DukeHealth.org: Your Child's Health

Newborn Screening

Wed, 24 Feb 2010 10:56:42 -0500

Over four million babies are born in the United States each year. Thankfully, most of these newborns have no medical problems and will be healthy.

However, very rarely, some babies are born with serious medical conditions that can only be detected by a simple blood test. Newborn screening is a program in which babies have a small amount of blood sent to the state public health department to test for these serious health problems.

Alex Kemper, MD, MHS, MS, of Duke Children’s Primary Care explains why we screen newborns.

--Dennis Clements, MD, PhD

Alex R. Kemper, MD, MPH, MS

What medical conditions are included in newborn screening?

All of the conditions included in newborn screening require treatment before the baby has any symptoms.

Newborn screening began in the 1950s with testing for phenylketonuria (PKU). Now newborn screening includes more than 29 recommended conditions, including congenital hypothyroidism, sickle cell disease, and cystic fibrosis.

Newborn screening has recently expanded to also include testing for hearing impairment.

What do I have to do to make sure that my baby is screened and how do I get the results?

All babies in North Carolina are routinely screened. You do not have to sign any forms to make sure that your baby is screened.

Screening does not depend on your ability to pay for it. However, it is important to make sure that your baby was tested before you go home from the hospital.

The results from the hearing screening will be available before you leave. The blood test results are not usually ready for about one week.

Although your pediatrician should receive information about the results of the test, we think that it is a good idea for you to also check. Sometimes the state public health laboratory will contact families directly if the newborn screening test is positive.

What about testing for conditions that are not included on newborn screening?

There are some differences across states in the conditions that are included in newborn screening. We recommend that you talk with your baby’s pediatrician if you have questions about supplemental testing.

North Carolina tests for all of the conditions currently recommended by the federal Department of Health and Human Services.

What should I do if my baby has a positive newborn screen?

A positive newborn screen does not mean that your baby has one of the conditions. However, it does mean that your baby needs close follow-up testing to make sure that there is no problem.

Depending on the condition that you baby had a positive screen for, testing may involve simply sending another newborn screening sample to the state public health laboratory or ordering more specialized tests.

Sometimes your pediatrician may recommend a specific baby formula while waiting for the follow-up testing to be completed. Having a positive newborn screening test can be very stressful. However, the good news is that treatments are available for the conditions included in newborn screening.

Although false positive newborn screens are not uncommon, it is important that you have follow-up testing.

What do I do if my baby is diagnosed with one of the conditions through newborn screening?

Of course, the care that your child receives will depend on the exact condition. Regardless of the condition, it is important that you have a medical home for your child.

A medical home is a primary care clinic that knows you and your family, that can coordinate all of the care that your child needs, that can partner with you to monitor the growth and development of your child, and that can help your child reach his or her potential as an adult.

Duke Children’s Primary Care has many services available to provide a comprehensive medical home for children with special health care needs.

What newborn screening research is happening at Duke?

Researchers at Duke University have led the development of many of the tests included in newborn screening and are developing exciting new tests and treatments, which promise to expand newborn screening further.

Researchers at Duke are also involved with developing the health policy necessary for newborn screening to be effective.

-- Alex R. Kemper, MD, MPH, MS, is a physician with Duke Children's Primary Care.

-- Dennis Clements, MD, PhD, is the chief of primary care pediatrics at Duke Children's Hospital.

Children's Radiology: CT or MRI?

Tue, 26 Jan 2010 08:52:14 -0500

When a child needs an evaluation involving radiology, parents often ask me, "What is the difference between a CT and a MRI?"

Radiology can be a pandora's box. Donald P. Frush, MD, chief of Duke Radiology’s Division of Pediatric Radiology, tells us what we need to know both as patients, and as physicians trying to explain these procedures to patients.

--Dennis Clements, MD, PhD

Donald P. Frush, MDEither computed tomography (CT or CAT scan) or magnetic resonance imaging (MRI) is useful in the evaluation of children. There are situations in which CT is preferred, and times when MRI should be obtained.

To address these circumstances, it is important to have a basic understanding of how CT and MR imaging work, and the disadvantages of both modalities.

Computed Tomography

CT is a sophisticated x-ray machine that takes detailed pictures of the inside of the body. For a CT examination, the child lays on a bed that will move through the doughnut-shaped gantry containing the x-ray tube, opposite the detectors that capture the x-rays once they pass through the patient.

Often contrast (dye) is needed, which requires an IV. When the IV contrast is administered, your child will have a warm sensation for a minute or so. For many abdomen examinations, oral contrast material (mixed with a liquid such as juice) helps to define the gastrointestinal tract.

The CT examination may take less than one to 20 seconds to perform. Most of the rest of the time is setting up the x-ray machine, and reviewing the pictures. Occasionally, sedation may be necessary. This is usually only required from about one-to-two years of age or older if the child has special needs.

CT can be used in many different situations. It is the best modality we have to look at the lungs such as for complicated infection, trauma, or cancer. Because CT can be performed so quickly, CT scanners are often in the emergency department. In this setting, CT is helpful in evaluation of acute abdominal pain (possible appendicitis or renal stone), or injury to the head, abdomen, and spine. Blood vessel evaluation is excellent with CT (CT angiography).

Disadvantages include radiation. The amount of radiation can vary depending on examination and the size of your child and range to from less than 50 to more than 100 chest x-rays in the amount of radiation. This amount is still low. We are not certain about risks of low level radiation, but if there is a risk, it is extremely small and the information obtained from the examination, even if normal, is far more valuable than the potential risk. It is important, though that the CT examination is adjusted based on the size or age of your child, the region being examined, and the question to be answered.

Magnetic Resonance Imaging

The MR scanner contains a very powerful magnetic and makes pictures from the radiofrequency pulsation (the knocking or buzzing noise) effects on organs and structures inside the body. The child will go into a tunnel. The examination time is longer and ranges from 20 to 60 minutes of actual imaging time, generally 30 to 40 minutes.

Several sequences are performed and the child must be completely still during these sequences. For this reason, children may need to be sedated up to about six years of age.

For some MR examinations, IV contrast material may be necessary. The technologist, as during a CT scan, will sit in the adjoining control room but is always able to see the scanner area. Especially when sedation is used, heart rate, respiratory rate, and blood oxygen is monitored.

Contraindications to MR include internal electronic equipment such as cardiac pacemakers. Other metallic material such as clips for bowel surgery or orthopaedic surgery is generally fine to undergo MRI examination six weeks after the operation.

MRI is superior to CT in evaluation of the brain, spine, and musculoskeletal system (bones, tendons, ligaments, cartilage, and muscles) in the setting of injury, infection, and cancer. MRI is better at evaluation of most sports-related injuries, for example. However, CT is better for evaluation of complex fractures.

MRI is also excellent at looking at intra-abdominal organs, but it does not provide information on lung tissue like CT. MRI can also be used to evaluate the heart and blood vessels. MR tends to give better structural (anatomy) and functional information of the heart than CT but the detail of smaller blood vessels, such as coronary arteries, is better with CT.

Is CT or MR Better?

This will depend on the indication. The benefits are outlined in the above discussion. Understand that sometimes the choice is not straightforward and either would provide useful information. This may be discussed between the health care provider and the patient or parent. In general, if CT and MR provide equal information, MR is preferred due to the amount, even though small, of radiation from CT.

Further information: www.inforad.org and www.imagegently.org

-- Donald P. Frush, MD, chief of Duke Radiology’s Division of Pediatric Radiology

-- Dennis Clements, MD, PhD, is the chief of primary care pediatrics at Duke Children's Hospital.

Gastroesophageal Reflux (GER)

Wed, 16 Dec 2009 10:40:07 -0500

As a practicing pediatrician I have been seeing more patients with symptoms of reflux, and more parents who are concerned about the implications of this condition.

Gastroesophageal reflux (GER) does seem to be more common in children now than in previous generations, but there's also another reason we hear about it more often: pediatricians and parents are more aware of it.

Dr. Tom Lin, a pediatric gastroenterologist at Duke, explains what reflux is and what can be done about it.

-- Dennis Clements, MD, PhD, MPH

Tom K. Lin, MD

Is gastroesophageal reflux (GER) becoming more common or are we becoming better at diagnosing it? The short answer is probably both.

Technological advances in medicine are ever-growing -- what were merely thoughts and fledgling ideas 20 to 30 years ago are today’s reality. Not only are we able to peer into the gastrointestinal tract (called endoscopy) with detail as crisp as high-definition television, but current medicine also allows us to sample tissue and directly treat diseases of the intestinal tract deep within the small bowel in a less invasive manner than previously believed possible without so much as leaving a scar.

