S

Scabies

http://www.cdc.gov/parasites/scabies/

Separation Anxiety

What is Separation Anxiety?
What Causes Separation Anxiety?
Who gets Separation Anxiety?
What are the Symptoms of Separation Anxiety?
How is Separation Anxiety Diagnosed?
How is Separation Anxiety Treated?

What is Separation Anxiety?
Separation Anxiety is a developmental disorder or stage where a child will get extremely agitated and anxious when separated from his or her mother, father or other care-giver.

What Causes Separation Anxiety?
Separation anxiety results from a complex set of interactions between the child and parent or care-giver. Every infant is different and every parent or care-giver is different. Therefore, every interaction between the child and the parent is different. As you and your child develop an emotional attachment toward one another, your child’s temperament will partially determine how he or she will respond when there is a separation between the two of you. It is not unusual to feel guilty about this common occurrence.
In order for children to become anxious about separation, they must first establish a significant attachment with their parent. The infant accumulates an increasingly sophisticated repertoire of memories of the parent. In a short time, your child will begin to compare these memories with the faces of other people that he or she encounters. Your child may develop a certain level of stranger anxiety in addition to separation anxiety.

Who gets Separation Anxiety?
Most often, children between 7 and 18 months of age will experience varying degrees of separation anxiety. However, separation anxiety may return to children at an older age during emotional or stressful times or during unfamiliar situations.

What are the Symptoms of Separation Anxiety?
A child suffering from separation anxiety may show extreme and excessive emotion or distress when separated from his or her parent or care-giver. Since your child has already had an opportunity to bond with you, he or she may have difficulty developing a level of trust with a stranger in a short period of time.
As a child gets older, she or he may be exposed to new situations that require prolonged separation from the parent, i.e. child care or school. The child may even resist going to school or elsewhere due to the anxiety. There may also be a fear that you will be harmed. Children may occasionally develop sleep problems, including nightmares or sleep refusal.

How is Separation Anxiety Diagnosed?
Separation anxiety is a normal developmental condition. There are no tests for diagnosis. However, if anxiety persists beyond age 2 years, an evaluation with your child’s health care provider may be necessary.

How is Separation Anxiety Treated?
This condition can be quite disconcerting to parents and it is important to remember that separation anxiety is fairly universal among babies and toddlers. It would be natural for a baby to get upset when he or she has been separated from the individual(s) with whom he or she has already bonded. The presence of separation anxiety should be a clue that you have succeeded in helping your child develop normally in the attachment process.
Your baby has been developing strong bonds with you over many months. It is important to realize that the treatment of separation anxiety is a gradual process, often requiring many months for your child to get comfortable with other caretakers. This is partly due to your child’s developmental stage in life. In fact, developmental behaviorists recognize that children may not develop object constancy (retain a stable image of his/her mother when she is absent) until 3 years of age.
As adults, we look for familiar patterns to comfort us whenever we encounter a unique or new situation. Our task with our young child should include the establishment of familiarity. Ask a new sitter to visit with you and the baby before leaving your child alone with him or her. Visit a nursery, church or health club center ahead of time before you make the initial separation. Leave a picture of yourself as well as a familiar toy, blanket (transitional objects) or a piece of your clothing from home. However, once you leave the location, you should leave without returning repeatedly. Creative mothers have used technology to bring themselves to their baby, making home videos of themselves doing routine tasks so that they can leave the video with a caretaker.
As a child gets older, it is important to prepare him or her for separations. Let her know ahead of time that there will be a time of separation and ask her to partner with you in finding familiar objects or circumstances that will help her to feel more comfortable with the temporary separation.
References
Simons, RC; Pardes, H; Understanding Human Behavior in Health and Illness, 1977, 1985, Williams & Wilkens
Reviewed by: Noah Makovsky MD
This Article contains the comments, views and opinions of the Author at the time of its writing and may not necessarily reflect the views of Pediatric Web, Inc., its officers, directors, affiliates or agents. No claim is made by Pediatric Web, the Author, or the Authors medical practice regarding the effectiveness and reliability of the statements contained herein and such individuals and entities disclaim any and all liability for the comments and statements contained in this Article and for any use or misuse of the statements made in this article in any specific medical situations. Further, this Article is intended to be general in nature and shall not be considered medical advice. The statements made are not to be utilized to diagnose and/or treat any individuals medical symptoms. If you or someone you know has symptoms which you believe are similar to this Article, you should discuss such symptoms with your personal physician or other qualified medical practitioner.
Copyright 2012 Pediatric Web, Inc., by Dan Feiten, M.D. All Rights Reserved

Sinusitis

What is sinusitis?
What causes sinusitis?
Who gets sinusitis?
What are the common findings?
How is sinusitis diagnosed?
How is sinusitis treated?
What are the complications?
How can sinusitis be prevented?
What research is being done?

David Nash, M.D. Assistant Professor of Pediatrics Children’s Hospital of Pittsburgh Ellen Wald, M.D. Professor of Pediatrics Children’s Hospital of Pittsburgh

What is sinusitis?
Sinusitis is the inflammation of one or more of the sinuses. At birth, the maxillary sinuses are found behind each cheek bone on each side of the nose. Initially, the maxillary sinus is a very small, slit-like space. As a child grows, the maxillary sinus becomes large enough to hold at least three teaspoons of fluid. The ethmoid sinuses also are present at birth, and they are located on each side of the bridge of the nose.
The ethmoid sinuses are comprised of many individual little air spaces. At about six or seven years of age, a child begins to develop the frontal sinuses. The frontal sinuses are located in the forehead just above the eyes. A fourth sinus space exists behind the ethmoid sinuses, and it is known as the sphenoid sinus. Each sinus is carpeted by the mucosa, a thin lining of cells and mucus.
Swelling of the mucosa and fluid collection in the sinuses cause the inflammation associated with sinusitis. Each sinus also possesses a very small drainage track (about the size of a pinhead) that empties into the nose. The diagram illustrates the position of the sinuses.
Physicians have divided arbitrarily (and with some controversy) patients with sinusitis into three groups depending on the duration of the symptoms. Patients are considered to have acute sinusitis when the symptoms have been present for less than four weeks. Patients are considered to have chronic sinusitis when the symptoms have persisted longer than 12 weeks.
The term “subacute sinusitis” is used to describe the symptoms that persist longer than 4 weeks, but less than 12 weeks. However, some physicians eliminate the “subacute” group because of its similarities to acute sinusitis. Decisions about the cause of sinusitis, the appropriate diagnostic testing, and the treatment options for it are based on the duration of the symptoms.

