Hand Foot and Mouth Disease

Hand foot and mouth disease (HFMD) is a well known and common illness. Let’s review.

Curiously, when I was a resident, this was mostly a summertime/early fall illness, but now I diagnose it almost year round.  I do not have a good explanation for that development.

HFMD was first identified in 1957 in New Zealand and Canada.  Initially, due to the mouth blisters,  HFMD was assumed to be caused by herpes virus, which explains one of its common names–“herpangina.”  However, we now know that it is caused by a different virus, called “coxsackie.”  This is a member of the “enterovirus” family, which means that its a GI virus and spread via hand/mouth contact from body fluids–not from “droplet” contact like from coughing and sneezing. Therefore lets note that best preventive measure is careful hand washing, as well as cleaning home surfaces and toys.  Many different strains of coxsackie can cause HFMD which explains why we keep seeing kids getting it year after year, and why your child can get it multiple times. HFMD incubates for 3-5 days after exposure, then may cause symptoms like fever, white or red spots in the mouth, throat, or lips as well as blister like lesions on the palms and soles and red spots on the rest of the body.  Any combination of the above is possible–a child does not have to have all of the above to have an HFMD coxsackie infection. Spread in public or nursery schools, day care/babysitting centers is universal.

HFMD can be sporadic, but I very typically see it in epidemics: when one case comes in I expect to be inundated.  Epidemics as large as 1.5 million cases are not uncommon.  Most infections occur in children < 10 years old.  Symptoms may last 7-10 days but generally resolve in < 1 week.  There is no specific treatment to shorten its course.  Use acetaminophen or ibuprofen for pain or fever. Cold compresses like ice pops are very helpful.  Honey or topical treatments like Abreva or Blistex can relieve the sore throat pain.  The only common complication is dehydration due to poor fluid intake caused by pain from numerous mouth lesions.  Those children may require ER or admission for IV fluids, but again, they almost always recover nicely.  There are numerous more severe but rare complications which have been reported.  In 33 years of practice I have never seen one personally, so there’s no reason to list them here just to make you folks nervous.

One last point.  HFMD affects children.  “Hoof and Mouth” disease infects cattle and is a completely different problem.  They have nothing whatsoever to do with each other.

Please send along questions or comments, and thanks for following.


Youth Tackle Football

OK, I may make some enemies in our community with what I am about to say, but here goes.  There is a growing consensus among health professionals who care for children–including pediatricians like me, neurologists, radiologists, and others–that organized tackle football should be avoided in younger players.  Children have larger heads and weaker neck muscles compared to adults, making collisions riskier.  Moreover, younger, less experienced players more often utilize poorer tackling technique which also raises the risk threshold.  While hard shell helmets do limit skull fractures, the evidence regarding concussion prevention is actually quite poor.

Of course, at these younger ages the brain is still developing.  Researchers at Wake Forest Medical School recently followed children 8-13 yrs during football season with MRI scans.  None of the boys had developed concussion symptoms during the study period, yet their scans showed subtle but clear disruptions of normal brain metabolism from pre to post season.  Related studies done at Boston University Medical School looked at former NFL players and found that those who had started in the sport <12 years old had a significantly higher incidence of “white matter” brain changes and more frequent difficulties with depression, cognitive impairment and behavioral problems in later life.  There are additional studies reporting similar patterns in people playing other contact sports from an early age compared to those who did not.

So where does that leave us?  Well, I am certainly NOT “anti-football”(well, maybe anti-NE Patriots, but anyway…).  > 1 million boys play high school football.  As I spend a good part of my time begging/yelling at my teen patients to get off their darn phones and to be more active, I strongly support this and all high school sports.  Presently there are approximately 1.2 million US 9-12 year olds playing youth football (numbers have decreased in the last few years because of these concerns) and those kids sustain approximately 240-585 head hits each season.  Note that youth football is a relatively recent phenomenon–when I was growing up in the 1960’s-70’s it hardly existed.  Back then, tackle football was something we played on weekends in the park if we could collect enough guys to make 2 teams.  There were no non-HS football “leagues”–tackle or otherwise– to speak of.