Such advances have led to the identification of milder cases of GER and unusual, atypical presentations of this common disorder. Hence, there are a greater number of diagnoses that would have otherwise gone unrecognized.

Signs and Symptoms of GER

Factors outside the influence of medicine have also lead to a heightened awareness resulting in a rise in the diagnosis of GER. Pervasive media coverage and pharmaceutical advertising have elevated the general public’s knowledge and understanding of GER.

It’s good for parents to learn and be able to recognize the early signs of the possible health complications related to GER. However, too often parents are led to believe that infants and children are too young to have this condition, when a more aggressive evaluation and treatment plan may be warranted.

The idea of a child having regurgitation or “heartburn” is disconcerting to parents. They may worry that it will lead to internal intestinal damage, with a worst case scenario resulting in a pre-cancerous lesion referred to as Barrett’s esophagus. This misconception is no fault of the parents, but parental anxiety can lead to unnecessary testing with its own set of potential risks and complications.

It is important for the medical professional to dispel the myths and misconceptions of GER, while also educating parents to recognize “red flag” signs and symptoms including when to seek the evaluation from a health care professional.

How can parents protect their child from unnecessary medical evaluations and tests while feeling confident their child does not have a serious medical condition? The old adage that knowledge is power applies here. Knowing the facts about GER and being able to recognize warning signs is the key to keeping your child happy and healthy.

Fact one is that most children do not need to undergo formal, definitive testing to be diagnosed with GER. Today, it is common and accepted medical practice to presumptively treat infants and children for possible GER if symptoms are compatible in the absence of signs/symptoms suggestive of a more severe, complicating disease or of an alternative diagnosis.

Performance of diagnostic studies are most often reserved for cases of persistent or unresponsive symptoms despite the use of anti-reflux medicines, symptom recurrence following the discontinuation of the medicines, or suspicion for another disease process.

To help demystify GER, it is important to address the facts about GER. GER is a normal physiologic occurrence in infants (particularly those born prematurely), children and adults. It is a common occurrence during infancy with approximately 95 percent of infants having “outgrown” it by 12 months of age.

Most GER occurs when the lower muscle controlling the opening between the esophagus and stomach opens intermittently, referred to as transient lower esophageal sphincter relaxation or TLESR for short, which occurs at a greater frequency in infants than it does in children.

When this occurs, it allows an open pathway for stomach contents, usually food and formula, to regurgitate through the mouth and at times through an infant’s nose because of the normal anatomical connection between the oral and nasopharynx (the throat cavity and nasal passages).

For older children, dietary factors may play a role in the development of symptomatic GER. Being overweight or obese can also contribute to the severity of a child’s GER, with weight loss being just one of a number of conservative measures that can help manage a child’s symptoms.

Treatments for GER

Often conservative measures may be all that is needed to help alleviate the symptoms of GER in infant and children. This includes:

Upright positioning after feedings
Avoidance of overfeeding
Thickened formula feedings
Formula change (possible milk protein intolerance)

Additional factors for older children:

Food eliminations (e.g., caffeine)
Weight loss/reduction (in children who are overweight or obese)
Avoidance of late-night eating

Specific abnormal symptoms or their persistent may be a sign of a more serious underlying health condition. The following are what parents should watch for and discuss further with their child’s health care provider:

Rectal bleeding
Persistent diarrhea
Vomiting blood
Poor growth or weight gain
Weight loss
Persistent poor feeding and oral intake
Prolonged period of feeding refusal, difficulty in swallowing or pain with swallowing
No breathing (apnea) or difficulty in breathing
Excessive or forceful vomiting in early infancy
Unusual changes in behavior, energy level, alertness
Chronic cough or recurrent pneumonia
Excessive, prolonged periods of crying
Chronic vomiting or regurgitation

Today, physicians are more equipped than ever to diagnose, manage and treat uncomplicated and complicated GER in children. Despite these current capabilities, we still do not possess all of the answers. Until that time comes, there needs to be continued efforts to maintain the delicate balance between over and under diagnosing GER.

-- Tom K. Lin, MD, is a gastroenterologist in the Duke Department of Pediatrics.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.

Do Vaccines Explain the Surge in Autism?

Tue, 08 Dec 2009 00:00:00 -0500

During office visits when its time for an immunization shot, parents frequently ask me whether vaccines cause autism.

It is a highly charged discussion, involving great emotion for many parents.

Jeffrey P. Baker, MD, PhD, director of Duke's History of Medicine Program and an associate clinical professor of pediatrics, discusses the evidence.

--Dennis Clements, MD, PhD

Jeffrey Baker, MD, PhD

The annals of medicine are full of stories about scientists who stubbornly cling to a “great idea” despite evidence to the contrary. The history of autism provides a classic example.

From the 1940s through at least the 1960s, autism was widely viewed as a psychiatric condition, typically attributed to highly educated mothers lacking the capacity to provide warmth or affection for their infants. The so-called “refrigerator mother” theory turned out to be based on little reality beyond the imaginations of its originators. It survived as long as it did because it promised (falsely, as it turned out) the possibility of cure through psychotherapy.

Today, another hypothesis has captured the imagination of many parents in the autism community. It is the conviction that vaccines are responsible for the dramatic rise in the disorder’s visibility over the past 20 years. Despite the failure of 10 years of scientific study to provide support, this belief remains powerful among parents’ groups and the internet. Why?

Although the cause of autism remains unknown, the vast majority of researchers believe that genetics play a central role. Siblings of children with autism have a 2 to 7 percent chance of the disorder, at least 50 times the rate of the general population. The concordance rate is higher for fraternal (5-10 percent) and highest of all for identical twins (60-90 percent).

Other studies have found a higher family risk of problems in communication, social relations, and anxiety, suggesting that a broader form of the disorder may be inherited that presents as classical autism only in its most severe form. Collectively, this research underlines that genetics likely represents the most critical factor leading to autism. The question is whether an environmental trigger may play a secondary role in genetically-predisposed children.

If autism is largely genetic, why has it seemingly become “epidemic” in recent years? There is no doubt that the disorder is diagnosed far more commonly (by a factor of at least 10) today than was the case 20 years ago. It is equally clear that its definition has been expanded tremendously, encompassing both higher functioning children (such as those with Asperger’s syndrome) and others who one would have been diagnosed with mental retardation.

At the same time, there has been a great push for physicians and schools to identify autism at earlier ages and with milder presentations. Many experts in the field believe that the rise of autism reflects the success of early intervention and school-based programs to heighten awareness of the disorder. Still, the possible role of an environmental exposure cannot be eliminated. And of the hundreds of agents to which pregnant women or infants are exposed, none are quite as visible as vaccines.

Activists in the last 10 years have promoted two particular theories linking immunizations and autism. One concerns the MMR vaccine against measles, mumps, and rubella. It became controversial in Great Britain following the publication in 1998 of a case report by Dr. Andrew Wakefield describing several children who developed signs of diarrhea and autistic regression following this vaccine. MMR immunization rates fell in the U.K., and outbreaks of measles followed.

The other hypothesis, originating in the U.S., concerns the preservative thimerosal, which was removed from infant vaccines between 1999 and 2001 as part of broader public health efforts to reduce infant exposure to environmental mercury.

These two theories are not easily reconciled. Parents blaming the MMR typically described infants who were normal prior to this particular vaccine; thimerosal/autism narratives told of infants who developed autism after any vaccine combination.

British parents often noted the correlation between the rise of autism and the use of the MMR, introduced in 1987 and the focus of national immunization drives in the early 1990s. The fact that MMR had been used widely in the U.S. since 1971, long before talk of an autism epidemic, was generally ignored.

Both hypotheses have been subjected an extraordinary amount of study in large populations. Comprehensive reviews by expert panels, most notably the U.S. Institute of Medicine, have concluded that the evidence simply does not support either vaccine/autism hypothesis.

In Britain, 10 of the 12 co-authors of Dr. Wakefield’s 1998 report have disavowed its conclusion regarding MMR. Wakefield himself is under investigation for serious professional misconduct for not having revealed his relationship to anti-MMR litigation groups when submitting his article to The Lancet. In the U.S., data published in 2008 from the state of California showed that the elimination of thimerosal from all routine infant vaccines in 2001 had no effect slowing down the rise of autism, despite many predictions to the contrary.

Among mainstream health researchers, the MMR and thimerosal autism hypotheses are in tatters. Yet like the hydra of ancient mythology that grew two heads whenever one was severed, the belief in a vaccine/autism connection continues to survive by taking new forms. Some activists are focusing on other vaccine additives, such as the aluminum salts used to boost the immune response.

