Constipation

Believe it or not, I see at least 2 children in the ER each shift with abdominal pain due to constipation. If any of you parents out there have ever been constipated, you know fist hand that it hurts! Children with constipation typically have severe (curl up in a ball and scream) kind of pain. Which can be very scary for parents. Most of the children who develop severe pain have had symptoms for 1-2 weeks, so intervention could have been made sooner if parents knew what to look for and how to treat it.

Constipation is the infrequent passage of hard, difficulty to pass stool - that is the standard definition. Now for what we really see:

Normal infants can have stools with every feed or 1-2 times per week, so constipation in this age group is typically diagnosed when they start having pain with pooping or they develop tears around their anus. It is very normal for infants and toddlers to turn red or purple in the face and grunt or strain with pooping. Infants rarely have constipation under 1 month of age and poop (color, consistency, and frequency) is an indicator of how much milk they are getting. After 1 month, if your baby is having pain with pooping or infrequent, hard stools, you can give 1 oz of Pedialyte, prune juice, apple juice, or pear juice for every month of age (for example a 3 month old could get 3 oz of juice per day for constipation). I recommend giving 1 oz at a time, in between normal feedings until you get results (poop, in this case). Other methods include glycerin suppositories or enemas and a warm bath. If your infant is eating solid food, then giving a high fiber fruit daily helps (prunes, pears).

Toddlerhood is a very common time to develop constipation. It usually starts when potty training begins. Toddlers like to control when and where they poop. When we interfere, they fight back with holding in the poop. These children can hold in their poop for a VERY long time. When the rectum (bottom part of the colon) is holding onto hard poop, it gets bigger and loses its urge to push the poop out. They can develop frequent liquid stools (like diarrhea) that has to make its way around the large, hard poop. These children start to eat less and less, then complain intermittently of belly pain. Typically, the pain is around the belly button or on their left lower side. If your child gets to this point, back off on potty training and go back to diapers or pull ups. Unfortunately, it is very difficult to change a toddler's diet. But, you can try and offer high fiber fruits and juice (4-6 oz per day). Suppositories and enemas also work in this age group, but there is also a very safe medication called polyethylene glycol (brand name Miralax) that has been used in children of all ages and is available over the counter. It works by pulling water into the poop, making it softer and easier to pass. You mix 1 capful of powder into 8 oz of fluid (I like to use juice). Most children only need 1-2 capfuls daily, but you will need to talk to your doctor specifically about your child's dose. You need to treat your child with this medication daily, so it is easy and pain-free for them to poop, then go back to the potty training. It takes 6-8 weeks for the colon to go back to its original size, so this is a long term solution, not a quick fix.

School age is the next time constipation is popular. Trust me, no one likes to poop at school! Plus, parents no longer pester kids this age about their pooping habits. Symptoms are very similar to toddlers', with decreased appetite, nausea, and sometimes vomiting. Belly pain is common and they usually complain in the morning (right before school), after meals, and even in the middle of the night. Treatment needs to be a bit more aggressive at this age. They may need an enema (Pediatric Fleet) to treat the immediate problem, then Miralax and a pooping schedule - have your child sit on the potty 2-3 times daily (morning, after school, and after dinner) for 10 minutes. Try to add high fiber food and juice to their diet, with lots of raw fruits and vegetables. But, even with changes in diet and treatment, it may take even longer to get your school age child regular and pain free, sometimes up to 6 months.

From the minute a baby is born, poop becomes a major concern in every parents' life. Most people think that once a child is potty trained, the poop talk is over...but trust me, it never goes away!

Heather Joyce, MD

Ouch! Traumatic Knee Injuries in Kids

Acute injuries vary from sport to sport, but the lower extremity (the knee in particular) is one of the most common joints injured in the young and older athlete.

So, you're watching your teenage daughter play basketball and all of the sudden she goes down in pain clutching her knee.  What happens next?  If your child is high school age, most commonly there is a trainer on the sideline that can quickly evaluate the injury, but if not, it's important to seek medical attention (or call your pediatrician for advice).  Few knee injuries necessitate a trip to the ER, but it is wise to talk to a medical professional if your child has an acute knee injury.

