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 Previous Columns by Dr. Paula Choosing The Right Pediatrician
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The Doctor's Journalby Dr. Paula
Case #1 ~ Ear infection This week I saw an 18 month old girl for the
first time , with a one month history of ear infection. She had been previously treated
for this infection with two different antibiotics, first Lorabid, and then with two
courses of Augmentin (properly dose d for her weight). She had a runny nose and cough at
the time of the diagnosis but most of that had already resolved. The ear infection,
however, continued and her parents were concerned about what next to do. Her previous
pediatrician had suggested an other round of antibiotics, different from the ones already
tried. This episode was the child's first experience with ear infections and her
irritability and resistence to taking medicine was really disturbing the whole family. I
found the patient to be a cheerful toddler, fairly easily distracted or engaged, while I
went through the different parts of the exam. Her nose was slightly runny with thin clear
fluid and she periodically produced a loud wet sounding cough that did n ot seem to bother
her at all. Her eyes were clear and her throat was not red but both her eardrums were red
and showed a large degree of fluid accumulation and relative immobility when I insufflated
(blew a tiny bit of air through the otoscope into the e ar canal to test the flexibility
of the eardrum - a standard part of any ear examination). Her chest was clear and the
remainder of her examination was all within normal limits. She did not seem particularly
irritable to me despite the natural reluctanc e to be examined. After the exam and while I
watched the child playing comfortably in the waiting room, I discussed with the parents
the possible options. Since she was too young to accurately test her hearing in my office
it was not possible to know precisely whether the se ear infections had impacted on her
hearing. Her grandmother seemed to think the child had periods lately when she did not
hear as well as other times although the parents suggested that maybe she just didn't want
to listen some of the time rather than not being able to hear. I inquired further as to
what the home scene was like when it was time to take medicine and once it became clear
that medicine taking was a horror for the child and for the family I decided to offer a
"wait and see" alternative. I explained that since the ear infection had begun
with a cold and since most ear infections are caused by viruses, it was entirely possible
that no antibiotic would make the difference in healing time and that the body just needed
a little encouragement to get passed this impasse. I suggested that over the next week the
family make efforts to keep the child's nose clear by steaming periodically, increasing
general hydration, and using saline nasal spray in the early morning. We also decided to
try a n asal steroid spray at bedtime for a few days to aid in nighttime clearance. I
decided to forego a trial of "cold medicines" since the little girl hated to
take medicines and I have not seen much in the way of good results from this approach in
the past. We agreed to use this approach with vigor and to have the child re-examined in
5-7 days unless she developed fever or obvious pain. Bingo!! 5 days later the happy family
returned claiming they had done all we had discussed and that their sense was that their
daughter was much improved. The acid test - the insufflation and a tympanogram confirmed
what my eyes saw through the otoscope (the instrument we use to see inside the ear);
perfect eardrums with excellent flexibility and no residual appearance of infection. I
urged the parents to approach the next episode of cold symptoms promptly and with the same
nose clearing techniques th ey had used this week. The message? Not all ear infections
need antibiotics and most situations like this can be managed with time and old fashioned
advice. Although not all ear infections end this happily, it is important to sometimes
consider different approaches to even co mmon illnesses.
Case #2 ~ Strep A bright eyed 4 year old came in to see me today with her mother, hiding behind her legs and refusing to be cajoled by my best efforts. Mom says her fever has been "through the roof" all weekend and today she refuses to eat or drink and is acting "strang e". In her sleep last night she was mumbling and gesticulating and it frightened her father who insisted mom bring her in. Questioning Lisa yielded no information except some words about Barney and stomach aches. Trying to touch her I could tell she was very hot and her skin had a pink hue to it along with cherry red lips. Taking her hand I could see the tips of her fingers were peeling and cold. I asked her if anything hurt and she said her head and then she threw up and became listless and pale. Since I was now able to examine her without resistence I took steps to cool her down as she felt extremely hot to touch - cool compresses and Children's Motrin were given and then I quickly examined her hoping to get to the bottom of this before she becam e even sicker. Ears, OK, chest - clear, throat - very red and her neck , though supple, had large tender lymph nodes that could be easily seen - throat culture - positive for strep!! She had all the classic signs but I was relieved to get the quick stre p results to confirm the diagnosis. The rest of the exam was normal - her chest was clear and she had no mummer. A shot of Penicillin (strong history of refusal to take oral medications and her vomiting episode led me to this choice instead of the usual oral route) and a little time for the Motrin to act and she started looking better before even leaving the office. I did a CBC, a complete blood count, in order to look at her white count and platelets. Mom handled all this well but needed some instructions for what to expect and what to do for the next day or so - stay at home, no contacts, expectation of more fever and what to do about it, fluid replacement, watch for more unusual behavior and call if listlessness doesn't respond to temperature control methods or she continues to vomit. Let me know if the other children at home get sick - don't wait if they have sore throats, call (they are both older and better able to describe their symptoms that th eir younger sister). There are some other illnesses that can mimic this picture and I was worried that she might be quite ill - maybe even have something acute and critical like Kawasackie disease which can also present with very high fever and red lips and peeling (usually t here is also a severe redness around the eyes). This condition is treated very differently from strep throat and has potential for severe cardiac complications. It is most often seen in Asian patients but can occur in anyone - cause unknown. Typically t hese children have a very high platelet count. Hers was within the normal range. Follow up - tonight she is without fever and feeling much better. Tomorrow is another day - I counseled dad that she may have fever again and that she should still be carefully watched. The rash , which was a classic scarlet fever rash (salmon colored a nd fine, like sandpaper in texture and worse in the folds of her skin) was still present and had begun to itch - a dose of Benadryl will help her sleep and not scratch. I hope she has a decent night. We'll talk in the morning. Another day.
