Conway Children’s Clinic & Greenbrier Children’s Clinic Andy Connaughton M.D., F.A.A.P. Rhonda Holland M.D., F.A.A.P. Judy Michaels M.D., F.A.A.P. Pebble Sutherland M.D., F.A.A.P. Kelly Staley M.D., F.A.A.P. Chris Killingsworth M.D. Debbi Wingfield A.P.N., C.P.N.P. Misty Birdwell A.P.N., F.N.P. Lisa Martin A.P.N., F.N.P. Kirsten Kravitz A.P.N., C.P.N.P.

Conway phone 501-327-6000

Greenbrier phone 501-679-6796

Conway Regional Medical Exchange 501-329-1199 or 1-800-811-9926 Poison Control 1-800-376-4766 1-800-3POISON Office Hours Monday - Friday….……………………..7:00 a.m.- 4:30 p.m.

Our Greenbrier location Clinic Phone 501-679-6796 Greenbrier Children’s Clinic is a satellite clinic owned and operated by the physicians of Conway Children's Clinic. For insurance and patient care purposes, the Conway and Greenbrier Clinics function as a single clinic. A child may be seen at either location, and any of our physicians may be listed as the primary care provider. When the Greenbrier Clinic is closed, the telephone is sometimes forwarded automatically to Conway, so you may dial Greenbrier and speak with a receptionist in Conway. Be sure and ask whether your appointment is in Greenbrier or Conway. Office Hours Monday - Friday…………………………8:00 a.m.- 4:30 p.m.

TABLE OF CONTENTS

I.

Introduction

II.

Clinic Policies and Procedures

III.

General Parenting Tips

IV.

Medicine Cabinet Necessities

V.

Medications and Dosages

VI.

Well Child Care and Immunizations

VII.

Common Medical Problems -- Newborn

VIII.

Common Medical Problems -- Older Infants and Children

IX.

Common Injuries --Trauma and Poisoning

I. INTRODUCTION The physicians and staff of our clinic are dedicated to providing quality pediatric care for your child. We appreciate the opportunity to share in your child’s growth and development. We welcome your questions and comments if you feel that there are ways in which our clinic can improve. Please direct your concerns to a physician or to our office manager.

Please sit down and spend an hour or so reading through this book. By familiarizing yourself with it in advance, you will become aware of the potential benefits when you have questions or problems later. If you have not read the book previously, it may not occur to you (in the middle of a crisis!) that your questions are answered here.

II. CLINIC POLICIES AND PROCEDURES APPOINTMENTS Clinic hours are listed at the front of this booklet. Patients with emergencies will be treated as quickly as possible. All other patients are seen by appointment. There is a $25 charge for missed appointments that are not cancelled in advance. “Walk-in” patients who do not require emergency care may be given an appointment at a later time.

WHO IS MY DOCTOR? We encourage you to identify with one physician or nurse practitioner as your child’s primary caregiver. Well child checkups can be scheduled in advance with this person. We appreciate your cooperation in seeing someone else when your primary caregiver is unavailable for a sick visit.

TELEPHONE CALLS Our staff is available to advise you when you have questions that are not answered sufficiently in this book. During office hours, a nurse will return most calls. The nurse may consult the physician or ask the physician to return the call if necessary. Most calls are handled on a “first-come” basis and may not be returned immediately. If your question or problem is urgent, please inform the receptionist so that the nurse or physician will be notified immediately. After-hours calls are for emergency or urgent medical questions. Please consult this book prior to such a call. Our calls are returned by Registered Nurses based at Arkansas Children’s Hospital. They have extensive training regarding telephone consultation and follow guidelines approved by our physicians. The nurse will consult with the physician on call for our clinic, if needed. If your call is not returned within 30 minutes, please call again. If for some reason the answering service is not functioning properly, the physician can be paged through the Conway Regional Medical Exchange (329-1199 or 1-800-8119926).

Always have available a pencil and paper as well as your pharmacy phone number.

GUIDELINES FOR HANDLING EMERGENCIES When time permits, call the physician before taking your child to the emergency room. Often these expensive visits can be avoided. If emergency care is required, an emergency department physician will evaluate your child. In some circumstances the pediatrician will be called to see your child also. The following problems are true emergencies. Call 911 or take your child immediately to the nearest emergency room. -Severe breathing difficulty with rapid respirations, turning blue, wheezing or choking. -Allergic reaction with breathing difficulty. -Loss of consciousness or seizures. The following problems may require emergency room treatment. Call the on-call physician immediately. (In some of the following instances you may appropriately decide to use the emergency room without first contacting a physician.) -Cut requiring stitches. -Uncontrolled bleeding. -Poisonous snake bite. -Serious accident. -Suspected broken bone. -Poisoning or accidental ingestion of drug. -Burn. -Wild animal bite. -Severe abdominal pain lasting more than 2 hours. -Bloody bowel movements in an infant less than 6 months of age. -Eye injury. -Stiff neck with fever, lethargy, or irritability. -Temperature 100.5 (rectal) or greater in an infant under 3 months of age.

BILLING Our clinic policy requires that all new patients pay at the time of their first visit to our office. For established patients credit can be arranged if necessary. If you are unable to maintain your account on a monthly basis, please consult our bookkeeper.

At each visit you will receive an itemized statement for services rendered. This information may be used for filing insurance claims and should be retained for income tax purposes.

III. GENERAL PARENTING TIPS AUTOMOBILE SAFETY One of the most important things you can do as a parent is to comply with the law and use an approved car seat or the seatbelt. Arkansas law requires that all babies and children should use a child safety seat until they reach age 6 years or weigh 60 pounds. However Newer Recommendations are much stricter than Arkansas law. We recommend the following:    

Use a rear facing seat until age 2 years or until your child reaches the height and weight allowed for your rear facing seat. After age 2 years use a forward facing child safety seat with harness until your child reaches the maximum weight and height. After the seat with harness is outgrown, a booster seat should be used until your child reaches the height of 4’9” (approximately age 8-12 years). All children should ride in the rear seat until age 12 years.

As a parent, you can model safe and legal behavior by always wearing your seatbelt.

SMOKE EXPOSURE Exposing your child to smoke places your child at increased risk for a variety of illnesses, including asthma, chronic nasal congestion, and ear infections. One way to partially protect your child from smoke is to smoke outside. Indoor smoke spreads evenly throughout the house. Your child is not protected by your smoking in another room. More importantly, children of smokers are more likely to begin smoking themselves. Your child respects your opinion and will imitate your behaviors. If you have a sincere desire to stop smoking, we recommend that your consult your physician or enroll in a smoking cessation program.

DAY CARE AND BABYSITTERS Many of our younger patients are cared for by a babysitter or are enrolled at a day care center. We understand and support the needs of working parents to find quality child care. We encourage you to take such decisions very seriously. Evaluate a variety of options before choosing what is best for your child. Your

child’s health, safety, emotional well-being, and mental and physical development are all important factors to be considered. We would be happy to discuss the options with you if you need help in deciding. Church nurseries and other optional group situations should be avoided prior to 3 months of age.

