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.

The test commonly used to identify strep is most accurate after symptoms have been there for awhile. This is because it tests for the antibodies your body makes against the strep bacteria, not for the bacteria itself. 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.

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!)

 

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

Bumps, ridges, and soft spots on a baby’s head. When should you worry?

Parents often worry about lumps and bumps on a baby’s head unnecessarily. Babies normally have ridges and soft spots on their head for a while after birth. Many have a type of swollen gland that parents can feel when rubbing the head. All of this is normal.

Skull anatomy

Let’s begin with a brief overview of a baby’s head. We are born with many bones in our skull. This allows the head to be squeezed out of the birth canal as the bony plates move together or even overlap one another.

Infant skull bones
Infant skull bones

Sometimes you don’t really notice much with these bones, but other times they overlap one another noticeably after birth. When a baby has a lot of head distortion due to overlapping of skull bones, we call it molding. It can make the head look pointed – which is often called cone head.  It can also make the head look flat on one side.

The good news? Even really odd looking heads are usually normal. Molding tends to resolve without intervention over the first few days of life.

Soft spots

There are 1-2 “soft spots” at birth. Usually the one on top to the head (the anterior fontanelle) remains open enough to feel for the first 18-24 months of life. The one towards the back of the head (the posterior fontanelle) is unable to be felt by about 2 months of age. It is often so small at birth that it’s not recognized.

Many parents fear that touching a soft spot will somehow damage the baby’s brain. Normal touching won’t hurt, even from a 2 year old sibling. There are several layers of skin and other tissues protecting the brain.

Doctors will feel the soft spots during routine check ups to be sure they are the right size for the growth of the baby’s head. There’s a lot of variation here, so if you question the size of your baby’s soft spot, discuss it at a visit with the doctor. He or she will need to not only feel the soft spot, but also will look at overall head growth, baby’s development, and the shape of the head.

Bruises and bleeding

Coming out of the birth canal can be traumatic for both mother and baby (and often for fathers too). Sometimes babies have a big soft or squishy bump on one side of the head, which usually is essentially a large bruise.

Bruises can cause yellow jaundice.

Any bruise can increase the risk of yellow jaundice in a newborn, so your doctor might watch your baby more carefully for this over the time that the blood is resorbed. This is because yellow jaundice is caused by breakdown of blood cells. Most babies show yellow color in their eyes and face. Even if it progresses to their chest and abdomen it can usually self-resolve with proper hydration, but it should be monitored. If the level gets too high it can be managed. Talk to your doctor if you’re concerned.

Cephalohematoma vs caput saccedaneum.

The two most common types of bruising are cephalohematoma and caput saccedaneum.

A cephalohematoma develops when there is bleeding between the skull and the bone lining called periosteum. Since it is outside the skull, it doesn’t affect the baby’s brain. It covers only one of the bones, and never crosses one of the suture lines.

Caput succedaneum is swelling of the scalp in a newborn. It develops from bleeding one layer above the periosteum in the skin. It can cross the bone areas since it’s not limited by the lining of the bone (periosteum). You will notice a soft, puffy swelling on the baby’s scalp, usually in the area that first came out during birth. Some will show bruising.

Both of these conditions can lead to increased risk of yellow jaundice due to breakdown of the blood collections, but usually self resolve without complications. If baby seems uncomfortable due to this area, discuss with your hospital nurse or doctor.

The picture below attempts to show the layers of bleeding described here and includes more uncommon (and more concerning) types of bleeding. Babies who have deeper bleeds need proper medical management. For information about subgaleal hematoma, see Seattle Children‘s website. Epidural hematomas are very rare in newborns.

Scalp hematomas

 

Flat spots

Flat spots are common, especially if babies prefer to always look to one side. This can cause the forehead to seem to bulge on one side or an ear to appear closer to the face than the other ear. This is usually due to baby laying one direction most of the time, allowing the brain to grow all directions but spot baby is laying on.

Babies always need to sleep on their back until they start to roll on their own, but this can encourage a flat head. It’s important to get baby to lay looking right sometimes, left other times. Supervised tummy time is helpful too. I recommend starting tummy time on day one. The earlier you start tummy time the less they seem to hate it!

When you hold and feed baby, alternate arms because they will look toward you and by simply holding in the right arm sometimes, left arm other times, they will turn their head. If your baby resists turning his head, check out this Torticollis information.

Lymph nodes

One of the most common head worries that brings parents to the office is a pea-sized (or bigger) movable bump on the back of baby’s (or even an older child’s) head. This is usually an occipital lymph node.

Lymph nodes of the head and neck
Lymph nodes of the head and neck

When I say it’s just a lymph node, some parents automatically worry about lymphoma.

Don’t go there.

Most of us remember having a swollen lymph node (AKA swollen gland) under our jaw or in our neck when we are sick. When they develop on the back of the head, it is usually from something irritating the scalp, like a scalp probe during labor, cradle cap, or bug bites in older kids. They can remain large for quite a while (often seeming to come and go when kids have scalp irritations), but unless they hurt to touch, enlarge rapidly, are red and hot, or a child looks sick otherwise, I don’t worry about them.

TL:DR

In short, most lumps and bumps on your baby’s head are normal. If you’re worried, bring your baby in to have your pediatrician look and feel.

Bumps, ridges, and soft spots on a baby's head is often normal - but when should you worry?
Bumps, ridges, and soft spots on a baby’s head is often normal – but when should you worry?

Is Miralax Safe?

Constipation is one of the most common problems that affects kids. Sometimes it’s mild and changes to diet and routines can help sufficiently. Those are of course the ideal treatments. But if it’s more severe or if kids are resistant to change, Miralax is my go-to treatment. Several parents have asked me about its safety due to what they’ve seen online. I know many more are probably worried but just haven’t asked. With all the concern, I thought I’d share some of the concerns and reasons that I still recommend it.

What is Miralax?

Miralax has been used since 2000, and since I finished my pediatric residency prior to that, I can remember the alternatives we used previously. Many of them were difficult to get kids to take due to poor taste or grittiness. When Miralax was first available, treatment of constipation improved significantly due to the tolerance and acceptance by kids. It was initially available by prescription only and expensive – thankfully both of those hurdles have been removed.

Miralax is the brand name for polyethylene glycol 3350 or PEG 3350. It is now available as an over the counter medication, so no prescription is needed. Generic versions are available. It has been used by many kids over many years, often for long periods of time, to treat constipation.

Is it a laxative?