We need a new paradigm, and I believe this is where flag football comes in.  The nonpartisan Aspen Institute recently issued a White Paper advocating for flag only <14 years.  Here in NJ, Assemblywoman Valerie Vainieri-Huttle (D-Bergen) has introduced a bill (A-3760) that would allow flag football but ban tackle statewide <12 yrs.  Given the above, the arguments against–that teaching younger boys proper tackling technique improves safety–are, at best, unconvincing.  I believe this bill deserves serious consideration; personally (and professionally) I support it.

Don’t all yell at me at once– but send along questions and comments, and thanks for following.

Flu Shots 2018

Our flu shots are in, so it’s time to get in and get vaccinated. I have discussed this before here, here and here.

The flu is not just a bad cold. Last year, 179 U.S. children died of influenza, which is the second most annual deaths ever (2009 was the worst). 80% of those deaths occurred in unimmunized children, and 49% of those deaths were in children who were previously healthy. The American Academy of Pediatrics recommends that everyone over age 6 months be immunized against the flu.

  • All healthcare and law enforcement personnel, and all who work with children should be immunized.
  • Pregnant women should be immunized. The immunity can pass across the placenta to the unborn baby and provide useful immunity in the first 6 months of life.
  • Children with egg allergy can safely receive flu shots. No special precautions are required.
  • Vaccination is safe for breastfeeding mothers and infants.
  • Children under age 3 should receive 2 doses of 0.25 cc vaccine at least 1 month apart in their first month immunized. In subsequent years, only one 0.25 cc dose is required less than 3 years.
  • Children 3-9 years should receive two doses of 0.5 cc at least 1 month apart the first year immunized. In subsequent years, they only need one 0.5 cc dose.
  • Above age 9, people required one dose 0.5 cc each year.
  • Injected, inactivated vaccine (“IIV4”) is the vaccine of choice. Note that since this is inactivated, there is no risk of infection from this shot.
  • Live, attenuated “quadrivalent” vaccine (“LA4”)–nasal spray–can be used in selected situations (greater than 2 years of age, no health problems). As this vaccine is less effective against H1N1, I have chosen to not stock this form.

As flu season is very unpredictable, AAP recommendations stress that the earlier the better to be immunized. If possible, by the end of October.

So give us a call.

Thanks for following.

Adolescent Health Update

With summer winding down and school revving up, let’s take a moment to review recent developments in adolescent health research.

First, the bad news(that we kind of already know): our kids don’t get enough sleep, and those practices extend far into their overall wellbeing.  British researchers report a strong correlation between poor sleep and weight problems.  You can see the study here.

I have written about the HPV vaccine before, and strongly recommend your child receive it.  Recent studies in Australia and New Zealand show that the expected health benefits predicted from HPV immunization are beginning to occur there (vaccine rates are much higher in those countries), with lower rates of genital warts being reported.  A recent US study did show that laws requiring HPV for school admission had no effect on adolescent sexual behavior.  Teens were no more likely to be sexually active after receiving it.  This research backs up previous work done at Kaiser Permanente  that demonstrated similar results.  Again, I strongly urge parents to get their teens and “preteens”(10-12 yrs) immunized, maximizing the opportunity to provide protection prior to any exposure to the virus later in life.  As I keep stressing–its a CANCER shot, not a sex shot.

Let’s end on a positive note.  Long term studies conducted at the University of Michigan strongly suggest that teens are abstaining from alcohol, psychoactive drugs, and tobacco at a much higher rate compared to decades past–as much as 5x less! That’s great news!!  The researchers did state that, as more states legalize the use of marijuana, this trend may change.  I will not advocate pro or con on this public policy issue as it plays out in NJ here.  But it is food for thought.