SUDDEN INFANT DEATH SYNDROME (SIDS) PREVENTION There are several things parents can do to help prevent SIDS or Sudden Infant Death Syndrome (“crib death“). A young infant should always be placed on his or her back to sleep, rather than lying on the stomach or side. Sleeping on the side is not a safe alternative and “wedges” and other positioning devices are not recommended. This “back to sleep” recommendation has resulted in a huge decrease in the SIDS rate. There should be no smoke of any kind in the house where a baby lives. Exposure to cigarette smoke increases a baby’s risk of SIDS. Pacifiers may be helpful if used between 1 and 6 months of age and have been shown to reduce the risk of SIDS. Breastfeeding should be well established before a pacifier is introduced so the pacifier will not interfere with the baby learning to breastfeed. Breastfeeding helps a baby fight off the infections that contribute to SIDS. The baby’s sleeping environment should not be overly warm and there should be no loose objects (blankets, toys, sheepskins, etc.) in the crib. The baby is safer sleeping in a separate bed. Some parents may bring the baby into their bed for nursing and comfort but the baby should return to the crib when the baby and parents are sleeping. On the other hand, sleeping in the same room with the parents does lower the risk of SIDS. Perhaps most importantly, make sure that other caregivers know the importance of all of these measures, especially placing the baby in the “back to sleep” position.

BEHAVIOR GUIDELINES Listed below are some suggestions regarding how to interact with your children in positive ways. While each child’s personality is different, behavior and discipline are in part determined by a child’s response to various forms of communication from his or her parents. -“Catch ‘em being good.” The single most important rule in living with a child is to work very hard to praise or pay attention to the child when he or she is behaving appropriately (not just when you are bothered by bad behavior.) -Let your children help you. Another important rule is to let your children help you to do the variety of activities involved in everyday living. By feeling involved and needed, a child develops self-esteem and a sense of responsibility.

-Monitor your children. When your child is playing quietly, catch ‘em being good! Don’t fall into the trap that you don’t want to disturb your child’s play. Check on your child frequently so you can give your child feedback on what he or she is doing. But don’t disrupt activities which you wish to encourage; a very brief interaction is all that is necessary. -Home routines and responsibilities should be orderly and predictable. Don’t let toddlers determine their own timetables. Bedtime in particular should be reasonable and consistent. -Discipline and enforcement of discipline should be as matter-of-fact as possible. When a child breaks a rule, the consequence should be immediate. After that time the incident should be left behind. “Time out” (a brief separation from other people and activities) is a more effective discipline tool than spanking. -Lectures belong in lecture halls, not at home. Do not lecture your children, even under the guise of reasoning. Threats and nagging are not helpful. Talking with your children is important, but be careful that you avoid talking with them only at times of crisis or problems. -Show consideration when you discipline. When a child has to miss a movie, a trip to McDonald’s, or an opportunity to play a game with a friend because he hasn’t been behaving, acknowledge the child’s disappointment. Do not give in, however. -Modeling. Children learn by what they see and hear you and others do. If your child breaks one of the house rules and you handle the whole issue matter-offactly, then your child will learn that problems can be handled matter-of-factly. If you yell when you’re angry, you can expect your children to yell. It is important for your children to see that you can handle problem situations without losing your cool.

IV. MEDICINE CABINET NECESSITIES The following are items which should be readily available to you at all times: -Tylenol or other acetaminophen “fever reducer”. Both liquid and rectal suppositories are available. -Children’s Motrin, Children’s Advil or other liquid ibuprofen (after age 6 months). -Thermometer: Rectal for children under 4 months of age, rectal or other for older infants and toddlers, oral or other for older children. -Diphenhydramine “allergy” syrup (Benadryl, generic).

-Band-Aids, sterile gauze and adhesive tape. -ACE wrap for older children. -Triple antibiotic ointment (Neosporin, generic). -Hydrocortison “anti-itch” cream, 1.0%. -Tweezers. -Cool mist humidifier or vaporizer. -Rehydration liquids: Pedialyte or generic electrolyte solution for infants, Gatorade for older children.

V. MEDICATIONS AND DOSAGES Acetaminophen (Tylenol, generic) is used for management of fever, pain, and discomfort associated with viral illnesses. It is also used to treat symptoms after immunizations. The dose varies according to body weight but is approximately 10 mg for every 2 pounds of body weight. Ibuprofen (Motrin, Advil, generic) is useful in children older than 6 months for treatment of fever or pain. It is the preferred medication for a mild orthopedic injury such as a wrist or ankle sprain. Giving medicine after vaccines: Parents do not need to automatically give medicines before or after vaccinations. Give medicines such as Tylenol only if your child seems sick, has high fever, or is very fussy. “Alternating”. Sometimes acetaminophen or ibuprofen alone will control fever and pain. If not, ibuprofen and acetaminophen may be alternated. For example, ibuprofen might be given at noon for fever and is not due again until 6:00 p.m. If fever is high at 3:00 p.m., acetaminophen is given, followed by ibuprofen again at 6:00 (12:00 ibuprofen, 3:00 acetaminophen, 6:00 ibuprofen, etc.) Cough and cold medicines are not effective for young children and the risks or dangers outweigh the benefits; thus they are NOT recommended for children under age 6 years. The only exception is as follows: for children age 2 years and up, diphenhydramine (Benadryl) at bedtime may relieve cough and nasal drainage and help a child rest better.

Diphenhydramine (Benadryl, generic) is also helpful for allergy-related symptoms such as runny nose and watery eyes. It may be used to relieve itching associated with certain rashes and bites. It is available in an elixir or syrup (12.5 mg/teaspoon) and the dose is 1 teaspoon for every 22 pounds of body weight (maximum 50mg). Antibiotics are prescribed when a particular bacterial infection is identified by physical exam or other means of evaluation. If your child may need an antibiotic, an appointment should be scheduled.

VI. WELL CHILD CARE AND IMMUNIZATIONS With many newborns being discharged from the hospital at 24 hours of age, our clinic practices early newborn follow-up. We make an effort to see babies for a weight check and complete physical exam within 2-3 days of hospital discharge in order to identify and manage any problems which may have developed after the baby’s hospital stay. We will decide then when the next visit is needed. The American Academy of Pediatrics recommends routine health maintenance visits (“check-ups”) at 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, and annually until age 6. After age 6 a child should have a checkup every 2 years. These visits assure that your child’s growth and development are monitored appropriately. A complete physical exam is performed rather than the more limited exam of a “sick visit”. These visits provide parents an opportunity to ask the pediatrician about issues such as nutrition, behavior, and development. It is recommended that you schedule regular check-ups even if your child’s immunizations are obtained at the Health Department.

