Top 10 Pediatric Symptoms – PediaCast 386

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Description

• Join us as we examine the top 10 pediatric symptoms. We consider possible causes, let you know when to worry and explore how providers determine a diagnosis and plan treatment. Are you ready for the fall and winter illness season? Listen and find out!

Topics

• Fever
• Headache
• Cough & Congestion
• Watery Itchy Eyes
• Earache
• Sore Throat
• Wheezing & Stridor
• Abdominal Pain
• Vomiting & Diarrhea
• Painful Urination
• Groin Pain
• Rash

Transcription

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital on Columbus, Ohio. 

It's Episode 386 for September 13th, 2017. We're calling this one "Top 10 Pediatric Symptoms". I want to welcome everyone to the program. 

I have something a little different for you this week. Rather than covering our usual collection of pediatric news items or interviewing a pediatric or parenting experts, I want to take a short break for our usual format and present you with something I hope will be super helpful, particularly as we head into fall and winter illness season, which happens each and every year.

And that something different is really just a simple rundown of what I would consider the top 10 pediatric symptoms. So, as parents and others who care for kids, day care workers, babysitters, teachers, coaches, grandparents, these are the symptoms who most likely to see — the classic symptoms, the Hall of Fame, if you will, of childhood illness. 

So, these are going to be the ten symptoms that pediatric providers see sometimes daily, definitely weekly. So these are the main things that people bring your kids in to be seen. There are all sorts of other things but these are the ones that are just always present, almost day in and day out. No matter where you live or the time of year, this stuff is always around. And those of us who care for kids more often than not, as medical providers, these are the reasons parents seek our help and guidance on an almost daily basis.

0:02:22

Now, in our usual PediaCast fashion, I'm going to stretch out the Top 10 a little bit. Get the most bang for your buck here by combining some symptoms that are commonly seen together. And I'm actually going to include 11 items or a combination of items, simply because I couldn't choose one to cut out. But I'm leaving the title of the episode as "The 10 List" because that sounds better than "The Top 11 List". But just so you know, you will be hearing a bonus symptom free of charge included in our discussion. 

The other thing is this — because we're going to cover so many symptoms, we're not going to able to go into a crazy amount of detail because we only have an hour together, maybe a little longer. And really, I could spend an hour talking about each of these symptoms which is what would happen in medical school. But this is not medical school and my plan is just to hit the highlights of each one. 

So, begin with the definition and just sort of some important considerations for each symptom or set of symptoms, I'll include a list of conditions that could cause the symptom, which is what we referred to as a deferential diagnosis.

We'll talk about when to worry. Now, of course, you're always allowed to worry as a parent. Sometimes, it seems like that's our job as mom or dad — to worry. And we always encourage phone call to your child's healthcare provider when worry comes your way. But I'm talking about when should you definitely worry about each of these symptoms. Even when you aren't worried, there are times you should be. When should a child with a given symptom definitely be checked out and sooner rather than later? So, we'll cover that. 

0:04:06

And then, what will your child doctor do to sort out which of the possibilities in the deferential diagnosis is really going on? In other words, what does the workup look like for that particular symptom? And finally, after arriving at a particular diagnosis, how is that symptom or illness condition then treated?

So, lots to cover, especially when you consider we'll have about five, maybe six minutes at most for each of these items. So, obviously, we're going to hit the most important highlights of what you need to know. But I think it will serve as a nice overview of childhood illness as we head into the fall and winter season of pediatric disease. 

Now, if one or more of these conditions happens to catch your attention and you do want to learn more, simply do a Google search for the symptom in question or a disease process associated with that symptom. And include PediaCast in your search string, because we've probably covered that symptom or illness at some point in the past in much more detail. If we haven't and you really want to learn more, just head over to the Contact page of PediaCast.org and suggest a longer treatment of the topic that has caught your curiosity.

Okay, so you probably want to know right here out of the gate, what 11 symptoms or group of symptoms make up our Top 10 list? And I'm going to travel roughly from head to toe as we present them. So, first, we'll talk about fever and then headache, cough and congestion. Also watery itchy eyes, ear ache, sore throat, noisy breathing, so wheezing and stridor, abdominal pain, then vomiting and diarrheal, a painful urination and that will include groin pain as well, and then rash.

So, lots to cover as we attempt an overview of the most common things that go wrong with kids. And you may want to bookmark this episode as we head into fall and winter because you are likely to encounter some, maybe even all of these symptoms in your homes, your day care centers, your schools. So let's get to it.

Before we do, however, one quick reminder. If you would like to suggest a topic or you have a question for me, it's really easy to get in touch, just head over to PediaCast.org and look for the Contact page. It'll be in one of the tabs at the top of the page, Contact Dr. Mike. Just click on that, fill up the form and we'll try to get your topic or your suggestion, your question on the program.

0:06:37

Also, I want to remind you, the information presented in PediaCast is for general, educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination. 

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at PediaCast.org. All right, let's take a quick break and I will be back to cover the top 10 pediatric symptoms, it's coming up right after this. 

[Music]

Dr. Mike Patrick: The first symptom that we're going to cover is fever. And I think a good place to start with fever is the definition of what constitutes a fever. And by definition, a fever is going to be body temperature that is 100.4 degrees Fahrenheit or 38 degrees Celsius or higher. 

Now, you hear a lot of folks say "Low-grade fever, that's not really a thing." And some folks you also hear say, "Well, my kids are usually 97, and so for them a fever's 99." No, there's a definition of fever and it is 100.4 degrees Fahrenheit or 38 degrees Celsius or higher. It does not matter how you take the temperature, just report the number and the method that you used, and let your healthcare provider interpret the result of that number in the way in which you took it.

0:08:32

Now, fever occurs as a by-product of the immune system in action. And the fever itself is not dangerous. It's just there? It lets us know that the kid is sick and that the immune system is at work trying to attack something. Usually, that's going to be an infectious organism, although there are other situations where the immune system can get activated and also cause a fever. In terms of seizures, fever does not really cause seizure based on a high temperature. So in other words, a high body temperature does not do something to the brain that causes the seizure.

What we think happens when you do have a febrile seizure is that it is actually the change, a rapid change in body temperature. So you've been cruising along with a normal body temperature for a long time, and then suddenly, you get a fever quickly. Doesn't matter so much how high that fever goes, it's really more of the rapid change in body temperature that can cause a brief seizure in people who are predispose probably genetically to having that happen. And it's usually a very brief seizure. It's scary to witness but it's not dangerous and it passes.   

Now, in folks with the epilepsy, fever can decrease the seizure threshold and so you do have some kids who have more of a serious seizure. But again, it wasn't  necessarily that the fever caused it, it just made the more likely to actually have their epilepsy show up as a first time seizure. So, that does sometimes happen but in most cases, febrile seizures are very brief and usually younger kids less than the school age and happen when the body temperature changes rapidly.

0:10:21

Now, in terms of what can cause a fever, I mentioned infectious diseases — so viruses, bacteria. Also immunizations, you're tricking your body into thinking that disease is present, and so the immune system can kick in and cause a fever. Also auto immune conditions such as juvenile idiopathic arthritis, that can cause recurrent fevers. And then also cancers, cancers can come along with an immune response to the cancer itself. You're also more prone to infectious diseases and so fevers can't show up with cancers as well.

When should you worry about a fever? Any fever in a young baby — less than about three months of age or so — that, if they get a fever, you want to call your doctor and let them know. You also worry when you don't see an evidence source of the fever. So, if it's an older child and they have a cold and they get a fever, that's expected. You treat the fever, you give them a little bit of time. 

Prolonged fever when it's lasting more than a couple of days, you want to see someone about that. Or if there's recurrence of the fever, so the fever was there. It lasts a couple of days, it goes away for a few days and then it comes back, you do worry about that a little bit more and should let someone know.

In terms of a workup, your doctor's going to do a history and physical exam, knowing all the symptoms that are present, sort of historically how they happened and what order they occurred and then what does your child look like, and actually doing the physical exam. Oftentimes, that's all you need to diagnose what's causing the fever. 

If it is not evident that there's infection, and especially if the fever is prolonged, then your doctor may do more of a work up to try to figure out what it is that's causing this prolonged fever that doesn't have an obvious cause. And some things they might do include a blood count, a blood culture, some inflammatory markers called the sed rate or a CRP. Then, they would do blood work for mono or Epstein-Barr virus. They might check the urine in the urine culture. They might check a strep test. 

