baby healthy, kids healthy

EXUALLY TRANSMITTED INFECTIONS (STIs) (e.g., Gonorrhea, Syphilis, Herpes)

Author’s Comment: Whatever the specific disease entity might be, it needs  to  be  diagnosed correctly  in  the  doctor’s office and  treated adequately. Appropriate  counseling is definitely advised, and sexual contacts should be sought out and treated if necessary.

1. What are the most common sexually transmitted infections in adolescents?
The  most  common  sexually transmitted  infection  in  the  United States is human papilloma virus (HPV). HPV can cause genital warts, cervical dysplasia (precancerous changes on the cervix), and genital cancers including cervical cancer.
Other  infections  common  in  adolescents include  gonorrhea  and chlamydia, which are bacterial infections; herpes simplex virus, which is a viral infection;  and  Trichomonas vaginalis  which  is a protozoan infection. Less common infections in adolescents include hepatitis B, hepatitis C, syphilis,  Pediculosis pubis (“crabs”), and human immunod- eficiency virus (HIV).
 
2. How are these infections spread?
HPV, herpes, and syphilis can be spread by intercourse, oral sex, or close genital contact.  Gonorrhea and chlamydia are more commonly spread by intercourse,  but  oral sex has resulted in  oral and  throat infections. Hepatitis B, hepatitis C, and HIV are spread by intercourse (vaginal or anal), needles, and blood transfusions. Pediculosis pubis is spread by intercourse,  close genital  contact,  and  infected  bedding. Trichomonas is spread through intercourse.

3. Which infections can be treated or cured?
Bacterial infections (gonorrhea,  chlamydia, syphilis) can be treated and cured with antibiotics. Trichomonas can also be cured with antibi- otics. Pediculosis pubis caused by the  crab louse is treated  and cured with  topical  medications,  removal of nits  (eggs), and  proper laun- dering  of clothing  and  bedding.  Viral  infections  such  as hepatitis, HPV,  and  herpes can  be cleared by the  body. However, sometimes these  infections  become chronic.  Medications  can  be used to  keep symptoms minimal and treat  flare-ups but cannot  actually cure the infection. HIV attacks the body’s immune system. Although medica- tions  are  available  to  improve  the  health  and  life  expectancy  of patients with HIV, there is no cure available at this time.

4. Can there be permanent damage from sexually transmitted infections?
Several infections can go on to cause organ damage if not diagnosed and  treated.  Gonorrhea  and  chlamydia can  lead to  scarring of the fallopian tubes, which can result in chronic pelvic pain and infertility. Syphilis can  go on  to  affect the  eyes, heart,  and  nervous  system. Chronic hepatitis infections can result in liver failure or liver cancer.
High-risk viral types of human  papilloma virus can lead to cervical cancer  and  other  genital  cancers.  HIV  attacks  the  body’s immune system resulting in susceptibility to infections ranging from minor to life threatening.

5. If my child is diagnosed with a sexually transmitted infection, does my child’s sexual contact(s) need to be advised?
Sexual partners should be notified when a sexually transmitted infec- tion  is diagnosed. Notification  will not  only allow other  potentially affected  people  to  seek  evaluation  and  treatment   but  also  may decrease  the   likelihood  of  your  child  getting  reinfected  by  an untreated partner.

6. What vaccinations are available to prevent sexually transmitted infections?
The hepatitis B vaccine has been part of the routine childhood vacci- nations now for many years. A vaccine for the four most common viral types of HPV was approved by the FDA in the spring of 2006. These viral types account for 70 percent of cervical cancer, 50 percent to 60 percent of high-grade dysplasia (precancerous changes on the cervix), and 90 percent of genital warts. The Food and Drug Administration (FDA) has approved the use of this vaccine in girls and young women ages nine to twenty-six years old.

KELLI WATKINS,  MD
Gynecology

SEXUAL ABUSE (Suspected)

Author’s Comment: Sexual abuse of a child can range from inappro- priate touching, fondling, or kissing of sexual organs to actual inter- course by either a stranger or person known to the child. If you suspect this very frightening event  has occurred to your child, contact  the doctor’s office as soon as possible.

1. What agency do I contact to report my suspicions and to help me investigate the situation?
A  suspicion of child  sexual abuse should be reported  to  the  local police department. Depending on the circumstances, Child Protective Services should be contacted  as well. If you are unsure whether  to report  suspicions or  who  to  call,  discuss your concerns  with  your child’s pediatrician.  An  alternative  source of information  available twenty-four hours a day is the National Child Abuse Hotline (800–422–4453/800–4–A–CHILD).

