Pediatric Medical Conditions

In the article “Understanding Pediatric Diseases” we talked about diseases and now we are talking about conditions, so what is the difference? Diseases are things caused by something infectious. The medical conditions are things that happen that are not necessarily infectious, but are still not right and in many cases suck more and for a longer time. Just like in the last chapter this is not going to give you enough information to go out and start a pediatric office. It hopefully will be a reference you can look at to put these conditions in terms you can understand so you can ask your doctor better questions and know why certain things are being done. Sometimes it is just nice to know your doctor does know what they are talking about and somebody out there writing a book would have done the same thing. Just know your baby is not the only one these things are going to happen to. These are discussions you will need to have with your baby’s doctor. There are never simple answers why these conditions occur or how they are treated.

Allergies:

In this category we are talking about seasonal and environmental allergies. At around the age of six months babies can start to develop allergies to the things around them all the time, these things commonly include allergies to pets, dust mites, molds and things found around the house. After the first year they can start to have allergies to seasonal things like pollen, grass, molds and ragweed. I like to describe allergies as being a tree with two big branches. On one branch we have the histamine side that causes the symptoms of watery eyes, runny nose, sneezing, coughing and itching. On the other branch we have the inflammatory symptoms which cause swelling and leads to the nasal congestion, sinus pressure, headaches, and secondary infections like ear and sinus infections. Babies and big people can have symptoms on one branch or the other or both at the same time. The histamine side of the tree is usually treated with antihistamines, and the inflammatory side is treated with nasal steroids and medications called leukotriene modifiers (such fancy words). If allergy symptoms become troublesome it is time to bother that pediatrician of yours and find out what they recommend using and the dose for your child. Allergy testing for babies less than two years old is not very useful except in cases where you suspect a specific allergen like dog or cat dander or a specific food such as shrimp. There are some allergies, which can be life threatening. Allergies to stings, medicines and food can lead to anaphylaxis.

Food Allergies:

Food allergies can happen with all types of foods and the symptoms and cause can be hard to detect. One thing to remember is the sooner solid foods are introduced the more likely the baby is to develop food allergies. Babies born into families with a strong history of food allergies are recommended to hold off on solid foods until six months of age. The first food a baby could develop an allergy to is milk. Symptoms of milk protein allergies range from eczema, diarrhea, bloody stools, fussiness, vomiting and hives. The doctors often test stools for blood and depending on the severity and the symptoms your pediatrician may consult a pediatric specialist called a gastroenterologist (try saying that 10 times fast). Babies are often tried on specialty formulas made for babies with allergies to milk. These formulas are very expensive and should only be recommended and changed by your doctor. It often takes days to weeks to see the results of the change and if you are changing too fast it makes it hard for your doctor to figure out what is going on. Some of these babies could even end up getting a procedure to look into their intestine to see what is going on. The next types of food allergies we start having pop up happen when we start introducing solid foods. Some of the most common foods to develop an allergy to are tree nuts, peanuts (bet you thought they were the same, but a peanut is not really a nut), shellfish, eggs, soybeans, wheat and fish. The symptoms of food allergies are itchy rashes like hives that are described later, eczema, abdominal pain, vomiting, diarrhea, shortness of breath and wheezing. If your child has sudden abdominal pain, wheezing and shortness of breath, they may have a special condition called anaphylaxis, which is life threatening and needs immediate emergency assistance (CALL 911). Any suspicion of allergy you should contact your pediatrician and get advice what to do and ways to prevent and treat in the future. The nice thing is most food allergies are outgrown by children except for nuts and shellfish that are not outgrown as often.

Eczema:

Eczema is a very common skin rash little ones can have on their body. It tends to run in families with allergies and asthma. Eczema can sometimes be a sign of a food allergy and should be suspected if you have just added a new food. Eczema tends to be worse on the face and trunk during the first year of life and on the arms, legs and around joints after the first year. For most children eczema is worse during the winter months. Eczema tends to have flares that come and go and can be triggered by allergies, illnesses or staying wet. Most doctors recommend infrequent bathing in babies with eczema, using good lotions twice a day (by good we mean lotions commonly used by adults as baby lotion is mostly so babies don’t smell like poop), and trying to keep them from scratching at the rash since digging makes it worse. Eczema comes in mild, moderate and severe forms, which range from a mild dry rash to a baby who looks like they are a burn victim. We often call eczema “the itch that rashes” because the more they scratch at it the worse it gets. Many of the modalities of controlling eczema involve trying to keep the baby from scratching their skin. If you baby is falling in the moderate to severe category its time to see the pediatrician and they may prescribe antihistamines for itching and prescription strength steroid creams.

