+ Dr. Christina Johns's Blog

I’ve got a good friend whose son Vincenzo, a 4th grader, has a regular problem with “stomachaches.” These are kind of unusual stomachaches, because they appear to be seasonal, almost exclusively occur during daytime hours, and are temporarily incapacitating. They don’t include fever or vomiting, and his bowel movements are normal. Last spring Vinny was afflicted nearly every day for several hours, and came home from school quite a lot. He saw his regular pediatrician who did multiple xrays and other tests, and when everything came up normal as summer arrived they agreed to watch him closely. He had a wonderful summer, filled with friends and vacation and no stomachaches. Last week he started his first day of school, and do you know what my friend Patricia told me this morning? You guessed it; Vinny had another stomachache today.

School phobia can manifest itself in many ways, but one of the most common ways is for kids to claim illness, often in the form of abdominal pain. It’s the oldest trick in the book—act sick so you don’t have to go to school. This can be a really difficult situation when it becomes a recurring issue, so it’s got to be handled delicately yet definitively. First, a visit to your child’s pediatrician is in order. It’s crucial to make sure that there really is NO disease process going on. Just as I help many parents with children acting sick who aren’t, there are those few who really do have a medical problem, and they must be identified. Once it has been determined that there really is no medical problem, then you can get to work tackling your child’s fears.

But don’t do it alone. Involve your child’s teachers as soon as possible so that you can partner with them as you fix the problem. The school guidance counselor may have helpful ideas such as suggestions about relaxation techniques and other behavior therapies to help your child overcome this anxiety. It’s important to set boundaries firmly that your child is indeed going to attend school—there can’t be any wiggle room on that, but then try to brainstorm on ways to ease into this reality—whether it means that you volunteer at school a few mornings a week so that your child sees you there regularly or that he/she gets a reward (not a material thing, but rather a treat like picking what’s for dinner) for making it through the day, the week, or whatever. Encourage your child to talk about his/her fears with you, or even write them down as a way to “get them out.”

What my pal Patricia did with Vinny last spring was work up at the school as a cafeteria monitor 3 days a week, and often she would bring him a lunch treat if things were going well. Since I’ve known him for a long time, once he had been to his primary pediatrician, I also did an abdominal exam on him and then told him I thought he was fine and invited him to call me every single day after school to discuss how his stomach had been that day. We celebrated the good days and didn’t give much energy to the bad ones, and what we found was after about 10 days Vinny was no longer that interested in calling me. He was too busy trying to get his homework done after school so he could get outside to play with his classmates from the neighborhood. His stomachaches disappeared too.

I’m going to offer the same thing to Vinny again. My guess is a couple of days of the same old routine for him will help him get through this transition time. I’ll let you know how it goes, but mostly I’m proud of Patricia for not letting this get out of hand, as it can indeed be a very serious problem for some kids. Don’t let your child be one of them.

While it may seem like the marketplace can’t start all of the “back to school” sales soon enough, I’m a firm believer in organization and early preparedness, so around the beginning of August I start developing a mental checklist of what I need to accomplish before school starts, and this involves more than just buying pencils and new shoes.

First, get the medical stuff squared away. Are the kids’ immunizations up to date? When was their last physical exam? I like to recommend that parents pick one time of year (and not the week before school starts because pediatricians’ offices are really busy) that’s the same time every year to have their child’s yearly check up. This way, it’s not a frantic mad dash right before school starts, and you won’t forget each year that you have to go. Recall that in many jurisdictions, for younger kids starting school for the first time you may not register your child unless they have proof of immunization status, and for older kids participating in school sports they need to have a physical exam prior to the beginning of practice. Make sure you have refilled any prescriptions that your child may need—inhalers for asthma for example, or if your child has ADD or ADHD, it may be time to re-start the medicine to get back into the “routine” after having the summer off.

Speaking of routines, I know a lot of people who start waking their children up progressively earlier each day for about two weeks before school starts so that the first day won’t start with tired, bleary-eyed kids. It’s not a bad idea to start setting some more structure during the day, like lunch at the same time or some quiet time reading in the afternoon to get kids mentally and psychologically prepared for sitting in the classroom for most the day.

