Mouth Injuries in Children

Introduction

     Mouth injuries in children are quite common. For the first years after someone learns to walk, falling onto the mouth is quite common. Read further for guidance on when to watch at home or when to seek medical attention.

Injured frenum or frenulum

     You may be asking “What is that?” A frenum or frenulum is the fleshy connection between the inside of the lip and the gums. A frenulum is a small frenum. These have quite a bit of blood supply and bleed easily if injured. Why many people no longer have an obvious frenum or frenulum is that they very likely injured it a long time ago, it bled, and then faded away and shrunk as it healed.

     Because they bleed easily, it can frightening to see when the frenum or frenulum is injured. Most children will cry for a few minutes, the bleeding will stop, and the area will look better in a few days. It is fine to offer Tylenol® or Motrin® for pain. If it is particularly sore, offering a Popsicle® or applying a cold cloth to the area should help. It may help to avoid acidic foods and citrus (for example, tomato sauce and orange juice) for a few days.

     We have not had a patient have this torn or injured frenum or frenulum that has needed stitches in the past. Having said that, if the bleeding did not slow to just an slow ooze after 20-30 minutes, we would recommend either contacting us or having your child seen at the Nationwide Children’s Close to Home Center Urgent Care or Emergency Department.

Injured lip

     Swelling and bruising of the lip or lips are common after mouth injuries. The lip, like the frenum or frenulum, often bleeds quite a bit if a cut occurs. Applying a cold cloth or ice pack often helps the swelling, although do not stress if your child does not tolerate this for just a few seconds. It is fine to offer Tylenol® or Motrin® for comfort sake.

     A cut lip often happens when the teeth bite into the lip with a fall. A deeper cut or one that the edges gap open easily often will benefit from being stitched. We do not do stitching here in the office and therefore recommend having your child seen at Nationwide Children’s Close to Home Center Urgent Care or Emergency Department if that would be needed. A shallow cut that does not gap and stops bleeding quickly will usually heal well in a few days without needing stitches.

Biting the inside of the cheek

     It can be super painful to bite the inside of the cheek. With a fall or with chewing, it is easy to accidentally bite the inside of the cheek. These may bleed a little but the bleeding often stops quickly. If a child is quite uncomfortable after a few minutes (when the pain is the worst), it is fine to offer Tylenol® or Motrin® for the pain. It may be helpful to offer a cold drink (ice water or cold juice) or a Popsicle® for the pain. Encourage your child to chew on the other side of their mouth for a few days.  If your child is old enough for chewing gum, avoid it for a few days afterwards also. Spicy, salty, or acidic (for example: tomato sauce and orange juice) foods should be avoided for a few days.

     These injuries generally do not need to be seen in the office. However, if the pain cannot be managed with the above measures or the bleeding cannot be stopped as described above, your child should be seen.

Injuries to the tongue

     Bites to the tongue with falls or chewing can be painful and bleed for a few minutes. If a child is quite uncomfortable after a few minutes (when the pain is the worst), it is fine to offer Tylenol® or Motrin® for the pain. It may be helpful to offer a cold drink (ice water or cold juice) or a Popsicle® for the pain. Spicy, salty, or acidic (for example: tomato sauce and orange juice) foods should be avoided for a few days.

     As scary as an injured tongue can be, the good thing is they rarely need to be stitched. If the edges line up well and the bleeding stops in less than 15-20 minutes, it will very likely heal well on its own in a few days. A tongue injury that did need stitches would need to be seen at Nationwide Children’s Urgent Care or Emergency Department. In addition, some pediatric dentists, oral surgeons, and some ENTs (otolaryngologists) also can treat these as needed.

Injuries to the teeth and gums

     These injuries occur most often with falls, bike and car accidents, and sports-related injuries. We think of these tooth or teeth injuries as falling into three categories:

-Mild injuries                 
Injury to the tooth and gum without loosening or change in position of the tooth.

