How did my child get an ear infection – Part I ??
Ear infections come in two basic varieties; external, commonly occurring in the warm weather and referred to as “swimmer’s ear”, and internal or middle ear infections occurring mainly in the colder weather. The designation of external or middle is dependent on which side of the ear drum the infection is located. The outer ear canal, seen from the outside if you try to get a look in an ear, is a narrow bony channel covered with skin leading to the eardrum which is totally air tight and seals the chamber. On the other side of the ear drum lies the middle ear cavity containing specialized bones and small organs that allow sound frequencies entering the outer ear to be converted to impulses that eventually reach the brain and are interpreted as sound. This space would also be a closed space if it were not for the Eustachian tube which goes from the back of the nose to the middle ear cavity and keeps the pressure the same as the external canal.
The frequency of sounds represents a pulsed pattern and each frequency has its own pulse pattern. As the sound, usually consisting of different frequencies, reach the ear drum they set the eardrum vibrating at different rates; these vibrations are transferred from the outer ear to the middle ear by way of the eardrum, and then picked up on the other side by a connected series of small bones or ossicles that transmit the information to the auditory nerve and then on to the brain.
Now that we know how the ear works as relates to the anatomy we can discuss more fully what ear infections are all about:
External otitis is caused by a damp, warm environment in the outer ear canal which breaks down the skin and causes irritation leading to possible mild bacterial infection. There is swelling in the skin lining that narrow canal and very little space to allow for that swelling. As a result there is more irritation and resultant pain which can be quite severe at times. As this occurs there is a change in acid content of the external ear leading to more discomfort.
The first thing to do is to prevent any further fluid or moisture from entering that ear canal, no swimming or diving for several days. If there is mild pain a ½ to ½ mixture of vinegar and alcohol can be used in that ear for several days, along with mild pain killers such as Tylenol or Advil. If the pain is severe go to see your Doctor who may prescribe further treatments. In general this is not a dangerous problem even though it can be very painful.
A middle ear infection starts with a pressure change in the middle ear cavity from congestion and narrowing or complete blockage of the Eustachian tube. AT this point the child may say he/she cannot hear well or the ear “feels full”, or even hear the sloshing of fluid. After some period of time there is a collection of clear fluid with more pressure buildup and resultant pain. As the fluid builds up, bacteria can migrate into that space and begin growing leading to more pressure, pain, discomfort and sometimes fever. Your Doctor will suggest treatment methods that will greatly decrease pain and help heal the infection.
Some children tend to get repeated episodes of ear infections and I will deal with that problem in Part II of this post.
Time for Colds and The Flu: What Can You & Your Family Do?
All the bugs and bacteria that plague human kind are essentially trapped indoors over the cold winter months: windows seldom get opened and cars are sealed shut with the heat on, schools harbor a variety of illnesses and are also sealed shut with temperatures way too high. It’s no wonder that this is a perfect season to share whatever cold or Flu with your closest neighbor. Young children, especially, are not the poster kids for hygiene, and touching and tasting the environment gives infants and toddlers a window on the world. Illnesses that get started in your child can spread rapidly to all members of the family.
Viral infections and Flu are composed of minute particles that are just waiting for an opportunity to invade the next host. The easiest way to gain entry to the human body is through the mucous membranes that we all have – moist skin that you seldom think about; inside your nose, throat, lining your eyeballs, etc. Once they gain entry they invade normal cells and begin to replicate, reproducing themselves and in so doing, alter or kill the host cells. Whichever cells are involved and how your body reacts to the invasion will dictate the symptoms that you will experience. Most invasions are short lived and most for the purposes of this post are in the respiratory tract, upper (nose and throat) and lower (trachea and lungs).
How to cure a “cold” has been a mystery for scientists forever, but since they are short lived and generally do not produce major problems it has never been worth the resources to attempt multiple and complicated testing to nail down a cure. So viral colds live on and disrupt many lifestyles along the way. The favorite medicines in the world to attempt to cure just about anything are antibiotics, but to do so will not only have no effect on the cold but can cause problems of their own – resistances by bacteria to the antibiotic and reactions to that medicine. So we are left with “taking care” of the cold with various simple measures. Over the counter cold medicines have been shown to have very little effect on the symptoms or length of a cold and also have unwanted side effects.