Once you’ve gotten some of these details worked out, it makes the shopping for backpacks and notebooks that much more fun and relaxing. That is, unless you’ve got a child who’s afraid of school, but that’s a topic for next time…

Most parents I know have at least one thing that they obsess about—their child’s speech development, motor function, or maybe even when their baby will get some hair on her head. For me, it’s eating and my child’s size, probably the worst obsession to have. Shame on me! I’m a pediatrician! I should know better than this! But here I am, with a toddler on the “small” size of normal, and I just can’t leave it alone. I could spend hours discussing my child’s daily caloric intake and making projections on how big he’ll be, to the point where I’m sure I’m completely boring all my friends.

Here’s the thing: Luke (age 2) is not a great eater, and I am sure that I have made it worse by giving the whole scenario way too much attention. We’ve used toys and TV for distraction, giving so much praise for eating that you would think the free world depended on his taking a bite of grilled cheese sandwich. I’ve stayed up nights worrying about whether or not his brain development has been impacted by the fact that he will not eat a single vegetable. We’ve seen feeding specialists and had several pediatrician visits where this subject was the primary topic of discussion. The bottom line: Luke is a normal kid who has been given a bit of a “problem” by the person who loves him most: ME. Imagine how mortified I feel given my profession.

So I’m starting to leave him alone (it’s killing me) with food, not making a big deal about it either way, and he’s actually doing better. I know that advice is in every parenting book, but those books don’t have to live with my kid day in and day out. They don’t really understand my stress when, yet again, Luke refuses his lunch and it lands on the floor. But I’m trying my best to keep a lid on myself and my obsession, and I tell my story so that maybe you will do the same with whatever is getting you. Don’t ignore your concerns but don’t let them take over your life, because inevitably it WILL reach your child.

So tell me, what’s your obsession?

Here’s a bittersweet story from one of my recent days at work. I saw a very grown-up 10-year-old girl named Nedra who came in because her left arm was hurting. As it turned out she had fallen off of some playground equipment directly onto her arm at the end of the school year (I saw her about five days later). Her mother thought she’d be ok, and her 5th grade promotion exercises were the day after the injury (which she didn’t want to miss) so they put some ice on it, and since nothing LOOKED broken, called it a day. The celebration went well, and not wanting to miss any of the fun, Nedra didn’t complain too much and just went about her business. Needless to say, the reason it was still hurting when I saw her was that she had broken her arm: specifically, broken her humerus bone, which is the upper arm. She had broken it right under her shoulder. Her mom felt horrible, and while Nedra was lucky that this fracture didn’t need surgery and will heal without difficulty, it brought to mind the importance of being really aware of your child’s seemingly simple injuries.

        A couple of things are critical to know. Obviously, any time that the skin is open and or there is “skin-tenting” and a fragment of bone is poking through the skin, the injury needs to be seen immediately. Also, any color change or loss of sensation of touch or temperature should be evaluated emergently. We talk in the fracture business a lot about “obvious deformity” and that is, for example, when a normally straight wrist has a curve or a dip in it that lets you know that the injury may be more than just a sprain. Both fractures and sprains can have a lot of swelling and pain, but any severe pain that persists for more than 24 hours needs to be examined by a physician.

        So what should you do if you see an injury that makes you suspicious for a fracture? First thing, don’t wind up feeling guilty like Nedra’s mom, and get your child seen immediately. You may give a dose of ibuprofen (like Motrin or Advil) but nothing else by mouth just in case any procedures need to be done. Try your best to immobilize the extremity as best as you can before moving it by securing it to a firm surface, even a large stick or a piece of plywood. Then get on in to the hospital. If your doctor thinks you need it, a simple x-ray can answer all the questions.

Back to Nedra—I couldn’t believe how tough she had been, and told her I was really proud of her for finally coming clean about how uncomfortable she actually was. Her mom then immediately responded and took her in to see me, and it all ended up working out just fine. Imagine—being 10 years old and walking around smiling with a broken arm for five days! Kids truly are incredible!

The other day I noticed multiple large red bites on my almost 2 year old son, Luke, and from the size of them it appeared as though he was bitten by some enormous prehistoric flying reptile. I knew they were mosquito bites, and then I felt guilty as a parent for not remembering to put any insect repellent on him. It was like a tennis match in my head:

“I thought some of those insect repellents are not to be used on kids.”
“But what about West Nile Disease?”

