Allergic Rhinitis (Hay Fever)

Allergic rhinitis (hay fever) is an especially common chronic nasal problem in adolescents and young adults. Allergies to inhalants like pollen, dust, and animal dander begin to cause sinus and nasal symptoms in early childhood. Infants and young children are especially susceptible to allergic sensitivity to foods and indoor allergens.

What causes allergic rhinitis?

Allergic rhinitis typically results from two conditions: family history/genetic predisposition to allergic disease and exposure to allergens. Allergens are substances that produce an allergic response.

Children are not born with allergies but develop symptoms upon repeated exposure to environmental allergens. The earliest exposure is through food—and infants may develop eczema, nasal congestion, nasal discharge, and wheezing caused by one or more allergens (milk protein is the most common). Allergies can also contribute to repeated ear infections in children. In early childhood, indoor exposure to dust mites, animal dander, and mold spores may cause an allergic reaction, often lasting throughout the year. Outdoor allergens including pollen from trees, grasses, and weeds primarily cause seasonal symptoms.

The number of patients with allergic rhinitis has increased in the past decade, especially in urban areas. Before adolescence, twice as many boys as girls are affected; however, after adolescence, females are slightly more affected than males. Researchers have found that children born to a large family with several older siblings and day care attendance seem to have less likelihood of developing allergic disease later in life.

What are allergic rhinitis symptoms?

Symptoms can vary with the season and type of allergen and include sneezing, runny nose, nasal congestion, and itchy eyes and nose. A year-long exposure usually produces nasal congestion (chronic stuffy nose).

In children, allergen exposure and subsequent inflammation in the upper respiratory system cause nasal obstruction. This obstruction becomes worse with the gradual enlargement of the adenoid tissue and the tonsils inherent with age. Consequently, the young patient may have mouth-breathing, snoring, and sleep-disordered breathing such as obstructive sleep apnea. Sleep problems such as insomnia, bed-wetting, and sleepwalking may accompany these symptoms along with behavioral changes including short attention span, irritability, poor school performance, and excessive daytime sleepiness.

In these patients, upper respiratory infections such as colds and ear infections are more frequent and last longer. A child’s symptoms after exposure to pollutants such as tobacco smoke are usually amplified in the presence of ongoing allergic inflammation.

When should my child see a doctor?

If your child’s cold-like symptoms (sneezing and runny nose) persist for more than two weeks, it is appropriate to contact a physician.

Emergency treatment is rarely necessary except for upper airway obstruction causing severe sleep apnea or an anaphylactic reaction caused by exposure to a food allergen. Treatment of anaphylactic shock should be immediate and requires continued observation and care.

What happens during a physician visit?

The doctor will first obtain an extensive history about the child, the home environment, possible exposures, and progression of symptoms. Family history of atopic/allergic disease and the presence of other disorders such as eczema and asthma strongly support the diagnosis of allergic rhinitis. The physician will seek a link between the symptoms and exposure to certain allergens.

The physician will examine the skin, eyes, face and facial structures, ears, nose, and throat. In some cases, a nasal endoscopy may be performed. If the history and the physical exam suggest allergic rhinitis, a screening allergy test is ordered. This can be a blood test or a skin prick test. In most children it is easier to obtain a blood test known as the RadioAllergoSorbent Test or RAST. This test measures the amount of specific Immunoglobulin E antibodies (IgE) in the blood responding to various environmental and food allergens.

The skin test results, often immediately available, may be affected by the recent use of antihistamines and other medications, dermatologic conditions, and age of the patient. The blood test is not affected by medication, and results are usually available in several days.

How is allergic rhinitis treated?

The most common treatment recommendation is to have the child avoid the allergens causing the allergic sensitivity. The physician will work with caregivers to develop an avoidance strategy based on the nature of the allergen, exposure, and availability of avoidance measures.

Cost and lifestyle are important factors to consider. For mild, seasonal allergies, avoidance could be the most effective course of action. If pet dander is the offender, consideration should be given to removing the pet from the child’s environment.

Severe symptoms, multiple allergens, year-long exposure, and limited resources for environmental control may call for additional treatment measures. Nasal saline irrigations, nasal steroid sprays, and non-sedating antihistamines are indicated for symptom control. Nasal steroids are the most effective in reducing nasal symptoms of allergic rhinitis. A short burst of oral steroids may be appropriate for some patients with severe symptoms or to gain control during acute attacks.

If symptoms are severe and due to multiple allergens, the child is symptomatic more than six months in a year, and if all other measures fail, then immunotherapy (IT) (or desensitization) may be suggested. IT is delivered by injections of the allergen in doses that are increased incrementally to a maximum that is tolerated without a reaction. Maintenance injections can be delivered at increasing intervals starting from weekly to bi-weekly to monthly injections for up to three to five years. Children with pollen sensitivities benefit most from this treatment. IT is also effective in reducing the onset of pollen-induced asthma.

Child Hearing Screening

Why Is Early Childhood Hearing Screening Important For Your Child?

Approximately two to four of every 1,000 children in the United States are born deaf or hard-of-hearing, making hearing loss the most common birth disorder. Many studies have shown that early diagnosis of hearing loss is crucial to the development of speech, language, cognitive and psychosocial abilities. Treatment is most successful if hearing loss is identified early, preferably within the first few months of life. Still, one in every four children born with serious hearing loss does not receive a diagnosis until 14 months old.

When Should A Child’s Hearing Be Tested?

The first opportunity to test a child’s hearing is in the hospital shortly after birth. If your child’s hearing is not screened before leaving the hospital, it is recommended that screening be done within the first month of life. If test results indicate a possible hearing loss,get a further evaluation as soon as possible, preferably within the first three to six months of life.

Is Early Hearing Screening Mandatory?

In recent years, health organizations across the country, including the American Academy of Otolaryngology – Head and Neck Surgery, have worked to highlight the importance of screening all newborns for hearing loss. These efforts are working. Recently, many states have passed Early Hearing Detection and Intervention legislation. A few other states regularly screen the hearing of most newborns, but have no legislation that requires screening. So, check with your local authority or hospital for screening regulations.

How Is Screening Done?

Two tests are used to screen infants and newborns for hearing loss. They areotoacoustic emissions (OAE) and auditory brain stem response (ABR).

Otoacoustic emissions involves placing a sponge earphone in the ear canal to measure whether the ear can respond properly to sound. In normal-hearing children, a measurable “echo” should be produced when sound is emitted through the earphone. If no echo is measured, it could indicate a hearing loss.

Auditory brain stem response is a more complex test. Earphones are placed on the ears and electrodes are placed on the head and ears. Sound is emitted through the earphones while the electrodes measure how your child’s brain responds to the sound.

If either test indicates a potential hearing loss, your physician may suggest a follow-up evaluation by an otolaryngologist.

Signs Of Hearing Loss In Children

Hearing loss can also occur later in childhood. In these cases, parents, grandparents and other caregivers are often the first to notice that something may be wrong with a young child’s hearing. Even if your child’s hearing was tested as a newborn, you should continue to watch for signs of hearing loss, including:

• Not reacting in any way to unexpected loud noises
• Not being awakened by loud noises
• Not turning his/her head in the direction of your voice
• Not being able to follow or understand directions
• Poor language development, or
• Speaking loudly or not using age-appropriate language skills.

If your child exhibits any of these signs, report them to your doctor.

What Happens If My Child Has A Hearing Loss?

Hearing loss in children can be temporary or permanent. It is important to have hearing loss evaluated by a physician who can rule out medical problems that may be causing the hearing loss, such as otitis media (ear infection), excessive earwax, congenital malformations or a genetic hearing loss.

If it is determined that your child’s hearing loss is permanent, hearing aids may be recommended to amplify the sound reaching your child’s ear. Ear surgery may be able to restore or significantly improve hearing in some instances. For those with certain types of very severe hearing loss who do not benefit sufficiently from hearing aids, a cochlear implant may be considered. Unlike a hearing aid, the implant bypasses damaged parts of the auditory system and directly stimulates the hearing nerve, allowing the child to hear louder and clearer sound.

Research indicates that if a child’s hearing loss is remedied by age six months, it will prevent subsequent language delays. You will need to decide whether your deaf child will communicate primarily with oral speech and/or sign language, and seek early intervention to prevent language delays. Other communication strategies such as auditory verbal therapy, lip reading and cued speech may also be used in conjunction with a hearing aid or cochlear implant, or independently.

Children and Facial Paralysis

About 40,000 people in the United States develop facial paralysis each year with children comprising a small percentage of that population. There are more than 50 known causes of facial paralysis but the most common in children is “Bell’s palsy,” the cause of which is not certain. This disorder effects one side of the facial muscles due to dysfunction of the seventh cranial nerve, usually thought to stem from a viral infection; Bell’s palsy is found in 20 out of 100,000 Americans, with the incidence increasing with each decade of life.

What causes Bell’s palsy?

In Bell’s palsy, facial paralysis results from damage (e.g., possibly from viral infection) to the facial nerve. Adults and children will either wake up to find they have facial paralysis or palsy, or have symptoms such as a dry eye or tingling around their lips that progress to Bell’s palsy during that same day. Occasionally symptoms may take a few days to progress to facial weakness or paralysis. Physical trauma to the head and neck region at birth and during childhood may cause facial paralysis. Other causes are:

• Chicken pox: Chicken pox and shingles are both caused by a single virus of the herpes family known as varicella-zoster virus (VZV). Varicella is the primary infection that causes chickenpox; Herpes zoster is the reactivation of the virus that causes shingles. Research studies suggest that Bell’s palsy may be due to a reactivation of herpes simplex virus (HSV). Between 75 percent and 90 percent of chickenpox cases occur in children under 10 years of age. According to a 2001 study, about 10 percent of children between ages five and nine and about two percent of 10 to 14 year olds get chicken pox each year.
• Infectious mononucleosis: This condition, with a peak incidence in the 15- 17 age group, can be caused by several different viruses. The leading causes are the Epstein-Barr virus and cytomegalovirus, both members of the herpes virus family. The infection is transmitted by saliva, sexual contact, respiratory droplets, and blood transfusions.
• Lyme disease: Lyme disease is an infection that’s spread by Ixodes ticks (black-legged or deer ticks in the eastern United States, and western black-legged ticks in the west). The second stage of Lyme disease usually appears two to three months after the tick bite, and may include facial palsy or paralysis among other symptoms.

What are the symptoms of Bell’s palsy in children?

