Headaches in Children

Monika Pis, PhD, CPNP

Headaches are common in children. However, they are always a reason for concern for parents, because their children may not be able to describe their headaches. They may become cranky, withdrawn, vomit, or prefer a darkened room. The most common causes of headaches in children are migraines, eye problems, sinus infections, and lifestyle.





Migraines
Research shows that 4% of children between 7 and 15 years of age experience migraines. Before age 10 years, boys are more likely to have migraines, but after puberty, girls are more likely to develop them. A family history of migraines, especially on the maternal side, is present in approximately 90% of children with migraines. In adulthood, 5-10% of men and 15-20% of women experience migraines. 

Factors that contribute to migraines include family history, hormonal changes, stress, bright flashing lights, and foods (see below). History of motion sickness in childhood is associated with migraines later in life as well.

Foods that may provoke migraines:
 Cheese 
 Chocolate 
 Herring 
 Soybeans 
 Nuts 
 Yeast (especially in homemade bread)
 Dried fruits (raisins)
 Mushrooms 
 Salty foods 
 Red plums 
 Ripe avocados and bananas
 Lunch meat (nitrates)
 Caffeine
 Alcohol

A common migraine in children is characterized by a throbbing or pounding headache that usually lasts 1-3 hours, but may persist for up to 24 hours. A migraine headache is often accompanied by intense nausea, vomiting, and abdominal pain. On occasion, children complain about aversion to odors, light, or noise, as well as tingling in the feet and hands during a migraine headache or experience an aura before the onset of the headache. Visual auras are not common in children, but may include blurred vision, distortion of objects, zigzags, or flashes of light. Some children complain about dizziness or light-headedness. 

Eye Problems
Nearsightedness in infants and school age children is not common. Its incidence increases during the school years, especially during the preteen and teen years. However, if your child has been complaining of headaches for a while, and perhaps you’ve noticed that he/she squints to see faraway objects or comes close to the television set, a visit to an optometrist is recommended. Poor vision produces eye muscle strain that may lead to headaches. If your child’s headaches do not go away after their vision is corrected, or if they are ever accompanied by the red flag symptoms (see below), take your child to a health care provider for an evaluation ASAP.

Symptoms to Worry About 
 Rapid onset of the first headache
 The worst headache ever
 Progressive headache lasting for days
 Headache present with straining (during coughing, sneezing, bowel movement)
 Weight loss or fever
 Seizures
 Loss of consciousness
 Stiff neck
 Morning headache, possibly accompanied by vomiting

If your child experiences any of the above symptoms, consult with a health care professional ASAP!

Sinus Infections
On occasion, a cold or uncontrolled allergies may turn into a sinus infection. Usually, cold symptoms are the worst on days 3 and 4 and then gradually improve. A sinus infection should be suspected if your child’s cold symptoms are more severe than usual, or if the symptoms persist for longer than 10 days. Headaches are very common with sinus infections and your child may complain of facial and tooth pain. If you suspect a sinus infection, take your child to her/his health care provider, as antibiotics are needed to treat the symptoms. 

Lifestyle
Many headaches in children can be contributed to irregularities in their lifestyles. For example, sleeping in or staying up late over the weekend, or skipping meals can result in headaches. This can be easily prevented by exercising good sleep hygiene (see below) and eating regular meals: breakfast, lunch, and dinner, and healthy snacks in between (listed below).

Practicing good sleep hygiene:
 Go to bed and wake up at the same time each day
 Avoid napping during the day
 Avoid caffeine 4-6 hours before bedtime
 Avoid heavy, spicy, or sugary foods 4-6 hours before bedtime
 Exercise regularly, but not right before bed
 Try a light snack before bed
 Establish a pre-sleep ritual

Healthy snacks:
 Fresh fruit
 Cheese packs or cubes
 Yogurt
 Cheese or peanut butter on low-fat crackers
 Pretzels
 Trail mix
 Dried fruits
 Granola bars
 Whole wheat pizza w/hummus
 Low-fat, microwave popcorn
 Veggies w/low-fat dip or yogurt
 Bananas or apples w/peanut butter and cream cheese
 Baked taco chips w/salsa

Soothe Your Sore Throat!

Monika Pis, PhD, CPNP

When the flu season is upon us, other viruses circulating in our communities contribute to cold symptoms such as sore throats, which make us feel cranky and uncomfortable.

Since viruses are the major cause of sore throats, there are no medications to alleviate them, however, there are certain natural remedies that will make your sore throat feel better while your body fights off the infection.

