, so you don’t want to clear it too much!

Keep out!

Never put anything solid into the ear canal.

Drying ears

Dry the ear canals when water gets in.

  • Tilt the head so the ear is down and hold a towel at the edge of the canal.
  • Use a hair dryer on a cool setting several inches away from the ear to dry it.
  • If kids get frequent ear infections or are in untreated water (such as a lake), use over the counter ear drops made to help clean the canal. You can buy them at a pharmacy or make them yourself with white vinegar and rubbing alcohol in a 1 to 1 ratio. Put 3-4 drops in each ear after swimming. The acid of the vinegar and the antibacterial properties of the alcohol help to clear bacteria, and the alcohol evaporates to help dry the canal.
  • DO NOT use these drops if there are tubes or a hole in the eardrum, if pus is draining, or if the ear itches or hurts.
Avoiding swimming when needed

If your child has a scratch in the ear or a current swimmer’s ear infection, avoid swimming for 3-5 days to allow the skin to heal.

Avoid bubble baths and other irritating liquids that might get into ear canals.

If there’s tubes…

If your child has tubes placed for recurrent middle ear infections, talk with your ENT about ear protection during swimming.

The use of ear plugs for swimming with tubes has been controversial, but are generally not needed. Dr. Burton discusses this in 5 Fantastical Ear Tube Myths .

Treating swimmer’s ear:

Pain control

If you think your child has swimmer’s ear, start with pain control at home with acetaminophen or ibuprofen per package directions.

Heating pads to the outer ear often help, but do not put any heated liquids into the ear.

Visit your doctor

Most often swimmer’s ear is not an emergency, but symptoms can worsen if not treated with prescription ear drops within a few days.

Bring your child to the office for an exam, diagnosis, and treatment as indicated. Most can go to their usual physician during during normal business hours if you can get adequate pain control at home.

When to be seen immediately

If the pain is severe, redness extends onto the face or behind the ear, the ear protrudes from the head, or there are other concerning symptoms, your child should be seen immediately at their primary care office or another urgent/emergent care setting.

Ear wicks

Occasionally we will remove debris from the canal or insert a wick to help the drops get past the inflamed/swollen canal.

Never attempt this at home unless you’ve been instructed on how to do it safely!

Prescription ear drops and oral medicine

The prescription ear drops may include an antibiotic (to kill the bacteria), a steroid (to decrease inflammation and pain), an acid (to kill bacteria), an antiseptic (to kill the bacteria), or a combination of these.  They are generally used 2-3 times/day.

Have your child lie on his or her side to put the drops in the ear. He or she should remain on that side for several minutes before getting up or changing sides to allow the medicine to stay in the ear. They can use a cotton ball or tissue to collect and dripping when they get up.

Symptoms generally improve after 24 hours and the infection clears within a week.

Oral antibiotics are usually not required unless the infection extends beyond the ear canal.

If an infection causes more itch than pain or does not clear with initial treatment, we might consider a fungal infection. This requires an anti-fungal medication.

No swimming until the infection clears.

Swimming just adds insult to injury. Let the skin heal before getting it soaked in the pool again!

Special circumstances

Kids (and adults) with diabetes or other immune deficiencies are more likely to get severely sick with any infection.

Visit your doctor early if you suspect a problem.

Can I talk to you privately?

Every once in a while a parent will tell the nurse that they want the child out of the room to discuss an issue with the doctor privately. This is usually something they perceive as a negative thing for the child to hear. Some of the most common concerns are about the child’s weight or behaviors. Sometimes it relates to a change in the family dynamics, such as divorce or a parent having a significant illness.

Secrets should never be kept…

While I understand the parent’s intentions, I find this to be disruptive and counter productive. As much as I try to find an excuse to have a child leave, it is usually obvious that the nurse keeps them out longer than needed.

If we have the child leave the room, he knows something is up. We are talking about him.

But not sharing with him.

What could possibly be so bad that we won’t talk to him about it?

How do you feel when you suspect people are talking about you?

When people talk secretively it hurts.
When people talk secretively it hurts.
And we should always live by example.

I teach kids from early on that there should be no secrets in families.

Why then should parents and doctors keep things from the child?

That doesn’t mean kids need to know everything.

We all know that as adults that we do shield our kids from things.

Kids do not need to know our financial worries. We can teach them financial responsibility without increasing their anxieties.

They do not need the burden of knowing about extramarital affairs. If there are problems in a relationship, they will know there are problems, but they do not need to know details.

I don’t think that kids need to know everything, but that doesn’t mean that we should make it obvious that we’re hiding something. Especially when it pertains to them.

What does the child know?

Any patient needs to know what the issues are so they can be addressed. This includes most kids.

My guess is most of these kids already know what the concerns are.

They may need help working on the concern or help adjusting to the home life situation.

If they are overweight, we need to talk about what they eat, how they exercise, and how they sleep.

When there are behavior problems, they need to give insight into how they feel and what leads to the behaviors.

Regardless of the issue, they need to be a part of the plan to fix the problems. If they aren’t on board, they won’t change their habits. I can talk about weight (or behavior, or drugs, or whatever the concern is) sensitively and in an age appropriate manner with the child. The kids at school are likely talking about it in a not-so-sensitive manner, so it’s best to not make it worse by secretly discussing it.

What if it really needs to be said?

If a parent really wants to let a physician know specific points without the child present, there are ways to do that without making the child feel left out.

  • Send in a letter or secure electronic message with your concerns before the appointment. Be sure it’s at least a few days before the appointment so the doctor has a chance to review it!
  • Schedule a consult appointment for just parents to come in without the child.
  • Call in advance to note your concerns so the physician can address it as needed during the visit.
  • Slip a note in with all the paperwork you’re turning in during check in so the physician can read it before coming into the room. Be sure whoever you give it to realizes it’s included with the standard paperwork so they can pass it on.
  • Don’t bring siblings to an appointment where you want to discuss a private matter with your child.
All of these help the physician know your concerns without blatantly kicking a child out to talk about something privately.

Your child will appreciate it.

Teens at the doctor’s office: developing independence

Teens are at a time of life that they need to develop independence. They need to master several things before leaving the nest, such as how to manage time, cook a simple but healthy meal, do simple home repairs, spend and save money wisely, and how to live with healthy habits. Allowing them to grow more independent with each passing year can help prepare them for life on their own. This includes letting them take charge of their healthcare in late teen years.

Independence at the doctor’s office

One important skill includes relying less on parents when they’re at the doctor’s office.

You don’t want them to show up at another health clinic for treatment without knowledge of their medical history. This is especially true for chronic issues, medications and drug allergies. Let them help fill out the paperwork and answer the questions from the nurse and doctor.

Teens need to learn how to summarize their concerns so the doctor can make a proper assessment. If parents do all the talking, they don’t learn how to do it themselves.

Questions, questions, questions!

Most parents have the best interest for their children at heart when they answer questions and want to be in the room for their teen’s visit. But if you really want to help them, it’s best to let them take more responsibility each year.

As kids get older, they should take more responsibility filling out forms and answering questions. They should even have an opportunity to spend time alone asking private questions.

Parents speak up then sit back.

We certainly want to hear parental concerns, but a teen should be allowed to do most of the talking. Over time this allows them to eventually visit a physician alone competently.

