Insect and “Spider” Bites

The season of bites and stings has begun in earnest.  Many parents call worried that an bite is from a spider or a tick. We cannot usually distinguish between an insect, spider or tick bite without seeing the actual offender in action.  However, these bites are all initially treated in the same way (providing symptomatic relief.)

Tick bites are less likely to cause initial inflammation and redness, and are only an issue if followed (3-30 days later) by a steadily expanding, ringed, pain/itch free, flat rash that is present for at least several days (or an acute, febrile, flu-like illness.)  If you are worried about a possible lyme rash, take a photo daily and come in if the area is increasing in size over several days.

Insects such as bees, ants, fleas, flies, mosquitoes, wasps and arachnids such as spiders may bite or sting when provoked or distressed, or bite to feed on our protein filled blood. The saliva or venom injected into the skin will cause the body to release histamine, a chemical that brings more blood flow into the area (to help fight infection.)  This results in swelling, redness, firmness, pain and/or itch in the area of the bite or sting. This type of localized reaction, while uncomfortable (and sometimes quite large) is of no danger.  It is often delayed, and some bites and stings are at their worst 24-48 hours later.

If you are very sensitive to an insect’s venom (“allergic”), bites and stings can cause a rare but potentially fatal condition called anaphylactic shock.  Typical symptoms of anaphylaxis include wheezing, hoarseness or difficulty breathing; nausea, vomiting or diarrhea; dizziness or feeling faint; difficulty swallowing and/or swollen face or mouth; and confusion, anxiety or agitation.   If you child experiences any of these reactions after a bite or sting, call 911 immediately and administer an epinephrine pen if available.

When the reaction is mild, the majority of bites and stings can be treated at home. Remove the stinger if it is lodged in your skin, wash the affected area with soap and water, and apply an ice pack to reduce pain and swelling. Topical anti-itch creams (Cortaid, Benadryl, Calamine or Caladryl), oral pain relievers (acetaminophen or ibuprofen) and antihistamines (Benadryl, Zyrtec, Claritin or Allegra) may be used to combat uncomfortable symptoms.

Benadryl, ibuprofen and acetaminophen dosages by weight can be found here.

Bugs that Bite:
Mosquitoes

Mosquitoes select their victims by evaluating scent, exhaled carbon dioxide and the chemicals in a person’s sweat. Only females bite! (Males don’t need blood as they don’t make eggs.)

Most mosquito bites are harmless, but occasionally a mosquito bite causes a large area of swelling, soreness and redness. This type of reaction, most common in children, is sometimes referred to as “skeeter syndrome”.

Mosquito bites start as puffy, white bumps that appear a few minutes after the bite.  The bumps usually swell and turn redder, itchier over 24-48 hours, and can sometimes become quite large.  Occasionally there will be a small blister in the center. As the swelling goes down, the area may look like a ringed lyme rash, but the size does not increase as a lyme rash would.

Fleas

Flea bites can be grouped in lines or clusters. If you’re particularly sensitive to flea bites, they can cause hives or blisters.

Photos of flea bites

Horse Flies 

Horse fly bites are more immediately painful than those of mosquitoes. Their bites may become very itchy, sometimes causing a large swelling that can take days to resolve.  Again, this is not dangerous allergic reaction- merely uncomfortable.

Black fly bites are common in the northeast from April to July, especially in wet areas.  These flies secrete an anticoagulant (blood thinner) into the skin, which both numbs the area and causes bleeding.  The bites often look like blood blisters, and tend to be around the neck and ears, or by the ankles.  Localized swelling and itch can last as long as several weeks.

Stinging Insects

Insects will sting humans only as a defensive move against a perceived threat. Typically, a bee or stinging ant’s stinger will be accompanied by a small amount of venom that, when injected into your skin, causes most of the itching and pain associated with sting, as well as any allergic reaction. Common stinging insects in the U.S. include bees, wasps, hornets, yellow jackets, and fire ants.