First of all, stay hydrated. If your sore throat is accompanied by other upper respiratory symptoms, such as runny nose, nasal congestion, or cough, drink chicken broth a couple times a day. Recent research confirmed what moms always told us about chicken soup: it definitely helps when we're sick! According to the scientific findings, chicken broth thins mucus in the respiratory system, stops excessive mucus production, and relieves nasal congestion. Therefore, chicken broth will lessen coughing and might decrease postnasal drip that often results in a sore throat.

Excessive coughing can also cause a sore throat. Since cough medications are ineffective in battling the cough, reach for honey. Any honey will do, however, researchers studied buckwheat honey and announced that it is more effective in cough control than dextromethorphan, the DM component of over-the-counter cough suppressants. I recommend that my patients take 1 teaspoon of honey 4 times a day. It can be eaten off the spoon, ingested with warm water or tea with lemon, or drizzled on toast with butter, pancakes, or graham crackers. (Note: honey should not be given to children younger than 1 year as it may cause botulism).

Consider these remedies to relive your sore throat:

 Gargle with chamomile tea--it has anti-inflammatory properties.

 Drink orange juice. It might sting, but the vitamin C will numb your throat instantaneously.

 Munch on raw almonds. They contain an aspirin-like compound that works wonders, not only to relieve migraine headaches, but also sore throats.

 Eat fresh or canned pineapple. Pineapple contains bromelain, an enzyme with anti-inflammatory properties.

 Sip on a warm tea with honey and lemon. Honey will coat your throat and the lemon juice will quickly numb it.

If your sore throat persists beyond 3-4 days, or is accompanied by a fever, rash, or bad headache, you have a difficult time swallowing your saliva, or you choke on food, see your health care provider ASAP.

The MMR Vaccine and Autism: What's the Connection?

Anna Tielsch-Goddard CPNP-PC

Worldwide vaccination of our children has provided major advantages to protecting against infectious diseases that in the past 100 years has claimed the lives of millions.

Diseases that are preventable by vaccines still occur throughout the United States. It is a myth though that just because we do not see these diseases as much anymore, we need to stop vaccinating against them.

One of the largest recent measles outbreaks took place in 2008 in San Francisco, California and was routed to one patient, an unvaccinated 7-year-old boy. He traveled to Switzerland where he contacted the measles and then returned to California. Subsequently, he infected 836 children. Vaccinating your children protects not only them, but also other kids who come in contact with them (a concept in epidemiology known as "herd immunity").

There is a common misconception that the MMR vaccine causes or is linked to Autism or the Autism Spectrum Disorder. This erroneous belief began after a physician, Dr. Wakefield, published a study in a journal called The Lancet (which was ran on the first page of the journal) that claimed that there was a correlation (meaning a connection, NOT a cause and effect) of the MMR vaccine with autism.  Dr. Wakefield was being paid money by a law firm to “prove” that vaccines caused harm to patients.  In 2004, the co-authors that published this article requested to take their names off the paper. Finally, in 2009, The Lancet retracted the article and Dr. Wakefield's medical license was revoked for falsifying data.  Both the retraction of an article by a distinguished journal and taking away a physician’s medical license are huge offenses that do not commonly happen in the health care field. Unfortunately, the article's retraction, the claims of data falsification, and the revocation of Dr. Wakefield's license for misconduct, was ran on the 12-th page of the journal and did not receive nearly as much press as the initial 1998 claim. This contributed to the continued public misconception and fear of the correlation of MMR vaccine and Autism.

Some parents might report seeing regressive autism symptoms shortly after the administration of the MMR vaccine. This is coincidental, because autism symptoms start to emerge around 12-18 months of age, and the MMR vaccine is administered right after the first birthday. Numerous research studies done by scientists, both nationally and internationally, have shown that autism symptoms are not caused by vaccines. The Center of Disease Control (CDC) has also stood behind these very thorough assessments and rigorous research efforts. More than 1,000 research articles have been published and reviewed by the Institute of Medicine that have not found vaccines to cause autism.

Many people argue that they have found “proof” and “claims” that vaccines cause autism from the Internet or Google research.  The public needs to be very careful when finding information in non-medical or non-health care sites or articles that are available through the World Wide Web, specifically if they have not been reviewed by medical professionals.  Although the Internet has provided society with instant access to information, not all of this information is correct, it can also be misleading and provide false claims.

All current evidence shows that vaccines do not cause autism, so delaying or withholding vaccines will not lessen the risk of autism; it will only increase the period of time during which children are at risk for vaccine-preventable diseases.