They will then be able to take care of their health when they move away from home and establish care with an adult doctor.

If they don’t know their medical history, current medications, allergies, or simply how to talk to a medical provider, they won’t be able to take care of themselves.

You won’t realize how much they don’t know unless they try to handle it themselves.

Let them fill out forms and ask if they need your help. You’ll learn what they don’t know and you can inform them as well as find a place for them to store that information for next time.

Privacy.

As kids get older, they need some time alone with the doctor at least yearly.

Even if they have nothing to hide, it’s a good idea to allow teens some private time alone with the physician. This allows them to develop a trusting relationship with the doctor. If something personal and private does develop, they are comfortable talking with that physician. This is one reason I strongly encourage a well visit once a year with the same person as much as possible. Routine visits allow a healthy doctor- patient trust to develop.

It’s hard as a parent to not know everything that your child talks to their doctor about. I know – I have two teens. And to complicate things, I work in the same office as their physician. I never ask her about my own kids unless I’m still in the room with them. I trust that she will take care of my kids and help to direct them into healthy healthcare decisions.

Teens should understand that they can talk to their physician openly without fear of judgement. While it is possible that the physician might ask to share the information, they usually will not if the teen does not allow it. Teens should be aware when the confidentiality will stand and when a physician must share their concerns. Most physicians will attempt to maintain the trust of a teen so that they will continue to discuss difficult health concerns. If the physician is afraid that the teen is at risk of being hurt or of hurting someone else, things change. We must ensure safety. This will mean other adults will learn of the issue, but the teen will be told first.

“But I’m the parent. I have a right to know.”

Many parents feel this way, but the reality is the law protects a teen’s privacy. Even when the parent carries the insurance and pays the bills, teens have the right to privacy.

And for good reason.

The problem is that if our kids don’t feel confident that the doctor will maintain confidentiality, they will not tell us important things that can help us help them. If they’re afraid to say that they’ve started vaping or that they are considering becoming sexually active, we can’t help them make smart and safe choices.

If they hide symptoms of an illness, whether it’s a sexually transmitted disease or depression, they won’t get the help they need.

We need them to be able to tell us those things that they don’t want their parent to know. It’s not that we want them to do these things, but we need to be able to help them stay as safe and healthy as possible.

We want them to talk with you, and you can certainly foster that at home. They still need to be able to be completely open with their physician without  the threat of a breach of confidence.

Be careful of assumptions.

It is natural to fear the worst if your child wants to talk to the doctor privately, but in the majority of cases it’s all pretty benign stuff that they want to talk about.

You will of course get bills from the insurance company that might suggest certain diagnoses or tests. We cannot verify or deny why those charges occur.

Let kids start taking responsibility at the doctor's office, but don't make presumptions when they need privacy.
Don’t make presumptions…

Don’t assume your child is having sex just because a pregnancy or STD test is done. There are many criteria that flag when a teen should have testing. Remember that guidelines are developed to not miss situations, so they are broad. For instance, many girls will get a pregnancy test done before certain procedures, even if they deny being sexually active. This is because we know that some kids lie and we don’t want to put an unborn child at risk, so all girls of a certain age will be tested before the procedure.

Encouraging communication.

Despite the fact that I will maintain confidentiality as required, I usually attempt to talk teens into talking to their parents.

If the teen agrees to us telling their parent together, it usually ends up bringing them closer as a family. This requires that the parents are able to not judge or punish a child for his or her decisions.

Teens often feel uncomfortable discussing it initially, but once they know that parents know whatever it is, they are often relieved. If the parent accepts the situation without harsh judgement, even if they are disappointed in their child, they can learn to work on things together.

If the parent responds inappropriately, it can damage the relationship. As with anything, if you can’t say something supportive, don’t say anything other than, “thank you for sharing. I need some time to think.” Give yourself time to reflect what you learn and then prepare what you will say.

They still might make bad choices.

Even with confidential communication, teens still will make bad choices.

The teen brain is well known to be impulsive and to not recognize consequences. We all know good teens who make bad choices. Caring adults will attempt to help the teen make smarter choices, but no one can change a teens behavior except the teen.

Be sure your teens know that you love them unconditionally. This will help them feel more comfortable coming to you if they need to talk. Let them know your expectations for behavior. If they open up to you about problems or bad situations, listen without judgement and offer help and support where you can. Be supportive and help them find ways to bring about positive change. There can be negative consequences, such as taking away their phone or not being allowed to go to a party, but do not belittle them. Belittling shuts the door of communication and they might not open it again.

Legal issues.

We legally cannot tell a parent about these things under most circumstances. State laws vary, but unless we think a child is in danger or will harm someone else, we must maintain privacy.

We know that teens have not established independence from parents fully. Teens usually still live under your roof and must abide by your rules. Parents usually support teens financially. But teens also are legally protected to be able to talk about sexual health, their feelings, and more without concern that parents will be told what is discussed.

There are exceptions to this confidentiality, which varies by state law. Typically if the teen is being abused, is involved in non-consensual sex, is at risk of self harm or if they are at risk for hurting others, the physician must notify others.

Watch them grow…

Parenting has its challenges, but in the end most parents want their kids to be healthy, happy, productive members of society. In order for this to happen, they have to allow their kids to gain a little more independence and accept a little more responsibility each year.

Enjoy the times!

My child won’t eat!

I hear from worried parents often that their kids won’t eat. There are many reasons for this. Usually as long as a child is hydrated, gaining weight appropriately, and getting a variety of nutrients, I’m not worried.

Some reasons kids don’t eat:

They’re really getting enough food, parents just have unrealistic expectations.

This is very common.

Portion sizes are smaller than many parents think. They vary with age and size of a child as well as his activity level. If your child is growing well and has plenty of energy throughout the day, why should he eat more?

Kids tend to eat small meals frequently and even on holidays they don’t overeat like the adults tend to do.

When offering snacks, think of them as mini meals to help balance out the nutrients of the day. Don’t let them snack all day long though or they’ll never really be hungry.

Schedule meals and snacks and allow water in between.

We have an obesity epidemic in this country, so if you’re comparing your child to another child, chances are that your thin child is healthy and normal, but the other one is one of the 30% who is overweight.

Or maybe not.

It doesn’t matter. Just be sure your child is getting a proper variety of nutrients. Parents can choose what foods are offered, but kids should determine how much to eat.

Talk to his doctor about growth at regularly scheduled well visits (more often if you’re concerned) to be sure it’s appropriate.

They’re sick and it’s temporary.

When kids are sick they lose their appetites.

This is normal.

It usually returns with a vengeance when they’re feeling better. They need to drink to stay hydrated and can eat what they feel up to it, but don’t force it. See their doctor if you’re worried.

It’s a new food and they just aren’t sure yet. 

I encourage that kids over 3 years old take one bite of a food.

Kids often hear me say, “taste a bite without a fight.” The bite needs to be enough that they taste it. If they like it, they can keep eating. If they don’t want more, resist trying to convince them to eat more.

Allowing them to take ownership of the decision of what to eat empowers them. Kids like power, right. Give it to them while modeling healthy eating behaviors yourself. They learn from what you do, not what you say — and not from what they’re forced to do.

When preparing a new dish, include familiar foods they like to balance out the meal so they can enjoy at least something on the plate.

They’re picky eaters.

Aren’t they all?

