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Language Development in Young Children

What is language?
What does a language disorder look like?
What causes a language disorder?
Who do I talk to about this first?
What is a speech language pathologist?
Therapy sounds like drudgery-my child will hate it!

by Melanie Potock, M.A., CCC-SLP Speech Language Pathologist Pediatric Rehabilitation Department Boulder Community Hospital’s Mapleton Center Boulder, Colorado
When you s to think about it, it is truly amazing that infants and young children learn language without conscious teaching, but simply by “soaking it up” as they listen, watch, and imitate those around them. As if by magic, the average 5-year-old child uses and understands a multitude of words. He/she can combine the words to decipher and generate lengthy sentences; add prefixes, suffixes, and various tenses; change the word order or the intonation to change the meaning; and add gesture and body positioning to emphasize his/her point. It is a complicated system that we take for granted, and, for some children, early language development can be challenging.

What is language?
It is easiest to explain what language is not-language is not speech. Speech refers to the developmental process known as articulation. Sounds, syllables, and words are formed when the vocal chords, tongue, jaw, teeth, lips, and palate change the stream of air that is produced by the respiratory system. The English language is a complicated system that can be defined by the following units: phonology, morphology, syntax, semantics, and pragmatics. Basically, the English language is governed by a set of rules. For some children, understanding (receptive language) and using (expressive language) these rules appropriately can be difficult. A significant delay in receptive and expressive language skills may be referred to as a language disorder. It is important to note that language processing and cognition are two different issues. Many very bright children have difficulty with language, and may simply require a “boost” in language skills from a qualified speech language pathologist.

What does a language disorder look like?
Because there are so many different aspects to language, not all language disorders look alike. For example, obvious delays in expressive language are evident in a 2-year-old child who has a vocabulary of less than 50 words, or in the 3-year-old child who cannot combine more than two words together. Some children with language disorders progress through their toddler years in a typical manner, but have difficulty when they are older using salient language or maintaining the ic of conversation. Other children may have difficulty with receptive language skills and appear to always misunderstand what has been said to them or be considered “poor listeners.” They may have problems with attention or following directions. Language problems may surface in the aspect of pragmatics, such as the child who always seems to say the wrong thing at the wrong time, or who has limited social skills with his/her peers. Language difficulties may be apparent when children have difficulties in reading and writing, and even in math.

What causes a language disorder?
True, kids not only “say the darndest things,” but they say them in such a cute way. What is not The cause of a language disorder depends on the type of delay. Sometimes, it can be pinpointed to an obvious event in the child’s life, such as a brain injury. However, many language disorders have no known cause. Although specific parts of the brain govern specific language skills, it is often impossible to determine why a child has difficulty with a certain aspect of language.

Who do I talk to about this first?
Parents should contact their child’s doctor to discuss the possibility of consulting with a certified speech language pathologist if they are concerned about their child’s language skills. Early intervention is considered the “best practice,” and it is especially important when the child appears to be having any type of difficulty with gestural, spoken, or written communication.

What is a speech language pathologist?
A speech language pathologist (commonly know as a speech therapist) holds a master’s degree or doctorate, and is trained to evaluate and treat speech, language, and learning issues. Some speech language therapists have additional training in feeding, augmentative communication, and other highly specialized areas. Some therapists work strictly with adults, while other therapists work with children. It is important to ask the therapist if he/she has experience with language disorders in children. Parents should always be sure that the therapist is certified by the American Speech-Language Hearing Association and is licensed by their state. A skilled speech language pathologist will assess the child’s skills, while consulting with other professionals to rule out other conditions that may be impacting language skills, such as hearing loss, sensory integration problems, or emotional disturbances.

Therapy sounds like drudgeryâ€¦my child will hate it!
Surprisingly to many parents, speech language therapy does not have to be a dreaded task. In fact, it does not feel like “therapy” to many children. Speech language pathologists incorporate group activities, games, movement, computers, crafts, and even cooking into the therapy sessions to facilitate language development.

