Who is in Day Care?
The 2000 census reported that of among the nation’s 19.6 million preschoolers, grandparents took care of 21 percent, 17 percent were cared for by their father (while their mother was employed or in school); 12 percent were in day care centers; nine percent were cared for by other relatives; seven percent were cared for by a family day care provider in their home; and six percent received care in nursery schools or preschools. More than one-third of preschoolers (7.2 million) had no regular child-care arrangement and presumably were under maternal care.

Day care establishments are defined as those primarily engaged in care of infants or children, or in providing pre-kindergarten education, where medical care and/or behavioral correction are not a primary function or major element. Some may or may not have substantial educational programs, and some may care for older children when they are not in school.

What are your child’s risks of being exposed to a contagious illness at a day care center?
Medline, a service of the National Library of Medicine and the National Institutes of Health, reports that day care centers do pose some degree of an increased health risk for children, because of the exposure to other children who may be sick.

When your child is in a day care center, the risk is greatest for viral upper respiratory infection (affecting the nose, throat, mouth, voice box) and the common cold, ear infections, and diarrhea. Some studies have tried to link asthma to day care. Other studies suggest that being exposed to all the germs in day care actually IMPROVES your child’s immune system.

Studies suggest that the average child will get eight to ten colds per year, lasting ten – 14 days each, and occurring primarily in the winter months. This means that if a child gets two colds from March to September, and eight colds from September to March, each lasting two weeks, the child will be sick more than over half of the winter.

At the same time, children in a day care environment, exposed to the exchange of upper respiratory tract viruses every day, are expected to have three to ten episodes of otitis media annually. This is four times the incidence of children staying at home.

When should your child remain at home instead of day care or school?
Simply put, children become sick after being exposed to other sick children. Some guidelines to follow are:

• When your child has a temperature higher than 100 º Fahrenheit, keep him/her at home. A fever is a sign of potentially contagious infection, even if the child feels fine. Schools often advise keeping the child at home until a fever-free period has existed for 24 hours.
• When other children in the day care facility have a known contagious infection, such as chicken pox, strep throat or conjunctivitis, keep your child at home.
• Children taking antibiotics should be kept at home until they have taken the medicine for one or two days.
• If your child is vomiting or has diarrhea, the young patient should not be around other children. Other signs of illness are an inability to take fluids, weakness or lethargy, sunken eyes, a depressed soft spot on top of infant’s head, crying without tears, and dry mouth.

Can you prevent your child from becoming sick at a day care center?
The short answer is no. Exposure to other sick children will increase the likelihood that your child may “catch” the same illness, particularly with the common cold. The primary rule is to keep your own children at home if they are sick. However, you can:

Teach your child to wash his or her hands before eating and after using the toilet. Infection is spread the most by children putting dirty toys and hands in their mouths, so check your day care’s hygiene cleaning practices.

Have your child examined by a physician before enrollment in a day care center or school. During the examination, the physician will:

• Look for otitis (inflammation) in the ear. This is an indicator of future ear infections.
• Review with you any allergies your child may have. This will assist in determining if the diet offered at the day care center may be harmful to your child.
• Examine the child’s tonsils for infection and size. Enlarged tonsils could indicate that your child may not be getting a healthy sleep at night, resulting in a tired condition during the day.

Alert the day care center manager when your child is ill, and include the nature of the illness.

Day care has become a necessity for millions of families. Monitoring the health of your own child is key to preventing unnecessary sickness. If a serious illness occurs, do not hesitate to have your child examined by a physician.

How Allergies Affect Your Child’s Health

Your child has been diagnosed with allergic rhinitis, a physiological response to specific allergens such as pet dander or ragweed. The symptoms are fairly simple — a runny nose (rhinitis), watery eyes, and some periodic sneezing. The best solution is to administer over-the-counter antihistamine, and the problem will resolve on its own ….right?

Not really – the interrelated structures of the ears, nose, and throat can cause certain medical problems which trigger additional disorders – all with the possibility of serious consequences.

Simple hay fever can lead to long term problems in swallowing, sleeping, hearing, and breathing. Let’s see what else can happen to a child with a case of hay fever.