Most kids go through phases where they love a food, then they suddenly dislike it. They might dislike a certain texture or a whole food group. While there are kids with real problems eating, most picky eaters can be encouraged to eat a healthy variety of foods as described above.

Some children really suffer from being overly restrictive. Children with autism, sensory problems, food allergies, and other issues are not included in this “typical” picky eater category.

A great series of blogs on picky eaters (typical and more concerning) is found on Raise Healthy Eaters.

They’re more interested in something else. 

Make meals an event in itself.

Sit together and talk. Turn off the television. Put away your phone.

Have everyone focus on the meal, which includes the food and the conversation. Try to keep the conversation pleasant and not about the food. Take the pressure off eating!

They’ve filled up already.

If kids have access to snacks all day, they won’t be hungry for meals.

Make sure they have set meal and snack times, but no foods between. They’ll come to the table hungry if they haven’t snacked all day.

Some kids drink too much milk, juice, or other calorie-filled drinks. While it might seem that milk or juice are healthy, the reality is that they do not have a variety of nutrients that our kids need. Milk at least has protein, but it’s missing iron and other key nutrients. Juice is mostly sugar and really should be avoided. Don’t let your kids fill up on drinks.

When they’re hungry, they’re more likely to eat what’s offered.

A medicine makes them not hungry.

Some kids take medicines that decrease their appetite.

If your child is on one of these, their physician will need to follow their growth carefully, but it doesn’t automatically mean they shouldn’t take the medicine. Most kids can get the calories they need for healthy growth despite these medicines.

In summary…

In general, parents should choose what foods kids are offered so that there’s a balance of nutrients, but kids determine how much they eat.

If they’re hungry, they’ll eat. If they’re not hungry, they shouldn’t eat. Learning to eat when not hungry is something that causes many of us to struggle with weight. Most kids are able to limit intake to needs. Don’t force them to change that great quality!

If you’re worried about your child’s appetite, talk to your pediatrician. The physician will need to see your child to check the growth pattern and to examine him or her for signs of illness. Labs are usually not needed, but can be done if there are concerns for some medical conditions. Medicines are rarely used to stimulate the appetite.

For more, see my related blogs:

If your child doesn't eat as much as you think he should, check out this list of possible reasons.
If your child doesn’t eat as much as you think he should, check out this list of possible reasons.

When vaccines are given too soon

Sometimes vaccines are given too soon to count toward the required vaccine schedule. This can easily happen if there are changes to the standard vaccine schedule for any reason, but what does that mean for the child? Are they in danger? Do they need extra shots? Is that even safe???

Early vaccines don’t count.

Don’t try to sneak in early before a recommended age.

It’s not appropriate in most cases to give vaccines at shorter intervals or before the recommended age.

The 12-15 month vaccines are occasionally given before the 1st birthday, which does not count in every state. State laws can dictate a grace period in which vaccines can be given earlier than the standard schedule, but not all do.

This is an issue with some children moving from a more lenient state to one with a lesser (or no) grace period.

In some states they can get their MMR a couple days before their first birthday.

Does this protect them against measles, mumps, and rubella?

~ Probably. (Nothing’s 100%.)

Does every school count it?

~No. If they move to a state that doesn’t, they need to repeat it.

International travel changes things.

It is recommended for international travelers over 6 months to get an MMR early due to worldwide measles outbreaks.

This dose does not count toward the 2 doses typically given after the 1st birthday because younger children do not make immunity as reliably, but is felt to potentially benefit those at higher risk due to travel.

Most babies are protected against measles for 6-12 months after birth.

If the MMR vaccine is given when they are already protected, the vaccine doesn’t work.

We don’t know if a 6-12 month old is safe or not, so when the risks increase, as with international travel, it is recommended to give a shot to help if needed.

But that shot might not work, so it should be repeated after the 1st birthday.

Minimal intervals are important.

Most vaccines are given as a series, and each vaccine within a series needs to be separated by a minimal interval.

Before vaccine logic was built into our electronic health record, it could be difficult to know which vaccines were recommended if people got off the standard schedule.

Not all EHRs have smart vaccine logic, so if you’re off schedule, be sure to discuss intervals before giving vaccines.

The hepatitis vaccines are more commonly given off an appropriate schedule than other vaccines. I’ll touch on each of them and why they’re problematic.

Hepatitis A vaccine interval problems.

My office routinely gives the first Hepatitis A vaccine at 12 months and the second at 18 months. The CDC schedule states:

Hepatitis A (HepA) vaccine. (minimum age: 12 months)

Routine vaccination:

  • 2 doses, separated by 6–18 months, between the 1st and 2nd birthdays. (A series begun before the 2nd birthday should be completed even if the child turns 2 before the 2nd dose is given.)

Despite warning parents to schedule the 18 month visit 6 months or more from the 1 year visit, sometimes they don’t have the correct spacing. This generally happens when they do the 1 year visit several weeks after the birthday but then try to “get back on track” and do the 18 month exam on time.

The good news is our smart EHR tracks minimal intervals and doesn’t suggest the vaccine if it’s too early.

I typically wait until the 24 month visit to do the 2nd Hepatitis A vaccine if it is too early at the 18 month visit, but I ask the family to come in just before the 2nd birthday. This allows the child gets the vaccine before 24 months of age and fit the main recommendation of getting both doses between the 1st and 2nd birthdays.

Sidenote about HEDIS

A delay to wait until the 2 year well visit follows the CDC recommendation to have the doses separated by 6-12 months.

Despite following the CDC guidelines, it fails to meet HEDIS benchmarks.

If a child gets the Hepatitis A vaccine after the 2nd birthday, the physician loses quality points.

These points help rank physicians for insurance company purposes.

As long as it doesn’t happen often, it’s not an issue.

But if schedules are off too often, a physician’s contracts with insurance companies could be at risk because they are seen as not high quality, regardless of why the vaccine is given after the 2nd birthday.

If you want to keep your favorite physician and use your insurance, please help them meet the standards of care for all metrics. This includes coming in for annual well visits and having regular follow up for chronic issues. It also means taking the recommended medications, such as preventative medicines for asthma and doing certain labs, such as lipid panels, or screenings, such as depression screenings.

Sidenote about vaccine shills

There are many groups sounding alarms about physicians getting paid huge amounts of money to vaccinate from Big Pharma. I wish this was true, but it’s not.

Don’t confuse the HEDIS measures and insurance contracts with this Big Pharma farce. First off, we pay pharmaceutical companies to buy their vaccines. They don’t pay us. Sometimes they buy a lunch for our staff so they can have our attention when they talk about their products, but there is no big money to be made from vaccine companies.

Insurance companies pay us for the vaccine and the costs associated with giving vaccines. These costs are not only for syringes and band aides. We must carry insurance for the vaccine inventory. There must be a dedicated refrigerator and freezer to safely store vaccines. We should use a refrigerator alarm system to alert us if the temperature is too warm or too cold. We pay staff to keep logs about refrigerator temperatures and inventory. All of these costs add up.

Trust me, no one gets rich off of vaccines.

Some insurance companies offer bonuses if we meet HEDIS measures, but more often I think they just pay less if we don’t meet measures.

Why do they pay more if we give vaccines?

Because the insurance company comes out ahead if we vaccinate. Vaccine preventable diseases cost them much more than vaccines. They want to encourage us to vaccinate to save them money.