Lead Poisoning

http://www.cdc.gov/nceh/lead/about/program.htm

Leukemia

What is leukemia?
What is acute lymphoblastic leukemia?
What causes acute lymphoblastic leukemia?
Who gets acute lymphoblastic leukemia?
What are the common symptoms at diagnosis?
How is acute lymphoblastic leukemia diagnosed?
How is acute lymphoblastic leukemia treated?
What are the complications?
What research is being done?
Links to other information

Linda C. Stork, M.D. Associate Professor, Pediatrics University of Colorado School of Medicine Pediatric Oncologist, The Children’s Hospital
What is leukemia?
Leukemia is a cancer of the blood cells that begins in the bone marrow or the lymph glands where the blood cells are made. Bone marrow occupies the center of all bones, especially bones of the pelvis, the lower spine, and the thighs. Lymph nodes are all over the body, but they usually are too small to feel.
Like all cancers, leukemia is caused by uncontrolled cell division and growth. There are “signals” and “switches” within the genetic material and proteins of each cell of the body that strictly control whether the cells start or s dividing to make more cells. For example, when a finger is cut, these “signals” and “switches” tell the skin cells to regrow just enough to replace the area of damaged skin and then to s, without forming big lumps of skin.
Leukemia usually develops in the white blood cells that normally circulate through the blood stream and the lymph nodes to defend the body against infection. Leukemia begins in one cell whose “signals” and “switches” have sped working correctly. This one abnormal cell divides into two abnormal cells, which divide into more and more abnormal cells. These leukemia cells eventually fill up the bone marrow space, thereby crowding out normal bone marrow cells and spreading into the blood stream and the lymph nodes. As a result, the cells that carry oxygen (red blood cells), the cells that help clot blood (platelets), and the normal white cells that fight infection are reduced greatly in number.

What is acute lymphoblastic leukemia?
Acute lymphoblastic leukemia is the most common leukemia and cancer of childhood. The word “acute” refers to the fact that patients diagnosed with this leukemia in the early 20th century survived for only a short time. The word “lymphoblastic” refers to the type of white cell that has become cancer. Normal lymphoblasts mature over days to weeks into lymphocytes that defend against infection. Lymphoblasts of leukemia cannot mature or fight infection.

What causes acute lymphoblastic leukemia?
The cause of this type of leukemia is unknown; therefore, it cannot be prevented at the present time. Several changes that occur in a normal lymphocyte over a period of time probably turn it into a leukemic cell. For some cases of acute lymphoblastic leukemia, the first change occurs in fetal life before birth.
Exposure to electrical power lines, toxic chemicals, radon, or radiation has not been proven to cause this leukemia. Although a specific virus causes leukemia in cats, viruses do not appear to cause acute lymphoblastic leukemia in children. This type of leukemia does not appear to be inherited because it very rarely occurs in more than one child per family.

Who gets acute lymphoblastic leukemia?
Acute lymphoblastic leukemia is rare. Its incidence is fairly similar worldwide. In the United States, about 3,000 children are diagnosed with this disease each year. For children between infancy and 15 years, acute lymphoblastic leukemia occurs yearly in 1 child among every 25,000 children. For patients aged 2 to 6 years, acute lymphoblastic leukemia occurs yearly in 1 child among every 5,000 to 10,000 children. Although very rare, even newborns and adults can develop acute lymphoblastic leukemia. In the United States, acute lymphoblastic leukemia is much less common among African Americans than Caucasians; however, the reason for this difference is unclear.

What are the common symptoms at diagnosis?
The symptoms of acute lymphoblastic leukemia often mimic more common illnesses of childhood. These symptoms are related to reduced numbers of normal bone marrow and blood cells. Patients develop anemia because of low numbers of the red blood cells; they often appear pale with fast heart rates, and, sometimes, they feel lightheaded and tire out easily. Patients with acute lymphoblastic leukemia often bruise more easily and get more nosebleeds because the cells that clot blood (platelets) are low in number. Patients often have several weeks of unexplained fever before acute lymphoblastic leukemia is diagnosed. Sometimes, these fevers are because of infections; other times, they are because of the leukemia itself. About 25% of patients experience bone pain for days to weeks before the diagnosis, especially in the pelvis, the spine, and the legs. About 50% of patients develop swollen lymph nodes in the neck, under the armpits, or in the groin. The liver and the spleen, usually tucked beneath the right and left lower rib cage in the abdomen, can enlarge and become painful as leukemic cells fill the many blood vessels within these organs. Occasionally, a boy’s testicles swell as leukemic cells invade them. The lymph nodes deep within the chest may become swollen with leukemic cells, causing a child to breathe faster and harder than normal.

