Croup

Definition:
Croup is a viral infection which occurs in the fall and winter.  Typically it begins with a runny nose and a loud barky or honking cough.  Most croup is caused by a virus called Para influenza, the same virus that causes laryngitis in older children and adults. It causes swelling of the vocal cords, voice box, and the breathing tube.  The fever and barky cough may last 5 days or more; and is typically worse at night. The virus can be spread from person to person like a cold.  Hand washing will limit the spread.  Cough medicine and antibiotics do not help croup.

Helpful Home Hints:
1. Keep your childs room humidified for 24 hours a day or hang some wet sheets or towels in the room (as they dry, the room will become humidified).
2. Encourage your child to drink clear fluids and less milk.
3. Do not smoke near or around your child.
4. If your child has fever or a sore throat; acetaminophen will help.

Croup Attacks:
Some children have croup attacks which consist of coughing spells accompanied by a sound which occurs while breathing in.  These can usually be controlled by one of the following:

1. Have the hot water running in the shower, with the bathroom door closed. While it is steaming up proceed to step
2. Open the freezer door and have your child breath in the mist from the freezer; if this does not allow significant improvement within 5-10 minutes proceed bring your child into the bathroom; which should be steamed up.  If this does not allow improvement within 5-10 minutes; proceed to step
3. Wrap your child in a blanket and take a walk in the cool night air.

Call Immediately if:

1. The above measures do not work.
2. Your child is breathing fast, has blue lips or looks uncomfortable.
3. Your child is drooling or not swallowing right.
4. Your child is unable to lie down comfortably and wants to sit up.
5. Your child is unable to bend his neck forward.
6. If your child could be choking on something that was put in the mouth.
7. It started suddenly after taking a medication, an insect bite or new food.
8. The temperature is greater than 103 degrees.
9. Your child is not drinking well and has not been urinating at least 3 times in the last 24 hours.

Spasmodic croup:
Spasmodic croup is related to infectious croup. However, its cause and symptoms are slightly different.  Most cases of spasmodic croup are caused by an allergic reaction. Viruses may trigger the allergic reaction in some cases. In rare cases, the airway irritation seems to be triggered by regurgitated (refluxed) stomach acid.

Spasmodic croup is a type of croup that is not infectious.  Differences include no fever and the symptoms typically last a shorter time than is the case for infectious croup.  Currently in the United States, infectious and spasmodic croup together account for about 15 percent of all respiratory illnesses seen by pediatricians. Infectious croup is most common in children younger than age 6, and boys are affected slightly more often than girls. Spasmodic croup usually strikes children who are older.

Instead of having a fever or cold symptoms, the child with spasmodic croup often looks fairly healthy before coughing starts. The rest of the family is usually not sick with any respiratory illness. Episodes of cough and loud, raspy breathing generally start without warning, often in the middle of the night. These symptoms often will pass if the child is carried into cool night air or taken into a steamy bathroom. Symptoms from spasmodic croup typically improve within a few hours, although it is common for the symptoms to reappear several nights in a row.

In most cases, we diagnose spasmodic croup based on your child’s recurrent history, symptoms and physical findings.

Treatment for spasmodic croup is similar to viral croup.

Other factors to consider:

Cover mattress and pillow allergy cover.
Limit dust collectors, like dressers, stuffed animals

The Today Show was recently at Four Seasons Pediatrics filming a segment on vaccines and our vaccine policy.  This segment should be aired September 1st between 8-9 am (tentative to being pre-empted by breaking news).  We will tweet any updates about this. 

Four Seasons Pediatrics Twitter page can be found at:

http://twitter.com/#!/fspedsGet

Get updates by texting “follow fspeds” to 40404.    We use twitter for quick alerts for those who prefer mobile alerts:  e.g. Flu vaccine arrives.