What causes sinusitis?
Persistent blockage of the narrow sinus drainage tracks can cause sinusitis. The sinus drainage tracks can be blocked because of: 1) swelling of the mucus membrane that lines these tracks; 2) a change in the quality (thicker/stickier) of the mucus, leading to the impaired flow of the mucus; or 3) physical blockage of the drainage path due to polyps or bony abnormalities. The most common causes of blockage are from viral upper respiratory infections (“colds”) and allergies.
The majority of patients develop acute bacterial sinusitis as a complication of a viral upper respiratory infection. Approximately 5% to 10% of colds ultimately lead to bacterial sinusitis. The nasal sniffing and blowing associated with colds push secretions that contain bacteria into the sinus drainage tracks. If the drainage tracks become completely and persistently blocked, a fertile environment for bacterial growth is created within the sinus. Bacteria cause the vast majority of cases of both acute and subacute sinusitis.
The cause of chronic sinusitis is not well understood. Although both patients and physicians often blame bacterial infection as the cause of chronic sinusitis, there are few data to support this theory. In fact, anecdotal experience in patients with chronic sinusitis frequently shows a poor response to antibiotics, suggesting that bacterial infection is not the main problem for these patients.
An alternate theory for the development of chronic sinusitis is based on the persistent exposure to allergens and irritants (e.g., tobacco smoke). Chronic exposure to these agents can cause either swelling of the mucus membrane or changes in the quality of secreted mucus, leading to blockage of the sinus drainage tracks and, ultimately, chronic sinusitis.
Rarely, the cause of chronic sinusitis may be because of either abnormal mucus secretions (cystic fibrosis) or abnormal mucus movement (immotile cilia syndrome). Almost all patients with immune disorders develop chronic sinusitis due to an increased susceptibility to infection.

Who gets sinusitis?
Both adults and children can get acute sinusitis; in fact, it is one of the most common complaints reported by patients to their primary care provider. Although the exact incidence is unknown, it is probably more common in children than in adults due to the high incidence of colds in children.
Chronic sinusitis is much less common than acute sinusitis. Although any healthy child can develop chronic sinusitis, exposure to year-round allergens and persistent irritants seems to increase the risk. Chronic sinusitis is found in almost all patients with cystic fibrosis, immotile cilia syndrome, or immune disorders.

What are the common findings?
Acute sinusitis can show up with either persistent (the most common form) or severe symptoms. Patients with persistent symptoms of acute sinusitis are differentiated from patients with simple colds solely on the basis of the duration of the symptoms. A simple cold usually lasts 5 to 7 days, and, even if symptoms linger, there should be improvement by 10 days. Cold symptoms that show no improvement after 10 days may be acute bacterial sinusitis.
The symptoms of cold viruses are indistinguishable from acute bacterial sinusitis. They usually include either nasal discharge (thin or thick; white, yellow, or green) or a cough (dry or wet) during both the day and the night. Some children also have bad breath, and/or swelling and darkening around the eyes. Complaints of a headache and facial pain are unusual until adolescence.
The second, less common appearance of acute sinusitis is a cold that seems more “severe” than usual. The severity is defined by the combination of a high fever (higher than 102oF) and thick white, yellow, or green nasal discharge, both of which persist for at least four days. In contrast, a simple cold may or may not have a fever; if a fever is present, it usually is present only for the first day of the symptoms. Patients with severe symptoms may have a headache or facial pain.
Chronic sinusitis is characterized by long-term nasal symptoms and/or a cough. The nasal symptoms may include a runny nose, post-nasal drainage, and/or congestion. When nasal discharge is present, it may be any color or thickness. In some patients, post-nasal drainage is the dominant symptom, leading to a cough or frequent throat clearing. Other patients develop persistent nasal congestion, leading to chronic mouth breathing and frequent complaints of a sore throat. Patients with chronic sinusitis also may complain of fatigue, nausea or vomiting (related to post-nasal drainage), decreased appetite, and impaired sleep.
In young patients with either acute or chronic sinusitis, physical examinations are rarely helpful. A physical examination is most helpful in identifying serious conditions that may make a patient more susceptible to sinusitis. For example, patients with cystic fibrosis tend to have poor growth, clubbing of the fingers, a barrel chest, respiratory findings, and nasal polyps.
Patients with immotile cilia may have respiratory findings, and about 50% of them will have situs inversus, i.e., the heart is on the right side of the body (called Kartageners syndrome). Patients with immune disorders may lack tonsillar tissue and other lymph nodes, and have poor growth, clubbing of the fingers, and other signs of infection.

How is sinusitis diagnosed?
It is important to recognize the similarity of the symptoms between acute sinusitis and simple colds, and not to over-diagnose colds as acute bacterial sinusitis. For the vast majority of patients, a diagnosis of either acute or chronic sinusitis will be based on the symptoms and their duration. Confirmation of the diagnosis by x-ray or CT images of the sinuses should be reserved for those patients who appear to have complications of sinusitis or non-typical symptoms.
Imaging studies must be used carefully, because even patients with common colds can have abnormal images of the sinuses. In general, imaging studies are the most helpful when they are normal and can be used to eliminate the diagnosis of sinusitis.

How is sinusitis treated?
In a joint publication, the Centers for Disease Control (CDC) and the American Academy of Pediatrics (AAP) outlined that “judicious antimicrobial therapy for bacterial sinusitis depends on limiting the use of these agents to children who have a high likelihood of benefiting from treatment.”
Amoxicillin is the antibiotic of choice for most patients with acute bacterial sinusitis because of its effectiveness, safety, and low cost. Although amoxicillin is the preferred first-line therapy for acute sinusitis, a more powerful antibiotic may be appropriate in the following situations:
A failure to respond to amoxicillin after two to three days of therapy
The use of other antibiotic therapy in the last 30 days
A high prevalence of antibiotic resistance in the community
The appearance of severe sinusitis
The possibility of sinusitis with complications
The presence of chronic sinusitis
Alternatives to amoxicillin include amoxicillin plus amoxicillin-clavulanate (Augmentin) or an oral cephalosporin. For most patients with acute bacterial sinusitis, the duration of antibiotic therapy should be 10 to 14 days.
In patients with chronic sinusitis, antibiotic therapy is controversial. Patients who do not improve with second-line antibiotics probably do not have an infection as the cause of their chronic symptoms and should not be retreated. If antibiotics have not been used in a patient with chronic sinusitis, it may be reasonable to consider one treatment course with a second-line antibiotic. Antibiotic therapy in patients with chronic sinusitis probably should be limited to three weeks; however, there are no data regarding the optimal duration of therapy for these patients.
Potential therapies that may be used in conjunction with antibiotics for acute and chronic sinusitis include saline sprays, ical intranasal steroids, antihistamines, and ical and oral decongestants. However, there are no studies that have examined systematically these therapies in patients with either acute or chronic sinusitis. Patients with underlying allergic disease are the most likely to benefit from antihistamines and ical nasal steroid sprays. Anecdotal experience suggests that some patients with chronic sinusitis benefit from daily nasal irrigation with saline.
Saline nasal washes are safe, inexpensive, and probably worth a try in these patients. ical or oral decongestants can relieve pain and obstruction in some patients. ical decongestants have a potential to be addictive, and their use should be limited to three to five days.

What are the complications?
Complications of sinusitis, which are rare in children, involve the spread of infection to nearby structures, including the eye, the facial and the skull bones, and the brain. Infection of the eye-the most common complication-causes redness of the eyelids, limitation in eye movement, bulging of the eye, and a loss or impairment of vision. Infection that spreads into the bony structures surrounding the sinuses causes obvious swelling and tenderness over the infected bone.
Infection can spread to the brain or the meninges (membrane around the brain). Any patient with a deep-seated headache, pain with eye movement, neck stiffness, a change in vision, localized swelling, or toxic appearance should be evaluated for potential complications of sinusitis.

