Author Archives: Dr. Raffi Sharon

Emergency symptoms not to miss

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Sick newborn Your baby is younger than 1 month and looks sick (eg, vomiting, cough, poor color) or acts abnormal (eg, poor feeding, excessive sleeping) in any way. At this age, these symptoms are serious until proven otherwise. During the first month of life, infections can progress quickly.

Severe lethargy Your child stares into space, won’t smile, won’t play at all, or hardly responds to you. Your child is too weak to cry, floppy, or hard to awaken. These are serious symptoms. Note: sleeping more when sick is normal, but when awake your child should be alert.

Confusion The sudden onset of confusion (delirium). Your child is awake but says strange things, sees things, and doesn’t recognize you. Note: transient delirium can be seen for 5 minutes or so with higher fevers. However, if not brief, confusion can have some serious causes.

Severe pain Severe pain is incapacitating. It interferes with all normal activities. The child just wants to be left alone. If your child cries when you  try to hold or move him, this can be a symptom of meningitis or appendicitis. Children also are unable to sleep or can only fall asleep briefly.

Inconsolable crying Inconsolable, constant crying is caused by severe pain until proven otherwise. Suspect this in children who are unable to sleep or will only fall asleep briefly, and when awake will not engage in any  normal activities. CAUTION: Instead of constant crying, severe pain may cause your child to groan, moan, or whimper.

Can’t walk If your child has learned to walk and then loses the ability to stand or walk, she may have a serious injury to the legs or a problem with balance. If your child walks bent over, holding her belly, she may have a serious problem such as appendicitis.

Tender abdomen Press on your child’s belly while he is sitting on your lap and looking at a book. You should be able to press an inch or so in with your  fingers in all parts of the belly without a problem. If your child winces or screams, it suggests a serious cause. If the belly is bloated and hard along with the pain, the problem is even more worrisome. Note: if your child just pushes your hand away, it probably means you  haven’t distracted him enough.

Tender testicle or scrotum Sudden pain in the groin area can be from twisting (torsion) of the testicle. This requires surgery within 8 hours to save the testicle.

Hard time breathing Breathing is essential for life. Most childhood deaths are due to severe breathing problems. If your child has trouble breathing,  tight croup (harsh sound when breathing in called stridor), or obvious wheezing or grunting with each breath, she needs to be seen immediately. Other signs of respiratory distress are fast  breathing, bluish lips, or retractions (skin pulling in between the ribs). Children with severe respiratory distress can’t drink, talk, or cry. Note: nasal congestion causes vibrations and some noisy breathing but usually without any trouble breathing. Check breathing after you clean out the nose with nasal washes and suction.

Bluish lips Bluish lips, tongue, or gums (cyanosis) can mean a reduced amount of oxygen in the bloodstream. Note: blueness only present around the mouth (but not the lips) can be caused by being cold.

Drooling The sudden onset of drooling or spitting when your child is ill means your child is having trouble swallowing. The cause can be  a serious infection of the tonsils, throat, or epiglottis (top part of  the windpipe). A serious allergic reaction can also cause trouble swallowing. Swelling in the throat could close off the airway.

Dehydration Dehydration means that your child’s body fluids are low. Dehydration usually follows severe vomiting or diarrhea. Suspect dehydration if your child has not urinated in 8 hours (more than 12 hours if your child is older than 1 year), crying produces no tears, the inside of the mouth is dry rather than moist, or the soft spot in the skull is sunken. Dehydrated children are also tired and weak. If your child is alert and active but not making much urine, she is not yet dehydrated. Children with severe dehydration become dizzy when they stand. Dehydration requires immediate fluid replacement by mouth or vein.

Bulging soft spot The soft spot in your baby’s head is tense and bulging. This means the brain is under pressure.

Stiff neck To test for a stiff neck, lay your child down, then lift his head until his chin touches the middle of his chest. If he is resistant, place a toy or other object of interest on the belly so he will have to look down to see it. Older children can simply be asked to look at their belly button. A stiff neck can be an early sign of meningitis.

Injured neck Talk to your child’s doctor about any neck injury, regardless of the symptoms. Neck injuries carry a risk of damage to the spinal cord.

Purple or blood-red spots or dots Unexplained purple or blood-red spots or dots on the skin could be  a sign of a serious bloodstream infection, especially if your child also has a fever. Note: bumps and bruises on the shins from active play are different.