Asthma:

Asthma is a narrowing of the airways in your lungs causing you to have problems breathing. The narrowing of the airways is caused by a spasm or swelling, with swelling being the most common. Triggers for an asthma attack include viruses, allergies or irritants. The viruses are typical cold viruses. Allergies can be of the seasonal variety or an allergic reaction to medicines or foods. Irritants can include dust, smoke, perfumes, or pretty much anything that annoys your airways. The stages of an asthma attack are as follows: first it takes longer to get air out, second a wheeze develops as you breathe out, third wheezing occurs when breathing in and out as it worsens, fourth there is only wheezing when breathing in, and fifth and finally no wheeze because not enough air is moving back and forth to make any noise. What does all this mean to you as a parent? Probably not very much, but it is nice to know what the doctor is talking about when they are talking about the severity of an asthma attack. What you need to know about a baby who is less than two years old is they are going to be breathing fast, working hard to breathe, and you may hear them making a whistling sound when they are breathing. You may also see what are called retractions, which is where they are pulling in between their ribs, under their ribcage and above their clavicle. If your baby is wheezing you need to see a doctor as soon as possible, this is not something you want to wait several hours before being seen. This is one condition where it is always a good idea to go to the emergency room if it is happening at night. Asthma often runs in families who have asthma, allergies and eczema. Your doctor is usually going to ask about a family history of asthma. For most babies they will eventually outgrow asthma, but this is one condition you want to take very serious because it can be life threatening. If your doctor recommends medicines be taken daily be sure and take them, if they recommend staying away from certain things, then it is a good idea to stay away from them. Sometimes you have to ask yourself who do I love more, my cigarettes (or whatever it is they are sensitive to), or my baby? (If your answer is not your baby you should stop reading this book and start reading one on how to set up an adoption). If you want to change your medicine it is time to go see your pediatrician and see what different medicines are available and get a plan of action.

Gastroesophageal Reflux Disease (GERD/ Reflux):

Commonly known as reflux, this is where the contents of the stomach come up into the esophagus. The esophagus is the tube connecting your mouth to your stomach. By definition it is any substance (fluid or solid) going from the stomach into the esophagus. It can go a short distance or can go all the way to the mouth and induce vomiting. All babies have reflux. Every baby spitting up has just had an episode of reflux. For the most part, reflux in babies is normal and does not cause any problems. Doctors are going to be concerned if the common reflux starts to cause uncommon problems. The problem begins if the baby starts to spit up so much they are not growing, starts to have pain from the burning of their esophagus from the stomach acid going up where it is not supposed to go, or stops breathing and turning blue from not being able to breath around the obstruction of the substance being spit up. Babies will be weighed and measured at all their checkups and plotted on a growth curve. Those curves are something to help the pediatrician decide if the reflux is affecting the baby’s growth. This is just one of the reasons it is important to keep all your well-baby appointments. A baby having pain from reflux will cry when eating, cry when spitting up, tend to be fussier generally and may arch their back while being unhappy. Of course if a baby is stopping breathing and turning blue you are going to notice it happening. If your baby is stopping breathing or turning blue, do not assume they are just having reflux, CALL 911 NOW! Do not think about anything else; do not call your mother, brother, sister or even your doctor for advice…CALL 911! Depending on the symptoms your baby is having your doctor may order some tests, may try some changes in feeding or positioning of your baby, may try some medications or even refer your baby to see a specialist.