How can sinusitis be prevented?
The prevention of sinusitis is difficult. Episodes of it can be prevented if the number of upper respiratory infections can be reduced. For children, reducing colds can be accomplished by removing them from the daycare setting or, at least, finding a smaller daycare program. Strict hand washing at home and in daycare settings helps to prevent the spread of upper respiratory infections. Decreasing exposures to known allergens and irritants should help patients with either recurrent acute or chronic sinusitis.
If hypersensitivity to allergens is found, ical intranasal steroid medications are helpful. A two- to four-week treatment trial of ical nasal steroids may be worthwhile even if allergen sensitivity is not found.

What research is being done?
The role of antibiotics in treating acute and chronic sinusitis continues to be investigated. The optimal length of antibiotic therapy is being studied in patients with acute sinusitis. The need for antibiotics is being questioned in patients with chronic sinusitis.
Other research is examining the role of therapies, such as saline sprays, hot steam mists, and ical nasal steroids, in patients with either acute or chronic sinusitis. The mechanism by which our bodies suppress or promote the inflammatory process associated with sinusitis also is being studied. Medications that support the ability of the body (or the sinuses) to regulate this inflammatory process are a possibility in the future.

References
Spector SL, Bernstein IL, Li JT, et al., eds. Parameters for the management of sinusitis. J Allergy Clin Immunol 1998;102:S117-44.
Wald ER. Diagnosis and management of sinusitis in children. Sem Pediatr Infect Dis 1998;9:4-11.
Wald ER. Chronic sinusitis in children. J Pediatr 1995;127:339-47.
About the Author
Dr. Nash is a pediatric allergist/immunologist practicing at Children’s Hospital of Pittsburgh. He divides his time evenly between clinical care and research. He has both research and clinical care interests in the management of children with either sinusitis or asthma.
Dr. Wald received her Bachelor of Science degree at Brooklyn College and her Medical Degree at Downstate Medical Center. She is currently on staff at Children’s Hospital of Pittsburgh and specializes in Allergy, Immunology and Infectious Diseases. One of her recent honors includes being named “Pennsylvania Pediatrician of the Year” by the American Academy of Pediatrics.
Copyright 2012 David Nash, M.D., All Rights Reserved

Smoking

http://www.cdc.gov/tobacco/basic_information/health_disparities/index.htm

Speech Development in Young Children

What is articulation?
What is an articulation disorder?
Lots of little kids talk funny – what’s typical and what’s not?
What causes an articulation disorder?
My child is in elementary school and has trouble with a few sounds. Will he/she grow out of it?
Who do I talk to about this first?
What is a speech therapist?
Therapy sounds like drudgery – my child will hate it!

by Melanie Potock, M.A., CCC-SLP Speech Language Pathologist Longmont, Colorado
You might know people who are really good at it, but talking is not easy, at least when it comes to learning the skill. Parents who notice a problem with their child’s speech or language production should discuss it with their child’s doctor.
What is articulation?
Learning to talk and produce all the sounds in a language is a 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. Articulation is complicated and often difficult to master.

What is an articulation disorder?
Children have an articulation disorder when they produce the sounds, syllables, or words atypically when compared with other children of the same sex and age. Severity may range from errors occurring on only one sound, such as an “s” or an “r” sound, to multiple errors that affect the intelligibility or clarity of speech and, thus, a child’s communication skills.

Lots of little kids talk funny – what’s typical and what’s not?
True, kids not only “say the darndest things,” but they say them in such a cute way. What is not typical is when the child’s speech pattern persists past a certain age or when it impacts intelligibility.
Most atypical sound production can be classified into one of four categories: omissions, substitutions, additions, or distortions. For example, an omission occurs when a child says “oos” for “juice,” and an addition occurs when a child adds a sound to a word, such a “joosk” for “juice.” Distortions occur when the child produces the sound in an unusual manner that sounds similar to the intended sound.
Atypical sound production may in fact be “typical” at a certain age for boys or girls. As children develop, they generally outgrow these speech patterns. Children should be producing all the sounds in the English language by age 8. However, it is not unusual for a child under age 3 to receive articulation therapy if his/her speech contains multiple errors that affect intelligibility and successful communication.

What causes an articulation disorder?
Some articulation disorders are caused by a physical disability, such as a cleft palate, hearing loss, or head injury. Some dental problems affect articulation.
Still, many children receive therapy even though they do not exhibit any physical disabilities. These children may simply have learned to produce speech sounds atypically, and the sound errors persisted past the age when their peers had learned the correct productions.

My child is in elementary school and has trouble with a few sounds. Will he/she grow out of it?
The most common errors that persist past 8 years of age include difficulty producing the “r,” “l,” and “s” sounds. However, speech therapy is often recommended for children younger than age 8 when any of these errors occur because the longer the incorrect speech pattern persists, the more difficult it is to correct. It is possible that a child will grow out of it, but it is always wise to discuss all articulation issues with a doctor.

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 speech or language production. Early intervention is considered the “best practice,” and it is especially important when the child is unintelligible to the unfamiliar listener or when the child appears frustrated by his/her difficulty in being understood.

What is a speech therapist?
A speech language pathologist (commonly know as a speech therapist) holds a master’s degree or doctorate, and is trained to evaluate and treat articulation disorders, as well as 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 articulation 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.
The speech pathologist will assess the child’s ability to say all the sounds in the English language individually, in single words, and/or in conversational speech. The therapist will determine which sound productions are typical for the child’s age and which sound productions are atypical.

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

About The Author: Melanie Potock, MA, CCC-SLP
Melanie Potock is a certified speech language pathologist in private practice in Colorado. In addition to helping young children develop speech and language skills, she is a national speaker on the ic of “feeding” and picky eaters. She is the author of Happy Mealtimes with Happy Kids and the executive producer of the acclaimed children’s album, Dancing in the Kitchen: Songs that Celebrate the Joy of Food! Mel is a regular contributor to national magazines and health related websites, including Pediatric Web and The Tender Foodie. She can be contacted at www.mymunchbug.com.
Copyright 2012 Melanie Potock, M.A., CCC-SLP, All Rights Reserved

Stevens-Johnson Syndrome

What is SJS?
What causes SJS?
Who gets SJS?
How does a drug reaction cause disease?
What are the common findings?
How is SJS diagnosed?
How is SJS treated?
What are the complications?
How can SJS be prevented?
What research is being done?

by William L. Weston, M.D. Professor of Dermatology University of Colorado Health Sciences Center
What is SJS?
SJS, or Stevens-Johnson Syndrome, is an abrupt, severe injury to the mouth, eyes, and skin, where large sheets of mucosa or skin are destroyed and then shed. The occurrence of SJS is uncommon.

What causes SJS?
For most individuals, SJS is the result of a drug reaction. Sulfa drugs, seizure drugs, and analgesics (pain relievers) are the most common medicines to cause SJS; however, a large number of drugs can cause it. In a few individuals, infections, such as pneumonias caused by Mycoplasma, may cause SJS.

