Common Medical Problems

Asthma

Attention Deficit Hyperactivity Disorder

Children who are impulsive, inattentive, or overactive are frequently referred to pediatricians for evaluation.  Between 4 and 12 percent of all school-age children may have Attention Deficit Hyperactivity Disorder (ADHD) making it the most common childhood neurobehavioral disorder.

The symptom complex of attention-deficit / hyperactivity disorder (AD/HD) has been described for more than 100 years.  The 1994 revision of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) contains the most widely accepted diagnostic criteria to date.  These criteria require that ADHD symptoms be present in two or more of a child's settings. For example, a child must show symptoms at both school and home. Some of the symptoms must be present prior to age 7, and the symptoms must adversely affect both the child's academic and social functioning in order to be diagnosed as ADHD.   

Evaluation of a child with ADHD should also include a thorough assessment for co-existing conditions. Those conditions include: conduct disorder, oppositional defiant disorder, mood disorders and depression, anxiety, and learning disabilities. This is important because as many as one-third of children diagnosed with ADHD also have a co-existing condition that contributes to or may even be the cause of school difficulties.  Occasionally, medical problems cause or contribute significantly to ADHD symptoms.  For this reason, a complete physical exam is a necessary part of the ADHD evaluation.

Diagnosis of hyperactivity and ADHD in children age 5 and younger is unreliable, because children change so rapidly during the pre-school years.

 National Institute of Mental Health ADHD web site:

http://www.nimh.nih.gov/

Northside Pediatrics maintains a high level of interest in providing the highest quality of comprehensive care for children and adolescents with learning differences and difficulties.  In consultation with area psychologists, psychiatrists, and school systems, we have established a practice process for evaluation and management of children with school difficulties.

Our process for evaluation and management of children with symptoms consistent with ADD and ADHD was developed in accordance with the American Academy of Pediatrics (AAP) guidelines for evaluation and management of children with ADD and ADHD (http://www.aap.org/healthtopics/adhd.cfm).

Our evaluation and management process incorporates items from the ADHD Toolkit which were developed by the AAP along with McNeil Pharmaceuticals and the National Initiative for Children's Healthcare Quality (NICHQ).  Vanderbilt initial and follow-up ADHD questionnaires (from the Toolkit) are available on this web page and our practice policy for evaluation and for management of children with suspected and confirmed ADD or ADHD is also on this web page.  

Our physicians are available by appointment to discuss the details of our process and your child's specific needs.

Additional Resources for patients with ADD/ADHD

Organizations

CHADD- Children and Adults with Attention Deficit Disorder-Atlanta, http://www.chadd.net/template.cfm?affid=183&p=about 770-394-0675.

State Department of Education-special education, learning disabilities, emotional and behavioral disorders, www.doe.k12.gr.us/curriculum/exceptional/index.asp 404/656-3963

Learning Disabilities Association of Georgia www.ldag.org  404/303-7774

Parents Educating Parents- 770/577-7771

Parent to Parent  www.parenttoparentofga.org  770/451-5484

 Computer Software/Support Companies

Educational Resources  www.edresources.com  800/860-7004

Gamco www.gamco.com 800/890-8166

 Educational Materials

ADD Warehouse  www.addwarehouse.com 800/233-9273

Continental Press www.continentalpress.com 800/233-0759

Educators Publishing Services  www.epsbooks.com 800/225-5750

Free Spirit Publishing  www.freespirit.com 800/735-7323

Lakeshore Publishers www.lakeshorelearning.com 800/421-5354

Landmark School Outreach Program  www.landmarkschool.org  978/236-3010

Pro-Ed  www.proedinc.com  800/897-3202

Reading for the Blind and Disabled  www.rfbd.org   866/732-3585

Steck Vaughn  www.steck-vaughn.com  800/531-5015

Zephyr Press  www.zephyrpress.com  800-232-2187

 Books:

Mel Levine, All Kinds of Minds; Keeping Ahead in School; Educational Care, Educators Publishing Services.

