Saturday, July 24, 2010

Deciphering the Common Cold

Viral upper respiratory illnesses, or common colds, are by far the most frequent illness I see in my office. It is called the common cold because it is, well, common. I typically can make the diagnosis with a high degree of certainty based on the pattern and the timing of the symptoms. Deciphering cold symptoms and knowing when to worry is what a pediatrician does more often than anything else, and I believe parents can learn how to do this as well. If a parent can get a handle on what a common cold looks like, they can certainly save some co-pays and visits to the doctor. You see, there is no real treatment for the common cold. I know, I know, this is the great failure of modern medicine.

Look at the chart below. Notice when the symptoms typically start and stop. A cold generally starts abruptly. Your child will be fine one day and then sick the next. Their nose becomes stuffy or runny and a cough usually develops. Older children may complain of a sore throat the first few days of the illness. The mucus in the nose will often thicken up and become yellow or green as the illness progresses. Contrary to popular belief, yellow or green mucus does not necessarily mean your child is getting worse. It may in fact mean he is getting better. Colds typically last 10 to 14 days. Nothing, including antibiotics, shortens the duration of the illness. Colds truly must run their course.

Fever is the big variable. As you can see, up to 20% of children will have fever within the first few days of the illness. So fever that starts at the beginning of the illness is not too concerning. Now if the fever starts later in the illness or does not go away by the 3rd day of the illness, something else may be brewing, such as an ear infection or pneumonia. This is very important and is illustrated in the picture below. Fever that starts during the first couple of days of the illness is probably related to the cold virus itself and not very concerning (green zone). Fever that starts after your child has had a runny nose and cough for several days, can represent a complication from the cold (red zone). The latter should be evaluated by a doctor.

During childhood, your child's immune system goes to school. Each cold teaches the immune system how to fight future viruses and prevent infection. As your child gets older, he will have fewer and fewer colds. The first couple of years will be full of these illnesses, especially if your child is in daycare. You will feel your child is always sick and something is wrong with him, but an average child in daycare will have about 10 colds a year. If each one last 14 days, well, you do the math.  Your child will have some sort of cold symptoms for close to half the year.

Thursday, July 15, 2010

Lumps and Bumps on the Head

I was recently scanning an online forum about pediatric health concerns. (What can I say?  I sometimes need inspiration.) There was one thread within the forum that was significantly longer than any other. Parent after parent posted about how they had noticed a knot on their infant or toddler. This concern parallels what I see in practice. An unexplained knot on the head is a common reason parents bring their child to be evaluated.

The first thing that comes to parents minds is that the lump represents something bad, like cancer. Fortunately, these lumps are almost always nothing to be concerned about. Worst case scenario is some lumps (cysts) may need to be surgically removed, but this is rare.

These are the things that parents notice:
  • Lymph Nodes.  By far these are the most common lumps that parent notice and worry about.  Most parents realize that lymph nodes can be found in the neck, but do not know that they are also found around the ears and at the back of the skull.  A pea-sized, rubbery knot beneath the skin is nothing to worry about. Often these are found in young infants (2 months old), leading to an office visit (if you have an infant, feel the back of his skull a few inches above the neck... you see what I mean?).  Healthy lymph nodes fluctuate in size, they grow and they shrink.  Bad lymph nodes keep growing and are not subtle.  If a lymph node is the same size that it was a month ago, it is healthy.  A lymph node needs to at least the size of a marble before I even bat an eyelash at it.  Even then, I will simply recheck it in a few weeks to make sure it is not continuing to grow. 
  • Congenital Cysts.  There are certain locations on the head that children can be born with a congenital cyst.  These can sometimes get infected and lead to problems.  However, some people could go their whole life with a cyst without having any problems.  Typical locations are in front of the ear (preauricular cyst), in the front middle of the neck (thyroglossal duct cyst), or the sides of the neck (brachial cleft cyst).  Cysts in these locations may also have dimples or tunnel from the skin down to the cyst.  Occasionally, these will need to be surgically removed.  Other times, they can be simply observed for problems.  (Your beloved, middle aged, blogging pediatrician has a thyroglossal duct cyst.  It has never caused me any problems and is not very noticeable, so I have just lived with it.) 
  • Dermoid Cysts.  I have probably seen 3 to 4 kids in my career with a cyst in their eyebrow.  These are typically located at the part of the eyebrow closest to the temple.  They are rubbery and the size of a pea or lima bean.  Because these can sometimes rupture due to trauma and cause a strong inflammatory reaction, they are often surgically removed. 
  • Bony Knot on an Infant's Skull.  Infants will often have swelling or bruising of their skull from delivery.  These areas of injury will sometimes calcify leading to a hard bony knot on the skull.  This is definitely something parents notice and worry about.  This calcified area is not dangerous and tends to remodel and go away as the skull grows, typically within several months.
These lumps certainly generate a disproportionate amount of anxiety relative to the true risk that exists from them.  If the lump is small and difficult for someone else to find, the chance it represents something that needs to be urgently evaluated is probably zero.  Things that make me concerned are typically blatantly obvious.  In other words, I can see it from across the room.  Otherwise, watchful waiting is probably going to be the safest, least invasive and most cost-effective approach to lumps and bumps on the head.

