Mosquito Bites

     We are in the middle of the mosquito season here in Central Ohio. I had a request via Facebook to discuss this topic. What follows is information about prevention of bites, treatment of bites, and diseases that concern us that are transmitted via mosquito bite.
     The two major infections we worry about from mosquito bites are West Nile Virus and the group of encephalitis-causing viruses (arboviruses). Both are uncommon enough that we see very few cases of these. I do not know of a single case of confirmed West Nile Virus illness in a patient at Hilliard Pediatrics. I am aware of a few children in our practice who have had a mosquito-bite related encephalitis. Therefore, please realize that the chance of a life-threatening illness from a mosquito bite is very, very small. Having said that, the chance of being infected from a mosquito bite is greatly reduced if you use good bite-prevention.
     There are at least 175 species of mosquitoes in the US. The female mosquito bites us (the males do not) because they need blood to develop fertilize eggs. As experience tells you, some people are more prone to bites from mosquitoes than other people. Scientists are still studying what it is about some people that attracts the bites, but it is known that carbon dioxide released from the skin attracts the mosquitoes. Some people release more from their skin than others. Scientists believe 85% of this "mosquito magnet"issue is genetic.
     To reduce the possibility of being bitten, regularly use an insect repellent on exposed skin; wear long-sleeved shirts, long pants, and hats to cover exposed skin; avoid being out in the early morning and in the evening; and consider applying permethrin-containing to clothing, shoes, tents, and other gear.
     There are different insect-repellents. For children less than 2 months of age, drape their carrier or bouncy seat with mosquito netting. For children 2 months of age and above, DEET and picaridin are excellent repellents. Both have been extensively studied. This link to the CDC website is a good resource about the insect repellents. I recommend the DEET-containing or picaridin products for children 2 months and above. Although concerns have been raised over the years with the toxicity of DEET, the risk is very, very low AND the potential risk of being unprotected is real. The higher the concentration of DEET, the longer it lasts (for instance, 5-10% lasts about 2 hours while 20-30% lasts 5-6 hours). The CDC also has a Frequently Asked Question page about insect repellents. The American Academy of Pediatrics states that DEET is safe for children 2 months and older if used as recommended. If one product does not protect you and your child from insect bites, try a different product or stronger concentration.
     For the mosquito bites themselves, try your best not to scratch the bites, use an anti-itch cream or gel (over-the-counter hydrocortisone cream, Itch-X gel, and Calamine or Caladryl are all helpful), and use oral diphenhydramine (Benadryl) if the itching is not well controlled by one of the creams or gels, and expect that the bites should gradually fade away over a few days to a week. The bites can last longer if repeatedly scratched. It is rare for the bites to pick up a bacterial infection. If that happens, it will have a crusty discharge, be tender, and more red.
     Many people become mildly allergic to the bites of some species of mosquitoes. It is very, very rare to see someone have trouble breathing (a worse allergic reaction). The mild allergic reactions have large (even 6-7 inches across), red, warm, itchy areas that often need oral diphenhydramine (Benadryl). Cool compresses often help also.  

Vehicle Safety Laws in Ohio and Pediatric Recommendations

     It is a common question for us to be asked: what is the law in Ohio about car safety? And are the American Academy of Pediatrics (AAP) recommendations the same or different? As of June 2012, the following are the current Ohio laws (here is a link) and the current AAP recommendations (here is a link). Realize the AAP recommendations are more conservative, safety wise.
     Ohio law says:
-- if your child is under 1 year of age and under 20 pounds, they must be in a rear-facing child seat.
-- if your child is at least 1 and weighs more than 20 pounds, they can ride in a forward-facing seat until they grow out of that seat.
-- if your child weighs over 40 pounds, they must ride in a booster seat.
-- your child must use the booster until he is 8 years old or at least 4'9" (57").
-- children under 12 years of age should ride in the backseat to prevent airbag injuries and fatalities.
-- drivers and front-seat passengers must wear a seat belt, even if air bags are available.
     The AAP recommends:
-- all infants and toddlers should ride in rear-facing car seats until they are 2 years of age or until they reach the highest weight or height by their car safety seat's manufacturer.
-- all children 2 years or older (or those younger than 2 years of age who have outgrown the rear-facing weight or height limit for their car seat) should use a forward-facing car seat with a harness for as long as possible, up to the highest weight or height allowed by their car seat's manufacturer.
--all children whose weight or height is above the forward-facing limit for their car seat should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4'9" (57") in height and are between the ages of 8 and 12 years of age.
-- when children are old and large enough to use the vehicle seat belt alone, they should always use lap and shoulder seat belts for optimal protection. All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.
     So what do we recommend? We recommend that you follow the AAP guidelines. You will be within the law of Ohio, but taking the extra step to be safe by following the American Academy of Pediatrics recommendations.
     By the way, the average child (boys and girls) does not reach 57 inches of height until they are 11 years of age. My 12 year old twins just stopped their booster seats in the last 6 months when they reached that height of 57 inches. Be safe!

Swimmer's Ear

     Swimmer's ear is a common summer time condition where a bacterial infection of the ear canal occurs. We want to see those kids for walk-ins or an appointment if you are suspicious of a swimmer's ear with pain in the ear and discomfort when the ear is touched or moved. Often these kids have been swimming recently. These infections are more common with untreated water (lakes, ponds, rivers, ocean), but often happen in treated water (pools, waterparks). See our website's protocol about ear aches for information about prevention and treatment of swimmer's ear here.

