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News10/06/2009: Traveling With Kids With vacation time here, this sixth article regarding warm weather hazards deals with preventing travel associated diseases and avoiding the pitfalls of traveling with children. As in any other area of endeavor, preparation will pay off with a safe, healthy and enjoyable trip. When traveling with your child(ren) bring along some favorite games, books or toys to keep your child occupied during the journey. Pack some favorite snacks and drinks, as well. If your child is not toilet trained, bring disposable diapers, wipes and other toiletries. If your child has a favorite blanket or stuffed animal, make sure you bring it in your CARRY-ON luggage and have a back-up. Sedating your child for travel may have some risks and is generally not recommended. Ask your doctor if you have any questions about medication for travel. Cash always seems to disappear on vacation, especially if you are using foreign currency. Have your bank issue you an internationally accessible ATM card. ATM terminals are commonly available in foreign urban centers. They will dispense cash in local currency while deducting it from your account in U.S currency at a favorable exchange rate. Also, carry your health insurance card and identification, preferably a photograph driver’s license, in addition to your passport. Make a photocopy of each person’s passport and keep it separate from the original. Prevention of travel associated medical problems falls into two broad categories, safe behaviors and immunizations. Safe behaviors, especially with children, demand childproofing every environment you encounter and always assuming your child will find the most ingenious way to get into trouble. If you take this approach, you are more likely to anticipate things your child can do and to be prepared for contingencies. Often, when families are on vacation, they sacrifice safety for convenience. How many of us use a seat belt when riding in a taxi cab? Or remember to bring our infant’s car seat along on a vacation that requires an airplane trip? We know we should maintain the same level of vigilance on vacation that we do at home, but being on vacation makes us want to relax and forget our responsibilities. The following is a list of precautions to take while on vacations. Of course, some will be more relevant than others depending on the age of your child(ren) and on where you travel. Consider each point carefully and remember to use sunscreen, wear a bike helmet and use your seat belts! If you plan to rent a car, find out from the rental agency whether the agency supplies age-appropriate auto restraints for your child(ren). If in doubt bring your own. If you plan to bicycle, use the same approach for helmets. Check with your insurance company to be sure your medical coverage extends to your foreign destination. If it does not, consider short term trip health insurance. Check ahead (hotels, airports) regarding facilities available for any disabled members of your travel party. Avoid swimming in fresh water that may harbor parasites, especially in tropical climates. If in doubt, stick to swimming pools with chlorinated water. Make sure children wear closed shoes (not sandals) when they are outdoors. Do not allow your child(ren) to play in dirt where toileting facilities are generally not available. Insist on careful handwashing before and after preparing foods, coming in from outdoors and after toileting or changing diapers. If you travel to an area where insect borne-diseases are prevalent, exposure can be minimized by modifying patterns of activity or behavior. Avoid outdoor activity during times when mosquitoes are most active (dawn and dusk). Avoid perfumes and brightly colored clothing as these may attract mosquitoes. Wear long sleeved shirts, long pants and a hat to reduce skin surface available for bites. Shirts should be tucked in and repellent applied to clothing, tents, mosquito netting and other gear. When accommodations are not adequately screened or air conditioned, bed-nets are essential to provide protection. Bed-nets should be tucked in under the mattress and sprayed with repellent (permethrin works best). Especially in rural areas, use insect repellents containing a 10% solution of N,N-diethyltoluamide, or DEET sparingly on the skin. Wash it off when returning indoors. Do not apply DEET repellents to broken skin or to portions of children’s hands that are likely to contact their eyes or mouth. Minimize use of these products in pregnancy (or consider rearranging your trip). When you get to your lodging, do a quick but thorough inspection for safety hazards. Childproof the area when possible--barricade glass doors with chairs, make sure balcony doors are locked, etc. Never leave young children unattended. In areas where chlorinated tap water is not available or where hygiene and sanitation are poor, drink only beverages made with boiled water (tea, coffee, soup) or canned/bottled carbonated beverages. Ice