Dr. Miller Comment:

Over the past few years, we were seeing a decline in the number of children being vaccinated, with an increase in delaying vaccines, splitting vaccines and picking and choosing which vaccines to comply with.   We believe that the diseases that we vaccinate against have not gone away.  They can and will and have made comebacks.  Witness the Pertussis outbreak with more cases than than California has seen in 50 years and 10 infant deaths under 3 months of age.  There are more cases of measles that have been seen since the 90’s. 

It is important to understand the concept of “Herd Immunity”.  Approximately 95-97% of children will develop immunity to any given vaccine.  The other 3-5% are still protected WHEN approximately 90% of the population is vaccinated.  When most of us are vaccinated, this LIMITS the spread of disease, making it harder for the disease to find the person(s) who never developed immunity.   When the community vaccinates less, we all are affected.

The providers in our practice, felt it was important to protect this concept of herd immunity within our practice.  Our policy affected only 0.5% of our practice.   The small number of people who do not vaccinate, refer to vaccines as a toxin or poison.  We found that studies that are well done, along with our recommendations will not affect their views on vaccines.  They are very loud and well organized and the media tends to focus on them.  This leads to much confusion to the majority of parents who really want to do what’s best for their child, but are paralyzed from making a decision that is best based on the thousands of studies that show vaccines are safe and effective. 

Our Vaccine Policy was developed in February 2010 after much thought and consideration.  It is not an “In Your Face” Policy and many parents may not remember the letter we sent out at that time.  Most parents are not aware of the policy, as they choose to vaccinate.  This policy affected 1/2 of 1% of our practice when it was enacted.  We want to assure you that we listen to your views and concerns.  At that same time, our first priority is to do all we can to prevent illness in the children in our practice.  We wanted to make a statement that shows how confident we are in our view that vaccines ARE the most important medical treatment that we can recommend for your child, and that you can do as a parent.  The sickest children come to see us in the doctors office.  The doctors office has been and will be the source for spread of some of these infections.  We  do our best to reduce your chance of infection in our office.  We have two separate waiting rooms.  You will also find hand sanitizer stations throughout our office.   Despite these precautions, parents will want to bring their children in when they are sick.   In the end our vaccine policy is not about those who do not vaccinate.  It is about those who do.  Children are our most precious assets.  We at Four Seasons Pediatrics, want to do all we can to protect them.  Our vaccine policy is consistent  with this principle.

Sincerely,

Dr. Harry Miller and Dr. Kimberly Elmer

September 1st Update:

The link to the story on the Today Show is here:

http://today.msnbc.msn.com/id/26184891/vp/44355062#44355062

Swimming Issue Calls

We are receiving a high number of phone calls related to swimming issues.  These issues involve:

• Swimmer’s Ear
• Chemical Conjunctivitis related to swimming
• Bathing Suit Irritation leading to urination symptoms

Dr. Miller Comment: 

Swimmer’s Ear: Due to the elevated outdoor temperatures and prolonged swimming we are seeing high numbers of children with these issues.   Please consider using preventive ear drops (1 part of rubbing alcohol with 1 part white vinegar).  Apply 2-3 drops in each ear (let sit for 5 seconds and drain); after swimming every day.  

Pool (Chemical) Conjunctivitis: Chemical conjunctivitis occurs because a chemical from the pool is irritating the eye.  Due to the high temperatures and prolonged swimming time, we suggest wearing goggles to prevent this.  If it occurs, it will cause a red eye and or discharge from the eye, especially upon awakening in the morning.  If this occurs, please soothe the eye with cotton balls soakedwith lukewarm water.  Give diphenhydramine for itching and swelling.  Avoid contact with water until this improves.  If you child must go swimming, wear goggles in the water. 