Not all children react the same to this disorder. However, recorded symptoms include:

• The child may complain of headache or pain behind or in front of the ear a few days prior to the onset of Bell’s palsy.
• Swelling or drooping on one side of the face.
• Drooling, excessive, or reduced production of saliva.
• An inability to blink or completely close one eye.
• The child has either excessive tears or marked dryness and inability to make tears in one eye.
• Sounds seem louder than they really are.
• The child is experiencing sensitivity to light.
• Episodes of dizziness.

Treatments for Facial Paralysis:

If infection is the cause, then an antibiotic to fight bacteria (as in middle ear infections) or antiviral agents (to fight syndromes caused by viruses like herpes zoster (Ramsay Hunt Syndrome) may be used. The prognosis for children with facial paralysis is generally very good. The extent of nerve damage determines the extent of recovery. With or without treatment, studies indicate that most pediatric patients with the disorder begin to get better within two weeks after the initial onset of symptoms and recover completely within three to six months. Adults may find residual symptoms remaining for an indefinite period of time.

What happens during the diagnosis?

After an examination, the otolaryngologist- head and neck surgeon may conduct a hearing test to determine if the cause of damage to the nerve has involved the hearing nerve, inner ear, or delicate hearing mechanism. Additional tests in the physician’s office include a balance test and a tear test, to measure the eye’s ability to produce tears. Eye drops may be necessary to prevent drying of the surface of the eye cornea. In some circumstances, the physician may recommend a CT (computerized tomography) or MRI (magnetic resonance imaging) test to determine if there is infection, tumor, bone fracture, or other abnormality in the area of the facial nerve. An additional diagnostic tool is the Electro neuronography (ENOG), which stimulates the facial nerve to assess how badly the nerve is damaged. This test may have to be repeated at frequent intervals to see if the disease is progressing.

Sources:

National Institute of Neurological Disorders and Stroke

Bell’s Palsy Research Foundation

eNotes.com

Children and Facial Trauma

What is facial trauma?

The term facial trauma means any injury to the face or upper jaw bone. Facial traumas include injuries to the skin, underlying skeleton, neck, nose and sinuses, eye socket, or teeth and other parts of the mouth. Sometimes these types of injuries are called maxillofacial injury. Facial trauma is often recognized by swelling or lacerations (breaks in the skin). Signs of broken bones include bruising around the eyes, widening of the distance between the eyes, movement of the upper jaw when the head is stabilized, abnormal sensations on the face, and bleeding from the nose, mouth or ear.

In the U.S., about three million people are treated in emergency departments for facial trauma injuries each year. Of the pediatric patients, 5 percent have suffered facial fractures. In children under three years old, the primary cause of these fractures is falls. In children more than five years old, the primary cause for facial trauma is motor vehicle accidents. Fortunately, the correct use of seat belts, boosters and car seats can dramatically reduce the risk of facial trauma in children.

A number of activities put children at risk for facial injury, such as contact sports, cheerleading, gymnastics and cycling. Proper supervision and appropriate protective gear, such as bicycle helmets, shin guards, helmets, etc., should always be employed during these activities. But when accidents do happen, children’s facial injuries require special attention, as a child’s future growth plays a big role in treatment for facial trauma. So one of the most important issues for a caregiver is to follow a physician’s treatment plan as closely as possible until your child is fully recovered.

Why is facial trauma different in children than adults?

Facial trauma can range between minor injury to disfigurement that lasts a lifetime. The face is critical in communicating with others, so it is important to get the best treatment possible. Pediatric facial trauma differs from adult injury because the face is not fully formed and future growth will be a factor in how the child heals and recovers. Certain types of trauma may cause a delay in growth or further complicate recovery. Difficult cases require doctors or a team of doctors with special skills to make a repair that will grow with your child.

Types of facial trauma

New technology, such as advanced CT scans that can provide three-dimensional anatomic detail, has improved physicians’ ability to evaluate and manage facial trauma. In some cases, immediate surgery is needed to realign fractures before they heal incorrectly. Other injuries will have better outcomes if repairs are done after cuts and swelling have improved. Research has shown that even when an injury does not require surgery, it is important to a child’s health and welfare to continue to follow up with a physician’s care

Soft tissue injuries

Injuries such as cuts (lacerations) may occur on the soft tissue of the face. In combination with suturing the wound, the provider should take care to inspect and treat any injures to the facial nerves, glands, or ducts. In younger children, many lacerations require sedation or general anesthesia to achieve the best repair.

Bone injuries

When facial bone fractures occur, the treatment is similar to that of a fracture in other parts of the body. Some injuries may not need treatment, and others may require stabilization and fixation using wires, plates, and screws. Factors influencing these treatment decisions are the location of the fracture, the severity of the fracture, and the age and general health of the patient. It is important during treatment of facial fractures to be careful that the patient’s facial appearance is minimally affected.

Injuries to the teeth and surrounding dental structures style

Isolated injuries to teeth are quite common and may require the expertise of various dental specialists. Because of the specific needs of the dental structures, certain actions and precautions should be taken if a child has received an injury to his or her teeth or surrounding dental structures.

• If a tooth is “knocked out” it should be placed in salt water or milk. The sooner the tooth is re-inserted into the dental socket, the better the chance it will survive, so the patient should see a dentist or oral surgeon as soon as possible.
• Never attempt to “wipe the tooth off” since remnants of the ligament which hold the tooth in the jaw are attached and are vital to the success of replanting the tooth.

References:

Stewart MG, Chen AY. Factors predictive of poor compliance with follow-up after Facial trauma: A prospective study. Otolaryngol Head Neck Surg 1997: 117:72-75

Kim MK, Buchman R, Szeremeta. Penetrating neck trauma in children: An urban hospital’s experience. Otolaryngol Head Neck Surg 2000: 123: 439-43

Child’s Hearing Loss

As the parent of a child with newly diagnosed hearing loss, you will have many questions and concerns regarding the nature of this problem, its effects on your child’s future, treatment options, and resources. This brief guide will give you necessary initial information, and provide guidance about the availability of resources, and the respective roles of different care providers.

It is always difficult for parents to receive bad news about any aspect of their child’s health. Reacting with anger, grief, and even guilt are not unusual when finding out that your child is hearing-impaired. These feelings are best managed by discussing them with a family member, close friend, clergy, or mental health professional. At times, the feeling may also result in a degree of denial. Feel free to seek a second opinion, but it is unadvisable to delay further recommended diagnostic evaluations for your child. The best treatment for hearing loss of any degree is appropriate early intervention. Significant delays may result in irreversible harm to your child’s hearing, speech, language, and eventual educational development.

You will come into contact with many healthcare and rehabilitation specialists during the long-term management of your child’s hearing loss. Some of them will be involved early in the journey and again at intervals. Others may step in later on. The following are professionals you will encounter and the role each of them will play in managing your child’s hearing loss.

The Audiologist

The audiologist is likely to be the first professional you encounter, and possibly the one who gives you the initial news regarding your child’s hearing loss. The audiologist will carry out behavioral or objective testing (such as auditory brainstem responses) or a combination of these approaches to determine the degree and type of hearing loss. The audiologist will also eventually recommend appropriate amplification, following a medical consultation. The audiologist will also provide your child with well-fitting ear molds along with the hearing aids, as he or she grows. The audiologist may also be the professional who provides you with information and referral to an early intervention program. Over time, the audiologist will provide periodic follow-ups to chart your child’s progress and to monitor his or her hearing loss.

Otologist, Otolaryngologist, or Pediatric Otolaryngologist (ENT Physician)

Upon diagnosis of hearing loss, your child will be referred to an ear, nose, and throat specialist, (otolaryngologist), or one who specializes in childhood ear and hearing problems. This physician’s initial role is to determine the specific nature of the underlying problem that may be at least partially causing the hearing loss. Additionally, the physician will also determine if the problem is medically or surgically treatable, and if so, provide the necessary medical or surgical treatment. Such treatments could include something relatively simple, like the placement of eardrum ventilation tubes, or more complex surgical procedures. The ENT specialist may also refer your child for additional diagnostic procedures such as imaging studies (X-rays, CT-scans, MRI scans) to further define the type and source of hearing loss. The doctor will also provide clearance for hearing aid fitting, after determining if no other intervention is indicated. If it is determined that your child needs a cochlear implant, the otolaryngologist, along with the audiologist, will carry out further tests and examinations, and will carry out the implant surgery.

Primary Care Physician: Pediatrician or Family Practitioner

Your child’s primary care physician may be either a pediatrician or a family practice doctor. If your child is not diagnosed with a hearing loss in the newborn period but develops hearing loss later in life, it is the responsibility of this doctor to make appropriate referrals to an ear, nose and throat specialist and an audiologist to rule out or diagnose hearing loss. Your child’s primary care doctor may also participate in the treatment of ear infections if they appear, or refer them to an otolaryngologist for treatment. The primary care physician or the otolaryngologist may also provide a referral to a doctor who specializes in medical genetics, to find out if your child’s hearing loss may be hereditary. That may help you determine if a similar hearing loss could occur in your other children.

Early Intervention Specialist

This professional is typically is someone with an education background. He or she can help you find resources in your community, define family members’ roles in early intervention and management of the hearing loss, and can help you deal with questions regarding future educational placement. This specialist will also help you deal with your observations and concerns about your child and give you information and support regarding your child’s educational needs in the future.

Speech/ Language Pathologist (SLP)

This professional will evaluate the impact of your child’s hearing loss on speech/language development, and monitor his/her progress, noting if progress with that development is falling behind. If this happens, the SLP may refer back to the audiologist or otolaryngologist to determine if any changes have occurred in your child’s hearing. The SLP will also help your child to learn proper speech production, including correct articulation of speech sounds. If you choose oral communication for your child, in addition to the speech language pathologist your child may also be treated by an auditory-verbal therapist, who can help your child acquire the full range of speech sounds and guide the family to additional medical or audiological treatments. The auditory-verbal therapist will also help the child’s family become familiar with appropriate speech/language, auditory, and cognitive developmental milestones you may expect for a child with hearing loss.

Finally, many other people can provide additional assistance for your hard-of-hearing child. Parents of older hard-of-hearing children, and hard-of-hearing adults, can share their experiences with you and may have suggestions for educational and recreational resources in the community.

Cochlear Implants and Meningitis Vaccination

What you should know

Children with cochlear implants are more likely to get bacterial meningitis than children without them. In addition, some children who are candidates for cochlear implants have inner ear abnormalities that may increase their risk for meningitis.

Because children with cochlear implants are at increased risk for pneumococcal meningitis, the Centers for Disease Control and Prevention (CDC) recommends that they receive pneumococcal vaccination on the same schedule recommended for other groups at increased risk for invasive pneumococcal disease. Recommendations for the timing and type of this vaccination vary with age and vaccination history, and should be discussed with a healthcare provider.