Any fever (above 100.4°F or 38°C) in the first 3 months of life Bacterial infections in young infants can cause serious complications. All children younger than 3 months with a fever need to be examined as soon as possible to determine if the cause is viral or bacterial.

Fever above 105°F (40.6°C) All the preceding symptoms are stronger indicators of serious illness  than the level of fever. All of them can occur with low-grade fevers as well as high ones. Fevers alone are considered a risk factor for serious infections only when the child’s temperature rises above 105°F (40.6°C). Therefore if your child has a fever above 104°F (40°C) that doesn’t come down below 104°F after taking a fever medicine, call your child’s doctor.

Chronic diseases Most active chronic diseases can have some complications. If your child has a chronic disease, be sure to find out what those complications are and how to recognize them. Chronic diseases at highest risk for serious infections are those that weaken the immune system (eg, sickle cell disease, HIV, chemotherapy, organ transplant, chronic steroids). If you are talking with a doctor or  nurse who doesn’t normally see your child, always tell the doctor or nurse about your child’s chronic disease (eg, asthma). Never assume the doctor or nurse already knows this.

Based on recommendations/advice in “My Child is Sick; Expert Advice for Managing Common Illnesses and Injuries”, 14th Edition, by Barton D. Schmitt

Bite, Animal or Human

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Definition:

* Bite or claw wound from a pet, farm, or wild animal

* Bite from a human child or adult

Risk of Bites Animal or human bites usually need to be seen because all of them are contaminated with saliva and prone to wound infection.

Types of Wounds:

* Bruising: There is no break in the skin. There is no risk of infection.

* Scrape (Abrasion) or Scratch: A superficial wound that doesn’t go all the way through the skin. There is low risk of infection. Preventive antibiotics are not indicated.

* Laceration (Cut): A wound that goes through the skin (dermis) to the fat or muscle tissue. There is an intermediate risk of infection. Most need to be seen. Wound cleansing and irrigation can help prevent infection by washing out the bacteria from the wound. Preventive antibiotics may be required.

* Puncture Wound: There is an intermediate risk of infection. Puncture wounds from cat bites are especially prone to getting infected; many physicians will prescribe preventive antibiotics for cat bites.

Types of Bites:

* Bites From Rabies-Prone Wild Animals: Rabies is a fatal disease. Bites or scratches from a bat, skunk, raccoon, fox, coyote, or large wild animal are especially dangerous. These animals can transmit rabies even if they have no symptoms. In the United States, 90% of cases of rabies in humans are attributed to bats. Bats have transmitted rabies without a detectable bite mark.

* Small Wild Animal Bites: Rodents such as mice, rats, moles, gophers, chipmunks, prairie dogs, and rabbits fortunately are considered free of rabies. Squirrels rarely carry rabies but have not transmitted it to humans.

* Large Pet Animal Bites: Most bites from pets are from dogs or cats. Bites from domestic animals such as horses can be handled using these guidelines. Dogs and cats are free of rabies in most metro areas. Stray animals are always at risk for rabies until proven otherwise. Cats and dogs that are never allowed to roam freely outdoors are considered free of rabies. The main risk in pet bites is serious wound infection, not rabies. Cat bites become infected more often than dog bites. Claw wounds from cats are treated the same as bite wounds because the claws may be contaminated with saliva.

* Small Indoor Pet Animal Bites: Small indoor pets (eg, gerbils, hamsters, guinea pigs, white mice) are at no risk for rabies. Tiny puncture wounds from these small animals also don’t need to be seen. They carry a small risk for wound infections.

* Human Bites: Most human bites occur during fights, especially in teenagers. Sometimes a fist is cut when it strikes a tooth. Human bites are more likely to become infected than animal bites. Bites on the hands are at increased risk of complications. Many toddler bites are safe because they don’t break the skin.

Dogs and Cats and the Risk of Rabies

* Indoor Versus Outdoor Pets: Dogs and cats that are never allowed to roam freely outdoors are considered free of rabies. Outdoor pets who are stray, sick, or unvaccinated AND living in communities where rabies occurs in pets are considered at risk for rabies in the United States and Canada.

* Metropolitan Versus Rural Location: Dogs and cats in most metropolitan areas in the United States and Canada are free of rabies (EXCEPTION: towns along the border with Mexico). Dogs and cats in rural areas have a higher risk of rabies.