Russell Barkeley, Taking Charge of ADHD; Defiant Children, Guilford Press.

Larry Silver, The Misunderstood Child; Dr. Larry Silver’s Advice for Parents on ADHD, Three Rivers Press

S. Garber, Beyond Ritalin, Harper

Betty B. Osman, No One to Play With, Academic Therapy Publishers

Betty B. Osman, Learning Disabilities and ADHD, John Wiley and Sons, Inc

Stephen Nowicki and Marshall Duke, Helping the Child Who Does Not Fit In, Peachtree Publishers

Sandra Rief, How to Reach/Teach Children with ADD/ADHD, John Wiley and Sons, Inc.

 Internet:

www.ldonline.org- Learning disabilities resources

www.chadd.org- Children and Adults with ADD, links to local chapters

www.ed.gov- US Department of Education site

www.wrightslaw.com- Special Education Advocate site

www.ideapractices.org- Council for Exceptional Children’s site providing resources to improve educational outcomes for special needs and gifted students

www.allkindsofminds.com- Nonprofit institute dedicated to helping students who struggle with learning  

Bronchiolitis

Bronchiolitis is a viral infection of the small airways of the Lungs. It is usually an illness of small children under 2 years of age. Several different types of viruses can cause it, but the most common virus is the Respiratory Syncytial Virus otherwise known as RSV.

Children acquire the viral infection from siblings or parents with colds, from daycare centers and from other public places. The illness is most common in the fall and winter months.

Initially Bronchiolitis starts off as a typical cold with a runny nose, mild cough and a fever. Within a few days, wheezing may develop along with more rapid breathing and difficulty eating.

If your child develops any signs of difficulty breathing such as wheezing, breathing very fast, using extra muscles to help him/her breath (if you can count their ribs sticking out or see their chest pulling in) call your doctor’s office immediately.

If your child is diagnosed with Bronchiolitis the doctor may try a breathing medicine called Albuterol to help open up the small airways of the lungs. Albuterol may or may not decrease your child’s symptoms since it has variable effects in patients with Bronchiolitis. Albuterol can be given by mouth or inhaled through a special device called a spacer or aerochamber. After the doctor examines your child, he/she will best be able to determine if Albuterol is appropriate for your child and which is the best way to administer it.

The illness typically last 7 to 10 days, but the period where you may notice difficulty breathing usually lasts 3 to 5 days. The doctor may want to recheck your child in the office to make sure they are getting better. Approximately 5% of children with Bronchiolitis will require hospitalization. These are usually children who require oxygen or very frequent breathing treatments.

Children who have Bronchiolitis are at a slight increase risk for having childhood Asthma, especially if there is a family history of Asthma.

Gastroenteritis

Gastroenteritis is also known to some as the "stomach flu", or "intestinal flu," but it is not really flu at all. It is due to a number of causes including several different viruses, bacteria, and parasites. The average child has 1 to 2 cases per year, but children in daycare can have up to 3 times more cases a year. It is spread through improper hand washing and contamination by stools or vomiting. Incubation is usually 1 to 2 days after exposure and symptoms last 2 to 7 days. Over 90% of the cases of gastroenteritis are caused by viruses and are usually brief and self limited (i.e. will go away with no therapy); however, some children can be severely affected becoming dehydrated, and requiring hospitalization. A small percentage of children die each year in the U.S. from these diseases. This overview is mainly related to viral gastroenteritis.

Although not always present, vomiting is usually the first symptom seen with gastroenteritis. It is often associated with low grade fevers. If there is any blood in the vomit or dark green color in the vomit, call your physician immediately. Vomiting (and diarrhea) cause your body to lose fluids as well as salts called "electrolytes" such as sodium and potassium. You need to replace these salts with the liquids that you are feeding your child. These salts can be found in "oral rehydration solutions (ORS)" such as Pedialyte, Infalyte, and Kayolectrolyte. To make these more palatable you can add one teaspoon of powdered Kool-Aid to each 8 oz. glass or bottle. Unfortunately, the salt content of regular juices, sodas and water is not enough to properly rehydrate your child and should be avoided. Water alone can cause a serious illness called water intoxication which can actually lead to seizures.

