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.