PEG3350 is a stool softener, not a laxative (despite the name).The molecule binds to water, but is too large to be absorbed through the gut so it passes through the gut and carries the water with it. It works by increasing the water content of the stool. The more PEG taken, the softer the stool.

PEG is not a laxative and should not cause cramps. It is not habit forming. As mentioned above, it is not absorbed into the body it just goes through the GI tract and leaves with the stool.

How is it used?

PEG 3350 is a tasteless powder that dissolves in liquids. It often needs to sit for a few minutes and re-stirred to fully dissolve.

It may be dissolved in water, with a slight change to its taste, but is palatable. Be careful of adding it to drinks high in sugar (even juice), since your child may be on it for a long time, and they don’t need the added sugar. Consider making flavored water with your child’s favorite fruit. Simply put cut up fruit in water in the refrigerator for a couple hours. Infused water tastes great and is a healthy base for your Miralax mixture – or anytime your kids need a drink and don’t like plain water.

I don’t recommend adding it to carbonated beverages.

I recommend mixing a capful of powder in 8 ounces of water and titrating the amount given based on need. My office website discusses this in detail.

Why do we need medicine?

Constipation is common.

Very common. It causes pain, poor eating habits, fear of toileting, and sometimes even leads to ER trips and CT scans. It can last months to years in some kids, so it is not a minor issue when kids suffer from it.

Diet changes are hard – especially in kids!

Kids are often constipated because they have a diet that is poor in water and fiber. They need to eat more fruits, vegetable and whole grains. Many kids drink too much milk and eat too much cheese.

Changing habits is very difficult in strong willed kids. When it comes to food, they’re all strong willed! Dietary changes of course should be done so they are healthier on many levels, but if their stomach hurts all the time, they are unlikely to get out of their comfort zone with foods. Habits change too slowly to help the constipation if used alone.

I encourage first changing the diet to help constipation, but if that fails, or if it is too significant of a problem, PEG 3350 is my first choice. I have recommended it for years without any known side effects or complications, other than the kids who have frequent watery stools on it. This usually responds to continuing the medicine to release the large stool mass that has built up. Some kids just need to decrease the dose a bit.

What’s the concern?

I was quite surprised in 2015 to see that researchers were starting a study on the drug. It surprised me not only because I’ve never heard valid concerns about the safety or efficacy of the medicine (I have seen some really weird stuff online, but nothing that is valid), but also because I’ve never seen headlines that a study is starting. Usually headlines report results of studies. Why did it hit the press before the study was even done? I have no idea.

Even more interesting… it seems the study hasn’t started yet. Three years later. Not a high priority, apparently. Which fits with the low level of concern I find among general pediatricians and pediatric gastrointestinal specialists.

Yet parents still ask about the risks.

What was the proposed study?

Initial reports stated that they were going to look at the safety of other molecules in the PEG 3350.

PEG 3350 itself is a very large molecule that isn’t absorbed by the gut, but there are concerns that smaller compounds could be found as impurities in the manufacturing process of PEG 3350 or formed when PEG 3350 is broken down within the body.

The question is if these smaller compounds are absorbed by the gut and accumulated in the bodies of children taking PEG 3350.

Some families have reported concerns to the FDA that some neurologic or behavioral symptoms in children may be related to taking PEG 3350. It is unclear whether these side-effects are due to PEG 3350 since neurologic and behavioral symptoms can lead to constipation.

What are the recommendations?

The 2014 guidelines for constipation diagnosis and management from the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition support the use of PEG 3350: Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN.

These guidelines basically state that not many studies are required to diagnose functional constipation after a thorough history and exam. This means that we don’t need to do expensive tests to make the diagnosis.

The common things we recommend (fiber, water, probiotics) don’t have any proof that they work. There is evidence that PEG 3350 works.

Why does the label say it’s for adults?

As a pediatrician I know that many (if not most) of the medicines we use in children are not tested in children before they come to market.

Historically once something is approved in adults, physicians start to use them in children. Companies generally don’t invest money in studies to expand uses after approval because they know that the products will be used in broader ways without the specific indication. They don’t want to spend money they don’t need to spend, which makes sense from a business perspective. It’s also more difficult to do studies in minors.

New rules encourage pediatric testing, but all the drugs previously used in children will not need to undergo this testing. Because they’ve been used for years, we rely on post-market safety data.

Are there studies in children?

Many of the news articles say that studies have not been done in children, but this isn’t true.

This 2014 research article reviews the history of PEG 3350 and compares to other medicines used in pediatric constipation. It also shows safe blood electrolyte levels while on PEG 3350 long term.

In 2001 a study was published showing safe and effective pediatric dosing.

2003 studyshowed safety and better tolerance than previously used medications for constipation.

A study specifically looking in children under 18 months of age showed safety.

2009 Canadian study shows its safety in children.

If you look at the references of any of these studies, you will find more. The only side effects noted are related to diarrhea, cramping, bloating — all things that would be expected with a large stool mass blocking the new, softer, water filled stools from coming out. Once the large stool mass is out, these symptoms resolve.

For what is PEG approved?

PEG is used in many products, not just stool softeners. It is found in ointments and pills to allow them to be more easily dissolved in water. PEG can also be found in common household products such as certain brands of skin creams and tooth paste.

PEG 3350 is approved for treatment of constipation in adults for up to 7 days. Approval is based on studies available at the time a medicine is approved. Many commonly used medications are not specifically FDA approved for use in children less than 16 years due to difficulties and expense in testing drugs on minors.

How do we know it works?

There have been several studies in children and the collective experience of pediatricians around the world showing improved tolerability over other treatments for constipation because PEG 3350 has no taste, odor, or texture.

It has been shown to be either as effective or more effective than other constipation treatments. See the links to these studies above. Until children can keep stools soft with adequate amounts of water, fruits, vegetables, and fiber, long term use of PEG is well tolerated.

How long can PEG be used in children?

This is a very difficult thing to study because the longer a study follows their subjects, the more subjects are lost to follow up.

There have been studies of up to 30 months that showed safe use. Blood electrolytes, liver and kidney tests were all reassuring that PEG is safe during the study.

Pediatric gastroenterologists and general pediatricians have often recommended even longer periods of time without any known side effects.

If my child has taken PEG 3350, should I worry?

Is miralax safe?
Is MiraLAX safe?

I cannot stress enough that the studies that have been done all support the safety and efficacy of PEG 3350.

After years of experience using PEG 3350 with many children, I have not seen any neurologic or behavioral problems caused by PEG 3350. I do see many kids with baseline neurologic and behavioral problems become constipated, so they often end up on PEG 3350, but if the issue is carefully assessed, the problems start prior to the treatment.