A bee sting feels similar to a wasp sting, but the sting and a venomous sac will be left in the wound. You should remove this immediately by scraping it out using something with a hard edge, such as a bank card. Don’t pinch the sting out with your fingers or tweezers because you may spread the venom.  Stings are often worse after 24-48 hours, but are not dangerous unless accompanied by symptoms of anaphylaxis.

Spider Bites

THESE ARE VERY UNCOMMON IN CONNECTICUT!

There are primarily two spiders in the United States that are harmful to humans: the brown recluse and the black widow.

Most active at night, the brown “recluse” spider hides and is not commonly found out in the open, preferring woodpiles and sheds, closets, garages, basements, and other places that are dry and generally undisturbed. The brown recluse is most commonly found in the South and is not native to any of the New England States.

A brown recluse spider bite initially often is not felt, or causes just mild discomfort.  Within the first hour, a local burning/stinging sensation develops. The bite area becomes red and skin temperature increases. Within four hours, the area exhibits a “bull’s-eye” appearance, forming a blister in some cases. This blister may rupture in 8 to 36 hours, creating an ulcer or brown/black scabbed center. There is no special treatment or medication used to treat a brown recluse spider bite. If infection develops it is treated with antibiotics.

Brown Recluse Spider:

BrownSpider

Brown recluse spider bite pictures can be found here.

Black Widows may be found throughout New England, but true black widow spider sightings or bites are uncommon.

If a black widow spider bites, do not panic! No one in the United States has died from a black widow spider bite in over 10 years. Very often, no serious symptoms develop. Black widow bites may go unnoticed or feel like a sharp pinprick. These spiders may bite more than once and may hold on for a few seconds. The wound site may show one or two small puncture wounds. Within 20 to 40 minutes the patient usually experiences a dull ache or numbing sensation near the bite site. Pain progresses and spreads to the abdomen (stomach cramps), back, and extremities.

If muscle cramps develop or pain is severe, take the patient to the nearest hospital for treatment of the symptoms.  Anti-venom is available, but rarely needed.

Black Widow Spider

blackwidwo

Photos of various stings and bites can be found here
For more information on tick bites, click here.
For more information on bug repellents, click here.

Advertisements

Poison Ivy

Poison ivy is caused by a reaction to an oily resin (urushiol) found in the leaves, stems and roots of poison ivy (and poison oak and sumac). The plant leaves can be light green to red, and occur in leaf triplets that grow on their own stem. The plant may have green or white berries, and grows as either a bush or a vine.

Though exposure is most common during the spring/summer months, the leaves and vines can be hidden in fall leaf piles. Burning the plant can cause dangerous fumes that may cause damage to airways and lungs. Contact with the plant most typically causes the rash, but oil carried on clothing, gardening tools or a pet’s fur can also be the culprit. About 70-85% of people are sensitive to the resin.

poisonivy1

poisonivy2

The rash typically looks like lines or patches of reddened, raised skin that then blisters, and is quite itchy. The reaction can take several hours to days to appear after coming in contact with the resin (which is absorbed by the skin, causing a hypersensitivity reaction.) The rash cannot be spread by itching or touching, but it can appear in stages depending on which area of skin was most exposed to the resin. The rash is not contagious (you must touch the resin to develop the reaction.) Most rashes last between 1-3 weeks.

poisonivy3

After known exposure to poison ivy, wash with soap and water ASAP to remove the resin from the skin. Once the rash is present, the resin has already been absorbed and simple washing will not help. Zanfel and Technu are topical solutions that can help remove bound urushiol from the skin, and can be used on a daily basis after the rash has appeared to reduce progression and severity (usually 1-2 applications are enough to halt progression and ease itch.)

Over the counter preparations such as calamine lotion and hydrocortisone 1% (Cortaid cream) are effective for mild cases of poison ivy. Apply 3-4 times a day. Cold compresses, ice packs, colloidal oatmeal creams/baths can also help itch, and Benadryl can reduce nighttime symptoms.

If the rash is on the face or genitals, or is extensive or spreading rapidly, you should make an appointment to be seen. Oral steroid treatment may be necessary, but we must confirm that the rash is indeed poison ivy prior to prescribing.