Send along questions or comments, and thanks for following

Trampoline (non) Safety

I’m surprised at myself–I’ve been at this blog for 4 years now and have not mentioned trampolines.  Time to fix that.

(Please note that here we are not discussing trampolines utilized as part of a specific organized athletic discipline program, like diving or gymnastics–assuming an approved practice facility with properly maintained equipment and trained coaches and spotters)

I’ve discussed the danger of recreational trampoline use throughout my career, and for good reason, I think.  According to the American Academy of Orthopedic Surgeons(AAOS), there are >250,000 trampoline injuries annually, approximately 186,000 of those <14 years of age.  The smaller the child the greater the risk–48% of injuries <5 years of age are fractures or dislocations.  75% occur when multiple people use the apparatus simultaneously.

Recently the AAP revisited the trampoline safety issue due to now rapidly proliferating “trampoline parks”–from 3 nationwide a decade ago to now >800 such facilities.  The industry is virtually unregulated.  Please note: proprietors insist that, given the inherent risk of trampolines, they make every effort to insure their patrons’ safety and I take them at their word.  Nevertheless, we note that annual ER visits from injuries at tramp parks have increased from 581 in 2010 to almost 7000 in 2014.  The AAOS recommends that no child < 6 years should use a trampoline.  We pediatricians are even tougher:AAP now says no children should use them recreationally, period.

Considering a trampoline in your yard?  Please remember the following:

  • Single user at a time
  • Keep at ground level if possible
  • No summersaults, flips, or other “trick” maneuvers–most common cause of serious neck injuries
  • Active adult supervision (mere “presence” is insufficient)
  • Adequate protective padding and a safety net.  Remember : the safety net does not replace adult supervision and does not prevent on-apparatus injuries.
  • Frequent safety inspection. Replace damaged, worn parts. If unavailable, the tramp should be discarded
  • This is key: MAKE SURE that your homeowner’s insurance covers trampoline liability. Many do not.  Also be aware that you are responsible for any child on your trampoline whether you gave permission for its use or not. That’s right: if a neighbor sneaks into your gated yard without your knowledge or consent and injures himself on your trampoline then YOU are still responsible, even if you were not home at the time.  The trampoline is an “attractive nuisance” in your possession on your property and the injured party is a child, so YOU are financially responsible for the injury, not him or his parents. Also be aware that if you fail to notify your carrier of the presence of a trampoline on your property then they might possibly use that information to cancel your policy even over an unrelated liability matter due to your failure to disclose

My question:  how many trampoline owners out there are following the above safety regimen?

My recommendation?  As almost always, I follow the AAP: best to forget the whole thing.  Its a health and financial catastrophe waiting to happen.  Do you really need this head/heartache?  Just ride a bike or have a catch with your kid instead!

Thanks for following

Housekeeping–CT, antibiotics

I just want to take time in this post for some “housekeeping” and touch very quickly on 2 subjects that have been fairly regular features of this blog.

#1 is the use and overuse of CT scanning, especially in the ED.  A recent study from the Netherlands Cancer Institute reinforced earlier information I had presented regarding cancer risk from the large radiation doses in CT scans.  I support the thoughtful statement of the authors who say:

“CT scans for children represent a potentially life-saving and quality of life-improving technique for many patients. In addition, the tumors evaluated here are associated with small absolute excess risks. Nonetheless, careful justification of pediatric CT scans and dose optimization, as are customary in many hospitals, are essential to minimize risks.”

Specifically, I have spoken of the use of CT at the ED in evaluating for possible appendicitis.  This month’s American Family Physician includes an article about that subject, which diagrams the evaluation process from an article by Dr. G Santilles from Academy of Emergency Medicine in 2012.  For negative CT, the authors say, possible discharge with follow up in 6-12 hours is appropriate.  In other words, if that person is sick enough to need a CT at that time then they are sick enough to need to be seen and re-evaluated in less than 24 hours.  Ideally, the ED doctor should call and speak directly to the primary care doctor to insure proper “hand off” of these cases, I believe.  This is of particular concern for weekend incidents when office hours may be more limited.  So, my advise?  If you are in this situation with your child, do not hesitate to request that the ED doc call your primary care to “touch base.”  It’s the right thing to do.  Safety first.  And BE SURE to be seen next day.