Others are arguing that giving too many vaccines somehow overwhelms the child’s immune system. This was the question at the heart of the Federal Vaccine Court’s decision to award damages to Hannah Poling, a girl with a mitochondrial disease (a very uncommon disorder disrupting her ability to process nutrients) who regressed developmentally and developed signs of autism after receiving several vaccines at age 19 months.

Cases such as Hannah’s are tragic, but raise more questions than they answer. There are in fact rare children with silent metabolic disorders who may develop normally until suddenly regressing after the stress of a childhood infection. Whether vaccines are a risk has not been proven. Certainly, the infections that vaccines prevent do constitute a danger for these children. Even if we could identify at-risk children, it is far from clear that holding or splitting vaccines would do them a service.

Before accepting the “multiple vaccine” hypothesis, it is worth remembering that more vaccines does not mean more stress on the immune system. The 14 vaccines given to young children expose them to a total of about 150 immunological units, or antigens. The MMR, for all the ballyhoo, contains only 24. In contrast, the old smallpox vaccine included 200 proteins, and the whole cell pertussis vaccine used before the 1990s contained 3,000.

In a nutshell, while more vaccines are being given to infants, these vaccines are far more targeted and purified than was the case twenty years ago. This is why giving vaccines separately makes so little sense to the scientific community. Splitting vaccines certainly makes the schedule even more complicated, and will likely lead to lower immunization rates. When these rates fall below a certain threshold in a community, outbreaks become possible. This has already happened with respect to whooping cough and measles in various locations in the United States.

It will always be possible to think of new mechanisms linking vaccines and autism as others are disproven. But after 10 years of extensive research on vaccines, it is time to entertain other ideas regarding environmental exposures. Vaccine opponents consistently disparage the positive benefits of vaccines, which the vast majority of physicians and public health leaders regard as one of our most powerful tools to protect the health of our children. Deferring or declining vaccines has consequences for our neighbors’ children as well as our own. It is important to learn about the diseases they prevent prior to questioning their benefits.

-- Jeffrey P. Baker, MD, PhD, is director of Duke's History of Medicine Program and an associate clinical professor of pediatrics.

-- Dennis Clements, MD, PhD, is the chief of primary care pediatrics at Duke Children's Hospital.

Hypertension in Children

Tue, 01 Dec 2009 00:00:00 -0500

Increasingly parents ask me if their child has hypertension (elevated blood pressure). This question often arises after the nurse or physician repeats the blood pressure during a regular checkup.

In fact, we are seeing more cases of hypertension in children and young adults, mainly as a result of obesity.

Michael J. Campbell, MD, a pediatric cardiologist at Duke, gives us some tips on what hypertension is and how to prevent it.

-- Dennis Clements MD, PhD, MPH

Michael J. Campbell, MD

What is hypertension?

Hypertension is defined as an elevation in blood pressure above what would be normal for a person’s age, gender, and height.

Blood pressure is controlled by the arteries that deliver oxygenated blood from the heart to the tissues and organs of the body. Arteries have a circular layer of muscle within the wall of the vessel that can relax and constrict to control the pressure within the arterial system.

Hypertension occurs when these vessels maintain the pressure within the arteries at an abnormally high level.

How common is hypertension?

The incidence of hypertension increases with age. Hypertension is a common diagnosis in the adult and elderly population.

Historically, hypertension in children has been rare except for in children with certain heart, kidney, or neurological problems. The incidence of hypertension in children and young adults, however, is increasing. This is in large part due to an increasing prevalence of obesity in children.

Why is hypertension harmful?

Prolonged exposure to elevated blood pressure can damage organs. Nearly all organs of the body can be affected by prolonged exposure to elevated blood pressure.

Hypertension can cause the heart to work harder as a result of having to pump blood against higher pressure. This can lead to thickness of the heart muscle and heart failure. Coronary arteries can be damaged by hypertension and people with hypertension are at increased risk of myocardial infarctions, or heart attacks.

Elevated blood pressures can damage blood vessels within the brain, which places people at increased risk of strokes. The arteries within the kidney can be damaged by hypertension, leading to subsequent kidney failure. Hypertension can also damage small arteries within the eye, leading to vision loss.

How is hypertension diagnosed?

Hypertension is diagnosed by measuring blood pressure with a sphygmomanometer. This is a common instrument found in many physician offices. When blood pressure is measured a systolic and a diastolic blood pressure are recorded.

The systolic blood pressure is a measure of the blood pressure in systole, the phase of the heart cycle when the heart is contracting.

The diastolic blood pressure is a measure of the blood pressure in diastole, when the heart is relaxing. These numbers are represented as systolic/diastolic. Hypertension is diagnosed when these numbers are above normal for a person’s age and size.

In pediatric patients, normal blood pressures increase with increasing age.

What if my child has an elevated blood pressure?

A person must have an elevated blood pressure on three separate occasions to be diagnosed with hypertension.

One of the most common reasons for someone to have a high blood pressure at the physician’s office is “white coat hypertension.” If one is nervous or anxious at the time of the visit, then this can elevate blood pressure above normal levels. In these cases it can be helpful to obtain a blood pressure outside of a physician’s office.

If a person is diagnosed with hypertension, then the next step is to evaluate for causes of hypertension. A narrowing of the aorta must be ruled out by measuring blood pressures in both arms and both legs. Kidney disease is a cause of high blood pressure.

Laboratory evaluation including blood tests, urinalysis, and a renal ultrasound can evaluate for causes of hypertension.

Less commonly, diseases of the nervous system and adrenal system can cause elevated blood pressure and should be considered. Certain medications can also cause hypertension. People with obesity are more likely to have hypertension.

In a large number of cases, an underlying cause for hypertension cannot be found. This is described as essential hypertension. Essential hypertension often runs in families.

What is the treatment for hypertension?

If an underlying cause for hypertension is identified, then steps should be taken to evaluate and treat the underlying cause. Patients with underlying diseases often need medications to control their blood pressure; however, the underlying cause must be addressed simultaneously.

In the case of essential hypertension there is no underlying cause of hypertension. In milder cases of essential hypertension, lifestyle modifications such as improved diet and exercise as well as weight loss can result in a return of blood pressures to a normal level. In more severe forms of essential hypertension and in patients who do not respond to lifestyle modifications, medications can be used to lower the blood pressure to normal levels.

What can I do for my child?

Screening blood pressure measurements are a part of all well child check-ups. Parents should take their children for their annual check-ups to ensure proper screening for hypertension.

Given the association of hypertension and obesity, parents should encourage children to develop healthy lifestyle habits, such as eating a well-balanced diet and getting plenty of exercise.

-- Michael J. Campbell, MD, is a pediatric cardiologist at Duke.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.

Community-Acquired Pneumonia

Fri, 30 Oct 2009 13:40:00 -0400

After a week of cold symptoms in their child, parents are frequently come to my office concerned that the child might have pneumonia. Most often in these cases, children do not have pneumonia -- but occasionally they do.

Dr. Heather McLean, a pediatric hospitalist at Duke, tells us how you might be able to tell the difference between a cold and pneumonia.

-- Dennis Clements, MD, PhD, MPH

What Is Pneumonia?

Heather S. McLeanPneumonia is an infection of the lungs that may be caused by a variety of microorganisms (germs) such as viruses and bacteria. Infrequently, these infections can start as an upper respiratory illness (cold) and then develop into pneumonia a few days later.

Pneumonia is a common and possibly very serious infection that occurs in children throughout the world. In children less than five years of age, the annual incidence of pneumonia in our country is between 34 to 40 cases per 1,000. The good news is that most children are easily treated by their health care provider and can remain at home.

Some common signs and symptoms of pneumonia may include, fever, cough, chest pain, fast breathing, fatigue, vomiting, abdominal pain, or a poor appetite. You should call your child’s doctor or health care provider if you suspect your child has any of the signs and symptoms of pneumonia.

Diagnosis and Treatment

Your child’s health care provider can diagnose your child with pneumonia based on symptoms and physical examination usually. Additional tests such as a chest x-ray or blood tests are sometimes performed to help make the diagnosis.

Most of the time, your child may be treated at home with oral antibiotics. Antibiotics are given to treat bacterial causes of pneumonia. The choice of antibiotic will depend on many factors such as the age of your child, her symptoms, medical health history, or allergies to medicines. If a virus is determined to be the cause of the pneumonia, then antibiotics are generally not used.

If your child has been given an antibiotic, you should give the medicine on schedule for as long as directed. You should encourage your child to drink fluids, especially if she has a fever. Do not force a child to eat but continue to encourage eating healthy foods if she feels up to it.