Treatment: Tylenol® or Motrin® for pain; soft diet for 2 weeks; follow-up with the dentist as needed.

                                          

Injury to the tooth and gum with loosening of the tooth but no change in position of the tooth. There may be bleeding at the gum line and tenderness at the tooth.

Treatment: Tylenol® or Motrin® for pain; soft diet for 2 weeks; follow-up in the next in the next few days with the dentist.

                                           

-Moderate injuries        
Injury to the tooth and gum with loosening and change in the position of the tooth.

Treatment: Tylenol® or Motrin® for pain; soft diet for 2-4 weeks; see dentist in the next 24 hours.                                                 

Tooth is pushed into the gums by the injury.Treatment: See dentist immediately if a permanent tooth. For a primary or “baby” tooth, see the dentist within a few days, sooner if the pain is hard to control with Tylenol® or Motrin®. 

Tooth is partially knocked out of the socket. 
Treatment: see dentist immediately.

-Severe injury            
Tooth is completely knocked out of the socket. 
Treatment: Do not replace a primary or “baby” tooth. See the dentist within the first 24 hours. For a permanent tooth, replace the tooth back in the socket, making sure to place it correctly (for example, the front of the tooth faces the front). If the permanent tooth cannot be put back in place, place it is cold low-fat milk or saline and see a dentist immediately.

If an injury happens after hours and your child’s dentist is not available, we recommend your child be seen at the Nationwide Children’s Hospital Emergency Department where a dentist is available 24 hours a day.              

What to do for your child's allergies?

     I know the allergy symptoms are bad this Spring. Although, I am on allergy shots, allergy eye drops, and a daily antihistamine, I have had to go back to doing a daily nasal spray too! You may have not discussed with us yet what to do if your child has symptoms of allergies. Here is a quick guide for what to do.

2-5 years of age

ANTIHISTAMINES (all over the counter)

Children’s Allegra Oral Suspension 5 milliliters by mouth every 12 hours

Children’s Claritin Syrup 5 milliliters by mouth every 24 hours

Children’s Zyrtec Allergy Syrup 2.5 milliliters by mouth every 24 hours

6-11 years of age

ANTIHISTAMINES (all over the counter)

Children’s Allegra Oral Suspension 5 milliliters by mouth every 12 hours

Children’s Allegra Meltable Tablets 1 tablet by mouth every 12 hours

Children’s Claritin 5 mg Chewables 1 by mouth every 24 hours

Children’s Claritin 5mg Reditab 1 by mouth every 12 hours

Children’s Claritin 10mg Reditab 1 by mouth every 24 hours

Children’s Claritin Syrup 10 milliliters by mouth every 24 hours

Children’s Zyrtec Allergy Syrup 5-10 milliliters by mouth every 24 hours

Children’s Zyrtec Dissolve Tab 1 by mouth every 24 hours

Zyrtec 10 mg Tablets 1 by mouth every 24 hours

STEROID NASAL SPRAYS (all over the counter)

Flonase Allergy Relief Nasal Spray 1 spray per nostril once a day

[Note: OTC ClariSpray® is the same ingredient and dosing as Flonase.]

Nasacort Allergy 24 Hour Nasal Spray 1 spray per nostril once a day

Rhinocort Allergy Spray 1 spray per nostril once a day

ANTIHISTAMINE EYE DROPS (over the counter)

Zaditor Eye Itch Relief 1 drop to each eye every 12 hours

12 years of age and up

ANTIHISTAMINES (all over the counter)

Children’s Allegra Oral Suspension 10 milliliters by mouth every 12 hours

Children’s Allegra Meltable Tablets 1 tablet by mouth every 12 hours

Children’s Claritin 5 mg Chewables 2 by mouth every 24 hours

Children’s Claritin 5mg Reditab 2 by mouth every 12 hours

Children’s Claritin 10mg Reditab 1 by mouth every 24 hours

Children’s Claritin Syrup 10 milliliters by mouth every 24 hours

Children’s Zyrtec Allergy Syrup 10 milliliters by mouth every 24 hours

Children’s Zyrtec Dissolve Tab 1 by mouth every 24 hours

Zyrtec 10 mg Tablets 1 by mouth every 24 hours

STEROID NASAL SPRAYS (all over the counter)

Flonase Allergy Relief Nasal Spray 2 spray per nostril once a day

[Note: OTC ClariSpray® is the same ingredient and dosing as Flonase.]