At that moment I decided it was time for a major review, so I checked in with the American Academy of Pediatrics’ AAP News from July 2007 (Vol. 12, No. 7), and I found some great info.

First, and this probably sounds obvious, don’t let your kids apply insect repellent themselves—apply it for them—this way, you’ll decrease the likelihood that they’ll get it in their mouths by accident. It’s best not to apply it directly on their skin: put it on your hands first, and then apply to their skin. You CAN use DEET (a common chemical in repellents) in up to a 30% preparation in children over 2 months old. Don’t ever apply repellents to open cuts or rashes, or the eyes and mouth, and use as little as you can on the ears. Only apply insect repellent to exposed skin; don’t put it on underneath clothing, and make sure you wash it all off at the end of the day.

Finally, I’m going to quote the AAP News because I think this is so interesting:

        “Combination products containing DEET and sunscreen are not recommended,

        primarily because sunscreen should be reapplied frequently, particularly for

        activities centered around water, which will remove the sunscreen. In contrast,

        repellents should be applied as infrequently as possible.”

You definitely don’t want to wind up with kids who have been both burned and bitten.

        So now I’m on the case. I’m no longer freaked out about using DEET, Luke won’t scratch constantly, and he won’t look like someone has gone a little crazy with a red magic marker all over his skin. What about those magic markers, anyway…..

I’m completely paranoid about Luke, my almost 2 year old, getting a cut that would require stitches. I’m not sure why, because I put in and take out stitches all the time and can see that:
a. while not fun, kids (even really young ones) tolerate the procedure beautifully;
b. now with the new skin “superglues” sometimes you don’t even need stitches to close a wound;
c. cuts (formally known as lacerations) heal pretty well when cared for correctly.
So in the spirit of connecting with all the other parents out there who are also paranoid about their kid getting a similar type of cut, I thought I’d share a few things that I think are good to know if you actually have to face this fear.

First, have a sense of what types of cuts need to be evaluated by a doctor. Not all breaks in the skin that bleed need an immediate trip to an emergency department. Abrasions (the scraping off of the very top layer of skin) like a skinned knee or lip rarely need stitches, and just require vigilant cleaning of the wound, application of an over the counter antibiotic ointment like Bacitracin or Neosporin, and close observation. Deeper cuts that are gaping open, continuing to bleed, or are on a delicate area of skin like over joints or on the face always need to be seen as soon as possible by a doctor. Once a laceration is older than around twelve hours old, even if it ordinarily would need stitches, it’s too late. This is especially important on the face where scarring is important (as we all want our kids to be as blemish-free for life as we can!). One of the goals of stitches is to make a nice cosmetic wound closure so don’t delay in getting a laceration on the face seen!

Once the wound is glued or stitched and dressed, it’s important to follow your doctor’s instructions closely. ANY opening in the skin is at risk for infection, so it’s crucial to know what these signs are. Fever or pus drainage (thick yellow or white fluid) from the wound is worrisome, as are increasing pain and red streaks around the wound. Should you see any of these signs, have the cut looked at promptly—sometimes the fix can be quick and simple—either re-opening the wound slightly to help drainage (better than the whole thing opening up), or adding antibiotics early in the course of the infection can save a lot of headaches later. There may be a little debate among health care providers on whether or not wounds should be covered, but I’m a big fan of covering them with a dressing for the first 24 hours and then having them open to air to help dry out and heal faster. A stitched wound should be dry for the first day, then washed gently with soapy water twice a day thereafter. Make sure you’re clear on when exactly the stitches should come out, or if they are the absorbable kind that don’t require removal.

My final tip is that all cuts need to be covered with high-SPF sunscreen year round for at least one year after sustaining the injury to help prevent further scarring. Sun damage to skin is a well known fact, but sun damage to already damaged skin is even worse. Be careful and have a gorgeous, healthy child!

Now I feel better. Maybe just going through the steps of what I already know and practice will help me be less anxious when Luke barrels down the slide at the playground face first. I hope it does the same for you. Let me know if you have any good tips for managing cuts and scrapes; let’s learn from each other!