Bathing Suit Irritation:  Prolonged contact with a wet bathing suit (and or sand in the suit) may irritate the genital area.   Wet swimming suits (many of which are synthetic and do not breath well) may cause irritation, frequent urination, and painful urination.  We suggest getting out of the suit during breaks in swimming.  If irritation occurs, give a sitz bath.  This consists of soaking in a tub of lukewarm water with 2 tablespoons of baking soda.  Sit for 20″ twice during the first day and once the day after.  Give real cranberry juice.  This makes the urine less irritating.  If there is itching or the rash persists for more than 24 – 48 hours, apply clotrimazole (brand name lotrimin) cream to the area twice a day for 10-14 days.  This will treat any yeast component that keeps the irritation going.  If your child has a fever, this may mean a urinary tract infection.  Please call so that we can assess that possibility.

OVERVIEW – SWIMMER’S EAR

Swimmer’s ear is a condition that occurs when the ear canal becomes irritated. The ear canal is the part of the ear that leads from the outer ear to the ear drum (figure 1).  “Swimmer’s ear” is the name for external otitis that occurs in a person who swims frequently.

RISK FACTORS

Several factors can increase your risk of swimmers ear.

Cleaning the ear canal removes ear wax. Ear wax serves to protect the ears from water, bacteria, and injury. Excessive cleaning or scratching can injure the skin, potentially leading to infection.

• Swimming on a regular basis removes some of the ear wax, allowing water to soften the skin. Bacteria, which normally live in the ear canal, can then enter the skin more easily.
• Wearing devices that block the ear canals, such as hearing aids, headphones, or ear plugs, can increase the risk of external otitis (if worn frequently) by injuring the skin.

SYMPTOMS

The most common symptoms are:

• Pain in the outer ear, especially when the ear is pulled or moved
• Itchiness of the ear
• Fluid or pus leaking from the ear
• Difficulty hearing clearly

DIAGNOSIS

If you think that your child could have swimmer’s ear, you should call us to make an appointment.  We will examine the outside and inside of your ear to confirm the diagnosis.

TREATMENT

Treatment aims to reduce pain and eliminate the infection. Most people with external otitis can be treated at home.  In some cases, we will flush out your ear with water and hydrogen peroxide before you begin treatment; this speeds healing by removing dead skin cells and excess ear wax.

Ear drops — Ear drops are usually prescribed to reduce pain and swelling caused by external otitis. It is important to apply the ear drops correctly so that they reach the ear canal:

• Lie on your side or tilt your head towards the opposite shoulder.
• Fill the ear canal with drops.
• Lie on your side for 20 minutes or place a cotton ball in the ear canal for 20 minutes.
• Finish the entire course of treatment, even if you begin to feel better within a few days.

You should begin to feel better within 36 to 48 hours of starting treatment. If your pain worsens or does not improve within this time period, call us.

Pain medication — If you have bothersome ear pain, you can take a non-prescription pain medication.

Avoid getting ears wet — During treatment, you should avoid getting the inside of your ears wet. While showering, you can place a cotton ball coated with petroleum jelly in the ear. However, you should not swim for 7 to 10 days after starting treatment (or until your child has NO pain with wiggling the ear and pressing on the part of the skin that protrudes from the ear).  Avoid wearing hearing aids and in-ear headphones until pain improves.

PREVENTION

The old saying, “Don’t put anything smaller than your elbow in your ear” to clean the ear is true. The ear is self-cleaning; fingers, towels, cotton-tipped applicators, and other devices should not be used to clean the inside of the ears.

If you swim frequently, we recommend the following tips to reduce the chance of developing swimmer’s ear:

• Shake your ears dry after swimming
• After a day of swimming apply 2-3 drops of a preventive solution.  This can be purchased, or you can make it up yourself by adding 1 part of rubbing alcohol to 1 part of white vinegar.  Mix this into a eye dropper bottle and keep it in your swim bag.

The United States is experiencing a high number of reported measles cases in 2011, many of which were acquired during international travel. From January 1 through June 17 this year, 156 confirmed cases of measles were reported to CDC.