ROUTINE IMMUNIZATIONS Birth 6-8 weeks 4 months 6 months 9 months 12 months 15 months 18 months 4-6 years 7-8 years 9-10 years 11-12 years All ages “catch up”

HepB Pediarix, HiB, Prevnar, Rota Pediarix, HiB, Prevnar, Rota Pediarix, Prevnar (check-up only, no shots) HepA, MMR, Varivax, Prevnar DTaP, HIB HepA DTaP-IPV, MMR, Varivax (HepA if not previously) (check-up only, catch up if needed) HPV (girls and boys) HPV (girls and boys), Tdap, Mening (HepA if not previously) 2nd Varivax if wasn’t given with 4-6 year shots

HepB = Hepatitis B HiB = Hemophilus influenza B Rota = Rotavirus MMR= Mumps, measles, rubella IPV = Injectable polio vaccine Tdap = tetanus + pertussis booster HPV = human papillomavirus

Pediarix = Diphtheria, tetanus, pertussis, polio, HepB Prevnar = Pneumococcus HepA = Hepatitis A Varivax = chicken pox DTaP = Diphtheria, tetanus, pertussis Mening= meningitis vaccine

ADDITIONAL INFORMATION REGARDING VACCINES Immunization schedules may vary slightly as new vaccines are developed and incorporated into use. Our clinic will follow the recommendations of the Centers for Disease Control and the American Academy of Pediatrics. Varicella (chicken pox) now requires two doses. Children and adolescents who started kindergarten in 2006 or prior need a second dose of Varivax given as a separate shot. Tetanus booster shots now include a booster for pertussis (whooping cough) as well. The vaccine is called Tdap (Adacel or Boostrix.) Vaccinating teenagers against whooping cough will help provide “herd immunity” and prevent whooping cough in babies and elderly people as well. HPV (for girls ages 9-24 years and boys 11 and older) will help prevent infection by HPV or human papillomavirus, the virus that causes cervical. HPV vaccine is given in 3 doses over a 6-month period. Side effects: Most vaccines in use now have very mild or no side effects. Pain at the injection site, decreased appetite and increased sleep are the most common side effects. If a child is particularly fussy or has low-grade fever, acetaminophen may be given every 4 hours. If a child has a temperature over 103 or severe crying lasting longer than 3 hours, the physician should be notified. Following the MMR vaccine it is common to have fever or a rash 6-12 days after the vaccine. What if you don’t want your child to be immunized? Our clinic policy is that all of our patients receive immunizations. Our physicians are in agreement with experts in the field of vaccine safety and believe that the benefits of immunizations far outweigh the risks. With rare exceptions, even those parents who have considered not immunizing their children have decided to proceed with immunizations after a conversation with one of our providers. If parents feel strongly that they do not want to have their child immunized, we suggest that they look for another doctor to care for their child.

VII. COMMON MEDICAL PROBLEMS -NEWBORN BREASTFEEDING We encourage breastfeeding if at all possible. Some mothers may be returning to work within a few weeks and this may limit the amount of time they have to breastfeed. However, the nutrition and infection-fighting components of colostrum (the kind of breast milk present in the first few days) are very important for the baby and will benefit the baby even if the switch to formula is made very early. Milk production is based on “supply and demand”. The only way for a mother to produce an increased supply of breast milk is if the baby nurses frequently and “demands” more. This is why it is important not to supplement in the early days of breastfeeding. If the baby takes a bottle and is satisfied, he or she will not have a desire to nurse for several hours, and there will be no “demand” to stimulate an increased supply of breast milk. If a good milk supply is not established after a few days the provider may recommend a supplement, but usually this is not necessary. A new breastfeeding mother must take good care of herself as she is establishing her milk supply. She needs plenty of rest (“sleep when the baby sleeps”), a balanced diet, and plenty of fluids. Together with frequent nursing, these things should help get breastfeeding off to a good start. Some babies and mothers begin breastfeeding with little or no difficulty. But often it is a bit of a challenge to get breastfeeding established, and extra care and attention are required. Almost all mothers CAN breastfeed. Almost all mothers make “enough” milk!! Our physicians and nurse practitioners will work with you individually. Please call the clinic for advice when needed.

JAUNDICE Many babies have some degree of jaundice (yellow eye or skin color) in the first few days of life. This is because the liver of the newborn baby is not yet mature enough to break down the bilirubin that is normally produced in the blood. As the infant gets older, the liver matures and the yellow color disappears. If you are concerned that your infant is very jaundiced, call the clinic for an appointment. If jaundice persists for more than ten days or if it reappears after having gone away, call for an appointment.

UMBILICAL CORD CARE

The umbilical cord usually falls off within the first four weeks of life. There may be a small amount of bleeding for one to two weeks after it falls off. Although alcohol is no longer recommended routinely, you may clean the area with alcohol if there is a foul odor or discharge. If there is excessive bleeding, drainage of pus around the cord or redness of the skin around the cord, an appointment should be scheduled.

EYE DISCHARGE The eyes of a newborn during the first week of life are often somewhat red and swollen and may have some discharge. This is caused by the medicine that is put in the eyes at birth to prevent serious infections. It is not normal for the symptoms to persist more than a few days. If the eyes are not particularly red but mucus builds up and is forming in the corner, the infant may have a blocked tear duct. In a normal tear duct, there is continual, unnoticeable watering to moisturize the eye. In a partially blocked tear duct, mucus builds up and is pushed out periodically in large clumps. This is very common. The redness of the eyelids is caused by irritation from the discharge itself and from being wiped all the time. It usually resolves by the age of 3 to 6 months. Massaging the duct several times daily may help to keep it open. This is done by gently massaging with your finger placed between the bridge of the nose and the inside corner of the eye. (Wash your hands first, and use care not to scratch the eye.) This can be discussed at the next well child check-up, unless the whites of the eyes are red in which case you should call the clinic during office hours.

RASHES Many newborns have a migrating, splotchy red rash scattered over their body which remains for a few days. Newborns may also have many small white bumps on the nose called milia. Newborns can also develop acne in the first one to two months. All of these rashes go away without treatment and leave no scars. Infants also get prickly heat, a rash consisting of red bumps on the face and chest. Keeping the child cool and dry may be helpful.

THRUSH Thush is very common in newborn babies and older infants when antibotics are used. White patches form on the side of the mouth. The patches look like milk, but do not wipe off as easily as milk does. Thrush is caused by yeast and is not dangerous. It can sometimes cause mild discomfort. Call the clinic during regular hours and we will call in a prescription for Nystatin. Sometimes breastfeeding mothers need to be treated as well. Thrush is not contagious to other children and should not keep your baby out of day care.

SPITTING UP AND VOMITING Most young infants who spit up frequently have a very common and harmless condition known as reflux. The muscle between the esophagus and the stomach is not yet mature, and contents of the stomach often “reflux,” coming back up into the mouth. These babies cannot tolerate a large amount of fluid in their stomachs. Reflux is not related to milk allergy, and changing the formula is not helpful. Some helpful measures in a child with reflux are outlined below: -Burp often during feeding. -Feed the baby smaller amounts more frequently. While some infants can tolerate 5-6 ounces per feeding, other infants cannot handle more than 2-3 ounces at a time and will spit up consistently if allowed to have more. Parents must experiment to learn how much milk their “spitty” baby can tolerate. -Keep infant in an upright position with limited movement for 30 minutes after feeding. -Elevate the head of the bed. Place a pillow or folded blanket under one end of the crib mattress so that the mattress is on an incline. Do not place infant directly on a pillow. Babies with more severe reflux symptoms (extreme fussiness, chronic wheezing or noisy breathing, etc.) may need medical attention. Call the clinic for an appointment. If your newborn is a few weeks old and begins to have forceful vomiting in larger amounts, a more worrisome condition known as pyloric stenosis may exist. If there is forceful vomiting over several consecutive feedings, call the clinic immediately. Babies with more severe reflux symptons (extreme fussiness, chronic wheezing, or noisy breathing, etc) may also need medication. Call the clinic for an appointment.