Book Review: The Explosive Child

theexplosivechild

The Explosive Child: A New Approach to Understanding and Parenting Easily Frustrated and Chronically Inflexible Children

The Explosive Child is a book I find myself recommending to parents so frequently that I thought it might be worth reviewing here. Written by Ross Greene, Ph.D., a psychology professor at Harvard Medical School, The Explosive Child: A New Approach to Understanding and Parenting Easily Frustrated and Chronically Inflexible Children, offers a compassionate and functional approach to understanding children who react explosively to everyday frustrations. The volatility and inflexibility of these children can require a tremendous amount of energy from their parents, interfere with sibling relations, and, worse, drain the joy from family life.

In his book, Greene discusses what underlies explosive behavior. He argues that “children will do well if they can” and postulates that while explosive children often feel bad about their behavior and are motivated to change, deficits in specific skills make it difficult for them to behave more appropriately. Much as a child with a learning disability wants to read but finds the task difficult without extra help, explosive children also need additional support to develop the skills needed to manage their world. Greene presents an alternative approach to discipline that focuses on teaching children these skills rather than punishing their behavior.

Although Greene’s case studies often involve children with psychiatric diagnoses, his approach to the issues underlying explosive behavior can be effectively applied to helping children with mild to moderate issues as well. Greene’s strength is his theoretical framework that allows parents to better understand their children’s struggles and to empathize with them rather than view them as defiant adversaries. This shift can be pivotal in creating a happier, more harmonious family life and supporting positive parent-child relationships for years to come.

A revised version of this book is scheduled for release May 20th, 2014

Nancy H. Sedlack, Ph.D. is a clinical child psychologist working as a parenting consultant at Village Pediatrics. She would be happy to meet you to further discuss this book or any other issues concerning your children. You can reach her at Village Pediatrics (203) 221-7337.

The Truth about TamiFlu and the Flu Vaccine

Recent media reports are announcing a “Tamiflu shortage” just as Influenza A has become widespread in our area. Tamiflu (Oseltamivir) is an antiviral medication commonly used to treat Influenza A and Influenza B. Influenza viruses gain entrance to the body thru the mouth or nose, then quickly replicate in the cells lining the airway. Tamiflu works by blocking the effect of a neuraminidase, chemical made by the influenza virus which helps it spread. Once infection has spread Tamiflu is of limited use.

Tamiflu’s benefits in typically healthy children and adults do not appear to outweigh its risks. Published studies suggest that Tamiflu, if started within 24-48 hours after symptoms begin, reduces the duration of symptoms by at most 0.5-1 day, and may minimally reduce transmission of the virus. Tamiflu does not appear to significantly prevent hospitalization or death from Influenza. In addition, Roche, the manufacturer of Tamiflu, has yet to release much of its clinical data regarding the medication after years of its use, which is of obvious concern.

We do know that Tamiflu has significant side effects. The most common adverse drug reactions include nausea, vomiting, diarrhea, abdominal pain and headache. Less common side effects include severe skin reactions, allergic reactions and liver inflammation. Tamiflu has also been found to have uncommon neuropsychological side-effects including hallucinations, delirium, impaired consciousness and self-harm, and these behaviors are more common in children than adults. Japan, previously a heavy prescriber of Tamiflu, has limited its use in children as a result of multiple studies demonstrating increased unusual behaviors in children taking the medication.

Pediatricians are therefore quite selective in our use of Tamiflu. We consider its use in ill children at higher risk for influenza complications (having a history of asthma, immunosuppression or other underlying medical conditions), children with severe disease requiring hospitalization and children under the age of 2. We DO NOT recommend Tamiflu routinely for prevention of influenza after exposure, or in otherwise healthy children over the age of 2 as the risks do not appear to outweigh the benefits of its use.

Beyond basic hygiene methods such as handwashing, the single best way to avoid severe influenza is thru immunization. This year’s strain of flu, the H1N1 (“swine flu”) is known to disproportionally affect children and young adults. This year’s vaccine does cover the H1N1 virus, but does not prevent all recipients from getting the flu. It does, however, limit the illness much more effectively than Tamiflu (preventing hospitalization, co-morbidities such as ear infections and pneumonia, and deaths), and prevents the illness in most who receive the vaccine.