Hepatitis B Interval problems.

Hepatitis B vaccine is given in 3 doses, with the second 4 weeks after the first, then the 3rd at least 8 weeks from the 2nd and 16 weeks after the 1st.

There are vaccines that just have hepatitis B protection (monovalent vaccines) that can be given starting at birth. They can be used for all three doses.

There are other vaccines that combine the hepatitis B vaccine with other vaccines (combination vaccines). The combination vaccines are given at different intervals, depending on what is in the vaccine. They cannot be given under 6 weeks of age, but it’s still recommended to give the first dose within 24 hours of birth.

Yes, it’s confusing.

From the CDC guidelines:
  • A complete series is 3 doses at 0, 1–2, and 6–18 months. (Monovalent HepB vaccine should be used for doses given before age 6 weeks.)
  • Infants who did not receive a birth dose should begin the series as soon as feasible.
  • Administration of 4 doses is permitted when a combination vaccine containing HepB is used after the birth dose.
  • Minimum age for the final (3rd or 4th) dose: 24 weeks.
  • Minimum intervals: Dose 1 to Dose 2: 4 weeks / Dose 2 to Dose 3: 8 weeks / Dose 1 to Dose 3: 16 weeks. (When 4 doses are given, substitute “Dose 4” for “Dose 3” in these calculations.)

There are even additional recommendations if the mother is a known Hepatitis B carrier or if her status is unknown.

If any of the doses are given too early, they need to be given again. This is considered safe.

Live viruses need special attention.

Live viruses must be given either at the same time or at least 28 days apart. If they are given at a shorter interval, the second vaccine is presumed to not be effective and must be repeated.

This is another great reason to not alter the standard vaccine schedule your provider uses. If your child gets off track, you run the risk of him or her needing additional vaccines.

Common live virus vaccines include MMR, Varicella, MMRV, and Flumist.

Some vaccines, like the oral typhoid vaccine, cannot be given at the same time as antibiotics.

Quiz yourself!

See if you know what vaccines your child needs.

To avoid vaccines that are given too soon:

  • Be sure that whoever is giving vaccines knows any recent vaccines and medicines your child has had recently.
  • Try to stay within the recommended vaccine schedule as much as possible to avoid needing extra doses.

Vaccine schedules for children birth – 6 years and 7-18 years:

 

 

 

Summer Penile Syndrome

Did you know there’s a name for the super swollen male parts from bug bites? Actually two names: Summer Penile Syndrome and Lion Mane’s Penis. Doctors might even call it seasonal acute hypersensitivity reaction. If you’ve ever seen it, you know it can be quite impressive.

What is summer penile syndrome?

Summer penile syndrome is a fairly common concern during the summer months. It’s usually due to a chigger bite on the sensitive skin of the penis or scrotum. You can often find a small bug bite near the center of the swelling.

They can itch like crazy, but usually don’t interfere with urinating.

Despite the significant swelling, there isn’t usually much pain, only itching. Unless there’s a secondary infection, there won’t be any fever.

What is a chigger?

Chiggers are a type of mite, which is an arachnid in the same family as spiders and ticks. They are also called harvest mites, harvest bugs, harvest lice, mower’s mites, or red bugs. Chiggers are so small they often go unnoticed until several hours after they attach to our skin. They can attach even under clothing, and the most common places that we notice chigger bites are in the areas of our pants.

Chiggers live in moist, grassy and wooded areas. They are commonly found in the warm summer months.

Adult chiggers don’t bite. It’s the larvae that cause itchy problems. The larvae are red, orange, yellow, or straw-colored, and no more than 0.3 millimeters long.

File-Chigger bite
Chigger. Source: https://commons.wikimedia.org/wiki/File:File-Chigger_bite.svg 
After crawling onto the skin, the larvae inject digestive enzymes into the skin that break down skin cells. They do not actually bite the host even though the bumps are called chigger bites. They form a hole in the skin called a stylostome. Their saliva goes into deep skin layers, which results in severe irritation and swelling.

People usually start to itch within a few hours and often scratch the feeding chiggers away. A hot shower with plenty of soap will kill chiggers and prevent them from finishing their meal, so showering after being in grassy or wooded areas can help prevent deeper reactions.

The good news is that in the US, chiggers are not known to carry diseases.

Prevention

Even though they don’t cause disease, chigger bites are something to avoid because they can cause significant itching for weeks.

Bug sprays with DEET will deter the chiggers. DEET is approved for use in children over 2 months of age.

Clothing can be treated with permethrin to avoid ticks and chiggers. Permethrin can be purchased at sporting goods stores to pre-treat your clothing. It should not be used directly on skin. Once dried into the clothing, permethrin will last for about six washings. You can also treat your shoes, which makes a lot of sense since chiggers are usually found in the grass and crawl up onto your skin.

Even untreated clothing can help a little if you don’t have time to pre-treat with permethrin. Wear long sleeves and long pants. Be sure to tuck the pant legs into your socks so they can’t enter from the bottom leg hole.

For more on bug sprays, including citronella, picaridin, oil of lemon eucalyptus and more, see the EPAs information on registered and unregistered products. You can even use this handy tool to find the right product for your needs.

How do you treat chigger bites?

Much like any bug bite, control of the itch is important. If kids scratch any itch, it can become secondarily infected from the break in the skin allowing germs in.

Antihistamines

Antihistamines are used for allergic reactions. We commonly use them for seasonal allergies, but they can help most allergy reactions.

Bug bites itch when our bodies react to the saliva injected into our skin with histamine. Histamine is our body’s allergic response and it itches. If you aren’t allergic to the bite, you won’t itch from it. This is the way we react to allergies, which is why we get itchy eyes and noses with allergies to pollen.

Diphenhydramine (Benadryl) is a short acting antihistamine that can help control allergic reactions, but tends to make kids tired or wired. It also only lasts a few hours, which can require frequent dosing.

I don’t like topical antihistamines, which are often sold to treat bug bites. I worry that kids will get too much of the medicine when it is applied to each bite. It’s a low risk, but still a risk. Just because they aren’t taking it by mouth doesn’t mean it isn’t absorbed. Children using a topical antihistamine for an extended time over large areas of the skin (especially areas with broken skin) may be at higher risk, especially if they also are using other diphenhydramine products taken by mouth or applied to the skin.

I am a fan of using an oral long-acting antihistamine, such as cetirizine or loratadine, to treat bug bites. Most kids with one bug bite have many. One dose of an oral antihistamine helps to control the overall histamine reaction, making each bite itch less.

Antibiotics

Despite the significant swelling, these usually do not require prescription antibiotics.

If your child has open areas from scratching the skin, you should keep the area clean and consider using a topical antibiotic ointment to help prevent infection.

Steroids

Over the counter topical hydrocortisone is a very low dose steroid. It can be used on insect bites to help stop the itch.

Stronger steroids that require prescriptions are occasionally used, but you will need to see your physician to discuss the risks and benefits of prescription steroids.

Oatmeal baths

Soaking in an oatmeal bath might help the itching. It works very well for dry skin conditions and sunburn relief as well.

You can buy commercially made oatmeal bath products or you can grind regular plain oats to make it fine enough that it dissolves in bath water. Test a small amount in a cup of water to see if it’s finely ground enough before putting 1 cup of oats into the bath water.