Generally if the stools are softer, you can more easily work with the behavioral issues that cause the constipation, such as loss of appetite/poor diet and failure to sit on the toilet long enough to empty the stool from the rectum.

If you decide it is time to stop the medicine, be sure to discuss this with your child’s doctor to keep them in the loop about how things are going!

Should your child have an Athletic Heart Screen?

In recent years I’ve been getting more and more reports of athletic heart screenings. Local schools and sports clubs are offering to have athletes get a heart work up for a relatively small fee. Of course most are perfectly normal, which is a peace of mind to parents. Some have found minor things that aren’t of much consequence, but a few have found important heart issues. So why is there even a question of whether or not to do an athletic heart screen if it discovers important heart issues?

Why worry about healthy athlete hearts?

Sudden cardiac death in athletes has been in the news a lot over the years. We all want to minimize the risk that our child has an undiagnosed heart condition that may cause sudden death when exercising. We want to prevent sudden death by identifying those at risk and keeping them from the activities that increase risk.

Communities and schools now are more likely to have defibrillators on hand in case of problems, but some children might benefit from an implantable defibrillator.

If you’ve not taken a CPR class in the past few years, a lot has changed, including teaching people how to use defibrillators. And you no longer follow “A B C” so it is very different. CPR is recommended for all teens and adults.

Is the cost of a heart screen worth it?

Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age): A Scientific Statement From the American Heart Association and the American College of Cardiology is a review of whether or not electrocardiograms (ECGs) are beneficial for all athletes prior to sport participation. It is endorsed by the Pediatric and Congenital Electrophysiology Society and American College of Sports Medicine.

There has been a lot of controversy over the years whether or not routine ECG screening of athletes is a cost-effective means to find at risk young people. Northeastern Italy has done a comprehensive screening program of competitive athletes and has lowered their sudden cardiac death rate, which is evidence for the ECG screening. Despite this shown benefit, there are many problems with the feasibility of testing a broad range of athletes to evaluate for risk of sudden death (SD).

Complex issues from the Statement linked above:
  1. the low prevalence of cardiovascular diseases responsible for SD in the young population
  2. the low risk of SD among those with these diseases
  3. the large sizes of the populations proposed for screening
  4. the imperfection of the 12-lead ECG as a diagnostic test in this venue

It is generally agreed upon that screening to detect cardiovascular abnormalities in otherwise healthy young competitive athletes is justifiable in principle on ethical, legal, and medical grounds. Reliable exclusion of cardiovascular disease by such screening may provide reassurance to athletes and their families.

In short: 

To do an ECG screening on all athletes is not inherently unwarranted nor discouraged, but it isn’t recommended either.

What is recommended?

Although an ECG is not recommended, it is recommended to do a 14 point questionnaire for all athletes at their pre-participation sports exam. This is listed below.

Why isn’t an ECG (commonly called EKG) recommended?

Positive findings on the history (questionnaire) or physical exam may require further testing, but using an ECG as the initial screen for underlying problems in the 12- to 25-year age group hasn’t been found to save lives.

Changes in the heart in growing teenagers can make it difficult to tell if an ECG is abnormal or a variation for age (unless read by a pediatric cardiologist, which is often not possible for these mass screenings).

False negative and positive results can lead to missed diagnoses (normal ECG but real underlying condition) or unneeded testing (abnormal ECG with a normal heart).

Mass ECG screening of athletes would be very expensive and has not been proven to save lives.

If your family can bear the cost and wants to do the screening, it should be done. But if the screen is abnormal, do not jump to the conclusion that your athlete will be banned from sports forever. A more complete exam by a pediatric cardiologist will sort that out.

Know that hearts can change over time. One normal screen does not guarantee there will never be a cardiac event in your child.

If you do not feel that the screening is something you want to pay for or if you feel that it is not necessary for your child who has a negative 14 point screening, you should not be required to do so.

The evidence does not support mass required screenings.

If your child has identified risks based on the questionnaire, a more thorough testing should be done.

What are the 14 points?

These 14 points are listed in Table 1 of the above linked statement: The 14-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes

Medical history*
Personal history 

1. Chest pain/discomfort/tightness/pressure related to exertion
2. Unexplained syncope/near-syncope†
3. Excessive and unexplained dyspnea/fatigue or palpitations, associated with exercise
4. Prior recognition of a heart murmur
5. Elevated systemic blood pressure
6. Prior restriction from participation in sports
7. Prior testing for the heart, ordered by a physician

Family history

8. Premature death (sudden and unexpected, or otherwise) before 50 y
of age attributable to heart disease in ≥1 relative
9. Disability from heart disease in close relative <50 y of age
10. Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of genetic cardiac conditions in family members

Physical examination

11. Heart murmur‡
12. Femoral pulses to exclude aortic coarctation
13. Physical stigmata of Marfan syndrome
14. Brachial artery blood pressure (sitting position)§

  • AHA indicates American Heart Association.
  • *Parental verification is recommended for high school and middle school athletes.
  • †Judged not to be of neurocardiogenic (vasovagal) origin; of particular concern when occurring during or after physical exertion.
  • ‡Refers to heart murmurs judged likely to be organic and unlikely to be innocent; auscultation should be performed with the patient in both the supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
  • §Preferably taken in both arms.

What do I recommend?

I think that if you can afford the screen and any potential follow up recommended if it is abnormal, it is a great tool. It can be reassuring, though nothing can guarantee that no problem will develop.

In a perfect world cost wouldn’t matter, but I know it does, so if people can’t afford the screening, they should not feel like they are not doing the right thing if they skip it.

The 14 point question is all that is recommended to be done and can catch the majority of problems if done with a thorough physical exam.

A plug for an annual well visit in your medical home.

I think all kids and teens should have annual physicals in their medical home. The medical home is where their primary care physician is.

I know this is difficult due to the requirement of all athletes have a physical in a specified time frame before a season starts, but there are benefits to doing a physical in the medical home. At your usual physician’s office there should be record of growth over the years, a complete personal and family medical history, and previous vital sign measurements. Not to mention that your regular clinic should be able to update your vaccines if needed so there are no surprises when your school nurse looks at your record in the fall. Seeing your physician yearly also helps to build a relationship, so there is a better comfort level to talk if problems develop.

At this time insurance generally covers one well visit per year. Most physicians will fill out the sports physical form at this annual visit. When you go elsewhere, you usually must pay cash. You might as well get a comprehensive physical using your insurance. You pay a monthly fee for the privilege of having it – use it! Just be sure to schedule well in advance – everyone needs physicals at the same time due to state or club requirements, so slots fill up quickly.