The other subject is the overuse of antibiotics.  Another recent study found that urgent care center visits for respiratory illness result in prescriptions for antibiotics in 40% of cases.  However, careful scientific analysis shows that bacteria are actually responsible for perhaps 5% of these illnesses.  The rest are viral; the antibiotics are unnecessary, unhelpful, and not infrequently can themselves cause harm.  Now, I understand the convenience of these urgent care centers; not too small an issue for busy parents.  However we should keep in mind the old consumer adage that “you get what you pay for” and this data shows pretty clearly that, in too many instances, the advantage of convenience comes at the cost of a lot of over treatment and not useful medicines.  So, again,–my advise?  If at all possible, wait for your doctor’s office to be open the next day. Doing it right is almost always better than doing it fast.

For a review of the risks of antibiotic misuse please check here.

Thanks for following.

Penicillin Allergy

Let’s talk a bit about antibiotic allergy. While I have gone on forever about the dangers of overuse, of course antibiotics are one of modern medicine’s most useful tools. It is therefore of benefit to have the option to use any of these agents should the appropriate picture present.

And, naturally, the first among equals in this medicine class are penicillins (and related cephalosporins).  While being able to prescribe is great, seeing a patient develop complications is troubling.  Most know the typical side effects of drug allergy: hives and swelling, as well as coughing or wheezing; also there are more serious ones like “serum sickness” (fever, joint pains, nausea, also rash), and more threatening allergy reaction with thready pulse, shock, throat closing, loss of consciousness.

And reports of penicillin allergy are quite common–10% of patients.  But HOLD ON–careful study demonstrates that the large majority of those reports actually have no medical basis.  Adverse side effects like abdominal discomfort, nausea, vomiting, diarrhea, are common, as well as vaginal itch, discharge, thrush, and mild body rashes.  Many of these problems are inaccurately labelled “allergy” by lay public and even well meaning if uninformed medical providers.  Additionally, some report “penicillin allergy” based on vague personal history from distant past or even because of close family members reporting allergy.  While these problems can be annoying, they have no predictive value of the more dangerous medical allergy reactions listed in the previous paragraph.  Those true allergic reactions are caused by activation of the body’s allergy/immune/IgE system which can progress to dangerous problems and must be taken more seriously.  Therefore, that diagnosis should be made carefully and cautiously. One study from Mayo Clinic demonstrated that of 384 people claiming “penicillin allergy” 94% actually were not when tested scientifically and these people all subsequently tolerated penicillin well.  The incidence of anaphylaxis is only 0.1-0.5%.

Over diagnosis is not a trivial problem.  People diagnosed as penicillin allergic are then given other “broad spectrum” antibiotics that typically have greater risk of side effects like abdominal problems compared to penicillin.  There is also a significant cost factor.  One recent study demonstrated a savings of over $192,000 in one year in one large municipal ER alone by accurately assessing children labelled “penicillin allergic” and avoiding the use of  more expensive alternatives.  Those patients, again, were administered penicillins safely.  Of greater importance and concern is the risk of infection caused by these alternative drugs themselves.  A large study from Massachusetts General Hospital reported its findings that use of these agents increased the risk of MRSA infection by 69% and of Clostridium dificile (“C dif”) infection by 26%.  That is a major concern both individually and as a matter of public health.

So I urge those designated “penicillin allergic” to carry a healthy dose of caution and skepticism regarding that diagnosis for your child.  Please come in to discuss it with me.  Let’s explore it carefully and diagnose it accurately, for your child’s best health and protection.

Thanks for following.