• Ear infections: One of children’s most common medical problems is otitis media, or middle ear infection. These infections are especially common in early childhood. They are even more common when children suffer from allergic rhinitis (hay fever) as well. Allergic inflammation can cause swelling in the nose and around the opening of the Eustachian tube (ear canal). This swelling has the potential to interfere with drainage of the middle ear. When bacteria laden discharge clogs the tube, infection is more likely.
• Sore throats: The hay fever allergens may lead to the formation of too much mucus which can make the nose run or drip down the back of the throat, leading to “post-nasal drip.” It can lead to cough, sore throats, and husky voice. Although more common in older people and in dry inland climates, thick, dry mucus can also irritate the throat and be hard to clear. Air conditioning, winter heating, and dehydration can aggravate the condition. Paradoxically, antihistamines will do so as well. Some newer antihistamines do not produce dryness.
• Snoring: Chronic nasal obstruction is a frequent symptom of seasonal allergic rhinitis (hay fever) and perennial (year-round) allergic rhinitis. This allergic condition may have a debilitating effect on the nasal turbinates, the small, shelf-like, bony structures covered by mucous membranes (mucosa). The turbinates protrude into the nasal airway and help to warm, humidify, and cleanse air before it reaches the lungs. When exposed to allergens, the mucosa can become inflamed. The blood vessels inside the membrane swell and expand, causing the turbinates to become enlarged and obstruct the flow of air through the nose. This inflammation, or rhinitis, can cause chronic nasal obstruction that affects individuals during the day and night.

Enlarged turbinates and nasal congestion can also contribute to headaches and sleep disorders such as snoring and obstructive sleep apnea, because the nasal airway is the normal breathing route during sleep. Once turbinate enlargement becomes chronic, it is irreversible except with surgical intervention.

• Pediatric sinusitis: Allergic rhinitis can cause enough inflammation to obstruct the openings to the sinuses. Consequently, a bacterial sinus infection occurs. The disease is similar for children and adults. Children may or may not complain of pain. However, in acute sinusitis, they will often have pain and typically have fever and a purulent nasal discharge. In chronic sinusitis, pain and fever are not evident. Some children may have mood or behavior changes. Most will have a purulent, runny nose and nasal congestion even to the point where they must mouth breathe. The infected sinus drains around the Eustachian tube, and therefore many of the children will also have a middle ear infection.
• Seasonal allergic rhinitis may resolve after a short period. Administration of the proper over-the-counter antihistamines may alleviate the symptoms. However, if your child suffers from perennial (year round) allergic rhinitis, an examination by specialist will assist in preventing other ear, nose and throat problems from occurring.

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

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

What is the difference between designated “obese” versus “overweight?”
Unfortunately, the words overweight and obese are often interchanged. There is a difference:

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

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

Additionally, there are psychological consequences; obese children are subject to depression, loss of self-esteem and isolation from their peers.

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

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

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

• The American Academy of Pediatrics identifies obstructive sleep apnea syndrome (OSAS) as a “common condition in childhood that results in severe complications if left untreated.” Among the potential consequences of untreated pediatric sleep apnea are growth failure; learning, attention, and behavior problems; and cardio-vascular complications. Because sleep apnea is rarely diagnosed, pediatricians now recommend that all children be regularly screened for snoring.
• Middle ear infections: Acute otitis media (AOM) and chronic ear infections account for 15 to 30 million visits to the doctor each year in the U.S. In fact, ear infections are the most common reason why an American child sees a doctor. Furthermore, the incidence of AOM has been rising over the past decades. Although there is no proven medical link between middle ear infections and pediatric obesity there may be a behavioral association between the two conditions. Some studies have found that when a child is rubbing or massaging the infected ear the parent often responds by offering the child food or snacks for comfort.
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When a child does have an ear infection the first line of treatment is often a regimen of antibiotics. When antibiotics are not effective, the ear, nose and throat specialist might recommend a bilateral myringotomy with pressure equalizing tube placement (BMT), a minor surgical procedure. This surgery involves the placement of small tubes in the eardrum of both ears. The benefit is to drain the fluid buildup behind the eardrum and to keep the pressure in the ear the same as it is in the exterior of the ear. This will reduce the chances of any new infections and may correct any hearing loss caused by the fluid buildup.

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

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

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

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

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

Sleep disordered breathing in children, from infancy through puberty, is in some ways a similar condition to adult Sleep Disordered Breathing (SDB), but has different causes, consequences, and treatments. A child with SDB does not necessarily have this condition as an adult.

SDB is a common problem for adults leading to hypertension, heart attack, stroke, and early death. Other consequences are bedroom disharmony, excessive daytime sleepiness, weight gain, poor performance at work, failing personal relationships, and increased risk for accidents, including motor vehicle accidents.