Schedule your physical when you schedule a sport or camp.

When you sign your kids up for any new school, sport or camp, look to see what forms are needed. Call your doctor’s office at the same time you sign up for the sport or camp to schedule the annual physical. Just be sure the date you schedule is in the time frame that is needed  to get the forms completed.

Pay attention to your insurance rules for how often physicals can be done. Don’t necessarily schedule near your child’s birthday if it is outside the range that is needed to fulfill form requirements so you can avoid a second physical when only one per year is allowed.

If in doubt, call your pediatrician’s office and ask!

Should your child have an Athletic Heart Screen?
Should your child have an Athletic Heart Screen?

Top Reasons to Follow the Recommended Vaccine Schedule

Every once in a while we see a child whose school nurse says the child’s vaccines didn’t count and need to be repeated. This can be due to many things, usually inappropriate timing of vaccines. Some electronic health records now have intelligent vaccine recommendation abilities. These smart vaccine logic systems are catching kids who had incorrect spacing before this technology. Staying on the routine vaccine schedule and keeping all records in one place can help avoid extra doses due to inappropriately spaced vaccines.

One thing to remember if your child needs extra doses: you don’t need to worry. They’re safe!

What’s in this post?

First you’ll need to understand about the different types of vaccines to know why they are scheduled like they are. Some are given in a series to boost the initial response, but others need to be repeated to cover those who weren’t protected with a first dose.

Then we’ll do a quick review of the risk of the diseases to remind us why we vaccinate in the first place.

Hopefully after learning some basics, you’ll see why the timing of vaccines is so important and why we should all follow the recommended vaccine schedule.

What’s not in this post?

If you want to know what to do if a recommended vaccine has been delayed, see What happens if a vaccine booster is delayed?

Dr. Vincent Iannelli has a list that includes some issues not discussed in this post, such as improper storage.

How vaccines work

Vaccines are made in different ways and the body responds to them in different ways.

Live attenuated vaccines

Live attenuated vaccines are made from weakened virus that teaches the body to recognize the real virus but doesn’t cause the symptoms of the virus in healthy people.

Those with weak immune systems should talk to their physician before receiving a live virus vaccine. The amount of immune compromise and specific vaccine must be taken into account on an individual basis.

It’s usually okay to be vaccinated with a live virus vaccine if you’ll be around an immunocompromised person, but again, let your physician know the risk of exposure.

Examples of live virus vaccine:
  • rotavirus
  • measles
  • mumps
  • rubella
  • varicella
  • nasal flu vaccine (NOT the injectable flu vaccine)

Many people respond sufficiently to the first dose of these, but repeat doses are given to help those who missed the response the first time.

The second dose doesn’t boost the first, but it gives a person a second chance at making immunity.

Spacing between doses:

Because of the way these vaccines work, they must follow special separation rules. More than one live virus vaccine can be given on the same day, but they cannot be given on separate days that are closer than 4 weeks apart.

If one live virus vaccine is given, you must wait a minimum of 28 days to give another. If they’re given too close together, the body doesn’t make immunity as well to the second one given. This second vaccine wouldn’t count.

As an example, if the FluMist (nasal flu vaccine) is given on January 1 and the Varicella vaccine is given January 15 of the same year, the Varicella vaccine will not count and must be repeated.

Live virus vaccines are the only vaccines that are subject to this 28 day rule. If another vaccine type is needed, it is okay to give in a shorter time frame.

For example, if a child has the MMR at his 4 year well visit, it is okay to do an injectable flu vaccine at a flu clinic later that same month. (Note: the nasal flu vaccine is a live virus vaccine, so it is NOT okay to give the FluMist within the month before or after the MMR.)

If there is less than 28 days between live virus vaccines, the one that was given second must be repeated.

I see this quite frequently in kids who move to the US from other countries. It seems quite common elsewhere for kids to get the varicella (chicken pox) vaccine about 2 weeks after the MMR. When this happens, another varicella vaccine is needed.

Live virus vaccines aren’t recommended under 1 year… usually

Many parents worry that we don’t give live virus vaccines to infants because they’re less safe, but that’s not why at all.

Maternal antibodies (fighter cells from mom that got into baby during pregnancy) can inhibit the body from being able to build its own antibodies well against a vaccine.

Maternal antibodies are good because as long as they’re in the baby’s body, they fight off germs and protect the infant! They tend to hang around for the first 6-12 months of life.

If a disease has a low incidence, it is acceptable to let the maternal antibodies do their job for the first year.

By the first birthday most maternal antibodies have left the infant, so a vaccine can be used to build the baby’s immunity.

International travel increases risks

If there is a high risk of exposure it is recommended to give the vaccine as early as 6 months in case the maternal antibodies are already too low for infant protection. Many parts of the world have high measles rates so fit into this recommendation.

If the antibody levels are still high, the vaccine won’t work, but the baby should still be protected against the disease from mom’s antibodies.

At some point the maternal antibodies go away, we just don’t know when exactly, so the baby who gets the MMR early needs another dose after his first birthday to be sure he’s making his own antibodies once mom’s go away. This dose after the birthday is the first that “counts” toward the two MMRs that are needed.

The next dose of MMR can be anytime at least 28 days after the first counted dose, but we traditionally give it between 4-6 years with the kindergarten shots.

Yes, I realize there are some measles outbreaks in the US, but the experts have not said to start giving that extra dose to babies who are staying here yet. If you’re worried, talk to your doctor.

Inactivated virus vaccines

Inactivated virus vaccines are made by killing the virus and using it to make the vaccine.

They aren’t as effective as live virus vaccines, so several doses are needed to build immunity to these.

Examples of inactivated virus vaccines:
  • inactivated polio vaccine
  • injectable flu vaccines
  • hepatitis A vaccine

Subunit, recombinant, polysaccharide, and conjugate vaccines

Subunit, recombinant, polysaccharide, and conjugate vaccines use specific pieces of a virus or bacteria to make a vaccine.

Because these vaccines use only specific antigens, they give a very strong immune response that’s specific to the infectious particle and side effects are less common.

This type of vaccine is safe for nearly everyone, including people with weak immune systems.

One limitation of these vaccines is that you may need booster shots to get ongoing protection against diseases.

Subunit, recombinant, polysaccharide, and conjugate vaccines include:
  • Hib (Haemophilus influenzae type b) – not related to influenza vaccine at all
  • Hepatitis B
  • HPV
  • whooping cough
  • pneumoccal disease
  • meningococcal disease

Toxoid vaccines

Toxoid vaccines prevent diseases caused by bacteria that produce toxins in the body.