The CDC has issued new pneumococcal vaccination recommendations for individuals with cochlear implants. These can be viewed on the CDC website.

• Children who have cochlear implants or are candidates for them, and who have not received any previous doses of PCV7, should receive PCV13. PCV13 is now recommended routinely for all infants and children (see Table 2 in the CDC March 13, 2010 report at the website above for the dosing schedule).
• Older children with cochlear implants (between age 2 and 6) should receive two doses of PCV13 if they have not previously received any PCV7 or PCV13. If they have already completed the four-dose PCV7 series, they should receive one dose of PCV13 (up to age 6).
• Children 6 through 18 with cochlear implants may receive a single dose of PCV13, regardless of whether they’ve previously received PCV7 or the pneumococcal polysaccharide vaccine (PPSV) (Pneumovax®).
• In addition to receiving PCV13, children with cochlear implants should receive one dose of PPSV at age 2 or older, and after completing all recommended doses of PCV13.
• Adult patients (19 and older) who are candidates for a cochlear implant, and those who have received an implant, should receive a single dose of PPSV.
• For both children and adults, the vaccination schedule should be completed two weeks or more before surgery.

Additional facts

• According to the Food and Drug Administration (FDA), as of April 2009, approximately 188,000 people worldwide have received cochlear implants, including roughly 41,500 adults and 25,500 children in the U.S. There are 122 known reports of meningitis in patients in the U.S., who have received cochlear implants, with 64% of these cases in children.
• Meningitis is an infection of the fluid that surrounds the brain and spinal cord. There are two main types of meningitis, viral and bacterial. Bacterial meningitis is the more serious, and the type that has been reported in individuals with cochlear implants. The symptoms, treatment, and outcomes may differ, depending on the cause.
• The vaccines available in the U.S. that protect against most bacteria that cause meningitis are:
  • 13-valent pneumococcal conjugate (PCV13) (Prevnar 13®)
  • 23-valent pneumococcal polysaccharide (PPSV) (Pneumovax®)
  • Haemophilus influenzae type b conjugate (Hib)
  • Tetravalent (A, C, Y, W-135) meningococcal conjugate (Menactra® and Menveo®)
  • Tetravalent (A, C, Y, W-135) meningococcal polysaccharide (Menomune®)
• Meningitis in individuals with cochlear implants is most commonly caused by the bacterium Streptococcus pneumoniae (pneumococcus). Children with cochlear implants are more likely to get pneumococcal meningitis than children without them.
• There is no evidence that children with cochlear implants are more likely to get meningococcal meningitis than other children.
• The Haemophilus influenzae type b (Hib) vaccine is not routinely recommended for those age 5 or older, since most older children and adults are already immune to Hib. However, it can be given to older children and adults who have never received it. Children under age 5 should receive the Hib vaccine as a routine protection, according to the CDC guidelines. Most children born after 1990 receive the Hib vaccine as infants.
• Healthcare providers (family physicians, pediatricians, and otolaryngologists) and families should review the vaccination records of current and prospective cochlear implant recipients to ensure that all recommended vaccinations are up to date.

Facial Sports Injuries

Playing catch, shooting hoops, bicycling on a scenic path or just kicking around a soccer ball have more in common than you may think. On the up side, these activities are good exercise and are enjoyed by thousands of Americans. On the down side, they can result in a variety of injuries to the face.

Many injuries are preventable by wearing the proper protective gear, and your attitude toward safety can make a big difference. However, even the most careful person can get hurt. When an accident happens, it’s your response that can make the difference between a temporary inconvenience and permanent injury.

When Someone Gets Hurt:

What First Aid Supplies Should You Have on Hand in Case of An Emergency?

• Sterile cloth or pads
• Scissors
• Ice pack
• Tape
• Sterile bandages
• Cotton tipped swabs
• Hydrogen peroxide
• Nose drops
• Antibiotic ointment
• Eye pads
• Cotton balls
• Butterfly bandages

Ask “Are you all right?” Determine whether the injured person is breathing and knows who and where they are.

Be certain the person can see, hear and maintain balance. Watch for subtle changes in behavior or speech, such as slurring or stuttering. Any abnormal response requires medical attention.

Note weakness or loss of movement in the forehead, eyelids, cheeks and mouth.

Look at the eyes to make sure they move in the same direction and that both pupils are the same size.

If any doubts exist, seek immediate medical attention.

When Medical Attention Is Required, What Can You Do?

• Call for medical assistance (911).
• Do not move the victim, or remove helmets or protective gear.
• Do not give food, drink or medication until the extent of the injury has been determined.
• Remember HIV…be very careful around body fluids. In an emergency protect your hands with plastic bags.
• Apply pressure to bleeding wounds with a clean cloth or pad, unless the eye or eyelid is affected or a loose bone can be felt in a head injury. In these cases, do not apply pressure but gently cover the wound with a clean cloth.
• Apply ice or a cold pack to areas that have suffered a blow (such as a bump on the head) to help control swelling and pain.
• Remember to advise your doctor if the patient has HIV or hepatitis.

Facial Fractures

Sports injuries can cause potentially serious broken bones or fractures of the face. Common symptoms of facial fractures include:

• Swelling and bruising, such as a black eye
• Pain or numbness in the face, cheeks or lips
• Double or blurred vision
• Nosebleeds
• Changes in teeth structure or ability to close mouth properly

It is important to pay attention to swelling because it may be masking a more serious injury. Applying ice packs and keeping the head elevated may reduce early swelling.

If any of these symptoms occur, be sure to visit the emergency room or the office of a facial plastic surgeon (such as an otolaryngologist-head and neck surgeon) where x-rays may be taken to determine if there is a fracture.

Upper Face

When you are hit in the upper face (by a ball for example) it can fracture the delicate bones around the sinuses, eye sockets, bridge of the nose or cheek bones. A direct blow to the eye may cause a fracture, as well as blurred or double vision. All eye injuries should be examined by an eye specialist (ophthalmologist).

Lower Face

When your jaw or lower face is injured, it may change the way your teeth fit together. To restore a normal bite, surgeries often can be performed from inside the mouth to prevent visible scarring of the face; and broken jaws often can be repaired without being wired shut for long periods. Your doctor will explain your treatment options and the latest treatment techniques.

Soft Tissue Injuries

Bruises cuts and scrapes often result from high speed or contact sports, such as boxing, football, soccer, ice hockey, bicycling skiing, and snowmobiling. Most can be treated at home, but some require medical attention.

You should get immediate medical care when you have:

• Deep skin cuts
• Obvious deformity or fracture
• Loss of facial movement
• Persistent bleeding
• Change in vision
• Problems breathing and/or swallowing
• Alterations in consciousness or facial movement

Bruises

Also called contusions, bruises result from bleeding underneath the skin. Applying pressure, elevating the bruised area above the heart and using an ice pack for the first 24 to 48 hours minimizes discoloration and swelling. After two days, a heat pack or hot water bottle may help more. Most of the swelling and bruising should disappear in one to two weeks.

Cuts and Scrapes

The external bleeding that results from cuts and scrapes can be stopped by immediately applying pressure with gauze or a clean cloth. When the bleeding is uncontrollable, you should go to the emergency room.

Scrapes should be washed with soap and water to remove any foreign material that could cause infection and discoloration of the skin. Scrapes or abrasions can be treated at home by cleaning with 3% hydrogen peroxide and covering with an antibiotic ointment or cream until the skin is healed. Cuts or lacerations, unless very small, should be examined by a physician. Stitches may be necessary, and deeper cuts may have serious effects. Following stitches, cuts should be kept clean and free of scabs with hydrogen peroxide and antibiotic ointment. Bandages may be needed to protect the area from pressure or irritation from clothes. You may experience numbness around the cut for several months. Healing will continue for 6 to 12 months. The application of sunscreen is important during the healing process to prevent pigment changes. Scars that look too obvious after this time should be seen by a facial plastic surgeon.

Nasal Injuries

The nose is one of the most injured areas on the face. Early treatment of a nose injury consists of applying a cold compress and keeping the head higher than the rest of the body. You should seek medical attention in the case of:

• Breathing difficulties
• Deformity of the nose
• Persistent bleeding
• Cuts

Bleeding

Nosebleeds are common and usually short-lived. Often they can be controlled by squeezing the nose with constant pressure for 5 to 10 minutes. If bleeding persists, seek medical attention.

Bleeding also can occur underneath the surface of the nose. An otolaryngologist/facial plastic surgeon will examine the nose to determine if there is a clot or collection of blood beneath the mucus membrane of the septum (a septal hematoma) or any fracture. Hematomas should be drained so the pressure does not cause nose damage or infection.

Fractures

Some otolaryngologist-head and neck specialists set fractured bones right away before swelling develops, while others prefer to wait until the swelling is gone. These fractures can be repaired under local or general anesthesia, even weeks later.

Ultimately, treatment decisions will be made to restore proper function of the nasal air passages and normal appearance and structural support of the nose. Swelling and bruising of the nose may last for 10 days or more.

Neck Injuries

Whether seemingly minor or severe, all neck injuries should be thoroughly evaluated by an otolaryngologist — head and neck surgeon. Injuries may involve specific structures within the neck, such as the larynx (voicebox), esophagus (food passage), or major blood vessels and nerves.

Throat Injuries

The larynx is a complex organ consisting of cartilage, nerves and muscles with a mucous membrane lining all encased in a protective tissue (cartilage) framework.

The cartilages can be fractured or dislocated and may cause severe swelling, which can result in airway obstruction. Hoarseness or difficulty breathing after a blow to the neck are warning signs of a serious injury and the injured person should receive immediate medical attention.

Prevention Of Facial Sports Injuries

The best way to treat facial sports injuries is to prevent them. To insure a safe athletic environment, the following guidelines are suggested:

• Be sure the playing areas are large enough that players will not run into walls or other obstructions.
• Cover unremoveable goal posts and other structures with thick, protective padding.
• Carefully check equipment to be sure it is functioning properly.
• Require protective equipment – such as helmets and padding for football, bicycling and rollerblading; face masks, head and mouth guards for baseball; ear protectors for wrestlers; and eyeglass guards or goggles for racquetball and snowmobiling are just a few.
• Prepare athletes with warm-up exercises before engaging in intense team activity.
• In the case of sports involving fast-moving vehicles, for example, snowmobiles or dirt bikes – check the path of travel, making sure there are no obstructing fences, wires or other obstacles.
• Enlist adequate adult supervision for all children’s competitive sports.