How is acute lymphoblastic leukemia diagnosed?
The symptoms described above will prompt a physician to draw the child’s blood for a complete blood count (CBC). Often, this CBC shows that the number of red blood cells, and/or platelets, and/or type of white cell called “neutrophils” is low. The total number of white cells in the CBC may range from very low to very high. The lymphoblasts may be recognized on the blood smear when viewed in the laboratory under the microscope.
The final diagnosis of acute lymphoblastic leukemia is made by a bone marrow examination. The bone marrow procedure entails placing a needle into the pelvic bone a few inches to the right or left of the spine and a few inches above the buttocks. This needle goes through the skin, the muscle, and the bone, and into the bone marrow space. From here, liquid bone marrow, filled with leukemic cells, is aspirated into an attached syringe. The bone marrow aspiration procedure is painful; a child usually is sedated and given pain medicine during the procedure.
Children with symptoms similar to those of patients with leukemia may have a different diagnosis. In those cases, the CBC is either completely normal or has abnormalities of only one blood cell type. Certain viral infections, joint diseases, or other blood diseases can mimic the symptoms of leukemia. Occasionally, children with acute lymphoblastic leukemia have symptoms of fever and bone or joint pain and a completely normal CBC. In such cases, the diagnosis is uncertain until the bone marrow aspiration shows the leukemia.

How is acute lymphoblastic leukemia treated?
If untreated, acute lymphoblastic leukemia is a fatal disease. However, with modern day treatment, the majority of children with acute lymphoblastic leukemia are cured. Since the 1960s, many children with acute lymphoblastic leukemia and other cancers have participated in randomized clinical trials sponsored by national cooperative organizations, such as the Children’s Cancer Group and the Pediatric Oncology Group. Major progress in the treatment of childhood cancers has been made because of the research efforts of these groups.
Children with leukemia are treated by pediatric oncologists and nurses in specialized facilities; patients and families usually are supported by social workers and child life specialists.
The medicines used to treat leukemia and other cancers are called chemotherapy. Chemotherapy drugs can be taken by mouth or injected into the blood stream through a vein, into soft tissue, or into muscle. Because leukemic cells tend to “hide out” in the lining of the brain and the spine, specific chemotherapy is injected into the spinal fluid by a procedure called a lumbar puncture. This procedure involves inserting a small needle into a space between two vertebrae of the lower spine, removing some spinal fluid, and injecting chemotherapy into the spinal fluid space. This procedure usually is performed with ical anesthetic and sedation.
Some of the chemotherapy drugs originally came from products of nature, such as the periwinkle and may apple plant or the bark of the yew tree, or from microorganisms, such as fungus. Other chemotherapy drugs were designed in laboratories. The first chemotherapy drug was developed in the late 1940s. Before that time, patients with acute lymphoblastic leukemia did not survive; all of them died of infection or bleeding within several months of diagnosis.
Treatment of acute lymphoblastic leukemia has evolved during the past 40 years; today, a child may receive up to 15 different chemotherapy drugs during a 2- to 3-year period. Occasionally, radiation therapy is given to the brain. After the first month of treatment, the child is usually in “remission”; 99% of the leukemia cells have been killed, and the CBC and the bone marrow look normal. During the next 2 to 3 years of treatment, chemotherapy attempts to kill the remaining 1% of leukemic cells, which are heartier than those initially killed.
For at least 70% of children, the leukemia never reappears, and these children grow up normally. If the leukemia recurs, it is called a “relapse” and is found in the blood and the bone marrow, the spinal fluid, or the testicles. A relapse can occur any time after remission, but it usually is between 18 months and 5 years after the initial diagnosis. A CBC is performed frequently, along with a physical exam, throughout the course of treatment and for many years thereafter to document continued remission or to diagnose a relapse. About 50% of patients who relapse can be cured with either bone marrow transplantation or several more years of intensive therapy.

What are the complications?
Most patients require treatment with antibiotics and transfusions of red blood cells and platelets at diagnosis and during treatment. Once a child is in remission, complications of treatment are from side effects of chemotherapy and not from the leukemia itself. Chemotherapy drugs circulate throughout the entire blood stream and affect normal cells, especially those cells that are dividing rapidly. One common side effect is hair loss, which usually grows back after the first year of treatment. Some side effects can be prevented; most of them are reversible. Occasionally, a child in remission dies from a complication of treatment, usually an overwhelming infection.

What research is being done?
Randomized clinical trials that aim to improve the cure rate of leukemia are being conducted by the Children’s Oncology Group in most children’s hospitals in the United States and Canada. Research on leukemic cells is being carried out in many laboratories throughout the world. The purpose of this research is to develop new strategies to treat leukemia; to determine what changes occur in a cell to cause leukemia; and, ultimately, to prevent a child from developing leukemia.