Contrary to popular myth, the flu vaccine cannot give you the flu. The injectable vaccine contains only bits of protein made by the virus which cannot cause illness on their own. The nasal vaccine contains a weakened form of the virus, which cannot reproduce or spread at temperatures lower than that of the human nose. Both forms of vaccine work by training the body to recognize the Influenza virus proteins and learn to fight them off prior to being exposed to the real virus (generally the body needs 2 weeks to develop full immunity.)

It is NOT TOO LATE to be immunized- call the office if you or your child needs either the Flumist or injectable flu vaccine.

For more on the Influenza vaccination and facts about Influenza symptoms and treatment look here:
http://www.flu.gov

For more on Tamiflu uses and side effects, look here: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm188859.htm
http://www.forbes.com/sites/harlankrumholz/2013/01/08/the-myth-of-tamiflu-5-things-you-should-know/

Important: Severe Influenza Widespread in the Area!

From the CDC (http://emergency.cdc.gov/HAN/han00359.asp):

From November through December 2013, the CDC has received a number of reports of severe respiratory illness among young and middle-aged adults, many of whom were infected with influenza A (H1N1) pdm09 (pH1N1) virus.

Multiple pH1N1-associated hospitalizations, including many requiring intensive care unit (ICU) admission, and some fatalities have been reported. The pH1N1 virus that emerged in 2009 caused more illness in children and young adults, compared to older adults, although severe illness was seen in all age groups. While it is not possible to predict which influenza viruses will predominate during the entire 2013-14 influenza season, pH1N1 has been the predominant circulating virus so far.

For the 2013-14 season, if pH1N1 virus continues to circulate widely, illness that disproportionately affects young and middle-aged adults may occur.

The 2013/2014 Flu vaccine DOES cover the H1N1 strain. While it does not guarantee protection from getting influenza, the vaccine does greatly decrease the odds of infection and also prevents severe disease and hospitalization.

We STRONGLY URGE all unvaccinated children to come in for a Flumist or flu-shot; we have enough vaccine for caretakers and parents as well. Walk-ins are permitted for Flumist, call for an appointment for a flu shot.

Got Headaches?

Headaches are a common pediatric complaint, and fortunately rarely signify something serious.  Many children experience headaches in conjunction with fever, strep throat, and viral infections.  However, some kids do experience recurrent headaches unrelated to illness.   If your child experiences recurrent headaches, much of our diagnosis will be based on headache history.  Please have the answers to the following questions ready when coming in for an appointment:
  • When did the headaches begin?
  • What is the pattern of the headaches- daily or monthly, morning or evening?  Are they worsening or increasing in frequency?
  • How often does the headache occur, and how long does it last?
  • Does your child have one type of headache or more than one type?
  • Are there warning signs or can your child tell that a headache is coming?
  • Where is the pain located and what is the quality of the pain: pounding, squeezing, stabbing, or other?
  • Are there any other symptoms that accompany the headache: nausea, vomiting, dizziness, numbness, weakness, or other?
  • What makes the headache better or worse? Do any activities, medications, weather patterns, menses or foods cause or aggravate the headaches?
  • What do your child do when they get a headache? Do they stop activities with a headache?
  • Does your child have other symptoms between headaches?
  • What are you using to treat the headache?  If medication, what is it and how often do you use it?
  • Is there a family history of migraine?

Diagnosis:Headaches are usually diagnosed based on history alone in children.  CT scans and MRIs are typically only necessary if there are neurological findings on exam, or if the headaches have changed in nature over time.  EEGs are rarely indicated unless there is reason to believe the headache is part of a seizure.  Blood tests are also not indicated unless there are other symptoms consistent with infection (i.e. Lyme Disease) or endocrine abnormality (i.e. thyroid disease.)

