Is it a urinary tract infection?

Urinary tract infections are always something that need attention, but sometimes we aren't sure if we are dealing with an actual infection or just an irritation. The symptoms may overlap.

The urinary tract is the body's drainage system for removing waste and extra water. A normal body has  two kidneys, two ureters, a bladder, and a urethra. The urine should drain in only one direction-from the kidneys to the bladder and then gets peed out. Urine is usually sterile, (remember that when your baby pees in your face) but once in awhile bacteria from the surrounding skin or stool can make it's way into the urinary tract, causing an infection. If the germs make their way all the way into the kidneys it is much more serious and usually causes a much higher fever.

Holding urine for long periods of time, not drinking enough and constipation seem to make folks much more prone to infections.

In my experience, girls are much more likely to get an infection. Circumcised boys are the least likely.

UTIs will usually  come along with fever, tummy ache, back ache and maybe vomiting. You might notice your child grabbing at their crotch. Kids who are old enough to verbalize may complain that it hurts to pee. Toilet trained kids may have some accidents. Urine may have a stronger smell than usual. Young infants may simply be fussy, not feeding well and feverish. Any mystery fevers warrant a urine check to make sure that a urinary tract infection isn't the source.

Irritation around the urethra can also cause quite a bit of discomfort when peeing. This is fairly common among the newly potty trained girls. They are just not all that good at wiping.

Have you done any bubble baths lately??? Those are a very common culprit. Besides bubble baths, any harsh soaps can be irritating. Get in the habit of letting your child do their bath play without sitting in soapy water. Let them play and then when they are almost done do the gentle soap, rinse, exit the tub and towel off. If there is no fever, your child seems quite well but is complaining about pee pee hurting, check to see if you notice any redness in the area.

I am fine doing a one day watchful waiting combined with some natural treatment to see if things clear up. I would suggest:

*A nice soak in a tub with a splash of apple cider vinegar.

*After the bath apply some Vaseline or gentle ointment that can act as a moisture barrier and protect the irritated skin from the urine. 

*Increase their fluid intake; diluted urine is much less likely to sting.

*Probiotics/ less sugar in the diet will make the body less yeast prone.

*Cranberry juice.There are a lot of mixed studies out there, but most of them agree that cranberries may be useful at preventing UTIs. They have properties that prevent the bacteria from taking hold and hey, fluid is good. You may as well make it cranberry juice if they will drink it.

*Loose cotton panties; watch out for tight tights that little girls like to wear.

If your child is complaining that it hurts to pee, and there is any fever or tummy ache, they need to be seen and have their urine checked that same day.

For young babies that are not able to pee in a cup we will apply a sterile urine bag on the area and wait...and wait...and wait, to get a specimen. It is okay if the bag leaks a bit. We don't actually need much more than a teaspoon of urine. Murphy's Law loves this process - there is nothing like a good urine bag in place to make a great big messy poop come along. Sorry folks, even if it looks like the poop didn't get into the bag, we can't use that specimen. We will need to clean them off and try again.

For older kids, we will try to have them pee into a cup. Make sure they are cleaned off thoroughly before urinating. It would be great to get a mid stream specimen, but that often poses too much of a challenge and we will take whatever we can get (as long as it is clean.) If you are obtaining the specimen at home, any clean jar or tupperware that has been through the dishwasher will be fine.

If you don't relish the job of being the "cup holder" reach in with a clean ladle to collect the urine. (I learned that from my niece Molly who was a vet tech at a time when I needed to get a urine specimen from my dog. It works!) Urine poured out of a potty is NOT okay, no matter how clean you think that potty is.

Once we have the urine we will do a couple of tests. The first test, is with a dipstick that we can do in the office. The second step is a culture that takes a few days for the results. In our office we usually do a little basic culture that gives us some info the next day, but we also send the urine off to the lab where they can identify the bacteria and check which medication it will be sensitive to. That first dipstick checks for an assortment of qualities including blood, bacteria, protein, and urine concentration. This test can give us clues but is usually not conclusive. Many little girls have a bit of bacteria in the area that shows up on the test even if there is no infection. Some irritations may also cause a bit of blood and protein. I have also seen specimens that look perfectly clear on the dipstick, but still grow something  on the culture. We will have to weigh all of the symptoms and information when making the decision about whether or not we immediately treat.