Swelling in the knee joint is never normal in kids and shouldn't be ignored.  There are only a few things that can cause swelling in children when they injure their knee (broken bones and torn ligaments are the most common in kids), and each of those causes need further evaluation and treatment.

The ACL (one of the 4 ligaments in the knee) gets a lot of attention thanks to Sportscenter - but it is actually one of the more common traumatic knee injuries in adolescents.  It can happen before adolescents, but it is rare because young children still have open growth plates.  Females are more prone to tear their ACL and it is most common in cutting/pivoting sports like basketball, soccer, and football.  Rarely does someone tear their ACL from colliding with another player - the injury usually occurs on a landing or turn/pivot.

Is it always necessary to get an MRI?  In short, no.  Most traumatic knee injuries can easily be diagnosed by the physical exam.  However, an MRI helps assess any other injuries that may be present and also helps prepare for surgery if necessary.

What knee injuries in kids need an operation?  ACL repair is necessary after tearing the ligament, because you can't cut or pivot without it.  Other traumatic injuries that may need an operation are meniscus injuries (the cartilage in your knee) or severe knee cap dislocations.  However, every child is different and some of these injuries do well with physical therapy and other treatments, so surgery can be avoided.

Just like in adults, some of these injuries can be prevented if your child maintains their flexibility and strength in their core and lower extremities.  For instance, their are specific ACL prevention programs that exist (especially for females), which include things like quad and hamstring strength and proper technique for landing and cutting/pivoting.

Your child can definitely get back to playing his or her sport after a traumatic knee injury, but it is important to understand what the cause of the injury is and get it treated appropriately!

Rachel Brewer, MD

Infant Reflux

This post was inspired by a friend who is having a tough time with a fussy newborn, but dedicated to all the parents out there who have ever cared for a baby with reflux, my husband included.

Reflux, colic, gas, milk intolerance, or general demeanor...there are many reasons for an overly fussy baby. Many babies who cry excessively swallow lots of air and always appear to have belly pain or gas, so figuring out the reason for a baby's fussiness can be challenging. I will focus on infant gastro-esophageal reflux in this post, though many of these suggestions can help a baby with colic. Some babies with reflux are not fussy at all (they just make huge messes with spit-up), while others can have discomfort, poor weight gain and feeding problems. The symptoms of reflux are caused by milk that makes its way back up through a weak muscle at the top of the stomach, into the esophagus, and to the back of the throat or mouth. Infants do not all have the same symptoms, but can have spitting up, frequent hiccups, swallowing or grunting, arching of the back or neck, coughing, wheezing, difficulty feeding or excessive crying. Most infants with reflux act like they are always hungry, this is because they cry and root as a reaction to discomfort - often 1-2 hours after a previous feeding. If your child has been diagnosed with reflux or exhibits these behaviors, there are many techniques you can use to decrease symptoms.

1) Feed sitting upright - with bottle feeding, this is easy; but with breastfeeding you will have to find the most comfortable position for both you and your baby.
2) Burp frequently - with bottle feeding, this means every 1/2-1 oz; with breastfeeding it is still best to burp in between breasts or after 10-15 minutes.
3) If you are bottle feeding, find the right nipple and bottle. Babies who drink too quickly or swallow too much air spit up more. There are many choices and you may have to try several, but I say go with the one that works best for you and your baby.
4) Feed small amounts, frequently. For small infants, this means 1-2 oz every 1-2 hours; bigger infants need 2-4 oz every 2-3 hours and increase gradually. Do not over-feed your baby, this will lead to more discomfort!
5) Keep your baby sitting upright 20-30 minutes after each feed. Easy to say, not so easy to do (especially in the middle of the night or when you are chasing around another child). You do not have to hold your baby, you can use any contraption that works for you - bouncy/vibrator seat, upright swing, head elevating positioner, wedge with a sling, baby carrier/sling, just to name a few.
6) Position your baby to sleep elevated (30-45 degrees). The easiest way to do this is to put a couple of books under the legs at the head of the crib or bassinet. If you are using a co-sleeper or pack and play, a couple of rolled up towels or receiving blankets under the thin mattress works well. They also make special foam wedges for this purpose.
7) Do not lie your baby down flat on their back, especially after feeding. If possible, try to change your baby's diaper prior to feeding.