Who gets SJS?
SJS mostly occurs in toddlers and in young children.

How does a drug reaction cause disease?
The skin of the person who has a reaction to a drug may not correctly eliminate it. The reaction most likely occurs because of a genetic mutation in one of the enzymes that is responsible for eliminating drugs from the body. The drug builds up in the lining of the skin, mouth, and eyes, and severely damages the tissue. It is similar to a burn, but the damage occurs from the inside out. Internal organs also may be involved.

What are the common findings?
The initial signs of SJS are bloody crusts on the lips, a sore mouth that has a foul smell, and purple-red tender spots on the skin. Drinking and eating are difficult, and light is painful to the eyes. Large areas of tissue death occur, and large blisters may form, followed by a loss of large sheets of the skin or the mouth. The linings of the eyes have pus drainage, and they may heal with scarring so that the eyelids do not move normally. The cornea also may erode. Fingernails may be shed, and a loss of skin color may occur. Severe stomach problems may occur in some individuals, and diarrhea and kidney or liver damage may result. The internal lining of the airway may slough off, blocking breathing.

How is SJS diagnosed?
Most physicians diagnose SJS from the involvement of the mouth and the eyes, plus the appearance of skin lesions. Sometimes, a skin biopsy may be needed to distinguish SJS from other conditions, such as pemphigus, which is another blistering condition.

How is SJS treated?
There is not a specific treatment for SJS at the time of an attack. Treatment for SJS consists of replacing fluids, calories, and salts, and then treating the skin as if it was a burn. If a drug is suspected of causing SJS, it should be sped.
SJS is a severe, life-threatening condition, and the best treatment occurs when the child is admitted to a hospital with a pediatric burn unit or a pediatric intensive care unit.

What are the complications?
The complications of SJS are similar to a severe burn. The following complications may occur: infection through the open skin, dehydration, salt disturbances, fever, scarring, fingernail loss, loss of skin color, breathing problems, pneumonia, kidney failure, liver problems, and death.

How can SJS be prevented?
SJS may be prevented by avoiding those drugs that have caused reactions in the past, and by not taking those drugs that are more likely to cause SJS. However, for most individuals, SJS appears unexpectedly and cannot be prevented.

What research is being done?
Researchers are currently examining treatments that block the cell death pathways. Potential genetic mutations also are being examined, which may help in developing tests that can predict who will get a severe reaction to a particular class of drugs.

About the Author
Dr. Weston is a Professor of Pediatrics and Dermatology at the University of Colorado Health Sciences Center and Chair of the Department of Dermatology. His scientific and clinical interests include Cutaneous immunology, Cutaneous virology, and Pediatric Dermatology.
Dr. Weston is the primary author of the Color Textbook of Pediatric Dermatology (Weston, Lane, Morelli; Mosby, Inc.) which is used by clinicians worldwide and is published in 4 languages.
He created the Genetic Skin Disorders clinic at the University of Colorado in 1998.
Copyright 2012 William L. Weston, M.D., All Rights Reserved

Strep Throat-Acute

What is Strep Throat?
What causes sore throats?
Who gets strep throat?
How does strep cause disease?
Common findings
How do you diagnose strep throat?
Treatment
What are the complications of strep throat?
How do you prevent strep complications?
What research is being done?
by Michael E. Pichichero, M.D. Professor of Microbiology and Immunology, Pediatrics and Medicine University of Rochester Medical Center Elmwood Pediatric Group
What is Strep Throat?
Streptococcal pharyngitis (“strep throat”) is one of the most common bacterial infections in children. Although there are over 20 types of streptococci, the group A strain is the most frequently encountered as a cause of sore throat. The changes of acute strep throat are confined to the tonsils, back of the throat, and the draining lymph nodes in the front of the neck. Changes in the infected tissues reflect an inflammation which produces redness, swelling, and pus on the surface of the tonsils and back of the throat.
Blisters and ulcers are uncommon. In infants, the nose is more typically involved in the infection as opposed to the throat. Infection may be transferred from the back of the throat or the nose to the skin, causing facial impetigo. Localized extension of strep may occur to adjacent cites to include the sinuses, the middle ear (acute ear infection), the epiglottis, and regional lymph nodes. Further extension may lead to meningitis in rare cases.

What causes sore throats?
The largest proportion of children (15-40%) and adolescents (30-60%) with sore throat have a viral infection. About 8-30% of children and 5-9% of teenagers with fever and throat inflammation have a strep infection. Other bacteria infrequently cause throat infection. Particularly among teenagers, the differential diagnosis includes other species of streptococci (group C and group G) and even the possibility of gonococci (gonorrhea germ) causing a sore throat. Other bacteria include Mycoplasma pneumoniae, Chlamydia pneumoniae and Arcanobacterium haemolyticum as causes of symptomatic sore throat.
In developing countries, diphtheria remains a cause of sore throat. Very often sore throats are of unknown course and this may represent viruses which at present cannot be identified, post nasal drip, allergy, etc.

Who gets strep throat?
Strep throat infections are spread person-to-person. Humans are the natural reservoir of this bacteria. The nose and back of the throat are the main sources of carriage of this bacteria. The skin and feces are potential sites. Aerosolized upper respiratory mucus serves as the primary source of the strep germ spreading to others. Direct contact with infected nose and throat tissues (by kissing) is of less importance as is contact with contaminated objects, such as toothbrushes.
Spread of strep throat requires the presence of a susceptible child and is facilitated by close contact.
Acquisition of infection is rare in infancy due to mothers’ immunity conferred transplacentally. Infection is uncommon below the age of two years. When infection occurs during the toddler years, it most often involves the nose. Children in day care and grade school more frequently contract and spread strep throat. Teenagers and adults usually have had contacts with the bacteria over time to provide immunity, thereby rendering strep uncommon in these age groups.

How does strep cause disease?
Strep produces a self-limited localized inflammation of the throat, generally lasting 3-5 days. Antibiotic treatment, if prompt and appropriate, reduces the duration of symptoms, shortens the period of contagion and reduces the risk of localized spread and complications. A major objective of administering antibiotics is to prevent rheumatic fever and possibly reduce the occurrence of post-strep kidney damage.

Common findings
Strep throat cannot be accurately diagnosed on the basis of history and examination in most patients. Classically, strep throat patients have fever, redness and swelling of the throat with pus on the tonsils and back of the throat. Swollen and tender lymph nodes in the front of the neck typically occur. It is quite unusual for a patient with strep throat to also have a runny nose and a cough. Strep throat occurs most commonly in mid-winter to early spring. If all of the typical history and symptoms of strep throat are present, then the likelihood of strep approaches 60-70% in children and 20-30% in teenagers.

How do you diagnose strep throat?
In 1954, the first reports of using a throat culture in an office setting initiated an era of office based laboratory diagnosis for pediatricians and family doctors. The use of a throat culture to confirm the presence of strep throat has become a common practice and has grown steadily such that by the early 1980’s the Centers for Disease Control estimated that between 28-36 million throat cultures were performed annually in the United States. The value of this simple laboratory test in avoiding unnecessary antibiotics and in identifying children and teenagers requiring treatment is considerable.
Rapid strep detection tests came into wide use in the 1990’s. These tests can be performed quickly at a cost that is comparable to a 10 days supply of penicillin. These tests, if properly performed, have the same reliability as a throat culture.