Hives:

Hives in medical lingo is known as urticaria (which is hard to say and even harder to spell, but I guess it sounds smart). These are reddish-colored blotches that can appear anywhere on the body. They are usually slightly elevated and the edges are usually a little darker than the center. It is hard to comprehend, but one hive or a hundred hives mean the same thing to a doctor. They are usually moving around and can’t really stay in the same spot, if they do stay in the same spot for more than about a day it is not a hive. Hives can be caused by an allergy to something coming in contact with the skin or an allergy to something the baby ate such as food or medicines. Babies can break out in hives secondary to illnesses or stressors, from being in cold water, being out in the sunlight too long or for any number of reasons even your pediatrician cannot figure out (these reasons are called idiopathic which in my lingo means we are too big of an idiot to figure them out). You should always call your pediatrician to figure out what the cause was and what you need to do to help your little one. If your child has any wheezing, problems breathing, vomiting, or uncontrollable crying you need them to be seen as soon as possible…CALL 911! Some causes of hives may require a referral to a specialist for additional testing.

Apnea:

Apnea is a pause in breathing lasting greater than 20 seconds. Try to hold your breath and count 1 Mississippi…2 Mississippi…3 Mississippi… etc. and you will get the idea it feels like forever. The other problem is they hardly ever say, “Hey Mom and Dad! Watch me I’m about to stop breathing so start doing the Mississippi counting thing.” So just try to count when you notice them stopping breathing as they are usually going to do it more than once if it is truly apnea. This is another one of those emergency times for which you must CALL 911! GO TO THE HOSPITAL! So what could be causing the apnea? It could be caused by a severe infection that could range from a blood infection, urinary tract infection, or meningitis. It could be caused by reflux. A baby can stop breathing if they are having a seizure, have had some kind of brain trauma or a brain malformation. They can also have what is called obstructive apnea from something getting in the way of their breathing like really big tonsils or adenoids. Because of this a baby having apnea is going to have tests to rule out infections, reflux and brain problems while they are in the emergency room or hospital.

Sudden Infant Death Syndrome (SIDS):

SIDS, or Crib Death as it used to be called, is when a baby is found dead while it has been asleep. It is what we are worried about may happen when a child is having apnea. It was once recommended babies sleep on their bellies that was found to contribute to SIDS. Since the recommendations for babies to sleep on their backs started, the numbers of babies dying from SIDS has greatly reduced. We do know there are certain risk factors for SIDS, which can be identified, and babies can be watched closer and the risk factors removed. Babies at highest risk are male; aged one to six months (it being the highest between the second and third month); premature; low birth weight babies; of Black, American Indian, or Native Alaskan ethnicity; born to a mom using tobacco or drugs during pregnancy; exposed to second hand smoke; in a house that is too warm; born in the winter; and finally who’ve had a sibling who died of SIDS. The take home message would be put your baby to sleep on its back, do not use drugs, do not smoke, do not keep the house too hot and if you have had a baby who died of SIDS before, let your pediatrician know.

Colic:

I would like to change the name colic to Crazy Parent Syndrome. The reason for my suggested change in name is colic falls into two categories: parents who are just crazy and think a baby is never supposed to cry or parents who will soon be crazy because a truly colicky baby will drive someone stark-raving mad. The definition of colic is a baby who cries nonstop for at least two hours for five out of seven days for at least two weeks. The best way I can personally describe a colic baby is one that screams like you were cutting off their finger. A colicky cry truly gets on your nerves. We do not really know what causes colic, but we think it has something to do with the intestinal tract since some of the interventions we have found that work have to do with manipulation of formulas or medicines affecting the gastrointestinal tract.

Babies with colic like to be moving constantly. I tell my parents you can diagnose colic by driving in the car; a baby with colic will be calm while driving and will start crying every time the car comes to a stop. I have had parents calm them down in swings, bouncy seats, and going for car rides. They also like what is called white noise which is static. I have had parents calm their little one down with static from radios or televisions, the sound of fans, vacuum cleaners (parents have burnt out the motor in their vacuum cleaner), and buying little machines to make white noise. You will need to talk to your pediatrician before you go crazy to see what he suggests trying to do to help your family. He may recommend a change in formula, have some other tricks up his sleeve and sometimes even medicine may be recommended.

Gas:

Gas is simply air coming out of one end or the other. Most of the air going out is air they have previously swallowed. Babies swallow air while they are drinking their milk either by breastfeeding or bottle-feeding or while they are crying. Once air has been swallowed and gets into the stomach it will have to come back up the esophagus and exit as a burp or travel through the entire intestinal tract and exit as flatulence (fart, toot, poot, cutthe-cheese, pixie, let one loose, or whatever your parents called it). Just for the record I had never heard the whole pixie thing until my wife told me that is what she called them when she was a little girl. The average baby is going to pass gas 10-20 times per day. Gas can also be formed in the intestinal tract from the breakdown of food products.