Article References and to Find More Information:

Andrews N, Miller E, Grant A, Stowe J, Osborne V, Taylor B. (2004). Thimerosal exposure in infants and developmental disorders: a retrospective cohort study in the United Kingdom does not support a causal association. Pediatrics. 114:584-591.

Centers of Disease Control (CDC): Immunization Safety and Autism – Thimerosal and Autism Research Chart. Available at: http://www.cdc.gov/vaccinesafety/00_pdf/VSD_Chart_of_Autism_Studies-Updated_Sep_27_2010.pdf

Center for Disease Control (CDC). Measles, Mumps, and Rubella (MMR) Vaccine Safety: Available at: http://www.cdc.gov/vaccinesafety/Vaccines/MMR/MMR.html

Center for Disease Control (CDC). Vaccine Safety Centers of Disease Control and Prevention: Available at: http://www.cdc.gov/vaccinesafety/Concerns/thimerosal

Center of Disease Control (CDC). Outbreak of Measles --- San Diego, California, January--February 2008 MMWR February 22, 2008 / 57 (Early Release);1-44. Available at:http://www.cdc.gov/mmwr/preview/mmwrhtml/mm57e222a1.htm

DeStefano F, Bhasin TK, Thompson WW, Yeargin-Allsopp M, Boyle C. (2004). Age at first measles-mumps-rubella vaccination in children with autism and school-matched control subjects: a population-based study in metropolitan Atlanta. Pediatrics; 113:259-266.

DeStefano F, Chen RT. (1999). Negative association between MMR and autism. Lancet. 353: 1986-1987.

Farrington CP, Miller E, Taylor B.(2001).  MMR and autism: further evidence against a causal association. Vaccine. 19: 3632-3635.

Fombonne E, Chakrabarti S. (2001). No evidence for a new variant of measles-mumps-rubella-induced autism. Pediatrics. 108: E58.

Honda H, Shimizu Y, Rutter M. (2005). No effect of MMR withdrawal on the incidence of autism: a total population study. J Child Psychology Psychiatry. 46:  572-579.

Heron J, Golding J. Thimerosal exposure in infants and developmental disorders: a prospective cohort study in the United Kingdom does not support a causal association.
Pediatrics. 2004; 114: 577-583.

Hubbard, S. (2011). Autism and Vaccine Details. The Kids Dr. Available at:http://www.kidsdr.com/your-baby/autism-vaccine-report

Infectious Diseases in Children. October 2011. IOM: Vaccines do not cause autism. Available at: http://www.pediatricsupersite.com/view.aspx?rid=87016

Kimerblin, D. (Oct 2011).  The wars of the world: Saving lives through vaccination.  Infectious Diseases in Children.  Available at:http://www.pediatricsupersite.com/view.aspx?rid=87076

Stehr-Green P, Tull P, Stellfeld M, Mortenson PB, Simpson D. (2003). Autism and thimerosal-containing vaccines: lack of consistent evidence for an association.
American Journal of Preventive Medicine.  25: 101-106.

Vaccine Education Center at the University of Pennsylvania: Vaccines and Autism. Available at:  http://www.chop.edu/export/download/pdfs/articles/vaccine-education-center/autism.pdf

Vaccine Adverse Event Reporting System (VAERS). Available at:http://vaers.hhs.gov/index

ANNA TIELSCH-GODDARD CPNP-PC Anna Tielsch-Goddard CPNP-PC is a Pediatric Nurse Practitioner for Children’s Medical Center Dallas at Legacy. She practices on the Perioperative Surgery teams in both presurgical assessment and pediatric-surgery.

Jaundice of the Newborn

Monika Pis, PhD, CPNP

Hyperbilirubinemia, also known as jaundice, is a common condition in newborns, as it is observed in 60% of full-term and 80% of pre-term infants. In most cases, jaundice is a benign condition. Nevertheless, symptoms must be recognized and treated appropriately to prevent the neurological toxicity called kernicterus (see below). 

In utero, infants rely on oxygen supply from the mom’s bloodstream. In order to transport as much oxygen as necessary to the developing vital organs, unborn babies have an extra amount of red blood cells (RBC) that carry oxygen where it’s needed. After birth, those additional RBC are no longer necessary and start to break down, producing bilirubin, the yellow pigment that accumulates in the skin and eyes, called jaundice.

The so-called physiological jaundice occurs in more than 50 percent of newborns. The bilirubin levels rise on day 2-4 of life and are caused by the slow processing of bilirubin by the immature liver. The physiological jaundice may last for 1-2 weeks and the levels of bilirubin that are reached are harmless.