To treat your child’s vomiting:

1. Rest the stomach for 30 to 60 minutes after vomiting occurs.
2. When starting fluids give very small amounts (one ounce) of clear ORS’s every 15 to 30 minutes.. .
3. If your child vomits during this treatment, give nothing for one hour and then start over with smaller amounts such as 1 tsp. to half an ounce.
4. After 6 hours without vomiting, you may gradually increase your child’s diet to a soft or bland diet. If your baby takes formula or breast feeds start slowly with these. You may use your breast milk as an ORS by nursing every 15 minutes, 2 to 3 minutes each time as long as the baby tolerates it without vomiting. If vomiting persists, switch to a clear ORS such as Pedialyte, Infalyte, or Kayolectrolyte.

Diarrhea usually begins within 48 hours of vomiting, although it is not always present. A wide variety of stools occur with gastroenteritis from a few mild loose or mushy stools to severe constant watery explosive stools. If you ever notice blood or mucus in stools, call your physician’s office immediately. A green stool indicates a very rapid passage of contents through the gastrointestinal tract. Keeping your child on nothing but clear fluids more than two days can cause green watery stools called "starvation stools." The American Academy of Pediatrics and many universities have done studies on what to feed children with diarrhea. The results were surprising to many people. In general, you can feed your child a regular age appropriate diet once the vomiting has stopped. This includes milk products. This has been found to help provide nutrients which aides the lining of your intestines to heal. Regular diets usually do not lengthen the time of diarrhea or worsen the symptoms of the illness. Well tolerated foods are complex carbohydrates such as starchy foods like breads, cereals and rice.

Dehydration is the side effect of gastroenteritis that we are trying to avoid with all of the above therapies. Signs of dehydration include:

• No urine output for 8 hours
• Dark colored urine
• Moisture not seen on the inside of the mouth
• Sunken eyes or fontanelles in infants
• No tears when crying
• Listless or difficult to arouse children

If any of these symptoms occur call your physician’s office.

Occasionally gastroenteritis will mimic other conditions which can be more serious, or your child may have a more serious bacterial gastroenteritis. If your child has any of the following symptoms call our office right away.

• Shortness of breath
• Worsening abdominal pain
• Stomach swelling
• Bloody or mucusy stools
• "Currant jelly" appearing stools
• Diarrhea lasting longer than 7 days

There is no medication to make viral gastroenteritis go away any quicker or decrease symptoms without causing side effects to your children. Medications such as Immodium (Lomotil), Pepto Bismol or Kaopectate can actually make your child’s symptoms last longer. Your child’s immune system is the best medication against gastroenteritis. By using the above measures, your child should recover without complication from gastroenteritis within 2 to 7 days.

Influenza

Influenza, or the “flu,” is a respiratory virus that infects the nose, throat, windpipe and lungs. Typical symptoms include fever, chills, muscle aches, congestion, runny nose, sore throat, cough and difficulty breathing. Although some people with the flu have nausea, vomiting or diarrhea, these are not common symptoms. The flu usually occurs between October and April of each year and is very contagious spreading from person to person by coughing, sneezing or talking. Many viruses cause similar symptoms but flu tends to be more severe and prolonged.

Every year in the United States approximately 200,000 people are hospitalized and 36,000 die from complications of influenza infection. The elderly, children under the age of two, people with chronic medical conditions that affect their ability to fight infections (such as diabetes, cancer, immune deficiency, asthma and heart disease), and those on immune suppressing medications are most at risk for serious complications and hospitalization from the flu.

