Tuesday, August 2, 2011

Is White Rice Cereal Bad for Infants?

Close to one third of American children are overweight.  Theories abound as to why this dramatic shift has occurred over the past 3 decades.  Is it just too much fast food and too much TV, or is something else contributing to childhood obesity?

I recently read a theory that infant rice cereal may be predisposing children to obesity.  For years pediatricians, including myself, have recommended white rice cereal as one of the first solid foods to give to babies. Dr. Alan Greene of Stanford University has started a grass roots campaign to change how we feed our infants. Here is his explanation:

I am not sure there is overwhelming scientific evidence supporting Dr. Greene's theory, but I find it interesting nonetheless. Whole grain products are certainly safe to give an infant, so why stick with the highly processed, flour-based white rice cereal? I have started recommending whole grain cereal for my patients instead of white rice cereal. As long as the whole grain cereal is iron-fortified, it should offer everything that white rice cereal offers, except less starch. Whole grain cereal also contains essential fats, protein, and minerals that are not found in white rice cereal.

Time will tell if white rice cereal truly is leading children down the obesity path.  In the mean time, there seems to be no risk to switching to whole grain rice cereal for infants.

Saturday, April 23, 2011

Mastering the Snotty Nose: Sinusitis

In previous posts, I have described ways for parents to sort out the difference between allergies and the common cold (or upper respiratory infection).  You are becoming very strong in the ways of the snot.  I believe you are ready for the next step.   I am going to give away another trade secret.  I am going to show you how you can diagnose sinusitis, a bacterial infection in the sinus cavities.  Unfortunately, my medical degree does not give me the capacity to view the sinuses with x-ray vision to determine if there is a bacterial infection present.  I must rely on the history of the illness to make the diagnosis, which you can do also. 

The American Academy of Pediatrics and the American Academy of Family Practice have published guidelines regarding the management of sinusitis.  These are recommendation for how physicians should diagnose and treat sinusitis based on the current scientific evidence.  The central theme from both of these guidelines is that the diagnosis should be based on the duration of the illness.  Before diagnosing sinusitis (and prescribing an antibiotic), the child should have had upper respiratory symptoms (runny nose and cough) for at least 10 days.  Most cases of bacterial sinusitis are going to occur after a child has a cold virus.  A cold virus will typically get better, or at least be improving, by 10 days.  Pretty simple, right?  Less than 10 days, you are dealing with a cold.  Over 10 days, you have a sinus infection.  One requires an antibiotic, the other does not. 

Note: I am using 10 days as the cut off for simplicity's sake, but in reality 10-14 days is probably a more realistic cut off.  See the chart below of cold symptoms and note that many people will still have symptoms from a common cold beyond 10 days. 

Here are a few common misconceptions about sinusitis:

Facial Pressure/Pain Means Bacterial Sinusitis:  Nope.  Colds and allergies can cause sinus pressure also.  Over 10 days means bacterial sinusitis, facial pressure or pain does not.

"But His Mucus is Green!":  Sorry, it means absolutely nothing.  Mucus can be clear, yellow, or green with a common cold or allergies.  In fact there is a normal transition that occurs as a child progresses through a cold.  Typically, the mucus thickens up and becomes more yellow or green  towards the end of the illness.  Look at duration of symptoms, not the color of mucus. 

Sinus Infections are Contagious:  Wrong.  I often see a child who has an obvious cold virus, and the dad tells me that he saw his doctor and was diagnosed with a sinus infection. 
Me: "Really? Were you put on an antibiotic?"
Dad: "Yes, I am on Zithromax."
Me: "How long have you been sick for?"
Dad: "I got sick about the same time as Johnie, three or four days ago, I guess."
Me: "Hmmm, let me explain why I do not think Johnie needs an antibiotic at this point...."

Viruses (colds) are very contagious.  If a family has several people with a runny nose and cough, almost always this is a viral illness and antibiotics are not going to do anything to help.  Sinus infections are not contagious, the cold virus that can lead to the sinus infection is.  Once again, over 10 days of symptoms is the key. 

In reality, it is not always this cut and dried, there are times when I will make the diagnosis earlier than 10 days, such as when a child has had a cold for 8 days and now has 102 degree fever.  There are other times where I will hold off on antibiotics beyond the 10 days.  Some children just take longer than 10 days to get better from a cold, but these kids are typically showing gradual improvement by the 10th day. 

I always suggest parents wait out a runny nose and cough for at least 10 days before coming to see me (assuming the child is not extremely sick and does not have other confounding factors).  Before 10  days I am unlikely to do much beyond reassure the parent, after 10 days I am likely to treat the child for sinusitis.  Sometimes that reassurance is very valuable to a parent, so I never begrudge a parent for coming in under 10 days, but my medical management is going to be vastly different after 10 days of symptoms.