How Allergies Affect your Child’s Ears, Nose and Throat

Does your child have allergies? Allergies can cause many ear, nose, and throat symptoms in children, but allergies can be difficult to separate from other causes. Here are some clues that allergy may be affecting your child.

Children with nasal allergies often have a history of other allergic tendencies (or atopy). These may include early food allergies or atopic dermatitis in infancy. Children with nasal allergies are at higher risk for developing asthma.

Nasal allergies can cause sneezing, itching, nasal rubbing, nasal congestion, and nasal drainage. Usually, allergies are not the primary cause of these symptoms in children under four years old. In allergic children, these symptoms are caused by exposure to allergens (mostly pollens, dust, mold, and dander). Observing which time of year or in which environments the symptoms are worse can be important clues to share with your doctor.

Ear infections:

One of children’s most common medical problems is otitis media, or middle ear infection. In most cases, allergies are not the main cause of ear infections in children under two years old. But in older children, allergies may play role in ear infections, fluid behind the eardrum, or problems with uncomfortable ear pressure. Diagnosing and treating allergies may be an important part of healthy ears.

Sore throats:

Allergies may lead to the formation of too much mucus which can make the nose run or drip down the back of the throat, leading to “post-nasal drip.” It can lead to cough, sore throats, and a husky voice.

Sleep Disorders:

Chronic nasal obstruction is a frequent symptom of seasonal allergic rhinitis and perennial (year-round) allergic rhinitis. Nasal congestion can contribute to sleep disorders such as snoring and obstructive sleep apnea, because the nasal airway is the normal breathing route during sleep. Fatigue is one of the most common, and most debilitating, allergic symptoms. Fatigue not only affects children’s quality of life, but has been shown to affect school performance.

Pediatric sinusitis:

Allergies should be considered in children who have persistent or recurrent sinus disease. Depending on the age of your child, their individual history, and an exam, your doctor should be able to help you decide if allergies are likely. Some studies suggest that large adenoids (a tonsil-like tissue in the back of the nose) are more common in allergic children.

Kids’ Summer ENT Health

Tips for keeping kids safe and healthy this summer season!

Summer Allergies – Summertime allergies can affect children very differently than adults, so administering over-the-counter medications before consulting with a physician is not advisable. Simple hay fever can lead to long-term problems in swallowing, sleeping, hearing, and breathing for children, so it is important to have a thorough check-up if your child appears to be suffering from common allergy symptoms like sneezing, itchy eyes, and congested sinuses.

Swimmer’s Ear – The outer ear tissue is delicate and infection can occur often in swimmers, when water is trapped in the ear canal. Bathing or showering may also cause this common infection. In kids, the symptoms may include complaints of an earache (can be very painful), pulling on the ear lobe, and complaining of the ear feeling “full” or “blocked.” If caught early, the infection may be treated with ear drops. Acute cases may require antibiotics.

Ears and Altitude – If you are traveling by plane for a family vacation, your child may experience some discomfort from the changing air pressure during the flight. Tell children in advance about this common problem and ask as you take off and land if their ears are bothering them. If they are, have them swallow several times, drink some water, or chew on a piece of sugarless gum to “pop” their ears. Very young children who cannot talk yet can be fed a bottle, as swallowing will help relieve pressure in the ears.

Skin Cancer – The head and neck are two very common areas for skin cancer to develop due to constant exposure to the sun. Severe childhood sunburns are also a common risk factor for developing skin cancers later on in life. Protect your child by applying a waterproof SPF 15 or higher sun block every day and limiting the amount of time they have direct exposure to the sun between 10 a.m. and 2 p.m., when the sun’s rays are most powerful.

Summer Camp – Before sending your child off to summer camp, make sure you compile a list of any medications or devices your child needs and send them with an adequate supply, including emergency allergy medications (and possibly ear plugs if your child has ear tubes). Be sure to review all health concerns with the camp staff, giving specific instructions for care, and providing day and evening contact numbers if your child becomes ill.

Trip to the Beach – When traveling to the beach or pool (where the sunshine/uv index is high (above 5) kids should get SPF of 30 or above protection.

Tonsillectomy Surgery – Tonsillectomy with or without adenoidectomy is one of the most common operations performed on children, usually for obstructive sleep apnea or recurrent tonsil infections. Summer is an ideal time to schedule a tonsillectomy, which may require a special diet and limited physical activity for up to 2 weeks.

With some advance planning and the ability to recognize early signs of trouble, children and parents can make the most of this summer vacation. For more information on kid’s ear, nose, and throat health, visit www.entnet.org.

Laryngopharyngeal Reflux and Children

What is laryngopharyngeal reflux (LPR)?

Food or liquids that are swallowed travel through the esophagus and into the stomach where acids help digestion. Each end of the esophagus has a sphincter, a ring of muscle, that helps keep the acidic contents of the stomach in the stomach or out of the throat. When these rings of muscle do not work properly, you may get heartburn or gastroesophageal reflux (GER). Chronic GER is often diagnosed as gastroesophageal reflux disease, or GERD.

Sometimes, acidic stomach contents will reflux all the way up the esophagus, past the ring of muscle at the top (upper esophageal sphincter or UES), and into the throat. When this happens, acidic material contacts the sensitive tissue at back of the throat and even the back of the nasal airway. This is known as laryngopharyngeal reflux or LPR.

During the first year, infants frequently spit up, and in most infants, it is a normal occurrence that resolves in the first year. Only infants who have associated breathing or feeding problems require evaluation by a specialist. This is most critical when breathing-related symptoms are present.

What are symptoms of LPR?

There are various symptoms of LPR. Adults may be able to identify LPR as a bitter taste in the back of the throat, more commonly in the morning upon awakening, and the sensation of a “lump” or something “stuck” in the throat, which does not go away despite multiple swallowing attempts to clear the “lump.” Some adults may also experience a burning sensation in the throat. A more uncommon symptom is difficulty breathing, which occurs because the acidic, refluxed material comes in contact with the voice box (larynx) and causes the vocal cords to close to prevent aspiration of the material into the windpipe (trachea). This is known as “laryngospasm.”

Infants and children are unable to describe sensations like adults can. Therefore, LPR is only successfully diagnosed if parents are suspicious and the child undergoes a full evaluation by a specialist, such as an otolaryngologist (ear-nose-throat doctor). Airway or breathing-related problems are the most commonly seen symptoms of LPR in infants and children and can be serious. If your infant or child experiences any of the following symptoms, timely evaluation is critical.

• Chronic cough
• Hoarseness
• Noisy breathing (stridor)
• Croup
• Reactive airway disease (asthma)
• Sleep disordered breathing (SDB)
• Spit up
• Feeding difficulty
• Turning blue (cyanosis)
• Aspiration
• Pauses in breathing (apnea)
• Apparent life threatening event (ALTE)
• Failure to thrive (a severe deficiency in growth such that an infant or child is less than five percentile compared to the expected norm)

What are the complications of LPR?

In infants and children, chronic exposure of the laryngeal structures to acidic contents may cause long-term airway problems such as a narrowing of the area below the vocal cords (subglottic stenosis), hoarseness, and possibly eustachian tube dysfunction. The latter can cause recurrent ear infections, or persistent middle ear fluid, and even symptoms of sinusitis. The direct relationship between LPR and the latter mentioned problems are currently being researched.

How is LPR diagnosed?

Currently, there is no good standardized test to identify LPR. If parents notice any symptoms of LPR in their child, they may wish to discuss with their pediatrician getting a referral to see an otolaryngologist for evaluation. In the office, he or she may look directly at the voice box and related structures with a flexible scope or order a 24-hour pH monitoring of the esophagus. The otolaryngologist may also decide to perform further evaluation of the child under general anesthesia. This would include looking directly at the voice box (direct laryngoscopy), trachea and bronchi (bronchoscopy), and esophagus (esophagoscopy). LPR in infants and children remains a diagnosis of clinical judgment, based on history given by the parents, the physical exam, and endoscopic evaluations.

How is LPR treated?

Since LPR is an extension of GER, successful treatment is usually based on successful treatment of GER. In infants and children, basic recommendations may include use of smaller and more frequent feedings, thickening of the food/liquid, and keeping an infant in a vertical position after feeding for at least 30 minutes. A trial of medications, including H2 blockers or proton pump inhibitors, may be necessary. Similar to adults, children with severe symptoms who fail medical treatment or have diagnostic evaluations demonstrating anatomical abnormalities, may require surgical intervention.

The Necessity of Early Intervention in Hearing to Optimize Hearing Health

Why Is Early Childhood Hearing Screening Important For Your Child?

Everyday in the United States, approximately 1 in 1,000 newborns (or 33 babies every day) is born profoundly deaf with another two to three out of 1,000 babies born with partial hearing loss, making hearing loss the number one birth defect in America. Many studies have shown that early diagnosis of hearing loss is crucial to the development of speech, language, cognitive, and psychosocial abilities. Treatment is most successful if hearing loss is identified early, preferably within the first month of life. Still, one in every four children born with serious hearing loss does not receive a diagnosis until age three or older.

Why is it Important to Have My Baby’s Hearing Screened Early?

The most important time for a child to be exposed to and learn language is in the first three years of life. In fact, children begin learning speech and language in the first six months of life. Research suggests that those who have hearing impairment and get intervention have better language skills than those who don’t. The earlier you know about deafness or hearing loss, the sooner you can make sure your child benefits from strategies that will help him or her learn to communicate.

How Early Should I Have My Baby’s Hearing Screened?

The first opportunity to test a child’s hearing is in the hospital shortly after birth. If your child’s hearing is not screened before leaving the hospital, it is recommended that screening be done within the first month of life. If hearing loss is suspected, make sure an otolaryngologist orders tests for your baby’s hearing by three months of age. If hearing loss is confirmed, it’s important to consider the use of hearing devices and other communication options by six months of age.

Is Early Hearing Screening Mandatory?

In 2003, more than 85 percent of all newborns in the United States were screened for hearing loss. In fact, some 39 states have passed legislation requiring some form of hearing screening of newborns before they leave the hospital. This still leaves more than a million babies who are not screened for hearing loss before leaving the hospital.

How Is Screening Done?

Two tests are used to screen infants and newborns for hearing loss. They are:
Otoacoustic Emissions (OAE): Involves placement of a sponge earphone in the ear canal to measure whether the ear can respond properly to sound. In normal-hearing children, a measurable “echo” should be produced when sound is emitted through the earphone. If no echo is measured, it could indicate a hearing loss.

Auditory Brain Stem Response (ABR): Earphones are placed on the ears and electrodes are placed on the head and ears. Sound is emitted through the earphones while the electrodes measure how your child’s brain responds to the sound.