Not all gas is normal and there can be things causing babies to have excessive gas. Excessive burping can be caused by swallowing too much air while eating because of a nipple not flowing right, or crying and swallowing air secondary to pain or colic. Flatulence can be abnormal because of problems with digestion such as lactose intolerance or an allergy to foods. Gas should not be painful since it is something normal that happens without them even noticing it. If your baby is crying do not just blame the gas as the gas may be happening because of what is causing the pain. Babies having excessive gas and pain should warrant a call to your pediatrician.

Failure to Thrive:

Failure to thrive is the term you will hear pediatricians use if your baby is not growing the way they would predict. A baby’s growth is plotted on curves to follow the baby’s length, weight, and head circumference. If a baby’s growth is not what the curves would predict then we need to figure out why. If the baby was large and the parents are pigmies then should not be a surprise when their growth starts to fall down the curve. If the baby’s head starts to look small it would be nice to know everyone in the family has really small heads. There are many reasons why a baby might not grow the way we would predict but it should stimulate some questions by your pediatrician and maybe even some tests.

Urinary Reflux:

Urinary reflux is where urine goes the wrong direction and flows from the bladder back up to the kidney. Urinary reflux can lead to urinary tract infections and long-term kidney damage. Urinary reflux is diagnosed using a test called a voiding cystourethrogram or VCUG. This test is done by injecting dye into the bladder and watching via x-ray to see where the dye goes. Urinary reflux is graded from I to V. Grade I reflux goes up into the tube connecting the kidney to the bladder which is known as the ureter. Grade II is where urine goes backwards all the way up the ureter to the kidney. Grade III is when the urine goes all the way up the ureter into the kidney and causes mild dilation of the kidney, which is called hydronephrosis. Grade IV is when the urine goes all the way up the ureter to the kidney and causes moderate dilation of the kidney. Grade V is when the dilation of the kidney is severe and the ureter is very swollen and kinked. Grade I and II are often watched over time and usually if urinary tract infections are prevented they will go away on their own. Grade III will go away on its own about half the time. Grade IV and V usually need surgery to fix. Most of the time if your baby is diagnosed with Grade III, IV or V reflux you will be referred to a pediatric urologist, which is a surgeon specializing in children’s urinary tract surgeries.

Teething:

All babies will get teeth. The symptoms that come along with getting them are called teething. How many symptoms they have will vary with every baby as does how long they will last and how severe they will be. First off know that extreme symptoms should not be blamed on teething. For example if your baby looks very sick then think about everything else before you blame their teeth. Symptoms attributed to teething include low grade fevers (never above 101), runny nose, drooling, chewing on things, not wanting to eat, sporadic choking sounding coughs, pulling on ears, and loose stools. Most commonly these symptoms are annoying at the most. If the baby is having a hard time with their teeth pediatricians will recommend acetaminophen, something cold or hard to chew on and lots of love. There are several homeopathic treatments available that are not routinely recommended by pediatricians for teething because of safety concerns. If you have lots of coughing, fevers higher than 101, and more than six stools per day you have an illness, not teething.

A baby’s first tooth can come in any time between two months and 18 months old. About a half of the babies will have a tooth by the time they are six months old. About 80 percent of the time their first teeth will be the two bottom front teeth, followed by the four top front teeth, then the other two bottom front teeth, then the molars and the canine teeth coming in last. Top teeth seem to have more symptoms than the bottom teeth. We recommend just brushing teeth with a brush and water until they are one year of age and then using flavored fluorinated toothpaste after their first birthday. The pediatric dentists recommend their first dental visit one year after their first tooth, but I routinely recommend their first visit after they are two years of age.

Vomiting:

Vomiting is different from spitting up. Think about spitting up being the amount to fill up maybe two or three teaspoons. When you can fill up small bowls then we are talking about vomiting. If you have vomiting and diarrhea then you most likely have a virus. If you have only vomiting then there are many things that could be the cause. If you have more than two episodes of vomiting and no diarrhea then it is probably time to call the doctor. Things important to think about are: does your baby have fever, are they urinating normally, are they awake and acting normal, and do they have any other symptoms like cough or crying? So what kinds of things is your doctor going to be thinking about? Terrible things like strep throat, pneumonia, meningitis, urinary tract infections, blood infections, intestinal obstructions, and probably at least a hundred other reasons causing vomiting. Now you understand why it is time to call a doctor; make them sweat and work out why your baby is vomiting as opposed to taking on that responsibility yourself.