Links to other information
For more information on acute lymphoblastic leukemia, log on to the following Web sites:
NCI Web site: http://www.nci.nih.gov
Leukemia Society Web site: http://www.leukemia.org
CCG Web site: http://www.nccf.org
POG Web site: http://www.pog.ufl.edu

References
Lilleyman JS. Childhood Leukemia: The Facts. Oxford, England: Oxford University Press; 1994.
Laszlo J. The Cure of Childhood Leukemia: Into the Age of Miracles. New Brunswick, NJ: Rutgers University Press; 1995.
Albano EA, Stork LC, Greffe BS, Odom LF, Foreman NK. Neoplastic disease. In: Hay W, Hayward A, eds. Current Pediatric Diagnosis and Treatment. Stanford, CT: Appleton & Lange; 1999:774-777.
About the Author
Dr. Stork is an associate professor of pediatrics at the University of Colorado Health Sciences Center and The Children’s Hospital in Denver. She earned her undergraduate degree from Yale University and her medical degree from Columbia University. Dr. Stork is actively involved in clinical trials that treat children with acute lymphoblastic leukemia.
Copyright 2012 Linda C. Stork, M.D., All Rights Reserved

Lung Hypoplasia

What is Lung Hypoplasia?
What Causes Lung Hypoplasia?
Who Gets It?
How does it cause disease?
Common Findings
Diagnosis
Treatment
Prevention

Reese H. Clark, M.D. Director of Research Pediatrix Medical Group, Inc. Fort Lauderdale, Florida
What is Lung Hypoplasia?
In general terms lung hypoplasia means under developed lungs. Hypo means small, plasia means formed. The lungs are a vital organ and without them we can not live. The lung is made up of small gas exchange units called alveoli. Alveoli are thin walled structures that are surrounded by small veins and arteries called capillaries. Gas in the alveoli is exchanged with gas in the blood allowing oxygen to be delivered to tissue as a key element for body function and carbon dioxide to be eliminated from the body.
When the lung is hypoplastic the number of alveoli that are available for gas exchange are decreased. If the lungs are very hypoplastic the number of gas exchange units reaches a critically low level and adequate gas exchange can not be maintained. Newborn babies with very hypoplastic lungs die of lung failure in the first few days of life if they cannot be supported long enough to grow more lung.

What Causes Lung Hypoplasia?
The lung begins forming very early in fetal development. Any thing that restricts growth of the chest can cause the lung to be under developed. It is important to distinguish lung hypoplasia from lung immaturity. They are not the same things though, functionally, they have the same effect. Both lead to inadequate gas exchange and lung failure. Babies born prematurely have immature lungs with a developmental normal number of alveoli. The goal in caring for these babies is to support them in a manner that prevents injury to the lung. If injury is avoided these babies can have normal lung development.
In contrast events that impact fetal lung growth may effect future lung growth and may prevent babies with lung hypoplasia from ever developing a normal complement of alveoli.
The most common causes of poor fetal lung growth are: inadequate amniotic fluid, congenital diaphragmatic hernia, hydrops fetalis, certain types of dwarfism, pulmonary agenesis, cystic adenomatous formation, and cystic hydroma. In each of these anomalies, the fetal lung does not grow to its normal size. Inadequate amniotic fluid is most commonly due to early leaking of amniotic fluid due to premature rupture of the membranes that surround the fetus. This is known as oligohydramnios (too little amniotic fluid). If amniotic fluid leaks out from around the baby, the chest wall movement that occurs with fetal breathing may be restricted. Fetal breathing and adequate fluid pressure are both believed vitally important for normal lung development.
The second most common cause for inadequate amniotic fluid is fetal renal anomalies. Amniotic fluid is produced by the amniotic membranes and by the fetal kidneys. Severe abnormalities of the kidneys (eg. polycystic kidneys, hydronephrosis, renal agenesis) can cause too little amniotic fluid to be formed (oligohydramnios) and are commonly associated with lung hypoplasia. Babies with kidney and lung problems have a particularly grave prognosis because they have two organ systems that have failed.
Structural problems in development may also impair lung growth. In babies with congenital diaphragmatic hernia, the diaphragm that separates the lung form the abdomen fails to develop. As a consequence, the intestines move into the chest cavity and restrict lung growth. Similarly, certain types of dwarfism or congenital anomalies of the lung restrict the area in which the lungs can grow normally. While most of these anomalies are rare (1:3000), they are commonly life threatening.