COLIC Colic is a poorly understood phenomenon which is unfortunately fairly common. Typically, an infant with colic has periods of extreme fussiness characterized by crying and pulling the knees to the abdomen as if in severe pain. During these periods the infant does not calm to things which are usually consoling. The infant may act hungry and eat often, but is not satisfied by feeding. Often the period of fussiness occurs later in the day and lasts for several hours.

Because almost nothing satisfies a colicky baby for any length of time, colic can be frustrating and exhausting for parents. The following measures may be helpful: -Bundling. Wrapping the baby from the shoulders down in a tight blanket and holding the infant very close to you may be soothing. -Motion. These babies often want to be walked for hours on end. An automatic swing or a ride in the car may be soothing. -Decrease gas. Burp the infant after every 1-2 ounces of formula or every 2-3 minutes of breastfeeding. Mylicon drops (0.6 ml every 6 hours) may help decrease gas and can be purchased without a prescription. -Breast-feeding mothers may experiment with avoiding certain foods which may be bothersome to the baby. In fact the most common food allergy in babies is allergy to cow milk, so a breast-feeding mother may want to try avoiding all dairy for a short time. (She will need to take extra calcium supplementation if she avoids dairy products.) -Get help! If extended family or friends are available to give you an occasional break, take advantage of the offer. Whether you sleep or do something else for yourself, you will come back refreshed and better able to continue caring for your baby.

CONSTIPATION Many parents mistake normal bowel habits for constipation. A baby with constipation has very hard stools which are difficult to pass. A normal baby may have a bowel movement only every few days, but if the stool is soft, the baby is not constipated. It is especially common for breastfed infants, after initially having a bowel movement with every feeding, to gradually transition to much less frequent bowel movements. Some breastfed babies may go for 5-7 days without a bowel movement! If the baby is feeding well and acting normally, and if the bowel movement when passed remains soft, there is not a problem. When bowel movements are hard, the situation should be corrected. To treat constipation in the newborn: -Increase fluids. Give the baby an ounce or two of water or juice each day in addition to the usual formula or breast milk. -Karo syrup. Add one tablespoon of dark Karo syrup to 4 oz. of formula (or water for breast-fed babies). This can be repeated as often as necessary.

-Glycerin suppositories. If the baby does not respond to the consistent use of Karo and is straining to have a bowel movement, a glycerin suppository may be given. This may be done daily for 2-3 days but no longer. Some parents are concerned that the iron in infant formula is causing constipation. While it may be true that iron contributes to the problem, it is better to continue the iron formula and treat constipation than to withhold iron and cause iron-deficiency anemia.

SIGNS OF SERIOUS ILLNESS IN THE NEWBORN While many illnesses suffered by young infants are caused by common viruses, newborns can also have much more serious bacterial illnesses. Early in the course of the illness it is difficult to differentiate between the two. Thus there are certain “worry signs” which are very important in newborns. These are: -Fever (rectal temperature above 100.5). -Significant decrease in feeding. -Significant change in activity (increased sleeping or lethargy). -Repeated vomiting which is different from the usual spitting up. If your child is under 3 months of age and any of these signs occur, call the physician immediately.

VIII. COMMON MEDICAL PROBLEMS -OLDER INFANTS AND CHILDREN FEVER Normal body temperature varies with age, time of day, activity, and the environment. Rectal temperatures are preferred in children under 6 months of age because they are more accurate and reliable. Normal rectal temperature is usually below 100.2; oral and axillary temperature is usually below 99.5. These are rough guidelines, however. Axillary (underarm) temperatures are nontraumatic and fairly reliable. Please do not “add a degree”. If you tell us your child’s temperature, tell us the temperature recorded and the method used. Fever in and of itself is not bad. It is not dangerous. It is part of the body’s normal infection-fighting mechanism. Fever may make your child feel bad, and it is for this reason that we treat fever. We want your child to feel better. In the majority of situations, you can treat your child with acetaminophen, ibuprofen, or

a sponge bath (room temperature water; no ice or alcohol baths) and delay seeking treatment until regular clinic hours. Dosages are outlined in the preceding Medications and Dosages section. There are a few situations in which you should seek care more quickly. Call the on-call physician immediately if your child has fever and: -is under 3 months of age. -has irritability and a stiff neck. -has a rash which doesn’t turn pale when pressure is applied. -is delirious and remains so even after temperature returns to normal. -has a seizure.

RASHES AND OTHER SKIN PROBLEMS Diaper rash is usually attributable to one of two conditions: nonspecific irritation from exposure to urine or stool, and yeast infection. Yeast infection is particularly common if a child has been on antibiotics. Yeast infection is usually on the genitals and is recognizable by the spots or raised red areas located out around the edges of the rash which are called “satellite lesions”. Nonspecific irritation is red and “angry” but doesn’t usually have these distinct spots. Several measures may be helpful with nonspecific irritation: -Change diaper frequently. -Use a washcloth with water only; avoid wipes and soaps. -Apply zinc oxide (Desitin) or other diaper ointment (A & D). -Allow exposure to air by leaving the diaper off; this is most convenient during naps when the child can be laid on a towel. If the appearance of the rash is suggestive of a yeast infection, apply clotrimazole (Lotrimin or generic) with every diaper change or call the clinic during office hours for a prescription for nystatin ointment. Contact rashes are those reactions caused by the skin coming into contact with something to which a child is allergic. Common contact rashes include reaction to poison ivy, soap, detergent or new clothing. The following measures may be helpful: -Apply calamine lotion to skin to control itching.

-Apply hydrocortisone 1.0% to skin to decrease inflammation. -Give diphenhydramine (Benadryl) by mouth to decrease itching.

Urticaria and hives are terms used to describe viral or allergic rashes which may involve many places on the body rather than just the portion which had contact with an offending agent. Hives usually consists of large, raised, red areas of skin which itch. Causes of hives include certain foods, certain drugs (particularly antibiotics), bee stings and some substances in the air. Hives may also be caused by many common viruses. In fact in most cases childhood hives is the result of viral illness rather than allergy reaction. If your child has repeated outbreaks of hives, try to keep a list of exposures which precede each outbreak: you may be able to determine what is causing the allergic reaction. The itching associated with hives is treated with diphenhydramine (Benadryl) given by mouth. Many viral infections have rashes as part of the complex of symptoms. Therefore a viral rash may be associated with low-grade fever, cold symptoms, vomiting or diarrhea. In most cases these illnesses are mild and the rash itself is not a cause for concern. Such rashes do not respond to any particular treatment but disappear after a few days. Chicken pox is caused by a specific virus and is important because the extreme itching can be very uncomfortable. It is also important because it is quite contagious. The time from exposure to onset of the rash ranges from 7-21 days. Chicken pox initially appears as small red bumps which soon look more like blisters and proceed to break open and form a crust. These lesions appear and evolve over a period of about one week. The child is contagious until all lesions have broken open and are dry and crusted. Several measures may make your child more comfortable: -Apply calamine lotion to skin. -Diphenhydramine (Benadryl) given by mouth may relieve itching. -A bath with baking soda or an oatmeal preparation (Aveeno) added to the water may relieve itching. -Keep child dressed in cool clothing. -Keep child’s fingernails clean and short to decrease the likelihood of secondary infection caused by scratching.