Case #3 ~ Sex and the 13 year old girl Once again, I tried to reach an adult in the family and was able to find the aunt who after only a few seconds of description of her niece's pain asked if she could be pregnant. Once the door had opened it was easier to explain that there were many possi bilities and that she would need blood tests and a gynecologist's examination with cultures and perhaps a sonogram in order to figure out what exactly was wrong. Her pain was increasing and she was not able to walk out of the office as easily as in. Her aunt was unable to join us and could not reach any other custodial adult and was willing to give me permission to act in locum parentis (in place of a parent), a job that pediatricians are sometimes required by law to take on as in the case of a sick ch ild without an available adult or if the adult is unable to care for the child. After sending samples of her blood to the lab, I took her to a nearby female gynecologist who is familiar with teens' issues and who was also willing to act in locum parentis . Her exam and sonogram revealed a leaking ovarian cyst which was small enough to allow a natural course of resolution to proceed as the patient's pain was again subsiding. Cultures for possible infections were obtained and first blood test results indi cated that at least she was not anemic or pregnant, and there were no signs of emergency infection. Her urine was normal as well. The remainder of the day's events included counseling and advice for the future and instructions on returning to our office s in the next few days. Her aunt arrived 2 hours later and was fairly sympathetic to her niece although she was less than kind to the doctors and nurses giving her care. The aunt claimed she had not given permission for her to be examined and that we ha d violated her rights. Despite the relatively good outcome of the patient's pain and the benign nature of the diagnosis, the aunt's only focus was on the medical intervention that she perceived as invasive and "way out of line". The aunt refused to pay any medical bills and threatened to sue everyone in sight. She also believed that our examinations had "robbed" her niece of her virginity and despite our efforts to assure her otherwise she was unconvinced. The scene was not a pretty one and although we had moved to the next room, the teen patient could partially overhear what was being said. Still wanting to protect her privacy and her right to decide what and when to share with her family, no mention of the sexual history was made leaving the aunt 's accusations even more difficult to dispute. As the heat rose and the nursing staff became concerned about the HIV testing we had considered and had not as yet obtained consent for, the 13 year old came to the rescue. "Aunt Loretta, please , can I tal k to you alone?" The end of the story is that aunt Loretta was sadder and wiser, and the patient was relieved but still scared. She and her aunt consented to sign the forms for HIV testing and promised to return as a family and individually to see the s ocial worker we had arranged to help normalize things between them. Drained and shaken but glad for the teen, we all went back to our patients.
Case #4 ~ The cause of the cough Four year old male with cough since September returns to my office because his mother says he is up many times in the night coughing. He usually has a runny nose, presumably the reason for the cough, but many times lately his cough is dry. Twice since September he has had fever and on one occasion he was diagnosed with pneumonia by my partner. Today he has no fever but he looks drawn and tired as does his mother. On examination Justin has pale mucus lining in the nostrils and throat and his eyes are slightly injected and there are dark circles beneath them. His chest is clear although each deep breath results in coughing. His skin is generally dry and there are areas of patchy scales on his arms and back. His eardrums are retracted perhaps from chronic cough. His chest looks almost muscular in shape - larger than you would expect given his size and age. Justin's mother tells me that there are several family members with asthma and that many are also highly allergic to house dust and animal hair. When asked about Justin's environment it is found that there is a new addition to the family, a cute shiatsu puppy, Jesse James.. Justin's new bedding also includes a feather blanket which he likes to sleep completely beneath since the weather turned colder. My suspicion rising, I gave Justin a "treatment" with a bronchodilator, albuterol, via nebulizer, and his cough seemed to subside. We decided to send the nebulizer home with the family and taught them how to give the medicine and instructed them to evaluate Justin's cough after 2-3 days of treatments. Also, the dog was invited out to a "friend's" and the blanket was double encased with cotton covers. Justin improved greatly over the next few days. We assumed that the reason for his cough was related to allergies and that Justin might benefit from a change of environment. The dust level was reduced by thorough cleaning of carpets and curtains, removal of the many stuffed animals (the favorites were cleaned and returned of course) and the feather covers were replaced with synthetic material. As Justin's cough diminished the nebulizer was no longer necessary and the dog was brought home for a trial visit. So far so good, so the dog can stay for now and Justin is scheduled for a RAST test, a blood determination of his degree of allergic sensitivity to a variety of things including dog hair. Hopefully Jesse James can stay. Sometimes a cough is the only symptom of asthma. We call that "cough variant asthma" or cough only type asthma. It responds to the same treatment as regular asthma, you just have to think of it or the cough never quite seems