2. How do I go about investigating whether an incident truly took place?
The  age of your child  will determine  how much  information  your child can give you. However, if you have a suspicion of sexual abuse, contact  your doctor or your local police department.  If you suspect recent or ongoing abuse, it is important  to report your suspicions as quickly as possible. Ultimately,  the  job of investigating  a potential incident  will be the  responsibility of the  local authorities  and  not yours as the parent.

3. What type of proof do I need?
In  cases of sexual abuse, tangible proof may be difficult to  obtain. Sometimes there will be evidence of abuse found on physical exam. However,  proof is not  needed  to  warrant  an  investigation.  If you suspect sexual abuse, contact  your doctor or the  police department immediately, whether or not you have proof.

4. Do I need to remove my child from the suspicious environment?
If there is a question of sexual abuse, it is best to remove your child from the suspicious environment.  Trust your instincts. Children have limited means to protect themselves. Removing your child from any potential further harm is the safest alternative.

5. Should my child be seen by any specific medical facility that would more legally substantiate my accusations or suspicions?
Your child’s pediatrician  is a good place to  start  for direction  on where to go for further evaluation if needed. In some cases a phys- ical  exam  could  provide  forensic evidence  for prosecution  of the abuser. The earlier the exam is done relative to the suspected abuse, the  greater the  chance  for obtaining  forensic evidence.  However, physical evidence  is only  found  in  a  small percentage  of exams.
There  are  strict  criteria  for maintaining  the  chain  of custody of evidence in rape or sexual abuse cases. This type of exam should be done by doctors who are experienced in pediatric sexual assault and the procedures for maintaining evidence. The exam is performed in a way that is as gentle and as noninvasive as possible. In some cases, an exam is required to treat  injuries, evaluate for possible internal injuries, or to test for sexually transmitted infections. If the victim is a girl who has begun to go through puberty, medication to prevent pregnancy may be offered.

6. Should I have my child seen by a therapist to counteract any possible psychological  damage?
Even without physical injury, sexual abuse can result in psychological damage with long-lasting effects. This can be true whether the abuse was a one-time event or a series of events over time. Counseling offers emotional support, a means for confronting the issues associated with abuse, and the opportunity for psychological healing. You can find a counselor in your area who specializes in childhood  sexual abuse by asking your child’s pediatrician  or  contacting  the  National  Child Abuse Hotline (800–422–4453).
KELLI WATKINS,  MD
Gynecology

SEIZURES

Definition:
Convulsions.
Author’s  Comment:  These  episodes are  always very  frightening. Fortunately, today there are newer medications available to treat the seizures that are quite effective when used by themselves or in combi- nation  with other  medications under strict doctor’s supervision. On the bright side, many children outgrow certain types of these convul- sive disorders.

1. What causes this condition, and how did my child develop it?
A seizure is an episode that is the result of excessive activity of a group of nerve cells in the brain. There are different types of seizures. They may consist of staring, turning the body to one side, or jerking of the arms and legs either on one side or both sides. What  type of seizure your child  has  is often  dependent  upon  the  cause for the  seizure. Sometimes in young children (six months to five years of age), fever may cause a seizure, but not all seizures associated with fever in young children  are  due  to  the  fever.  Increasingly today,  we  are  finding genetic causes that  can result in seizures. Sometimes these are inher- ited, and sometimes they represent a new mutation in the child.
Abnormalities in the structure of the brain can also cause seizures. These abnormalities can be the result of the brain not forming prop- erly, such as with focal cortical dysplasia or congenital malformations of the brain. Injury or trauma to the brain can cause scarring that can cause seizures. Infection, tumor, and stroke are also causes of seizures, although  fortunately tumors and strokes in children  are uncommon causes. Sometimes even a decreased blood flow to the  brain, as can occur with a fainting episode, may result in a brief seizure.

2. Can the type of seizures that my child has cause brain damage?
It is possible that with very long seizures (greater than fifteen to thirty minutes) or with very frequent seizures, brain injury may occur. But in most cases, there  is no evidence that  brief seizures, especially when infrequent, cause brain damage.