Treatment
Treatment should relieve the symptoms of acute strep throat, eliminate transmission and prevent complications. Ideally, the chosen antibiotic should be easy to administer free of side effects and affordable. None of the antibiotics used in the treatment of strep throat achieves all of these goals in all infected patients-including penicillin which is the gold standard of therapy. In considering treatment of strep throat, the physician is faced with a large number of generic and brand name antibiotics with wide ranges of effectiveness, side effects and costs.
Strep germs are highly susceptible to penicillin, amoxicillin, Augmentin, and the cephalosporins (Keflex, Duracef, Ceclor, Lorabid, Cefzil, Ceftin, Vantin, Omnicef and Cedax). 90-95% of strep strains are susceptible to erythromycin, Biaxin, Zithromax and Cleocin. Ten days of oral penicillin and erythromycin are necessary to achieve a maximum cure of strep throat. However, completion of 10 days therapy is often problematic as parents and teenagers forget to administer or take the antibiotic as symptoms improve over the first few day of treatment.
A five day course of therapy with several cephalosporins has been shown to produce a similar or superior cure compared with 10 days of oral penicillin. The cephalosporins tested for five days include Duracef, Ceftin, Vantin and Omnicef. Zithromax may be administered for five days because the antibiotic persists in the throat tissues for five days after discontinuation of the drug.

What are the complications of strep throat?
The main concern with strep throat relates to the development of acute rheumatic fever. This is an infection of the heart valves which leads to permanent heart valve damage with the possibility of progression to heart failure. Strep throat also causes kidney damage if not prevented by use of antibiotics. The kidney damage of the filtering system can lead to both acute kidney failure and chronic kidney problems. Of course, strep can also spread to tissues in the upper airways (for example, deep throat infections and infections of the draining lymph nodes at the front of the neck. Extension from the throat to the brain rarely occurs thereby producing meningitis or brain abscess.

How do you prevent strep complications?
Antibiotics, if promptly initiated, will prevent virtually all of the complications of strep. Rheumatic fever can be prevented if antibiotic therapy is begun within 9 days of the onset of first symptoms.

What research is being done?
New antibiotics are usually tested for their effectiveness in the treatment of strep throat and antibiotics which can be administered for shorter durations of time do represent the possibility of a treatment advance because of the tendency for everyone to prefer shorter treatment durations for a complete cure. Vaccines for the prevention of strep throat have now reached clinical studies in humans. The difficulty in development of an effective vaccine for strep throat has been the diversity of strep strains.

About the Author

Dr. Michael E. Pichichero is currently a Professor of Microbiology and Immunology, Pediatrics and Medicine at the University of Rochester in Rochester, NY.
A graduate of the University of Rochester School of Medicine, Dr. Pichichero completed his postgraduate pediatric residency at the University of Colorado in Denver, followed by a Chief Residency and two fellowships resulting in board certification in Pediatrics, in Adult and Pediatric Allergy and Immunology and in Pediatric Infectious Disease.
Dr. Pichichero is a partner in the Elmwood Pediatric Group where he continues to practice in primary care and as a subspecialist consultant.
A recipient of numerous awards and a member of most professional societies in his fields of interest, Mike has over 300 publications in infectious diseases, immunology, and allergy.
His major practice and research interests are in vaccine development, streptococcal infections, and otitis media: in each of these areas he is a prominent international authority.
Reviewed 11/4/10
Copyright 2012 Michael E. Pichichero, M.D., All Rights Reserved

Strep Throat-Recurrent

Are the sore throats actually caused by strep?
Did the patient finish the prescribed antibiotic?
Is the problem antibiotic resistance or tolerance?
Is the patient experiencing repeated exposure to strep?
Is the patient not responding to antibiotics?
Has prior antibiotic therapy eliminated protective throat bacteria?
Has early, prompt antibiotic treatment suppressed natural immunity?
Is the patient a strep carrier?
What antibiotic should be selected?
Should a tonsillectomy be performed?

by Michael E. Pichichero, M.D. Professor of Microbiology and Immunology, Pediatrics and Medicine University of Rochester Medical Center Elmwood Pediatric Group
If a child or a teenager has repeated episodes of streptococcal tonsillitis or pharyngitis (“strep throat”), several possible explanations should be considered.
Are the sore throats actually caused by strep?
Many physicians diagnose strep throat infections based on a patient’s history and an examination. However, without the aid of a throat culture or a rapid strep detection test, recurrent strep throat infections are difficult to accurately diagnosis. The complaint of a sore throat is frequent in the primary care practice setting. Yet, at the peak of the strep throat infection season (late fall through early spring), strep is the cause of a sore throat in less than 30% of children and 10% of teenagers.
Therefore, strictly on a percentage basis, physicians, who diagnose strep in the majority of patients with a sore throat, over-diagnose 90% of teenagers and 70% of children. Even in a patient with typical symptoms-a fever, a red throat with yellow pus on the tonsils, swollen and tender neck lymph glands, and the absence of a runny nose and a cough-misdiagnosis is common. In one study, an overestimate of the probability of a positive strep culture was observed for 81% of the patients.
To accurately diagnose strep throat infections, physicians use throat cultures (the gold standard) or rapid strep detection tests. Rapid strep detection tests improve the accuracy of diagnosing strep throat infections. The accuracy of rapid strep detection tests varies between products, but the main variable is in the carefulness of performing the test. The critical factor is attention to detail and strictly following the manufacturers’ guidelines for the test.
Table 1. Causes of Pharyngitis
Peak Incidence (%)
Cause Children Adults

Bacterial 30 to 40 5 to 10
GAS 28 to 40 5 to 9
Group C, G, or F Streptococcus 0 to 3 0 to 18
N gonorrhoeae 0 to 0.01 0 to 0.01
A haemolyticum 0 to 0.05 0 to 10
M pneumoniae 0 to 3 0 to 10
C pneumoniae 0 to 3 0 to 9
Viral 15 to 40 30 to 60
Idiopathic 20 to 55 30 to 65

Data compiled from Reference 1.

Did the patient finish the prescribed antibiotic?
Patients often do not finish the complete treatment of antibiotics. The symptoms of strep throat end quickly with antibiotics; patients feel completely better within two to three days after beginning treatment. Because of this improved well being, parent motivation to continue the medicine diminishes.
Studies from hospital-based clinics and private practices have confirmed that as many as 50% of patients have sped taking penicillin for strep throat by the third day, 70% by the sixth day, and over 80% by the ninth day. In the same populations, over 80% of the families claimed that all of the prescribed medicine had been taken.

Is the problem antibiotic resistance or tolerance?
The following antibiotics-penicillin, amoxicillin, and cephalosporins (i.e., Keflex, Duricef, Ceclor, Lorabid, Ceftin, Cefzil, Vantin, Suprax, Cedax, and Omnicef)-are effective in treating strep throat infections. Infrequently, strep throat infections are resistant to Erythromycin, clarithromycin (Biaxin), and azithromycin (Zithromax).