* Provoked Versus Unprovoked Bite: An unprovoked attack by a domestic animal increases the likelihood that an animal is rabid. Note that bites inflicted while a person is attempting to feed or handle a healthy animal are considered provoked.

* Developing Countries Versus United States and Canada: Dogs and cats in developing countries have a higher risk of rabies; rabies postexposure prophylaxis is indicated if a bite occurs in a developing country. International travelers need to remain alert. Nurses and physicians must check with the local public health department about the risk for rabies in their community.

First Aid Advice for Bleeding: Apply direct pressure to the entire wound with a clean cloth.

First Aid Advice for All Bites and Scratches: Wash all bite wounds and scratches immediately with soap and warm water.

Based on recommendations/advice in “My Child is Sick; Expert Advice for Managing Common Illnesses and Injuries”, 14th Edition, by Barton D. Schmitt

NEW: BOOK APPOINTMENTS ONLINE

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Did your child wake up in the middle of the night with ear pain or fever? Are you counting down the hours till the phone lines open, and/or are you getting frustrated by the busy-signal of the office phone? With online bookings you don’t have to worry about any of this. It’s available 24/7 and you can go back to sleep rest-assured knowing your child has an appointment with Dr. Sharon that same day! You can also look ahead and book a regular check-up weeks or months in advance online.

Did you know Dr Sharon also has an evening clinic on Tuesday evenings? Now your child does not have to miss school and/or you don’t have to take time off work for non-urgent visits that can be planned ahead of time. Once you have booked, you will get an automatic confirmation via email and you will receive a reminder 24 hours prior to your appointment. If you have a smartphone, you will be able to click on a link to save the appointment automatically in your calendar.

I have made a brief tutorial to show how easy it is to book appointments. You can watch it here:


“Stuck in a tunnel”: the common problem that is constipation

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One of the most common problems I encounter in the pediatric office, are problems with regards to bowel movements. It is very frustrating as a parent to see your baby, toddler or child in pain while trying to push out that stool. You just wish you could do something for them. Constipation can present as abdominal pain, skipping days of bowel movements (or weeks in extreme case) or even as diarrhea. In this article I will discuss the most common causes of constipation, how to treat it, and how to maximize everything you can do to prevent it from happening (again).

What is constipation?

Constipation is defined as having a bowel movement fewer than 3x a week. Often the stools will be dry and hard, but this does not always need to be the case. Stools come in all shapes and forms (just look at the picture; Types 4 and 5 are considered “normal”). In fact, in cases of really bad constipation stools can actually become quite liquid, and soiling may occur.

What are conditions/situations that make constipation appear most often?

Babies can have irregular bowel movements, and only have a bowel movement once every 4-5 days. As long as they are not bothered by it, that is ok. Some babies will have a bowel movement with every diaper change, some will skip 4 or 5 days.

When transitioning to solid feeds (often with the introduction of rice cereal) some babies may get constipated.

Another common time one can encounter constipation, is when your child is getting potty-trained. We are teaching them to hold their bowel movement until they reach their potty. Some kids love to have the power to hold their stools, and will try to hold it for as long as possible. Others are only inclined to have a bowel movement in their own home, and will hold it while at daycare, school or out camping. This ultimately leads to the most common vicious cycle in constipation: they will hold it, making the stool harder and bigger. When they do eventually have a bowel movement, it will cause them pain because it is too large. The next time they have to go to the washroom they will hold it even more because (like any human being) they do not want to experience pain again. This eventually turns into a vicious cycle, and at this point a doctor’s visit is often required to help resolve the constipation.

If one is prone to constipation, then a time when one is dehydrated (for example after a stomach flu with lots of vomiting and/or diarrhea) or when your child is hardly eating or drinking because they feel sick, could be the start of constipation.

All of these forms of constipation are called “habitual constipation”. There are also medical conditions that can cause constipation. These are rare, but in persistent cases of constipation, your primary care physician should rule them out and/or refer your child to a specialist. Again these are rare, but here is a list of some of the most common, rare causes: celiac disease (a gluten-allergy), hypothyroidism (thyroid is working too slow), Hirschsprungs disease (last part of intestine is missing nerves) and (exceedingly rare) Cystic Fibrosis (there is usually a family history of this, and many more other symptoms). With Hirschsprungs disease it will often manifest itself in the first week of life, when it will take very long for your baby to have their first bowel movement after birth (the so-called “meconium stool”). If your baby’s first meconium occurred > 48 hrs after birth, and they continue to suffer from constipation that is hard to treat, you should talk to your child’s physician about ruling out this disease.