3. What tests are needed to better establish the cause? In many instances, if a child is taken to an emergency room following a seizure, he or she will have some blood and urine tests. If the child had previously been normal and healthy, these are usually normal. In most cases, the  doctor will want to  look at your child’s brain with either  a CT  or MRI head scan. In most instances if your child has previously been normal and healthy and recovers from the seizure, an MRI head scan is the preferred way to look at your child’s brain. Your doctor will also want to get a brain wave test (electroencephalogram). If your child  has a fever, the  doctor  may want  to  do a spinal tap (lumbar puncture).
4. What medicines are used to control the seizures? There are a number of medications available today to treat seizures. Decisions about  which  medication  is  best  for  your child  may  be dependent upon the type of seizure that your child has or the cause for the  seizure. Some  of the  older  medications  used to  treat  seizures include  phenobarbital,  phenytoin  (Dilantin),  carbamazepine (Tegretol), and valproic acid (Depakote).
In the last fifteen years, a number of new medications have come onto  the  market. These include  lamotrigine (Lamictal),  topiramate (Topamax),   levetiracetam  (Keppra),  gabapentin  (Neurontin),   and others. While  these newer medications have not  been shown to be more effective in  treating  seizures, in  some instances they  do offer safety advantages.

5. How long will my child need to stay on these medicines, and what are their potential side effects?
How long your child will be treated will depend on a number of factors including  whether  or  not  your child  is completely  seizure free on medication   and  the   underlying  cause  for  the   seizures. In  many instances, if a child’s seizures are completely controlled for between two and four years, it is reasonable to give the child a trial off medica- tion. About 65 percent of children will remain seizure free while 35 percent will relapse. Like any medication, there is always the poten- tial of side effects. In general, these medications are quite safe.
The most common side effect is sleepiness. This will usually go away once the child gets used to the medication. Other side effects, such as dizzi- ness, and behavioral problems can be seen. Other individual side effects may be seen with a particular medication, and your doctor will discuss that with you during the process of choosing what medication to use.
 

6. Do we need to consult with a neurologist?
In most cases, your pediatrician will want your child to see a neurolo- gist. There may be rare instances, such as if a child has a brief seizure associated with fainting or if your child has a seizure clearly associated with a fever, where a neurological consultation is not necessary.

7. When do you wish to see my child again for this condition?
If a neurological consultation  is not necessary, such as with a febrile seizure, a  specific follow-up examination  is not  necessary. If your doctor decides that it would be best for your child to see a neurologist, then the neurologist will discuss follow-up with you.

ROY D. ELTERMAN, MD
Neurology

SCOLIOSIS

Definition:
Curvature of the spine.
Author’s Comment: This condition needs to be followed closely by your child’s doctor or at a recommended orthopedic facility. Most children end up needing no treatment,  but occasionally the condi- tion  will progress to  the  point  where  more  aggressive therapy  is needed.

1. What causes this condition to occur in my child? Scoliosis occurs at different ages and for different potential  reasons. The common version of scoliosis is the type that occurs in preadoles- cence to adolescence, mainly in girls, and has no currently known cause. There is a genetic component of scoliosis, but there is no iden- tifiable gene or genetic test to determine if one is at risk for devel- oping scoliosis, other than family history.
Other  children  with scoliosis are born with abnormalities of the spine, but this is very uncommon. Some children will develop scol- iosis due to  an  abnormality  of the  spine development;  this  is also unusual as well, but it is looked for during the  examination  of the child. Other conditions that can cause scoliosis are underlying imbal- ances in the nervous or musculature system.

2. Is it hereditary?
The type of scoliosis that occurs in preadolescence and adolescence can be hereditary. If the family history is positive for scoliosis, the children should be screened. Other  disorders that  can cause scoliosis are abnor- malities of the spinal cord or brain and are not typically hereditary.

3. What is the natural progression of this disorder?
The natural progression is unpredictable. Some people have scoliosis that never changes, some have scoliosis that progresses a little bit and then  becomes static, some people have scoliosis that  progresses and requires treatment. Once a curve starts to develop, it can progress at a rate of one degree every month. So, over the course of an entire year, a curve can progress twelve degrees. Rarely can it progress more; it is a very variable condition. An important feature is that it can progress while the child is still growing.
Once the child has completed growth and the skeleton is mature, as long as the curve is less than forty degrees, it will not progress as an adult. If the curve is greater than forty degrees, there is a steadily increasing risk that the curve will progress, even after the child has completed growth. The size of the curve at the end of growth is an important feature to note because this determines the lifetime risk of progression.