should be avoided. Avoid brushing your child(ren)’s teeth with contaminated tap water. All raw food is subject to contamination. In areas where hygiene and sanitation are inadequate, avoid salads, uncooked vegetables, unpasteurized milk and milk products, and eat only foods that have been cooked and are still hot or fruit that you have peeled yourself. Undercooked and raw meat, fish or shellfish may carry parasites and viruses. Cooked food that has been allowed to stand for several hours at room temperature may allow bacterial growth and should be thoroughly reheated before eating. Meticulous attention to food and drink will minimize the chance of developing gastrointestinal disturbances. Pack a medical kit, including the basic items listed below under "recommended". The second list, "optional", covers things that may be useful in special situations. Keep the medical kit in your carry-on luggage, in case your checked luggage ends up at a different destination! Recommended: -A medical card describing each traveler’s age, weight, height, medical conditions, routine medications, allergies and blood type (especially if traveling to a developing country). If your child has a complex medical condition, ask us for written information. (S)he should carry or wear a card, tag or bracelet identifying any physical condition that may require emergency care. -Antibacterial skin ointment, such as bacitracin, Neosporin®, Mycitracin® or Polysporin®. -Benadryl® (diphenhydramine) or equivalent antihistamine for itching and colds/allergies -Motion sickness medication (Bonine® or Dramamine® for children) -Acetaminophen or ibuprofen for pain or fever. -Insect repellent (Permanone® and, if disease-causing insect exposure is expected, a 10% DEET preparation). -1% hydrocortisone cream. -Sunscreen (SPF at least l5). -First-aid supplies (bandages, tape, gauze, elastic bandage wraps, alcohol wipes, a good pair of tweezers. -Any currently prescribed medications, including antimalarial agents. Take enough for the entire trip plus a few extra days in case of unexpected delays or lost doses, especially for children with chronic diseases. If you or a family member suffer from anaphylactic reactions, take your automatic adrenaline injector (Epipen® or Ana-Kit®). -packets of Hydralyte® or Kaolectrolyte® powder (to be mixed with water to make an electrolyte solution to give children with vomiting or diarrhea) if traveling to tropical zones with children under 2 years old. -Medication for traveler’s diarrhea (Immodium AD®, Children’s Kaopectate® or Diasorb®). -extra pair of prescription eyewear Optional: -car lock de-icer -sewing kit -Rhulli Gel®, Itch-X® or Caladryl® (topical anesthetic for stings and itches) -Moleskin® for blisters on the feet -A small sterilizing filter pump or Iodine tablets if camping away from potable water sources -scissors -cotton swabs -chemical cold packs for sprains -Vaseline® -Visine® -safety pins -Blistex® cream or lip balm -tissues -plastic bags -skin moisturizer -Lactaid® drops or pills for those who are lactose intolerant -Tums® or Pepto-bismol® for heartburn -Chloraseptic® lozenges -Wash’n’Dries® -soap -Cadlesene® Powder -nail clipper Animals for the most part pose the same types of hazards in other areas that they can cause at home. Do not allow children to approach animals that are not known to be domesticated and immunized for rabies. Certain parts of the world are known for specific animal hazards. A partial list includes Nepal (rabies from bats); developing countries in Africa, Asia and Latin America (rabies from dogs); Southwestern United States (Hantavirus from rats); and Australia, southern Asia, the Middle East and the Americas (poisonous snakes). Immunizations are available for pre-exposure protection from certain animal-transmitted diseases (rabies), but not all. Direct exposure to animals is not necessary to acquire certain diseases that are found more commonly in certain parts of the world. The presence of these diseases may be good enough reason to alter your itinerary. Some mosquito-borne diseases(for example, malaria and mosquito-transmitted forms of encephalitis) are vaccine preventable, others (e.g., Dengue or most forms of arboviral encephalitis) are not. Yellow fever, a mosquito-borne disease for which there is a vaccine, is common in Africa and South America. Typhoid fever is caused by salmonella bacteria, found wherever sewage treatment facilities are lacking. The majority of typhoid is found in Mexico, Peru, India, Pakistan, Chile and Haiti. Careful food preparation is critical in prevention efforts for Typhoid. It is also vaccine preventable. New Zealand has 10 times the incidence of acute rheumatic fever (usually caused by strep throat) than that in the United States. Meningococcal infections, usually caused by group B of these germs is also common in New Zealand. The meningococcal vaccine contains groups A, C, Y and W, but not B. Sub-Saharan Africa from June to December, Mecca and Nepal, however are known for the vaccine-preventable group C