Is the patient experiencing repeated exposure to strep?
Some patients are effectively treated for a strep infection with antibiotics, only to return to an environment where the infection continues to circulate. The patient then becomes re-infected and returns to the physician with a recurrent strep throat infection. Certain circumstances-crowded working conditions, schools, day care settings, and larger families-more frequently transmit strep. One small study and one case report have suggested that, in rare instances, dogs also may be carriers of strep; however, other investigations have not corroborated this possibility.

Is the patient not responding to antibiotics?
Even when all strep infections are laboratory confirmed with throat cultures or rapid strep detection tests, and the antibiotic is finished, failure to respond to treatment still occurs. The highest treatment failure rates observed are with penicillin; about two-thirds of presumed strep throat infections are treated with either penicillin or amoxicillin. Penicillin and amoxicillin treatment failures vary geographically, and the incidence of penicillin treatment failures for strep throat infections may be rising. Patients most likely to experience a penicillin or amoxicillin treatment failure are those who have recently received treatment with these drugs and are then retreated with the same antibiotic.

Has prior antibiotic therapy eliminated protective throat bacteria?
Prominent, normal bacteria of the throat include another type of streptococci (alpha hemolytic). These bacteria make natural antibiotic substances (to provide an advantage for themselves) in the throat. Penicillin or amoxicillin therapy may change the natural environment for throat bacteria by killing these alpha hemolytic streptococci; their elimination provides an opportunity for disease-causing strep to gain access to the throat cells. This is another reason for patients to avoid unnecessary antibiotic use.

Has early, prompt antibiotic treatment suppressed natural immunity?
With the availability of rapid strep detection tests and the publication of several convincing studies that describe faster clinical improvement from prompt treatment, many physicians have been prescribing antibiotics sooner after diagnosing strep throat infections.
Immediate penicillin treatment has been shown to be a cause of recurrent strep infections. Early antibiotic treatment suppresses the natural immune response to strep. Delaying antibiotic therapy for two days after the onset of a sore throat allows an immune response to develop, which may reduce the chance of a relapse or recurrence of strep throat infections.
Two similar studies compared immediate penicillin treatment with treatment delayed for 48 to 56 hours in 343 children with documented strep throats. Early antibiotic therapy produced a three-time increase in the frequency of recurrent infections as compared to those for whom treatment was delayed.
Table 2. Recurrence Rates of Immediate versus Delayed Treatment of GAS Tonsillopharyngitis with Penicillin
Treatment Group (n)(%)*
Recurrent Acute GAS Pharyngitis Immediate Treatment(n=70) Delayed Treatment (48 to 56 hr) (n=173)

Early recurrence 32 (19) 14 (8) 0.006
Late recurrence 22 (13) 5 (3) 0.001
Total recurrence 54 (32) 19 (11) <.001

*Treatment groups compared by x2 of Fisher’s exact test, as appropriate; data compiled from References 12 and 13.
A delay in treatment does not increase the risk of rheumatic fever since a delay of up to nine days from the onset of symptoms can be made. Nevertheless, for patients who appear severely ill or in times when highly infectious strains of strep are circulating, intentionally delayed treatment should not be considered.

Is the patient a strep carrier?
A positive throat culture or a rapid strep test alone cannot distinguish between the patient with strep throat and the patient with an acute viral sore throat who is a chronic strep carrier. The strep carrier has a positive throat culture, but does not show symptoms of an acute strep infection or show a rise in strep antibody levels. In clinical practice, identifying a strep carrier is problematic.
Following treatment, the patient needs to be seen again to determine whether strep is present when the patient does not have a sore throat. In addition, antibody levels need to be drawn when the patient has a sore throat and then drawn again four to six weeks later to measure strep antibodies. If antibiotic therapy has been given to treat prior symptoms, it may suppress the antibody rise, thereby negating the usefulness of this test.
Table 3. Short-Course Treatment of Streptococcal Phayngitis
Bacteriologic Cure
Duration of Rx(days) Cephalosporin or Azithromycin Penicillin (10 days)

Cefuroxime axetil 4 82/90 (96%) 77/80 (96%)
Cefadroxil 5 87/104 (84%) 93/105 (89%)
Cefpodoxime proxetil 5 59/61 (97%) 49/52 (94%)
Cefpodoxime proxetil 5 79/82 (96%) 64/68 (94%)
Cefuroxime axetil 4 83/97 (88%) 90/103 (87%)
Cefpodoxime proxetil 5 112/121 (93%) 101/130 (78%)
Azithromycin 5 167/176 (95%) 130/187 (77%)
Azithromycin 5 139/147 (95%) 88/127 (69%)

Data compiled from Reference 15.

What antibiotic should be selected?
Many antibiotics—such as penicillin-can be used to treat recurrent strep throat infections.
Clindamycin or rifampin, in combination with a second antibiotic, such as penicillin, amoxicillin, or a cephalosporin, has been used to treat acute, recurrent, and carrier strep throat infections. Routine use of clindamycin is not advocated because diarrhea is a rare, but significant, side effect. Rifampin must be used with a second antibiotic because strep will rapidly become resistant to it when it is given as a single therapy. Patients should be advised that rifampin produces orange discoloration of the urine and tears (permanently staining contact lenses).
Oral cephalosporins (Keflex, Duracef, Ceclor, Lorabid, Ceftin, Cefzil, Suprax, Vantin, Omnicef, and Cedax) have gained widespread use in treating recurrent strep throat infections. When cephalosporin antibiotics are used to treat strep throat infections, a failure occurs less than 5% of the time; however, they are more expensive than penicillin or amoxicillin.
Amoxicillin/clavulanic acid (Augmentin) has been evaluated to treat strep throat with superior or equivalent results in comparison to penicillin.
Table 4. Penicillin versus Cephalosporins in the Treatment of Streptococcal Pharyngitis
Treatment Regimen n Bacteriologic Failure Rate (%) n Clincial Failure Rate

Cephalosporins 1290 8.01 926 5.02
Penicillins 1169 16.01 865 11.02

1p = 0.0001
2p < 0.001
Data compiled from Reference 8.

Should a tonsillectomy be performed?
If a patient has six to seven recurrent strep throat infections over a one-to two-year time span, then a tonsillectomy should be considered after consulting with your primary care physician. Families should be advised that the procedure reduces the frequency of sore throats, and, specifically, strep throats, for two to three years after surgery.