Who Gets It?
Babies born to mothers with prolong rupture of amniotic membranes and oligohydramnios.
Newborns with severe renal anomalies, born to mother with resultant oligohydramnios.
Newborns with certain congenital anomalies

Congenital diaphragmatic hernia
Thanahoric dwarfism
Cystic hydroma
Cystic adenomatosis malformation
Newborns with hydrops fetalis
Newborns with neuromuscular diseases

How does it cause disease?
Small lungs fail to accomplish normal gas exchange (oxygen in, carbon dioxide out.)
Common Findings
The presentation is variable and dependent on the severity of the hypoplasia. Some babies may present with mild tachypnea (fast breathing) others may have signs of severe respiratory failure: fast breathing, labored breathing, blue color, and gasping.

Diagnosis
The most important factors leading to a diagnosis are: history of fetal anomalies associated with lung hypoplasia, history of mom having too little amniotic fluid, and a chest radiograph showing small lungs.

Treatment
Currently, treatment is primarily supportive. This means that there is currently no available medicine that makes babies grow lungs. So, until lung growth occurs to an extent that the lung can support normal gas exchange, the babies must be supported by artificial means. The main problem is that all modes of artificial respiratory support are associated with lung injury. The trick is to support normal gas exchange without causing injury and to support good nutrition so that the lung can grow. Babies have an incredible capacity to grow and develop. In time, if the lung is not too underdeveloped the baby can usually wean off artificial support and go home. Therapies used to support gas exchange in order of level of support are: oxygen, assisted ventilation, high frequency ventilation, and extracorporeal membrane oxygenation (ECMO).

Prevention
There are no methods for preventing babies with certain anomalies from developing lung hypoplasia. Research is currently focused on maintaining normal amniotic fluid and pressure and prevention of restriction of lung growth. Investigators are also looking at factors that promote normal lung growth. The hope is that neonates with lung hypoplasia might be treated with lung growth factors that would promote growth of normal lung, reduce the need for artificial support and its attendant propensity to cause injury and allow for a healthier life.

About the Author
Dr. Clark, a leading clinical researcher for the care of critically ill newborns, is the Director of Research for Pediatrix Medical Group, Inc. and a Consulting Associate Professor at Duke University.
A native of North Carolina, Dr. Clark earned both his Bachelor of Arts and medical degrees from the University of North Carolina at Chapel Hill. He completed his pediatrics residency and his neonatal fellowship at Wilford Hall United States Air Forces Medical Center. He is a board-certified pediatrician and neonatologist.
Copyright 2012 Reese H. Clark, M.D., All Rights Reserved

Lyme Disease

What is Lyme Disease?
What causes Lyme Disease?
Who gets Lyme Disease?
How do the bacteria cause disease?
What are the common findings?
How is Lyme Disease diagnosed?
How is Lyme Disease treated?
What are the complications?
How can Lyme Disease be prevented?
What research is being done?
Links to additional information

by Eugene D. Shapiro, M.D. Yale University School of Medicine
What is Lyme Disease?
Lyme Disease is an infectious illness that has different manifestations depending on the stage of the illness (i.e., early localized disease, early disseminated disease, and late disease).

What causes Lyme Disease?
A type of bacteria called a spirochete, which is named Borrelia burgdorferi, causes Lyme Disease. The bacteria is transmitted by ticks of the Ixodid species; in the United States, this is usually Ixodes scapularis, which is also known by its common name, the deer tick.