0:12:19

And if it's a young baby with a fever, they may also do a spinal tap to check the spinal fluid to make sure that there's no infection there. And then there's all sort of fancy laboratory test that can be done called PCR test, where you look for genetic material of particular pathogens in the blood in respiratory secretions, in the urine, and spinal fluid. And again, that's going to be when you're really scratching your head and you have this prolonged fever and no obvious source for it. You really want to get to the bottom of it. 

In terms of a treatment for fever, the basic treatment is like with any other illness — rest and fluids. Your body's got a job to do and it needs the energy to do it, so you're going to feel tired and you're going to need rest. And fevers, you sweat, you lose some fluid that way and so it's important to replace those fluids by drinking a lot. 

And then just keeping your child comfortable, you can treat them with a fever reducers, things like ibuprofen, which is the active ingredient and things like Motrin and Advil, or acetaminophen which is the active ingredient in a medicine like Tylenol. And of course, if the fever is sticking around depending on what other symptoms are present, you're also going to want to identify and treat the underlying cause of that fever. And that may take a trip to your doctor again, so they can do a history and physical and ask you all those questions.

So, fevers are common. And hopefully, that helps you understand them a little bit better. 

Next stop, we have headaches and again, moving quickly, covering the highlights. Headache really, the first thing you want to think about with the headache is the quality and character of the headache. So, where is it allocated? Is it on the front? Is it in on the sides of the head? Is it in the back? Is it everywhere? Is the headache on one side or is it on both sides? Is it a constant pain? Or is it a pounding pain? 

0:14:11

And then, are there any other symptoms associated with the headache? So things like visual disturbances, either before the headache started or during the headache, feeling sick to your stomach, photophobia or light bothering you. Is there any neck pain or stiffness that's associated with the headache? Is there any fever?

So, you just really want to try to characterize the headache and anything that's going along with it. And then, also the frequency of the headache, is there something that's just one off event or is it something that happens recurrently? And if it does happen recurrently, how often? What time of day? What other factors maybe present? Could it be during the menstrual cycle at a certain time or certain time of day? 
All those kind of things, and that's why we sometimes have patients keep a headache diary, just so that we can get a better idea of the answers to all of those questions. 

Now, the reason that characterizing the headache in such a way and anything that's associated with the headache is because the deferential diagnosis for headache is pretty long. And so the more information that we have about the history and character of the headache will help us figure out which of those things is going on because the description is different.

So, what kind of things are we talking about? Well, probably the most common headache is the tension-type headache, also migraines. Infections can cause headaches — things like strep and mono. But really any infection if it's causing a fever, you can get a bit of a headache with it as well. 

If you have a stiff neck or neck pain, we worry about meningitis with a fever. When there's a fever present with the headache of a stiff neck, so meningitis is a concern. But most headaches are not caused by meningitis and usually the history and physical can let the doctor know right away if that's going on.

Concussion or head injury, headaches can go along with those. Also allergies, sinus infections. Some vision, if you need glasses and you're squinting, that is less likely to cause headaches but still something to consider. And it's always a good idea to have your child's vision checked out just to be sure. But tension headaches are going to be much more common on those kids than an actual vision problem causing the headache.

0:16:24

And then, there's one called pseudotumor cerebri, which is an increased pressure in the head, that we don't completely understand what causes it. There's usually visual disturbances during the headache. Particular clinical scenario that can occur but something else to think about with the severe headaches and that's most common in teenagers. But again, very rare, but I just want to point out that there is a big laundry list of things that can cause headache.

Now, when you consider so many different things, it becomes important when should you worry about child's headache. And really, anytime that a headache is recurring and interfering with your child's daily life, the headache is really impacting their life, then that's a reason to worry. 

Stiff neck that's associated with the headache, always a reason to worry. If your child's neck hurts and they have a bad headache, then make sure you see your doctor right away. Also, fever with a headache, there's probably then an infectious disease is going on. Vomiting with a headache is also concerning. 

Headaches that wake you up out of sleep, that's more of a concern. And a severe and progressing headaches following a head injury, all of those would be reasons to worry. But again, if your child has any sort of headache recurrently and you're worried, see your healthcare provider. You're never bothering us and we would love to really capture more of the history, learn more about the headache, examine your child and try to figure out what's going on. 

More often than not, it is going to be a tension-type headache. Those are very common in adults and in kids, but you do want to make sure that there's not something else going on, especially if there other associated things going with it that are interfering with your child's daily life. 

So how does a physician go about working up a headache? Again, we start with the history in physical. Always very important, and again to really characterize what the headache is like and what your child's physical exam looks like — their neurological exam, how's the brain working? Are there any concerns there?

0:18:24

In terms of imaging, getting a CAT scan or an MRI, a lot of parents want that done. But in the absence of other concerning symptoms and findings or in the absent of abnormalities on the neurological exam, it's very unlikely that you're going to find something on imaging of the bran. But if there are concerns, we do it. 

You also have to consider that with CAT scans, it's a lot of radiation exposure, which is not benign. We know that radiation exposure can increase one's chance of getting cancers down the road and so we want to limit radiation exposure when we can. So, we only want to do CAT scan if they're absolutely necessary. 

MRI, there's no radiation associated with that, but they are expensive. And a lot of young kids actually needs sedation to do the MRI because you're in an enclosed space with lots of loud clanking noises, can be kind of scary. They have to hold still. And so, sedation may be required and there are risks that go along with sedation.

So you got to think about all these things as you think about risks and benefits, and that's really best to do with your doctor. 

You may also just, in terms of the workup, try a treatment. So if we're thinking the headaches could be cause from a migraine, you treat it like a migraine. If it goes away, stays away, then you have your diagnosis. Same thing with allergies. Treat the allergies. If the headaches seem to be going away, then that's was probably the cause.

So, treating the underlying etiology can be part of the work up. If you do know what's causing it, by all means treat it, as we think about treating, so that you can get rid of the headaches. And then, rest and fluids are really important with headaches because headaches can occur from lack of sleep. They can also occur from being mildly dehydrated. So, drink lots of fluid, get plenty of sleep. And of course, treatment with normal pain medicine like Ibuprofen and acetaminophen. Those things may be helpful as well. 

0:20:21

Next stop, we have congestion and cough. Boy, these are really, really common symptoms in the winter time, in the fall, in the early spring, as we make more mucus. And that mucus causes the runny nose and congestion, and the mucus is there to trap microorganisms and allergens. So, these things are trying to get in your body and trying to invade deeper, and so your body makes mucus to trap them. Then you began to cough to protect your airways. 

So, you got all of that mucus. It's draining down, can go down the back of the throat. It's got microorganisms and allergens in there. And so your body is really trying to keep that stuff out of the lungs and so, you start to cough. Also, when you get a virus that can infect the little hair cells that line the trachea which goes from the back of throat down to the lungs. 

And those little cilia cells sweep upward. They're like little, little sweepers and they move things up out of the lungs. So, anything that starts go down there — mucus, bacteria, viruses — it helps bring them back up. So they don't get down there. It's like trying to walk the wrong way on an escalator. 

But sometimes, if you get a virus, those cilia cells become damaged. And so, you lose that elevator so to speak of bringing things back up.  Makes it easier for things to go down, things like microorganisms and allergens. And so, you begin to cough to protect your airway, so they don't get near the airway to begin with.

Now, when those cilias get damaged, your body has to make new ones. And that can take several weeks and that is why sometimes you get this cough that's just nagging after an illness. And you tried several things and nothing seems to work. And then one day, like three weeks down the road, it just shuts off one day, the cough is gone. And that's a very common occurrence. It frustrates parents, frustrates medical providers as well. And then one day, it goes away so that's the good news.

0:22:15

You can also have prolonged symptoms from cough and congestion do the untreated allergies. You can get back-to-back viruses. So if each virus lasts for 10 to 14 days and you get two of those back to back, the next thing you know, you're sick for three to four weeks. And it's just that you get protection against one virus strain, but then another virus strain comes along. It's a little bit different and it causes a new illness. 

You can often tell when that happens because a lot of times there's fever — just brief, a day or two — at the beginning of the virus. And then, you're fine for a few days. A week later you get another fever for a day or two. And that could be a clue that you have another virus that's coming along. 