Hand, Foot, and Mouth Disease

     One of the common childhood illnesses that we see is Hand, Foot, and Mouth (HFM) disease. Many years, it is a later warm-weather illness (August, September), but this year we have seen cases throughout the Spring and still see cases nearly every day in the office. Nationwide, it has been reported that other doctors are seeing similar cases.
     HFM disease is a illness causes by a virus in the enterovirus family called Coxsackie virus. It runs it course without special treatment, but typically the fever and mouth discomfort will be helped by using fever-reducers and a combination of liquid diphenhydramine (Benadryl) and Maalox or Mylanta. See our website here for more information about the illness and its treatment.  
     On a personal note, my parents recall very well that I ruined a vacation to New York City with a bad case of Hand, Foot, and Mouth disease when I was little. And, fittingly, two of my children had the illness when we took a vacation they were toddlers. It is NOT a fun illness. But it will pass with a rough few days to a week.

Human Papillomavirus (HPV) -- warning: some mature content!

     We have now had the human papillomavirus vaccine available for the last 5 years. The ongoing research into the vaccine has shown excellent protection for those young women who were first vaccinated 11 years ago when it was first being studied. We have actively recommended the vaccine to pre-teen and teen females over the last few years. Now there is an added recommendation to vaccinate the boys. We recommend this for our pre-teen and teen boys in the office. We have recently found that the insurance coverage is now very good and the vast majority of insurance plans are covering it for girls and boys. There are two vaccines, Gardisil and Cervarix. Based on many factors, we now recommend (as many national experts do) that the girls receive the Cervarix and the boys the Gardisil. Vaccinating the boys protects them from genital warts and their partners and spouses from possible cervical cancer. For boys and girls, the vaccine is a three part vaccine: one initially, one 2 months later, and the final dose 6 months after the first.
     More background on human papillomavirus (HPV): HPV is a family of viruses with different types. The different types infect the skin or mucous membranes. They cause genital warts, cervical cancer, throat and mouth cancers, and other cancers of the private parts. HPV is the most common sexually transmitted infection in the US. It is estimated 75-90% of sexually active people will become infected some time in their lives. It has been shown that between 20-25% of all women who are virgins at marriage become infected with the virus through their spouse. HPV is passed from one person to another through genital contact, usually during sex.
     Most people with HPV do not develop symptoms or health problems (with no symptoms, it can be hard to avoid passing to someone else). The body's immune system clears the HPV infection 90% of the time within 2 years. If it does not clear the infection, it may be months or years later that a pre-cancerous or cancerous change occurs. During this time, the vast majority of these people have no symptoms or signs of a problem (no warts, no pain, no abnormal bleeding or sores). Most people with cervical pre-cancer or cancer find out with their Pap smear by their gynecologist at their annual visit. Cervical cancer causes 300,000 worldwide deaths every year. Some women with cervical cancer require a hysterectomy and then are unable to have children.
     Occasionally families ask me if I believe that vaccinating the teenager against HPV is sending a wrong message. I do not believe this is true. Although the virus is spread through sexual contact, I do not believe protecting someone against HPV is sending the wrong message. I often will tell teens "we hope you are not sexually active until you are in a long-term, committed relationship, ideally marriage". And I do not believe anyone has ever abstained from sexual activity due to a fear of cervical cancer.
     So we remain big advocates for the vaccine to prevent cervical cancer. If you have questions, please discuss it with your physician. The following websites contain lots of good information.
Gardisil
Cervarix
CDC's information

Fluoride

     Fluoride is important for helping to prevent dental caries. Fluoride is available in city water supplies, some bottled water, over the counter fluoride rinses, treatments at the dentist office, and prescription drops and dissolvable tabs. Too little fluoride in your system and the teeth are prone to tooth decay. Too much fluoride and your teeth (and bones!) will become speckled or permanently stained with a discoloration.
     The need to supplement with fluoride is based on wanting to protect the teeth from both tooth decay (caries) and too much fluoride. Over the 18 years I have been a pediatrician, the recommendation has changed in trying to make sure we find the right balance. These are the current recommendations as of now for daily adequate intake:
0-6 months: 0.0 1mg/day AND additional supplementation is not recommended at this time
7-12 month: 0.5 mg/day
1-3 years: 0.7 mg/day
4-8 years: 1 mg/day
9-13 years: 2 mg/day
14-18 years: 3mg/day

The recommended daily fluoride dose of supplement, if needed, is adjusted in proportion to the fluoride content of drinking water.
Fluoride content of water  ==> Daily dose of oral fluoride (mg)
<0.3 ppm
Birth-6 months ==> 0
6 mo-35 mo ==> 0.25 mg
3-6 yr ==> 0.5 mg
6-16 yr ==> 1 mg
0.3-0.6 ppm
Birth-3 yr ==> 0
3-6 yr ==> 0.25 mg
6-18 yr ==> 0.5 mg
>0.6 ppm
All ages ==> 0

Commonly prescribed forms of fluoride include the following:
Luride(r) Drops (0.5mg/ml -- comes in 50ml. bottle)
Luride Lozi-Tab (0.25, 0.5, and 1mg -- comes in a bottle with 120 tabs)

     If you have well water, it is important to check the fluoride content of the well water before supplementing. There are families with wells that happen to contain a high amount of fluoride and supplementing these kids will just stain their teeth. For families with no fluoride in their well [we have well water at our home and we found it has no fluoride], we can discuss when you are in the office if your child needs a fluoride supplement. For families who do not drink tap or well water and primarily get water from bottled water, we can discuss at their check-up whether your child needs a fluoride supplement.

A good concussion reference.

     The Healthy Children website has a very good information page about concussions. I am adding a concussion protocol and information sheet to our Hilliard Peds website in the near future. Here is a link to the Healthy Children website information page on concussions.