Who gets Lyme Disease?
Lyme Disease occurs most commonly in areas where deer ticks are abundant and where the proportion of ticks that are infected with the bacteria that cause Lyme Disease is high (20% to 50%)-southern New England, southeastern New York, New Jersey, eastern Pennsylvania, eastern Maryland, Delaware, and parts of Minnesota and Wisconsin. The majority (greater than 75%) of the reported cases occurs in a small number of counties (less than 70) in these endemic areas.
Lyme Disease is uncommon in the Pacific states because, although the tick found there-Ixodes pacificus (the Western black-legged tick)-can transmit B. burgdorferi, few of these ticks are infected with the bacteria. People with increased occupational, recreational, or residential exposure to tick-infested woodlands and fields (the preferred habitat of ticks) in endemic areas are at an increased risk of developing Lyme Disease.
There are a number of factors associated with the risk of transmission of B. burgdorferi from ticks to humans. First, a tick has to be infected to be able to transmit the organism. The proportion of infected ticks varies greatly both by the geographic area and by the stage of the tick in its life cycle. Even in areas with the highest incidence of Lyme Disease, only about 20% to 30% of nymphal-stage ticks (the stage most likely to cause Lyme Disease) are infected.
Lyme Disease develops after an infected tick inoculates bacteria into the skin of its human victim. The risk of transmission of the bacteria from infected deer ticks is related to the duration of feeding. It takes hours for the mouth parts of ticks to implant fully, and much longer (days) for the tick to become fully engorged.
Experiments with animals have shown that nymphal-stage ticks must feed for 48 hours or longer, and adult ticks must feed for 72 hours or longer, before the risk of transmission of B. burgdorferi from infected ticks becomes substantial. The duration of time that a tick has fed can be estimated from measures of engorgement derived from experiments with animals.
Based on these studies, there is evidence that approximately 75% of persons who recognize that they have been bitten by a deer tick remove the tick less than 48 hours after it has begun to feed. Indeed, the majority of persons who develop Lyme Disease do not recall a tick bite. Unrecognized tick bites probably are associated with a greater risk, since unrecognized ticks may feed longer.

How do the bacteria cause disease?
The bacteria cause inflammation in the tissues that are infected. First, the inflammation usually causes a rash in the skin (known as erythema migrans) at the site of the tick bite. The bacteria may then enter the bloodstream and spread to other sites, which include other parts of the skin, the nervous system, and the heart. The bacteria may also infect the joints and cause inflammation that leads to arthritis. Rarely, but particularly in people who have a certain genetic predisposition, an autoimmune inflammatory process may develop in the joint so that inflammation continues even after the bacteria are killed by antibiotic treatment.

What are the common findings?
By far, the most common manifestation of Lyme Disease is the characteristic reddish rash, erythema migrans, which usually develops 7 to 14 days (and up to as many as 30 days) after the tick bite. This rash occurs in approximately 90% of children with Lyme Disease. It is a circular (or oblong) rash that increases in size over time, sometimes growing to as much as a foot or more in diameter. Although central clearing may occur (causing a characteristic “bull’s eye” appearance), it is probably even more common for the rash to be uniformly red. Fungal infections of the skin (“ringworm”), insect bites, and circular or “nummular” eczema rashes commonly are confused with erythema migrans.

Erythema Migrans
Approximately one-quarter of the children with erythema migrans will have multiple erythema migrans, which is a sign that the bacteria have spread through the bloodstream and “seeded” other sites in the skin. The “secondary” rashes are usually smaller than the primary rash, and fever; pains in the muscles, joints, or neck; headache; and/or fatigue often accompany them. Multiple erythema migrans is a manifestation of “early disseminated” Lyme Disease.
Another finding in the “early disseminated” stage of the disease is paralysis of the facial nerve. Rarely, patients may have meningitis or arrhythmia of the heart.
The common manifestation of late Lyme Disease is arthritis. The knee is usually affected (greater than 90% of the cases), but any joint may be involved. Although the joint is swollen, it may be either very painful or it may be associated with relatively little pain, and the patient sometimes is able to pursue most normal activities with little impairment. Fever and other signs, such as headache or fatigue, may or may not be present.
It is important to realize that although patients with Lyme Disease often have non-specific symptoms, such as headache, fever, fatigue, or muscle pain, these symptoms are virtually always accompanied by specific signs of Lyme Disease, such as the characteristic rash, facial palsy, or a swollen knee. These non-specific symptoms, when present without more specific signs of Lyme Disease, are virtually never caused by Lyme Disease.

How is Lyme Disease diagnosed?
The most common sign of Lyme Disease-the erythema migrans rash-is usually diagnosed based on its typical appearance; the history of possible exposure to ticks; and the fact that it enlarges over time, if untreated.
Tests for antibodies are not appropriate in persons with a single erythema migrans rash because they usually are negative at this early stage of the illness. By contrast, if the rash is not present, but other signs, such as facial palsy or a swollen knee, are present (and the clinical and epidemiologic history is consistent with Lyme Disease), antibody tests usually are used to diagnose the illness.
It is of critical importance to realize that, because false-positive tests are common, tests for antibodies against B. burgdorferi should not be used as a “screening test” for persons with only non-specific symptoms, such as fatigue, muscle or joint pain, or a headache. Use of the antibody tests for Lyme Disease in such situations has resulted in a very high frequency of misdiagnosis of Lyme Disease, and it has helped to perpetuate the myth that Lyme Disease is difficult to diagnose and to treat.