Cough and cold medicines will not help your child recover and are not recommended. Treating your child’s fever with ibuprofen (Motrin or Advil) or acetaminophen (Tylenol) may help them feel better.

Children with pneumonia occasionally require hospitalization if they:

Require supplemental oxygen therapy
Are vomiting and can’t keep their medicine down or become dehydrated
Have a severe case with rapid or labored breathing or sepsis (bloodstream infection)
Have other medical problems including those that affect the immune system
Are young, such as babies under three months of age
Have gotten worse despite treatment at home with oral antibiotics
Have recurrent (repeated) episodes of pneumonia

Your child will be discharged home to complete the antibiotics once she has improved and no longer requires more intensive therapies such as oxygen and intravenous fluids.

Complications

Rarely children with pneumonia develop a “complex pneumonia” or pneumonia with an effusion with some types of infection. An effusion is a fluid collection that develops between the lung and chest wall.

If this fluid turns into an empyema (pus), then your child may require an operation to remove the fluid and place a chest tube, so she can get better in addition to the antibiotics already being given.

Prevention

Most causes of pneumonia are not contagious -- although the upper respiratory viruses (cold viruses) that lead to them are.

Here are some tips to prevent the spread of infection to other people:

Wash your (and your child’s) hands frequently especially after coughing or sneezing.
Avoid sharing cups and eating utensils.
Avoid exposing your child to cigarette smoke, as tobacco can damage your child’s lung and ability to ward off infection.
Give your child immunizations (shots) that prevent common causes of pneumonia such as Hib (Haemophilus influenzae type b), Prevnar (Streptococcus pneumoniae), and the yearly influenza vaccine.

-- Heather S. McLean, MD, is a pediatric hospitalist in Duke's Department of Pediatrics.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.

Infant Pulmonary Function Testing

Tue, 29 Sep 2009 10:35:30 -0400

It is overwhelming to have your child referred to a pediatric pulmonologist for breathing difficulties.

It is especially stressful when it is your infant, unable to describe what is wrong with his or her breathing, and unable to undergo many of the standard tests we do in our clinic to help diagnose the problem.

At Duke, we are able to provide physicians and families with state-of-the-art equipment to help us understand what is happening with an infant or small child’s lungs. This study is called Infant Pulmonary Function Testing and is only available at certain hospitals and facilities across the country.

Stacey Peterson-Carmichael, MD, of Duke's Divisions of Pediatric Critical Care and Pediatric Pulmonary and Sleep Medicine explains what we need to know about this test.

-- Dennis Clements, MD, PhD, MPH

What Is Infant Pulmonary Function Testing (IPFT)?

Stacey L. Peterson-Carmichael, MD

Infant pulmonary function testing (IPFT) is a reliable way to measure your child’s breathing.
Pulmonary function tests measure how well your child’s lungs are working. The information from pulmonary function testing is important in diagnosing lung problems, and testing the effect of medications your child may be taking.
Young children and infants are unable to follow instructions for adult-type pulmonary function testing, so we perform infant pulmonary function testing (IPFT) with conscious sedation (described below).
IPFT’s are safe, and they provide important information to pediatric pulmonologists deciding on a specific therapy for your child. IPFT’s are routinely used in conditions such as: cystic fibrosis, asthma, wheezing, pulmonary hypoplasia, and airway anomalies.
The entire test takes about one-and-a-half hours, but it may take longer for recovery from sedation.

Does My Child Need Infant Lung Function Testing?

This is a decision for your pediatric pulmonologist. Your pediatrician may refer your child to our pulmonary team with this particular test in mind or for consultation regarding your child’s respiratory illness.
If your pulmonologist at Duke decides that it would be important to know if there is “air trapping,” “airflow obstruction,” or a response to various medications such as bronchodilators (e.g., Albuterol or Xopenex), then you will be referred to our IPFT lab for further evaluation.
Various conditions such as cystic fibrosis, chronic lung disease of infancy, and others qualify for routine pulmonary screening including IPFT studies. This allows us to follow your child’s lung function and development as he or she grows.

How Is An IPFT Study Performed?

The study tries to provide the same data regarding breathing and airways that we are able to obtain from older children and adults in the pulmonary clinic.
There will be at least two people performing the study and monitoring your child prior to, during and after the testing.
Your child will be given a gentle sedative (chloral hydrate) by mouth to make your child drowsy. This takes effect in anywhere from 20-45 minutes. You may stay with your child as he or she is falling asleep.
Chloral hydrate is a sedation medication given by mouth so that your child will sleep and allow breathing maneuvers to gather IPFT information. Your child will not be deeply sedated, but will not remember the IPFT study afterwards. A physician will give your child the medication and ensure close monitoring throughout the testing period.
After falling asleep, your child will be placed on his or her back and the lung function measures will then take place.
A mask will be placed over your child’s nose and mouth (while he or she is breathing comfortably) and will supply oxygen as needed throughout the study.
The mask is connected to the IPFT computer which will measure airflow. A vest will be wrapped around your child’s chest and abdomen. This will inflate to give “a hug” that will allow your child to blow all of the air out of the lungs.
Your child will be given a breathing treatment, albuterol, through the mask and the test will be repeated to look for lung function improvement.
Your child will wake up after the study and stay in the IPFT lab until he or she is able to drink and eat without difficulty.

Early Detection Is Key

Detecting early lung disease in infants and young children with various illnesses -- such as cystic fibrosis (CF) -- may lead to earlier intervention and improved prognosis.

Infant lung function testing may be helpful in characterizing the progression of early lung disease.

With the recent implementation of newborn screening for CF in North Carolina, identifying early CF lung disease is critical for developing future therapies as well as helping the clinicians who care for the young patient with CF.

In addition to providing this clinical testing, Duke will soon launch several research studies using IPFT’s to help us better understand chronic lung disease of infancy, congenital diaphragmatic hernia and lung injury in various other disease states.

-- Stacey Peterson-Carmichael, MD, is a physician in Duke's Divisions of Pediatric Critical Care and Pediatric Pulmonary and Sleep Medicine, and director of the Infant Lung Function Laboratory at Duke Children's Hospital.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.

Preventing and Treating Group B Streptococcus

Wed, 26 Aug 2009 13:19:50 -0400

When interviewing parents who are about to have a baby I am frequently asked "What is Group B strep infection? My obstetrician said I would be tested for it and possibly treated."

For the last 10 years it has become customary to test -- and treat mothers who are positive -- for Group B infection, which can be a serious infection in newborns if not treated.

Dr. Robert Lenfestey, an expert in neonatology, describes this condition and its treatment.

-- Dennis Clements, MD, PhD, MPH

Robert W. Lenfestey, MDBefore women and babies were routinely tested and treated for Group B streptococcus (GBS) infection, as many as 50 percent of babies with GBS died from the infection. Since that time deaths from GBS infection have fallen dramatically.

Pregnant women are usually tested for GBS by their obstetrician between 35 and 37 weeks of pregnancy. To test for GBS, a urine test and a swab of the vagina and rectum are sent to see if GBS is present.

If GBS is found, then antibiotics will be given at the time of labor. Additionally, a pregnant woman who previously gave birth to an infant with GBS infection will also receive antibiotics during pregnancy.

Occasionally, pregnant women in labor do not know if they have GBS. This may be because they are in premature labor before 35-37 weeks of pregnancy and have not been tested yet, or because they did not receive the test for GBS during their pregnancy. In this case, a woman will be given antibiotics during labor if she is delivering at less than 37 weeks of pregnancy, or if she has a fever more than 100.4^ºF, or her water has been broken for more than 18 hours.

Penicillin or ampicillin are the most effective antibiotics against Group B strep. To be considered effective, the antibiotic must be given more than four hours before delivery.

In rare cases, women are allergic to penicillin and ampicillin. In these cases clindamycin is given; however, clindamycin is not as effective as penicillin or ampicillin at preventing GBS infection in babies.

Diagnosing GBS in Babies

Once the baby is born, he or she will be evaluated by the doctor to see if the baby has any sign of an infection.

If the mother has been diagnosed with an infection of the uterus or if the baby has any signs of infection then the baby will have a blood test for infection sent and will be started on antibiotics. In addition to the blood test, a spinal tap to test the fluid around the baby's brain and spinal cord may be done.

If the baby was born at less than 35 weeks of pregnancy or if the antibiotics were given less than four hours before delivery or if another antibiotic besides penicillin or ampicillin was used, then the baby is still at risk for GBS infection and will have a blood test for infection performed.

However, the baby does not need to be started on antibiotics or have additional tests performed unless the blood test or the baby shows signs of infection.

If the baby is born after 35 weeks of pregnancy and the mother received penicillin or ampicillin greater than four hours before delivery, then no testing or antibiotic treatment are needed for the baby.