How do we treat constipation?

If the constipation is mild and only started relatively recently, one can try diet modifications such as increasing fluid intake, eating prunes and/or drinking dilated prune or pear juice (1:1 ratio of prune/pear juice and water). In babies sometimes the old-fashioned trick of brown sugar-water can help (2 oz of water with 1 teaspoon of brown sugar). It is important to note that this should not be given daily. If these conservative measurements are not helping do not wait too long before seeking medical attention.

Your child’s physician may decide to prescribe a stool-softener which will basically attract water into the intestine, making the stool softer (for example lactulose liquid, or Polyethylene glycol powder also known as PEG3350). It is important to stress that one can NOT become dependent on these products.

On occasion it may be necessary to give your child enemas. These are typically given to children who are so full of stool, that they need to “get the cork out” in order to facilitate the rest of the stool to start moving.

“My child has a tendency to get constipated. Is there something I can do to prevent it from happening so often?”

Making sure the children are properly hydrated is by far the most effective way to prevent constipation. Ideally toddlers should drink at least 4 cups of water a day, and older children 6-8 cups of water a day. One of the contributing factors to constipation in toddlers is that they do not drink enough water in the first place. Some parents will put a tiny bit of juice in a cup, and then add lots of water and for some children that works. If that is not effective, sometimes a physician may give the kids a stool softener to help them.

Some parents might buy over-the-counter fibre products such as Benefibre or Metamucil. These products certainly provide extra fibre, however they only help treat the constipation if you drink even more water than your physician told you. This is often not possible for the kids. So, I do NOT recommend using these products. I suggest trying to encourage the kids to eat their fruits and vegetables to provide them with a natural source of fibre. The third step in preventing constipation is exercise. Luckily, most kids are very active so this is something that already occurs naturally.

Lastly, a regulated toilet regime can help your child prevent constipation. I suggest putting your child on the potty or toilet 3x a day for 5 minutes. If they produce, that is wonderful, if they don’t it is ok too. Typically about 15-20 minutes after a meal our bowels are most active. So for example, after breakfast, lunch and dinner would be a good time to put your child on the toilet/potty.

“My doctor/pharmacist told me to use a suppository to help with constipation”

It is true that glycerine suppositories can help getting some stool out of the rectum. I tend not to recommend them in most cases, for 2 main reasons: it only helps to get rid of the stool that is in the rectum (much more stool is left in rest of intestine), and sometimes you can create a small cut (also known as fissure) with the introduction of the suppository. Now your child or baby may experience pain again with a bowel movement, start holding the stool etc. Now we have actually created more problems than help with that suppository.

“My child has a bowel movement every day (albeit a bit hard); he cannot be constipated, can he?”

Oh yes, he can be constipated. The analogy I like to use for this is the accident in the tunnel. Imagine about 3/4 into a tunnel a traffic accident occurred and the 2-lane road has turned into a single lane (don’t worry, nobody got hurt). If you look at the entrance of the tunnel, you will see free-flowing traffic in 2 lanes going into the tunnel. However, if you are standing at the exit of the tunnel, you see cars coming out one by one, slowly in a single lane. Once the site of the accident in the tunnel has been cleared, there will be free-flowing traffic in the tunnel again. At no point did cars stop coming out of the tunnel, it was just slower and it took more time. With this kind of constipation, we need to help your child “clear the site of the accident” so to speak.

“Our doctor has already prescribed a stool softener, but it is not working”

This could indeed be the case, and then more vigorous treatments, possibly further investigations and/or referral to a specialist would be necessary. Alternatively, the dose of the stool softener prescribed was not high enough, or the stool softener was not used for an adequate amount of time.

Dr Raffi’s constipation tips:

1. Make sure your child drinks enough fluids, and eats their fruits and vegetables to provide sufficient fibre intake

2. Have a strict toilet regime

3. Don’t wait too long before seeking medical help (or restart previously prescribed stool softeners) in order not to get stuck in the vicious cycle of holding, experiencing pain and constipation.

4. If constipation persists despite all these therapies, talk to your child’s physician to rule out rare medical causes, and/or refer to a specialist Pediatrician or Pediatric Gastro-Enterologist

Scratch that itch: Head lice, a common and harmless occurrence

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A few times each year I will receive phone calls from parents who are in a panic, because they either have a child with head lice or because someone in their child’s class has head lice. Sometimes I will receive calls asking if they should pull their child out of school, not because their child has head lice, but to prevent them from getting it.