How is Lyme Disease treated?
An antibiotic administered by mouth (usually doxycycline or amoxicillin) is very effective in treating Lyme Disease. Occasionally, an antibiotic (usually ceftriaxone or penicillin) is given intravenously to treat infection of the central nervous system, such as meningitis, or in the rare instances in which arthritis does not respond to one or two courses of oral treatment.

What are the complications?
Complications are very rare. The most common cause of failure to respond to treatment is misdiagnosis, that is, the patient either does not have (and never did have) Lyme Disease, or the patient had Lyme Disease in the past, and the current symptoms are unrelated to the previous Lyme Disease. Very rarely, facial palsy may persist (usually only to a very mild degree). Very rarely, an autoimmune arthritis that does not respond to antimicrobial treatment and that is not related to persistence of bacteria may develop in persons with a genetic susceptibility to this problem, especially when antibiotic treatment has been delayed.
Chronic inflammation of the central nervous system with memory loss has been reported as a rare complication in adults for whom treatment was delayed for a long time (often not until years after the presumed time of the infection). Congenital Lyme Disease (transmission from a pregnant woman to her child) has not been documented; likewise, transmission of Lyme Disease via breastfeeding has not been shown to occur.

Links to additional information
There are many Internet sites that provide information about Lyme Disease; however, many are not supported by scientifically sound data, including many sites controlled by “patient-advocate” groups or individuals. One worthwhile site is that of the American Lyme Disease Foundation at www.aldf.com. Information also is available through the Web site of the Centers for Disease Control at www.cdc.gov/ncidod/dvbid/lyme/.

About the Author
Dr. Shapiro trained at the UCSF School of Medicine, Children’s Hospital of Pittsburgh, and the Yale School of Medicine, where he is currently a Professor of Pediatrics and of Epidemiology and Public Health.
He has conducted numerous research studies of Lyme Disease, the efficacy of vaccines, and bacteremia in children.
Copyright 2012 Eugene D. Shapiro, M.D., All Rights Reserved

Lymphadenopathy

What are swollen glands?
What causes enlarged lymph nodes?
Who gets enlarged lymph nodes?
What are the common findings?
How is an enlarged lymph node diagnosed?
How is an enlarged lymph node treated?
What are the complications?
How can enlarged lymph nodes be prevented?

Edythe A. Albano, M.D. Associate Professor of Pediatrics University of Colorado Health Sciences Center Pediatric Oncologist The Children’s Hospital Denver, CO
What are swollen glands?
The lumps that you feel in your neck or under your jaw when you have a cold or a sore throat are called lymph nodes. Lymph nodes are part of the body’s immune system. They help to destroy infectious germs, such as viruses (e.g., the common cold virus) and bacteria (e.g., strep). The lymph nodes make antibodies that will help keep you from being infected with a particular germ in the future.
Lymph nodes are located in the areas beside the head and the neck region. They can be found in the armpits, the groin, above the elbow, and deep inside the chest and the abdomen (belly). Their function is the same regardless of their location.

What causes enlarged lymph nodes?
When lymph nodes are active in fighting infection, they may become swollen and painful. Usually, the pain is mild, and the lymph node does not get much bigger than 2 centimeters (slightly under 1 inch) in size.
While lymph nodes are the most common cause of a lump or a bump in the neck, there are other, much less common causes, e.g., cysts from abnormalities of fetal development or thyroid gland enlargement. Usually, us can tell the difference on a physical examination.

Who gets enlarged lymph nodes?
Frequently, children have enlarged lymph nodes. The immune system of a child is constantly being exposed to germs that it has never seen before, and the lymph nodes may swell in reacting to those germs. In contrast, the immune system of an adult has seen most of the common germs, and has developed immunity to them.
Therefore, the lymph glands do not need to work so hard, and they are much less likely to become swollen. In fact, a study published in 1975 showed that 100% of children who are under 12 years of age had lymph nodes that could be felt in the neck.