Baby Jake was in the hospital for 10 grueling days. I’m not sure who had it the hardest, Jake or his parents. Jake is the 3-month-old son of my colleagues and good friends Liz and Dan (both pediatric specialists), and he had a horrendous bout of the stomach flu. He was dehydrated and miserable, and Liz told me he went through about 200 diapers over the course of 3 days. He required blood draws in the middle of the night, transfer from a community hospital to a large university hospital, multiple visits from different physicians, and placement of a long-term intravenous line (to give him fluids and nutrients by vein), among other difficult events. Liz and Dan were understandably worried, anxious, and upset. Thank goodness he’s now home and doing fine, but Liz, Dan, and I talked a lot about what it’s like to be a patient and be “on the other side of the examining table.” They (and consequently I) learned a lot, and together we came up with some thoughts that might be helpful if your child winds up as an inpatient in a hospital.

                      First and foremost, remember that you are your child’s best advocate. It is okay, normal, appropriate, and reasonable to ask many questions of whomever enters your child’s room, request clarification if you don’t understand something, and don’t give up if at first something doesn’t make sense. Everyone plays a role in helping a sick child to get better, but remember that as a parent or guardian YOU know your child the best. Liz knew that even though Jake’s vital sign numbers looked pretty good, he just didn’t seem to be getting better. He was still pale and too sleepy. She didn’t stop telling people until she had everyone’s attention.

Make sure that everyone you encounter gives you an introduction and identifies what their role is. Ask yourself, “Did that person do a good hand wash before approaching my child?” If the answer is no, it is absolutely fair to politely request that they do so. This seems like common sense, but during a stressful time it is often the little things that go out the window.

                        A hospital is not a hotel. Don’t expect it to be like that. While every hospital wants its patients to be comfortable, safety and wellness are the first priorities. This can be hard to understand when you’re exhausted and frustrated, but I can’t tell you how many times I’ve seen hospital staff trying their best to satisfy everyone, only to bear the brunt of unwarranted criticism. It was tough for even Liz and Dan to remember that there were other (even sicker) children in the same unit, which meant Jake’s nurse wasn’t always available at the ring of a bell. All this being said, know that you are part of the team charged with getting your child well, and you do have a voice in your child’s care. For example, if he/she is doing well, close to being discharged, and absolutely hates being woken up in the middle of the night for vital signs, I think it is okay to ask to cut out that one set of heart rate and blood pressure checks if you think your child will sleep better. Recognize that the staff may have a very valid reason or protocol to say no, but it doesn’t hurt to ask and brainstorm with them about ways to make your stay a more comfortable, productive, and pleasant one.

                        In the end, that’s what Liz and Dan did and it was probably how they stayed sane and reasonable and upbeat while Jake got better. And that first night home sleeping in their own bed never felt so good! I’m sure Jake agrees.

"Trauma-Rama,” we all call it. The Emergency Department was busy this weekend. By 7PM, business was booming. It seems like the minute the weather heats up, so do the numbers of injured patients in the E.D. ("E.R." is what you watch on TV; "E.D." is what the Emergency Department is really called). Sometimes it can be tough to see a lot of preventable injuries, like kids on bicycles who weren’t wearing helmets and wind up with head injuries. Whether or not they were wearing a helmet is one of the first questions I ask, and all too frequently the answer is supplied by their injury before the word “no” is even spoken. This surprises me a little, and I (yet again) give my well-rehearsed speech about how not only can a helmet prevent major head injury, but it can also prevent some cosmetic damage to the face, and in many jurisdictions it’s against the law not to wear one if you’re under a certain age (usually 16)! Little by little, I hope I’m convincing people about how important this really is.

Every year in the US, there are over 500 000 injuries attributed to bicycles www.helmet.organd they range from simple cuts and scrapes to skull fractures and devastating internal brain injuries, even death. I always say that in a match-up between unprotected skull and pavement, pavement almost always wins.

So please, put on your helmet! Be a good example to others around you and don’t wind up learning the hard way like little 9 year old Joshua that I took care of recently. A car ran into him while he was on his bike unhelmeted and he went careening across the car hood, sustaining a brief loss of consciousness and a significant scalp laceration. Fortunately, he did well. After his stitches and CT scan I asked him if he’d ever ride his bike again without his helmet, and he replied, “no way, and I’m going to watch my brothers and cousins too. I smiled and thought to myself, “mission accomplished.” At least for now.

At least for today.