How to prevent a cold or Flu, or viral illness from spreading is the main issue. Since these particles gain entry through mucus membranes, and are usually carried to that area by contact with your own colonized hands, it is very important to wash hands regularly and completely. Too often this is a cursory act of applying soap and washing it off, but scrubbing the hands for about 20 seconds (enough time to sing “Happy Birthday” twice) is usually necessary to do an adequate job. Avoid touching your face as most mucus membranes are in that area, especially your eyes. Of course the group that is most important (children) is not usually compliant with these issues, so you must teach this at home. Spread can also occur by droplets pushed into the air by coughing and sneezing and then transferred to others on your hands. Sneeze into the inside of your elbow and avoid spreading droplets into the air around you.
Unfortunately simple apparent cures, taking extra vitamins, etc. have been shown to have very little if any effect on a cold.
So, bear with it, it will be over soon, and do your best not to share it with anyone. And remember to get Flu immunization for your entire family (age six months and older) as soon as it comes out on the market, and since some Flu seasons can last into April get that Flu vaccine even in early March if you missed it at the end of last year.
Pneumonia, Bronchitis and Kids – More Common Than You Think
Pneumonia in kids is probably more common than we all realize. It represents an infection of the lung tissue which can be caused by viral illnesses, bacterial illnesses or a type of organism that is somewhere between a virus and bacteria called mycoplasma. The most common cause of pneumonia is usually viral, but viral illnesses can predispose lung tissue to become infected with bacteria. Other ways of acquiring pneumonia are by inhalation (this is unusual but certain illnesses such as
tuberculosis and anthrax may be acquired in this manner).
The best way to diagnose kids with pneumonia is through a thorough history and physical exam that your doctor will perform on your child. Another way that can be used to diagnose pneumonia is through the use of a chest X-ray, but small areas of pneumonia or early pneumonia might not show up on X-ray. Your Doctor will be able to diagnose this early on by piecing together what you tell him and his observation and examination of your child.
One thinks of pneumonia as an illness with high fever and severe productive cough but this is not always the case and sometimes all that is seen are the symptoms created by the body to help compensate for the changes occurring in the lungs. If a large amount of lung tissue is involved and it becomes difficult for the gas exchange (oxygen in and carbon dioxide out) to take place then a signal is sent to the brain to increase the rate of breathing so that more air is forced in and more oxygen can be extracted. When it is even more difficult to breathe the child may use muscles not ordinarily used to help with breathing such as abdominal muscles and neck muscles and one can observe this. With further progression of the disease less oxygen will reach the body and mild blueness or cyanosis will be seen in the skin.
OK we’ve talked about the more severe problems with pneumonia but let’s get back to the beginning and restate that most pneumonia is mild and might very well be a natural progression of a cold. In a considerable amount of children with mild pneumonia the diagnosis might never be made because it is not severe. And because most of these are viral in nature, they will clear up as the cold clears without the use of an antibiotic, and the child never exhibits the signs and symptoms mentioned in the previous paragraph.
If your Doctor pieces together the parts of the history and physical exam and decides your child might have pneumonia, and if your child appears sick or ill, he might very well begin an antibiotic because the exact nature of the pneumonia might be difficult to determine. Most of the time pneumonia can be adequately treated at home without the need for hospitalization and he/she will recover fully without any subsequent problems.
Bronchitis is a wastebasket term describing what is thought to be inflammation and mucous collection in the tubes that lead from your nose and mouth down into your lungs due to many causes- again usually viral. Any cold with a significant loose cough probably represents some degree of bronchitis or tracheitis (higher up). Generally, it also does not necessarily need an antibiotic to “cure” it because bronchitis, like mild pneumonia, will also go away as the cold resolves. There are instances, again, when your child’s doctor might very well decide to use an antibiotic for your child and those would include when your child looks sick or ill (because significant bronchitis and pneumonia can look exactly the same) or if your child has any sort of chronic lung condition such as asthma or cystic fibrosis where the chance of bacterial infection is increased.
So, especially during the winter months, if your child is diagnosed with pneumonia or bronchitis, you needn’t panic or assume the worst. Just follow your child’s doctor’s advice and he/she will be just fine.