After utilizing these techniques, your baby may still spit-up. If they are happy and gaining weight, your next step is to stockpile burp cloths, bibs, and wet wipes. If your baby has extreme fussiness, coughing, wheezing, difficulty feeding or poor weight gain, you need to take them to the pediatrician. They may recommend an elimination diet (for breastfeeding mothers), a formula switch, or medication for your infant. This can be a very stressful time as a parent, so keep in mind that whatever is causing fussiness in your baby will pass with time.

Heather Joyce, MD

Mommy Time

Any new moms out there?  Wondering when it's safe to rev up your exercise routine again?  Even if you're not a brand new mom, was your New Year's resolution to give more time to yourself to get fitter and healthy?  Every single one of us needs to account for time in our busy schedules to maintain a healthy lifestyle and help our kids see just what a healthy lifestyle means.

So new moms, I now you're exhausted.  Lacing up your running shoes or getting on the elliptical may seem like an afterthought.  There are simple things you can do at home to prepare your body to get back to your cardio routine.  Clearly, your core strength was not at it's pre-pregnancy best after giving birth, but working on those core muscles first will make running, swimming, biking, or whatever your cardio of choice is, that much easier to resume.

Don't assume that "core strength" is just ab work.  Your core is abs, low back, hips, quads, and hamstrings.  There does need to be a focus on ab work and your pelvic floor following the delivery of your child, but don't forget that it goes a little beyond that region of your body in order to get back to and surpass your pre-pregnancy strength.  Here are some great handouts that give you several exercises to do at home to regain your core strength (they are at the bottom of the list - core strengthening phases 1 and 2).  Classes like yoga or pilates are great substitutes for a core strengthening routine as well.  Try to do some exercises a minimum of 3 times a week.

Once you have spent couple weeks regaining your core strength (at around 4-6 weeks following delivery) it feels a lot easier to start exercise like running again.  And don't feel like you should be right back at your pre-pregnancy activity level.  Take your time getting there - doing it too fast will only make you frustrated and cause you to get injured.  And my personal preference is to set a goal so that you can stick to your new routine - whether that is a 5K, marathon, or any event, I think it's a great motivator.  

And try to involve your kids if possible!  Strap them in a jogging stroller or involve them in your home strength routine.  They'll see you doing it and figure out someday that being healthy is important.  Have fun getting fit - it shouldn't be a chore.  If you have specific questions about a training plan or strength routine, don't hesitate to contact me!

Rachel Brewer, MD

Croup

Waking up suddenly to your child coughing and struggling to breath can be one of the most frightening situations you will have as a parent. If you have ever experienced this, you will never forget the sound of a barking, seal-like croup cough and the stridor that comes with it. My goal is to help you recognize the illness and have a plan to help your child get through it with as little anxiety as possible. Croup is caused by a virus and children can have fever, runny nose, cough, and a hoarse voice - until they wake up suddenly with difficulty breathing. These symptoms are caused by swelling in the vocal cords and the high-pitched wheezing noise with inspiration (breathing in) is called stridor. Croup can be mild with a barky cough alone or severe with cough, stridor and difficulty breathing. With mild symptoms, supportive care with nasal saline, honey, humidified air and ibuprofen or acetaminophen is appropriate. If your child wakes up with sudden difficulty breathing, take these steps:

1) Remain calm and calm your child! Anxiety will make your child worse (I know, easy for me to say).

2) Turn your shower on to the hottest setting in your smallest bathroom 

3) While steam is filling up the bathroom, take your child outside in the cold air

4) If it is not cold outside, hold your child in front of the freezer

5) Sit with your child in the steam-filled bathroom for 10-20 minutes 

6) If stridor continues after these steps, or your child appears blue, is drooling or struggling to breath, seek medical care - urgent care or emergency department is appropriate. There, your child will receive a dose of steroids and possibly a breathing treatment. Rarely, children need to stay in the hospital for humidified oxygen and frequent breathing treatments. 

If your child goes back to sleep, without stridor or difficulty breathing after these steps, then call your pediatrician the next day. A dose of steroids can help decrease the severity and length of symptoms. Typically, croup lasts 3-5 days and the worse symptoms are nights 2 and 3, so a trip to your pediatrician can help you and your child get a better night's sleep.   