Signs of Hearing Loss in Children

Hearing loss can also occur later in childhood, after a newborn leaves the hospital. In these cases, parents, grandparents, and other caregivers are often the first to notice that something may be wrong with a young child’s hearing. Even if your child’s hearing was tested as a newborn, you should continue to watch for signs of hearing loss including:

• Not reacting in any way to unexpected loud noises
• Not being awakened by loud noises
• Not turning his/her head in the direction of your voice
• Not being able to follow or understand directions
• Poor language development
• Speaking loudly or not using age-appropriate language skills

If your child exhibits any of these signs, report them to your doctor.

What Happens If My Child Has Hearing Loss?

Hearing loss in children can be temporary or permanent. It is important to have hearing loss evaluated by a physician who can rule out medical problems that may be causing the hearing loss, such as otitis media (ear infection), excessive earwax, congenital malformations, or a genetic hearing loss. If it is determined that your child’s hearing loss is permanent, hearing aids may be recommended to amplify the sound reaching your child’s ear. Ear surgery may be able to restore or significantly improve hearing in some instances.

For those with certain types of profound hearing loss who do not benefit sufficiently from hearing aids, a cochlear implant may be considered. Unlike a hearing aid, a cochlear implant bypasses damaged parts of the auditory system and directly stimulates the hearing nerve and allows the child to hear louder and clearer sound.

You will need to decide whether or not your deaf child will communicate primarily with oral speech and/or sign language, and seek early intervention to prevent language delays. Research indicates that habilitation of hearing loss by age six months will prevent subsequent language delays. Other communication strategies such as auditory verbal therapy, lip reading, and cued speech may also be used in conjunction with a hearing aid or cochlear implant, or independently.

Is My Baby’s Hearing Normal?

If you think that your child has hearing loss, you might be right. The following checklist will assist in determining whether or not your child might have a hearing loss. Please read each item carefully and check only those factors that apply to you, your family or your child.

During pregnancy did…

• Mom have German measles, a viral infection, or flu?
• Mom drink alcoholic beverages?

Did your newborn baby (birth to 28 days of age)…

• Weigh less than 3.5 pounds at birth?
• Have an unusual appearance of the face or ears?
• Have jaundiced (yellow skin) at birth and had and exchange blood transfusion?
• Stay in neonatal intensive care unit (NICU) for more than five days?
• Receive an antibiotic medication given through a needle in a vein?
• Have meningitis?
• Fail newborn hearing screening test?

Did your infant baby (29 days of age to two years)…

• Received an antibiotic medication given through a needle in a vein?
• Have meningitis?
• Have a neurological disorder?
• Have a severe injury with a fracture of the skull with or without bleeding from the ear?
• Have recurring ear infection with fluid in ears for more than three months?

Does one or more individual(s) of your family…

• Have permanent or progressive hearing loss that was present or developed early in life?

Response to the Environment (Speech and Language Development)

My Newborn (Birth to 6 months)…

• Does not startle, move, cry or react in any way to unexpected loud noises
• Does not awaken to loud noises
• Does not freely imitate sound
• Cannot be soothed by voice alone
• Does not turn his/her head in the direction of my voice

My Young Infant (6 through 12 months)…

• Does not point to familiar persons or objects when asked
• Does not babble or babbling has stopped
• By 12 months is not understanding simple phrases us as “wave by-bye,” “clap hands” by listening alone

My Infant (13 Months through two Years)…

• Does not accurately turn in the direction of a soft voice on the first call
• Is not alert to environment sounds
• Does not respond on first call
• Does not respond to sounds or does not locate where sound is coming from
• Does not begin to imitate and use simple words for familiar people and things around the home
• Does not sound like or use speech like other children of similar age
• Does not listen to TV at a normal volume
• Does not show consistent growth in the understanding and the use of words to communicate

If your child has one of more of these indicators you should take him or her to a physician, preferably an otolaryngologist, for an ear examination and a hearing test. This can be done at any age, as early as just after birth.

Noise-Induced Hearing Loss In Children

The National Institute on Deafness and Other Communication Disorders reports approximately 28 million Americans have lost some or all of their hearing, including 17 in 1,000 children under age 18. Noise exposure is increasingly common in the age of iPods and other personal music players. Overexposure to noise can cause both temporary and permanent hearing loss.

Loudness of common sounds:

• 30 decibels (dBA) – whisper
• 60 decibels – Normal conversation
• 60 – 80 decibels – Cars to a close observer
• Above 85 decibels – Can cause permanent hearing loss

Although 10 million Americans suffer irreversible noise-induced hearing loss, with 30 million more exposed to dangerous noise levels each day, very little has been reported on the risk of such hearing loss in children.

How does noise exposure cause hearing loss?

Very loud sounds damage the inner ear by damaging the hair cells of the cochlea. When loud sounds are exposed to the ear for a short time, one may experience what’s called a temporary threshold shift, or a temporary hearing loss. This hearing loss may be accompanied by tinnitus (a ringing in the ears). One may recover from the temporary loss. But if the ear is exposed to loud sounds over longer periods of time, the hair cells can be permanently damaged, causing permanent sensorineural hearing loss.

Should MP3 player use be limited?

The maximum sound from an iPod Shuffle has been measured at 115 decibels, a level that can cause hearing loss to listeners of all ages. A survey sponsored by the Australian government found that about 25 percent of people using portable stereos had daily noise exposures high enough to cause hearing damage. Further research from the Netherlands reports that 90 percent of adolescents listened to music through earphones on MP3 players, almost half used high-volume settings, and only 7 percent used a noise limiter.

Researchers at Boston Children’s Hospital determined that listening to a portable music player with headphones at 60 percent of their potential volume for one hour a day is relatively safe. The maximum volume limit is adjustable on many current MP3 players.

Why earplugs are important at concerts

Parents should be aware that various medical studies have found sound levels at rock concerts often to be significantly higher than 85 dBA, with some reports suggesting that sound intensity may reach 90 dBA to as high as 122 dBA.

To experience 85 dBA, listen to an electric shaver or a busy urban street. If levels are maintained at values greater than 85 dBA for long periods of time, this may lead to a significant noise exposure. Frequent concertgoers may experience some potentially irreversible hearing loss from their experience.

A research study, “Incidence of spontaneous hearing threshold shifts during modern concert performances” (Opperman, Reifman, Schlauch, Levine; Otol-HNS 2006, 134:4: 667-673), examined sound intensity throughout a well known concert venue, and the effectiveness of earplugs. The findings stated that sound pressure levels appeared equally hazardous in all parts of the concert hall, regardless of the type of music played. Accordingly, you should use earplugs at every type of musical concert, regardless of your distance to the stage.

A good rule of thumb: When a child accompanies a parent to any activity or location with excessive noise, ear protection should be worn by the entire family.

Pediatric Food Allergies

Dust, mites, pet dander, and ragweed are not the only allergic threats to your child. Food allergies and sensitivities may cause a wide range of adverse reactions to the skin, respiratory system, stomach, and other physiological functions of the body.

Determining what foods are the cause of an allergic reaction is key to treatment. Before you identify the culinary culprit you must consider what type of food allergy your child has. There are two types, classified as:

• Fixed food allergies: A fixed food allergy may be very apparent, such as the child whose lips swell and throat itches immediately in response to eating peanuts. The cause for this type of food allergy is similar to that of inhalant allergies, so the diagnosis is more easily reached. Blood testing (i.e., RAST test) is typically used to verify fixed food allergies. Approximately 5 to 15 percent of food allergies are of the fixed variety.
• Cyclic food allergies: These allergies are far more common but less understood. Delayed food allergy symptoms can take up to three days to appear. This type of reaction is associated with the body’s immunoglobin G (IgG) or antibodies. Unlike fixed food allergies, this allergic response is cyclical in nature. As an example, a child may be IgG sensitive to milk. Consequently, symptoms might appear if the child increases the intake and/or frequency of milk consumption.

Both children and adults are susceptible to food allergies. The bad news for children is that they often have more skin reactions, such as eczema, to foods than do adults. But the good news for the young patient is that a child often outgrows his or her food sensitivities over time, even those that are positive on a RAST test. Food allergies may fade, and then inhalant (e.g, dust, ragweed) allergies may begin to manifest themselves.

Diagnosing and treating the cyclic food allergy

If your child is experiencing allergic reactions to food of unknown origin, you should ask, “Are there any foods that my child craves or any food that I avoid offering?” These foods may be the ones that are causing difficulties for the young patient.

Your physician may also suggest the Elimination and Challenge Diet. This dietary test consists of the following steps:

1. Keep a detailed food diary, tracking what was eaten (including ingredients), when it was eaten, medications taken, and any symptoms that developed. Be honest! Some well-meaning parents or caregivers often create a food diary that looks healthier than it really is. Your child can receive the best diagnosis if the diet records are accurate, timed precisely, and truthful. The diet diary can be evaluated by the doctor to identify food items that may be the culprits.
2. Conduct an elimination and challenge diet at home based upon your physician’s assessment of your child’s diet diary. It is best if you carefully maintain a new diet diary for your child during this period. During this diet, your child must abstain from one, and only one, of the possible food culprits at a time for a period of four days. This can be difficult to carry out if the food is very common, such eggs or cereal, so you need to pay strict attention to your child’s diet during the elimination phase. Any cheating will invalidate the results. On the fifth day, you will be asked to feed your child the suspected culprit food item. This is the challenge! Provide your child an average-sized portion of the food in question to be eaten in five minutes. In one hour the child should eat another half portion if no symptoms have developed. Any symptoms that develop are then timed and recorded. With a true cyclic food allergy, you would expect a significant worsening of the symptoms described in the original diet diary, although the challenge symptoms may vary as well.
3. If the Elimination and Challenge Diet confirms a cyclic food allergy, then you will be asked to abstain from feeding your child this food for a period of three to six months. After this time you can slowly reintroduce the food on a rotary basis; it is not to be eaten more frequently than every four days (once or twice a week).

For minor, moderate discomfort from the testing, the caregiver may choose to offer one the following: 1) a child’s laxative to decrease the transit time through the digestive system; 2) Alka Seltzer Gold®; 3) Buffered Vitamin C (one gram).

Fixed food allergies should never be deliberately challenged unless under the direct supervision of a physician.

Pediatric GERD (Gastro-Esophageal Reflux Disease) and Your Otolaryngologist

Everyone has gastroesophageal reflux (GER), the backward movement (reflux) of gastric contents into the esophagus. Extraesophageal Reflux (EER) is the reflux of gastric contents from the stomach into the esophagus with further extension into the throat and other upper aerodigestive regions. In infants, more than 50 percent of children three months or younger have at least one episode of regurgitation a day. This rate peaks at 67 percent at age four months. But an infant’s improved neuromuscular control and the ability to sit up will lead to a spontaneous resolute ion of significant GER in more than half of infants by age ten months and four out of five at age 18 months.