On the other hand, you can get complications of viruses like pneumonia, ear infection. And so, that second fever can also be one of those things going on. So, I wouldn't diagnose back-to-back viruses at home on your own. If your child gets a fever after not having a fever for a few days, always see your medical provider for that.

Now, we've talked about upper respiratory tract infections, particularly viruses that can cause congestion and cough. We've mentioned allergies, asthma can also cause recurrent cough, as can pneumonia. And in little kids, we think about foreign bodies, too. Could they have inhaled something? Can there be a foreign body of some sort that's trapped in the trachea? That's sometimes happen. We see that with the coins and seeds and little tiny toys. And so, especially in a kid who has no other symptoms at all. It just this persistent cough in a young kid that maybe something to think about as well. 

Now, when should you worry about cough and congestion? Prolonged symptoms, so if a cough and a congestion's lasting more than about a week, you'd want to see someone. If there's a fever that's lasting more than a couple days or the fever went away and then it came back. If there's any trouble breathing, difficulty breathing, noisy breathing, things like wheezing and stridor, which we're going to cover as we move on. 

0:24:18

 And then, also chest pain, which chest pain can happen pretty commonly with cough because as you cough, you were using chest muscles that you're not used to using. And you can pull and strain those chest muscles. And so, chest pain with cough is common. Usually, that's going to be after you've been coughing for a couple of days and then it's worst when you take a deep breath or when you move your chest. Or when you cough, you may feel more the pain. But if you have a constant pain or your worried about chest pain, definitely see your medical provider for that.

What will your doctor do when you come in with a congestion and cough? Well, like all things, we start with the history and physical examination. We want to get as much information about this cough. When did it start? What other symptoms are present? Are we around anyone who's been sick? And then, what does the physical examination look like? 

We may check what's called a pulse oximeter, which let us know the saturation of oxygen in your blood. You've probably seen this. It's a little probe with the red light, you get a number read out. If that number is 90 to 95, yeah, you worry a little bit. If it's 95 to 100, you worry less. If it's less than 90, you worry a lot. So, it just gives you an idea how well you're getting oxygen into your blood, how well your upper respiratory and your lower respiratory symptoms are working. 

Sometimes, you'll get a chest X-ray, especially if there are concerns for the possibility of a foreign body or we have concerns for pneumonia. Although pneumonia doesn't need a chest X-ray to be diagnosed. There's certainly a classic presentation in terms of the history and physical examination for pneumonia, so that can be diagnosed clinically. Doesn't always need a check X-ray, but sometimes especially if the diagnosis is in question, we might get a chest X-ray. But we want to avoid radiation exposure when we can. 

And then, just like we talked about with headaches. Sometimes, we'll do a treatment trial. If we think allergies could be the cause, we'll just treat for allergies. Or if we think a persistent cough might be caused by asthma, we might try an inhaler. And if it goes away, then that's probably what it was. But if it doesn't get better, then we need to move on and look for other things.

0:26:26

In terms of treatment for the cough itself, remember that cough is probably protecting the airway for one reason or another. So, you don't necessarily want to completely get rid of it. But at the same time, our bodies can sort of overdo coughing. And so, things you can do — rest of course, you body needs rest if it's fighting a virus. Fluids, you have those mucus production and you can get a little dehydrated from that. We want to thin up the body mucus by keeping yourself hydrated. Humidifier in the bedroom or in the house so humidification can help loosen up that mucus. 

And then in older kids, decongestants and cough suppressants. We try not to use those too much. Definitely in younger kids, they're not recommended. Honey in kids who are older than 12 months of age. Sometimes, the honey can kind of coat the back of the throat and help with the cough a little bit. And then of course, treat the underlying condition whether that's a virus — virus you can really treat that, you just have to let your immune system fight it off — but the allergies, asthmas, pneumonia, those things can all be treated. And by treating those, you're going to help get rid of the cough. 

[Music]

0:28:02

Dr. Mike Patrick: Next up is watery, itchy eyes and I know we're going through this really quickly, hitting the highlights. And if you're finding that a little frustrating, it's also a little frustrating to me. Because as I said, I could take each one of these things and talk for an hour about it. But we're keeping it brief. 

So, watery itchy eyes, this is usually caused by what we call conjunctivitis. And the conjunctiva is sort of thin see-through membrane that covers, protects and nourishes the outer layer of the eye. So, normally you can't really see your conjunctiva, but when you get an infection or something else going on there, your body increases blood flow to the area and those little tiny capillaries that are present become enlarged and then the conjunctiva appears to be red.

And so, a lot of times when you have watery itchy eyes, you'll notice some redness associated with the other white part of the eyes. So, it gets a red look to it. And the white part's still white. It's just that outer covering, the conjunctiva has inflammation. It gets what we call injected because there's more blood going to it, and that's what gives your eye that red appearance. 

So things to consider, how intense is that injection, that redness? Is there drainage present? And if there is eye drainage, is it clear or is it pussy or purulent, as we would call it? Sort of a yellow or green color to it. And then, is it a thin discharge and just a tiny bit of it? Or is there just lots of thick yellow discharge coming out of the eye? Sort of characterizing it in that way can help us determine what is going on. 

Also what associated symptoms are there? Is it itchy? Is it painful? Are there visual disturbances? Is there any redness or swelling of the skin around the eye or the eyelids that are associated with it? And then, are there any non-eye associated symptoms things like congestion, cough, runny nose, fever, is there ear pain or an ear infection present? All of these things we're going to be collecting on that the history and then the physical exam in helping us to decide what is causing the watery itchy red eyes.

0:30:15

So, what kind of things are we looking at in terms of a differential diagnosis? Certainly, the most common is probably a viral conjunctivitis. So the virus is causing a little runny nose and congestion. Maybe a cough is also causing the conjunctivitis. For that, not much to do. The body's immune system will fight if off and that's that.

Now, some little kids with the viral conjunctivitis, we may go ahead and treat with the antibiotic eye drops. But keep in mind, we're not treating what's there. It's just that little kids have a tendency to put their fingers in their mouth and rub their eyes a lot, and so you can easily get mouth bacteria starting to grown in the eye and causing a bacterial conjunctivitis. And so, we sometimes we use an antibiotic eye drops to prevent that from happening, especially in kids who are going to be messing with their eyes a lot because they're watery and itchy. So sometimes we use that preventatively.

You can also have a bacterial conjunctivitis, which is more likely to have more of the goop coming out of the eyes and less likely to have viral symptoms along with it. Although sometimes you do. And that we would treat with antibiotic eye drop as well. 

Allergic conjunctivitis is also common, especially in the spring and fall. And if you're prone to getting watery itchy eyes the same time every year, then that's probably what you have going on. That does have usually a little bit of a different appearance to it, usually, the discharge is more clear, not quite as thick. And the conjunctiva itself can have like a little bubbly appearance to it. And there are medications that we can use for allergic conjunctivitis as well.

If there's pain present, then you think about foreign bodies. You can get a little speck of dirt, all sorts of things that kids can get into their eye. And so, that can cause watery itchy eyes, especially if it's painful. And then, a corneal abrasion where the cornea, which is the part that cover the outer part of the eye that is directly over the pupil and the iris.

0:32:14

So, if you kind of look at the eye form the side, you'll see a dome and that dome is the cornea. And especially if you rub your eye or you get a foreign body in your eye, that can get an abrasion which can cause you to have pain. But also, your eyes will water and can sometimes feel itchy, like there's a foreign body there. It feels like something is present.

Now, when should you worry about watery itchy eyes? Well, anytime there is pain present, that's definitely reason to worry. You want someone to take a look at that right away. When there's photophobia, meaning that light bothers your eyes — so kids will squint and keep their eyes closed as much as they can — definitely a reason to have it seen right away.

If it's a young infant that has goopy eyes, we worry a little bit more about that, especially if it's right around the time they were born, because they can get infections through the birth canal. Bacteria ones, some of which can be serious and so we want to see all those.

And then, anytime there's redness or swelling around the eyelids or what we'd call the periorbital region, the skin around the eye. That's going to be more of a concern. And of course, prolonged symptoms, anytime you're worried, you want to see your provider but those are some reasons to be worried particularly.