If it is an infection, Your child will need antibiotics. If we aren't assured that your child is feeling MUCH better after 48 hours or so, we may also ask for some urine mid treatment to make sure they are on the right medication. We will almost always want a follow up specimen after the course of medication to make sure things have completely cleared up. If your child has a history of even one UTI, you need to be a little more suspicious whenever they don't feel well  and it is probably worth checking urine for any future fevers.

Also, kids who get  urinary tract infections usually need a follow up with the urologist to make sure that all is well with the "plumbing". With little girls, we may give them a pass until they have had more than one, but little boys usually should be checked out the first time it happens.

Be aware of something called "urinary frequency syndrome".  I see it enough that it is worth mentioning. Your young potty trained child suddenly needs to pee all the time. It doesn't actually hurt to pee. They are otherwise well. There is NO fever. There is NO irritation that you can see. Once they are asleep, they sleep quite well and don't seem to have the urgency at night. With any  sudden frequency, we do want to do a dipstick and culture just to make sure there is nothing up. If everything looks fine with the urine, it is likely this odd little syndrome. It goes away after a few weeks. Patient X was actually my daughter Alana. She often played  the "stump the doctors and nurses game". When she was four years old, she suddenly needed to pee all the time. All the workup was normal. I actually ended up driving with an inflatable potty* in my car because otherwise we couldn't go anywhere. With all the doctors mystified, we ended up at the urologist who gave us the instant diagnosis. I think with us it lasted about 2 weeks. If it was longer than that I blocked it out. It was an aggravating several weeks to say the least. Since then, I have seen it multiple times....thank you Alana as always for educating me. If this is your kid, just let them pee whenever they need. It will pass. Remember we are not going to use this diagnosis until we have a negative urine culture.

*Inflatable potty - Take an inflatable inner tube ( think pool toy) , tuck it under a kitchen size plastic garbage bag  (place the garbage bag over it as if you were placing it over a very very shallow garbage can)....voila, instant potty, the pee or poop are ready to dispose of in the bag. We subsequently used this idea for camping trips or long car rides.

Nurse Jen blogs about how the use of words can make a difference

Words Matter: To Get Kids to Help, Try Switching How You Ask 

(summarized from KQED's Sate of health blog, May 2, 2014. Link below)

Enlisting your kids to help out with household chores can be frustrating if not downright maddening.  Recently in the journal Child Development, researchers report a tactic that may get kids to cooperate. Rather than asking your child to help you, try calling them  'a helper' instead. It may seem small but it makes kids feel like they're embodying a virtue, says Christopher Bryan, a psychologist at the University of California, San Diego and one of the researchers behind the study.

 

Preschoolers who got the talk about being helpers (versus being asked to help out) actually dropped their toys to offer aid 20 percent more often than kids who heard a lesson about helping!

 

The phenomenon isn't unique to kids. In a previous study, Bryan found that asking grown-ups, "How important is it to you to be a voter?" was more likely to motivate them to get to the polls than asking them about the importance of voting.

 

 

Interestingly, Bryan says, "Noun-based appeals to not cheat are [also] more effective than a verb-based approach." Sure, you may not want to cheat - but you really don't want to see yourself as a cheater.

 

 

But Don't Go Too Far: Skills vs. Virtues

With kids, we should be careful not to take the approach too far, Bryan says. In some cases, it can set kids up to fall harder if they fail.

"Helping isn't something you can fail at," Bryan says. But drawing is. An earlier study from Stanford University found that kids who were told they were "good drawers" (versus "good at drawing") were much harder on themselves when they thought they had created bad artwork.

When adults put labels on kids - whether it's helper, drawer or something else - the child's identity and self-worth becomes entangled with the label, says Andrei Cimpian, a psychologist at the University of Illinois at Urbana-Champaign, who led the drawing study. "Later, down the line when they encounter difficulties, that's going to be a lot more painful," he says.