GBS Take Home Points

The mother should get antibiotics at delivery if:

Tests for GBS are positive in the mother or
The mother has a risk factor or
The mother had a baby with GBS infection previously

The baby requires no treatment if:

The mother does not have GBS or
The mother was treated with penicillin for more than four hours before delivery

The baby should get blood tests for infection if:

The mother is diagnosed with an infection called chorioamnionitis or
The mother has GBS and was not treated with Penicillin for more than four hours before delivery

The baby should get blood tests for infection and antibiotics if:

The baby has signs of infection on examination by the doctor or
Blood tests indicate that the baby has an infection

-- Robert Lenfestey, MD, is a Duke neonatologist with a research focus in infectious disease and quality improvement.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.

When to See a Pediatric Neurologist

Fri, 31 Jul 2009 11:41:05 -0400

The nervous system of a child develops rapidly during childhood. Because of this, it is valuable to have some guidelines about when neurologic symptoms suggest a visit with neurologist would be beneficial.

Persistent headaches or developmental delay issues are often the symptoms that indicate a referral may be desirable.

Dr. Mohamad A. Mikati, chief of Duke Children's Division of Neurology, describes from the neurologist's point of view when a referral would be a good idea.

-- Dennis Clements MD, PhD, MPH

Mohamad A. Mikati, MD

A pediatric neurologist specializes in treating children who have problems of the nervous system, including the brain, spinal cord, and peripheral nerves.

If your child experiences the symptoms below, you should see your pediatrician for an initial consultation. If warranted, your pediatrician can then refer you to a neurologist for more specialized attention.

Headaches

Persistent headaches that do not have a clear-cut explanation or that have some "red flags" may warrant consultation with a child neurologist. However, they do not necessarily always indicate that there is something serious.

Red flag headache warning signs include:

Headache that wakes the child up at night or is associated with vomiting
Sudden, very severe headaches, or recurrent headaches that are associated with change in personality and behavior
Neurological signs associated with the headache including blurring of vision or numbness, dizziness, and problems with walking or weakness

Sudden Changes in Consciousness

Symptoms such as obtundation (unable to arouse) and lethargy require an evaluation by a neurologist, particularly if they are associated with fever or sudden loss of consciousness.

Other symptoms such as dizziness and vertigo (which is not readily explained) also warrant additional consultation.

Episodes of Focal Weakness

Focal weakness on one side or generalized weakness (on both sides) can be secondary to neurological problems of the brain, spinal cord, or peripheral nerves, and, at times, muscles. These require neurologic consultation and testing.

Seizures

Seizures are episodes of involuntary movements or sensations with or without loss of consciousness that result from abnormal electrical surges in the brain. They can take the form of stiffening or shaking of all or part of the body.

They can also manifest as staring eye flutter or automatic movements with partial change of consciousness.

Febrile seizures (seizures with fever that occur between the age of five months and five years) that are short and do not recur are usually handled by the pediatrician.

However, if they occur only on one side of the body or are prolonged or recur, then an evaluation by a neurologist is usually warranted. Seizures that occur without fever will require an evaluation by a neurologist.

Involuntary Movements, Loss of Consciousness, or Abnormal Sensations

These may be due to epileptic seizures or to other disorders such as habit tics (like eye blinking or twitching). They can also be symptoms of localized abnormalities in the nervous system.

A neurologist should evaluate your child if he or she exhibits these symptoms. At times, special therapies may be needed.

Development Problems

If the child isn't acquiring the usual milestones including sitting, walking, talking, and socialization, or has abnormalities in these functions (e.g. unstable to walk or abnormal articulation comprehension or reading), then this requires an evaluation by a neurologist.

In addition, if a child acquires the milestones and starts to lose them, you should see a neurologist for evaluation. For example, a child who has difficulty going up the stairs even though that it was possible for him before should be evaluated.

School Difficulties

School difficulties that cannot be addressed by the teachers -- such as difficulties with attention, reading or specific subjects -- may also need a referral to a neurologist.

What to Do

In general, your child see his or her primary care physician first if you see any of these symptoms.

Your child's primary care doctor may be able to diagnose the easier issues and refer on the neurologist the more serious issues.

For more information pediatric neurology services at Duke, visit us at dukechildrens.org.

-- Mohamad A. Mikati, MD, is chief of Duke Children's Division of Neurology.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.

Transition Health Care

Tue, 30 Jun 2009 09:58:11 -0400

Parents can find themselves in an uncomfortable position when their child who has had a chronic disease reaches late adolescence and young adulthood, or when their child may be diagnosed with an "adult" disease.

The doctor that has served their child for so long may no longer feel comfortable managing these medical conditions. At the same time, the child may not readily be accepted into the adult medical world because his or her chronic disease is less common in adults. That's where transitional health care providers can be helpful.

Jane Trinh, MD, of Duke Med/Peds Primary Care describes transitional health care and answers common questions about it.

-- Dennis Clements MD, PhD, MPH

Jane V. Trinh, MD

What do you mean my child is too old for the pediatrician?

More parents are learning that their children have “aged out” of the pediatric health care system. Their adolescent or young adult has developed “adult” problems and is “too old” to be followed by their pediatrician. However, for years they have seen the pediatric subspecialists for the management of the specific chronic disease.

The transition to finding health care that is adult-oriented, but also knowledgeable about childhood illnesses, has become a challenge for many families.

What is transition health care?

Transition health care is the purposeful movement of adolescents and young adults with chronic physical and medical conditions from child-centered to adult-oriented health care.

One goal of Healthy People 2010 is to provide uninterrupted services to young adults with chronic conditions as they transition from pediatric to adult health care. Healthy People 2010 is a set of health objectives designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats, and is managed by the U.S. Department of Health and Human Services.

Why is there a need for transition health care now? Does it affect that many children?

Almost 20 percent of children have a chronic physical, emotional, behavioral, or developmental condition. Examples include asthma, diabetes, congenital heart disease, cystic fibrosis, spina bifida, cerebral palsy, and more.

Nearly half a million children with special care needs become adults every year.
Amazingly, over the past three decades, the life expectancy of children with chronic illnesses has increased dramatically, with over 90 percent of such children surviving beyond their 20th birthday. For example, less than one-third of patients with spina bifida survived beyond age 20 in the 1970s and more than 80 percent do now.

Why can’t they continue to see the pediatric subspecialist?

All adults with special health care needs deserve an adult-focused primary care physician. This is to ensure that just as children receive optimal primary care in a medical practice experienced in the care of children, adults too benefit from receiving care from physicians who are trained and experienced in adult medicine. The most successful transition requires communication and collaboration among primary care specialists, subspecialists, young adult patients, and their families.

Why can’t they just start seeing an adult subspecialist?

Adolescents and young adults with chronic conditions share many of the same health issues and concerns as their peers without chronic conditions.

Thus, transition health care providers should be prepared to address common concerns of young people, including growth and development, sexuality, mood and other mental health disorders, substance use, and other health promoting and damaging behaviors.

Adults, including those with childhood-acquired chronic conditions, should receive adult-oriented primary health care from appropriately trained and certified providers, in adult health care settings. The primary care provider, in partnership with the patient and family, will also take responsibility for coordinating primary health care, specialty health care, and ancillary health services.

When should a family start to transition a child’s medical care?

Transitioning is a process -- not an event -- and should start early, often in the preteen years. A well-timed transition from child-oriented to adult-oriented health care allows young people to optimize their ability to assume adult roles and functioning.

For many young people with special health care needs, this will mean a transfer from a child to an adult health care professional; for others, it will involve an ongoing relationship with the same provider but with a reorientation of clinical interactions to mirror the young person’s increasing maturity and emerging adulthood.

What can you do to start the transition process for your child?

Assess your teen’s knowledge of their disability -- fill in gaps of understanding.
Teach your teen to call the doctor if they experience a danger sign and to tell you about any danger sign.
Teach your teen to take their medication and tell you how much is taken.
Discuss the long-term course of the disability with your teen and what they might expect in the future.
Teach your teen to go to doctor visits without you. Encourage your teen to communicate directly with the doctor.
Teach your teen to take his temperature and manage specific self-care.
Help your teen find adult health care providers.
Discuss how to pay for health care -- and help your young adult find insurance.

(Adapted from Washington State Adolescent HealthTransition Project presentation for young adults and parents, accessed 3/1/2009)

Who provides transitional care medicine at Duke?

We have combined internal medicine and pediatrics (Med/Peds) trained physicians at Duke who are certified to provide adult-oriented primary health care to adults with childhood-acquired chronic conditions in adult health care settings.