Some people have even made a paste of oats and applied it directly to the itchy skin for relief.

Baking soda

Another kitchen remedy for bug bite itch relief is baking soda. Mix a pinch of baking soda with a few drops of water to make a paste. Put this paste on the bites. Reapply as needed.

Ice or cool cloth

One more kitchen treatment is ice. Many kids won’t tolerate this one, but if they can’t tolerate an ice pack placed over clothing, you can try applying a cool wet washcloth directly to the skin.

When should you see your doctor?

If your child has any of the following symptoms, talk with your doctor.

  • Trouble urinating.
  • Pain or itch not controlled with the above measures.
  • Fever.
Fear has big eyes
By Robbie Grubbs from Houston (What????) [CC BY-SA 2.0 (https://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons

Infant Poop: What’s Normal and What’s Not

Who would think they would focus so much on poop as new parents do? Color. Consistency. Frequency. So many things to worry about with infant poop! One of the most common concerns I hear is that a baby who used to poop several times a day stops pooping for days at a time. They might have a bowel movement (poop) just once a week – sometimes less. That worries parents, but constipation isn’t defined by how often babies have a bowel movement.

First stools

During the first few days of life the stool looks black and is thick. This is called meconium. It occurs in both breast fed and formula fed babies.

Meconium DiaperMeconium stool. Photo by Azoreg via Wikimedia Commons

If your baby doesn’t have meconium within 24 hours of birth, an evaluation to decide if there’s a problem should be done. Be sure to talk with your baby’s doctor if he doesn’t poop within 24 hours of birth.

Transitioning stage

After the first few days there is a period of transition stool. The stools become more green and sticky. This is the meconium mixed with breastmilk or formula stools. It happens earlier in formula babies and after mother’s milk comes in for breast fed babies.

2nd week and beyond

After the transitional stools, the stools will vary in color and consistency depending on if the baby gets breastmilk or formula.

Breast milk

If breast milk is the primary food, the stools can vary quite a bit. They often look like yellow cottage cheese, with a lot of liquid and chunks. It often becomes a bit thicker (like pudding) as a baby gets older.

It is not diarrhea just because it is watery. I cannot repeat this enough. Breast milk stools tend to be watery. It is not diarrhea.

Breast fed stools can vary in shades of yellow to brown or green, often changing depending on what the mother ate. Bright green and frothy stools can indicate a low fat diet in a breast fed baby.

The fore milk has less fat than the hind milk, so if the baby consistently has frothy bright green stools we will monitor the baby’s weight closely to ensure adequate growth and evaluate the amount of milk the mother is producing and baby is drinking. Green milk is not necessarily problematic though.

A breastfed baby might have a bowel movement every time he eats (and in between) or he might go less than once a week. (Watch out when it finally comes – it often escapes the diaper!)

Formula

If a baby is taking formula, the stools can look shades of yellow and brown and be the consistency of peanut butter, pudding, or thick oatmeal. Formula fed stools tend to smell more foul than breast milk stools, but even breast fed baby poops can stink.

Most formula fed babies have a bowel movement 1-3 times a day.

Breast milk + formula

Babies who get some breast milk and some formula can have characteristics of each feeding type.

Solids

After 4-6 months your baby can start solid foods.

Once a baby eats solids (or pureed foods) the stools can thicken a bit but should never be hard. They usually become more foul-smelling at this time.

Sometimes chunks of food (especially carrots, corn, and raisins) can be seen in the stool. This is normal.

Iron supplements

If a baby takes an iron supplement the stools might turn dark green or black. This is normal and not a concern.

This does not happen from the amount of iron in baby formula. All formula should have iron. It is an important nutrient for all babies and low iron formula is not recommended.

What’s important?

  • A term baby should gain about 15-30 grams per day after the first week of life until about 4 months of age.
  • Blood in the stool can be from swallowed blood (often from a crack in mother’s nipple), constipation, food allergy (usually cow’s milk protein), or infection and should be evaluated.
  • It is normal to have different shades of yellow, brown, and green stools.
  • A baby with a swollen (distended) abdomen and discomfort or a change in feeding patterns should be examined.
  • A baby should not have formed stools as long as they are on primarily breast milk or formula.
  • Poop should never be a shade of white (liver concerns), red (blood), or black -if not on iron supplements (digested blood).
  • Mucus in stool could be simply swallowed mucus but can be a sign of infection or food allergy.

Suddenly my child’s peeing all the time… what’s up?

When children suddenly start peeing all the time, we need to consider the many potential causes. There are many reasons kids have frequent urination. Sometimes it’s as simple as they like to flush the toilet or splash in the sink. This is common in newly potty trained kids. But peeing all the time can also signify a medical problem that needs to be addressed. Learn the potential risks of why children run to the restroom frequently or start to have accidents. This can help parents decide if they need to rush to the ER.

Associated symptoms to identify

Frequent urination can be associated with other things that give us a clue as to what is going on. Sometimes they do not seem connected to the urine, so you might not associate the symptoms. Discuss the issues that apply to your child with your child’s physician.

Behavioral changes

Behavioral changes can be a clue. For instance, look for signs of anxiety. Remember that anxiety does not always look like fear. The frequent urination might be due to worrying about not making it to the bathroom in time and having an accident.

Pain

Pain while urinating might signify an infection. Infections often have other symptoms as well.

Pain might also be from skin irritation due to improper wiping in girls. In uncircumcised boys, pain can develop from improper cleaning under the foreskin. Staying in wet swimsuits too long also can lead to skin irritation and painful urination.

Pain in the abdomen, back or side can indicate problems with the kidneys or an infection. Sometimes this is due to constipation. It will require a physical exam and possibly testing to determine the cause. Schedule an appointment with your child’s primary care physician. If the pain is so severe that he or she cannot sleep, walk, or move easily, go to the ER.

Change in urine odor and color

A change in urine smell and color is important to note. Red, brown, cloudy or smelly urine can be signs of kidney damage, infection, bleeding problems, dehydration, and other serious conditions.

Some foods, such as asparagus and coffee, can change the smell of urine. Color changes can also happen as a result of foods, such as beets or berries turning urine red, or rhubarb or fava beans turning urine brown.

Many medications and vitamin supplements can change the color and odor of urine. It will be important to discuss your child’s recent foods, medicines, and supplements with his or her physician.

Other signs of illness

Other signs of illness can offer clues. Think about fevers, cough and cold symptoms, swelling of the eyes or legs, joint pains, and more.

One example to consider would be Rhinovirus. Rhinovirus typically causes upper respiratory tract infections with cough, runny nose, and pink eye. It can also sometimes cause vomiting and diarrhea or urinary tract infection symptoms.

Causes of frequent urination

Diabetes

Frequent urination can be a sign of diabetes. This is a potentially life threatening issue and needs to be addressed immediately.

Symptoms of diabetes will include being very thirsty and frequent urination. Kids might appear dehydrated despite the high urine volume. They can have weight loss, dry mouth, and low energy. Kids with untreated diabetes usually appear sick and tired.

When sugars reach a critical level, diabetics develop fruity breath. This is associated with a pattern of breathing called Kussmaul breathing. This is a medical emergency. Diabetes can be a rapidly developing problem. If you notice this breathing pattern, get to an ER immediately.