-Treat fever with acetaminophen or ibuprofen. Never use aspirin in a child with chicken pox. The most common complication of chicken pox is secondary infection. If a lesion appears particularly red and has pus-like drainage, it should be treated with an antibiotic. (See Impetigo section below.) If a child with chicken pox has severe headache or stiff neck, the physician should be contacted. Likewise if a child develops extreme lethargy or vomiting during or soon after an episode of chicken pox, the physician should be called. Chicken pox is now preventable with a vaccine (Varivax) given after 12 months of age. Hence we see very few cases of chicken pox. Roseola is another specific viral illness in which a rash is seen. Most children with roseola are infants or toddlers and have high fever for 2-3 days before the rash begins. The rash is primarily on the face, head, and chest, though it may spread all over. By the time the rash appears, the fever has usually subsided. There is no specific treatment, and the rash disappears after 1-2 days. Measles has become extraordinarily rare. We are often asked about measles when a child has one of the much milder viral illnesses mentioned above. Most likely, if there is not news of a measles epidemic in central Arkansas, your child does not have measles. Potentially worrisome rashes are those caused by certain bacteria which cause very severe illness to develop very quickly. Such rashes are sometimes purple (spots may look like bruises) and the lesions do not turn pale when pressure is applied. If your child’s rash has these characteristics, contact a physician immediately. Impetigo is a bacterial infection of the skin which usually begins in one location but may eventually spread to other areas of the body via the bloodstream. Impetigo is characterized by weeping, honey-colored drainage which dries and forms crusts around the lesions. A common location for impetigo is around the mouth and nose where the skin becomes infected after repeated rubbing and wiping. Mild impetigo can be managed with the following measures: -Wash well with soap and water. -Apply triple antibiotic ointment (Neosporin) 2-3 times daily. If this is not helpful, mupirocin (Bactroban) is prescribed. -Keep fingernails clean and short to reduce further spread of infection. -Place freshly laundered clothes on the child each day. Repeated wearing of unwashed clothing will cause continued spread of infection.

Seborrhea or cradle cap is seen primarily in infants and is similar to dandruff seen in adults. Excessive oils in the glands of the scalp result in the formation of flakes or thick scales. Initial measures for management of cradle cap include: -Wash hair or scalp daily with a selenium shampoo (Selsun Blue). -Gently scrub the moist scalp with a soft brush or fingernails to remove scales. Lice is a skin infection which is identifiable by the white “nits” (eggs or larvae) which adhere to the hair close to the scalp, particularly just above the hairline on the back of the neck. Itching is usually the only symptom, and is not always present. Nits look like specks of dandruff but cannot be removed as easily. Adult bugs are tiny and fast-moving. Treat lice at home as follows: purchase Nix shampoo (over the counter), apply 2 ounces of the shampoo to dry hair, add warm water, lather and scrub the scalp and hair. Leave the shampoo on for 20 minutes, rinse thoroughly, and towel dry. Comb hair using any fine-tooth comb; some nits will be removed on the comb but most nits will have to be removed individually by sliding them off the length of the hair shaft with your fingers. Separate the hair into small sections and look carefully through each section (if the lice was acquired recently, all the nits will be very close to the scalp.) This can be a time-consuming and frustrating process. You may have to repeat the nit-removal several days in a row, as it is very difficult to find every single nit. However, the child can return to school the day following treatment if you have used the shampoo and carefully removed as many nits as possible. Lice are an extreme nuisance but are not otherwise harmful. If lice persist or recur after the above treatment, you may suffocate the lice with mayonnaise! Use only 100% real mayonnaise, applied generously over the entire scalp, and cover with a tight shower cap overnight. You will still have to remove the nits individually. Clean the house: Lice can’t live for more than a few days without human contact. Vacuum thoroughly and wash bedding and all clothes worn in the past 3 days in hot water. Items that can’t be washed (stuffed animals, etc) can be sealed in a plastic bag for 3 weeks and then used again. Combs and brushes should be soaked for 1 hour in anti-lice shampoo. Scabies is another skin infestation which causes a rash which is very uncomfortable due to itching. The rash is common on the trunk and groin and on the hands, especially between the fingers. Sometimes “tracks” can be identified where the mite has burrowed underneath the skin. Call the clinic during office hours if you believe your child has scabies.

HEADACHES

There are many causes of headache including fatigue, allergy, and viral infection, and bacterial sinus infection. Also, migraine headaches are often seen in children, usually in cases where there is a family member with migraine headaches. Most headaches can be managed with acetaminophen or ibuprofen. If your child has headaches often (perhaps twice a week or more) or if the headaches are associated with nausea or vomiting, an appointment should be scheduled.

HAND-FOOT-AND-MOUTH DISEASE Hand-foot-and-mouth is a common, contagious viral illness in babies and young children. Symptoms include fever, mouth sores, and rash, and the mouth sores can be very painful making it hard for the child to drink. The rash can be flat or bumpy with small blisters and is often on the palms and soles but can also be elsewhere on the arms and legs and in the diaper area. The illness runs its course and goes away on its own. Using over-the-counter medicine for fever and pain will help the child feel better and drink better.

EYE PROBLEMS Conjunctivitis ("pink eye") is a general term used any time there is irritation, inflammation, or infection of the lining of the eye. It can be caused by many things. Sometimes dust or pollen irritates the eye and other times there may be an infection with a virus or bacteria. If the eyes are primarily itching and watering the cause is probably allergy. If there is pus or pain it is more likely to be infection and need antibiotic drops. Please call to discuss this during regular clinic hours. If the child is having severe pain with the pink eye, or if the eyelid is very swollen and discolored, call the doctor immediately.

EAR PROBLEMS Earaches can be caused by several things, including increased pressure, bacterial infection, and viral illnesses ("colds"). A sudden earache following a cough, sneeze, crying, or yelling is probably caused by pressure and will likely resolve spontaneously after a short time. Earaches may occur when a child has a cold; the eustachian tube connecting the throat and the middle ear is blocked, causing increased pressure and pain, but there is not necessarily middle ear infection. Finally, earaches may be caused by bacterial infection which will likely require antibiotic therapy. Management of earaches is described below: -Pain may be managed with acetaminophen or ibuprofen. A warm washcloth applied to the ear may be helpful, also. If these measures are not adequate, the child should be examined.

-If a child has a severe earache during the night, the child should be examined the following day even if the pain goes away by morning. -Children with persistent earaches and fever should be examined. -It is generally not appropriate for a physician to treat an earache over the phone. An accurate diagnosis cannot be made without an exam, and harm can result from treatment based on an inaccurate diagnosis. -Sometimes local anesthetic ear drops are prescribed for pain. Do not use these drops if the child has tubes in the ears or if there is drainage from the ear. Swimmer’s ear is often seen in older children during the summer months. You may be able to see swelling or discharge inside the ear and touching the ear may be very painful. Ear drops containing antibiotic and steroid are often used, and sometimes antibiotics by mouth are prescribed as well. Swimmer’s ear can be very painful.