Your doctor, of course, will start with the history and physical examination, always the most important thing. If they're worried about a foreign body or a corneal abrasion, they may do what we call a fluorescein exam or they look with a Woods lamp or black light and put some flourescein in there, which lights up and you're able to see things like abrasions a little bit better.

In terms of treatment, it really depends on what's going on. For the drainage itself, and because of that drainage of the eyes, your eyelids are matting together, especially in the morning we may recommend a warm compress. And then it really depends on what's going on. If it's a bacterial conjunctivitis, we would treat with antibiotic eye drops or ointment. Might use those two if it's viral depending on the age of the child. 

If there's ear infection present, we just may treat with an ear antibiotics. And if there is a periorbital cellulitis or skin infection around the eyes, then we might use an antibiotic shot or even IV antibiotics. And of course, we talked allergic conjunctivitis. There are antihistamine type eye drops that can be used for that.

0:34:27

What about going to school? Really depends on your school's policy. Conjunctivitis is contagious. But as long as kids wash their hands frequently and don't touch things, especially in older kids, it's less likely that is going to be acquired by another child at school. But some school don't want your child to be back in school until the eye symptoms are resolved completely, especially with the viral conjunctivitis which can spread so easily.

On the other hand, if it's allergic conjunctivitis, no reason that your child should be out-of-school for that because that's not contagious at all.

Ear aches are another very common symptom that we see with kids, pretty much all year, but maybe for different reasons. A little bit of background on ear aches and things to think about just in general. Some young kids, you can't necessarily tell if their ears are hurting. And so your doctor ask if your young child has been pulling on their ears or grabbing at it, putting their fingers in their ear. That could be a sign that they have an ear ache. 

On the other hand, lots of kids discover their ears. And it's a handle, it's something that they can pull on. And so then, it becomes more difficult because it's a child who always pulls on their ears, so that may not be helpful. 

But if it's kid who's fussy and have runny nose and congestion, maybe a fever, they're not usually ear pullers and now they are, that could be an indication that they're having an ear ache. 

Also, those symptom I mentioned that can go along with the ear infection that don't necessarily pertain to the ear, a lot of times they start out with a virus and then you get an ear infections, the complications of that. And so, if they have a runny nose and congestion, decreased eating, fussiness, fever, then we do think about ear infection as being a little bit more common. 

0:36:10

And when we talk about those cilia cells in the trachea, they can get infected and cause cough or result in cough because your body is trying to prevent stuff from going down there until those cilia get healed. The same sort of situation happens in the ear because the cilia cells also line the Eustachian tube, which connect the back of the throat to the middle ear space. Usually those sweep back toward the throat. So any mouth bacteria or nose bacteria that try to go up into the ear, they get swept back. But if those little cilia cells get infected from a virus, then mouth and nose bacteria can go up there into the middle ear space and cause an ear infection.

So, that's why a lot of times you have a kid with the runny nose and congestion for a few days and then they get their ear infection. That's the reason that happens. And again by knowing your child's history, did the ear infection just start out of the blue? Is there a cold present there first? Are they pulling their ears? Do they have a fever? All these things are important as we think of a differential diagnosis. 

And the differential diagnosis would be, first, infection, and that can be caused by a virus or bacteria. You can't always tell if it's a viral or bacterial. Just the cold virus itself can also get up in the middle ear space and cause infection. Antibiotics are not going to help that. But the only way that you would know for sure what's going on is to puncture the ear drum and let it drain, and take some of that drainage and culture it to see what's there, to see if there's bacteria. 

Or you could do some PCR testing on it to see if there's a virus present. We don't do that. We used to, back like in the '60s. They would sometimes rupture ear drums and culture it out. But we don't do that anymore. 

And a lot of times if they have a bulging red ear drum in a young kid who's pulling on the ear and fussy and they have a cold, we'll just assume that it's a bacteria ear infection and go ahead and treat that with an antibiotic. But some of those are viral ear infections. They get a bit overtreated.

0:38:05

Now, in the summertime, swimmer's ear or otitis externa, this is really a skin infection of the ear canal. And that can happen from swimming often. Also, just having a lot of wax in the ear can be uncomfortable and can also impact hearing as can any fluid in the middle ear space. So, that's another thing we think about, in terms of the history. Are you having trouble hearing with your ear pain? Have you been swimming recently? If we're thinking about swimmer's ear. And then, do you have a history of having ear wax problems and needing your ears irrigated? If so, that may be the problem that's going on.

Sometimes, babies and young toddlers who are teething, sometimes especially with their molars, they may get a little bit of discomfort referred to the ear. So, it's really more of a back jaw issue. And also dental carries and any tooth decay that's going on can also get some referred pain to the ears. So, your brain thinks it's your ear that's the problem, but really those signals are coming from the back of the jaw and your molar area. So, we always take a good look at the teeth, too, when kids complain that their ears hurting.

And then, what we'd call Eustachian tube dysfunction. The Eustachian tube, its job is to equalize the pressure on the inside part of the ear drum. So, you have a room air coming into the ear canal. But on the back side of the ear drum, since it's a very mobile surface, you want the air pressure to be about the same. 

And if the Eustachian tube sort of collapses on itself and you get a pressure differential of the air that's on each side of the ear drum, that can cause some discomfort, some popping, cracking, kind of like you go up and down on the mountains or going up and down in an airplane. Those are all examples of pressured differential on each side of the ear drum and keeping Eustachian tube open can help that. 

That's why in older kids, we recommend chewing gum when you have that discomfort. Or you can kind of manipulate your jaw in such a way to sort of open up the Eustachian tube and equalize that pressure. That's something else to consider with the ear discomfort.

0:40:08

Now, when to worry? If it's significant pain, if it's pain that's long lasting, if you have a fever associated with it or vomiting, definitely reasons to get that checked out. And, of course, your physician, your healthcare provider will do thorough history and physical examination. They'll look to see how much wax is in the ear canal. They might have to get that wax out in order to get a good look at the ear drum. 

They'll also look at the skin of the ear canal and all of that will help them determine which of those things is going on and then determining treatment, whether that's just getting the wax out using antibiotics. Maybe taking a watch-and-wait because even bacterial ear infections sometimes will just resolve on their own. So, for older kids, you may just want to give it a couple of days and see if it will get better on its own. And then, of course, treating the pain itself with the things like ibuprofen and acetaminophen.

Another common symptom that we often see in kids is sore throat. And again, we want to start with the character and the history of this. So, when did it start? Is it only present in the morning? Is it there all day? How many days has it been there? Is it something that's recurrent? Or is it just started out of the blue right now? Is it constant or intermittent? And how severe is it? It's just a little, little scratch or is it really severe throat pain?

So, really getting a characterization of the sore throat can be very important in terms of determining what exactly is going on. We also want to think about associated symptoms, so are there cold symptoms present? Runny nose, congestion, cough? Is there a fever? Is the child having difficulty swallowing? Are there lymph nodes — swollen tender lymph nodes in the neck that are present? 

Does your child have voice changes associated with the sore throat? Do they have a spasm of that trauma? So is it difficult for them to open their mouth because the muscles in the jaw feel really tight? That can be very concerning.

0:42:04

And then, the physical examination, how much redness is there? How much swelling, if any? Is there puss on the tonsils? Is the uvula which hangs down in the middle, is that shifted over to one side or is it hanging down in the middle? Are there little red spots on the roof of the mouth, what we'd call palatal petechiae? All important parts of the physical examination. 

And as I've mentioned, with all of these symptoms, probably the most important thing to do in terms of figuring out what's going on is just to really get a good history and physical examination because there's so many little nuances that you have to consider in coming up with the right answer. 

Now, what are the choices? So what sort of things can cause sore throat? Well, one is going to be and probably the most common is going to be a viral illness. So the illness that causes the runny nose, congestion, cough, also causes your throat to be a little sore. And so viral sore throats by and large are going to be the most common thing. 

Now, strep throat is what everybody's worried about. And as it turns out, strep throat usually go away on its own. So, even if you have strep throat, you're going to more than likely get better. 

Now, the problem is that strep throat's contagious and there's also a very small risk — but it's a risk nonetheless — of untreated strep throat leading to rheumatic fever down the road. Now, that's different than scarlet fever, which is a strep throat with a fever and skin rash. Rheumatic fever really is a bigger problem. It's an autoimmune disorder, so your body's immune system was attacking the strep. But now, it's going to start attacking other parts of your body like your joints and your heart. And it can cause a very distinct-looking rash and some skin nodules. 