Some schools demand that parents pick-up their children right away once diagnosed with lice, or state that kids should stay home for at least 2 days after treatment. So, why are there so many questions, concerns and/or misconceptions? Is your scalp getting itchy just reading about this topic?

I am hoping this blog article will provide parents, and schools with all the data that we have at our disposal to take away any myths or misconceptions. And I hope this in turn will prevent potential outbreaks of massive hysteria amongst parents, and school staff alike.

I will use several references throughout this article. If you wish to use this blog article to show your school or other parents what current recommendations regarding head lice are, I would urge you to print the information from the different references I provide, rather than the actual blog.

What are head lice?

Head lice are wingless, 2 mm to 4 mm long (adult louse), six-legged, blood-sucking insects that live on the scalp of humans. Infested children usually carry fewer than 20 mature head lice (more commonly, less than 10 head lice), each of which, if untreated, live for three to four weeks. Head lice stay close to the scalp for food, warmth, shelter and moisture. The head louse feeds every 3 h to 6 h by sucking blood and simultaneously injecting saliva. After mating, the adult female louse can produce five to six eggs per day for 30 days, each in a shell (a nit) that is ‘glued’ to the hair shaft near the scalp. The eggs hatch nine to 10 days later into nymphs that molt several times over the next nine to 15 days to become adult head lice. The hatched empty eggshells (nits) remain on the hair, but are not a source of reinfestation. Nymphs and adult head lice can survive for up to three days away from the human host. While eggs can survive away from the host for up to three days, they require the higher temperature found near the scalp to hatch.

The classic symptom is itchiness to the scalp area leading to subsequent scratching.

Headlice do NOT spread disease.

Unlike body lice, head lice are not a health hazard, a sign of poor hygiene or a vector for disease, but are more a societal issue.

How are head lice transferred?

Head lice are spread mainly through direct head-to-head (hair-to-hair) contact. Lice do not hop or fly, but can crawl at a rapid rate (23 cm/min under natural conditions). Pets are not vectors for human head lice.

How to treat head lice?

There are special “Headlice” shampoos available. There are topical insecticides that have  been most commonly used. Some contain permethrin 1% (eg “Nix” shampoo). If one is allergic to ragweeds or chrysanthemums one should not use this. There are other non-insecticide shampoos on the market in North-America that do not contain permethrin (one example is “Resultz”).

Apply the product on dry hair, using enough to wet the hair. Make sure to follow the directions on the bottle, and leave in for 10 min. Then wash hair out. Use the special lice comb to lockout any nits that are left. After 48 hours, check again for any live lice. If there are, use the special shampoo again.  Check again after 7-10 days and repeat treatment.

Bedding, clothes, hats, stuffed toys etc. should be washed in hot cycle and then put in dryer in the hottest cycle. Clothes that cannot go in the dryer, can be drycleaned or sealed in plastic bag for 2 weeks. Combs, hairbrushes etc should be soaked in hot water with soap for 1 hour. Kids with long hair could have their hair pulled back while in school in order to minimize hair-to-hair contact.

Information for schools

The American Academy of Pediatrics, Canadian Pediatric Society and Centre for Disease Control all agree on return to school policy as well as whether a child should be sent home. As the lice have likely been in the hair for past 3-4 weeks prior to noticing it, there is no reason to send the child home earlier than at end of the day. Schools should provide a letter to all parents explaining someone in school has been found to have headlice, and to make sure to check their own children for lice. If lice are found, treat them. A child can be sent back to school as soon as he/she is treated (so if treated the evening before can go to school next day). Finding nits in hair does not equal “live lice”. In the past some schools in the U.S. tried a “No nits policy”, however this policy had no scientific basis. For an example of information that a local/provincial health authority distributes in school, check this link for Alberta Health Services. Please check your local health authority for more information as they might use a variation of this information.

Again, everyone should bear in mind that although a nuisance when it comes to causing itchiness and having to wash bed sheets, pillow cases etc, head lice do NOT spread disease.

Bottomline, Dr Raffi’s tips on Headlice:

1. Headlice do NOT spread disease

2. Treat with special shampoos, recheck after 48 hrs and again after 7-10 days

3. Once treated, a child can return to school

4. Useful websites are: AAP, CPS, CDC