Researchers have found that 10 percent of infants (younger than 12 months) with GER develop significant complications. The diseases associated with reflux are known collectively as Gastro-Esophageal Reflux Disease (GERD). Physically, GERD occurs when a muscular valve at the lower end of the esophagus malfunctions. Normally, this muscle closes to keep acid in the stomach and out of the esophagus. The continuous entry of acid or refluxed materials into areas outside the stomach can result in significant injury to those areas. It is estimated that some five to eight percent of adolescent children have GERD.

What symptoms are displayed by a child with GERD?

GER and EER in children often cause relatively few symptoms until a problem exists (GERD). The most common initial symptom of GERD is heartburn. Heartburn is more common in adults, whereas children have a harder time describing this sensation. They usually will complain of a stomach ache or chest discomfort, particularly after meals.

More frequent or severe GER and EER can cause other problems in the stomach, esophagus, pharynx, larynx, lungs, sinuses, ears and even the teeth. Consequently, other typical symptoms could include crying/irritability, poor appetite/feeding and swallowing difficulties, failure to thrive/weight loss, regurgitation (“wet burps” or outright vomiting), stomach aches (dyspepsia), abdominal/chest pain (heartburn), sore throat, hoarseness, apnea, laryngeal and tracheal stenoses, asthma/wheezing, chronic sinusitis, ear infections/fluid, and dental caries. Effortless regurgitation is very suggestive of GER. However recurrent vomiting (which is not the same) does not necessarily mean a child has GER.

Unlike infants, the adolescent child will not necessarily resolve GERD on his or her own. Accordingly, if your child displays the typical symptoms of GERD, a visit to a pediatrician is warranted. However, in some circumstances, the disorder may cause significant ear, nose, and throat disorders. When this occurs, an evaluation by an otolaryngologist is recommended.

How is GERD diagnosed?

Most of the time, the physician can make a diagnosis by interviewing the caregiver and examining the child. There are occasions when testing is recommended. The tests that are most commonly used to diagnose gastroesophageal reflux include:

• pH probe: A small wire with an acid sensor is placed through the nose down to the bottom of the esophagus. The sensor can detect when acid from the stomach is “refluxed” into the esophagus. This information is generally recorded on a computer. Usually, the sensor is left in place between 12 and 24 hours. At the conclusion of the test, the results will indicate how often the child “refluxes” acid into his or her esophagus and whether he or she has any symptoms when that occurs.
• Barium swallow or upper GI series: The child is fed barium, a white, chalky, liquid. A video x-ray machine follows the barium through the upper intestinal tract and lets doctors see if there are any abnormal twists, kinks or narrowings of the upper intestinal tract.
• Technetium gastric emptying study: The child is fed milk mixed with technetium, a very weakly radioactive chemical, and then the technetium is followed through the intestinal tract using a special camera. This test is helpful in determining whether some of the milk/technetium ends up in the lungs (aspiration). It may also be helpful in determining how long milk sits in the stomach.
• Endoscopy with biopsies: This most comprehensive test involves the passing down of a flexible endoscope with lights and lenses through the mouth into the esophagus, stomach, and duodenum. This allows the doctor to get a directly look at the esophagus, stomach, and duodenum and see if there is any irritation or inflammation present. In some children with gastroesophageal reflux, repeated exposure of the esophagus to stomach acid causes some inflammation (esophagitis). Endoscopy in children usually requires a general anesthetic.
• Fiberoptic Laryngoscopy: A small lighted scope is placed in the nose and the pharynx to evaluate for inflammation.

What treatments for GERD are available?

Treatment of reflux in infants is intended to lessen symptoms, not to relieve the underlying problem, as this will often resolve on its own with time. A useful simple treatment is to thicken a baby’s milk or formula with rice cereal, making it less likely to be refluxed.

Several steps can be taken to assist the older child with GERD:

• Lifestyle changes: Raise the head of the child’s bed about 30 degrees while they sleep and have the child eat smaller, more frequent meals instead of large amounts of food at one sitting. Avoid having the child eat right before they go to bed or lie down; instead, let two or three hours pass. Try a walk or warm bath or even a few minutes on the toilet. Some researchers believe that certain lifestyle changes such as losing weight or dressing in loose clothing my assist in alleviating GERD. Even chewing sugarless gum may help.
• Dietary changes: Avoid chocolate, carbonated drinks, caffeine, tomato products, peppermint, and other acidic foods as citrus juices. Fried foods and spicy foods are also known to aggravate symptoms. Pay attention to what your child eats and be alert for individual problems.
• Medical Treatment: Most of the medications prescribed to treat GERD either break down or lessen intestinal gas, decrease or neutralize stomach acid, or improve intestinal coordination. Your physician will prescribe the most appropriate medication for your child.
• Surgical Treatment: It is rare for children with GERD to require surgery. For the few children who do require surgery, the most commonly performed operation is called Nissen fundoplication. With this procedure, the top part of the stomach (the fundus) is wrapped around the bottom of the esophagus to create a collar. After the operation, every time the stomach contracts, the collar around the esophagus contracts preventing reflux.

Pediatric Obesity and Ear, Nose and Throat Disorders

Today in the United States, studies estimate that 34 percent of U.S. adults are overweight and an additional 31 percent (approximately 60 million) are obese. Combined, approximately 127 million Americans are overweight or obese. Some 42 years ago, 13 percent of Americans were obese, and in 1980 15 percent were considered obese.

Alarmingly, the number of children who are overweight or obese has doubled in the last two decades as well. Currently, more than 15 percent of 6- to 11-year-olds and more than 15 percent of 12- to 19-year-olds are considered overweight or obese.

What is the difference between designated “obese” versus “overweight?”

Unfortunately, the words overweight and obese are often interchanged. There is a difference:

• Overweight: Anyone with a body mass index (BMI) (a ratio between your height and weight) of 25 or above (e.g., someone who is 5-foot-4 and 145 pounds) is considered overweight.
• Obesity: Anyone with a BMI of 30 or above (e.g., someone who is 5-foot-4 and 175 pounds) is considered obese.
• Morbid obesity: Anyone with a BMI of 40 or above (e.g., someone who is 5-foot-4 and 233 pounds) is considered morbidly obese. “Morbid” is a medical term indicating that the risk of obesity related illness is increased dramatically at this degree of obesity.

Obesity can present significant health risks to the young child. Diseases are being seen in obese children that were once thought to be adult diseases. Many experts in the study of children’s health suggest that a dysfunctional metabolism, or failure of the body to change food calories to energy, precedes the onset of disease. Consequently, these children are at risk for Type II Diabetes, fatty liver, elevated cholesterol, SCFE (a major hip disorder), menstrual irregularities, sleep apnea, and irregular metabolism. Additionally, there are psychological consequences; obese children are subject to depression, loss of self-esteem, and isolation from their peers.

Pediatric obesity and otolaryngic problems

Otolaryngologists, or ear, nose and throat specialists, diagnose and treat some of the most common children’s disorders. They also treat ear, nose and throat conditions that are common in obese children, such as:

Sleep apnea:

Children with sleep apnea literally stop breathing repeatedly during their sleep, often for a minute or longer, usually ten to 60 times during a single night. Sleep apnea can be caused by either complete obstruction of the airway (obstructive apnea) or partial obstruction (obstructive hypopnea—hypopnea is slow, shallow breathing), both of which can wake one up. There are three types of sleep apnea—obstructive, central, and mixed. Of these, obstructive sleep apnea (OSA) is the most common. Otolaryngologists have pioneered the treatment for sleep apnea; research shows that one to three percent of children have this disorder, often between the age of two-to-five years old.

Enlarged tonsils, which block the airway, are usually the key factor leading to this condition. Extra weight in obese children and adults can also interfere with the ability of the chest and abdomen to fully expand during breathing, hindering the intake of air and increasing the risk of sleep apnea.

The American Academy of Pediatrics has identified obstructive sleep apnea syndrome (OSAS) as a “common condition in childhood that results in severe complications if left untreated.” Among the potential consequences of untreated pediatric sleep apnea are growth failure; learning, attention, and behavior problems; and cardio-vascular complications. Because sleep apnea is rarely diagnosed, pediatricians now recommend that all children be regularly screened for snoring.

Middle ear infections:

Acute otitis media (AOM) and chronic ear infections account for 15 to 30 million visits to the doctor each year in the U.S. In fact, ear infections are the most common reason why an American child sees a doctor. Furthermore, the incidence of AOM has been rising over the past decades. Although there is no proven medical link between middle ear infections and pediatric obesity there may be a behavioral association between the two conditions. Some studies have found that when a child is rubbing or massaging the infected ear the parent often responds by offering the child food or snacks for comfort.

When a child does have an ear infection the first line of treatment is often a regimen of antibiotics. When antibiotics are not effective, the ear, nose and throat specialist might recommend a bilateral myringotomy with pressure equalizing tube placement (BMT), a minor surgical procedure. This surgery involves the placement of small tubes in the eardrum of both ears. The benefit is to drain the fluid buildup behind the eardrum and to keep the pressure in the ear the same as it is in the exterior of the ear. This will reduce the chances of any new infections and may correct any hearing loss caused by the fluid buildup.

Postoperative vomiting (POV) is a common problem after bilateral myringotomy surgery. The overall incidence is 35 percent, and usually occurs on the first postoperative day, but can occur up to seven days later. Several factors are known to affect the incidence of POV, including age, type of surgery, postoperative care, medications, co-existing diseases, past history of POV, and anesthetic management. Obesity, gastroparesis, female gender, motion sickness, pre-op anxiety, opiod analgesics, and the duration of anesthetic all increase the incidence of POV. POV interferes with oral medication and intake, delays return to normal activity, and increases length of hospital stay. It remains one of the most common causes of unplanned postoperative hospital admissions.

Tonsillectomies:

A child’s tonsils are removed because they are either chronically infected or, as in most cases, enlarged, leading to obstructive sleep apnea. There are several surgical procedures utilized by ear, nose and throat specialists to remove the tonsils, ranging from use of a scalpel to a wand that emits energy that shrinks the tonsils.

Research conducted by otolaryngologists found that:

Morbid obesity was a contributing factor for requiring an overnight hospital admission for a child undergoing removal of enlarged tonsils. Most children who were diagnosed as obese with sleep apnea required a next-day physician follow-up.