Saturday, July 10, 2010

Tired of Waiting at the Doctor's Office?

We all hate it when the cable company tells us that the technician will be at our house sometime between 11 a.m. and 5 p.m. Fantastic! Going to the pediatrician's office can be the same way. Your appointment may be at 9 a.m. but you may not get out of the office until noon. Unfortunately, this is the nature of running a medical practice. What should take ten minutes for one reason or another may take 30 minutes. Once the doctor is 20 minutes behind schedule, every patient will likely have to wait an additional 20 minutes for the rest of that day.

Here are some tips to make your appointment as fast and efficient as possible:
  • Ask for the first appointment in the morning or the first appointment after lunch.  If there are no patients before your appointment, the doctor is less likely to be running behind.  If you ask for the 4:30 p.m. appointment, understand that there are probably 10-15 patients the doctor has to see before she gets to you.  Each one of these patient encounters provides the opportunity for the physician to get further behind schedule. 
  • Ask about paperwork.  Inquire if there is any paperwork that may be required at the visit.  Most offices can fax or email these to you before your appointment.  Many offices have a website where forms can be downloaded.  You can then complete the paperwork before your appointment in the quiet of your own home and not in a waiting room full of screaming kids. 
  • Schedule yearly check-ups in the Summer.  Due to the seasonality of childhood illnesses, most pediatric practices are less busy in the Summer.  Less busy means less waiting time. 
  • Write down your questions before the appointment.  This allows you to efficiently inquire about your concerns.  This will not only get you through the office quicker, but will probably help the doctor stay on schedule.  Consider it an altruistic gesture for the parents who have appointments after yours.  Very noble, indeed. 
  • Pay your copay and schedule your follow-up appointment while in the waiting room.  You can save time at checkout by doing these things instead of watching Saving Nemo for the 23rd time.

Sunday, July 4, 2010

Laundry Problem or a Health Problem?

There is nothing that disturbs new parents more than their infant spitting up. If I were to make a top ten list of things about infants that provoke anxiety, spitting-up would be firmly ranked number one. Nothing else is close. Whether it is the breast milk, formula, or the infant, something is definitely wrong from the parent's perspective. When a baby spits up in a movie or on TV it is funny, but when it is your baby, it is no laughing matter!

At some point in time, spitting up went from a normal part of being a baby to being an abnormality that requires fixing. I am not sure how this happened, but I suspect it is related to the development of medications for reflux. There are medicines that decrease a baby's spitting-up. So when a parent expresses concern about spitting-up, pediatricians reach for medications to "fix" the problem. As more and more infants are being treated for reflux, we have shifted spitting up from a normal part of being a baby to an abnormality that requires drug therapy.

Why do babies spit-up?

There is a muscle (Lower Esophageal Sphincter or LES) at the top of the stomach that is responsible for closing and preventing stomach contents from coming back up. In babies, the LES is not very strong. Although parents always identify the formula or breast milk as the problem, the root of the issue is this muscle. It does not matter what liquid you put down into the baby's stomach, if the LES does not close down tightly, food is coming back up. Despite the fact that only one type of formula (one with added rice starch) has been shown to decrease spitting up, parents jump on the formula carousel. They switch from one formula to the next trying to fix the infant's spitting up. To their amazement the infant continues to spit up. That is because it is a stomach issue not a formula issue.  Combine a weak LES with a liquid diet and the fact that infants spend the majority of their life laying down, babies are born to reflux.

"Does my baby have acid-reflux?"

Reflux implies that the food went the wrong way and the stomach definitely has acid in it. So, yes, if your baby spits up, your baby does have acid reflux. The more important question is: "Does my baby have acid reflux disease?" Disease implies that the acid reflux is causing a problem. The vast majority of infants do not have any problems associated with their reflux (other than frequent clothes changes), so they do not have acid reflux disease.

When should parents worry about spitting up?
  • Poor weight gain. The pediatrician will determine this by looking at the infant's growth chart.
  • Projectile vomiting. This is a forceful vomiting that will shoot several feet. This may require evaluation to ensure there is not a blockage where the stomach empties into the small intestine.
  • Recurrent breathing problems. This most commonly presents as recurrent episodes of wheezing (a noise heard with a stethoscope within the lungs).
  • Excessively fussy infant. It is often hard to tell if an infant is fussy related to reflux or due to other causes, such as colic. But if an infant is miserable and spits up a lot, then reflux may be causing some pain.
These problems are rare. Most infants who spit up are completely healthy and happy, and, therefore, a laundry problem exists but not a health problem. Spitting up is a normal part of being a baby. Accept it. Embrace it. Laugh at it. But you don't have to fix it.