When it comes to behavior that's skill-based, as opposed to virtue-based, Cimpian says, parents might do better to use verbs instead of nouns. For example, instead of telling your little Picasso that she's a great artist, he says, "Say, 'Wow, you spent a lot of time on that. It looks great!' "

Sound confusing? Don't stress out about it too much. Unconditional love and support are really what our kids need most. But next time you fearfully anticipate your adorable toddler maturing into a self centered teenager, call your '#1 helper' over and give her some clothes to fold! 

http://blogs.kqed.org/stateofhealth/2014/05/01/words-matter-parents-to-get-kids-to-help-try-switching-how-you-ask/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+kqed%2FStateOfHealth+%28KQED%27s+State+of+Health%29

You baby's growth/link to growth chart

At every routine checkup one of the things that we do is to measure the weight, the height and for the first several years, the head circumference as we follow your child's growth. Of course measuring the growth rate  is only one aspect of the visits. We also will be monitoring developmental milestones and administering age appropriate vaccinations.

The first 3 years the routine visits are as follows:

NB (within several days of getting home from the hospital and then careful monitoring as needed until your baby is back to birth weight)

1 month

2 month

4 month

6 month

9 month

12 month

15 month

18 month

24 month

30 month (check with your insurance to see if this visit is covered)

36 months

and then yearly

Once your child is over 6 years of age, some folks opt to come in every other year if there are no issues or concerns, but you are welcome to do an annual visit.

We will check the weight at other visits as well, especially if there has been any vomiting, diarrhea or feeding issues.

Having a current weight on file is important in case the need arises to prescribe medications. Even giving an accurate dose of Tylenol depends on knowing the weight.

When your baby is born one of the things  that folks focus on is the baby's birth-weight. Although most of the time this data point quickly becomes irrelevant , it tends to be something we remember.

For the record,  my firstborn Lauren was 8 pounds ½ ounce at birth.

Three years later, when I was trying to figure out why it was taking so long to push out baby number two, along came Alana  at a whopping 9 pounds 8 ounces. (Nurse Judy takes a bow)

Here in the office we focus on the weight as a symbol that everything  is going in the right direction, your baby is getting fed and growing.

Many breastfeeding moms can find themselves feeling frustrated and somewhat vulnerable that they don't know exactly how much milk  their baby is getting.

*Can you hear a swallow when they are nursing?

*Are they peeing?

*Are they pooping? Are the stools  turning yellow and seedy?

*Are they having some calm alert time (even a few moments counts) in between feedings?

If you answer yes to these questions, most likely everything is great, but proof will be found on the scale.

Don't fret, it is typical for babies to lose a bit of weight during that first week.

If the weight loss is larger than 10% of the total weight, we pay closer attention and may feel the need to add supplement if you are breast feeding.

We like to make sure that someone is keeping tabs on things those first couple of weeks and that the weight is being monitored. If you have a home nurse visit, or a scale at home we don't necessarily need to see you in the office, we just want to be assured that the weight gain is steady.

After that initial drop, we like to see an increase of ½ ounce-1 ounce a day.

Once they are back to birth-weight, things usually start to roll in the right direction.

This rapid gain usually lasts for a few months before things tend to slow down a bit.

From 4-7 months you might see an increase of roughly 1 to 2 pounds a month

The scales in our office are calibrated and are accurate enough that  except for rare exceptions, it really doesn't matter which scale your baby is weighed on.   

If you come in for a lactation consult it is likely that will be weighed on Charity's special gram scale 

 

Human errors can occur, so if a weight seems really off, lets take the baby off the scale, make sure the scale is perfectly balanced and try again. Maybe this weight is accurate but the last one was off.

Keep in mind that a large stool or a big feeding can have a measurable impact on the weight.

If your baby just ate 2 ounces, expect them to be 2 ounces heavier. On the other extreme if they just had enormous poop, they will be lighter.

We usually measure the babies with no clothes or diaper for better accuracy.

Trust us, if we are worried about the result of the weighing , at that point we will double check it on the original scale if possible.

Once you are safely back to birth weight I am way less focused on the actual numbers.

Look at your baby, not the scale!! If the baby seems well, but the numbers aren't backing that up, relax and lets make a plan to recheck in a week or so.

Another measurement that we follow is the height.

Parents are often confused at the first visit if it looks like the baby has shrunk in the height department.

No one is going to accuse you have having put them in the dry cycle for too long.....

there are a few reasons that this happens.