meningococcal infections. Summer and Fall in Asian countries are the high seasons for mosquito transmission of the Japanese encephalitis virus. There is a vaccine for this infection. Hepatitis A is ubiquitous. It can be food or water borne, as well as acquired directly from another person. It is vaccine preventable. Without animals or mosquitoes, how are the other mentioned diseases spread? They are spread by contact with that most dangerous animal of all--humans. Person to person contact is responsible for strep throat, meningococcal infections, tuberculosis (prevalent in Africa and Asia, as well as in certain areas of U.S. urban centers), polio (especially in the middle East), hepatitis A and B and Diphtheria (now frequently found in Eastern Europe). These disease with names that most of us recall only from history books or conversations with our grandparents are routinely prevented in the United States by virtue of usual childhood immunizations. Thus it is imperative that routine immunizations be completed before any foreign travel. This includes polio, diphtheria, whooping cough (pertussis), tetanus, measles, mumps, rubella, hemophilus influenza type b and hepatitis B. Hepatitis A vaccine is recommended for most travelers outside the U.S. and western Europe. A baseline tuberculin test should be obtained before travel to high risk areas and a follow up screen 6-8 weeks later after . This allows early detection and treatment of infection. Other vaccines and medication depend on your itinerary. Check with your physician at least two months in advance of anticipated foreign travel to allow adequate time for research and administration of appropriate immunizations. Remember, too, that the symptoms of most of these disease take up to 6 weeks to appear after infection. Malaria can take from 6 months to one year. Since no vaccine is perfect, report any symptoms up to a year after foreign travel to your doctor. Remind the doctor of your travel itinerary and dates to help the doctor arrive at a diagnosis. Avoiding environmental effects can be tricky. Simple things such as seeking non-smoking areas in airports, hotels and restaurants can be adopted as a matter of course. More difficult are avoiding the hazards of travel on unpaved roads (dust inhalation), travel at high altitudes (malaise, nausea, headache, insomnia, fatigue and altitude sickness) and travel to or through areas of toxic or radioactive spills. The CDC can give you information on potential trouble spots (see below). Avoiding areas of political upheaval and violence is equally as important as avoiding medical health hazards. By calling the Department of State (see below) you can obtain information on world hot spots. For further information, contact the following sources: The International Association for Medical Assistance to Travelers (a non-profit organization that offers listings of English speaking doctors overseas and publishes updates on immunization requirements, malaria and other tropical diseases) 1-716-754-4883. US State Department Overseas Travel Advisory, provides up to date information on travel conditions, visa requirements, political situations, etc. 1-202-647-5225. The Centers for Disease Control (http://www.cdc.gov/flu/) 1-404-332-4559 or 1-888-232-3228, fax 1-404-332-4565. The American Association of Poison Control Centers (www.AAPCC.org).
10/05/2009: Hair Loss in Children As adults, we see hair loss as a sign of lost youth and we resign ourselves to the inevitable. However, when our children lose hair, we feel betrayed and alarmed that youth is slipping away from them before they have a chance to bask in the glory of ribbons, barrettes, beads, corn rows and pompadours. Whether we view hair loss as a sign of wisdom and maturity, or a sign of youth stolen prematurely, we should be aware of the signs that differentiate a pathological process from simple aging and genetics. Some newborns emerge with enough hair to carpet a room, whereas others present with a shiny pate. Although most lose hair (sometimes all of it) over the first three months of life, some retain their birth endowment. Most seem to have enough hair to support a part or a ribbon by one year of age. A common newborn skin condition, cradle cap ("seborrhea") is manifested by flaky skin on the scalp that often comes off in clumps with tufts of hair. This condition is harmless and does not result in long term hair loss or abnormal scalp hair patterns. If your child manifests this condition and you are concerned about it, consult your pediatrician for some simple ways to improve its cosmetic appearance until it spontaneously resolves. Children are subject to several causes of hair loss, some common, some rare. The most common cause is a simple physiologic pause in hair growth. Termed "telogen" phase, the hair goes through spurs and lags in growth just as does the entire body. During the rest phase between spurts, the bulb at the end of the hair root decreases in volume and the hair becomes loose. Although exaggerated during