This is the highest reported number since 1996. Most cases (136) were associated with importations from measles-endemic countries or countries where large outbreaks are occurring.  The imported cases involved unvaccinated U.S. residents who recently traveled abroad, unvaccinated visitors to the United States, and people linked to these imported cases. To date, 12 outbreaks (3 or more linked cases) have occurred, accounting for 47% of the 156 cases. Of the total patients, 133 (85%) were unvaccinated or had undocumented vaccination status.  11 (8%) had received 1 dose of measles-mumps-rubella (MMR) vaccine.
  
Measles was declared eliminated in the United States in 2000 due to our high 2-dose measles vaccine coverage, but it is still endemic or large outbreaks are occurring in countries in Europe (including France, the United Kingdom, Spain, and Switzerland), Africa, and Asia (including India). The increase in measles cases and outbreaks in the United States this year underscores the ongoing risk of importations, the need for high measles vaccine coverage, and the importance of prompt and appropriate public health response to measles
cases and outbreaks.

Measles is a highly contagious, acute viral illness that is transmitted by contact with an infected person through coughing and sneezing. After an infected person leaves a location, the virus remains contagious for up to 2 hours on surfaces and in the air. Measles can cause severe health complications, including pneumonia, encephalitis, and death.

Four Seasons Pediatrics follows the CDC recommendations.  These recommendations may affect you if you leave the United States and include the following:

For those who travel abroad, CDC recommends that all U.S. residents older than 6 months be protected from measles and receive MMR vaccine, prior to departure.
    –Infants 6 through 11 months old should receive 1 dose of MMR vaccine before departure. 
    –Children 12 months of age or older should have documentation of 2 doses of MMR vaccine (separated by at least 28 days).
    –Teenagers and adults should have documentation of 2 appropriately spaced doses of MMR vaccine.

Infants who receive a dose of MMR vaccine before their first birthday should receive 2 more doses of MMR vaccine,  the first of which should be administered when the child is 12 through 15 months of age and the second at least 28 days later.

Comment from Dr. Miller:

At the present time - for children not traveling abroad, there are no changes to the vaccine schedule posted on our website.   For children from 6 months to 15 months, who will be traveling abroad, we recommend getting one to two MMR immunizations as noted above.  These are new recommendations based upon the current outbreak.   This outbreak and the current outbreak of whooping cough highlight the need to have timely vaccination.   Our practice noted less people choosing to vaccinate in 2010.  Now more than ever, it is important to vaccinate, and to vaccinate in a timely basis.

Four Seasons Pediatics would like to announce a recent change in Infant Tylenol dosing.  This change is consistent with FDA recommendations to offer a single concentration of acetaminophen for children. 

Old INFANT DROPS: 80 mg / 0.8 ml

New INFANT SUSPENSION: 160 mg / 5 ml

Current CHILDREN’S LIQUID: 160 mg / 5 ml

For more information see the link below:

McNeil’s Link for Frequently Asked Questions

Four Seasons Comment:

This is an industry wide initiative.  There will continue to be the old concentration of infant drops (in generic brands) while the new concentration of TYLENOL brand acetaminophen hits the shelves.  The transition for other products will continue through 2012.  This change aims to reduce possible medication errors.  We are concerned that the availability of the new concentration with the words “Infant” may increase dosing errors.  Please refer to the dosing chart on our website and match the concentration of your acetaminophen to your child’s weight. 

You may access our NEW web portal at the following link:

Patient Portal Login

Using the portal you will be able to:

• Confirm and Update all your information on file with the practice
• Email with Four Seasons Pediatrics, securely and efficiently
• View your Personal Health Records
• Receive and review your lab results and statements
• Request for appointments, see date and time of upcoming appointments
• Request a prescription refill from pre-populated list of currently refillable prescriptions

To get started, ask about a user name and password in our office, or call us to get registered.