MOUTH PROBLEMS Thrush is very common in newborn babies and older infants when antibotics are used. White patches form on the inside of the mouth. The patches look like milk, but do not wipe off as easily as milk does. Thrush is caused by yeast and is not dangerous. It can sometimes cause mild discomfort. Call the clinic during regular hours and we will call in a prescription for Nystatin. Sometimes breastfeeding mothers need to be treated as well. Thrush is not contagious to other children and should not keep your baby out of day care. Aphthous ulcers are small white sores on the inside of the mouth which occur frequently in children. Usually there is only one sore, but there may be several. They are uncomfortable, but generally do not cause any significant problems with eating and drinking. They often occur when the child has a cold or other minor illness, but may occur without other signs of illness. They do not require treatment and will resolve in a few days. Acetaminophen or ibuprofen may be used for discomfort. Herpetic stomatitis is a painful infection in the mouth caused by a type of herpes virus. Fever and considerable discomfort are usually present for several days. Ulcers in the mouth, redness of the gums and lining of the mouth, and bleeding often occur. We recommend treatment of the symptoms as outlined below: -Encourage fluids. The major problem with this infection is getting the child to drink enough fluids. Allow him to drink any kind of fluid he likes, but try to avoid carbonated drinks and citrus or acidic juices because they may sting. Milk, ice cream, popsicles, Jell-O, Gatorade, Pedialyte, and water are all good choices.

Don't worry about food intake as long as fluid intake is good and the child is urinating 2 or 3 times per 24 hours. Please refer to the section on dehydration and call the clinic if you have any questions. -Acetaminophen or ibuprofen may be given for the pain and fever. Sore throat: If your child has a mild sore throat without fever, the pain can be treated with salt water gargles, throat lozenges, or spray (chloraseptic) in an older child, or popsicles in a young child. A child who has fever and a very sore throat should have an appointment to evaluate for strep infection. If a sore throat persists for more than three days, the child should be examined. If strep throat is diagnosed, it is extremely important to complete the entire course of the prescribed antibiotic in order to prevent the rare complication of rheumatic fever. Teething: All new babies begin to chew their fists, gnaw on toys and other objects, and drool more than previously when they reach the age of 3 or 4 months. While "teething" is often presumed to be the culprit, these are actually behaviors which are an expected part of the infant's development. The infant has just achieved the ability to get objects to his or her mouth and explore them further by gnawing on them. The infant is not very efficient at swallowing the extra saliva which results from this stimulation, and may drool almost continuously. The first teeth usually erupt at around 6 months of age, but may erupt anywhere from 4 to 15 months of age. Prior to the eruption of a tooth, the gum may appear slightly swollen or discolored. On the other hand, teething pain may occur as a tooth works its way through the jaw but long before it appears at the gum's surface. Therefore, a child may indeed be "teething" but have no outward signs to aid in identifying the source of the discomfort. For severe teething pain, we recommend acetaminophen or chewing on cold or frozen objects (teething rings, wet washcloths). We discourage the use of teething gels marketed for teething pain; they are not very effective and may be harmful. The only medical significance of teething is that physicians are sometimes called on to look for other causes of a child's fussiness. Teething does not cause fever, runny nose, or diarrhea!

UPPER RESPIRATORY INFECTIONS ("COLDS") Upper respiratory infection ("the common cold") is one of the most frequently diagnosed conditions in pediatrics. Colds are caused by viruses, and there are many different viruses which cause cold symptoms. These symptoms include runny nose, congestion, cough, sore throat, and fever. Nasal discharge may be yellow or green in the first few days of a viral illness, but will gradually turn clear. In most cases the cough is a productive cough and is the result of upper

respiratory drainage into the throat rather than infection in the chest. Over-thecounter cold medicines do not shorten the course of the illness, but in some cases they decrease the discomfort. Because colds are caused by viruses rather than bacteria, antibiotics are not helpful. Some measures which may be helpful are listed below: -Increased fluid intake. Drinking extra fluid will help keep nasal secretions thin and manageable. There is no need to pressure your child to eat solid foods. -Cool mist humidifier or vaporizer. Increasing the humidity of the child's environment will also help to keep secretions thin and manageable. Place the humidifier close to the bed where the baby sleeps. -Suctioning the nose of infants. Most parents have a blue bulb syringe which was supplied by the hospital at delivery. These can be purchased and are sometimes called "ear syringes." (Nasal aspirators are generally too large for use with children.) The bulb syringe is used to suction mucus from each side of the nose. If done before eating and before sleeping, the child can breathe more comfortably to perform these activities. If the mucus is very thick or dry, saline nose drops may be helpful. Several drops are inserted into each nostril and allowed to remain for a short time to help loosen the mucus. The nose is suctioned to remove the saline and the loosened mucus. Drops can be purchased at a drugstore or can be made at home each day by mixing one teaspoon of salt and one cup of boiled water. -Elevate the head of the bed (or keep baby upright in car seat.) -Cold medicines are generally not effective in children and are not recommended for children under age 6 years. The only exception is that for children over 2 years of age, single ingredient short-acting antihistamines such as diphenhydramine (Benadryl) given at bedtime may reduce secretions and may help a child rest better.

LYMPH NODES ("GLANDS") It is normal to have small "glands" or lymph nodes in the neck and other areas of the body. These will often become more noticeable when a child has a cold or other minor infection. The enlarged nodes may remain prominent for several weeks. As long as the nodes are relatively small, moveable, and non-tender, they are rarely of consequence. If the nodes are enlarging rapidly, tender, red, or accompanied by persistent fever, the child should be examined.

NOSEBLEEDS

Most nosebleeds are the result of repeated trauma (nose picking) or cracking of the lining of the nose due to repeated infections. A humidifier or vaporizer in the room where your child sleeps may relieve dryness and irritation and thus help prevent nosebleeds. A nosebleed is controlled by applying constant pressure for at least five to ten minutes. The sides of the nose are pressed between the thumb and forefinger; the entire upper nose should be compressed rather than just the nostrils. Do not release pressure to check on your progress; bleeding will likely resume if you do. Likewise, do not wash out the nostrils after bleeding has stopped; bleeding will probably resume if you do.

RECURRENT COLDS Having six to ten colds per year is not unusual for a small child, particularly if the child is frequently exposed to other young children. If your child seems to have more colds than other children, he or she may have allergies or may be exposed to some irritant. However most babies and children who seem to “keep a cold” are just experiencing one cold virus after another and will have a strong immune system as a result! Rarely, such a problem might be a clue to an immune system defect. Things to consider which might help decrease the number or the duration of respiratory illnesses experienced by your child include: -Avoidance of cigarette smoke. Children of smokers have more colds and ear infections and more hospitalizations for asthma and pneumonia than do children of non-smokers. Do not smoke around your child. Smoke should be outside! Even if you smoke in another room, smoke spreads throughout the house and is contained in your clothing and furniture. -Avoidance of large group child care. This may be impossible for your family, but if arrangements can be made to have your child around only a few small children, your child will be exposed to fewer contagious illnesses. -Avoidance of house dust. These suggestions are primarily for a child with confirmed or strongly suspected allergy to dust. The child should not sleep with stuffed animals or other toys which can't be washed. Pillows should be featherless, washable, and enclosed in zippered, dust-proof covers. The child's bed should not be close to heat or air conditioning vents. The child's bedroom should be dusted several times a week. Curtains should be washed regularly and carpet should be removed if possible. -Avoidance of cats and dogs. If a child has known or suspected allergy to a pet, the pet should be kept outside if at all possible. -Avoidance of certain foods. Certain foods are sometimes found to cause allergy symptoms. Common offenders include milk, peanuts, egg, soy, wheat, and fish. You may try eliminating some or all of these foods for a period of two

weeks, and then add foods back to the diet one at a time. If cold symptoms recur or worsen after the addition of a particular food, your child may be allergic to that food. If none of these measures is helpful, your child may need to undergo an allergy evaluation or tests to determine the status of his or her immune system.