So it's a bad thing. And we don't want that to happen. And in the past, there were probably some strains of strep throat that were more likely to cause rheumatic fever that may be aren't as prevalent these days. And so, that's one of the reasons that we don't see it as much even in kids who don't get treated for their strep throat.

0:44:12

On the other hand, it can cause some lifelong problems. And so, this is one of those instances where we do want to treat everyone that we find who has strep throat because we want to avoid rheumatic fever whenever we can. And also, we want to prevent the spread of strep throat. And the length of time that you're contagious is less when you get the antibiotic. 

So, we will do a throat swab very often for a rapid strep test. There's also throat cultures that can be done and gene probes that can be done on that swab looking for strep DNA. And when we find strep throat, we generally treat it. 

Now, we also have to keep in mind that a significant percentage of the population is a carrier for strep. It's not causing disease. It's not really causing strep throat. It's just sort of dormant in the back of the throat. And so, there's a lot of kids with viral upper respiratory inspections who have a little bit of a sore throat with it. We do the swab, it's positive. Or did they really have strep throat or are they just a carrier? And you can't really tell the difference between those two. And so, those kids usually treated with an antibiotics as well, which maybe overkill and cause more resistant bacteria. 

So, more and more  kids who have a definite viral upper respiratory tract infection with a mild sore throat, whose throat exam really doesn't look that bad. A lot of times nowadays, we won't even do the strep test because it's so unlikely that it's really strep throat and more likely that we're just going to catch a carrier state and treat unnecessarily. 

Other things that can cause sore throat, mono or Epstein-Barr virus. And then, more invasive bacterial infections of the throat — things like peritonsillar abscess and retropharyngeal abscess. And these are all things that are serious and oftentimes require IV antibiotics, sometimes even surgery for those. But they're not common. The most common is a viral illness causing your sore throat. And most of the time, a doctor can differentiate between these things with the history and physical exam. 

0:46:08

Sometimes, it helps again to do the strep test. There's also a mono test, that's a blood test that can be done. If we're worried about a retropharyngeal abscess, for example, we might get some neck X-rays. 

And then, when should you really worry about sore throat? Well, significant pain that makes it difficult to swallow, if it's lasting for several days. When there's not upper respiratory tract infections — so cough, congestion, runny nose — when those things are not present. When your child has voice changes, what we call a hot potato voice. Their voice sounds like they're holding a hot potato in the back of their throat. And they're talking funny. When they do have the muscle spasm of the muscle between the jaw. They open and closes their jaw. If they have difficulty swallowing. You're worried they're getting dehydrated, all reasons to see your physician. 

And then what would they prescribe? Depends on what's going on. Rest and fluid always. Antibiotics if it's strep throat or there's one of those more invasive infections going on. Sometimes, if there's a lot of throat swelling, we'll go do a steroid called Decadron that can help reduce that swelling. And then, of course, pain medication like ibuprofen and acetaminophen.

[Music]     

Dr. Mike Patrick: All right, we are moving along. And for the most part, keeping up with the schedule feels a little bit like out of control train here, as we're recovering all of these common pediatric symptoms really hitting the highlights. But hopefully, you're finding this helpful. 

0:48:03

Next up, we're going to talk noisy breathing. And by this, I mean wheezing and stridor. Now, a lot of times, a things get called wheezing that are not really wheezing. And so, it's not a bad idea for a parent to look up on YouTube a video of a child who's wheezing and a child who has stridor so you can just hear for yourself and see for yourself what these things look like and sound like. So that you have a better grasp of whether it's really wheezing or just noisy breathing from nasal congestion, which is also very common.

So wheezing usually starts out as an expiratory sound. So, you'll hear it when your child breaths out. It's kind of a high pitch noise. It may just be at the very end of when they're breathing out. But as the inflammation down deep in the lungs that causing the wheezing, as it's just air flowing against swollen tissue, then you first just hear the end of expiration. But then, as that swelling of the tissue gets worse and there's more turbulent airflow, then you're going to hear it during all of the expiration. 

And then, you can even start to hear it during inspiration as well. So, sometimes wheezing will be so bad, you hear it as they breath in and when they breath out. Oftentimes, they're also breathing fast. So that's wheezing. And oftentimes, it goes along with asthma, can also go along with bronchiolitis, which we've done whole shows on those things that you can check out.

Stridor on the other hand is a different sort of character to it. And it is an inspiratory sound, often will accompany a barky cough. And so, you only hear that during inspiration, where wheezing, you're more likely to hear during expiration. And again, they have a little bit of different character to them. 

And so, listen to those if you're interested. Really good idea, especially if your child's having some noisy breathing. Although, if your child's in distress — so if they have noisy breathing and they're breathing fast — don't waste your time looking at YouTube, what it could be. Just have your child seen or call your doctor right away because airway's important.

0:50:09

Other things that can cause noisy breathing. As I mentioned, nasal congestion. But sometimes, there are other things that can wheezing and stridor — foreign body, for example. If your child has a foreign body in the airway, that could cause stridor. There's something called epiglottitis, which we don't see very often these days, thanks to the H flu vaccine or the Haemophilus influenzae vaccine. 

That's a bacteria that used to cause oftentimes deadly disease where kids would get critical swelling of their epiglottis, which is that little flappy tissue that sort of closes off the airway when you swallow. If that gets really swollen, it can close off the airway even when you're not swallowing, and there were kids who would die from that in years past. But the H flu vaccine has really eliminated the incidents of epiglottitis. But as we're seeing more and more kids not get their immunizations, that does increase the risk that that could be going on again. And so, something that to consider. 

Croup oftentimes will cause stridor with a barky cough associated with it. And in terms of wheezing, allergic reactions. So anaphylaxis, if you're having a really severe allergic reaction to something, you're covered in hives, sometimes those folks will have some wheezing and respiratory problems as well. 

So, when to worry with noisy breathing? Unless it's caused by airway congestion up above — so runny nose, congestion causing some noisy breathing at the level of the nose. And sometimes, you'll hear that at the level of the mouth as well. But if there's any concern that it's something more than just nasal congestion, that there really is wheezing or stridor, particularly if there's difficulty breathing associated with that — rapid breathing, or you noticed that their skin seems to be sort of sucking in with each breath between the ribs or on top of the breast bone down below the rib cage — if any of those things are going on, you want your child to have an evaluation or call your doctor right away. 

0:52:05

If they are known to have reactive airway disease or asthma, use their rescue medication when you hear them wheezing. And if it's a sudden and unexpected onset of symptoms with no other symptoms present especially in the young child, you got to think about foreign body. Could they have put something in their mouth that's causing obstruction in the airway and resulting in them having noisy breathing?

Now, what would your doctor do? Again, like with any of these other things, a thorough history and physical examination can often tease it out, especially because we're used to hearing these things. So, we don't need to look at the YouTube video. We know what wheezing sounds like. We know what stridor sounds like and can diagnose it and think about what other things are going on and what it could be. 

Pulse oximetry, where we check for the amount of oxygen in the blood, can be helpful as we evaluate for noisy breathing. Sometimes, we'll get a chest X-ray if we're concerned that there could be a foreign body or that pneumonia might be present or that we're worried about other things in the chest. 

And sometimes, we'll get neck films if we're thinking about there being epiglottitis, that it could possibly be present. Or a foreign body in the airway, other reasons to get neck X-rays, as well, when we think about noisy breathing.

Again, chest X-ray and neck films are not always needed. In fact, most of the time, they're not needed. But there's a thing that can help you out if there is some question about whether it really is asthma, reactive airway disease, or croup, or if there could be something else that's going on. 

In terms of treatment, it really depends on what the cause is and whether it's wheezing or whether it's croup. If it's wheezing and we think that it's react to bear a disease or asthma, we usually use albuterol or we called DuoNeb, which has ipratropium added to it. Steroid medicines like Orapred or prednisone can also help reduce airway inflammation. We've had lots of other shows in the past on wheezing and asthma. 

With croup, sometimes, we need to do aerosol treatment, not with albuterol but with racemic epinephrine. And those kids oftentimes need to be admitted to the hospital or at least watched for awhile after they get their treatment. Also, we can use steroids for them but instead of  Orapred, we typically use dexamethasone or Decadron instead of the prednisolone. 