 Headache Diaries: We can often identify headache triggers by keeping a diary. Each time your child has a headache, record it noting the time of day, what she ate and drank in the preceding 24 hours, and where and what she was doing when the headache began.  Other conditions to take note of include the weather (changes in barometric pressure), menses, sleep deprivation, and medications.  Note any medication given to treat the headache and whether it helps.   Recurrent headaches fall into several categories:

  • Tension Headache:  dull pressure or tightness in a band-like distribution around the head, sometimes involving the neck.  Can last 30 minutes to several days, and can occur either infrequently or daily.  Often accompanied by fatigue.
  • Cluster headache:  sharp, severe pain developing rapidly on one side of the head (usually around or behind the eye.)  Lasts 15 minutes to several hours, and can recur several times over a day/days in “clusters.”  Often accompanied by nasal congestion, unilateral runny nose, eye redness and/or eye tearing, and feeling of agitation.
  • Migraine Headaches:  Moderate to severe throbbing on one side or both sides of the head, lasts several hours to several days, and can recur with varying frequency.  Often accompanied by nausea, vomiting, sensitivity to light, smell and/or sound, and increased pain with physical activity.

Pediatric migraines can also fall into various categories, including migraine without aura (common migraine), migraine with aura (classic migraine) and several periodic conditions that can present along with migraines (cyclic vomiting, abdominal migraine, and benign paroxysmal vertigo of childhood.)  Many migraines are preceded by an “aura”- an early warning sign such as flashing lights, ringing in the ears, blind spots, smelling an unusual aroma or tingling in the face, arm or leg.   Basilar migraines are characterized by episodes of dizziness, vertigo, visual disturbances, dis-coordination and double vision, followed by a headache.  The pain may be in the back (occipital) part of the head.    Benign paroxysmal vertigo is marked by sudden unsteadiness and ataxia (uncoordinated gait, shaky inaccurate reach) along with nausea.  These episodes often result in (and go away with) sleep.   Cyclic vomiting is a pattern of episodes of severe vomiting every 2-4 weeks with intervening periods of wellness.  There are typically no other symptoms (such as diarrhea or fever) that indicate an gastrointestinal infection as the cause of the vomiting.   Abdominal migraine is characterized by episodic, vague, periumbilical pain that generally lasts for hours without other symptoms or cause.   What causes migraines?   People who suffer from migraines are thought to have hyper-excitable brains; when a disturbance of the calcium channels within the brain takes place a “wave” of cortical depression spreads throughout the brain which can trigger auras such as visual and auditory distortions.  The depolarization also triggers vascular dilation that causes inflammation around the vessels in the brain’s covering (dura and pia maters.)  This inflammation causes pain as well as hypersensitivity to many types of stimulation (light, sound, touch.)  The sympathetic nervous system also responds with feelings of nausea, diarrhea, and vomiting.   The most common triggers for migraines include:

  • Sleep changes: getting too much or too little sleep, jet lag
  • Stress and anxiety
  • Medications:  oral contraceptives and vasodilators.
  • Strong odors: perfumes, paint/other fumes or secondhand cigarette smoke
  • Bright lights (sun glare) or loud sounds
  • Foods: The most common food offenders include aspartame, an artificial sugar substitute; foods that contain tyramine (a substance that forms as foods age), such as aged cheeses, hard sausages, and Chianti wine; foods that contain monosodium glutamate or MSG, a key ingredient in many broths, Asian foods, and processed foods; caffeinated or alcohol drinks, particularly beer and red wine; citrus fruits; and foods that contain nitrates, such as hot dogs, bacon, and salami. Skipping a meal or fasting may also increase your likelihood for a migraine.
  • Changes in the weather and barometric pressure
  • Hormonal changes: In many women fluctuations in estrogen, caused by menstruation, pregnancy, or menopause, may cause a migraine. Hormone medications, including oral contraceptives and hormone replacement therapy, can trigger or even worsen migraines, too.
  • Physical activity: Physically exerting yourself-whether through exercise, sexual activity, or physical labor-may cause a migraine.
  • Medication-overuse If pain medication is used more than 3-5 times a week for a period of several months, overuse headaches can develop.  The medications not only stop relieving pain but also cause recurrent headaches.