About 5-10 percent of breastfed newborns may have breast-feeding jaundice. This type of jaundice is caused by inadequate intake of breastmilk, thus dehydration and inadequate caloric intake. It appears around day 2-4 of life and lasts for 1-2 weeks.

The third type of jaundice is breast-milk jaundice that occurs in 1-2 percent of babies who are breastfed. This type of jaundice is related to an enzyme secreted in breast milk. This enzyme is responsible for increased absorption of bilirubin from the intestines. The breast-milk jaundice starts on at 4-7 days of life and may last for 3-10 weeks.

If your infant was born jaundiced or jaundice occurred within the first 24 hours after birth, she may have jaundice related to blood incompatibility. If the mom and the baby have different blood types, the mom may start to produce antibodies that destroy the newborn’s RBC. This causes sudden buildup of high levels of bilirubin that is evident within the first day of life. Should that happen, the infant will be placed under special lights (phototherapy) that will help her bilirubin levels decrease rapidly. Very rarely, when the levels of bilirubin do not decrease with desired speed, the baby may require a blood transfusion to prevent kernicterus.

Treatment 

To make sure that your infant is healthy and safe, always follow the advice given to you at the hospital or at your health care provider’s office. Determining the cause of jaundice and assessing the level of bilirubin in your newborn is always very important in order to prevent possible serious complications.

If your health care provider decides that your baby has physiological jaundice, you will need to feed you infant frequently (every 1-2 hours) and place her by the window, so that she is exposed to daylight. Frequent feedings will promote frequent bowel movements with which bilirubin will be excreted. In addition, resting in a sunny spot will help your infant’s body breakdown bilirubin more readily--thus jaundice should improve faster!

If your newborn is diagnosed with breast-feeding jaundice, your health care provider may suggest more frequent feedings, or alternating breastfeeding and formula bottles. And if breast-milk jaundice seems to be the problem, you may need to stop breastfeeding for 48 hours and supply your infant with formula during that time.

Whatever the cause of your newborn’s jaundice, if you are uncomfortable with how she looks or acts, NEVER hesitate to contact your health care provider for advice.

What is Kernicterus?

Kernicterus is a neurologic syndrome resulting from bilirubin accumulationg in brain cells. The duration of exposure to higher levels of bilirubin to produce toxic effects is unknown. Kernicterus is usually associated with bilirubin levels >20mg/dL. The initial sign and symptoms are lethargy, poor feeding, and loss of Moro reflex. Progressively, the infant may start to appear very ill, experience respiratory distress, convulsions, and produce a shrill high-pitched cry. Survivors of kernicterus may experience mental retardation, deafness, and spastic quadriplegia. To help prevent this condition, always follow-up with your health care provider as directed at the hospital or in the office.

Hippotherapy and Autism

Monika Pis, PhD, CPNP

The word hippotherapy is derived from the Greek word "hippo," which means "horse." It describes physical, occupational, or speech therapy that uses the multidimensional movement of a walking horse to stimulate the rider and help enhance balance, good posture, mobility, coordination, and strength. Often, hippotherapy aids mental functioning, improves mood and self-confidence as well.

The rhythmic and multidimensional movement of the horse provides variable yet repetitive sensory stimulation to patients. That stimulation can be varied and manipulated by a trained therapist to fit a patient's needs and stimulate improved functioning of daily living. For example, physical therapists can use a variety of horse movements to improve gross motor abilities, such as sitting, standing, and walking.

According to the American Hippotherapy Association, hippotherapy is indicated for children and adults with mild to severe neuromuscular dysfunction. It aids impairments such as abnormal muscle tone; impaired balance, coordination, and sensory function; postural asymmetry; poor postural control; and decreased mobility. Hippotherapy has been used for conditions such as cerebral palsy (CP), developmental delays, traumatic brain injury, stroke, and autism.

Hippotherapy has been used in the U.S. since the 1970’s. However, it is still considered an experimental and investigational treatment because there is insufficient scientific evidence for its effectiveness in the treatment of CP, autism, and other conditions characterized by motor dysfunction.

A recent study by Bass, Duchowny, and Llabre (2009) examined the effects of a 12-week-long therapeutic horseback intervention on social functioning in children with autistic spectrum disorder. The results showed improved social interaction and less inattention and distractibility in autistic children. These findings indicate that hippotherapy may have a place in the treatment of children with autism. However, more studies need to demonstrate its therapeutic effectiveness before hippotherapy is widely recommended as a treatment for autism. 
Reference:
Bass, M., Duchowny, C., & Llabre, M. (2009). Journal of Autism and Developmental Disorders, 39(9), 1261-7.