The toxins are weakened into toxoids so they cannot cause illness and are used to make the vaccine.

When the immune system receives a vaccine containing a toxoid, it learns how to fight off the natural toxin.

Example of toxoid vaccine:
  • diphtheria and tetanus portions of the DTaP vaccine

Several shots are needed to build and continue immunity over time.

Passive immunization

Passive immunization is a bit different than any of the above.

Either catching a disease or getting any of the above vaccines stimulates your immune system to make memory cells to fight of that specific germ if it comes in contact with it.

Passive immunity results when a person is given someone else’s antibodies.

The protection offered by passive immunization is short-lived, usually lasting only a few weeks or months, but it helps protect right away.

Example of a passive vaccine:
  • Synagis (RSV) vaccine

Why are vaccines repeatedly given?

Vaccines interact with the T and B cells of our immune system to make memory cells.

If you want to learn more, see How Vaccines Work. It’s a really cool slide show from The College of Physicians of Philadelphia.

Some vaccines need several doses to help the body develop a strong immunity against the germs. Later boosters are required to maintain that level of protection.

Other vaccines require more than one dose to insure that most people develop the protection.

Age at time of vaccine matters

The CDC Immunization schedule allows for age ranges for many vaccines to be given. Many states allow a grace period around those ages, but not all do.

Some vaccines have been shown to work best at certain ages. Our vaccine schedule reflects the best ages to give vaccines so that they are safe and effective.

If a child receives a vaccine within the grace period of their current state, it might “count.” But if that child moves to another state, the vaccine might not count per the new state’s laws.

My office only gives the routine MMR, Varicella, and Hepatitis A vaccines on or after the first birthday to help prevent a child from moving to a location that does not have a grace period. This is despite the fact that Kansas does have a 4 day grace period.

We will give the MMR earlier under certain circumstances as discussed above, but it does not count toward the two needed after the 1st birthday.

Spacing matters

Many vaccines need to be separated by a minimum timeframe, often 4 weeks, but sometimes longer. The Hepatitis A vaccine has a minimum timeframe of 6 months between doses, for example.

If the vaccine doses are not separated by a minimum time, one or more will need to be repeated.

For spacing rules, see the CDC vaccine schedule at the bottom of this post. Click on “footnotes” to see the details for each vaccine.

Why not space them out further?

Many parents have come to believe the “too many too soon” theory. They believe this despite the overwhelming evidence that vaccines are safe and effective when given according to the CDC schedule.

The risks to waiting to give vaccines are many.

Increasing vaccine preventable disease rates

Young adults of today have grown up without seeing the suffering of vaccine preventable diseases. But we’re seeing an increase in these diseases where vaccine rates have fallen.

Infants who aren’t vaccinated are at risk of diseases that can lead to death. They are among the most vulnerable and need protection.

More trips = more exposure

Not only are underimmunized children more at risk for vaccine preventable diseases, but bringing them to a clinic more frequently to do one vaccine a time increases risk. Each time they visit the clinic, they’re exposed to all the common viruses. Why risk bringing them back again and again to get more exposures?

Giving the vaccines together has been shown to be safe and effective.

More visits = more stress

There are studies that show less overall stress to the body if vaccines are given together.

Studies have shown that the first injection causes a stress response measured by elevated heart rate, blood pressure, cortisol levels, and cry. Subsequent injections given at the same time do not increase as significantly the stress when compared to returning on different days to get further injections.

The immune system can handle it

Are you worried about “too many too soon” and that vaccines will overwhelm the immune system? Stop worrying. These fears are simply unfounded.

As Paul Offit summarized in Addressing Parents’ Concerns: Do Multiple Vaccines Overwhelm or Weaken the Infant’s Immune System?:

Current studies do not support the hypothesis that multiple vaccines overwhelm, weaken, or “use up” the immune system. On the contrary, young infants have an enormous capacity to respond to multiple vaccines, as well as to the many other challenges present in the environment. By providing protection against a number of bacterial and viral pathogens, vaccines prevent the “weakening” of the immune system and consequent secondary bacterial infections occasionally caused by natural infection.

Keep your child’s vaccine record handy

I see many kids who transfer to my office but I don’t have access to their vaccine records at the time of the visit. This makes it difficult to know which (if any) vaccines are needed.

Hopefully as we use Electronic Health Records with portals and vaccine registry databases more this will become a non-issue. At this time it’s still a problem.

This is one of the many reasons I prefer for all vaccines to be given at the same clinic. If you’re changing primary care providers, be sure records are transferred before your first visit.

Flu vaccines are especially troublesome.

Flu vaccines are commonly given in many locations: your primary care provider (PCP) office, a parent’s workplace, a local pharmacy, at a school flu vaccine drive. They need to be repeated yearly, so it’s easy to forget if each of your kids has had it this year.

It’s common for one parent to not know if their child got a flu vaccine already this season. That leads to a missed opportunity or vaccines given unnecessarily.

I have seen a few kids who couldn’t get their kindergarten vaccines at their well visit because they recently had a FluMist elsewhere. That requires another trip to the office for the family.

I have seen a few kids who did get the kindergarten vaccines inappropriately because the parent didn’t realize the other parent had taken them for a FluMist elsewhere. They needed to repeat the MMR and varicella vaccines, which didn’t make the kids happy!

FluMist is coming back to the US for the 2018-2019 flu vaccine season. It is not the preferred vaccine by many experts due to continued concerns about its effectiveness, but it will be preferred by many kids who hate needles. If your kids worry about shots, learn how to make them less painful.

Be sure to keep track if your kids get a FluMist – especially if they’re getting kindergarten vaccines around the same time!

Learn more about vaccine preventable diseases:

This comic book can teach kids and adults about viruses and how science works:

Dr. Paul Offit is one of the leading experts on vaccines. His many books can show how vaccines work and why they’re needed. He delves into the anti-vaccine movement in many of his books. He shows how delayed vaccine schedules are not effective or necessary in most of his books. I have many of these at my office available for patient families to check out. Just ask if you’re in my office. Otherwise, read about each on the links to see what best fits your needs.


Note: As an Amazon Affiliate Member, I will get a small percentage for the sale of the books if purchased from these links. This is at no additional cost to you.

Vaccine Resources for Kids and Teens is a great list of resources from the Children’s Hospital of Philadelphia.

15 Common Anti-Vaccine Arguments and Why They are a Load of Crap

How Math (and Vaccines) Keep You Safe From the Flu Simple (or not so simple) math shows how herd immunity works. Widespread vaccination can disrupt the exponential spread of disease and prevent epidemics.