NECK Children will often awaken with a neck ache or suddenly have a pain in one side of the neck. The head may be drawn slightly to one side and movement of the head may be painful. This is usually a muscle spasm or "crick" in the neck. The best treatment is a heating pad and ibuprofen. If a child has fever and a stiff neck, the doctor should be notified immediately.

COUGH The majority of coughs seen by pediatricians are “productive” coughs caused by mucus draining into the throat from the upper respiratory tract. These coughs are not a sign that the cold has "moved into the chest" but simply the body's way of clearing mucus drainage from the entrance to the lungs. Cough suppressants generally are not indicated: if mucus is obstructing the airway, a child needs to cough to clear his or her throat. Another common cause of cough is wheezing or cough-variant asthma. This occurs in a child who has asthma (possibly undiagnosed) or reactive airway disease and has a frequent, harsh cough which is not necessarily productive. Such a child should be evaluated. If the child is not in distress and an albuterol inhaler has been prescribed previously, albuterol may be given until time for the child's appointment. Much less frequently a child's cough may be caused by pneumonia or bronchitis. A child with pneumonia generally has a fever and feels bad most of the time. The child may have rapid or labored breathing; if so, the child should be evaluated quickly. A dry, hacky cough which is due to irritation rather than mucus may indeed be lessened by the use of an over-the-counter cough suppressant. Prescription cough suppressants are used rarely and only after evaluation by a physician.

CROUP Croup is a viral illness characterized by swelling in the airway just below the vocal cords. Symptoms include stridor (a form of high-pitched, noisy breathing heard during inspiration or breathing in) and a cough which sounds like the barking of a dog or seal. Fever may be present also. Croup is usually not a

serious illness, but the noisy breathing does worsen at night and can be alarming. Sometimes croup is severe and causes true respiratory distress. The following measures may be helpful: -Encourage fluids. -Use a cool mist humidifier (or vaporizer if humidifier is unavailable) next to the bed where the child sleeps. -If breathing becomes very noisy or slightly labored, use the hot shower in the bathroom to create a steam-filled environment. Sit in the bathroom with your child for 15 to 30 minutes. -If symptoms do not improve in a steam-filled room, take the child outside for a walk or a drive in the car. The cool night air often brings the episode to an end. -If these measures fail and you believe your child is in distress with very labored breathing, the child should be evaluated in the emergency room.

WHEEZING Wheezing (a form of noisy breathing heard on expiration or breathing out) originates in the lungs in a child with asthma or reactive airway disease, or sometimes a short-term viral illness. Audible nasal or throat congestion is sometimes confused with wheezing and is not a symptom of serious importance. However, it may be impossible to differentiate between the two without a trained ear and a stethoscope. A child wheezing should be evaluated promptly unless the child has had wheezing treated repeatedly in the past and parents are very comfortable with its management. If your child has asthma or reactive airway disease, further reading material is available at the clinic.

VOMITING AND DIARRHEA Vomiting and diarrhea are caused most commonly by an infection called viral gastroenteritis or "stomach virus." Other causes of vomiting include upset stomach due to excitement, overeating, food poisoning,or rarely appendicitis. Appendicitis is usually accompanied by severe and persistent abdominal pain; a child with such pain should be evaluated. Other causes of acute diarrhea include infection with bacteria or parasites. If your child has vomiting or diarrhea or both, follow the treatment plan outlined below: -Limit diet to clear liquids in small amounts for 2 hours or until vomiting has stopped. Pedialyte or other rehydration fluids are the best clear liquid to keep your child adequately hydrated. Pedialyte popsicles serve the same purpose and are often preferred by older children who refuse to drink Pedialyte. The high electrolyte content is important to maintain a safe salt balance; the low sugar

content is important to reduce the severity of diarrhea. For children who refuse Pedialyte, Gatorade is the next most suitable liquid. Most other liquids which are typically offered contain less salt and more sugar and will be less helpful. However, Sprite, Kool-Aid, and plain popsicles are usually better than nothing if your child refuses the salt-containing fluids. -When vomiting has stopped the diet may be advanced gradually. Begin with bland foods such as crackers, toast, rice and baked potato. If these are tolerated, progress to regular diet. -Avoid milk and other dairy products until vomiting has stopped and stools are beginning to return to normal. Sometimes soy or lactose-free formula is a good temporary substitute for milk formula. If the child is breastfed, breast milk may be continued. -Avoid fruits and juices until diarrhea has stopped. -Medicines to treat diarrhea are not safe for use in children. -Please do not call and ask for suppositories for vomiting. If your child's illness is this severe, an evaluation is needed. The greatest danger in gastroenteritis is the risk of dehydration. In almost all cases a child's hydration can be maintained by giving clear liquids in very small amounts as outlined above. If you feel your child is becoming dehydrated, the child should be seen by a physician. Signs of dehydration include the following: -Dry mouth. Lips will generally appear dry after any vomiting; dryness inside the mouth is a sign of dehydration. -Decreased urination. An infant should have a wet diaper every 8 hours or so; an older child should urinate 2 or 3 times a day. -Extreme lethargy or inactivity.

CONSTIPATION Constipation is characterized by large, hard stools which are difficult to pass. Infrequent bowel movements may be normal if the stool is soft and is passed easily. Children sometimes get into a pattern of constipation around the time of toilet-training. The child may avoid using the toilet for some reason or may simply be "too busy" to take time to have a bowel movement. A vicious cycle is created: delay in having a bowel movement results in harder stool which then causes further avoidance due to pain associated with its passage. In older children this pattern sometimes becomes very severe, resulting in a situation

which may take months to resolve. Therefore, it is important to recognize the problem and intervene early. Some helpful measures for mild constipation are outlined below: -Get plenty of exercise and eat a nutritious diet with plenty of fruits, vegetables, and whole grain breads and cereals. Constipation is more common in children who are overweight and children who exercise very little. -Drink more liquids, including juice and water. When treating constipation, do not dilute juice. Prune juice is surprisingly popular among children. -Limit milk intake to 1 pint per day and limit cheese and other dairy products. -Your physician may recommend a fiber product such as Metamucil or a laxative such as milk of magnesia or Miralax. In general, children do not become “dependent” on laxatives in the way that adults do.

ABDOMINAL PAIN Stomachache is very common in children and is somewhat like headaches in adults. Often it is caused by stress or fatigue and no other cause can be identified. Another common and often unsuspected cause of abdominal pain in children is constipation. If your child complains frequently of stomachache, pay careful attention to the child's bowel habits for a few days and refer to the section above on constipation. Rarely, abdominal pain is caused by appendicitis or other serious illness. If any of the symptoms below are present consult the physician: -Severe and persistent pain. -Persistent vomiting. -Pain localized in the right lower portion of the abdomen. -Persistent fever. -Painful urination. -Bloody stools or black, tarry stools.