A study from the University of Texas found that morbidly obese patients have a significant increase of additional medical disorders following tonsillectomy and adenoidectomy for obstructive sleep apnea or sleep-disordered breathing when compared to moderately obese or overweight patients undergoing this procedure for the same diagnosis. On average they have longer hospital stays, a greater need for intensive care, and a higher incidence of the need for apnea treatment of continuous positive airway pressure upon discharge from the hospital. The study found that although the morbidly obese group had a greater degree of sleep apnea, they did benefit from the procedure in regards to snoring, apneic spells, and daytime somnolence.

What you can do

If your child has a weight problem, contract your pediatrician or family physician to discuss the weight’s effect on your child’s health, especially prior to treatment decisions. Second, ask your physician about lifestyle and diet changes that will reduce your child’s weight to a healthy standard.

Pediatric Sinusitis

Your child’s sinuses are not fully developed until late in the teen years. Although small, the maxillary (behind the cheek) and ethmoid (between the eyes) sinuses are present at birth. Unlike in adults, pediatric sinusitis is difficult to diagnose because symptoms of sinusitis can be caused by other problems, such as viral illness and allergy.

How Do I Know When My Child Has Sinusitis?

The following symptoms may indicate a sinus infection in your child:

• a “cold” lasting more than 10 to 14 days, sometimes with a low-grade fever
• thick yellow-green nasal drainage
• post-nasal drip, sometimes leading to or exhibited as sore throat, cough, bad breath, nausea and/or vomiting
• headache, usually in children age six or older
• irritability or fatigue
• swelling around the eyes

Young children are more prone to infections of the nose, sinus, and ears, especially in the first several years of life. These are most frequently caused by viral infections (colds), and they may be aggravated by allergies. However, if your child remains ill beyond the usual week to ten days, a sinus infection may be the cause.

You can reduce the risk of sinus infections for your child by reducing exposure to known environmental allergies and pollutants such as tobacco smoke, reducing his/her time at day care, and treating stomach acid reflux disease.

How Will the Doctor Treat Sinusitis?

Acute sinusitis: Most children respond very well to antibiotic therapy. Nasal decongestant sprays or saline nasal sprays may also be prescribed for short-term relief of stuffiness. Nasal saline (saltwater) drops or gentle spray can be helpful in thinning secretions and improving mucous membrane function. Over-the-counter decongestants and antihistamines are not general effective for viral upper respiratory infections in children, and the role of such medications for treatment of sinusitis is not well defined. Such medications should not be given to children younger than two years old.

If your child has acute sinusitis, symptoms should improve within the first few days of treatment. Even if your child improves dramatically within the first week of treatment, it is important that you complete the antibiotic therapy. Your doctor may decide to treat your child with additional medicines if he/she has allergies or other conditions that make the sinus infection worse.

Chronic sinusitis: If your child suffers from one or more symptoms of sinusitis for at least 12 weeks, he or she may have chronic sinusitis. Chronic sinusitis or recurrent episodes of acute sinusitis numbering more than four to six per year, are indications that you should seek consultation with an otolaryngologist (an ear, nose, and throat—ENT—specialist). The ENT may recommend medical or surgical treatment of the sinuses.

Diagnosis of sinusitis: If your child sees an ENT specialist, the doctor will examine his/her ears, nose, and throat. A thorough history and examination usually leads to the correct diagnosis. Occasionally, special instruments will be used to look into the nose during the office visit. An x-ray called a CT scan may help to determine how completely your child’s sinuses are developed, where any blockage has occurred, and confirm the diagnosis of sinusitis. The doctor may look for factors that make your child more likely to get sinus infection, including structural changes, allergies, and problems with the immune system.

When Is Surgery Necessary For Sinusitis?

Surgery is considered for the small percentage of children with severe or persistent sinusitis symptoms despite medical therapy. Using an instrument called an endoscope, the ENT surgeon opens the natural drainage pathways of your child’s sinuses and makes the narrow passages wider. This also allows for culturing so that antibiotics can be directed specifically against your child’s sinus infection. Opening up the sinuses and allowing air to circulate usually results in a reduction in the number and severity of sinus infections.

Also, your doctor may advise removing adenoid tissue from behind the nose as part of the treatment for sinusitis. Although the adenoid tissue does not directly block the sinuses, infection of the adenoid tissue, called adenoiditis (obstruction of the back of the nose), can cause many symptoms that are similar to sinusitis, namely, runny nose, stuffy nose, post-nasal drip, bad breath, cough, and headache.

Summary

Sinusitis in children is different than sinusitis in adults. Children more often demonstrate a cough, bad breath, crankiness, low energy, and swelling around the eyes, along with a thick yellow-green nasal or post-nasal drip. Once the diagnosis of sinusitis has been made, children are successfully treated with antibiotic therapy in most cases. In the rare child where medical therapy fails, surgical therapy can be used as a safe and effective method of treating sinus disease in children.

Pediatric Sleep Disordered Breathing /Obstructive Sleep Apnea

Overview of Sleep Disordered Breathing

Sleep-disordered breathing (SDB) is a general term for breathing difficulties occurring during sleep. SDB can range from frequent loud snoring to Obstructive Sleep Apnea (OSA) a condition involving repeated episodes of partial or complete blockage of the airway during sleep. When a child’s breathing is disrupted during sleep, the body perceives this as a choking phenomenon. The heart rate slows, blood pressure rises, the brain is aroused, and sleep is disrupted. Oxygen levels in the blood can also drop.

Approximately 10 percent of children snore regularly and about 2 – 4% of the pediatric population has OSA. Recent studies indicate that mild SDB or snoring may cause many of the same problems as OSA in children.

Could my child have Obstructive Sleep Apnea?

The most obvious symptom of sleep disordered breathing is loud snoring that is present on most nights. The snoring can be interrupted by complete blockage of breathing with gasping and snorting noises and associated with awakenings from sleep. Due to a lack of good quality sleep, a child with sleep disordered breathing may be irritable, sleepy during the day, or have difficulty concentrating in school. Busy or hyperactive behavior may also be observed. Bed-wetting is also frequently seen in children with sleep apnea.

A common physical cause of airway narrowing contributing to SDB is enlarged tonsils and adenoids. Overweight children are at increased risk for SDB because fat deposits around the neck and throat can also narrow the airway. Children with abnormalities involving the lower jaw or tongue or neuromuscular deficits such or cerebral palsy have a higher risk of developing sleep disordered breathing.

Potential consequences of untreated pediatric sleep disordered breathing

• Social: Loud snoring can become a significant social problem if a child shares a room with siblings or at sleepovers and summer camp.
• Behavior and learning: Children with SDB may become moody, inattentive, and disruptive both at home and at school. Sleep disordered breathing can also be a contributing factor to attention deficit disorders in some children.
• Enuresis: SDB can cause increased nighttime urine production, which may lead to bedwetting.
• Growth: Children with SDB may not produce enough growth hormone, resulting in abnormally slow growth and development.
• Obesity: SBD may cause the body to have increased resistance to insulin or daytime fatigue with decreases in physical activity. These factors can contribute to obesity.
• Cardiovascular: OSA can be associated with an increased risk of high blood pressure or other heart and lung problems.

How is sleep apnea diagnosed?

Sleep disordered breathing in children should be considered if frequent loud snoring, gasping, snorting, and thrashing in bed or unexplained bedwetting is observed. Behavioral symptoms can include changes in mood, misbehavior, and poor school performance. Not every child with academic or behavioral issues will have SDB, but if a child snores loudly on a regular basis and is experiencing mood, behavior, or school performance problems, sleep disordered breathing should be considered. If you notice that your child has any of those symptoms, have them checked by an otolaryngologist (ear, nose and throat doctor). Sometimes physicians will make a diagnosis of sleep disordered breathing based on history and physical examination. In other cases, such as in children suspected of having severe OSA due to craniofacial syndromes, morbid obesity, or neuromuscular disorders or for children less than 3 years of age, additional testing such as a sleep test may be recommended.

The sleep study or polysomnogram (PSG) is an objective test for sleep disordered breathing. Wires are attached to the head and body to monitor brain waves, muscle tension, eye movement, breathing, and the level of oxygen in the blood. The test is not painful and is generally performed in a sleep laboratory or hospital. Sleep tests can occasionally produce inaccurate results, especially in children. Borderline or normal sleep test results may still result in a diagnosis of SDB based on parental observations and clinical evaluation.

Treatment for sleep disordered breathing

Enlarged tonsils and adenoids are a common cause for SDB. Surgical removal of the tonsils and adenoids (T&A) is generally considered the first line treatment for pediatric sleep disordered breathing if the symptoms are significant and the tonsils and adenoids are enlarged.

Pediatric Thyroid Cancer

The thyroid is a butterfly shaped gland located at the base of the throat. It has two lobes separated in the middle by a strip of tissue (the isthmus). The thyroid itself secretes three main hormones: (1) Thyroxine contains iodine, needed for growth and metabolism; (2) Triiodothyronine, similar in function to Thyroxine, effects body size, tissues growth, and function: and (3) Calcitonin, which decreases the concentration of calcium in the blood and increases calcium in the bones. All three of these hormones have an important role in your child’s growth.

Thyroid cancer is the third most common tumor malignancy in children. It occurs six times more often in females than males and shares several characteristics with adult thyroid cancer patients. Surgery is the preferred treatment for this cancer and although the procedure is often uncomplicated, one of the risks of thyroid surgery involves vocal cord paralysis. Consequently, an otolaryngologist—head and neck surgeon should be consulted.

Types of thyroid cancer in children:

Papillary: This form of thyroid cancer occurs in cells that produce thyroid hormones containing iodine. This type, the most common form of thyroid cancer in children, grows very slowly.

Follicular: This type of thyroid cancer also develops in cells that produce thyroid hormones containing iodine. The disease afflicts a slightly older age group and is less common in children. This type of thyroid cancer is more likely to spread to the neck via blood vessels causing the cancer to spread to other parts of the body, making the disease difficult to control.

Medullary: This rare form of thyroid cancer develops in cells that produce calcitonin, a hormone that does not contain iodine. This cancer tends to spread to other parts of the body and constitutes about 5-10 percent of all thyroid malignancies. Medullary thyroid carcinoma (MTC) in the pediatric population is usually associated with multiple endocrine neoplasia type 2 (MEN2), an inherited genetic form of the cancer.

Anaplastic: This is the fastest growing of the thyroid cancers, with extremely abnormal cells that grow and spread rapidly, especially locally in the head and neck region. This form of cancer usually is found in older patients.

Symptoms:

The symptoms of this disease vary. Your child may have a lump in the neck, continuous swollen lymph nodes, a tight or full feeling in the neck, and/or trouble with breathing or swallowing, hoarseness.