Because influenza is a virus, it can’t be successfully treated with antibiotics. Therefore, it is important to try to prevent the flu. This is best accomplished by vaccination. Since the flu virus changes from year to year, it is necessary to receive vaccine every year to be protected. The vaccine will prevent moderate to severe disease in 70-90% of people who receive it. The vaccine is especially important in children, even healthy children with no risk factors. In 2003-2004, 152 children died from influenza; many were previously healthy and not in a high risk group. Additionally, people over 65 are most likely to catch the flu from young children so protecting the children has the added benefit of preventing deaths in the elderly. The flu shot is very safe. It is made from completely inactivated viruses and cannot possibly cause the flu. Some side effects include pain, redness or tenderness at the site of injection, muscle aches and low grade fever. Our office uses the injectible flu vaccine. A nasal spray form of the vaccine is available for healthy people ages 5-49 and may be available through the health department and some pharmacies.

Urinary Tract Infection (Question/Answers)

What is a Urinary Tract Infection (UTI)?

A UTI is a bacterial infection of the Urinary Tract involving the bladder (cystitis) and/or the Kidneys (pyelonephritis). UTI's occur in 3-5% of Girls and 1% of Boys. There are many risk factors for UTI's including the following: female, uncircumcised male, vesiculoureteral reflux (see below), urinary tract abnormalities, voiding dysfunction, bubble baths, constipation, tight clothing, sexual activity, and pregnancy.

Who gets tested for a UTI?

We test for a UTI in any child with symptoms including the following: pain with urination, increased frequency of urination, unusual odor to urine, back or lower abdominal pain, or fever without another cause (usually boys under 6-12 months of age and girls under 3 years of age).

How do we test for UTI's?

Catheterized specimens are the most accurate, followed by a clean catch specimen. Clean catch specimens are usually acceptable for toilet-trained children who are able to cooperate with the collection. Catheterized specimens are used for infants, children not yet toilet trained, and acutely ill patients. Bag specimens are not reliable and therefore are not used regularly to test for a UTI.

What if my child has a UTI?

If your child's urine culture comes back positive for a UTI they will be placed on an antibiotic that will most appropriately treat the bacteria causing the infection. Usually, children will be placed on a ten-day course of antibiotics. Then after completing antibiotics, we request that they have a repeat urine culture 3 to 4 days later. If the child becomes sicker or symptoms do not seem to improve within 48-72 hours they will need to be re-evaluated.

If your child was diagnosed with a UTI and is a boy at any age, a girl under the age of 6, or an older girl with recurrent UTI's your doctor will discuss the need for further studies.

What further studies may be necessary?

A renal and bladder ultrasound look at the size, shape, and structure of the urinary tract system to identify any structural abnormalities, evidence of scarring, or poor growth of the kidneys.

A Voiding Cystourethrogram (VCUG) checks for vesiculoureteral reflux (VUR). VUR is particularly important because infected urine flows retrograde to the kidneys and can cause kidney scarring and damage. The only way to detect it is through a VCUG. The VCUG involves instilling contrast into the bladder by catheterization and then imaging during bladder filling and voiding to look for the grade reflux. Of children undergoing a VCUG, 40% will have reflux. Approximately 1/3 of siblings of children with reflux have it as well.

What if the studies are abnormal?

Your doctor will discuss the results with you after the tests are done. Usually the results are available within one to two days. If your child has VUR the doctor will discuss prophylactic antibiotics that are taken at bedtime to keep the urine sterile until they outgrow the VUR. Depending on the antibiotic used, a complete blood count may be necessary every 6 months. A repeat VCUG will be necessary each year until they outgrow the VUR. If there are any other abnormalities on the test your doctor will discuss what else, if anything, needs to be done.