Testing for diabetes initially uses a sample of urine. Urine is tested for sugar. If there is sugar in the urine, blood will also be checked.

Children with newly diagnosed diabetes are referred to an endocrinologist. Endocrinologists are specialists in diabetes and other hormone issues. Newly diagnosed diabetics often spend a few days in the hospital for stabilization of medical issues and teaching of how to manage at home.

Urinary tract infection

Urinary tract infections (UTIs) commonly cause frequent urination. Other symptoms, such as fever, pain with urination, and urinary accidents, often occur. Bacteria and viruses can cause UTIs.

UTIs are more common in girls and in boys who are not circumcised.

A urine test can help to determine if there is a UTI. A quick urinalysis can suggest an infection, but a culture is needed for actual diagnosis. A urine culture takes up to 2 days to grow bacteria. Bacterial UTIs are treated with antibiotics. Viral UTIs self resolve after a few days.

Constipation

Many parents are surprised at all the things pediatricians blame on constipation. I can’t say how many parents deny that their child is constipated when they are. An x-ray often shows the abdomen is full of poop even when kids poop every day.

Note: I don’t always get an x-ray to diagnose constipation. Studies are only needed to help with diagnosis if the exam findings are not clear. Usually it’s obvious from the description of the stooling pattern and the look of the poop. Kids often cannot describe their poop accurately, so I use a Bristol Scale. You can use this at home to talk to your kids about their bowel movements.

Many children with constipation don’t initially seem to be constipated so a trial of Miralax is often recommended. This treats the constipation if it exists and is part of the diagnostic evaluation. Diet changes and changes to toileting habits are also important. These take longer to make a difference so I still recommend Miralax.

If treating the constipation helps, continue to treat until it is no longer needed.

Pollakiuria = increased frequency of childhood

Increased frequency of urination, also called pollakiuria, is common and not harmful. Other terms that have been used to describe this condition include extraordinary daytime urinary frequency and increased frequency of childhood.

The cause of this is unknown but often is triggered by a stressful event. Kids with this have a normal physical exam and urinalysis.

Pollakiuria involves frequent urination during the day. Kids will feel the need to urinate frequently, even though there’s really no physical reason.

Most children do not change their nighttime urinary pattern. If they previously wet the bed, they still will. If they previously stayed dry all night, they will continue to stay dry at night.

Pollakiuria is seen more often in boys, but also occurs in girls. It’s most common between 4 and 10 years.

Despite the frustrating symptoms, it’s not a serious illness and it self resolves. It generally lasts 1-6 months and can be quite problematic due to the frequent bathroom trips needed. Some kids pee as often as every 30-90 minutes.

To diagnose this, a child should be seen to discuss the symptoms and to do a physical exam. Often constipation aggravates this issue, so close attention to stool patterns and the abdominal exam are important. A urinalysis should be done to rule out diabetes or urinary tract infection. Pollakiuria is a diagnosis of exclusion. This means there is no test for it, but we rule out other potential causes of frequent urination.

This problem typically starts suddenly and ends suddenly. It can last for months.

What can you do to help if there’s no treatable cause?

If there is a treatable medical condition, treating that condition will usually help the frequent urination. While it seems like there’s nothing to do to help if there’s no cause found, don’t get discouraged! There are things to do that can help.

Contrary to what many intuitively think, drinking plenty of water is beneficial. Don’t limit water!

Don’t punish kids for needing to use the restroom or for having accidents. It may not be under their control at all. If it is a behavioral issue, the child needs support, not punishment. Punishment or belittlement will only make them feel bad. This worsens the situation. It can be hard to not get frustrated, but take a big breath and try to remain calm. Use words that are neutral and not judgmental.

Be sure the teacher knows what’s going on. If your child needs to go to the bathroom frequently, he needs to be allowed.

Remind your child that he or she is healthy. This can help to reduce the anxiety and stress in their minds. Stress can make this condition worse, so reassurance is very important!

Show your child that it’s possible to wait for a longer period of time to urinate. Explain that there will be no urine leakage because that fear increases anxiety about not going to the bathroom. The more confidence they develop, the better their bladder control. Practice waiting a little longer before going to the bathroom and celebrate small improvements.

Foods to avoid if your child has frequent urination:

The foods and drinks listed below may or may not increase frequent urination.

Avoid these for at least for 2 weeks. Slowly re-introduce one at a time to see if they lead to increased urination.

  • Highly acidic foods such as salsa, sodas, teas, coffee, cranberry juice and orange juice.
  • Caffeine acts as a diuretic and increases urine. It’s found in coffee, tea, chocolate, sometimes ice cream or other treats.
  • Spicy foods such as chili peppers, jalapeño peppers, horse radish, curry and salsa.
  • Artificial colors.
  • Carbonated beverages.

Most importantly…

The most important thing to remember is to first rule out medical causes that need to be treated.

Once those are ruled out, this is a lesson in patience. Don’t belittle your child or use harsh words when they need to use the bathroom again. And again. This will pass.

Work on having your child hold their urine for a few minutes longer with encouragement. Frequent urination usually stops as suddenly as it started.

New back to school recommendations for strep throat!

Many years ago I heard about research showing that throat cultures clear within 12 hours after the first dose of antibiotic for strep throat. I’ve been waiting since then for a change to our recommendation that kids must stay home from school for 24 hours after starting antibiotics. Guess what? The new Red Book (an infectious disease book from the American Academy of Pediatrics) is out and the back to school recommendations for strep throat have changed! This can help many parents get back to work when their kids can return to school and daycare earlier. But it doesn’t mean you should rush in to demand antibiotics for every sore throat!

Redbook return to school strep guidelines, 2018.
Red Book return to school strep guidelines, 2018.

I have summarized the Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America previously. These official guidelines have not been updated, but the Red Book represents the AAP official recommendations.

What is Strep throat?

Strep throat is not just any sore throat. Many viruses can cause sore throats but strep throat is caused by group A Streptococcus bacteria, also known as Streptococcus pyogenes.

Strep throat is not common in kids under 3 years. The incidence of strep throat peaks in young childhood and is less common in teens and adults.

A strep test is needed to diagnose strep throat in kids. Physicians and other healthcare providers can use Centor Criteria for adults, but a clinical diagnosis alone is not recommended in children.

Strep throat typically causes a sore throat, fever, swollen tonsils, and swollen lymph nodes (gland) under the jaw. Some kids will get a sandpapery rash on their trunk. When this happens, it is called scarlet fever. I also see a significant number of kids who get a stomach ache and vomiting with strep.

Pos strep
Strep throat sometimes causes white patches on the tonsils. This is called exudate.
Streptococcal pharyngitis
Red spots on the roof of the mouth is considered very specific for strep throat.

Does strep throat need to be treated?

Most parents and kids want antibiotic treatment so that the miserable symptoms of strep go away faster, but do we need to treat strep?

You might be surprised, but antibiotics are not prescribed to treat strep throat symptoms. Antibiotics are used to prevent serious complications from the strep bacteria. Pain relievers, such as acetaminophen or ibuprofen, can be used to treat the fever and sore throat symptoms. School aged children, teens, and adults can also use throat lozenges for sore throats. (Do not use these in kids who are still at risk of choking.)

So the simple answer is we don’t always need to treat strep with antibiotics. In the days before antibiotics, most people got better. Even now there are some people who don’t go to a clinic when they’re sick, so they recover on their own.