So your doctor tells you your baby has a virus, now what do you do? Your doctor is probably going to give you a plan of action, but in case they did not or you forgot, I will tell you my advice and my rationale behind it. I tell everyone with a vomiting baby not to give their kiddo anything to eat or drink for at least two hours after they last vomited. Once they have gone two hours it is time to start slowly introducing clear liquids. Now the American Academy of Pediatrics recommends the World Health Organization’s rehydration formula, the problem is this has to be made by mixing things together which are not necessarily found in every modern day kitchen these days. It is also not something available at the store (maybe I should figure out a way to package and sell it so I can be rich) and to be honest it tastes like crap. So let’s assume you live here in the real world with me and eat food at restaurants, work at a real job, and do not have loads of free time to be concocting solutions to feed to your baby. I recommend unflavored Pedialyte® for the little babies less than a year of age and flavored Pedialyte® for the ones over a year of age. Pedialyte® is also available as popsicles for the older child which is a way to slowly give them fluids. In a pinch I also recommend a form of Gatorade® called G2 that has less sugar than the regular sports drink. I recommend you try to give them just a suck or two on a bottle or sippy cup every five minutes or so for the first two hours.

I like to describe a stomach virus like it makes the inside of your stomach look like a raw sore. Imagine if you skinned up your knee and it was bleeding. If you kept bending your knee it would keep bleeding, but if you were still for a couple of hours it would form a scab and stop bleeding. Now as long as you only bent your knee a little you would be fine, but if you start bending it a lot the scab will crack and start bleeding again. Now if you apply that thought process to your stomach it makes a lot more sense why you have to go real slow with pushing the fluids. Once they have held down the sips for a couple of hours then I recommend they go up to a couple ounces at a time every 30 minutes. Once they have made it six hours without vomiting then they can restart breastfeeding or formula (although I recommend changing to a lactose free formula or soy formula for about three days). The older babies can start on some bland foods and crackers. I recommend they stay away from any dairy products for three days. If they start vomiting again, start the whole process over. Typically once the vomiting has been gone for about eight hours you are usually done with it unless you give them some dairy too early.

Constipation:

Constipation is hard stools that are large and painful to pass. Babies may have infrequent stooling, but if it is soft and non-painful when they do pass it, they do not have constipation. The frequency of stooling varies widely from baby to baby and from different stages of development and types of food choices. If a baby has stool that comes out in hard balls or are larger in diameter than you could imagine coming out of a baby, then it has constipation. If your baby has constipation, it is time to call your doctor. There is no one right way to treat constipation and every doctor has his or her own way of trying to control the problem. I will give you the suggestions I give parents, which may be different from another doctor and trust me we could both be right. I tell parents once a baby gets constipated and has hard stool at the end of their intestinal tract there is nothing you can give them by mouth that is going to make stool that is already hard, come out soft. We are going to have to get the baby to get the hard stool out before we can keep them from getting hard stool again. I usually recommend a pediatric glycerin suppository inserted up their little bottom. The glycerin is just a type of grease lubricating the exit and makes it easier to pass a larger stool. Inserting the suppository also stimulates a reflex making the intestinal tract start to contract and initiate a bowel movement. I repeat the suppository every 6-8 hours until the stools are no longer hard (other doctors may recommend infant enemas which are also effective). Once the hard stool is removed some babies are done and will not get constipated again. This is often true in babies around a year of age, babies that have had a change from breastfeeding to formula, a change in formula, or a change from formula to whole milk. It is also not unusual for babies to get constipated following a diarrhea illness. If your baby is getting repeatedly constipated it is either from types of food they are eating or because they are just reabsorbing too much water out of the large intestine and making the stools dry and hard. Foods that can be constipating include bananas, cereals, peanut butter, breads, cheese and whole milk. Foods can also help clean your baby out and include your gritty fruits like prunes, pears, peaches, apples and apricots. Some babies just pull too much water out of their large intestine and have problems no matter what we add or take away from their diet. In this case your doctor may recommend adding some clear corn syrup to your baby’s bottles, which has a sugar that is not so easily absorbed and pulls water into the intestine, or sometimes some medicines containing artificial sugars which do the same thing to loosen stools. Babies should never hurt when they are stooling so never accept hard painful stools as normal.