Simulation of how herd immunity works. Is a free online simulation. Try it!

The CDC schedule:

 

 

Is your teen driver a safe driver?

Summertime is a common time that teens learn to drive, but also the most dangerous time. Teens have more free time during the summer, so have more opportunity to drive than during the school year. Car crashes are the #1 cause of death in teens. We are now entering the “100 Deadliest Days,” the time between Memorial Day and Labor Day. This is when the average number of deadly teen driver crashes climbs 15% compared to the rest of the year. Make sure your teen is a safe driver before you let him or her hit the road alone.

Teens tend to be impulsive risk takers. Even cautious new drivers are inexperienced, so they are at risk of not knowing how to handle a situation. In addition to riding along with your teen as they learn the rules of the road, you should talk to them about expectations and safety. Continue the talks as they gain confidence because the risk of accident actually increases in the late teen years.

May is Global Youth Traffic Safety Month to educate about safe driving.

Driving Contract

After talking to your teen, get your thoughts down in writing. There are many driving contracts available online.

This contract from the CDC has areas to write in your specific details.

The idrivesafely contract allows you to enter details for each point covered.

The AAA Driving Agreement has a nice chart depicting privileges that vary based on circumstance.

NOYS Global Youth Traffic Safety Month
From https://noys.org/global-youth-traffic-safety-month/

Special Situations

Overconfidence of the teen driver

Research has shown that after the first few driving years, teens risk of having an accident actually increases. This may be due to teens gaining confidence and taking more risks.

According to the 2017 study, 75 percent of high school seniors “feel confident” in their driving abilities, and 71 percent use a phone behind the wheel. Driving while drowsy, speeding, having multiple passengers and browsing music become more prevalent as new drivers gain confidence.

Distraction

Distractions are a common cause of accidents. Younger drivers have the highest proportion of distraction related fatal crashes.

Over 70% of teens admit to using their cell phone while driving despite recognizing the dangers of this distraction.

Parents need to model safe behavior and stay off their phone while driving. Texts can wait. If it’s that important, pull over to check your phone. Have your teens agree to no cell phone use in a driving contract.

One of my favorite ads shows just how quickly accidents can happen.

Other passengers are another source of distraction. Teens easily distract one another. Limit the number of passengers your teen is allowed to chauffeur.

Even changing the radio station can be a significant distraction. Ask teens to set the station and leave it – or to make a soundtrack and play it for the road.

Speeding

Speeding is a contributing factor to many crashes. Speed limits are set for safety and going faster makes it harder to maintain control of the vehicle.

Talk to teens about the importance of not only following speed limits, but also about adjusting speeds to road and weather conditions.

It is better to arrive alive but late rather than to speed to attempt to get there faster. Talk to your teen about calling if they plan to be late rather than just trying to speed home to make curfew.

ADHD

The symptoms of ADHD, such as an inability to pay attention and impulsivity, can make driving even more dangerous than it is for a typical teen. There are more car accidents among teens with ADHD than the general population, but newer studies show ADHD drivers on medication are at a significantly lower risk than those not taking medicine. Talk to your teen about medication management if he or she has ADHD.

Safety tips for safe driving

  • Buckle up – it’s the law but even more important, it’s the safest way to travel. Make sure any passengers are properly buckled before you drive.
  • Avoid carpooling to reduce the distraction of others in the car. The more kids in the car, the higher the risk.
  • Avoid eating while driving.
  • Ignore your cell phone. (Parents be forgiving if your kids don’t answer your call or text right away.)
  • Know where you are going and how to get there before you get on the road. If you aren’t sure you’ll remember, set a GPS before hitting the road and turn the sound on to minimize the need to look at the screen.
  • Don’t drive when you’re tired. Drowsy driving is equated to drunk driving. If you have trouble staying in your lane or keeping your eyes open, you’re too tired to safely drive.
  • Adjust seats, mirrors and climate controls before driving.
  • Set your music for the road before you start driving.
  • Watch for pedestrians and bicyclists. Five percent of teen deaths in crashes are pedestrians and 10% are bicyclists.
  • Don’t drive under the influence of alcohol or any drug that affects your ability to focus behind the wheel. Car crashes are the leading cause of teen death and about 25% involve an underage drinking driver.

Follow the law and parental expectations

It goes without saying that teens must follow the law when driving. They must respect the rules of the road for their own safety and the safety of others.

In addition to the laws, household rules about passengers, nighttime driving and cell phone use can be individualized to your teen’s abilities and weaknesses. Even if a teen can legally drive alone, if he or she hasn’t demonstrated the ability to do it safely, parents should not allow it. More supervised hours can make a difference in their experience and if they in general do not show the ability to make safe choices, they should not have the ability to drive a vehicle unsupervised.

Sun and Water Safety: Don’t take risks. Follow these tips.

Memorial Day signifies the start of summer, the opening of pools and trips to the beach. Regardless of where you’ll be outside or around water, it’s always important to be safe. Make sun and water safety a priority! Bug safety will be covered separately in a future post.

Safe in the sun!

Keep kids safe in the sun with many methods, not just sunscreen.
Keep kids safe in the sun with many methods, not just sunscreen.

Protecting your child in the sun is very important. Make sure you understand how various sunscreens work, how they should be used, and what else you can do to protect your kids from the sun.

Infants under 6 months

Babies under 6 months of age should be kept out of the direct sunlight as much as possible.

Move your baby to the shade or under a tree, umbrella or the stroller canopy. Be careful near reflective surfaces, such as water. Shade may reduce UV exposure by only 50% if there’s reflected sun.

Dress them in lightweight but long sleeved clothing and wide brimmed hats to keep the sun off their skin.

It’s okay to apply sunscreen to small areas of the body that you cannot cover with clothing, such as face and hands.

Make sure infants stay hydrated in the heat. Do not give extra water to infants until they are on solid foods. Breastfeed more often or give extra formula to prevent dehydration.

Mineral vs chemical sunscreens

The sunscreen does not have to be baby specific, but chemical sunscreens are absorbed more than mineral sunscreens. One of the concerns of young infants using sunscreen is they absorb chemicals too much, so mineral sunscreens are preferred for them.

I think most things marketed for babies are really for parent’s piece of mind. They aren’t necessarily better for baby. And they can mark up the cost just because it says it’s for Baby. But one of my favorite sunscreen brands for babies – Blue Lizard – actually prices competitively for the baby product. I like this brand because it was developed in Australia to be used safely at all ages. All of their products are mineral based.