Please complete a review of your electronic health record.  In December we completed a transition to a new electronic record.  We have imported your information to the new system.  Please verify each area to be sure we have accurately imported all information.  This includes the Problem List (your list of active medical problems, including active chronic problems and episodes of ear infections as well as strep throats), Surgeries, Hospitalizations, Medications, Allergies, Immunizations and Family History.  

Intake Forms

If you wish to update any information on your Medical History, Family History or Social History, please feel free to fill out and submit these forms.

Appointments

You may view appointments that are scheduled and upcoming.  In addition you may view alerts that show when appointments are due.   

Labs and Radiology Studies

Most normal lab and radiology studies will be released to our web portal.  You will recieve an email that you have a new result available on the portal.  Please log in to review our interpretation of the results and the actual results.  For example, you will know that your cholesterol is normal, and the cholesterol number (158 for example).  You will also be able to compare the previous result if a repeat is done. 

Billing Questions

Feel free to email any billing inquiries to our billing department.  Brian Koehler and Barbara Miazga will address questions you send in to us.

We hope you will enjoy this new phase of electronic communication.  We feel that it will allow you to be a more effective partner in your care. 

Four Seasons Pediatrics

Ticks continue to be widespread at this time. Deer ticks are active in April through July. It is these ticks that transmit Lyme Disease. We recommend that you check your child daily if they are outside. Most ticks can be found at the edge of properties in wooded areas. The overall risk of Lyme Disease from a TICK is less than 1-2%. For a full description of Lyme Disease, see the section of our website entitled “Read Past Newsletters” at the bottom of the homepage. Prevention is the best approach for Ticks (use a repellant like Repel – plant based lemon eucalyptus or 3M Ultrathon Insect Repellant 8 – both provide protection for more than 8 hours according to Consumer Reports). We recommend one application rather than multiple applications. In addition, check you child daily for TICKS and remove them carefully. We recommend using a TICK remover or tweezers. Gently pull up enough to tent the skin and wait for the TICK to detach. (Please have a seat and be patient, the Tick will usually release on its own in 1-4 minutes – do not attempt to pry the Tick off as it will likely break). If you break the Tick, the embedded piece does not need to be removed, it will come out on its own and does not increase the risk for lyme disease. Other preventive measures include: 1) wear light colored clothing and tuck pants into socks and shirts into pants 2) after removing a tick, disinfect the bite with soap, rubbing alcohol or hydrogen peroxide. See below for more information about ticks and lyme disease.

SUNBURN PREVENTION

SUNSCREEN DO’S AND DONT’S:

DO SLATHER ON ENOUGH. People typically use about 25 to 75 percent less sunscreen than they should, according to studies. Be sure to apply 2 to 3 tablespoons of sunscreen for maximum full-body protection of an adult.

DON’T USE EXPIRED SUNSCREEN. Sunscreens aren’t required to post expiration dates as long as manufacturers can prove that they’ll last for at least three years. So if your sunscreen doesn’t have an expiration date, be sure to write the date on it in permanent marker when you buy it. And remember to discard it after three years.

DON”T MISS THESE SPOTS. Lips, ears, feet, hands, bald spots, and the back of your neck are all areas that are easy to forget.

DO REAPPLY REGULARLY. The maximum protection time of a sunscreen is based on the number of minutes it takes for you to burn multipled by the SPF number. So say you have fair skin and burn within 20 minutes and you’re using enough of an SPF 15 sunscreen. That will give you about five hours of protection. Nevertheless, reapply sunscreen every two hours. If you’re swimming or doing lots of sweating on the beach or the tennis court, you may want to reapply it more often than that. Also, keep in mind that reapplying sunscreen after you’ve exceeded your maximum protection time doesn’t mean that you can safely stay in the sun longer. Instead, be sure to cover up or get out of the sun!