If you had a vaginal birth, the heads can be elongated....remember the Cone Heads from the early years of Saturday Night Live???

As the head shape normalizes, your baby may actually lose an inch or so.

Also, I hazard a guess that newborn height measurements are somewhat inaccurate.

Often babies still tend to be more comfortable in fetal position, and rarely is it worth stretching them out fully if it is uncomfortable, the measurement simply isn't that critical.

As we collect these numbers we watch the trend of the height and the weight together as your child grows.

If there is a dramatic change in just one of them, it bears watching.

We track these by plotting the numbers on the growth chart that is kept in your child's file

Feel free to ask to see it during the visit. Many parents like seeing where the kids are on the curve.

In my experience about ⅔ of my patients actually follow the curve and by the time they are 2 or so we can roughly predict how tall they will end up.

On the other hand, about ⅓ of the patients don't like to follow the rules and they bounce up and down the chart, having slow growth periods that make the parents nuts and then having wild growth spurts.

Again, what we are watching is that the height and weight are increasing with the same tendency.

We also measure the head circumference. This one can be challenging on an uncooperative baby, and therefore the measurement might vary somewhat. The Head circumference should be measured  from the middle of the forehead  around to the widest part of the head.

This measurement is not usually critical at birth but becomes more important as your child grows.

What we are looking for is the rate at which the head is growing. If it seems like it is growing out of proportion the the height and the weight, that could indicate some fluid in the head that shouldn't be there and would need further evaluation. Big heads are fine. Big heads that are growing way more rapidly than the other measurements warrant attention.

More often than not, if we have a patient with a large head, they are perfectly normal. Look in the mirror, this runs in the family and usually one of the parents also has a big head (ego irrelevant).

It may be worth checking in with Grandma to see if there was anything interesting about mom and dad's growth rate. It is not unusual for your kids to follow the pattern of one of the parents. If one of you started out small and then sprouted as a teen, the apple may not have fallen far from the tree.

If you would like to print out a growth chart, you can find the appropriate one for you child's age and sex  by clicking on this link.

http://www.cdc.gov/growthcharts/cdc_charts.htm

 Growth Charts

Roseola

Roseola is a very common childhood illness.

Other rarely used names for it are exanthema subitum (which means sudden rash), roseola infantum, or sixth disease.

There are a few different strains of the Herpes virus that  can cause it, so some kids may seem to get it more than once.

It is most common among children between the ages of 6 months and 3 years.

Patients present with a very high fever, but here is the big clue...they are acting fairly normal.

I have had many phone calls when the parents call to report that their child has a temperature that is over 104, and yet I can hear the child chattering or even singing happily away in the back ground.

Keep in mind that anytime I have a child with a very high fever who is also very fussy, I am likely going to suggest that they get seen. Fussy kids might be telling us something. I would want to rule out an ear infection or a urinary tract infection. I would want to check their throats and listen to their lungs.

Roseola kids, on the other hand are typically not terribly fussy at all. The fever can hang on for about three days and then the fever is gone and here comes there rash.

This is a very rosy red rash that started all over the trunk and spreads.

It will lighten when you press on it.

Once the rash comes along many of my patients also may become somewhat fussy for the next several days. In general they seem to be a bit more miserable in the rash phase of the illness than they were with the fever.

Roseola is one of the reasons that I have my "3 day fever rule".

If I have a reasonably happy patient who is eating and drinking I am fine waiting to see if we are dealing with this very common illness.

At day 3, the fever is usually gone and the rash has declared itself.

Any fever that is lingering longer than 3 days needs to be checked.

With Measles back on the horizon, we need to be a little more wary of the fever/ rash combination illnesses.

With Measles, the fever and rash may at the same time. 

The child will look sick.

To Review: 

Classic Roseola clues include

*child does not look or seem very sick even though they have a high fever

*the rash comes out AFTER the fever is gone

As with many viral syndromes the only treatment is symptomatic.

Keep your child hydrated and keep the fever down with baths, Tylenol or Advil.

Because about 10% of children can have a seizure (usually harmless but super scary) with very high fevers, I suggest treating a fever if it is higher than 101.5

Roseola is contagious.