WORMS Pinworm is relatively common in children. The worms are about the size of a pencil lead and may be up to 1 inch in length. Often the worms are not seen and persistent itching around the anus is the only symptom. Mild abdominal discomfort may be present also. If pinworm is suspected, call the clinic and a

prescription will be phoned to your pharmacy. Generally, it is best to treat the entire family in order to prevent recurrence. If you find a worm which does not fit the description of pinworm, place the worm in a clear container and bring it to the clinic.

BEDWETTING Most children achieve night-time dryness by age 4 to 5 years, but some children are much later in achieving this milestone. Persistent bedwetting is more common in boys. If your child is older than 6 years and you wish to discuss the situation with a pediatrician, call for an appointment.

URINARY TRACT INFECTIN AND PERINEAL IRRITATION Symptoms of urinary tract infection include painful urination, accidents, avoidance of urinating due to pain, and urinating frequently in very small amounts. These symptoms may be present in the absence of infection if a child has irritation of the skin around the urethra. This is common in girls and may be caused by the use of bubble bath or by poor hygiene associated with toileting. Girls should wear cotton panties and should be instructed to wipe themselves from front to back. Improved bathing technique and thorough rinsing after the bath is helpful also. The area around the vagina should be inspected for scraps of toilet paper which may have become trapped in the area. After cleaning with water, a soothing ointment such as A & D Ointment may be applied. If painful urination persists or if the child has fever, an appointment should be scheduled to evaluate for the presence of infection.

BLEEDING AND BRUISING Parents often question whether or not their child has excessive bruising. Most bruises are normal and are the result of healthy, active play. These bruises occur mostly on the shins and knees with an occasional bruise on the head or arms. Bruises of concern are those that grow quite large or are caused by bleeding in and around the joints. Bleeding around the gums is also worrisome. Also, a sprinkling of tiny, pinpoint bruises can be a sign of serious infection. Call the clinic if you have further questions or if you are worried that your child has been abused.

SEIZURES If your child has a seizure, with or without fever, call the clinic or go to the emergency room immediately.

Breath-holding spells are not seizures but may look like seizures and are very frightening. Even very young toddlers can, in the event of crying, frustration or anger, hold their breath to the point of passing out. When this happens, the child’s eyes may “roll back” and the child loses consciousness for a few seconds, but breathing resumes immediately and the child returns to normal very quickly. Breath-holding spells are not dangerous or harmful to the child.

IX. COMMON INJURIES -- TRAUMA AND POISONING BITES AND STINGS Most insect bites are uncomfortable rather than dangerous. Wasp and bee stings are dangerous in children who are allergic to particular stings. Insect bites and bee stings are treated as follows: - Remove stinger (if present) with horizontal scraping motion. -Place a cool compress or ice on the area to minimize pain and swelling. -Apply hydrocortisone cream to decrease itching. -Give diphenhydramine (Benadryl) by mouth for severe itching. -If there is a sensation of fullness of the tongue or throat or breathing difficulty, go immediately to an emergency room. -If your child has a history of a significant allergic reaction to a sting, consult our clinic about obtaining an emergency epinephrine kit. Dog or cat bites should be cleaned well with soap and water. Triple antibiotic ointment should be applied. Call the clinic if signs of infection such as swelling, redness, warmth, or pus-like drainage occur. Be certain your child's immunization status is current. If the dog is a stray or has not had its vaccination, it should be quarantined to observe for signs of rabies. Human bites from should be treated in the same way dog bites are treated, observing carefully for infection. Snake bites from non-venomous snakes should be treated in the same way dog bites are treated. If a child is bitten by a venomous snake, the child should be taken immediately to the emergency room. Constricting jewelry and clothing should be removed. Do not attempt other treatments.

CUTS AND ABRASIONS

Bleeding is controlled by applying pressure continuously with gauze or a clean cloth. Wounds should be cleaned with hydrogen peroxide followed by the application of antibiotic ointment. If it is apparent that bleeding in uncontrollable or if you suspect that stitches are necessary for a satisfactory cosmetic outcome, call the clinic or go to the emergency room.

BURNS A small burn which has not caused breaking or charring of the skin can be managed using the following measures: -Run cold water over the burn for approximately 5 minutes. -Apply antibiotic ointment or aloe vera. -Apply a clean, loose dressing for protection. (A clean, white sock is good to cover hands or feet.) -Acetaminophen or ibuprofen may be given for pain. -Be certain immunizations are current. (Call during office hours if you are uncertain.) If the burn causes a large blister, breaking of the skin or covers a very large area, call the physician or go to the emergency room for evaluation.

HEAD INJURY Children often have minor head injuries caused by ordinary play. Fortunately, most of these do not cause any damage. If after a blow to the head your child cries immediately and returns fairly quickly to normal activity, it is unlikely that problems will occur. Mild pain can be treated with acetaminophen. The most prevalent myth regarding head injury is that the victim should not be allowed to sleep. Sleep itself does is not harmful. However, a change for the worse may go unnoticed if a child is sleeping. Therefore, after a mild head injury, a child whose initial reaction has been vigorous may be allowed to sleep but should be awakened every 1 to 2 hours to observe for signs of worsening. Your child should recognize you and respond to you appropriately, should be able to move all extremities vigorously, and should have pupils which are equal in size and which react equally to light. Call the physician if you need further information. There are a number of danger signs which require immediate attention by a physician:

-Loss of consciousness. -Marked change in mental status or personality. -Double vision or other vision changes. -Pupils which are unequal in size. -Vomiting (though this may occur in very mild injury). -Seizures or convulsions. -Severe headache. -Weakness of an arm or leg. -Unusual fluid drainage from the nose or ear.

LIMP AND EXTREMITY PAIN Following a known injury, a child may limp or favor one arm for a day or two. Such injuries usually require rest and local comfort measures only. If the abnormality persists for more than 2 or 3 days, an appointment should be scheduled. Some situations involving the extremities which do require evaluation are listed below: -Unexplained refusal to bear weight on the legs or use an arm normally. -Limp with associated fever. -Unexplained, frequent falls. -Unexplained joint inflammation (pain, redness, or swelling). -Any deviation of the extremity from its normal position.

MOUTH TRAUMA Bleeding: A common injury in children is tearing of the small web of tissue located between the gum and lip (the frenulum). If bleeding is persistent, apply pressure outside the lip for several minutes. Acetaminophen and a cold washcloth may help with discomfort. This will heal completely.

Teeth: If your child sustains a blow to the mouth, look carefully for active bleeding around the teeth or teeth which are loose or dislodged. If any of these problems occurs, contact your dentist. Sometimes permanent teeth can be reimplanted. A tooth which comes out should be kept in milk on the way to the dentist‘s office.

POISONING If your child swallows a potentially dangerous substance, call the clinic or call Poison Control (1-800-3-POISON)(1-800-376-4766) immediately. Syrup of Ipecac (previously used to induce vomiting) is not recommended for use at all.