Nasacort Allergy 24 Hour Nasal Spray 2 spray per nostril once a day

Rhinocort Allergy Spray 2 spray per nostril once a day

ANTIHISTAMINE EYE DROPS (over the counter)

Zaditor Eye Itch Relief 1-2 drops to each eye every 12 hours

PLAN:

1. Do a daily antihistamine when your child has their symptoms. If one does not agree with them or does not work after a week or two, try a different one.

2. If you have tried the antihistamines, your child is 6 years of age or above, and there has not been a big improvement, add a nasal spray.

3. If the eyes are itchy despite doing an antihistamine (or antihistamine plus the nasal spray), add Zaditor eye drops.

4. If you have tried all of the above, your child would benefit from seeing an allergist. They can assist with knowing what your child is triggering the allergy symptoms. They also discuss with you other treatment options, including allergy shots. Call our office during regular office hour to discuss.

ANTIHISTAMINE NOTES

Allegra is the least likely antihistamine to make someone sleepy. If Claritin or Zyrtec makes someone sleepy, try taking it at night.

Each of the three antihistamines work for many people, but many people respond much better to one or the other. You may have to try 2 or 3 to see how someone responds.

Antihistamines work quickly – they should help within a few days of starting the medication.

STEROID NASAL SPRAY NOTES

The spray with the most scent: Flonase. If your child is bothered by the “flowery” smell, try a different brand.

The spray with the least amount of spray: Rhinocort. If another causes too much drip down the back of the throat after using it, try Rhinocort.

These sprays take a week or two to work at their best.

EYE DROP NOTES

If the drops causing stinging, keep them in the refrigerator.

These eye drops works quickly – they should help within a few days of starting the medication.

      As always, call during routine office hours if you have questions. Good luck!

Why is the 2015-2016 such a mild influenza season?

     This has been a busy winter with so many cold, coughs, vomiting and diarrhea illnesses! But remarkably, it has been a very mild influenza season. We have only seen a handful of cases since the start of the season. Many parents are asking me "Why, Dr. Tim?".
     Weather plays a part in many illnesses. The classic pediatric example is croup. The number of cases of croup we see is correlated with weather changes. The more the weather flip-flops around, the more cases we see. That has been true this cold and flu season. However, it is hard to say that this milder winter is changing our influenza season. The last really mild winter a few years ago was accompanied by a really bad influenza season! So, we cannot give credit to the weather this past few months.
     How many people are vaccinated with the influenza vaccine plays a part in the influenza season. I would love to say that this influenza season has been mild because we vaccinated so many kids with the vaccine in the Fall, but that is just not the fact. Due to the nationwide shortage of the FluMist (nasal spray influenza vaccine), we vaccinated about 1000 kids less than we usually do each year. Judging by that fact, we should be having a bad influenza season. But that is not the case.
     How well the influenza strains of the vaccine match the virus in the community plays a part in the severity of the influenza season. There are four (4) different strains in the injectable flu vaccine and the FluMist. Some years, the educated guessing game that the scientists play in picking the four strains is more successful that other years. This year, there is a very good match between what strains are out and about in the US and what was in the vaccine. So that is helpful, but probably not enough to help prevent the influenza as successfully as has happened.
     Why then are we having a mild season? I think the vaccine strains matching the strains in the community is helping. Plus we are just lucky enough to be having a good, mild year! Keep getting vaccinated!