About the Author
Dr. Michael E. Pichichero is currently a Professor of Microbiology and Immunology, Pediatrics and Medicine at the University of Rochester in Rochester, NY.
A graduate of the University of Rochester School of Medicine, Dr. Pichichero completed his postgraduate pediatric residency at the University of Colorado in Denver, followed by a Chief Residency and two fellowships resulting in board certification in Pediatrics, in Adult and Pediatric Allergy and Immunology and in Pediatric Infectious Disease.
Dr. Pichichero is a partner in the Elmwood Pediatric Group where he continues to practice in primary care and as a subspecialist consultant.
A recipient of numerous awards and a member of most professional societies in his fields of interest, Mike has over 300 publications in infectious diseases, immunology, and allergy.
His major practice and research interests are in vaccine development, streptococcal infections, and otitis media: in each of these areas he is a prominent international authority.
Copyright 2012 Michael E. Pichichero, M.D., All Rights Reserved

Stuttering and the Young Child

What is the difference between typical disfluencies and stuttering?
How do I know it is not “true” stuttering?
What causes stuttering?
My child’s playmate stutters. Will my child learn to stutter too?
My grandfather stuttered. Is it inherited?
Could an upsetting event in our lives have caused this?
Is this my fault as a parent?
What can I do at home to help my child?
Maybe my child will just grow out of it.
Links to other information

by Melanie Potock, M.A., CCC-SLP Speech Language Pathologist Pediatric Rehabilitation Department Boulder Community Hospital’s Mapleton Center Boulder, Colorado
Many young children between the ages of 1 1/2 and 5 have periodic speech disfluencies. Disfluencies are disruptions in the smooth flow of single words, phrases, or conversational speech. As children learn to negotiate the complexities of the English language, they may appear to have trouble speaking smoothly.
They may repeat syllables or whole words once or twice, such as “ba-ba-ball.” They may hesitate or fill in the pauses with markers, such as “uh,” “um,” or “well.” Sometimes, these disfluencies come and go for weeks or months at a time. These disfluencies can be part of normal language development, or they may be early signs that a child has a predisposition for stuttering.
What is the difference between typical disfluencies and stuttering?
Disfluencies are interruptions in the smooth flow of single words, phrases, or conversational speech. True stuttering impacts not only the flow of words, but also has specific behaviors associated with the disruption in flow. Not all of the behaviors are present for every child. Some of the behaviors to watch for are:
Consistent disturbance in speech production
Frequently repeating sounds three or more times
Prolongation of a word or part of a word in many speaking situations
Awareness of his/her own difficulty speaking as evidenced by the following reactions to the disruptions in flow
Tension, tremors, or struggling in the muscles of the eyes, lips, cheeks, chin, throat, or chest while speaking
Consistent presence of “starters,” such as “um” or “so”
Rise in pitch associated with repetition of sounds
“Blocking” on words demonstrated by no voice and/or airflow while attempting to speak
Anxiety or fear in a child’s face as he/she anticipates his/her need to speak a difficult word
Avoiding or “talking around” a specific word

How do I know it is not “true” stuttering?
If your child exhibits one or more of the behaviors noted above, he/she might be developing a true stuttering problem. If parents have any concerns about their child’s speech fluency, the first person to consult is their child’s doctor. The doctor may refer the child to be evaluated by a certified speech language pathologist who specializes in fluency disorders.

What causes stuttering?
Researchers vary on their opinion of what causes stuttering. However, most researchers agree that the following factors are associated with increases in normal disfluencies:
Difficulty with fine motor coordination and/or timing of the respiratory and oral motor muscles
Interpersonal stress
Disturbing, stressful events that are unanticipated by the family
Certain stages of complex language development

My child’s playmate stutters. Will my child learn to stutter too?
Although this is a common myth, stuttering is not contagious. However, a child can be a positive influence on his/her friend’s speech if the child is aware of some of the ways that he/she can help. (Please refer to “What can I do at home to help my child.”)

My grandfather stuttered. Is it inherited?
Researchers do not know if stuttering is an inherited trait. It is true that stuttering seems to run in some families, but a specific gene for stuttering has not been identified. Family studies show that many stutterers have a predisposition for stuttering, but it is unclear what physical markers exist that may prove inheritance. In twin studies, stuttering occurs more often in identical twin pairs than in fraternal twin pairs. Again, it appears from the twin studies that stuttering is inherited, but the inherited physical marker is unclear.

Could an upsetting event in our lives have caused this?
Emotional stress may aggravate stuttering, but it is not considered to be a cause. Children who may be vulnerable to stuttering will often become more disfluent during stressful times.

Is this my fault as a parent?
Current research indicates that parents do not cause stuttering. However, you can play an important role in facilitating normal fluency in your child’s speech.

What can I do at home to help my child?
Parents should keep the following advice in mind when talking with their child:
Be aware of your own rate of speech during conversations. Speak in a slow, relaxed, yet natural manner. By doing so, you will be subtly modeling a slower conversational speech rate for your child. A slower rate also is less taxing to the listener and, thus, less stressful for your child.
Respond to what your child is saying, not to the stuttering. Focus on the content, not the way it is presented.
Be careful not to interrupt your child or to finish the sentences for him/her. Wait patiently until your child is done talking, and support him/her by gentle responses that say “I’m listening,” such as head nods, eye contact, smiles, and verbal markers (e.g., “uh-huh”).
Count to three before replying. Avoid speaking immediately when your child pauses or ss talking.
It is easy in a hectic day to pick up the pace, hurry from one activity to another, and rush about. Try to make a conscious effort to prepare your child for transitions between activities and tell him/her the plan for what will happen next.
Take a look at common stressful moments at home. For example, is it always hectic in the morning before daycare? Or, does tension increase in the evening when you are preparing dinner? How do these moments affect your child’s fluency? What can you do as a family to ease the tension?
Examine your daily routine. Is it highly structured, mildly predictable, or total chaos? A predictable daily routine, which also allows for flexibility, is ideal.
Ask fewer questions, and only one at a time. Wait and listen intently while your child answers. Respond with interest. Again, focus on the content and not on the stuttering.
Encourage family members, baby-sitters, and teachers to speak in a relaxed rate, to listen carefully to your child, to give appropriate eye contact, to respond positively to your child’s comments, and to allow your child to finish his/her thoughts.

Maybe my child will just grow out of it.
Many children who show signs of mild disfluencies do “grow out of it.” However, because typical disfluencies may mimic early signs of stuttering, it is highly recommended that parents consult with a doctor. It is worth the peace of mind to know that 1.) your child’s disfluencies are typical for his/her age and development, or 2.) your child’s stuttering can be helped significantly through early intervention with a certified speech language pathologist.

Links to other information
For additional information on childhood stuttering, please contact the Stuttering Foundation of America, P.O. Box 11749, Memphis TN 38111-0749.

Swine Flu

This information is provided by the Center for Disease Control
What is novel H1N1 (swine flu)?
Novel H1N1 (referred to as swine flu early on) is a new influenza virus causing illness in people. This new virus was first detected in people in the United States in April 2009. This virus is spreading from person-to-person worldwide, probably in much the same way that regular seasonal influenza viruses spread. On June 11, 2009, the World Health Organization (WHO) signaled that a pandemic of novel H1N1 flu was underway.

Why is novel H1N1 virus sometimes called swine flu?
This virus was originally referred to as swine flu because laboratory testing showed that many of the genes in this new virus were very similar to influenza viruses that normally occur in pigs (swine) in North America. But further study has shown that this new virus is very different from what normally circulates in North American pigs. It has two genes from flu viruses that normally circulate in pigs in Europe and Asia and bird (avian) genes and human genes. Scientists call this a “quadruple reassortant” virus.

How does novel H1N1 virus spread?
Spread of novel H1N1 virus is thought to occur in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing by people with influenza. Sometimes people may become infected by touching something such as a surface or object with flu viruses on it and then touching their mouth or nose.