Loose Stools/Diarrhea:

Trust me there is a difference between the two but you would not be able to tell it with one diaper. Both of them are very runny and thus gross. To meet the criteria for diarrhea it is a volume diagnosis. We consider any loose stools greater than six per day as diarrhea. Any number less than six per day is simple considered loose stools. Viruses, bacteria, or problems with absorption can cause diarrhea. Loose stools can be affected by fluid intake, the amount of fruit or fruit juices, the type of milk the baby eats (mainly breast milk), the normal stooling pattern (some babies always have loose stools), and even what time of year it is (we have more loose stools in the spring and fall).

We do not worry about loose stools, as they can be very normal. Diarrhea is usually nothing to worry about unless it is red or black (which can both indicate blood), lasts longer than five days, or leads to dehydration; all of these should prompt you to go see your doctor. It is not unusual for babies to get 2-3 diarrhea illnesses per year. If diarrhea lasts longer than five days or has blood in it, we worry it may be due to a bacterial infection or some process affecting absorption. It would not be uncommon for the doctor to order some test on the stool so bring the baby’s last dirty diaper to the office with you (to be nice to your fellow men with noses it is best to seal it up in a zip-lock bag). For signs of dehydration, see the dehydration topic.

Blocked Tear Ducts:

In medical lingo blocked tear ducts are called nasolacrimal stenosis (I usually charge at least 10 dollars for that word). It means the drain at the inside corner of each eye is blocked which causes the normal tears produced by the eye for lubrication not to drain. This blockage will cause the baby to look like they are constantly crying during the day and when they sleep will cause their eye to mat shut. It is a very common condition and is the most common reason for you to see tears in a baby who is less than two months old. Most babies will outgrow this condition and for the majority of them it goes away between two and six months of life. We usually recommend you take a soft warm washcloth and gently rub in a circular motion at the inner corner of the eye for 3-5 minutes a couple times a day. If the blockage does not resolve by the time the baby is nine months old your pediatrician will usually refer you to a pediatric ophthalmologist who will take a look at your baby and possibly recommend a surgical procedure to open up the tear duct.

Dehydration:

Dehydration occurs when your balance of fluid is low. This can happen either by losing more fluid than is being taken in, or by just not taking enough fluid in to replace the amount your body is always naturally losing through urine, stool, sweat, or in your breath. For the most part it is going to happen through losses from diarrhea or vomiting more than the fluid being taken in. Signs of dehydration include decreased urination (keep track of wet diapers if your baby is sick), the inside of the mouth getting dry and tacky looking, lips getting dry (which can be peeling or all wrinkled looking), decreased tears, dry loose feeling skin (we call it tenting if you pinch the skin and it sort of just stays there in a tent appearance), or lethargy (this means just lying around and very hard to arouse). Dehydration is a very serious problem and if you believe your baby is dehydrated you need to get to your doctor’s clinic or the emergency room as soon as possible.

Umbilical Hernia:

To be honest, every baby will have an umbilical hernia, at least for a while. An umbilical hernia is a hole in the abdominal wall formed from where the umbilical cord goes through the abdominal wall of the baby. When the umbilical cord falls off the hole where the cord went through the abdominal wall it is called a hernia. When the baby cries or pushes out their abdomen when they are pooping you will see a bulge in their belly button. Umbilical hernias will usually close off by the time your baby is two years of age. I like to apply my “rule of thumb” in this situation; if I can put my thumb through the hole there is a good chance it is not going to go away. The umbilical hernia can bulge out quite a bit and I have seen some about the size of a peach that still go away on their own (the parents never believe me, but they do). If the umbilical hernia is still there after they are two years old then it probably is not going to go away. Most pediatric surgeons like to wait until they are between four and six years of age to fix them so the risk of putting them to sleep for the surgery goes down. This is something to ask your pediatrician, because they will know what is normally done in your area.