4. What symptoms can occur because of this condition? Most scoliosis is completely asymptomatic and  causes no  pain  or discomfort at all in the early stage. Since there are no early symp- toms,  the   early  diagnosis  of  scoliosis  is  made  with  screening.
Scoliosis is common enough now that  school nurses screen for this, as well as the pediatrician upon a wellness examination  at the age of six years and beyond.
Symptoms can occur because of scoliosis, the most common being the  child holding one shoulder higher than  the  other  or sometimes having a feeling of imbalance. Once  the  curve becomes larger than forty degrees, back pain can start to occur. When  the spine curves to this degree, it puts abnormal forces on the joints of the back that can cause pain. Sometimes the ribs will literally bend over and touch the pelvic bone, which can cause discomfort. Curves that progress beyond sixty degrees can start to cause measurable changes in lung function. Curves that progress beyond eighty degrees can cause changes in heart function and become life threatening.

5. How will this condition limit my child’s participation in athletics?
Scoliosis itself does not  interfere with activities. Children  or adults who have scoliosis can be active and do any activity. In fact, there are good reasons to be physically active to keep your child’s muscles in balance  and  his or her  posture well aligned. To  that  end,  physical activity  is encouraged.  Participation  in  athletics  is not  limited  by having scoliosis.

6. What is the treatment for this disorder?
The  treatment  depends on the  degree of the  curvature. Curves that are less than  twenty degrees are just observed and checked periodi- cally with repeat physical examinations and X rays. If the curve of the spine becomes larger than  twenty degrees, the  degree of maturity of the spine and pelvis are used to judge the risk or further progression.
Based on this knowledge, a decision for bracing may be recommended. In  children  who have  a lot  of growth remaining  whose curves are larger than twenty degrees, bracing may well be recommended.
There  are two options for bracing, either  full time or nighttime. The Boston brace is the full-time brace, also referred to as TLSO. The Boston brace is considered full-time bracing and needs to be worn for at least eighteen hours a day. With  some curves that  affect only the lower back, there is an option for wearing a nighttime brace known as a Charleston brace; this is worn only during sleeping. There are only a few curves where this brace can be used.
Physical therapy has not been objectively shown to improve the condition,  but  it  certainly  helps  from a  sense of well-being and overall good health.  I believe it  is important  to  learn  good back mechanics and posture. A short course of physical therapy to teach these behaviors is helpful. Along the same line, other activities that help teach posture, balance, and form, such as dance or martial arts, can also be helpful.
The next level of treatment  is surgery. Surgery is reserved for chil- dren whose curves are progressing despite the use of a brace and whose curves are  larger than  forty degrees. The  main  reason  for recom- mending  scoliosis surgery is that  curves that  are  larger than  forty degrees are likely to  continue  to  increase as time  passes. In  many respects the sooner that scoliosis surgery is accomplished to straighten the spine and keep it from curving, the easier it is technically to do the  surgery. The  surgery itself has a fairly lengthy recovery time; it takes almost three months to recover from having the spine straight- ened and fused. Scoliosis surgery can be done into the adult years, but with  age, the  spine  is stiffer and  the  potential  for difficulties and complications is greater.
The surgery itself involves straightening the spine and holding the spine straight with a series of metal rods placed into the spine to keep it straight while the bone fuses. The tradeoff is that it takes the spine that  is flexible and curved and changes it to a spine that  is straight, fused, and stiff. The decision to proceed with surgery does not need to be rushed. There is plenty of time to seek a second or third opinion. This is a major, potentially life-threatening surgery that involves a lot of blood loss and a long period of recovery. On average, it takes most people six weeks from the surgery date to feel comfortable again and almost three months to regain energy.

7. How often will X rays be required to follow its progress?
This depends on the age of the person upon diagnosis, the maturity of the spine, and the degree of curve. Since the fastest rate of progression of a curve is roughly one degree per month,  most orthopedists will perform X rays every six months to follow curve progression. If rapid curve progression is suspected, the X rays can be requested every four months. Since X rays involve radiation, it is important to try and keep the X rays to those that are needed and not more.
Upon the initial diagnosis, it is important to get an X ray of the spine looking at it from the front and side. To just follow the scoliosis itself, a front view X ray only is needed; this cuts the radiation dose in half. Doing another X ray to take a look at the spine from the side really only needs to be done again if surgery is being contemplated for a final picture of the spine. X rays can be done to show the spine with shielding of important organs. In young females, the breasts can be shielded with special lead aprons. The gonads in males can also be shielded. If the X ray technician does not offer to do this, it is important to request this shielding.
 
8. Are there any exercises that can be performed to strengthen the back and to slow down the progression of this condition?
There are no studies on the  value of exercise in slowing down scol- iosis. Regardless of the condition,  it is important  to learn good back posture, training, and mechanics. To this end, seeing a physical ther- apist for some back exercises is useful. Other activities that are useful for controlling the back and helping alignment are yoga, dance, and martial arts.