0:54:19

If we think that there's a foreign body in the airway or the epiglottitis is at play, then a lot of times, we'll just sort of leave them alone, let the child protect their airway. Then, we get the specialist involved who would be able intubate them or remove the foreign body, the ear, nose and throat folks and the anesthesiology and have that done in the controlled environment in the operating room. It's that scary to remove a foreign body out of the airway like that. Unless it's urgent and needs to be done immediately. And again, that's something that's decided at the point of care in the emergency department.

So, noisy breathing, very serious, possibly can progress to significant seriousness. And so, that's not something that you want to ignore when your child has noisy breathing, unless you're absolutely sure that it's upper respiratory and just nasal congestion. In which case, you suck up their nose, they should get better.

We are to abdominal pain and belly aches in kids. Boy, huge list of a possible causes. And so, it's going to be really important right at the beginning of an evaluation for abdominal pain to really get a good idea of the history of the pain. 

Really, try to describe its character. Where is the pain located? How long has it been there? Does it come and go? If so, what's associated? Is it there before meals? Is it there after meals? Is it there in the morning? Does it wake you up out of sleep? Is it just a little  mild vague pain? But your child's still playing and active. Even though they say their belly hurts, they still are acting normal? Or are they laying in bed doubled up moaning that their belly hurts so much or somewhere in between?

0:56:02

So it's important to really describe the character of the pain and any associated symptoms. How's their appetite? Do they have any vomiting or diarrhea? 

We want to think about their age, their sex. Girls have parts in their belly that boys don't.  And boys have parts girls don't have that can cause referred pain up into the abdomen. We want to think about their social history including sexual activity. Lots of things that can cause abdominal pain. And so, that history and physical is so important. 

In terms of differential diagnosis, things to think about are viral gastroenteritis, just a viral… A lot of people sometimes cause stomach flu which is not really flu at all. It's kind of a bad term. But just that vomiting and diarrhea with the belly ache, that often is the cause.

Constipation is very common. Gastroesophageal reflux or heartburn could be going on. Appendicitis, kidney stones, urinary tract infections, ovarian cysts or twisted ovaries can happen even in young girls. Menstrual cramps, sexually transmitted infections, pregnancy, swelling lymph nodes in the abdomen, what we'd call mesenteric adenitis which can actually go along with the throat infection. So viral infections can cause those. 

Something called intussusception, where the intestines sort of telescopes in on itself. Pneumonia can cause referred pain into the abdomen. Hepatitis, gallbladder disease, pancreatitis, trauma. You can have a liver or a spleen laceration with trauma that can cause abdominal pain.

So, huge list, but you usually can narrow it down when we think of those things I mentioned. Like the character of the pain, then the natural course of it. Any associations, thinking about their social history, all of those things together then help you really start to narrow down what exactly could be causing that abdominal pain. 

In terms of when to worry, actually, the longer the pain has been there, probably the less likely you have to worry about it. So, things like appendicitis and kidney stones and trauma and tubal pregnancies, these are things that usually get bad fast. So, sudden onset, or a progressive onset, but very quickly, within a few hours, you have significant pain where you started at zero and it just is getting worse. That's not something you want to wait. You want someone to take a look at that right away. 

0:58:28

On the other hand, if it's vague abdominal pain and the kid that's been still playful and active and eating, they just complain of their belly and it's been months they've been doing that, that's less of a concern. You still want to get a workup, don't get me wrong, but less of a worry that there's something significant, possibly life threatening that could be going on. 

Also vomiting is associated with abdominal pain. We worry about dehydration then becoming a possibility. We also worry if there's fever associated with the abdominal pain, if there's some underlying infection that we would need to identify and figure out what's going on. 

Strep throat, mono, both of these things can have abdominal pain associated with them. Lots of things can.

And those chronic ones, if it's just persisting and then begins interfering with your child's daily living, definitely want to get that looked into. Anytime you worry about abdominal pain, by all means, see your doctor. But those really bad quickly progressing abdominal pains, vomiting, fever, definitely you want to have those seen sooner, rather than later.

In terms of a workup, it really depends on what it is you think might be going on. So, as you think about that huge differential diagnosis, you start to narrow it down. And then, there's something you can do to tease out which of those possibilities is actually going on. But what you do is going to depend on what you're worried about among that list. 

So obviously, it starts with the history and physical. Oftentimes, that'll include a genital exam, especially in boys, you want to make sure they're not having a hernia or they're not having a twisted testicles that could be causing abdominal pain. So, your doctor's probably going to look at your kid's private parts, especially in boys, if they have abdominal pain. 

1:00:11

And in girls, especially older girls, that may mean also do looking at their genitals and doing what we call a bimanual exam to see if they have tenderness of deep inside. Especially if sexually transmitted diseases are a possibility, which we do see in teenagers and high school kids. And high school kids whose parents don't think that would be going on, sometimes it is. And so, it's something we don't want to assume it's not and then miss something.

Ultrasound examinations of the abdomen, especially if we're worry about appendicitis, or twisted ovaries or problems with the kidneys. Ultrasound can help us out, particularly with ovaries and appendix. And then, plain X-rays maybe helpful as well, just a flat plate, just a regular X-ray of the abdomen can help us determine if there's obstructions, if there's constipation that could be problems. 

Bloodwork, we can look at blood counts if we're worried about infections. We can look at liver function test, lipase if we're worried about the pancreas. 

We may check urine. Urinary tract infections can also cause abdominal pain. And so, we're looking for abnormalities in the urine that may suggest UTI or blood that could mean that the kidney stones is happening or other things. We'd do a urine pregnancy test and workup for sexually transmitted diseases. 

So lots to consider with the workup. And also lots to think about in terms of treatment, but there's so many different possibilities. So really got to get that diagnosis, and then you have a better idea on exactly how to treat the abdominal pain.

And right on the heels of abdominal pain, I want to talk about vomiting and diarrhea. Sometimes, these go along with the abdominal pain, and sometimes not. Sometimes, one is present and other times both vomiting and diarrhea are there. And knowing which one it is or is both, is there abdominal pain present? 

1:02:09

Is there nausea? Do they have painful urination? Are they having fever? Are they dehydrated? Or have they been around anyone with vomiting and diarrhea? Are there other kids at home or at school or adults that they've been around who've had one or both of those things recently?

So, those are sort of little things you want to think about historically as we consider vomiting and diarrhea. And just like a lot of these symptoms, there is a fairly large list of things that can cause them. When they're together — the vomiting and the diarrhea with some mild abdominal pain — especially if it's just been going on a day or two and there's other people at home or at school with the same, then it's probably going to end up being a viral gastro enteritis. 

You have a little virus infection in the belly. Sometimes that gets called stomach flu, which is again not the flu at all. But it's a viral infection that's causing some inflammation in the intestine that gets better on its own fairly quickly but can have some vomiting and diarrhea associated with it. 

Now in terms of more serious intestinal infections, so things like salmonella, Shigella infections, E.coli, C.diff, Clostridium difficile, these things are bacterial infections and often they can have a little bit of vomiting associated with them. But the diarrhea really is profused and may have blood in it as well. 

So, anytime that you see a lot of blood or mucus consistency to diarrhea, you want to have someone take a look at that. If it just a water with no blood or mucus present and it's just been there a day or two, then you're more likely on the viral side. But if you see the blood and mucus, you worry a bit more about bacterial infections. 

And none of those things are 100%, and so if you have to kill with diarrhea, it's been there for more than a couple of days or you're worried that they're getting dehydrated, you definitely want to see someone who can ask you those questions and sort things out further.

1:04:04

In terms of vomiting, if it's a young baby, we do worry more about bowel obstructions. And sometimes your doctor will ask, is it projectile vomiting? Projectile vomiting really means forceful vomiting that flies across the room. So, you don't want to put a link on it but it's usually more than arms length. So, most kids when they vomit, there is some pressure. There are some pressure associated with the vomit coming out because it started down on the stomach and it had to have enough force to it that it get up the esophagus and out the mouth. 

And so, oftentimes, vomiting will fly but usually not out pass about arms length or so, the parents arms length. But if it's flying out pass that, then we may start to call that projectile vomiting. So even more forceful than what we would normally expect. And if there's any blood in the vomit, or there's any green bile in the vomit — sometimes a yellowish-greenish color — then that can be a more concerning for a bowel obstruction. 