Obesity

The Problem

Childhood obesity has rapidly become a public health problem in the United States.  Over 15% of children ages 6-19, more than 9 million children and adolescents, are overweight and another 15% are “at risk” of becoming overweight.  The causes for this epidemic are multiple but mostly relate to a decrease in physical activity and poor eating habits.  Very few children are obese due to genetic or endocrine problems.  Overweight is a problem with energy balance – calories eaten verses calories burned.  Overweight children are at risk of major health problems, including: Insulin resistance and Type 2 diabetes, liver disease, gall stones, high blood pressure, sleep apnea, orthopedic problems and many others.  Overweight children also experience mental health problems such as low self-esteem, loneliness, depression, and nervousness.  These behaviors can lead to other behaviors associated with poor health such as smoking, alcohol use, and increased overeating.  These issues are much better prevented than treated.  The sooner your child adopts healthy habits, the more likely they are to carry them into adult life with obvious benefits to their health today and in the future.

Why now?

Over the past two decades, American children’s eating habits have changed.  They consume foods higher in fat and sugar content and eat bigger portion sizes.  Many meals are eaten outside the home and on the run, resulting in excess calories and poor nutritional value.  The amount of physical activity in which our children participate has dramatically changed.   Sedentary behaviors such as watching T.V., playing on the computer, and playing video games often replace physical activity.

Who can help?

If you feel your child is at risk of becoming overweight or is overweight, you should seek help from your pediatrician.  He will need to take a good history and perform a physical exam and calculate your child’s Body Mass Index (BMI).  Your child also may need a blood pressure and blood work.  Your pediatrician should provide you with information about healthy eating and physical activity.

Watching your child’s weight is not just about preventing him/herthem from becoming fat or too thin.  It is intended to help them develop good habits for a lifetime.  Unless specifically directed by your pediatrician, do not focus on restricted diets or on losing weight.  Set an example for your children through healthy eating habits and participation in physical activity. Serve healthy food as part of a healthy life style.  Have your children help with food selection and preparation. A guide to appropriate portion sizes generally can be based on everyone’s own fist size.  The Food Guide Pyramid can also teach healthy eating habits and is geared toward children older than 6.  You can find this pyramid at www.usda.gov/cnpp.  For children 6 and under, the appropriate pyramid can be  found at www.usda.gov/cnpp/KidsPyra/LittlePyr.pdf.  This pyramid has smaller portion sizes.

Promote healthy eating

Emphasize meal time and good mealtime behavior. .  Families who eat meals together at home eat more vegetables and less saturated fat and fried foods.  All meals and snack should be eaten at the table.  Eating together as a family without the distraction of TV encourages conversation and slows down the eating process.  Once your stomach is full, it takes your brain about 20 minutes to know you are full.  Eating more slowly will decrease how much you and your children eat. Liquids can be filling, so having a glass of water before meal time will limit a child’s intake.  REMEMBER, juice, sports drinks and soda are loaded with calories and increase the risk for cavities.  Diet soda will reduce the sugar and calorie intake but provide no nutritional value, and all carbonated drinks decrease bone density.  Water is the best “DIET” drink.  Snacks should consist of healthy food to help kids grow.  This is a great time to offer more vegetables or fruit.  Most toddlers and children need one snack.  Make sure the snack is eaten at least one and a half hours before a meal.  Most children (and many adults) have little will power so if sugary or high calorie foods are in the pantry, someone is going to eat them.  Try to stock your pantry and refrigerator with healthy alternatives   Food SHOULD NOT be used as a reward.   High-calorie desserts on occasion are reasonable, but fruit can be a healthier choice.

Promote physical activity

Encourage physical activity and do this as a family. Moderate physical activity is activity that causes one to sweat and the US Surgeon General recommends children engage in at least 60 minutes 5-6 days per week. Send the kids outdoors for a break before homework.  Limit TV, computer, video game time to less than 2 hours a day- the less the better. If the weather is not nice or the neighborhood is not safe, find alternative activities that can be done indoors such as dancing, tumbling, jumping rope and hoola-hoop.

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