The premiere symptom of sleep disordered breathing is snoring that is loud, present every night regardless of sleep position, and is ultimately interrupted by complete obstruction of breathing with gasping and snorting noises. Approximately 10 percent of children are reported to snore. Ten percent of these children (one percent of the total pediatric population) have obstructive sleep apnea.

When an individual, young or old, obstructs breathing during sleep, the body perceives this as a choking phenomenon. The heart rate slows, the sympathetic nervous system is stimulated, blood pressure rises, the brain is aroused, and sleep is disrupted. In most cases a child’s vascular system can tolerate the changes in blood pressure and heart rate. However, a child’s brain does not tolerate the repeated interruptions to sleep, leading to a child that is sleep deprived, cranky and ill behaved.

Consequences of untreated pediatric sleep disordered breathing

• Snoring: A problem if a child shares a room with a sibling and during sleepovers.
• Sleep deprivation: The child may become moody, inattentive, and disruptive both at home and at school. Classroom and athletic performance may decrease along with overall happiness. The child will lack energy, often preferring to sit in front of the television rather than participate in school and other activities. This may contribute to obesity.
• Abnormal urine production: SDB also causes increased nighttime urine production, and in children, this may lead to bedwetting.
• Growth: Growth hormone is secreted at night. Those with SDB may suffer interruptions in hormone secretion, resulting in slow growth or development.
• Attention deficit disorder (ADD) / attention deficit hyperactivity disorder (ADHD): There are research findings that identify sleep disordered breathing as a contributing factor to attention deficit disorders.

Diagnosis of sleep disordered breathing
The first diagnosis of sleep disordered breathing in children is made by the parent’s observation of snoring. Other observations may include obstructions to breathing, gasping, snorting, and thrashing in bed as well as unexplained bedwetting. Social symptoms are difficult to diagnose but include alteration in mood, misbehavior, and poor school performance. (Note: Every child who has subpar academic and social skills may not have SDB, but if a child is a serious snorer and is experiencing mood, behavior or performance problems, sleep-disordered breathing should be considered.)

A child with suspected SDB should be evaluated by an otolaryngologist – head and neck surgeon. If the symptoms are significant and the tonsils are enlarged, the child is strongly recommended for T&A, or tonsillectomy and adenoidectomy (removal of the tonsils and adenoids). Conversely, if the symptoms are mild, academic performance remains excellent, the tonsils are small, and puberty is eminent (tonsils and adenoids shrink at puberty), it may be recommended that SDB be treated only if matters worsen. The majority of cases fall somewhere in between, and physicians must evaluate each child on a case-by-case basis.

There are other pediatric sleep disorder diagnoses. Sudden infant death syndrome (SIDS) and apparent life threatening episode (ALTE) are considered forms of sleep disordered breathing. Children with these conditions warrant thorough evaluation by a pediatric sleep specialist. Children with craniofacial abnormalities, primarily abnormalities of the jaw bones, tongue, and associated structures, often have sleep disordered breathing. This must be managed and the deformities treated as the child grows.

The sleep test is the standard diagnostic test for sleep disordered breathing. This test can be performed in a sleep laboratory or at home. Sleep tests can produce inaccurate results, especially in children. Borderline or normal sleep test results may still result in a diagnosis of SDB based on parental observation and clinical evaluation.

Treatment for sleep disordered breathing
Enlarged tonsils are the most common cause for SDB, thus tonsillectomy/adenoidectomy is the most effective treatment for pediatric sleep disordered breathing. T&A achieves a 90 percent success rate for childhood SDB. Of the nearly 400,000 T&As performed in the U.S. each year, 75 percent are performed to treat sleep disordered breathing.

Not every child with snoring should undergo T&A. The procedure does have risks and possible complications. Aside from the mental anguish experienced by the parent and child, potential problems include: anesthesia risks, bleeding, and infection.

Your child’s sinuses are not fully developed until age 20. Although small, the maxillary (behind the cheek) and ethmoid (between the eyes) sinuses are present at birth. Unlike in adults, pediatric sinusitis is difficult to diagnose because symptoms can be subtle and the causes complex.

How do I know when my child has sinusitis?
The following symptoms may indicate a sinus infection in your child:

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

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

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

How will the doctor treat sinusitis?