And so, vomiting in any young kid, particularly when it's out of the ordinary for them and associated with what maybe abdominal pain, fussiness, we worry about that a lot more.

On the other hand, lots of little babies spit up. And just the valve that's between the lower esophagus and the stomach has sort of a looseness to it. And when the stomach squeezes to push food down into the small intestine, some of it can pop back up. And so, if they do have a little bit of vomiting that's non-projectile, there's no blood in it, there's no green bile, they're not choking on it, they're not particularly fussy, they're just more of a happy spitter after they eat, and they're gaining weight, that we don't worry about so much. 

But if you're worried it, obviously, see your healthcare provider and again, let them sort of sort through that. But lots of babies do spit up but when it becomes a truly projectile, blood in it, green or yellow bile associated with it or they're, acting like their belly hurts, they're not gaining weight, you're worried about dehydration, all reasons to have your child, especially your young baby, seen for that.    

1:06:10

In older kids, we do worry too about inflammatory bowel disease, especially if there's blood present in the diarrhea. Also kids as they get older — and even toddler-aged kids — can get constipated because once their potty trained and they get good in holding their bowels, sometimes they hold their bowels too well. And the poops start to back up, and that can actually then lead to diarrhea. Because if your large intestine is full of stool that's not moving, the liquid stuff from the small intestine doesn't really have any room to form into compact stool. And so, it can sort of leak around the bulk of stool that's just sitting there. And so, kids who have chronic constipation can actually show up with diarrhea.
    
So, I know it sounds confusing. And another reason why when your child's having these problem, see your doctor so they can ask you this question, do an exam, and figure out what's going on.

Also, diarrhea, it can be a non specific sign of any infection. So, just the inflammatory process in general can increase bowel transit time which can cause some loose stools. So, you'll see kids with viral upper respiratory tract infection or an ear infection. They have sore throat or strep throat, sometimes they'll have diarrhea. 

Usually, it's not profused watery diarrhea, just looser than it normally is. And that's just because the inflammatory process is affecting the whole body, just like the cause of fever but also increase gut transit time and that can lead to some looser stool. 

So, when should you worry? I mentioned projectile, truly projectile vomiting out pass arm's length, blood or bile in the emesis, in the vomit,  blood or mucus in the stool, when there's associated fever. Especially if it last more than a couple of days, persistent abdominal pain or severe abdominal pain, painful urination, all reasons not to wait but to have someone take a look sooner rather than later.

1:08:06

When can you wait? If your child just vomits a couple of times, they have some loose stool, maybe a little nauseated but they've been around others who have the same symptoms, that's the kind of situation you can give it a couple of days and see if it's going to resolve. 

In terms of workup for vomiting and diarrhea, again, history and physical exam, very important. And then, it just depends on what other symptoms and then the character of what's present. For vomiting, there's a medicine called Sofran that we can use to treat. Although, if it's just a little vomiting and you avoid milk and dairy and you avoid greasy foods and small amount of fluid frequently, oftentimes you can get through that vomiting episode without necessarily having to have Sofran. 

With diarrhea, you become temporarily lactose intolerant when you have diarrhea. So we'll say avoid milk and dairy products, things with lactose in it. Probiotics may be helpful to replace the good normal bacteria in your gut after about a diarrhea. And then lots of fluids to replace what you're losing, which is harder to do with vomiting than it is with diarrhea. So, if you're worried about your child being dehydrated, definitely see your doctor. And some kids with vomiting and diarrhea need IV fluids if oral fluids aren't going to be enough to rehydrate their body. 

So lots to think about with the vomiting and diarrhea. And when those are persisting or have those other assisted symptoms — projectile, blood, green mucus — then you want to see your doctor again, sooner rather than later.

[Music]

1:10:06

Dr. Mike Patrick: All right, we're going to move on to painful urination and groin pain in general. Sometimes, it's hard to differentiate which of those things is going on, especially in younger kids who may not be able to pinpoint where the discomfort is. 

Before we get to that though, one more thing I wanted to mention on diarrhea, and that is you see these commercials for anti-diarrheal medication. You know, you're able to ride a mule for the grand canyon and get to the whole trip without having diarrhea. You've probably seen those commercials before. 

So, we do have a lot of families asking, "Can we give him something to stop the diarrhea?" When the reason for the diarrhea is infection, particularly viral infections — so you have a viral gastroenteritis — you're really best leaving your child to have the diarrhea for a few days, because that diarrhea is helping get the causative agent, so the virus and in some cases bacteria, out of the intestine. And so, you don't necessarily want to stop that diarrhea because then you're also stopping the ejection of the virus or bacteria. And that can cause the illness to last longer. You can get more cramping if you're not getting that fluid out of the intestine. 

And so, really, we recommend that kids, just let them have the diarrhea. But so they don't get dehydrated, replace with they're losing by having then drink more and keeping themselves hydrated. Of course, if you're worried about this, talk to your doctor. But in general, we don't use diarrhea medication to stop diarrhea in kids. All right, just wanted to add that.

In terms of painful urination, lots to consider when kids have urinary pain, whether it's pain when they pee or if it's pain that's there all the time. If it's just the genital region in general, just trying to pinpoint where they're hurting. But sometimes that can be difficult to do. Things that can help you out is are there any other symptoms associated with their discomfort? 

So, in terms of urination, are they going frequently? Is it small amounts that they're peeing frequently or large amounts frequently? Are they having urinary urgency, where you feel like you have to pee all of a sudden and then you got to get to the  bathroom or you're going to have an accident? Blood in the urine, is there any vaginal discharge? 

Are they having any associated symptoms elsewhere outside of the private parts? So, are they having belly pain? Are they having fever? Vomiting? These sorts of things. What other symptoms may or may not be present?

1:12:28.

In terms of what we think about, urinary tract infections definitely come to mind immediately when we think about painful urination. In older kids, sexually transmitted infections can also cause discomfort in that region. 

In the younger kids, one thing that's common is contact dermatitis or contact urethritis. The urethra is the tube that connects the bladder to the outside world. You pee through it. And the tip of that is prone to getting inflamed when it comes in contact with chemicals like soaps and shampoos. Even laundry detergent and fabric softeners that haven't been completely rinsed out of the fabrics can cause irritation down there and also can cause irritation of the skin as well.

So, sometimes kids will complain of their bottom hurting. And you look and they're inflamed and red. It's really the skin and not necessarily urinary tract infection. Although we do still often will check the urine because they've got their hands down there, rubbing, because it hurts, by the manipulating, bacteria can be encouraged to head up into the urethra and cause urinary tract infection. Even if they have contact dermatitis on the outside. 

So, especially little girls, when they're complaining of any discomfort down there, we'll check the urine even if we suspect it's more soap or shampoo or detergent that could be causing those things.

Hernias will cause pain in the genital region. That's something that your doctor would have to examine to see if there's a hernia present. Testicular torsion, so when the testicles are twist on itself that can cause significant pain in the scrotum. So, you'd want that checked out. That's again something you don't want to wait for if they have pain down in their testicles. You want to have that checked out right away because if the testicle twists, it can cut off its blood supply. And that can be really important to intervene quickly, to save the testicle. 

1:14:24

When to worry about pain? That's one — any scroto or testicular pain, you're going to want to have someone take a look at. Also, any swelling, unusual swelling in the scrotum or the labia in girls that could indicate a hernia. If there's fever abdominal pain, vomiting, blood in the urine, any of those things you'd want to have your child seen sooner rather than later.

In terms of a workup, as always, history and physical examination, most important thing and oftentimes you can figure out exactly what's going on based just on those. Urinalysis is going to be important. Urine culture to be find out what's growing in there. That's really important because you want to know what organism you're dealing with, to make sure you're choosing the right antibiotics. So, it's important if you diagnose the urinary tract infection with the urinalysis. Now, we're also then following that up with the urine culture, so we can make sure that we're doing the right treatment.

Testing for sexually transmitted infections, in any girl who's having discomfort, especially if there's also vaginal discharge, abdominal pain, fever, really important that you don't just assume that your child's not sexually active. You still want to do that testing. It's not something that you want to miss because that can lead to public inflammatory disease, which can have implications on future fertility. So again, we want to be sensitive to the fact that your child is not sexually active, and at the same time being realistic in that lots of kids are and their parents don't know about it. So, things to think about.