Use antibiotics wisely

There are a lot of reasons to use antibiotics only when necessary.

One major reason is to help delay antibiotic resistance.

Some people have allergic reactions or side effects to antibiotics, so we should not use them lightly.

They also can increase total healthcare costs. Although penicillin and amoxicillin (which are recommended for strep throat) are inexpensive, treating strep throat does increase healthcare costs. The sheer number of illnesses that present to clinics for evaluation, the cost of testing, and the cost of the treatments can all add up. Of course, returning to work a day earlier can make an impact on our economy as well.

If your child has symptoms not characteristic for strep and is not otherwise high risk, you can monitor and treat for a few days at home.

But antibiotics make us feel better faster, right?

Antibiotics tend to shorten the symptoms by about 16 hours.

They have been shown to prevent serious consequences of strep infections, but those are rare, so the risk/benefit ratio may not support treating every case of strep. (Though I still do treat strep when I see it.)

Look at risk/benefit ratio for all treatments

If you want to read an example of the risks/benefits of treating strep throat, see this (slightly technical) case report.

Remember that this report simply highlights one case, it cannot be generalized to everyone with strep throat. It shows how doctors work through the risks and benefits with everything we treat. We don’t always state things like this out loud, but they go through our mind as we develop treatment plans.

It’s common in medicine to have case reviews such as this. Any one case does not change our treatment guidelines, but they can help us start to understand issues. They often serve to initiate further studies.

Are there risks to not treating?

Untreated Strep infections can lead to complications.

The character Beth in the classic book “Little Women” died of heart complications after scarlet fever.

(If nostalgia hits you, you can get the entire series of the March family on Kindle for less than a dollar!)

Complications from untreated strep can include tonsil abscesses, ear infections, sinus infections, arthritis, heart damage, and kidney damage. While some of these can be severe, thankfully the more severe complications are rare, even without treatment.

There is also a condition called PANDAS (pediatric autoimmune neuropsychiatric disorders) that some experts think is related to strep. This can involve the sudden onset or worsening of tic disorders, obsessive compulsive disorder, mood changes, and change in quality of school work. Throat swabs can be normal, but a blood test can help to identify a recent strep exposure. Testing is not recommended for everyone with tics or OCD, but talk to your pediatrician if symptoms start out of the blue and you’re concerned.

Don’t let the new recommendations make you rush in…

Strep throat is rarely an emergency. Don’t rush to the ER after business hours to have your child checked as soon as you notice symptoms. You can use pain relievers as well as cold drinks, smoothies and popsicles to manage the symptoms at home initially. Just because the back to school recommendations for strep throat allow return 12 hours after antibiotics start, coming in too soon might not help in the long run.

About the testing available:

The test commonly used to identify strep is most accurate after symptoms have been there for awhile. The rapid Strep test for the presence of the strep bacteria about 97% of the time. A culture done at the same time may grow the strep bacteria in a few days, but antibiotics are not recommended until either the rapid test or culture is positive, so you’re not getting a head start on antibiotics if the initial rapid test is negative.

Because the rapid strep test looks at the presence of strep , strep testing just tells you the germ is there. The clinical symptoms of strep disease is why you need treatment.  Up to 30% of school age children have strep in their throat. The strep is not necessarily causing disease without symptoms of strep. These symptoms include rapid onset of sore throat, headache, tummy ache and fever, without cough and runny nose.  This is the tricky part and the reason you need your pediatrician to determine if testing is needed.
Do not use telehealth to get your sore throat treated.

In children it is not recommended to diagnose strep throat without a throat swab test. This should be done in a medical clinic to avoid inaccurate testing.

Treating early in the course might diminish the opportunity for your body to fight strep off the next time it’s exposed. Yes, treating may allow a return to work, school or daycare in 12 hours, but if you can prevent the next occurrence (of course no guarantees…) wouldn’t you want to?

When should you not test or treat?

Kids under 3 years old

Strep throat is not common in kids under 3 , so it’s not recommended to test them.

I admit that if an older sibling or caregiver has strep and they have strep symptoms, I will test 2-3 year olds.  The recommendation is to not bother. Even if they have strep, treating does not tend to alter their course. Kids in this age group tend to not develop the severe consequences of strep like older kids, even when not treated.

Viral symptoms

Although both viruses and strep bacteria can cause fever and sore throat, there are clues that it is not strep. When strep carriers get sick, they can have a false positive throat culture. The strep that shows on testing is not the cause of their symptoms and leads to over treatment.

If there is a cough or runny nose, the sore throat is most likely a viral illness. A strep test is not recommended.

When there are blisters in the mouth or a characteristic hand, foot, mouth rash, they have a viral illness. A strep test is not recommended.

Recent strep

Because the rapid strep test looks at antigens the body makes in response to strep and not the bacteria itself, recent strep can affect rapid strep testing. The antigen can remain in the throat for a time after treatment, so a strep culture is recommended for several weeks after treatment of strep throat.

It is not recommended to do a throat culture after treatment unless a person is high risk for complications, such as rheumatic fever.

contacts of someone with strep

It isn’t recommended to test people who have been exposed to strep unless they have symptoms. If they do not have symptoms, a positive test is more likely to be a falsely positive (not true) test. It could lead to unnecessary antibiotics.

If a sibling over 3 years of age develops symptoms, it is recommended to test and not just treat.

Pets?

Pets do not get strep, so no need to swab your pet!

Why not just test every sore throat?

Studies show that 1 in 4 kids can have strep in their throat at any given time. They are simply carriers, but not truly infected with strep. Contrary to popular belief, strep carriers are not likely to spread strep infections.

If a strep carrier has a viral illness, they can have a positive test but the strep is not the cause of their illness. Antibiotics are not needed for this at all. A positive test leads to using antibiotics that are not needed, which can increase the risk of side effects and allergic reactions. They give a false sense of security of treatment, but if it’s a viral illness, antibiotics are not treating anything. Kids can be sent back to daycare or school while still contagious simply because they’re “being treated.”

“My child always has a negative rapid test but the culture is positive. Can’t we just treat?”

There are many reasons this can happen.
One of the reasons is that the child is a strep carrier, so has no strep disease. In this situation, there aren’t antigens to make the rapid test positive, but the culture will grow the bacteria. If you recall from above, carriers do not need to be treated with antibiotics in most cases. I often find that these kids continue to feel sick several hours after starting antibiotics for strep. Most kids with strep feel better really quickly after antibiotics are started!
It’s also possible that the child is brought in for testing early in the course of illness each time so the antigens have not yet developed. This is one reason to not rush in at the first sign of possible strep. Let the body do its thing first.

My back to school recommendations for strep throat:

If your child has some of the symptoms of strep (sore throat, fever, tender bumps in the neck, vomiting, or rash) consider strep throat.

Symptoms of typical viral illnesses make strep less likely. These might include runny nose, cough, red goopy eyes, or diarrhea. No testing is recommended.

It can be difficult to tell if a runny nose from allergies despite the strep throat or if the runny nose is part of the viral illness that includes a sore throat, so if in doubt, bring your child in for evaluation. The doctor can determine if testing should be done. Do not use telehealth for this. I recommend seeing your primary care physician during normal business hours.

If there is strep throat, penicillin or amoxicillin are the preferred treatments unless there is documented allergy.