Get more information about our adolescent health care services.

-- Jane Trinh, MD, is a physician with Duke Med/Peds Primary Care.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.

When Should Your Child See a Cardiologist?

Mon, 01 Jun 2009 00:00:00 -0400

When I am performing an annual check-up, I frequently encounter a child with a heart murmur.

Most of the time I can reassure the parents that it is normal. But sometimes I can’t –- and sometimes I cannot be sure myself.

Fortunately, we can send our patients to pediatric cardiologists who can do further testing to verify that everything is normal -- or clarify what any abnormalities might be.

Dr. Sara K. Pasquali, a pediatric cardiologist at Duke, tells us what we need to be aware of when visiting a pediatric cardiologist and whether symptoms should be of concern.

-- Dennis Clements MD, PhD, MPH

Sara K. Pasquali, MD

Your pediatrician or family doctor may refer your child to see a pediatric cardiologist for many different reasons. Pediatric cardiologists have special training in diagnosing and treating congenital heart defects and other problems affecting the heart in infants, children, and adolescents.

Pediatric cardiologists at Duke see over 10,000 patients each year in their clinic at the Duke Children’s Hospital & Health Center and other clinics in North Carolina.

Some of these reasons your child should see a cardiologist include:

Heart murmurs: Most children will have a heart murmur at some point while they are growing up, and most often this represents the normal sound blood makes as it is flowing through the growing and developing heart and blood vessels. These normal or “innocent” heart murmurs often get louder at times when your child is sick or has a fever.

Other types of heart murmurs may represent a defect in the heart such as a hole between chambers, leaking valve, or other more severe problem. These heart problems may be associated with symptoms such as problems with feeding and growing, breathing difficulties, reduced energy or activity level, or fainting.

If your child has a heart murmur associated with any of these symptoms, or an abnormal EKG (electrocardiogram), they should see a pediatric cardiologist.

Fainting: Most often, fainting episodes are not related to the heart -- instead, fainting episodes are usually due to being dehydrated or standing for long periods of time, especially in the heat.

However, if your child has a fainting episode that occurs during exercise, is associated with heart palpitations or feeling of a fast heart beat, or has fainting spells that occur often despite drinking plenty of fluids, see a pediatric cardiologist.

The cardiologist will evaluate for any problems with the heart or heart rhythm, and for problems with the body’s regulation of blood pressure.

Chest pain: Usually chest pain is not related to the heart; instead it is caused by breathing difficulties or asthma, acid reflux, or by costochondritis -- inflammation of the cartilage next to a rib.

Visit a pediatric cardiologist if your child has chest pain that occurs with exercise or is associated with fainting or heart palpitations.

Palpitations: Heart palpitations, or the feeling of a fast or skipped heart beat, that are associated with dizziness, weakness, nausea, turning pale in color, or fainting may indicate an abnormal heart rhythm and your child should be referred to a cardiologist for evaluation.

High blood pressure: In infants and children, high blood pressure (when compared to other children of the same age and size) is most often due to problems with the kidneys.

In older children and teenagers, obesity or a strong family history of high blood pressure may also play a role.

A pediatric cardiologist will evaluate for any heart defects that may cause high blood pressure. In addition, if your child’s blood pressure is persistently high and does not respond to changes in diet, exercise, or weight loss (if they are overweight), a pediatric cardiologist may prescribe a blood pressure lowering medication.

They may also perform an ultrasound of the heart (echocardiogram) to see if the high blood pressure has resulted in any thickening of the heart muscle.

High cholesterol: If your child is found to have high cholesterol levels or if there is a history of very high cholesterol levels that runs in your family, he or she may be referred to see a pediatric cardiologist.

The cardiologist will work with your pediatrician or family doctor to follow these levels and may prescribe a cholesterol lowering medication if needed.

Medical history: If your child has a history of other medical problems he or she may be referred to see a pediatric cardiologist.

These include certain types of genetic defects, syndromes, or birth defects. Children with these problems are at higher risk of being born with a congenital heart defect.

Family history: Your child may be referred to see a pediatric cardiologist for evaluation if there is a history in the family of congenital heart defects, sudden unexplained deaths, or heart attacks that have occurred at a young age in other family members.

-- Sara K. Pasquali, MD, is a pediatric cardiologist at Duke.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.

Bacterial Infection or Virus?

Tue, 31 Mar 2009 09:37:45 -0400

In the office I am frequently asked how I can tell whether a child has a serious bacterial infection or “just a virus.” It is not an easy question to answer since both may manifest fever and irritability.

Dr. Betty Staples, one of our primary care physicians and director of Duke's Pediatric Residency Program gives us some advice on how to tell the difference between these two types of infection.

-- Dennis Clements MD, PhD, MPH

Betty B. Staples, MD

Every day, parents bring their children to the pediatrician for help in determining whether their sick child has "just a cold" or something more.

Children's colds costs us 22 million missed school days and 20 million parental missed days of work every year. In most cases, these are the "just a cold" variety of virus. However, we also know that other, less common infections can develop in our children, and these need evaluation by the pediatrician to determine if antibiotics are required.

Viral Infections

Common viral infections such as an upper respiratory infection (URIs) can typically be detected by runny nose, cough, low-grade fever, sore throat, and difficulty sleeping. No antibiotics or anti-viral medications can hasten recovery from the cold.

Of note, when compared to adults, URIs in children may last longer (up to 14 days) and occur more frequently (average six to eight per year).

Influenza is a viral illness that can cause many of the same symptoms but also is frequently accompanied by intense body aches and higher fever. Unlike URIs, the flu's duration -- if detected within the first 48 hours of illness -- can be shortened by antiviral medication.

A dose of flu vaccine (or two doses a month apart in the young child receiving flu vaccine for the first time) given at the start of each "flu season" can help to prevent influenza infections.

Bacterial Infections

In some cases we become more concerned that the infection may be caused by a bacterial infection. Bacterial infections may be the result of "secondary infection" (meaning that the virus initiated the process but a bacteria followed) when the:

Symptoms persist longer than the expected 10-14 days a virus tends to last
Fever is higher than one might typically expect from a virus
Fever gets worse a few days into the illness rather than improving

Sinusitis, ear infections, and pneumonias are common examples of secondary infections. For example, a runny nose that persists beyond 10-14 days may be a sinus infection that would be best treated with an antibiotic. Ear pain and new onset fever after several days of a runny nose is probably an ear infection. Depending on your child's age, these infections may or may not require an antibiotic.

Pneumonia may be detected by persistent cough, stomach ache, or difficulty breathing. Your physician may diagnose pneumonia by physical exam or may request a chest x-ray.

Other bacterial illnesses that we are concerned about include urinary tract infections (UTIs), which can be hard to detect and can cause kidney damage if they are untreated. If your child has a fever without a great source of infection, your doctor will likely want to check the urine. UTIs are more common in little girls and in baby boys under one year of age who are not circumcised.

More serious concerns are bacterial illnesses like sepsis (bacteria in the blood) and bacterial meningitis (bacterial infection in the lining of the brain and spinal cord). We become concerned about meningitis in older children with a stiff neck or changes in mental status. Babies are less likely to be able to show us these symptoms, and we are more likely to do more tests on them to make sure these infections are not part of the illness.

Remember that many of the vaccines that your child receives in the first years are meant to prevent these serious bacterial infections.

Diagnosing Bacterial Infection

Tests that are frequently performed to help us with the diagnosis of a bacterial infection include a complete blood count and cultures of fluid that we are concerned about. This may include a blood culture, urine culture, or spinal culture (which requires a spinal tap).

Whether the infection turns out to be caused by virus or bacteria, you should watch your child for any of the following signs and bring them to medical attention if they develop:

Dehydration, demonstrated by decreased fluid intake; urination less than three times in 24 hours; or decreased tears with crying
Increased work of breathing including fast breathing, nostril flaring, use of rib, stomach, or neck muscles to breathe
Markedly decreased activity or responsiveness
No improvement over a three - to five-day period
All children under three months of age with a fever

Children who are around other children will have more frequent infections. But remember most children these days (thanks to vaccines that prevent most serious secondary bacterial infections) will have viruses that take supportive care only.

-- Betty Staples, MD, is a physician at Duke Children's Primary Care and director of Duke's Pediatric Residency Program.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.

Scoliosis

Fri, 27 Feb 2009 09:03:36 -0500

When examining teenage girls for sports physicals, I often note a slight curve to the spine. If further examination is needed, I will order x-rays to determine how much curve there is.

As soon as I mention the word "scoliosis" the family has a million questions. Particularly, they’re worried about how severe it will be and if surgery will be needed.