What are the common findings?
In children, once a lymph node becomes enlarged, it may stay enlarged for a long time. Sometimes, several lymph nodes can become enlarged at the same time. Usually, the lymph node will begin to decrease in size within two to three weeks, but a little bump (less than 1 centimeter, or 1/4 to 1/2 inches, in size) may be present for months.
However, lymph nodes should not continue to grow in size (especially grow greater than 1 inch in diameter). If they do, you should contact us. Your doctor may want to measure the lymph node and record the findings in your chart for accurate comparison on your next examination.
Typically, a fever accompanies enlarged nodes when it is part of an infectious process. You also may have a sore throat, enlarged tonsils, an earache, a dental problem, or skin irritation or infection. Often, the problem that caused the swollen gland will bring you to us and not the swollen lymph node.

How is an enlarged lymph node diagnosed?
Generally, enlarged lymph nodes are evaluated by a physical examination. Your doctor will note:
the size and the location of the enlarged lymph node;
if one or more lymph nodes are involved;
if the node is tender
if it is associated with redness of the overlying skin; and
how it feels, e.g., soft, firm, rubbery, or hard.
Your doctor will examine the areas that the lymph node drains. For example, a lymph node under the jaw should prompt a careful examination of the mouth and the throat. Your doctor also will look for abnormalities that often are seen with enlarged lymph nodes, such as a skin rash or a swollen liver and/or spleen.
Enlarged lymph nodes that grow progressively or are very large in size (generally more than 3 centimeters, or 1 1/4 inches) may require more extensive evaluations, to include a blood count; blood tests for infections, e.g., mono; a skin test for TB; or an x-ray. This is particularly true if you have been losing weight, have joint pain or swelling, have persistent fevers and/or night sweats, or have other abnormalities that are found on a physical examination.

How is an enlarged lymph node treated?
Sometimes, an enlarged lymph node needs no treatment at all, particularly if it is enlarged because it is fighting a viral infection. Occasionally, antibiotics will be prescribed if the lymph node is infected with a bacterial germ or is enlarged due to a bacterial infection (e.g., strep throat). If the lymph node tenderness is a problem, acetaminophen or ibuprofen can be taken to ease the discomfort.
Although steroids (prednisone) will cause the lymph nodes to decrease in size, regardless of the cause of the enlargement, it is strongly discouraged because it could mask a serious underlying cause of the enlarged nodes, delay the correct diagnosis, and, possibly, complicate the treatment.
Rarely, us may recommend surgery to remove the lymph node so that it can be examined under the microscope for the presence of cancer or unusual infections. Usually, a course of antibiotics is administered first, before surgery is recommended. However, surgery is most likely to happen if:
the lymph node is large (greater than 3 centimeters, or 1 1/4 inches);
there are other abnormal physical examination findings, e.g., an enlarged liver and/or spleen;
the blood count is abnormal; or
the chest x-ray shows enlarged nodes.
Most people worry that a persistently enlarged lymph node is something very serious, like cancer. In children, this is rare. Even if us recommends a lymph node biopsy, it is not very likely to show cancer. In fact, in one study of 239 children who underwent lymph node biopsy, only 13% of the removed lymph nodes showed cancer.

What are the complications?
The lymph node itself may become infected (called lymphadenitis), which can be very painful, and is associated with redness and swelling. Usually, it requires antibiotics for treatment. Infrequently, the lymph node may have a pus pocket inside of it (i.e., an abscess) that requires an operation to drain it.
An enlarged lymph node that is felt immediately above the collarbone is unusual and seldom is associated with infection. If it occurs, you should contact us, as it may be a sign of a more serious condition. For example, in teenagers, swollen glands felt right above the collarbone could be the first sign of Hodgkin’s disease, a type of cancer that occurs in the lymph nodes.

How can enlarged lymph nodes be prevented?
Enlarged lymph nodes cannot be prevented. The lymph node helps the body to fight infection, and, in the process, the lymph gland may increase in size. This is normal. The lymph tissue decreases in size after puberty, and it becomes less noticeable. However, you should contact us if:
the lymph nodes are larger than 3 centimeters, or 1 1/4 inches;
there are signs or symptoms of an infection, such as a sore throat, a fever, or an earache;
the lymph nodes are felt above the collarbone, regardless of their size; or
you have persistently enlarged nodes, lasting three or more weeks.

About the Author
Dr. Albano is a board certified pediatric hematologist/oncologist.
She graduated summa cum laude from Loyola University, Stritch School of Medicine and did both her pediatric residency as well as hematology/oncology fellowship at The Children’s Hospital National Medical Center in Washington, DC.
Besides a full time practice in clinical oncology, Dr. Albano is actively involved in research in infections that occur in immunocompromised patients and their treatment.
Copyright 2012 Edythe A. Albano, M.D., All Rights Reserved

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