to go away with ordinary cough management. Case# 5 ~ High LEAD level, from where? Tzvi is 11 months old and has had his share of ear infections and colds. He came today for an ear re-check (he was taking an antibiotic until yesterday), and for a routine well visit. Last visit he had blood tests for anemia (normal) and for lead. The exam was unremarkable except for how much motor progress Tzvi had made this month, and this time his ears were really clear. Glancing back at the blood tests done last month I noticed that his lead level, although technically normal, was 3.9mcg/dl. It struck me that most initial lead levels in this city on infants are much lower than that, often practically unmeasurable. For me this result is a red flag meant to alert the family to look for possible sources of lead in their environment. "How old is the building you live in?" , I asked. The parents told me the building was old but the pipes were "new". I explained why I wa s asking and the father asked me if lead can come from sources other than water. I explained about lead paint, lead dust, lead in household products. He thought a moment and said "Could lead come from paint stripping an old bridge?" It seems the family live a stone's throw from the Williamsburg Bridge, one of New York's oldest scenic sights and one that is undergoing a major renovation including stripping down to the original metal before repainting is done. Constant dust and particles fly through the ir window and it would not surprise anyone if lead were found in the spray. Further, a few years prior, lead was found in toxic levels in several children living around the Queensboro Bridge, another New York City landmark then undergoing similar renovat ion. I wondered which agency I should be calling. I gave the parents an FDA approved, simple to use kit for lead testing called KNOW LEAD (you can order it by calling 1-888-244-5306) and explained how to use it to test the bridge dust and any suspect ho usehold items. Just as an afterthought I asked if the home had vertical blinds or mini blind type window shades. Again, bingo! Tzvi's home had both and they were not "brand name" and they were not new. A few years ago lead toxicity was traced to window blinds of this type made in China and testing them was put on this family's "to-do" list for the day. Seems Tzvi loves to spend his time standing on the window sill with mommy playing with the vertical blinds and practically licking them as he drooled. Another likely source for this infant's normal but unexpectedly elevated lead level. I will speak later to the parents and then proceed with advise on how to get the lead out without having to move out. Economics also play a part in the lead toxicity i ssue which is why it is more often a problem in lower income families and urban dwellers. I think every home should be lead investigated when there are children growing up inside. It makes more sense to educate and test for lead before toxicity forces tr eatment and neurologic damage may have been done but there is little available for easy testing that isn't costly. I strongly suggest my patients purchase a KNOW LEAD kit and get the answers they need - besides being inexpensive and easy to use it is ver y accurate.
Case# 6 ~ The challenge of immunization Immunizations are very important but some children don't seem to ever get caught up. Today I saw a recently turned one year old boy who has had many respiratory illnesses since birth. He is growing and thriving and can almost walk and has a smile to mel t hearts. He also has an audible wheeze which has been defined as asthma for the last 2 months after a difficult round of bronchiolitis that landed him in the hospital. He has 2 lovely parents, intact extended family, and a 2 ½ year old sister. Despite frequent doctor visits over the year, Marc is way behind in his shots and my natural inclination to avoid giving more than one (certainly no more than 2) shots at one visit has not helped the situation. I approached this visit with a determination to ca tch up on vaccines, despite my sensitivity to the pain of the needles. Marc was wheezing and breathing rapidly despite no obvious distress. His ears were still infected 2 weeks after a course of antibiotics for the same condition, but no follow up visit was made after the treatment so it was not clear to me whether this is a chronic or recreant situation. His mother, sensitive to her children's health looked dismayed when I suggested we get some shots done today. The challenge of immunization includes the difficulties of parental anxiety regarding them. Marc's mother bel ieves that if he is not 100% well when he gets a shot, the shot may do him harm. She also wants him not to experience discomfort and so two shots are almost out of the question. Marc needs his 3rd set of DaPT and HIB and an MMR vaccine, not to mention t hat he hasn't had a CBC or test for lead or a tuberculin screening test (these three usually done at 10 months of age in my office). It was difficult to negotiate but I convinced the mom that the DaPT and HIB should be done and the blood work, letting th e MMR wait for the next visit. It is often a matter of compromise to get the job done in pediatrics and I am often grateful for the luxury of continuity of care I can give my patients. Not all kids are so lucky and often their well child care gets lost in the shuffle of shuffling between clinics, emergency rooms and doctor-go-rounds. I will always believe that government intervention in child health must begin at the basic level of providing continuity of care for each child. From there we have a figh ting chance.
Dr. Paula is a well-known and loved pediatrician in Manhattan. She is dedicated to helping you in your demanding job as a parent. She has her own Web site at DrPaula.com
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