adolescence, particularly in girls (due the influences of female hormones), even preadolescents can lose up to two hundred hairs per day. Despite finding hair all over the bathroom floor and in your drains, the scalp hair population appears normal in this condition. A microscopic examination of the hair root identifies the cause of the hair loss. Ringworm, which, of course, is not a worm at all but rather a fungal infection, can occur anywhere on the skin, including the scalp. When hairy areas are involved with ringworm, the hair shaft becomes brittle close to the skin and snaps off. The outward appearance of the scalp in this instance is that of an expanding circular or oval region that looks bald save for stubble that resembles a man’s facial skin twelve hours after a shave. If permitted to continue untreated, a invasion under the skin can supervene, changing the lesion to a soft squishy subcutaneous mass, called a kerion. Microscopic examination (the microscope is a handy tool in the diagnosis of different causes of hair loss) of a hair plucked at the periphery of the hair loss area reveals a characteristic disruption of the integrity of the hair shaft. Confirmation of the cause can be obtained by culturing the scalp for fungal organisms. The treatment consists of anti-fungal creams, shampoos and, sometimes, especially in the case of a kerion, oral medications. Alopecia, a spontaneous loss of hair, either in patches ("alopecia areata") or over the entire body ("alopecia universalis"), has no defined cause or predictably effective treatment. The areata variety usually resolves with time. The universalis variety is less likely to remit. The diagnosis is based primarily on ruling out other causes of hair loss. This condition has been known long before the advent of vaccines, antibiotics and environmental toxic contamination. Therefore, claims that any of these factors are responsible for this condition are unfounded. Certainly, it is known that various environmental toxins, in particular heavy metals (we are talking about mercury and other elements, not that music that people claim can make their hair fall out!), can cause hair loss, as well as skin and nail growth problems. This cause of hair loss is very uncommon and, when present, can be readily identified by coexisting symptoms and laboratory tests. We are all familiar with the unhappy state of hair loss as a result of chemotherapy. In that instance, the hair loss is the lesser of the evils, as the treatment can be lifesaving. If these descriptions of hair loss causes make you nervous, don’t pull your hair out! One of the most common causes for hair loss in children is trichotillomania, a nervous habit of hair pulling. This can effect hair on any body part, depending on which hair the child establishes as his/her target. Some choose the scalp, others the eyelashes. It is similar in cause to nail biting and knuckle cracking, those wonderful habits that drive parents batty. The appearance of the hair in this circumstance is stubble in an irregular distribution. The hair shaft is more often broken off near the skin than actually pulled out. The treatment is psychological counseling and trying to eliminate the child’s stressor(s). Of course, as in other conditions, there are always the genetic factors. A very rare genetic condition, known as pili torti, causes hair to be especially brittle so that it breaks off easily, giving the appearance of baldness when, in fact the hair is simply very short. Once again, the handy microscope can aid in making this diagnosis. Some of us are just fortunate enough to have inherited the ability to lose our hair earlier than do our peers (and certainly earlier than we would have otherwise wished). Despite the advertisements to the contrary, topical hair growth products are not particularly helpful, other than for the financial bottom line of the manufacturers of these products. As a former math teacher once said, "Grass does not grow on a busy street!" So grab your hat or sunscreen to protect that exposed skin. If you suspect any pathological cause of hair loss, ask your doctor to polish off the microscope and inspect your scalp.
07/15/2009: Trampolines What fun it is to jump and play! Trampolines certainly look like fun, with users flying through the air like a trapeze artist and flipping around only to bounce up again, not to mention the cardiovascular and muscular benefits conferred by this exercise. Because of the balance and conditioning benefits, trampolines were first used to train fighter pilots in WW II. Nevertheless, despite the apparent fun, trampolines present an unacceptable risk for serious injury. There have been numerous studies over the last fifteen years documenting these risks. The most recent is a study by Linakis, published this year in the Journal of the Academy of Emergency Medicine. Linakis found that trampoline injuries account for over 88,500 Emergency Department visits per year in the US. Of these injuries, 54% occur in males, 13% in children under 5 years old, 66% were in children aged 5-12 years old, and 21% in the 13-18 year old age group. Most injuries were bruises, fractures and dislocations, although an occasional child suffered a catastrophic spinal injury resulting in paralysis. Over three percent of injured children had to be hospitalized and a staggering 95% of the injuries occurred at home! As a result of this data, which has been conformed over the years by multiple investigators, the American Academy of Pediatrics has reconfirmed their policy statement: "Despite all currently available measures to prevent injury, the potential for serious injury while using a trampoline remains. The need for supervision and trained personnel at all times makes home use extremely unwise.