The exposure period is about 9-15 days.

This means that  they usually won't get sick until a week or two after they were around patient X. 

Kids can spread the virus starting about a day or two before you know they are ill.

They are usually no longer contagious once the fever is gone.

Many schools want kids home for at least 24 hours after a fever is gone. This is not unreasonable.

Consider this one just another "right of passage" 

Nurse Charity on warm weather nursing

As I was listening for swallows yesterday in the tiny well baby room, a mysterious hum filled the room, making it difficult to hear.  That strangely familiar, but not heard in a long time hum was the air conditioner, alerting me to the hot weather here in the Bay Area.  While we do not get the oppressive heat of other parts of the country we do travel to them, and have enough scattered hot days to feel the heat!  Hot days at the advice nurse desk mean a lot of calls about rashes, a lot of bug bites, some playground injuries, and for me it means a flurry of calls from moms worried about milk supply.

Breastmilk supplies all the water and nutrition your baby needs to the 6th month mark.  On very hot days your baby will not stick to the regular routine you know and love, no, they will want to nurse a couple of times an hour.  This is perfectly normal.  (In fact, if you lived full time in the desert, like the !Kung, you would regularly feed your baby 4-6 times per hour, and any less would label you a terrible mother, worthy of scorn and derision).

Because your baby is nursing frequently, and your breasts are soft all day, and perhaps your little one is cranky with a rash, it is natural to think- "Ack, my milk is gone. HELP!"

I am here to be THE VOICE OF REASON.  

If it is warmer than a delicious 72 degrees (or 22 for those working in Celsius)  Expect that your child will want to nurse more.  How much more?  Depends on how hot it is!   Hot and dry conditions will need more nursing.  You do not need to offer extra water, your body actually changes the composition in hot weather to give your child more H2O, tastier than the glorious Hetch Hetchy.  Just make sure you are drinking to thirst, not walking around with a sticky, dry mouth, and a headache; water, juice, drip-drop, anything that is not caffeinated and is drinkable is what you need!

If you are mixed feeding- some boob/some formula and it is HOT, then you can offer plain safe water in a cup or bottle in addition to the regular routine.  But nursing more often also does the trick.    

Total formula feeders can increase the water offered from 3-5 oz to 6-10oz.  Don't water down the formula, just offer some water at other times. Your thirsty babes will thank you!

  

So relax, no need to worry, or tote around a lot of extra stuff- 

KEEP

CALM

and

NURSE

ON

XO Nurse Charity

Impetigo

I have been getting a lot of calls lately from concerned parents who have gotten a notice from school or daycare that their child has been exposed to impetigo.

Our world is full of bacteria. There are beneficial ones and dangerous ones.

We are constantly surrounded by potentially harmful bacteria that seem to have the "if you don't bother me, I won't bother you attitude". Many folks, without being aware of it, are carriers and routinely  have bacteria such as staph on their skin.

Our skin is our all important protective barrier. Bacteria that is not causing any trouble as long as it remains on the outside of the body can wreak havoc if it makes it's way in. When there is a break in the skin from a cut, bite, or an itchy rash that has been scratched, the bacteria can take advantage of that, enter the body and cause an infection.

Impetigo is one of the most common skin infections out there.

It is usually caused by either Staph or Strep. By far, most of the time Staph is the culprit

There are two types of impetigo.

Bullous impetigo is less common and usually shows up in much younger children. This is characterized by large pus filled blisters.

More common is the non-bullous impetigo, this will have crusty, rashy areas that may have a honey colored glaze. Most of the time you will see these lesions around the mouth and the nose.

This also often affects the diaper area, but  can show up anywhere, more often on exposed parts of the body.

These spots and rashy areas can spread. They don't seem terribly painful and most of the time your child might seem quite well. The spots simply may flare up on and off  but usually don't  clear up completely without treatment.  

(super red/open rashy areas around the butt might be strep. We can do a test for that in the office) 

Young children and school age children are the most common victims of Impetigo, likely because they tend to come into more 'close contact' situations with others.

It is easily spread from direct touching with an infected person,or from coming into contact with contaminated surfaces like toys.

The incubation period is 1-3 days.