Your Kids, Strep and Strep Throat
Strep infections are caused by a bacterium called Streptococcus Pyogenes and can range from mild to very severe and, at times, life threatening. The bacteria enter the human body by one of three ways: airborne, direct touch, or circulating through the blood stream and seeding into various organs. The most common illnesses we see in children are those that are airborne or acquired by direct touch and cause mild to moderate illnesses.
Some forms of impetigo, a superficial skin infection, can be caused by strep or staph and, while contagious to touch, can be easily treated and will not cause any subsequent problems
The more well known infection is that causing tonsillitis, an infection in the tissue of the tonsils, those lumps of pink tissue just behind and above the tongue when you open your mouth wide. This is also contagious and travels from untreated person to person through air droplets. Usually in the winter time, the person becomes ill rather rapidly, over 1-2 days with some combination of sore throat, fever, headache, generalized tiredness, muscle pains, trouble swallowing, and sometimes tender swollen glands in the front and side of your neck, up under the jaw. Often times the symptoms are mild but almost always eventually results in severe sore throat as the primary symptom. Children under the age of two years old seldom get significant illness.
When your Doctor examines your child he may find any combination of red swollen tonsils occasionally with white or grey pus on the surface, tender swollen glands in the neck, foul breath, fine red rash all over, and occasional red tongue with a rash on it.
The diagnosis can be made easily in the office by a rapid throat swab test which is positive in about 85% of people with significant strep throat. If your Doctor finds a negative rapid test and really feels that your child has strep throat he/she may elect to have a culture done on the same swab and even begin an antibiotic. The culture test can take 48 hours for the results.
There are many antibiotics that can successfully treat strep throat* and relief from symptoms is felt by your child within 24-48 hours. The reason that strep throat is treated at all is that in a very small percentage of patients with untreated strep throat there can arise certain serious illnesses that might lead to heart damage or kidney damage. If left untreated, this illness would go away on its own over a 3 – 5 day period, just like a cold. In general, ten days of medication is necessary but occasionally that time can be shortened depending on the antibiotic used: it is important for your child to complete the entire course of the antibiotic as prescribed by your Doctor. Usually within 24 – 48 hours of onset of treatment there are no more strep bacteria in the throat and your child may return to school.
Once the treatment has been completed, the illness is over.
This does not mean that your child cannot get strep throat again by contacting someone with active untreated strep infection, but the chances of acquiring those serious secondary problems has been reduced to nearly 0.
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* It is of interest to note that although strep throat is a very common illness and the strep bacteria has been exposed to more antibiotics than most other bacteria, strep alone has remained sensitive to just about all of the antibiotics used. Other bacteria develop rapid resistances to antibiotics they are repeatedly exposed to.
Ticks and Lyme Disease: a Pediatrician’s Perspective
Lyme disease has gotten a bad name. Originally described in Connecticut and New York, on the coast, near the town of Old Lyme, it was found to be carried by the deer tick (the vector), a far less common tick than the tree or dog tick. It now has also been found in most parts of the country and cannot be transmitted from person to person. The deer tick is very small, about the size of the head of a pin, and as opposed to a wood (dog) tick will not engorge with the blood of other mammals, so it is often times very difficult to see when scanning the skin. This tick must remain attached and feeding for 24 to 48 hours before it is capable of transmitting disease. Only about 5% of tick bites with the deer tick in an endemic area will result in Lyme disease in the human. Ticks and tick bites are far more common during the summer months so that is when your powers of observation need to be finely tuned. You should carefully examine your children at least twice a day for the presence of any tick attached to your child’s skin. Be sure to look in those places not easy to observe such as the scalp, between the fingers and toes, and in the pubic and the perineal areas (between the genital area and the anus).
When found, these ticks should be removed from the skin by applying a tweezer to the mouth parts firmly very close to the skin, and with firm steady traction (not sudden and jerky) pull the tick from the skin. You may leave some dark mouth parts in skin; don’t try to remove them but cleanse the area well with soap and water and treat as you would for any abrasion or cut. Those mouth parts may very well come out on their own or may remain and not cause a problem. Of course these areas can become secondarily infected ( as any cut or abrasion might) with bacteria and that would result in redness, swelling, warmth over the area and pain or tenderness Since ticks actually breathe very infrequently the idea of smothering them with petroleum jelly or other thick substance would not be practical. Do not try to burn them off with a heated pin or freshly lit match head as the only thing you will probably burn is your child’s skin.