Infants with Acid Reflux

     I am in the process of completing my pediatric boards re-certification. This process ensures that doctors keep up with current medical recommendations and put in place steps to improve medical care within their practice. One of the activities I have been working on focuses on acid reflux, especially in infants. One of my sons had acid reflux during his first year of life.
     As part of my focus on acid reflux in infants I have found some good resources for parents with infants with acid reflux. I want to share them with you. This is a link to from GI Kids about coping when your infant has reflux. There is lots of good information here. Another good resource is here, also from GI Kids, that includes a checklist of common symptoms. GI Kids main page on Acid Reflux can be found here. My own handout (protocol) on Acid Reflux is here on our website, Hilliard Peds.
     I hope this information is helpful. If you have questions or concerns about acid reflux and your child, call during routine office hours.

Croup

     When the school year has begun and the weather starts flip-flopping from cold to warm, we see a big increase in the number of cases of croup. This is a viral illness caused by parainfluenza virus. It is transmitted from one person to another the way other respiratory viruses are transmitted: being near someone who has coughed, spread their cough or nasal germs on to some surface someone else touches, etc.
     Although it is the cough that sounds like a barking seal that tells us it is croup, what worries us about the illness is when the breathing is difficult (noisy, tight, or wheezy) in between the coughs when the child is breathing. See our protocol here for more information. Many of the hoarse voice (laryngitis), sore/scratchy throat, barky cough illnesses in the community are this illness.
     Stay healthy!

Prepare Now for Start-of-the-School-Year Asthma Issues

     Every year, pediatricians notice that there is a big surge in asthma issues early in the school year. It happens before the big stretch of "winter viruses" hit. It happens often when the weather is still nice. And it catches many families off guard. Read more so you can be prepared.
     It is thought that three things happen during September to make these asthma issues much worse. Mid August brings a surge in the weed pollen, especially ragweed pollen here in Central Ohio. The pollen can trigger asthma issues. Back to school time suddenly increases many children's exposure to viral upper respiratory illnesses. It may not be as severe as into the cold weather months, however these viruses can trigger asthma issues. In addition, the weather changes that start in September, with some cooler days then warmer days, can also trigger asthma issues. These three things can work together to dramatically increase the chances of asthma flaring up early in the school year. In the 2014-15 school year, there was such a surge of asthma issues that folks at Nationwide Children's Hospital were calling it "asthmageddon". We had quite a few patients whose asthma worsened during that time period last year, with many admissions to the hospital and visits to the office or urgent care.
     The other big reason asthma worsens at this time of year, and the reason I am writing this blog post, is that many families let their guard down with asthma prevention. It is human nature to get out of the habit of using the daily asthma prevention medicine during the "well time of the year", summer time. If the inhaled steroids or Singulair (montelukast) is not in their system, children's asthma may quickly worsen if one of the above triggers (or all three) occur. And please remember that these medicines are much less effective if they are started when symptoms start -- cough, wheezing, difficulty breathing. They are most effective when given for weeks ahead of time and continued on a daily basis. We are only about 6-8 weeks from this time period, so NOW is the time to start these preventative medicines if your child has been off the medicine during the warm weather months. If you have questions about this, contact us during routine office hours.

Changes in Central Ohio for emergency behavioral and psychiatric evaluations.

     Behavioral health services are evolving frequently. Nationwide Children's Hospital and Ohio State University are collaborating to provide psychiatric and behavioral emergency evaluations for Franklin County children and adolescents. The Emergency Department of Nationwide Children's Hospital will provide the evaluations for children 14 years of age and under. The Emergency Department at Ohio State University Hospital will provide evaluations for teens 15 years of age and above. An organization called NetCare that previously did psychiatric and behavioral crisis evaluations and hospitalizations will not longer provide these services for children and teens.
     More information is on the www.cap4kids.org/columbus website under the Behavior/Counseling/Addiction section.