Click here to listen to an example of stridor.

Heather Joyce, MD

What Does a Nursemaid Have to do with the Elbow?

If your child has had a nursemaid's elbow before, you're probably aware of what I'm about to write about next.  However, I also want to help any parents whose kids have experienced this problem if it happens again - you can try and fix it yourself.

A nursemaid's elbow is the dislocation of one of the bones in the elbow called the radius.  When a bone is dislocated it slips out of it's normal position.  This occurs when a child (usually between the ages of 2-5) gets pulled up forcefully by the hand or wrist.  It can also occur with a fall or from being swung by one arm.  When the dislocation occurs, the child will not want to use that arm and will complain of pain or point to his or her elbow, forearm, or wrist.  Sometimes you can see elbow swelling as well.

During the 3-4 weeks following a nursemaids elbow, it is more likely to occur again.  A nursemaid's elbow is rare in kids over 5 years old because the joints and structures around the elbow are stronger.  On occasion a nursemaid's elbow will reduce (or fall back into place) on its own.  You'll know that this has happened because your child will start using his or her arm again.  But most of the time it requires a certain maneuver to be performed in order to get the elbow in the right position.

The first time your child experiences a nursemaid's elbow it is better for a healthcare provider to perform the maneuver, but if your child has repeated bouts of nursemaid's elbow, you can try to put it back in place yourself.  You can flex the elbow and rotate the forearm so that the palm is facing upward.  Again, it is important that your healthcare provider discusses this with you and indicates that it is ok for you to try the maneuver in the instance that your child sustains another nursemaid's elbow.

Rarely are there complications from a nursemaid's elbow, but they can occur, especially if it goes untreated.  You can prevent this from happening - avoid lifting a child by one arm only (from the wrist or hand).  Lift from under the arms, from the upper arm, or from both arms.  Do not swing children by the hand or forearm.  You can swing your child in circles, just provide support under the arms and hold the upper body next to yours!

Rachel Brewer, MD

Low Back Pain

Is it worrisome if your child experiences low back pain?  In short, yes.  Unlike adults, back pain is not common in children and should raise concern.  However, as children transition to adolescence, back pain becomes more common and similar to mechanical back pain that adults often experience.

Young children experiencing back pain should always be seen by their pediatrician for a more thorough evaluation.  It is important to determine the cause of the pain with further tests (such as x-ray or MRI) because it is rare for young kids to have back pain purely from muscles (but it can happen), and and assessment for a tumor or other lesion must be performed.

As children reach middle school and beyond, back pain becomes more common and is usually attributed to mechanical back pain (mechanical means that the source of pain may be in the spinal joints, discs, vertebrae, or soft tissues and muscle).  However, like young kids, it is still important to get tests to evaluate the spine (x-ray, etc).  Adolescents can experience herniated discs, but that generally does not occur until adulthood, and more often the mechanical back pain is because of a muscle strain or tight lower extremity muscles.  Physical therapy is very effective in treating mechanical back pain. Core strengthening and flexibility is the focus of physical therapy and should become part of an adolescent's daily routine (like brushing your teeth) if he or she is diagnosed with mechanical back pain.  For a fantastic list of core strengthening and flexibility exercises click here.

A source of low back pain in the young athlete can also be a stress fracture in the bones of the low back (also known as spondylolysis).  This occurs in active children or teens, especially in sports such as swimming, gymnastics, football, tennis, volleyball - all which include repeated extension of the low back.  Stress fractures of the low back are treated with rest, physical therapy, and sometimes bracing.

Scoliosis (curvature in the spine) can be a cause low back pain, but it is often painless. Some states require children to be screened for scoliosis just prior to middle school (around 5th grade).  This is an important time to be screened because scoliosis can dramatically worsen during the years of rapid growth and puberty.  Your pediatrician should also screen your child by doing a simple exam at his or her annual physical. Scoliosis rarely requires surgery - if discovered early and the curve is big enough, it can be treated with bracing.  Bracing only prevents the curve from getting worse - it does not actually fix the curve.

Bottom line - don't ignore your child if he or she complains of back pain!

Rachel Brewer, MD