Products to consider:

We tend to get more calls this time of year for rashes after being in the sun with sunscreen. As many products have increased their SPF, they have added more chemicals to create the higher SPF. This has meant more rashes for children. Neutrogena and Aveeno both have excellent UVA/UVB coverage at SPF’s of 15 to 30 or higher. Higher is not better since some products (like Neutrogena) get 100% protection (if you reapply) and you only may increase the chance of a rash with a higher SPF. There are also more options for SPF clothing than ever before. Coverage with this clothing will give protection to areas that will not need to be re-coated with sunscreen. Just google “SPF clothing for children” or “babies” to see options. SPF clothing for a baby is ideal. For babies under 6 months the only sunscreen made for this age is Blue Lizard. We recommend SPF clothing as described above, a brim hat and avoidance during the peak high UV rays (10 am to 3 pm). If you must use a sunscreen, for this age, limit to the areas you cannot cover.

Patient information: What to do after a tick bite

Authors: Anna R Thorner, MD – Deputy Editor — Infectious Diseases – Instructor in Medicine, Harvard Medical School. Allen C Steere, MD – Editor — Lyme Disease – Professor of Medicine, Harvard Medical School. Leah K Moynihan, RNC, MSN – Associate Editor — Patient Information. ©2010 UpToDate, Inc.

TICK BITE OVERVIEW

There are many different types of ticks in the United States, some of which are capable of transmitting infections. The risk of developing these infections depends upon the geographic location, season of the year, type of tick, and for Lyme disease only, how long the tick was attached to the skin.

While many people are concerned after being bitten by a tick, the risk of acquiring a tick-borne infection is quite low, even if the tick has been attached, fed, and is actually carrying an infectious agent. Ticks transmit infection only after they have attached and then taken a blood meal from their new host []. A tick that has not attached (and therefore has not yet become engorged from its blood meal) has not passed any infection. The risk of acquiring Lyme disease from an observed tick bite, for example, is only 1.2 to 1.4 percent, even in an area where the disease is common.

If a person is bitten by a deer tick (the type of tick that carries Lyme disease), a healthcare provider will likely advise one of two approaches:

Observe and treat if signs or symptoms of infection develop

Treat with a preventive antibiotic immediately – only under certain circumstances

There is no benefit of blood testing for Lyme disease at the time of the tick bite; even people who become infected will not have a positive blood test until approximately two to six weeks after the infection develops (post-tick bite).

The history of the tick bite will largely determine which of these options is chosen. Before seeking medical attention, the affected person or household member should carefully remove the tick and make note of its appearance. Only the Ixodes species of deer tick causes Lyme disease.

HOW TO REMOVE A TICK

The proper way to remove a tick is to use a set of fine tweezers and grip the tick as close to the skin as is possible. Do not use a smoldering match or cigarette, nail polish, petroleum jelly (eg, Vaseline), liquid soap, or kerosene because they may irritate the tick and cause it to behave like a syringe, injecting bodily fluids into the wound.

The proper technique for tick removal includes the following:

Use fine tweezers to grasp the tick as close to the skin surface as possible.

Pull backwards gently but firmly, using an even, steady pressure. Do not jerk or twist.

Do not squeeze, crush, or puncture the body of the tick, since its bodily fluids may contain infection-causing organisms.

After removing the tick, wash the skin and hands thoroughly with soap and water.

If any mouth parts of the tick remain in the skin, these should be left alone; they will be expelled on their own. Attempts to remove these parts may result in significant skin trauma.

AFTER THE TICK IS REMOVED

Tick characteristics — It is helpful if the person can provide information about the size of the tick, whether it was actually attached to the skin, if it was engorged (that is, full of blood), and how long it was attached.

The size and color of the tick help to determine what kind of tick it was;

- Ticks that are brown and approximately the size of a poppy seed or pencil point are deer ticks. These can transmit Borrelia burgdorferi (the bacterium that causes Lyme disease) and a number of other tick-borne infections. Deer ticks live primarily in the northeast and mid-Atlantic region (Maine to Virginia) and in the midwest (Minnesota and Wisconsin) region of the United States, and less commonly in the western US (northern California).