Mineral based products use zinc oxide and titanium dioxide to reflect sun rays. There is minimal absorption. The downsides are they are not as light on the skin and they can wash off when sweating or swimming.


Chemical sunscreens, on the other hand, are absorbed into the skin. They absorb the sun rays that enter the skin. These are best for older children who are exercising outdoors and swimmers since they do not wash off as easily.

What is SPF?

SPF= Sun Protection Factor

The SPF increases the time you can spend in the sun, depending on your skin type. If you would typically burn in 1 hour, an SPF of 15 will keep you from burning for 15 hours, if you reapply every 2 hours. If you would burn in 20 minutes, an SPF of 15 used every 2 hours would protect you 15 x 20 minutes, or 5 hours. This is why fairer skinned people need higher SPF levels.

The sun protection factor (SPF) should be at least 25 and should cover both UVA and UVB rays. The sooner your skin burns, the higher the SPF you should use.

How should sunscreen be used?

For all infants and children over 6 months, be generous with sunscreen. Apply sunscreen at least 30 minutes before going outside, reapply it every 1-2 hours if sweating or swimming (even if it states it is waterproof), and use sunscreen even on cloudy days. One full ounce should be used to cover an adult.

Reapply the sun screen every 1-2 hours.

Try to keep children out of the sun between 10:00 am and 4:00 pm, when the sun’s rays are strongest.

Clouds are not sufficiently protective against the sun. UV rays on cloudy days may be reduced by only 20% to 40%.

Does sunscreen cause cancer?

I don’t know why this is a popular question these days. Well, yes, I know why people question it. The rumor that chemicals in sunscreen are dangerous is commonly circulated online. That’s why it’s questioned, but I don’t know what started this rumor.

Sun causes cancer.

Sunscreens have been studied extensively and have been shown to be safe. Use them.

What about eyes?

We often neglect our eye health, but there are ways to prevent sun damage to our eyes. This sun damage can lead to cancer, cataracts, and growths in the eye.

Sunglasses should be used to protect the eyes from sun damage. Hats with wide brims also keep sun out of the eyes.

Be sure your sunglasses are rated to protect against UVA and UVB 100%. Darker glasses don’t offer more protection necessarily. They must be rated to protect against UVA/UVB.

Bigger frames are better. Especially the ones that wrap around the sides of the face.

Higher cost doesn’t mean better protection – look for the rating! Even inexpensive sunglasses can provide protection. This is good, since most of us need several pair due to them getting misplaced or broken – especially the ones for our kids!

For more on sunscreens:

SMART SUN PROTECTION: UNDERSTANDING THE BEST SUNSCREEN OPTIONS from Dr.Michelle Ramírez at Dream Vibrant Health.

Which Dermatologist-Approved Sunscreen You Should Use To Keep Your Skin Safe from Dr. Dhaval Bhanusali, a medical and cosmetic dermatologist

Sunscreen Safety: Is It Worth The Hassle? from Dr. Nidhi Kukreja at The Growing Parent.

Water

"<yoastmark

How can I protect my child around water?

All parents should take a basic CPR course! Young children can drown in only a few inches of water, even if they’ve had swimming instruction.

Children who are swimming – even in a shallow toddler’s pool – should be watched closely. Even if there’s a lifeguard at the pool, there is too much to monitor when there’s a pool full of kids. You must watch your own kids until they’re strong swimmers.

It’s recommended that infants and toddlers have an adult within arm’s reach. For young children, you should continue to pay constant attention and be free from distractions. It’s easy to be distracted when talking to another person or checking your phone. Don’t consider it watching kids if you’re pool side reading a book.

Inflatable pools should be emptied and put away after each play session. (This also reduces unwanted mosquitoes!)

Enforce safety rules – no running near the pool and no pushing others underwater.

Water wings, tubes and other floating devices are not approved flotation devices and should be used only under direct and close supervision. Because they give a false sense of security, I don’t recommend them.

Be sure the deep and shallow ends of any pool your child swims in are clearly marked. Never allow your child to dive in the shallow end.

And then there are teens…

Talk to older kids and teens often about water safety. As they gain confidence in the water, they take more risks.

Teens are especially notorious for risk taking behaviors. Let them know your expectations. Teens might roll their eyes, but studies show they do best with rules and clear expectations from parents.

Of course they should not drink alcohol ever, but risks increase around water. They should never swim alone, even if they are captain of the swim team. If they are going to a river or lake, they need to be careful of inherit risks there, such as diving into shallow waters and boat safety.

As always, be sure you know where they’re going and when to expect them home. If they’re in water they won’t have a cell phone available at all times, so you might want to schedule “check in” times.

Drowning Risks

Drowning is a real risk. Dry drowning? Not so much.

Learn what distress in the water looks like. The movie depiction of drowning with a lot of yelling and thrashing around is not what usually happens.

If someone can verbalize that they’re okay, they probably are. Drowning victims can’t ask for help. There is a video linked to this page of what to look for with drowning that shows an actual rescue. From this site, signs of drowning:

  • Head low in the water, mouth at water level
  • Head tilted back with mouth open
  • Eyes glassy and empty, unable to focus
  • Eyes closed
  • Hair over forehead or eyes
  • Not using legs – Vertical
  • Hyperventilating or gasping
  • Trying to swim in a particular direction but not making headway
  • Trying to roll over on the back
  • Appear to be climbing an invisible ladder

What about swimming lessons?

The American Academy of Pediatrics does not recommend swimming lessons for children under one year of age because they cannot really learn skills to keep them safe.

Even young children who have had swimming lessons should not be unattended at the pool because they are not able to always make safe choices.

How can I protect my child around the backyard pool?

Inflatable pools should be emptied and put away after each play session. (This also reduces unwanted mosquitoes! Who wants mosquitoes in their backyard?)

If you have a swimming pool at home, it should be completely surrounded on 4 sides with a tall fence that has a self-locking gate. The house cannot serve as one side of the barrier. Keep the gate closed and locked at all times. Be sure your child cannot manipulate the lock or climb the fence.

If your pool has a cover, remove it completely before swimming. Never allow anyone to walk on the pool cover. Your child could fall through it and become trapped underneath.

Keep a safety ring with a rope beside the pool at all times. If possible, have a phone in the pool area with emergency numbers clearly marked.

Spas and hot tubs are dangerous for young children. They can easily drown or become overheated in them. Don’t allow young children to use them at all due to these risks. If older children use them, they should be supervised. Be sure they are well hydrated. After using a hot tub, be sure everyone showers. You don’t want hot tub folliculitis!

What about at the ocean or lake?