Congratulations! You can now tell the difference between a cold, allergies, and a sinus infection.  You are the master of all things snotty!

Saturday, April 9, 2011

Sneezing and Itchy Eyes: Allergy Symptoms in Children

Spring is here and so are allergies. Parents often have a difficult time identifying allergies from illnesses like colds or sinus infections. The term "allergies" can have many connotations, including a runny nose and cough, hives, anaphylaxis, food allergies, asthma, and eczema to name a few.  In this post, when I use the term "allergies," I am referring to allergic rhinitis and its associate symptoms (unless otherwise specified).  Before continuing, I suggest you read about the common cold, as I will referrence this and it is the entity that parents often confuse with allergies.

My experience is that parents often falsely assume that cold symptoms are due to allergies. They often try an over-the-counter allergy medicine and are baffled as to why it is not helping. So how does the astute, yet anxious, parent tell the difference between a cold and allergies? Here are some things to consider:

Age: If your child is under a year old, his symptoms are likely not due to allergies. Allergies take time to develop and a child under a year old typically has not developed an immune system capable of having allergic rhinitis (stuffy or runny nose from allergies). Other allergic phenomena, such as eczema and food allergies can occur in young infants, but these typically do not result in a runny nose.

Family History: Allergies tend to run in families. Unfortunately, falsely attributing cold symptoms to allergies also runs in families.

The Atopic March: It is well known that children prone to allergies often have eczema as infants. As they get older they tend to develop allergic rhinitis and some will go on to develop asthma. This is called the atopic march--the progression from eczema to allergic rhinitis to asthma. So if your child has a history of eczema, there is a greater likelihood that his runny nose is due to allergies.

Abrupt Onset vs Chronic Symptoms:  In general if your child is fine on one day and sick the next, this is probably not allergies. Allergies tend to be more chronic. If a parent can tell me the day the symptoms started, I am less suspicious of allergies. If the parent says the symptoms have been going on for "a while," allergies moves up my list of possible causes. One caveat to this is children in daycare. Their noses are always snotty due to one viral infection (cold) after another.  If examined closely, parent of the daycare child will describe episodes of cold symptoms that typically go away after 10 to 14 days, followed by no symptoms for a few days or weeks, then another similar illness.  In other words, there is typically a period of no symptoms between discrete illnesses.

Fever: Allergies do not cause fever. Viral illnesses do. If your child's runny nose started with a fever, the current symptoms are very unlikely to be allergies.

Itchy Eyes and Nose: A major chemical in the production of allergy symptoms is histamine. Histamine causes itching. So if an itchy nose or itchy eyes are part of your child's symptoms, allergies are more likely to be the cause.

Seasonality:  Many of the common causes of allergies occur during specific times of the year, such as pollen from trees or grasses.  Other causes of allergies, such as dust (dust mites) are typically year round.  Pet allergies are typically present when the child is around a type of pet dander to which he is allergic.  This may be constant if the child is constantly exposed to the pet.  So a repetitive pattern of symptoms during a specific time of year, such as every spring, makes me more concerned for seasonal allergies. 

Physical Findings: There are often things your pediatrician can identify during the physical exam that support the diagnosis of allergies, such as the allergic salute.  The repetitive (remember chronic symptoms) rubbing of the nose (remember itching) leads to a crease across the bridge of the nose.

The allergic salute
Crease across the bridge of the nose.

Other common findings are Dennie-Morgan lines and allergic shiners.  Dennie-Morgan lines are creases found below the eyes and allergic shiners are the dark circle under the eyes.

In reality it is sometimes hard to decipher the role of allergies in a child's symptoms.  Sometimes I will prescribe an allergy medicine to see if it helps.  If it does, that supports the idea that the symptoms are an allergic phenomena. Why not just do allergy testing?  Allergy testing is invasive, requiring blood tests or skin testing. Most children are not big fans of this. Testing can also be expensive (a typical blood allergy panel can cost over $500).  Often the results do not change the management of the child.  For example, if we discover through testing that a child is allergic to a specific pollen, there is little that can be done for this other than take an allergy medicine.  In other words, you cannot cut down all the oak trees in the neighborhood.  I typically do not pursue allergy testing, unless I am suspicious that we can decrease the child's exposure to the offending allergen, such as get rid of the cat or take dust mite precautions within the household.  Another reason I will utilize testing is when the child's symptoms are not controlled with allergy medicines or when there are problems controlling asthma that is triggered by allergies.  In these situations, allergy shots become a viable alternative to helping the child's symptoms.  To do allergy shots, we have to know what specifically is causing the child's allergies, thus, testing is required.