Your child may return to school 12 hours after the first dose of antibiotic if they are otherwise well. (If they are not feeling great, they likely have something else going on!)

Thank you!

Thanks to Dr. Kathy Cain of Topeka Pediatrics for some helpful editing tips!

 

ASK to save a life!

June 21, the first day of summer, is National ASK (Asking Saves Kids) Day. The ASK Campaign encourages everyone to ask if there are unlocked guns in the homes where children play. The Asking Saves Kids (ASK) Campaign encourages parents to ask a very important question before playdates: “Is there an unlocked gun in your house?” It’s a simple question, but it has the power to save a child’s life.

1 in 3 homes with children in America have guns. Ask to save a life.
Click to enlarge. Source: http://askingsaveskids.org/

Keeping a gun in the home increases the risk of injury and death, yet 1 in 3 American homes with children have at least 1 gun.

Every year thousands of kids are killed or injured by guns. When parents think of asking about guns in a playdate’s home, they often can’t imagine how to enter into that conversation.

It doesn’t have to be awkward to ask before your child visits friends. I’ll show you how.

But first let’s review why this is so very important.

Guns are common in our communities. Ask if they are in the area your children will play, and if so, be sure they're stored safely! #ASKingSavesLives
Guns are common in our communities. Ask if they are in the area your children will play, and if so, be sure they’re stored safely! #ASKingSavesKids

Gun Safety

One question could save a child's life. Ask.
Click to enlarge. Source: http://askingsaveskids.org/

Many parents buy a gun to help protect their family, but a gun in the home increases the risk of a family member being hurt or killed by a gun more than preventing a crime.

Kids have natural curiosity and if they find a gun, they are likely to play with it, even when they are taught to not touch guns.

Toy guns and real guns are so similar, it can be difficult to tell them apart.

Several studies over the years show that gun education programs fail. Diane Sawyer’s Young Guns episode showed that even soon after gun safety education, kids will play with a gun and not follow the rules they just learned.

Regardless of the reason for or type of gun, there are guns in 1 in 3 homes with children in America. Too many of those guns are not locked. A gun in the home increases the risk of homicide, suicide, and accidental injuries.

Don’t mistakenly think that your gun is needed to keep your family safe. For every time a gun in the home was used for self-defense, there were 4 unintentional shootings, 7 criminal assaults or homicides, and 11 attempted or completed suicides.

Accidental shootings

Accidental shootings occur far too often, especially in young children.

See the table below that lists the numbers of leading causes of injury deaths by age. In children under 15, there were 73 unintentional firearm deaths in 2016. That number does not include homicides and suicides.

10 Leading Causes of Death by age in 2016
Click to enlarge. Source: https://www.cdc.gov/injury/wisqars/leadingcauses.html
Homicide

Sadly there have been too many kids who have been killed by intentional gunfire, both at home and in public areas. The higher the number of guns in a community, the more gun deaths there are.

Our kids must practice active shooter drills at school because school shootings are occurring with more frequency. Many of these shootings are kids who bring their parent’s gun to school.

Suicide

Suicide attempts with guns are usually fatal. Sadly too many people consider suicide as an option when they’re down.

Having a gun in the home when a teen is depressed increases the risk of death by suicide. Over 80% of teen suicide by firearm is done with a family member’s gun.

Keeping guns locked with the ammunition locked separately is important even when you don’t have young children. It can deter teens from accessing guns in a time of despair.

Hiding guns

Parental perception of what kids know about guns is lacking.
Child knowledge of handling of guns in the home. Source: https://www.bradycampaign.org/sites/default/files/Kids-and-Guns-Report%202016_final.pdf

Hiding guns is not a safe plan. Nearly 80% of kids know where the family gun is hidden. Parents usually don’t realize the kids know.

I’ve seen more than a couple surprised parents when they learn that their child knows where the family gun is stored in a drawer or closet. They presumed the child had no idea about the gun, but kids know things. It’s bad enough if they know your secret hiding place for birthday gifts, but if they know where the unlocked gun is, natural curiosities can take over.

It’s not political

I don’t care if you’re a Republican, Democrat, Liberal, or other political affiliation. This isn’t about politics. It’s about keeping kids safe.

This is not about the Second Amendment. Americans have a right to bear arms. But with rights comes responsibilities.

This is about the responsibilities that come with the right to bear arms. Adults have a responsibility to keep children safe.

When having the discussion, keep it about safety. Don’t make it about politics. That turns people off and gets them on the defensive. Don’t judge whether it’s okay to own a gun. Focus on the issue of making sure all guns are safely stored unloaded and locked.

Make it less awkward

Parents must have awkward conversations. Don't let that stop you from keeping kids safe.
Click to enlarge. Source: http://askingsaveskids.org/

As parents there are many awkward things we must deal with. Being awkward or difficult doesn’t make it okay to just ignore it if safety is involved.

By introducing safety concerns that are not judgement issues, it can be more natural to then talk about more sensitive topics.

Use these non-controversial openers to start the conversation before playdates.

Pets

Allowing a dog who is not friendly and patient around kids to be with the kids is a red flag. Ask if there are pets and how they respond to kids, especially kids they don’t know. If you’re not comfortable with that pet, ask if the parent can keep the kids and pet separate.

When kids are afraid of animals, the other parent needs to be aware.

If there are any pet concerns, see if they can keep the pet in another room while your child is there. If not, have their child to your home instead.

Allergies

If your child has allergies to animals or foods, the other parent needs to be aware. Talk about the allergy and what can be done to help your child not suffer.

When the parent is not able to keep your child safe from allergens in their home, ask if their child can come to yours instead.

Other safety risks

There are numerous other safety risks that could be used as introductory concerns. You can’t ask everything, but pick the things that are most important to you.

Will the kids be riding bikes or scooters? Are there enough helmets for everyone or should your child bring his own?

Is there a wooded area that will require bug sprays or tick checks after the play date?

If they play outside, how closely are they supervised? Do you need to send along sunscreen?

Does your child need to wear sneakers or will they be staying indoors and the flip flops are okay?

If a parent will be responsible for driving your child, do they have an appropriate car seat or booster seat?

Do they have a trampoline or pool? If so, what are their rules and safety measures?

Be first

Be the first to ask a child to your home. With the invitation, list everything you think another parent might be interested in knowing. Hopefully they will reciprocate by giving similar information when they invite your kids over, but if not, ask.

“We’d love to have Johnny over. We have a German Shepard, but he’s really good with kids. If Johnny needs him to be put in the master bedroom, just let me know. We also have a trampoline, but if the kids get on it, a parent is always outside. If that’s not okay, let me know. And we have a rifle, but it’s in the gun safe and the ammunition is locked separately. Is there anything we need to know about Johnny?”

Take the ASK Pledge

Pledge to ASK if there are unlocked guns where your child visits. Encourage friends and family to do the same!

Pledge to ASK if there are unlocked guns where your child visits: http://www.bradycampaign.org/take-action/pledge-to-ask
Pledge to ASK: http://www.bradycampaign.org/take-action/pledge-to-ask

Resources

The Truth About Kids and Guns from The Brady Campaign

CDC’s WISQARS™ (Web-based Injury Statistics Query and Reporting System)

WISQARS Interactive Visualization

jose-alonso-589704-unsplashphoto credit:Jose Alonso