Resources: 
Joanna Jodko Photography
American Hippotherapy Association
Autism Society of America 
Autism Speaks 
CDC
Autism Research Institute

Language Development: 12 to 24 Months

Monika Pis, PhD, CPNP

Language development is intricately woven together with cognitive development. Often an infant’s gestures are a part of their emerging language. For example, a 1-year-old may point to a bottle of juice and grunt, letting her parent know that she wants it. Symbolic gestures at 13 months are highly correlated with future language ability. Children who have a rich gesture communication system in toddlerhood are likely to develop normal linguistic skills even if they are late bloomers.

The acquisition of new words between 12 to 18 months is slow. By 18 months of age, a toddler should say at least 5 words and understand more than 50.

2-year-olds start to show an understanding of the rules of language by putting words together. At this age the child produces more than 50 words, follows 2-step commands, points to objects and names them, and uses words to request things. She also develops new words daily, and may get confused if adults talk to her like a baby.

Receptive language is always ahead of expressive language, thus children will always understand more than what they are able to say. This usually results in moderate frustration due to inability to express feelings and desires, and temper tantrums might emerge. To prevent these kinds of temper tantrums, read to your child daily from birth. Reading together is a quality family time, and studies show that by making a habit of it, you will assist your child in early language acquisition. 

Developmental Milestones: Birth to 6 Months

Monika Pis, PhD, CPNP

Babies develop at all different rates but here's what to look for from newborn to 6 months of age.

Newborn to 2 months
The first two months of your baby’s life is a time of adjustment into her new environment. She will learn new sounds and become comfortable with her surroundings. This period is also the time for new parents to get to know their newborn.

From the very first days, your newborn knows how to communicate with her bodily movements, facial expressions, and sounds. Observe and listen to her carefully and in a very short time, you’ll be able to distinguish a hungry, tired or bored cry. Also, you’ll know when your baby needs a break from what she is doing because she will look away, arch her back, frown, or cry.

In the first two months of life, mutual gaze is a powerful form of socialization. Let you baby watch your face and exchange looks. Show your infant a colorful toy and slowly move it from side to side, allowing her gaze to follow the toy. Interaction with your baby will strengthen your bond, as well as help strengthen the eye muscles. 

Studies show that reading to you infant from a very young age allows for early acquisition of language skills. Therefore, spend a few minutes every day reading to your baby. You can also talk to her about your day and even sing--it makes for good family time and above all, your baby will love to listen to your voice!·

Milestones you should look for:

1-2 weeks:
- Responds to noise
- Looks at your face
- Tries to lift head when placed on the belly

2 months:
- Responds to noise
- Makes baby sounds
- Smiles back at you
- Follows people with her eyes
- Holds head up 45 degrees when placed on the belly

Things to do to enhance your baby's development:
- Read daily to your baby
- Observe to learn your baby's needs
- Respond to cries. It teaches your baby trust and that she is loved.

Age 2-6 months

Infants between 2 and 6 months of age are very interactive. They love to imitate anything that helps them learn new skills. For example, if mom sticks her tongue out, baby will usually do the same. This game teaches the infant the art of communication. Babies this age love to discover their voices, so you may hear your baby coo or babble frequently. As she coos and babbles, talk and babble back to her, as if you both understand each other very well. This exercise also teaches your baby how to communicate and, at the same time, lays groundwork for developing extensive vocabulary later on. 

At about 3-4 months of age, babies start to laugh out loud, they can sit with support, and grasp a rattle. Soon, at about 6 months of age, they’ll be reaching out for objects. Since infants learn by looking at, holding, and putting objects into their mouths, keep all small objects out of your baby’s reach. It’s good to remember the toilet paper roll rule: objects that can fit through a toilet paper tube, including plastic bags and deflated balloons, are too small for children younger than 3 years.

Closer to 5-6 months, babies start to have a better control over their bodies. They will be able to roll over, pull up to sit without a head lag, and transfer objects from hand to hand.

Milestones to you should look for:

4 months:
- Rolls over
- Sits with support (keeps head steady)
- Grasps a rattleLaughs out loud
- Holds head up 90 degrees when placed on the belly
- Looks around 180 degrees

6 months:
- Reaches for objects
- Transfers objects form hand to hand
- Bears weight on legs when standing up with support

Things to do to enhance your baby’s development:
- Talk and babble with your baby back and forth
- Read daily
- Lay baby on back and hold brightly colored toy over her chest to promote reaching
- Introduce one toy at the time to allow for exploration