If the disease is transmitted to your child (let me point this out again, this is rare) a mild illness with feverinitially might occur in some, this is more likely not the case however, and chronic long term vague illness is also not necessarily what you will see. The rash of Lyme’s disease also does not occur in all cases and is fairly 
characteristic: initially a reddened bump that subsequently clears in the middle leaving a red ring that slowly and inexorably enlarges. Sometimes there is more than one ring and other times that ring may enlarge significantly to cover entire body parts and extend to others. As a result, it is sometimes difficult to recognize this as a ring. There are blood tests that can detect the presence of Lyme disease but these might not be positive for several weeks. Treatment is easily accomplished through the use of an antibiotic for 21 – 28 days and there is time to begin treatment, up to a week to 10 days without fear of the disease progressing. The antibiotics used are common to everyone generally without side effects: Amoxicillin for young children and doxycycline (a form of tetracycline) for children 8-10 years and older.
This is a diagnoses made usually on clinical grounds; that is as a result of your child’s doctor’s experience in light of a certain constellation of signs and symptoms. Checking the tick for the presence of Lyme disease (if you have the tick) is not recommended and neither is preventive treatment if living in a high density tick area. There are reports of “chronic Lyme disease” and the treatment of such a suspected occurrence is not clear- probably the services of a specialist (infectious disease) should be sought.
Summary– Lyme disease is not very common even though you may hear of cases in your area. If you are concerned after a tick bite take your child to his/her doctor and he/she will make the diagnosis and suggest treatment if necessary. Check your child twice a day for the presence of any ticks and remove as described above. There is plenty of time to begin treatment and the antibiotics used are well tolerated; once treated it is not recommended to repeat lab work if done originally, and it can be assumed that the illness is gone and will not leave long lasting problems.
Is My Child’s “Barky Cough” CROUP and How Can I Help?
Croup, or laryngotracheobronchitis, is caused by many viral infections and falls into the category of upper respiratory infection along with the common cold. Croup tends to occur in the autumn and early winter months. In croup, the major areas affected are the ones referred to in the long name of this illness (above); the larynx, trachea and bronchi, which are all structures that convey air from the mouth and nose down toward the lungs. As with all colds or upper respiratory infections there is inflammation of the mucosa (most superficial covering) of the inside of the nose, mouth, throat and upper respiratory tract, leading to mucous production and irritation of those sites.
In croup, the area of the upper respiratory tract most prominently affected is the larynx, or the voice box area located very close to the firm lump in the front of your neck, the “adam’s apple”. When vocal cords are irritated and swollen, adults merely get hoarse or raspy talking and a “normal” sounding cough. Children have a much narrower windpipe and therefore with even the slightest swelling of their vocal cords, there is less room for air to get by and they also get hoarseness along with a cough and raspy breathing. There is also a characteristic barky (yes sounds like a animal barking) kind of cough and occasional difficulty breathing. All symptoms tend to be worse at night, a time when all illnesses seem to worsen.
For the most part this illness remains mild and the only treatment needed is a cool mist humidifier, fluid intake, elevated head at night and reassurance for the child and parents.
Rarely a child may progress to real difficulty breathing, with a characteristic whooping noise when taking a breath in versus a wheezing sound when breathing out found more commonly in those with asthma. So if your child exhibits difficulty breathing along with the above symptoms, call your doctor for further instructions.
Once a child has had croup, parents seldom forget what the barky cough sounds like and can make the diagnosis themselves. Usually, as with other upper respiratory viral infections there is a mild amount of fever and the child is not real sick.
If there is sudden high fever with the onset of “croup” and your child is drooling, cannot swallow or speak, and is very anxious, you must call your doctor immediately or call 911.
This symptom complex describes a rare but life threatening illness called epiglotitis which can be very dangerous. I stress that this is a rare illness which used to be far more common before we were able to vaccinate against the bacteria which causes this illness.