- Ticks that are brown with a white collar and about the size of a pencil eraser are more likely to be dog ticks (Dermacentor species). These ticks do not carry Lyme disease, but can rarely carry another tick-borne infection that can be serious or even fatal (Rocky Mountain spotted fever).

- A brown to black tick with a white splotch on its back is likely an Amblyomma americanum (Lone Star tick; named after the white splotch). This species of tick has been reported to spread an illness called STARI (southern tick-associated rash illness). STARI causes a rash that is similar to the erythema migrans rash, but without the other features of Lyme disease. Although this rash is thought to be caused by an infection, a cause for the infection has not yet been identified. This type of tick can also carry and transmit another infection called human monocytic ehrlichiosis.

A tick that was not attached, is still flat and tiny and is not full of blood, and was easy to remove or just walking on the skin, could not have transmitted Lyme disease or any other infection since it had not yet taken a blood meal.

Only ticks that are attached and have finished feeding or are near the end of their meal can transmit Lyme disease. After arriving on the skin, the tick that spreads Lyme disease usually takes 24 hours before feeding begins. Even if a tick is attached, it must have taken a blood meal to transmit Lyme disease. At least 36 to 48 hours of feeding is required for a tick to have fed and then transmit the bacterium that causes Lyme disease. After this amount of time, the tick will be engorged (full of blood). An engorged tick has a globular shape and is larger than an unengorged one.

The organism that causes Lyme disease, B. burgdorferi, lies dormant in the inner aspect of the tick’s midgut. The organism becomes active only after exposure to the warm blood meal entering the tick’s gut. Once active, the organism enters the tick’s salivary glands. As the tick feeds, it must get rid of excess water through the salivary glands. Thus, the tick will literally salivate organisms into the wound, thereby passing the infection to the host.

Need for treatment — The clinician will review the description of the tick, along with any physical symptoms, to decide upon a course of action. The Infectious Diseases Society of America (IDSA) recommends preventive treatment with antibiotics only in people who meet ALL of the following criteria:

Attached tick identified as an adult or nymphal I. scapularis (deer) tick

Tick is estimated to have been attached for =36 hours (based upon how engorged the tick appears or the amount of time since outdoor exposure)

Antibiotic treatment can begin within 72 hours of tick removal

The local rate of tick infection with B. burgdorferi is =20 percent (known to occur in parts of New England, parts of the mid-Atlantic states, and parts of Minnesota and Wisconsin)

The person can take doxycycline (eg, the person is not pregnant or breastfeeding or a child <8 years of age)

If the person meets ALL of the above criteria, the recommended dose of doxycycline is a single dose of 200 mg for adults and 4 mg/kg, up to a maximum dose of 200 mg, in children = 8 years. If the person cannot take doxycycline, the IDSA does not recommend preventive treatment with an alternate antibiotic for several reasons: there are no data to support a short course of another antibiotic, a longer course of antibiotics may have side effects, antibiotic treatment is highly effective if Lyme disease were to develop, and the risk of developing a serious complication of Lyme disease after a recognized bite is extremely low.

MONITORING FOR LYME DISEASE

Many people have incorrect information about Lyme disease. For example, some people are concerned that Lyme disease is untreatable if antibiotics are not given early (this is untrue; even later features of Lyme disease can be effectively treated with appropriate antibiotics). Many local Lyme disease networks and national organizations disseminate unproven information and should not be the sole source of education about Lyme disease. Reputable sources are listed below see below.

Signs of Lyme disease — Whether or not a clinician is consulted after a tick bite, the person who was bitten (or the parents, if a child was bitten) should observe the area of the bite for expanding redness, which would suggest erythema migrans (EM), the characteristic rash of Lyme disease

The EM rash is usually a salmon color although, rarely, it can be an intense red, sometimes resembling a skin infection. The color may be almost uniform. The lesion typically expands over a few days or weeks and can reach over 20 cm (8 inches) in diameter. As the rash expands, it can become clear (skin-colored) in the center. The center of the rash can then appear a lighter color than its edges or the rash can develop into a series of concentric rings giving it a “bull’s eye” appearance. The rash usually causes no symptoms, although burning or itching has been reported.