9. What role does surgery play in the correction of this disorder?
Surgery  plays  the   ultimate  role  in  straightening  the   spine  once the spine has curved more than forty degrees. Surgery straightens the spine and removes the  curve. To keep the  curve from coming back, the  spine is straightened,  metal  rods are inserted,  and  the  spine is fused. As a result, the spine is taken from a flexible curve to a rigid, straight spine. The  results of spine surgery can result in mechanical problems of the  back  decades later.  Further  back  surgery may be required.

10. Do we need to be referred to a doctor or institution that specializes in this condition?
Like any medical condition, one should see a physician and/or institu- tion trained to take care of that particular disorder. Pediatric orthope- dists are trained to take care of scoliosis. Only a small percentage of adult  spine  surgeons perform scoliosis surgery, and  they  treat  the patients as adults, not young, growing people. There are some centers that specialize in scoliosis surgery only and some that treat a variety of orthopedic issues. If you have any questions regarding the physician’s training or experience, please ask. The Internet  is very useful tool in this regard as well.

11.  What kind of follow-up will be needed in the future?
The follow-up depends on the age of your child, the size of the curve, and  the   potential   for  curve  progression.  In  general,  scoliosis is followed until (1) the child completes growth and the curve does not require treatment  or (2)  the  child continues  to grow and the  curve grows to the point of requiring treatment.  Once the child’s spine has completed growth, no further follow-up studies are needed. If scoliosis reaches the point of requiring surgery, once the spine has been fused there  is a one-year follow-up. If there  have  been  no  complications after one year, no further follow-up is needed.
W. BARRY HUMENIUK,  MD
Orthopedics

SCHOOL PHOBIA

Definition:
Fear of going to school.
Author’s Comment: This condition  can cause much frustration and fear on the part of the parent. The family should work closely with the doctor and other  recommended specialists to help get through  this problem area.

1. What is causing my child to act in this manner? School phobia is a specific subtype of separation anxiety disorders and is often caused by parental ambivalence or anxiety regarding a separa- tion  from their  children.  Parents will struggle to soothe their  child when  they  are  dealing  with  their  own  intense  anxiety,  and  this continues to worsen the cycle of anxiety for that child until he or she begins refusing to go to school or to sleep alone. In some cases, school phobia could be an early sign of possible future development of gener- alized anxiety or socializing disorder.

2. Is there anything that I, as a parent, am doing that is affecting the situation adversely?
Parents can often, unwittingly, contribute to separation difficulties through their efforts to care for and to protect (or overprotect) their children. Examples would include allowing their child to sleep in their bed or to stay home when he or she begins to experience physical symptoms such as headaches  or stomachaches.  Often  a parent  will give in when a child throws a tantrum prior to or at the beginning of the school integration process.

3. Should I discuss the situation with the teachers and get them involved in the treatment  program?
Yes, involvement of school officials and teachers can be key in helping a child overcome his or her school phobia early and get settled in the classroom. This  allows the  parents  to  leave  the  child  behind  and provides the necessary comfort during that separation. It is important that the process of dropping off children be brief and that it has been explained  so  that   the  children  can  already  anticipate   that   early morning transition with the identified school official.

4. Are there any further diagnostic steps that need to be taken to uncover any possible underlying problems?
First and  foremost, it  is important  to  be sure that  when  the  child complains of aches and pains, they are not legitimate physical prob- lems. Often  headaches  or stomachaches  will occur on  the  Sunday evening before school begins or during early morning routines in addi- tion to the school setting.

5. What else can be done to make this situation better?
Often both parents have to be involved in the process of helping chil- dren overcome their school phobia. Many times one parent has inad- vertently slipped into the “overprotective” mode and needs assistance in setting firm limits with his or her child.

6. Should we consult a psychologist or a psychiatrist? A psychologist or psychiatrist should only be consulted if the problems persist or tend to escalate in spite of these behavioral interventions. A psychologist could certainly help to identify specific themes that may be occurring that  are contributing  to  the  school phobia.  Examples would include conflicted family dynamics or the possibility that there is a legitimate stressor in the school causing the child’s phobia (such as a bully or other negative peer or student–teacher  interactions).  A psychiatrist would be consulted if one is considering the possibility of a  more  significant  anxiety  or  depressive disorder that  may require medication intervention.

7. What kind of follow-up will be needed with you? The  pediatrician and/or psychologist/psychiatrist will likely set defi- nite  follow-up dates to help guide you and your child through  this challenging period in your lives.
DANTE  BURGOS, MD
Psychiatry