Saturday, February 12, 2011

Photographic Potpourri (Part 2)

We are still not sleeping well in the Gonzalez house. Baby Aaron is a grunter. All night long, even when he is sound asleep, he grunts and groans. A few nights ago we moved his bassinet out of our room and that has helped. Such is life with a three week old.

Anyway, here are some more pictures that may be educational for the anxious parents out there.

Brick Dust Urine
Breast feeding infants will often have a red, salmon-color spots in their diapers during the first couple days of life. This is often confused for blood in the urine by parents. When a mother is breast feeding, she is not producing much milk the first few days. This leads to the baby being slightly dehydrated and the baby's urine being concentrated. Concentrated uric acid crystals in the urine react with the diaper to produce the "red" spots. Once the mother's milk comes in (day 3-5 of life), the brick dust urine should go away.

Sebaceous Nevus
This skin finding is rather rare, and, honestly, this is the first time I have ever seen one. It is a type of birthmark that typically is on the head or scalp. The skin is rough and bumpy and usually there is no hair. It may have a velvety appearance and it will typically be in a linear pattern. Sebaceous nevus may get more bumpy and wart-like in response to hormones during puberty. There is also a small chance of developing into a skin cancer as he gets older. Although, this is rare, birthmarks and other unusual skin findings are quite common. Most of the time, your pediatrician is going to recommend watching it over time and not rushing your infant to the plastic surgeons. I like to see what a lesion is going to do before pursuing any definitive treatment. Is it going to fade away? Is it going to grow? Is it going to cause a problem (get scraped and bleed, interfere with vision if around the eye, etc)? With Aaron, we are going to do just that, watch it and see what happens. There may be a point were we go see a dermatologist or elect to have it removed, but right now there is no rush.

Infant Acne
Babies will often develop pimples on the face between 2-4 weeks old. This is due to maternal hormones that the baby was exposed to when inside mom. Babies that are breast feeding are also exposed to mom's hormones through the breast milk. There is no treatment for this and it does not cause any scaring or problems. Unfortunately, it usually shows up right when you want to get some baby pictures made.

Saturday, February 5, 2011

Photographic Potpourri

I have not posted here is quite some time. This is the busy season in pediatrics and my hours are longer, stress is up, and I am pretty worn out at the end of the day. In addition, my family welcomed our third child, Aaron, in January. He is a healthy boy who weighed 6 lbs and 15 ounces.

Because I know you are wondering, yes, he spits up, he is gassy, he cries a lot, and he poops and pees out of his diaper. He always wants to be held and does not like his bassinet. The first few days of breast feeding were stressful for everyone (surprise, surprise). All in all, Aaron is a perfect, normal baby boy.

I figure I should take this opportunity to document some normal baby findings for the anxious-Internet-parenting-world and to give Aaron ammunition to use against me when he is older. I can hear it now: "Dad, I can't believe you put all those embarrassing pictures of me on the Internet." Hopefully, seeing some of this pictures will help parents know what is normal.

Erythema Toxicum:
This is a normal newborn rash that usually shows up when the infant is a few days old. It looks like little flea bites. It is not dangerous or anything to worry about. It goes away after a week or so. We do not know what causes it.

Jaundice and Erythema Toxicum:
You can see some more Erythema Toxicum on his abdomen in this picture. You can also see the yellow tint to his skin. This is jaundice. Jaundice is not uncommon in infants, but it can be dangerous if the bilirubin level (the chemical that causes jaundice) gets too high. It is pretty much standard of care for all infants to be screened for jaundice prior to leaving the hospital and then to have a follow up appointment a few days after leaving the hospital. If you are given an appointment to go see your pediatrician 2 weeks after leaving the hospital, you should question this. Because of this close monitoring, it is uncommon to have jaundice reach a level that can cause problems.

Bilirubin Blanket
When a baby gets jaundice that requires treatment there are two options: 1) a bilirubin blanket to use at home, 2) admission to the hospital for more intensive therapy. Certain wavelengths of light convert bilirubin to a molecule that can be more easily excreted, thus, improving the jaundice. Sunlight can help, but is not strong enough if the jaundice is considered significantly elevated. Regular house lights do not work. In this picture you can see Aaron on a bilirubin blanket. The "blanket" is up against his skin under his clothes. We used this for a few days and his jaundice improved.

Peeling Skin
Baby's skin often becomes very dry and peels after birth. This comes from living in water for 9 months. You do not need to do anything for this. It gets better after a few weeks. Parents often want to put lotion on the baby, but I am a believer that the less that parents put on a baby's skin the better. One exception to this is at the ankles and wrists. Occasionally if will get so dry that the skin will actually crack open. When this happens I recommend putting Vaseline petroleum jelly at that location.

More pictures to come in future posts....