Other Risk Factors:

  • Genes: About 90 percent of people with migraines have a family history of the severe headaches. If your parents, siblings, or children have migraines, you’re more likely to have them.
  • Gender: Seventy percent of migraine sufferers are women. However, in childhood, boys are more often affected than girls. The gender switch begins around the time of puberty.
  • Age: Most people will experience their first migraine in adolescence, but they can occur at any age.
  • Weight: Women who are mildly obese or obese have a greater risk for migraine headaches than women with a lower BMI.

Treatment: The best treatment for migraines is prevention.  That means avoiding risk factors such as food and odor triggers, fatigue, hunger, thirst and stress. If medication is necessary, we recommend:

  • Non-steroidal anti-inflammatory drugs such as ibuprofen are our first line of treatment.  These should be given as soon as an aura headache begins.  Used chronically, they can cause gastritis (inflammation with or without bleeding in the stomach) and medication overuse headaches.
  • Triptans which work by promoting constriction of dilated blood vessels and blocking pain pathways in the brain.  Sumatriptan nasal spray and zolmitriptan disintegrating tablets are most commonly used in children. These medications can also cause nausea, vomiting, dizziness and drowsiness.
  • If migraines are associated with menses, you can start treatment with ibuprofen just prior to the predicted onset of menstruation.
  • Opiods- narcotic containing medications such as codeine are typically only used for severe migraines, and for when NSAIDs cannot be used.
  • Anti-nausea medication- because migraines and the medications used to treat them can both cause nausea and vomiting, we will often combine an anti-nausea drug with a pain reliever.  Zofran can be given as a dissolvable under-the-tongue tablet, and Phenergan by rectal suppository.

Preventative Medications: We may recommend regular preventative medication if your child has 4 or more attacks a month, if the attacks last more than 12 hours, if pain relieving medications are not effective or if the migraine symptoms include neurological symptoms such as numbness or weakness.  These medications need to be used everyday for at least 4-8 weeks, and often longer.
The most common medications used for migraine prevention in children are Topamax (an anti-seizure drug), Amitryiptyline (a tricyclic antidepressant), Propanolol (a cardiac medication) and Periactin (an anti-histamine.)  Botox has also been used in teens and adults not able to tolerate other medications, but needs to be repeated about every 12 weeks.

Alternative Medicine: Some non-traditional therapies such as acupuncture and biofeedback have been found to be helpful in some patients.  Magnesium supplements may also be effective.  We do not routinely recommend the use of various herbs, vitamins or minerals as none have been found to be definitely safe and effective in children.  Please talk to us or your neurologist prior to trying any alternative therapies.

Got Warts?

We have seen a lot of molluscum contagiosum lately- a type of wart caused by a virus in the pox family. This infection is common in young children, and causes clusters of small, “pearly,” flesh-colored bumps with a little indentation in the center. They tend to spread when scratched, or infected, and are often found on the arms, legs and trunk. The virus can be spread to other children through direct contact, or by shared objects such as towels. Children with eczema are more prone to this rash, which tends to infect areas of irritated skin. While the rash is not dangerous, it can be annoying especially if it starts to spread.

At Village Pediatrics we have an easy, painless treatment called Canthridin- a blistering agent derived from a beetle (otherwise known as “beetle-juice!”) A small amount applied to each wart will cause a small blister that quickly disappears, along with the wart.  Read more about molluscum by clicking here.

Plantar warts are similar infections caused by human papillomavirus (HPV). Most commonly occurring on the palms or soles, the virus is generally picked up from moist walking surfaces such as showers and pools.  These benign epithelial tumors may persist for many months, and while harmless may cause discomfort at the site of infection or spread locally.  We treat these types of warts painlessly by shaving down the surface of the infection, then swabbing it with phenol, a chemical that destroys the HPV virus at the base of the wart.   For tougher warts, we may use a cold spray that freezes the wart with a minimum of discomfort.

All the doctors at Village Peds treat both molluscum and plantar warts in the office quickly and painlessly.  Contact our front desk if you need an appointment.