Dr. Robert Fitch, an orthopaedic surgeon at Duke, gives us insight into scoliosis and what steps may need to be taken.

-- Dennis Clements MD, PhD, MPH

What Is Scoliosis?

Robert D. Fitch, MDSimply put, scoliosis is an abnormal curvature of the spine that exceeds 10 degrees when measured on an x-ray. This curve is seen when observing the spinal column from behind.

This is differentiated from normal "postural" curves that should be present when viewing the spinal column from the side. In fact, scoliosis is a three-dimensional deformity that occurs as the spinal column bends and twists.

As scoliosis progresses, shoulder and waist asymmetry can be noted as well as rib or muscle prominence on the side that the curve is deflected. Postural curves can become flattened or exaggerated.

This radiograph demonstrates how the surgeon measures the size of the curve to determine appropriate treatment
Click to enlarge.Scoliosis can be associated with many disorders. The most common type is idiopathic scoliosis. "Idiopathic" is a medical term that means no known cause, and is seen in otherwise well individuals. The incidence of this condition in the general population is approximately 2 percent.

However, the vast majorities of curves are mild and will not progress to cause significant deformity or disability, and therefore do not require treatment. Less than 10 percent of those diagnosed with scoliosis will progress to require treatment -- either bracing or surgery.

What You Need to Know about Treatment

A patient's age, gender, and the size of the curve measured from a standing x-ray most influence treatment. While the incidence of scoliosis in boys and girls is nearly equal, girls are six times more likely to have the curves increase. The younger the age and the larger the curve is at the time of diagnosis, the more likely there will be progression.
Children with curves that measure less than 25 degrees generally will not undergo treatment, but will need to be followed by a physician until spinal growth is completed (usually age 14 for girls, age 16 for boys). The interval for follow-up visits is generally every four to six months.

Brace Treatment

Scoliosis patients who show progression of the curve to 25 degrees or present with curves of 30-40 degrees are considered for brace management if there is significant growth remaining.

The goal of bracing is to prevent progression of the scoliosis during this growth period. Bracing has been shown to be successful treatment in approximately 80 percent of patients.

Surgery

Preoperative radiograph of a patient with idiopathic scoliosis
Click to enlarge. Postoperative radiograph of a patient with idiopathic scoliosis
Click to enlarge.

If the scoliosis has reached 45-50 degrees, surgery will likely be recommended since further progression of the curve is probable. A rapid increase in the deformity will usually occur if there is significant spinal growth remaining.

In patients whose growth is complete, curve progression is expected but is likely to occur much more slowly, generally about 1 degree per year. Eventually a severe curve will develop and cause health concerns.

The goals of surgery are twofold:

Correct the curve and hold the spine in its corrected position. This is done by inserting stainless steel or titanium rods adjacent to the spine. The rods are secured to the vertebrae with hooks, wires, or screws.
Obtain a fusion (make the vertebrae heal together). Rods by themselves are not sufficient. If the vertebrae are not joined together, the rods will eventually break from the stress of every day activities.

Children and adolescents will generally recover from surgery quite quickly and soon resume a normal lifestyle and full activities.

-- Robert D. Fitch, MD, is an orthopaedic surgeon at Duke specializing in scoliosis.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.

Environmental Allergies

Fri, 30 Jan 2009 15:22:10 -0500

Many patients ask me what to do about their itchy, runny noses. The symptoms are often worse in the spring and fall, but sometimes they occur year-round. The problem is environmental allergies.

Dr. Michael Land describes below what environmental allergies are and what can be done about them.

-- Dennis Clements MD, PhD, MPH

Michael Land, MD

What are environmental allergies?

As your child grabs for a third tissue to blow that runny nose and sneeze in the process, it’s easy to wonder if he or she might have “allergies” or rhinitis.

Rhinitis is one of the most common conditions in the U.S., affecting over 50 million people. Typical symptoms include sneezing, watery/runny nose (also called rhinorrhea), nasal congestion (stuffy nose), and nasal itching.

Not all rhinitis is caused by allergies, but when it is, it is commonly referred to as “allergic rhinitis” or hay fever. Allergic rhinitis may be seasonal or perennial (year-round). About 10-30 percent of adults and up to 40 percent of children may suffer from allergic rhinitis.

When it is seasonal, common triggers may be from tree, grass, or weed pollens. If it is year-round, it may be triggered by dust mites, cockroaches, animal proteins, or spores from fungi.

Patients who have allergic rhinitis are also at a higher risk of having asthma or atopic dermatitis. Having uncontrolled rhinitis may make it easier to get upper respiratory, sinus, or ear infections.

People who have uncontrolled rhinitis may also have headaches, facial pressure or pain, fatigue, and a decreased sense of smell.

Why do we have a lot of allergies in North Carolina?

Living in one of the most beautiful states in the U.S., it is easy to see why we have so many adults and children who suffer from allergic rhinitis here in North Carolina and in the South.

We have beautiful blue skies, plenty of trees and wildlife, and a temperate climate that supports the growth of a lot of vegetation. Among the different types of pollens out there, tree pollens are the most prominent pollens in the springtime; while grasses dominate the summer, and weeds dominate the fall.

We are surrounded by trees, grasses, and weeds at home, at work, on our roads and highways, and in the parks where we bring our families. Our great weather and beautiful surroundings are also unfortunately responsible for our high load of allergens.

What can I do if my child has allergic rhinitis?

The best way to get rid of the symptoms of allergic rhinitis would be to avoid the allergen that is triggering the symptoms. Reducing exposure to outdoor allergens is important when the pollen count is high.

Keeping the windows closed in your home and car while running air conditioning to keep cool in warm weather is an important way to avoid outdoor pollens.

Also, pollens are often emitted in the early morning hours (between 5 a.m. to 10 a.m.), and avoiding early morning outdoor activity can help extremely sensitive people. In grass allergic people, mowing lawns and being around freshly cut grass can worsen their symptoms as well.

Checking the local pollen count and avoiding prolonged outdoor activity when the pollen count is high may also help reduce exposure. You can check your local pollen count by visiting the American Academy of Allergy, Asthma, and Immunology and clicking on the “Patients and Consumers” tab and “Pollen Counts.” Our local counting stating for North Carolina, Virginia, and West Virginia is located at the Duke Asthma, Allergy, and Airway Center here in Durham.

What are some medical treatments available for allergic rhinitis?

Establishing control of symptoms is a key element of treating the condition. The first step would be to identify the triggers and reduce exposure to them. Your doctor might send your child to an allergist for an evaluation and skin testing to identify the triggers.

In addition to avoidance, most people will need to take some medications. The most effective single maintenance medication for allergic rhinitis is a topical nasal glucocorticoid spray such as mometasone or fluticasone. These nasal sprays are used on a daily basis to limit inflammation in the nose and decrease nasal congestion.

Other medicines include antihistamines such as loratadine or cetirizine, anti-leukotrienes such as montelukast, cromolyn sodium, and ipratropium bromide. These may all help to decrease symptoms caused by allergen exposure. These will of course only be prescribed by doctors and only for children of the appropriate age.

What about allergy shots?

Allergy shots are considered by some to be a natural way of dealing with allergies, although they are still a medical treatment and need to be prescribed by a doctor trained in allergy/immunology and given in a doctor’s office.

Also known as immunotherapy or allergy vaccines, these injections actually expose your body to small amounts of what you’re allergic to. By starting with tiny amounts and gradually increasing regularly, these injections slowly change your immune system to be able to tolerate larger amounts of the allergens.

Over time, your body then has a lower “sensitivity” to what you were allergic to and you may be able to decrease your need for medicines to control your symptoms. Instead of treating your symptoms, allergy shots go directly to the source of the problem, your immune system, and in effect, the injections “train” your immune system not to react.

However, there is always a small theoretical chance you could have an allergic reaction to the shots each time you receive them -- and thus, you should always have them administered at a doctor’s office and wait at least 20-30 minutes after each shot to make sure you do not have a reaction.

Are there natural remedies for allergies?

There are many practitioners who might recommend non-medical treatments for allergic rhinitis.

Some patients benefit symptomatically from nasal saline rinse, which washes out debris and pollens from the nasal cavity. Based on the available medical literature, however, there is not enough strong evidence to recommend the use of herbal supplementation, acupuncture, or “special diets” for the treatment of allergic rhinitis.

Some complementary and alternative medicine treatments may actually be harmful in allergic rhinitis patients. In fact, patients who take St. John’s wort may decrease their levels of loratadine (a non-sedating antihistamine). Also, Echinacea, a common herbal supplement, is a derivative of the coneflower, which has extensive cross-reactivity to ragweed, and should be avoided in very sensitive ragweed-allergic patients.