In people with early localized Lyme disease, EM occurs within one month of the tick bite, typically within a week of the tick bite, although only one-third of people recall the tick bite that gave them Lyme disease. Components of tick saliva can cause a short-lived (24 to 48 hours) rash that should not be confused with EM. This reaction usually does not expand to a size larger than a dime.

Approximately 80 percent of people with Lyme disease will develop EM; 10 to 20 percent of people have multiple lesions. If EM or other signs or symptoms suggestive of Lyme disease develop, the person should see us for proper diagnosis and treatment.

Web Sites that are reputable:

National Library of Medicine: http://www.nlm.nih.gov/medlineplus/lymedisease.html

National Institute of Allergy and Infectious Diseases: http://www3.niaid.nih.gov/topics/lymeDisease

National Center for Infectious Diseases: http://www.cdc.gov/ncidod/dvbid/lyme/

American Lyme Disease Foundation, Inc: http://www.aldf.com/faq.shtml

• All infants and toddlers should ride in a rear-facing car safety seat (CSS) until they are 2 years of age or until they reach the highest weight or height allowed by the manufacturer of their car safety seat
• All children 2 years of age or older, or those younger than 2 years who have outgrown the rear-facing weight or height limit for their car safety seat, should use a forward facing car safety seat with a harness for as long as possible, up to the highest weight or height allowed by the manufacturer of their child safety seat
• All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt positioning booster seat until the vehicle lap and shoulder seat belt fits properly, typically when they have reached 4 feet 9 inches and are between 8 and 12 years of age
• When children are old enough and large enough to use the vehicle seat belt alone, they should always use lap and shoulder seat belts for optimal protection
• All children younger than 13 years, should be restrained in the rear seats of vehicles for optimal protection

Dr. Miller Comment:  It is important to understand that each transition to the next level is associated with a lower level of protection.  Therefore, you should delay this transition as long as possible.  When purchasing a child safety seat, we recommend that you choose one with a higher height and weight allowance.  This will allow you to keep your child longer in the rear facing than forward facing car safety seat.   Purchasing a forward facing car safety seat (with a harness) with the highest weight and height limits will allow you to keep your child in this seat longer.  The harness will be safer than a booster seat.  Purchasing a booster seat and keeping your child in one until 4′ 9″ and between 8-12 years, will keep your child safer than moving to a traditional safety belt.  Finally keeping your child in the rear seat until age 13 will optimize safety over using a front seat.   The key is to keep your child in the safer level as long as possible.  While you and your child may look forward to the new transition and while the law may allow transitions at an earlier time, we will all agree that we want to keep our children as safe as the evidence shows us. 

Dr. Miller comment: There have been several studies regarding solid food introduction and the risk of allergies in children.  These studies show that the more solids introduced before 6 months of age, increases the risk for allergies in children.  One study showed that the risk for allergies is not increased with introduction of rice cereal only at 5 months of age.   (Thus we still recommend waiting until 6 months, but give permissive advice to start solids at 5 months for parents who feel they want to start earlier).   Other studies regarding breastfeeding have shown that the risk for obesity is 2 times lower than with formula feeding.  This study adds to that work.  Formula feeding AND solids introduced early increase this risk for obesity.  When I first started practicing, I remember families that would introduce solids at 2 weeks of age despite our advice.  The normal timing for introducing solids has changed over the years.  It is wonderful that we continue to have well done studies that support the advice we give to parents.  These studies help guide and support parents who are pressured to start solids.  I can’t tell you how many parents continue to get advice from well meaning friends and family to “give him food”.  This study gives them one more piece of information to do the right thing!