2. The trampoline should not be part of routine physical education classes in schools. 3. The trampoline has no place in outdoor playgrounds and should never be regarded as play equipment. The limited use of trampolines under direct supervision of physical therapists, athletic trainers, or other appropriately trained individuals for specific medical conditions, including conditioning and/or rehabilitation of injuries, is not addressed in this statement." They further state that limited use of trampolines in supervised training programs (eg, gymnastics, diving, and other competitive sports), should include specific design and behavioral recommendations (see http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/5/1053). In any situation of trampoline use, no flips should be permitted, only one user at a time should be on the equipment, use should constantly be supervised and the trampoline frame should be padded. We certainly want children to maintain conditioning and want them to have fun, but in a way that does not pose such a serious risk of injury. We support the recommendations in the AAP policy statement and encourage parents and schools to seek alternative methods to accomplish these goals. 07/07/2009: Influenza and The Influenza Vaccines What’s a flu? In spring 2008, the New Jersey legislature mandated that all children under 5 years of age in school, day care, or preschool receive an influenza vaccine every fall. The CDC/ACIP* recommended that an annual influenza vaccination be administered to all children under the age of 18 years . Some parents have expressed skepticism, cynicism, or fear about the vaccination program against influenza. Here are the facts. THE DISEASE is common; the yearly influenza epidemic causes millions of infections per year. Influenza is very contagious; it causes "disease among persons in any age group, but the rates of infection are highest among children". Influenza can be serious. Influenza causes 226,000 annual hospitalizations in America, many in children under 5 years. Influenza kills -on average 36,000 Americans, including more than 150 children in 2004, the majority previously healthy without any underlying medical condition or risk factor. Influenza is a common, contagious and bad disease; but it can be prevented. The vaccine works. Influenza, or "flu", is a specific disease caused by one of several specific "Influenza A or Influenza B virus" that circulate in the Northeast USA every year from late fall through late winter. Sometimes confused with other viral diseases, influenza is usually more severe than the average cold, and often will include severe fatigue, muscle aches, and gastro-intestinal symptoms such as abdominal pain, nausea or vomiting. Both influenza A and B viruses are constantly undergoing minor changes-called "antigen drift". This antigen drift means each year a slightly different virus circulates; and, every year, everyone can be re-infected by either Influenza A or B (or both). If the current virus is similar to past flu viruses, a person will have varying amount of protection (immunity) from past infections, and that person will either not catch the current year flu or have a relatively mild form of the disease. Some years, Influenza A undergoes a major change a.k.a. "antigenic shift". Unlike Influenza B which can spread only from human to human, Influenza A can infect not just humans but also horses, swine, chickens and ducks. Unfortunately while living in these animals, Influenza A can obtain entirely different antigens from the animal- specific influenza viruses that naturally infect ducks and chickens. This antigen exchange occurs particularly in the far east, where humans live in close contact with these animals. Whenever the flu virus has a major shift, the majority of people worldwide will have no protective immunity from past infections and are at great risk for a more serious infection and death. This is what happened in the great flu epidemic of 1918-19, and what experts fear could happen if the avian flu ever shares its antigen with Influenza A. Influenza A and B are both transmitted from human to human via respiratory secretions, including air-born droplets from coughing. The influenza viruses in the secretions remain viable and infectious for many hours. During the