-- Michael Land, MD, is an allergy and immunology specialist with Duke Children's.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.

Children and Glasses: Making a Spectacle?

Tue, 30 Dec 2008 14:41:40 -0500

I am frequently asked about glasses for children. Common questions include: "Should their eyes be tested?" (the answer is yes) and "should they get glasses or contacts?"

Dr. Sharon Freedman, a professor of opthalmology at Duke, tries to make sense of the glasses question for parents.

-- Dennis Clements MD, PhD, MPH

Sharon Freedman, MD

Eye glasses (also called spectacles), are commonly worn by adults, but their use by children often raises questions and causes confusion on the part of parents, educators, and the public at large.

The ABCs of Eye Glasses

Eye glasses help bend incoming light rays so that they are focused properly on the back layer of the eye (the retina). Adults wear glasses to see more clearly, but children wear glasses for a variety of reasons.

Spectacles can correct some types of refractive error -- the problem that the eye has precisely focusing the incoming light rays on the retina. The main types of refractive error are called: myopia (near-sightedness), hyperopia (far-sightedness), and astigmatism.

Myopic eyes bend incoming light rays too much, usually because they are longer than the average eye. This causes near targets to appear clear, but distant targets are blurred. The solution is to place a concave lens over the eye to subtract refractive or bending power from the eye, and to move the eye’s near focus point to the distance.

Hyperopic eyes, by contrast, do not bend incoming light rays enough, often because they are shorter than the average eye. In hyperopic eyes, the target can only be placed in focus on the retina by adding extra power to the eye. This can be done either by placing a convex (magnifying) lens over the eye, or by thickening the lens of the eye (called accommodation).

The hyperopic eye has to work harder to see up close than it does far away, but young children and adults who still have the ability to change the shape of their lens (accommodation) can actually often see near and far even if they are hyperopic.

Eyes with astigmatism bend light slightly differently in one direction (or axis) than they do in another, usually because the front surface of the eye (the cornea) is just slightly oval rather than exactly round. Sometimes eyes with astigmatism also have myopia or hyperopia. All three of these common conditions can almost always be well corrected with spectacles.

Although most eyes that have a refractive error do not have a serious medical condition, sometimes eyes with a refractive error also have more serious coexisting problems, such as strabismus (misalignment of the eyes), amblyopia (lazy eye), or more rare conditions including cataracts (cloudy lens of the eye), glaucoma (high pressure inside the eyes), and retinal and optic nerve diseases (problems with the back layer or the nerve of the eye).

In these cases, the ophthalmologist will need to treat the serious eye condition and also will likely prescribe spectacles once the condition is under control.

Frequently Asked Questions

Why do children need glasses anyway?

Children wear glasses for four basic reasons:

Correct a refractive error so that the incoming light rays will be properly focused on the retina and the eye will have the best possible image or vision
Correct a refractive error that is worse in one eye than the other to help treat amblyopia (lazy eye)
Help a child see clearly without having to focus (accommodate) hard enough that the eyes cross (usually this is true for hyperopic or far-sighted eyes)
Help protect the eyes from injury, especially when one eye does not have good vision and the child would not be able to drive or conduct a normal visual life if something were to injure the better-seeing eye

How did the doctor know what glasses to prescribe for a baby or young child?

Fortunately there is a very easy way to determine the refractive error of any child’s eye, even one too young to provide feedback.

This process involves using special drops to relax the focus and dilate the pupil of the eye. A special machine or hand-held light and lenses can then be used to determine the actual refractive state of the eye, so that the eye care specialist (usually a pediatric ophthalmologist in the case of young children) can decide what spectacles, if any, are needed.

Not every child needs glasses, even if there is a small refractive error, and an ophthalmologist comfortable in the examination or care of children can determine whether or not glasses are needed.

My child squints and sits close to the television – does he/she need glasses?

Any child who frequently squints, closes one eye, holds his/her head in a consistent and unusual position, has a drift or misalignment of either eye, or has any visual complaint, definitely needs to have a full eye examination by an eye doctor comfortable with the care of children.

Most often the eyes are found to be normal, but these signs and symptoms can sometimes be the only evidence of a mild or even a more severe problem with the eyes that needs attention.

My child sees our pediatrician regularly -- does he/she need to have a separate eye examination anyway? And who should perform that eye examination?

Pediatricians regularly check each child’s eyes throughout infancy and childhood, beginning with the red reflex test right after birth. Vision screening occurs at the age of three or four years old and regularly after that time.

If the pediatrician does not feel that there is any problem with the eyes or the vision, and the parents agree, there is no need for a special eye examination. On the other hand, if the parents, teachers, or pediatrician feel that there is any issue that might be vision-related, it is very important to have a full eye examination, preferably by a pediatric ophthalmologist -- a medical doctor and surgeon specialized in children’s eye care.

In rural areas, an ophthalmologist (a medical doctor) or an optometrist (a non-physician eye doctor) can also do basic examinations on children’s eyes, but may refer to a pediatric ophthalmologist if a serious problem is found.

We have both worn glasses since childhood -- will our child need them, and at what age should he/she be examined to decide?

There is definitely a genetic component to most eye conditions, and refractive error is no exception. Parents who began wearing glasses in very early childhood should bring their young children for a full eye examination by the age of three years, or sooner if they or their pediatrician suspects any problem with vision, eye alignment, or eye appearance.

Children of a parent with a serious eye disease such as an eye tumor, cataract, childhood glaucoma, or other disease, should be seen in infancy by a pediatric ophthalmologist.

On the other hand, if parents began wearing glasses in middle childhood for myopia, the pediatrician’s vision screen is completely adequate to pick up a vision problem in childhood, and special eye examinations are probably not needed unless the pediatrician or family suspect a vision problem.

What happens if my child will not wear his/her glasses?

The consequence of not wearing glasses depends upon the reason for which they were prescribed in the first place.

For example, a young child who is given glasses to help treat amblyopia (lazy eye) or strabismus (crossed eyes) must usually wear these glasses during all waking hours for them to be maximally effective.

On the other hand, a child with mild myopia might need the glasses only during school hours to see the blackboard, but might be comfortable at home without them.

You should ask the ophthalmologist who prescribed the glasses exactly their purpose and how much they need to be worn. It is also important to be sure that the frame is properly fit to the child’s face, and that the spectacle has the correct power that was prescribed in each lens (sometimes the optical shop can make an error in grinding the lenses).

My child has a reading or learning problem, and “vision therapy” has been prescribed. Should we pursue the vision therapy?

All children with a possible or diagnosed reading or learning problem/disability need a full eye examination to rule out a correctable vision problem that might be making the reading/learning more difficult.

On the other hand, most learning disabilities are not related to vision or the eyes, but rather to the processing of the vision in the brain. Educational testing and special tutoring will be far more effective for the child than time and parental finances spent on vision therapy, which treats the eyes but not the visual processing problem.

Work with the pediatrician and the school system to maximally help the child with a suspected or diagnosed learning disability.

My child does not want to be seen in glasses -- can he/she wear contact lenses instead?

In young infants and children less than 11 years of age, contact lenses are usually only appropriate when a cataract has been removed from one or both eyes; however, for children who are 11-years-old or older, contact lenses are appropriate for the correction of refractive errors.

But before contact lenses can be used, the ophthalmologist must fully examine your child’s eyes to be sure contacts are medically safe, and then great care must be taken to be sure that the contact lenses are fitted and used by the child in a responsible and medically safe manner.

Every child wearing contact lenses in place of spectacles should still have a pair of properly-fitting, up-to-date glasses available for use when the contact lenses are not in the eyes. Contact lenses should usually be taken out of the child’s eyes daily.

How important are protective glasses for sports and recreational activities?

Accidental eye injuries continue to blind many eyes of children every day in this country, and most of these injuries are preventable.

Please take the time to purchase appropriate protective eyewear for children who are playing contact sports, especially for all children who have only one eye that sees well.

Protective eyewear is critical during games like paintball, and for children doing “shop” or other mechanical or automotive work.

How important are sunglasses for children?

It is clear that ultraviolet rays from the sun cause damage to our eyes that begins in childhood, but results in vision-threatening disease such as cataracts and age-related retinal disease only later in life.

Sunglasses or regular spectacles absorb most harmful ultraviolet rays and should be worn by all children when outdoors for any period of time.

How can I find out more about childhood eye diseases and about a pediatric ophthalmologist near my home?

The Web site for the American Association for Pediatric Ophthalmology and Strabismus (aapos.org) is a respected and very useful resource for this information.

-- Sharon F. Freedman, MD, is professor of ophthalmology and pediatrics at Duke.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.