If you are dealing with  a very small area, the standard treatment  is an antibiotic ointment. With a really mild infection over-the- counter Neosporin may take care of it. If you don't notice an obvious improvement within 48 hours you may need to be seen or talk to your doctor about getting a prescription ointment called Mupirocin (Bactroban is the trade name).

Some cases are severe enough to warrant a course of oral antibiotics. In our office we will almost always want an office visit to help make that determination.

If a family member has been diagnosed, wash any sheets, towels, toys etc

To prevent getting this in the first place, good hand washing is key.

Do your best to keep skin safe and intact. Dry, itchy skin is more at risk because of the tendency to scratch. Eczema seems to easily  get infected areas. Keeping the skin well moisturized can help. Calendula cream is thought by some to have a natural antibacterial property.

Keep nails short to avoid damaging scratching.

To prevent infection, any mild cut or open lesion should be kept covered  with an antibiotic ointment applied 2 or 3 times per day.  

If your child has a case of impetigo or has been exposed you may also want to put a thin film of Neosporin or Mupirocin  under the fingernails and inside the each nostril twice a day to prevent spreading. Dr Schwanke is a big advocate of getting the ointment inside of the nose since that is often the source of the bacteria.

Another thing to consider is a bleach bath. "What?" you say.

I know, the first time I learned about this I was fairly dubious, but it is currently a strong recommendation from many dermatologists.

Adding ¼ cup of basic bleach to a standard tub can be useful for preventing and treating a multitude of skin afflictions. This will kill any staph or bacteria that is hanging out on the skin. It turns out that it is usually not at all irritating and has very few adverse effects.

I just learned another fact that knocked my socks off. A recent study claims that at least 30% of our tubes of various ointments are contaminated with bacteria. It doesn't take much thought to figure out how that would happen. We touch the tube tip with our unwashed fingers, or we touch the tube to the surface of our skin.

Do me a favor, from now on, try to keep any new tube sterile. Squeeze the dose of ointment or cream onto an applicator (you can use a spoon) and avoid having any direct contact with the tip or rim.

Okay, to sum it up.

If you are one of the families who got the Impetigo warning....

Hopefully your school setting has done it's job and has thoroughly cleaned toys, surfaces etc.

Aside from that, checking your child to make sure they have no spots anywhere is the only action plan that I would advise.

If they have any questionable spots, treat as discussed.

As I mentioned in my recent post about contagiousness, A notice about impetigo exposure would not be a reason to keep them home from school.

Chances are, unless you have been out of day care for an extended period,  they have already been exposed.

Vicks VapoRub on your feet?

 

The internet is a minefield.

It is a goldmine of valuable information.

Unfortunately, it also has the power to terrify unwitting folks who go online to look up symptoms or whatnot.

Most wise folks know enough to realize that the good information is muddled up with loads of crap. It is hard to know what is real.

Therefore, when I got an email several years ago touting the magic of applying Vicks VapoRub to your feet to stop a cough, I promptly dumped it into my spam.

Frankly anything that tells you that it works 100% of the time is 100% false (Have fun with that statement!)

But then a variation of the same email came to me again and I thought it might be fun to see if there was any merit to it.

The claim is that covering the soles of the feet with the VapoRub and then putting socks on is very helpful for coughs.

I am always looking for safe, natural remedies to help relieve symptoms of colds and coughs for my patients without loading them with systemic medications.

So, several winters ago I set out to do a completely unscientific study.

While talking to the hundreds of my Noe Valley Pediatric parents who were trying to relieve the coughs that were keeping their kids up at night I enlisted them to give the Vicks on the feet a try. I asked them to report back.

To my surprise, well more than 50% of the folks who tried this seemed to find that it was quite helpful....imagine that! Even Snopes doesn't completely debunk it, just labels it as unproven.

No one who tried it had any ill effects.

I occasionally completely forget about this, but someone asked me about it the other day. With the colds and coughs out there in full swing, this might be something you want to try.

Before applying anything topical, it is important to make sure you or your child do not have a reaction. Place a small dab on the leg and rub it in. If there is no irritation within 30 minutes or so, you should be fine. (I do this same test with a new sunscreen) 

If you have an infant who is under 4 months of age with a cough that is keeping them up or interfering with their eating, they need to be seen.