Talk to kids about the pull of undertow if you’re wading into the ocean. (If you don’t know what this is, walk into the water without your kids first.)

Use coast guard approved life preservers correctly whenever needed. All people should wear a life preserver when riding in a boat unless they are inside a cabin. Children should wear a life preserver when they are near the water’s edge or on a dock, even if the law doesn’t require it.

A life preserver fits properly if you can’t lift it off over your child’s head after he’s been fastened into it. For the child under age five, particularly the non-swimmer, it also should have a flotation collar to keep the head upright and the face out of the water.

Adults should not drink alcohol when they are swimming or boating. They are not only at risk of dehydration from the alcohol, but they also risk lives. It presents a danger for them as well as for any children they might be supervising. Don’t ruin a fun time with a tragedy.

Keep it fun in the sun!

Sun and water safety are not only important, but if you’re not careful, it can ruin a vacation. Practice sun and water safety every day!

 

Swollen eyelid causes and treatments

There are many causes of swollen eyelids in kids (and adults). The good news is that the most common ones are usually not serious. Some swellings herald warning though and should be properly evaluated and treated by a doctor.

Warning signs include vision changes, pain, protrusion of the eye, fever, difficulty breathing, abnormal eye movements (or loss of movement), foreign body that cannot be removed, or signs of anaphylaxis (swollen tongue or throat, difficulty breathing, hives). Any warning signs deserve prompt medical attention.

Allergies

Allergies can make the eyelids puffy due to the histamine reaction. This is usually accompanied by itching, red eyes that are watery. There can be circles under the eyes.

Treatment involves either oral allergy medicines, topical allergy medicine (eye drops) or a combination of both. Washing the face, hair, and eyes after exposure to allergen can also be an important part of treatment.

Anaphylaxis

Anaphylaxis is a more serious allergic reaction. It involves swelling of the eyelids, throat, and airways.

This is a medical emergency. If epinephrine is available, don’t hesitate to use it. Call 911.

Blepharitis

Blepharitis is an inflammation of the eyelids that can cause swollen lids. It often includes flaky eyelid skin and loss of the lashes.

This chronic condition should be managed by an eye care specialist.

Bug Bites

Bug bites are the most common cause of swollen eyelids we see in our office. Usually there is a known exposure to insects and there may be other bug bites on the body.

Bug bites on the eyelid tend to itch rather than hurt despite the significant swelling they produce. There should be no fever or other signs of illness. The eyeball should move freely in the socket. (See “orbital cellulitis” below.)

Treatment of bug bites involves cool compresses and oral antihistamines. Occasionally oral steroids are required for significant swelling, but they require a prescription.

If the swelling is concerning to you or your child, bring him in to be seen.

Conjunctivitis

Conjunctivitis, also known as pink eye, causes inflammation of the surface of the eye ball and sometimes a puffy appearance to the eye lids. It can be from bacteria, virus, or allergies.

Bacterial conjunctivitis causes the whites of the eyes to look red and includes a yellow discharge from the eye. This is usually treated with antibiotic eye drops.

Viral conjunctivitis causes the white of the eye to look red, but there is no yellow discharge. This does not require antibiotic eye drops.

Allergic conjunctivitis is described above under “allergies.” Treatment of allergies is recommended.

If unsure which type your child has, or if it is probably bacterial, see your doctor.

Contact Lenses

Contact lenses can contribute to swollen eyes if they are dirty or damaged.

If you suspect problems with your contacts or your eyes continue to bother you and you wear contacts, see your eye doctor.

Crying

Crying can cause the eyelids to become puffy. The lacrimal glands produce an overflow of tears, so the fine tissues around the eyes absorb the fluid, causing them to appear swollen. This is compounded by the autonomic nervous system increasing blood flow to the face during times of strong emotion and rubbing the eyes to wipe away the tears. This cause of swelling is short lived.

Cool compresses and avoidance of rubbing can help decrease the swelling.

Graves’ Disease (Thyroid)

Graves’ disease can cause the appearance of swollen eyelids and protruding eyes. Sometimes a drooping eyelid or double vision occurs. It is caused by thyroid problems, which also can cause problems with appetite, fatigue, heat intolerance, and more.

These symptoms should be evaluated by a doctor.

Kidney Problems

Kidney problems can lead to fluid retention. If the eyes are puffy along with puffiness of the ankles or swelling of the abdomen, then kidney problems should be considered. Children can develop this suddenly from infections, like certain diarrheal illnesses or Strep throat. The urine may look tea colored or like it has blood in it.

This is a medical emergency and you should seek care immediately.

Sinus Infections

Sinus infections can cause puffy, swollen eyelids. Congestion, runny nose, headache, postnasal drip, and cough are typical symptoms. It must be present for a minimum of 10 days, but sometimes these symptoms happen with a viral upper respiratory tract infection.

See your doctor if you suspect sinusitis.

Styes and chalazion

Styes look like a swelling at the edge of the eyelid, often red or pink with a small white central area. It is caused by a blockage in one of the small glands in the eyelid. They can be painful or tender.

Another swelling from blockage of oil glands of the eyelid is a chalazion. These do not typically hurt but they can cause the whole eyelid to swell significantly.

Applying warm packs to the area several times per day often helps treat styes. Chalazions more often need to see an ophthalmologist for treatment.

If a stye persists beyond a few months or the lid swells to cover the pupil, see your doctor.

Trauma

Trauma of the eye or nose, like any trauma, can cause swelling. A broken nose can cause swelling and bruising to the eyelids.

Any significant trauma to the eye or nose should be seen by a doctor. Symptoms may include vision changes, chemical exposure, foreign body in the eye, blood in the eye, severe pain, or nausea or vomiting after injury.

Ocular Herpes

Ocular herpes is an infection of the eye by the herpes virus. (Not all herpes infections are sexually transmitted!) It can appear initially like a blister or cluster of blisters near the eye.

It can lead to permanent damage to the eye, so prompt care by an ophthalmologist is important.

Orbital Cellulitis

Orbital cellulitis is a potentially serious infection of the eyelids. The infection can extend behind the eyes, causing meningitis.
It is suspected when there is painful swelling of the upper and lower eyelids, fever, bulging eyes, vision problems, and pain with eye movement.  Inability to move the eyes is a serious symptom.
This is a medical emergency and if suspected, prompt medical attention is warranted. Treatment involves iv antibiotics. To assess the extent of swelling, imaging is often done.

Ptosis

Ptosis, or drooping of the eyelid, can look like a swollen lid. There are many causes and this should be evaluated by an eye specialist.