Diagnosis:

If any of these symptoms occur, consult your child’s physician for a diagnosis. The diagnosis could consist of a head and neck examination to determine if unusual lumps are present; a blood test to indicate how the thyroid is functioning; a sonography, which uses high-frequency sound waves and a computer to create an image of the thyroid gland; a radioactive iodine scan, which provides information about the thyroid shape and function, identifying areas in the thyroid that do no absorb iodine in the normal way; fine needle biopsy, removal for study of a small part of the tumor; and surgery, where a procedure known as a thyroid lobectomy, necessitates removal of the lobe of the thyroid gland that contains the tumor, for analysis.

Treatments for thyroid cancer:

If the tumor is found to be malignant then surgery is used to remove as much of the tumor as possible either by lobectomy or subtotal thyroidectomy (removal of at least one thyroid lobe and up to a near-total removal of the thyroid gland). If necessary, the otolaryngologist— head and neck surgeon may remove the entire thyroid, in a procedure called a total thyroidectomy. Surgery may be followed by radioactive iodine therapy which destroys cancer cells that are left after surgery and help prevent the disease from returning Thyroid hormone therapy may need to be administered throughout your child’s life when he/she has had surgery to remove the thyroid followed by radioactive iodine treatment to replace normal hormones and slow the growth of cancer cells. If cancer has spread to other parts of the body, chemotherapy, the treatment of disease by means of chemical substances or drugs, may be given. This therapy interferes with the cancer cell’s ability to grow or reproduce. Different groups of drugs work in different ways to fight cancer cells and shrink tumors. In general, treatment outcomes for this type of cancer in children tend to be excellent. The best outcome is achieved with teenage girls, papillary type cancer, and a tumor localized to the thyroid gland.

Source: National Cancer Institute “Population-based Outcomes for Pediatric Thyroid Carcinoma,” by Nina L. Shapiro MD, and Neil Bhattacharyya MD, Laryngoscope. 2005 Feb;115(2):337-40.

Reduced Choking Risks

Tips for Early Education and Child Care Settings

High risk foods and food characteristics:

• Hard candy
• Peanuts/nuts
• Seeds
• Whole grapes
• Raw carrots
• Apples
• Popcorn
• Hot dogs
• Chunks of peanut butter
• Marshmallows
• Chewing gum
• Sausages
• Foods that are round and could conform to a child’s airway

Since 60% of non-fatal choking incidents result from food, let’s examine some ways to reduce the risk of choking while children are eating.

Reducing Food Choking Risks

1. Children should be seated when eating — Caregivers/Teachers should ensure that children do not eat when standing, walking, running, playing, lying down, or riding in vehicles.
2. Children should not be allowed to continue to feed themselves or continue to be assisted with feeding themselves if they begin to fall asleep.
3. Active supervision is a must—
   1. Watch children for “squirreling” of several pieces of food in their mouth. This increases the risk of choking.
   2. Remember a choking child may not make any noise, so adults must keep their eyes on children who are eating.
4. Children at this age require increased supervision when eating because they are easily distracted and may not pay full attention to the task of eating.
5. Food should not be used for children’s games that involve catching the food item in the mouth or stuffing large numbers or amounts of food in the mouth.
6. Cut foods such as grapes and other fruits, meat, cheese, and raw vegetables into small pieces and shapes that will not block the airways. Cut hot dogs lengthwise and well as widthwise.
7. Cook vegetables so they become softer and easier to swallow
8. Give only small amounts of peanut butter or other similar foods to prevent them for blocking the child’s airway.
9. Offer plenty of liquids to children when eating, but make sure liquids and solids are not swallowed at the same time.
10. Remember, foods do not contain warning labels about possible choking hazards.

“Reprinted with the permission of AAP News (January, 2011)”

Secondhand Smoke and Children

Insight into effects and prevention

• What is secondhand smoke?
• Who is at risk?
• and more…

Secondhand smoke is a combination of the smoke from a burning cigarette and the smoke exhaled by a smoker. Also known as environmental tobacco smoke (ETS), it can be recognized easily by its distinctive odor. ETS contaminates the air and is retained in clothing, hair, curtains, and furniture. Many people find ETS unpleasant, annoying, and irritating to the eyes and nose. More importantly, it represents a dangerous health hazard. Over 4,000 different chemicals have been identified in ETS, and at least 43 of these chemicals cause cancer.

Is exposure to ETS common?

Approximately 26 percent of adults in the United States currently smoke cigarettes, and 50 to 67 percent of children under five live in homes with at least one adult smoker.

Smoke’s effect on…

The fetus and newborn

Maternal, fetal, and placental blood flow change when pregnant women smoke, although the long-term health effects of these changes are not known. Some studies suggest that smoking during pregnancy causes birth defects such as cleft lip or palate. Smoking mothers produce less milk, and their babies have a lower birth weight. Maternal smoking also is associated with neonatal death from Sudden Infant Death Syndrome, the major cause of death in infants between one month and one year old.

Children’s lungs and respiratory tracts

Exposure to ETS decreases lung efficiency and impairs lung function in children of all ages. It increases both the frequency and severity of childhood asthma. Secondhand smoke can aggravate sinusitis, rhinitis, cystic fibrosis, and chronic respiratory problems such as cough and postnasal drip. It also increases the number of children’s colds and sore throats. In children under two, ETS exposure increases the likelihood of bronchitis and pneumonia. In fact, a 1992 study by the Environmental Protection Agency says ETS causes 150,000 – 300,000 lower respiratory tract infections each year in infants and children under 18 months old. These illnesses result in as many as 15,000 hospitalizations. Children of parents who smoke half a pack a day or more are at nearly double the risk of hospitalization for a respiratory illness.

The ears

Exposure to ETS increases both the number of ear infections a child will experience, and the duration of the illness. Inhaled smoke irritates the eustachian tube, which connects the back of the nose with the middle ear. This causes swelling and obstruction which interferes with pressure equalization in the middle ear, leading to pain, fluid and infection. Ear infections and middle ear fluid are the most common cause of children’s hearing loss. When they do not respond to medical treatment, the surgical insertion of tubes into the ears is often required.

The brain

Children of mothers who smoked during pregnancy are more likely to suffer behavioral problems such as hyperactivity than children of non-smoking mothers. Modest impairment in school performance and intellectual achievement has also been demonstrated.

Who is at risk?

Although ETS is dangerous to everyone, fetuses, infants, and children are at most risk because it can damage developing organs, such as the lungs and brain.

Secondhand smoke causes cancer

You have read how ETS harms the development of your child, but did you know that your risk of developing cancer from ETS is about 100 times greater than from outdoor cancer-causing pollutants? Did you know that ETS causes more than 3,000 non-smokers to die of lung cancer each year? While these facts are alarming for everyone, you can stop your child’s exposure to secondhand smoke right now.

What can you do?

• If you smoke, stop now. Consult your physician for help, if needed. There are many new pharmaceutical products available to help you quit.
• If you have household members who smoke, help them stop. If it is not possible to stop their smoking, do not allow them to smoke in your home or near your children.
• Do not smoke or allow smoking in your car.
• Be certain that your children’s schools and day-care facilities are smoke-free.

Acknowledgment is made to the American Academy of  Pediatric Otolaryngology for contributions to this content.

When Your Child Has Tinnitus

Tinnitus is a condition where the patient hears a ringing or other noise that is not produced by an external source. This disorder can occur in one or both ears, range in pitch from a low roar to a high squeal, and may be continuous or sporadic. This often debilitating condition has been linked to ear injuries, circulatory system problems, noise-induced hearing loss, wax build-up in the ear canal, medications harmful to the ear, ear or sinus infections, misaligned jaw joints, head and neck trauma, Ménière’s disease, or an abnormal growth of bone of the middle ear. In rare cases, slow-growing tumors on auditory, vestibular, or facial nerves can cause tinnitus as well as deafness, facial paralysis, and balance problems. The American Tinnitus Association estimates that more than 50 million Americans have tinnitus problems to some degree, with approximately 12 million people having symptoms severe enough to seek medical care.

Tinnitus is not uncommon in children. Although it is as common as in adults, children generally do not complain of tinnitus. Researchers believe that a child with tinnitus considers the noise in the ear to be normal, as it has usually been present for a long time. A second explanation of the discrepancy is that the child may not distinguish between the psychological impact of tinnitus and its medical significance.

Continuous tinnitus can be annoying and distracting, and in severe cases can cause psychological distress and interfere with your child’s ability to lead a normal life. The good news is that most children with tinnitus seem to eventually outgrow the symptom. It is unusual to see a child carry the problem into adulthood.

If you think your child has tinnitus, first arrange an appointment with your family physician or pediatrician. If the child does not have a specific problem with the ears such as middle ear inflammation with thick discharge, then it may be necessary to have your child referred to an otolaryngologist (ear, nose, and throat specialist).

What treatment may be offered.

Most people, including children, who are diagnosed with tinnitus find that there is no specific problem underlying their tinnitus. Consequently, there is no specific medicine or operation to “cure” the problem. However, experts suggest that the following steps be taken with the child diagnosed with tinnitus:

• Reassure the child: Explain that this condition is common and they are not alone. Ask your physician to describe the condition to the child in terms and images that they can understand.
• Depending on the nature of the tinnitus, the doctor may order further testing, such as a hearing test, a CT scan, or MRI.
• Explain that he/she may feel less distressed by their tinnitus in the future: Many children find it helpful to have their tinnitus explained carefully and to know about ways to manage it. This is partly due to a medical concept known as “neural plasticity,” where children’s are more able to change their response to all kinds of stimulation. If carefully managed, childhood tinnitus may not be a serious problem.
• Use sound generators or provide background noise. Sound therapy, which makes tinnitus less noticeable, has been used to treat adults for some time, and can also be used with children. If tinnitus occurs on a regular basis, with sound therapy the child’s nervous system can adapt to the condition. The sound can be environmental, such as a fan or quiet background music.
• Have hearing-impaired children wear hearing aids. A child with tinnitus and hearing loss may find that hearing aids can help improve the tinnitus. Hearing aids can pick up sounds children may not normally hear, which in turn will help their brains filter out their tinnitus. It may also help them by taking the strain out of listening. Straining to hear can make your child’s brain focus on the tinnitus noises.
• Help your child to sleep with debilitating tinnitus. Severe tinnitus may lead to sleep difficulties for the young patient. Ask your otolaryngologist the best strategy to adopt if your child cannot sleep.
• Finally, help your child relax. Some children believe their tinnitus gets worse when they are under stress. Discuss appropriate stress-relieving techniques with your pediatrician or family physician.