annual epidemics, roughly half the people exposed to the virus become sick: typically 2-3 days after exposure. The illness begins abruptly with headache, malaise, achiness and fever. Over the next 72 hours, the flu will typically progress from a mild runny nose to convulsive fits of non-productive coughing. Photophobia (eyes hurting when exposed to light), extreme fatigue, loss of appetite and, in approximately 20% of the patients, gastrointestinal upset accompanies the respiratory symptoms. The symptoms fluctuate, being worse during the evening and night and when the fever rises. Severe symptoms usually peak at three to five days but the cough often lingers for a week or two. Symptoms of influenza are remarkably consistent from person to person and from year to year, enabling physicians to make a clinical diagnosis with reasonable certainty during the local epidemic. There is NO EFFECTIVE CURE for influenza. The management is non-specific: rest, fluids and pain relievers. An historical aside and important warning: never use aspirin to treat influenza. Medical researchers discovered in the 1970s that aspirin use in influenza can trigger a serious, often fatal, condition called Reye Syndrome. Several anti-viral medicines can inhibit viral replication, giving one's immune system time to fight the virus. These medicines, if taken when exposed to influenza, can sometimes prevent the disease. If already infected, these medicines can have a modest effect, sometimes foreshorten the disease by one- two days, but only if taken early, within the first 48 hours of symptoms. The major problem with all the anti-viral medicines is the influenza virus are constantly mutating, and are becoming increasingly resistant. PREVENTION is BEST. Vaccines prevent influenza disease more effectively than anti-viral medicines can. Effectiveness (i.e., prevention of illness in vaccinated populations) of influenza vaccines depend in part on the age and immunocompetence of the vaccine recipient (typically children respond better than the elderly), and the degree of similarity between the viruses in the vaccine and those in circulation (the more the antigen drift, the less the effectiveness). Obviously, the effectiveness also depends on the outcome being measured. When the measurement is lab- proven influenza illness, ER visits, hospitalizations and death, the protection is usually between 70-90%,(but closer to 60% when there has been large antigen drift). When the expectation is no winter illness, the effectiveness of the vaccine is erroneously underestimated. The flu vaccine will NOT protect against the many respiratory or intestinal illnesses (a.k.a. the common cold and GI bugs) caused by hundreds of other viruses that are not influenza viruses. Even with the flu vaccine, a typical child can still expect to catch on average 5 colds a winter. INFLUENZA VACCINES can be either the old injectible shot: "TIV" (trivalent injectible vaccine) or the newer inhaled vaccine: "LAIV" (live, attenuated, inhaled vaccine). Both vaccines will work. They both can be life saving, especially for the elderly or anyone with weak hearts, asthma or other lung disease. The injectible has been used since 1940 , it is inactive (dead, killed with formaldehyde), and can not cause disease. The injectible is currently made by several manufacturers and come in two distinct formulations one meant for both children and adults and a second meant only for adults (the later contains thimersol- a mercury-containing preservative). While there has never been proof that thimersol ever caused autism, all children vaccines --including the injectible FLUZONE® and the inhaled FLUMIST®-- are now made without the mercury. The major side effects of the injectible vaccine are local soreness in half of the recipients, usually lasting 1-2 days; diffuse body aches in 25% and fever in 10%; (interestingly in the largest study, 20% of the non-recipients also had diffuse body aches, and 8% fever). The injectible is approved for persons older than 6 months. The newer LAIV live-attenuated nasally inhaled vaccine, a.k.a. FLUMIST ® was approved in 2003 for persons between age 2 and 49years. The inhaled vaccine causes a runny nose in half of the recipients, usually less than 2 days; less than 10% of the recipient of inhaled vaccine complain of soreness or fever. Because it may exacerbate respiratory conditions, such as asthma, the inhaled vaccine is not to be given to people in high- risk groups. Lastly, neither vaccine should be given to persons with severe egg allergy without clearance from an allergist. Following current CDC/ACIP RECOMMENDATIONS, we are recommending that annual vaccination be administered to all children under the age of 18 years, but especially:
Children with medical conditions are encouraged to schedule their vaccination as early as possible. Updated information on influenza can be found on the Internet at www.cdc.gov/flu/. Expert opinion on various topics in Infectious Disease, including influenza, can be found at www.isid.org. |