Testicular ultrasound is something that can be done if we're worried about a torsed testicle, to ensure that there's good blood flow and it's not twisted on itself. 

1:16:02

And in terms of treatment, it really again depends on the underlying cause of the painful urination or the groin pain. Certainly, urinary tract infections, sexually transmitted infections, we think about using antibiotics. If it's a contact dermatitis or urethritis, we think about avoiding chemical exposure in terms of using small amount of laundry soap, double rinsing, not using fabric softener, dryer sheets, the clothes with chemicals. 

Sometimes even just synthetic, dyed, colored underwear can end up being a problem. That if the child's sweating and they're leaking a little here and there, that can dissolve out some of the fibers and the dyes and that can cause a contact inflammatory process with the skin or the tip of the urethra. And so, using a white cotton underwear that's been double rinsed and not using fabric softener or dryer sheets can also help with that problem becoming recurrent. 

And then, sometimes, for these things, surgery is needed. For instance, if it's a hernia or there's a torsed testicle that's going on.

All right, we have made it. We've made it to our final symptom check. And that is going to be rash. And like a lot of these, rashes have a huge laundry list of things that can cause them. And there's so many different looks that a rash can have. And here's a thing, you can look at the rash and say, "Okay, base on the look, these things come to mind." But the other things is that anyone of those things that come to mind can have different looks. 

So, it can become very complicated. And you often want someone who has seen a lot of rashes, and has treated a lot of them and seen what's worked and what doesn't work, and to get an idea of what all the different variations of those rashes can look like. Because there are so many different possibilities. 

But sort of places where you start are what does the rashes look like? Where is it in terms of distribution? Is it generalized all over the trunk and the extremities? Is it only on the exposed extremities and face? So where clothes are touching, the rash is not there. That can give you an idea about some things.

1:18:17

Or maybe the rash is only underneath the clothes and not on areas that aren't touching clothes at all. Is it just in the groin area? Is it just in the diaper area? Is it patchy or is it just all over the place? And then, the rash itself,  are they red patches? Are they bumps associated with it? So the more red spots, we would call macules, the bumps we call papules. Are they present together? Is there dryness? Is it itchy? 
Are there any associated symptoms with the rash? Do they have a fever? Do they have a sore throat? Runny nose, congestion? Have they had exposure to things that touch the skin? Like poison ivy or any other chemicals that maybe associated with these? Where do the rash start? Where has it spread to? In what has it spread? So all sorts of things to think about when we look at the rash.

In terms of the differential diagnosis, again, you narrow it down  pretty quickly based on what it looks like and where it is. But things to think about, viruses can cause rashes (what we call viral exanthems), strep throat, Lyme disease, contact dermatitis including poison ivy, insect bites and stings, bed bug bites, infections on the skin like impetigo, colitis, abscesses. 

Scabies is something that can happen in the skin. Ring worm, which is really yeast type of infections caused by tinia. Are these hives which can be caused by viruses? They can also be caused by more significant allergic reactions. 

And then, some serious things in the skin which the rash is actually bleeding in the skin. And that can be associated with things like meningococcemia, which is a very serious bacterial infection of the blood. And then, it can get into the spinal fluid and cause meningitis, which is why it's called meningococcemia.  

Something called idiopathic thrombocytopenic purpura or ITP, we have a little platelet count that can cause bleeding in the skin, which can sort of look like a rash at first glance. 

1:20:18

One way you can tell the difference between something that's more serious and less likely to be serious is to push on the rash and if it plunges, so it really turns more of a pale color, and then when you let go, it returns to the rash form. That's a little less serious than if when you push down, the rash stays. So the blood in the skin you can't push out. But if it's just increased blood flow to the skin, you can compress the vessels and blanch the skin. 

But again, this is not something that you necessarily want to diagnose yourself at home. If you're concerned about a rash, have your doctor take a look at it. They'll push on it and see if it blanches or not. And if it doesn't, that look likes what we'd call petechiae or purpura or bleeding in the skin. That demands quicker workup to try to get to the bottom of what's going on, as opposed to a little bit of redness that does get pale when you push. And it's itchy and you've been around poison ivy, that's a different situation. 

And then, we think about in terms of when you should worry as a parent. If they have a rash and they have a fever or sore throat, tick exposures, joint pain, any swelling in the skin, all reasons to worry. But again, as I have mentioned so many times before, if you're concerned with your child's symptoms including rash, by all means, have your doctor check it out.

What will your doctor do? Well, they'll definitely look in history and physical. I know I keep saying that with every single one of this. And it's so important, and that's why at the beginning of every one of this podcast we say, if you're worried about your child, see your doctor. So they can sit down face to face with you and get that history and do a hands-on physical examination. Just so important.

But in terms of what sort of workup they'll do, oftentimes, just based on the history and physical, they'll be able to tell you what's causing the rash. If there are questions and they need to do something, if you're worried about strep causing the rash, you can do a rapid strep test or a throat culture — one of those gene probes that I mentioned earlier, when we talked about sore throat specifically.

1:22:23

And sometimes, if you're worried about those bleeding in the skin, we'll do some blood work or we check the blood count. If we're worried it's infectious, especially with like meningococcemia, blood culture. But most of these things with rashes can be determined just with an experience healthcare practitioner. 

Treatment of rashes really depend on the cause. For itchiness, for a lot of things, whether it be poison ivy or insect bites, when rashes are itchy, using a steroid cream or if it's more widespread, using steroid by mouth may be helpful. Although not in the case of hives. Usually, with hives, steroids are not going to help that much. Unless there's history of anaphylaxis, which is not just the hives but there's other things going on, then we will use a steroid. But if it's just hives, really steroid aren't going to be so helpful. But it can be with bug bites and poison ivy. 

Antihistamines like a Benadryl, those can be very helpful eliminating itch. And in the case of hives, Benadryl is helpful whether if it's from anaphylaxis or just hives from a viral infection. The antihistamines like Benadryl can be helpful on that case. Scabies we talked about, there's a cream that you use, permethrin or Elimite cream. And if you have a skin infection like impetigo, cellulitis, abscesses, then we think about using antibiotics. 

So, it really depends on what's causing the rash in terms of what you're going to do to treat it. And to determine what's causing the rash, you really again want an experienced practitioner who's seen lots of rashes, looking at it, asking you some pointed questions and then making that determination. 

[Music]

1:24:43

Dr. Mike Patrick: All right, we are back with just enough time to say thanks to all of you for taking time out of your day and making PediaCast a part of it. Boy, we really covered a lot today. 

I know for some of you, especially those with lots curiosity, it may be a little frustrating to cover so many different topics and just cover the highlights. But again, I wanted a place where you could listen and just sort of be ready for any of these things that occur. If you like you know a little bit more about these symptoms and if you want to know more about a specific one, by all means Google that symptom or a disease process that we mentioned associated with that symptom and PediaCast. And in 11 years of doing programs, more than likely, you're going to find more than one episode where we talk in detail about any of these particular symptoms. 

On the other hand, if you can't find what you want, if there's something, some aspect of this hour that we talked about, that you really want to know more about and you can't find it, please use the contact page over at PediaCast.org and let me know what symptom, what disease process. And I'll either point you in the right direction, or we'll cover it. We'll cover it, if we've not done it before here on PediaCast, because we definitely want to be helpful to you with evidence-based information. 

1:26:03

Don't forget, you can find PediaCast in all sorts of places. Not sure how you found us today. Maybe you saw a Twitter link and you clicked on it and you listened. There may be some ways that you can listen and subscribe and have all of our shows ready when you are ready to listen to them. 

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1:28:20

Those programs are also available in many of the same places where you can find regular PediaCast, plain PediaCast without the CME, this program. Places like iTunes, Google Play, and iHeart Radio.

All right, thanks again for stopping by. I hope that as much as we covered and covered it quickly, I hope you were able to find that helpful and it gets you prepared for the fall and winter season that will soon be upon us, when kids are getting sicker as they're exposed to other children, particularly at school. And not only making each other ill, but also spreading all those illnesses and diseases to families and friends. It just happens, just part of life. Part of the ebb and flow. And we'll cover more of those in details as we move on over the next few months. 

And until then, the next time we meet, this is Dr. Mike, saying stay safe, stay health and stay involved with your kids. So long everybody. 
 
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Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.