What are the signs and symptoms of this virus in people?
The symptoms of novel H1N1 flu virus in people include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. A significant number of people who have been infected with this virus also have reported diarrhea and vomiting. As with seasonal flu, severe illnesses and death have occurred as a result of illness associated with this virus.

How severe is illness associated with novel H1N1 flu virus?
Illness with the new H1N1 virus has ranged from mild to severe. While most people who have been sick have recovered without needing medical treatment, hospitalizations and deaths from infection with this virus have occurred.
In seasonal flu, certain people are at high risk of serious complications. This includes people 65 years and older, children younger than five years old, pregnant women, and people of any age with certain chronic medical conditions. About 70 percent of people who have been hospitalized with this novel H1N1 virus have had one or more medical conditions previously recognized as placing people at high risk of serious seasonal flu-related complications. This includes pregnancy, diabetes, heart disease, asthma and kidney disease.
One thing that appears to be different from seasonal influenza is that adults older than 64 years do not yet appear to be at increased risk of novel H1N1-related complications thus far. CDC laboratory studies have shown that no children and very few adults younger than 60 years old have existing antibody to novel H1N1 flu virus; however, about one-third of adults older than 60 may have antibodies against this virus. It is unknown how much, if any, protection may be afforded against novel H1N1 flu by any existing antibody.

How does novel H1N1 flu compare to seasonal flu in terms of its severity and infection rates?
With seasonal flu, we know that seasons vary in terms of timing, duration and severity. Seasonal influenza can cause mild to severe illness, and at times can lead to death. Each year, in the United States, on average 36,000 people die from flu-related complications and more than 200,000 people are hospitalized from flu-related causes. Of those hospitalized, 20,000 are children younger than 5 years old. Over 90% of deaths and about 60 percent of hospitalization occur in people older than 65.
When the novel H1N1 outbreak was first detected in mid-April 2009, CDC began working with states to collect, compile and analyze information regarding the novel H1N1 flu outbreak, including the numbers of confirmed and probable cases and the ages of these people.
The information analyzed by CDC supports the conclusion that novel H1N1 flu has caused greater disease burden in people younger than 25 years of age than older people. At this time, there are few cases and few deaths reported in people older than 64 years old, which is unusual when compared with seasonal flu. However, pregnancy and other previously recognized high risk medical conditions from seasonal influenza appear to be associated with increased risk of complications from this novel H1N1. These underlying conditions include asthma, diabetes, suppressed immune systems, heart disease, kidney disease, neurocognitive and neuromuscular disorders and pregnancy.

How long can an infected person spread this virus to others?
People infected with seasonal and novel H1N1 flu shed virus and may be able to infect others from 1 day before getting sick to 5 to 7 days after. This can be longer in some people, especially children and people with weakened immune systems and in people infected with the new H1N1 virus.

Links to other information
Information regarding influenza is available through the Centers for Disease Control and Prevention (CDC) Web site at CDC Flu Information.
State and local health departments can be contacted for information regarding the availability of the influenza vaccine, access to vaccination programs, and information about state or local influenza activity.

Reviewed 9/5/2009 By Daniel Feiten MD Greenwood Pediatrics

Swine Flu (H1N1) FAQ

Marc Avner, M.D., Greenwood Pediatrics
My child has a cough and fever is this the Swine Flu?
The symptoms of the Swine (H1N1) Flu have been very similar to those of seasonal flu and include cough, fever, runny nose, sore throat, headaches, chills and body aches. Thus far in the US and Canada, cases of the Swine Flu have been mild to moderate in severity. Like many other viral upper respiratory tract illnesses or colds, the Swine Flu tends to be self-limited and resolves on its own without the use of any medication. Fever may last up to 3 days; runny nose 1-2 weeks; cough2-3 weeks.

Does my child need medication?
Most children and adults who have the Swine Flu do not need specific treatment other than symptomatic care. The anti-viral medications used to treat seasonal flu and Swine Flu, at best, shorten the duration of the illness by one to one and a half days. They do not cure the illness. Furthermore, these medications have been linked to GI and behavioral side effects. At this time, antiviral medications such as Tamiflu are being reserved for hospitalized patients and those in high risk categories, including children under two years and those with chronic illness such as asthma, heart disease, diabetes and immune system disorders. As with the overuse of other antibiotics, the overuse of Tamiflu can select out resistant organisms and render it ineffective for those who most need it.

Does my child need a test to see if it is the Swine Flu?
Even the most sensitive rapid flu tests miss positive cases about 30% of the time (almost one in three patients with Swine Flu will have a negative test). Given that Swine Flu tends to be self resolving and that most healthy children do not need antiviral medication, a positive flu test does not change the course of action for most children and adults

Does my child need to be seen?
Most seasonal flu and Swine Flu is self-resolving, and healthy children with mild to moderate symptoms are best treated with symptomatic care. However, some children may need to be seen by a medical provider, including those in high risk groups, as well as those with more severe symptoms or worrisome appearance. In some cases, secondary bacterial infection may occur. Signs of a secondary bacterial infection which would indicate the need to be seen include: difficulty breathing, ear pain, a fever that resolves for a few days and returns, acutely worsening symptoms after three days of illness, or persistent symptoms without improvement after 10 days.

How long does my child need to stay home from school?
If your child has flu-like symptoms, she should stay home from school until she has no fever for 24 hours without the use of anti-fever medications such as Tylenol or Ibuprofen.
Copyright 2012 Marc Avner, M.D., All Rights Reserved

Swine Flu (H1N1) Vaccine

This information is provided by the Center for Disease Control
Will the seasonal flu vaccine protect against the H1N1 flu?
The 2010-2011 flu vaccine will protect against an influenza A H3N2 virus, an influenza B virus and the 2009 H1N1 virus that caused so much illness last season.
While everyone 6 months of age and older should get a flu vaccine each flu season, itâ€™s especially important that the following groups get vaccinated either because they are at high risk of having serious flu-related complications or because they live with or care for people at high risk for developing flu-related complications:
Pregnant women
Children younger than 5, but especially children younger than 2 years old
People 50 years of age and older
People of any age with certain chronic medical conditions
People who live in nursing homes and other long-term care facilities
People who live with or care for those at high risk for complications from flu, including:
Health care workers
Household contacts of persons at high risk for complications from the flu
Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated)
What about the use of antivirals to treat H1N1 infection?
Antiviral drugs are prescription medicines (pills, liquid or an inhaled powder) that fight against the flu by keeping flu viruses from reproducing in your body. If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious flu complications. To date, the CDC has recommended that healthcare providers cautiously prescribe antivirals for those persons with severe illness or those at higher risk for flu complications. Hence, not all patients will be treated with an antiviral medication.
Links to other information
Information regarding influenza is available through the Centers for Disease Control and Prevention (CDC) Web site at CDC Flu Information.
State and local health departments can be contacted for information regarding the availability of the influenza vaccine, access to vaccination programs, and information about state or local influenza activity.
Reviewed 11/3/2010 By Daniel Feiten MD Greenwood Pediatrics

Swollen Glands

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.

S