• Acute sinusitis: Most children respond very well to antibiotic therapy. Nasal decongestants or topical nasal sprays may also be prescribed for short-term relief of stuffiness. Nasal saline (saltwater) drops or gentle spray can be helpful in thinning secretions and improving mucous membrane function.

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

• Chronic sinusitis: If your child suffers from one or more symptoms of sinusitis for at least 12 weeks, he or she may have chronic sinusitis. Chronic sinusitis or recurrent episodes of acute sinusitis numbering more than four to six per year are indications that you should seek consultation with an ear, nose and throat (ENT) specialist. The ENT may recommend medical or surgical treatment of the sinuses.
• Diagnosis of sinusitis: If your child sees an ENT specialist, the doctor will examine his/her ears, nose, and throat. A thorough history and examination usually leads to the correct diagnosis. Occasionally, special instruments will be used to look into the nose during the office visit. An x-ray called a CT scan may help to determine how your child’s sinuses are formed, where the blockage has occurred, and the reliability of a sinusitis diagnosis.

When is surgery necessary?
Only a small percentage of children with severe or persistent sinusitis require surgery to relieve symptoms that do not respond to medical therapy. Using an instrument called an endoscope, the ENT surgeon opens the natural drainage pathways of your child’s sinuses and makes the narrow passages wider. This also allows for culturing so that antibiotics can be directed specifically against your child’s sinus infection. Opening up the sinuses and allowing air to circulate usually results in a reduction in the number and severity of sinus infections.

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

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

It is a well-known fact among parents that children sometimes put things such as dried beans, small toys, or beads in their ears, nose, or mouth. Such inappropriate objects may cause harm if immediate medical attention is not provided. Often, caregivers are unaware that a child has taken in such an object and this makes getting the right treatment more difficult.

The symptoms caused by these objects range from discomfort and pain, to decreased hearing, changes or noises from breathing, difficulty swallowing or choking and sometimes drainage especially from objects in the ear or nose. If there is difficulty breathing, the object could cause serious problems and immediate action should be taken.

Doctors call these objects foreign bodies. A recent medical study has shown that with some people it is hard to see certain types of foreign bodies with the naked eye. It recommends that “these cases should be referred directly to otolaryngologists for otomicroscopic removal or removal with special light scopes.” In other words, an ear, nose, and throat specialist physician should remove such objects to avoid further harm.

Facts about foreign bodies in the ear, nose, and airway

• Children under age five are the most likely to ingest foreign bodies in the ear, nose, or airway. But teenagers and irresponsible adults have been known to engage in such activities as well, though these are often accidental happenings.
• Foreign bodies in the ear canal are found most often in children between the ages of two and four.
• Airway obstruction from foreign bodies may cause suffocation and death. This accounts for nearly nine percent of accidental deaths in the home, especially among children under the age of five years.
• About five percent of all children swallow coins, and a coin-swallower’s average age is three.

Foreign bodies in the ear
Children usually place things in their ear canal because they are bored, curious, or copying other children. Sometimes one child may put an object in another child’s ear during play. It is important for parents to be aware that children may cause themselves or other children great harm by placing objects in the ear. There may also be a link between chronic outer ear infections and children who tend to place things in their ears. Insects may also fly into the ear canal, causing potential harm. Any child with a chronically draining ear should be evaluated for a foreign body.

Some of the items that are commonly found in the ear (usually the canal) of young children include the following: food, insects, toys, buttons, pieces of crayon, and small button-shaped batteries. Teenagers sometimes have objects imbedded in the ear lobe due to an infection from a pierced ear or a poorly healed piecing.

Treatment
The treatment for foreign bodies in the ear is prompt removal of the object by your child’s physician. The following are some of the techniques that may be used by your child’s physician to remove the object from the ear canal:

• instruments may be inserted in the ear;
• magnets are sometimes used if the object is metal;
• cleaning the ear canal with water;
• filling the ear with mineral oil to suffocate an insect; and
• use of a suction machine to help pull the object out.

After removal of the object, your child’s physician will re-examine the ear to determine if there has been any injury to the ear canal. Antibiotic drops for the ear may be prescribed to treat any possible infections.

Foreign bodies in the nose
Objects that are put into the child’s nose are usually, but not always, soft things like tissue, clay, and pieces of toys or erasers. Harder objects, much like those commonly put in the ear, may also be put into the nose. From time to time, a foreign body may enter the nose while the child is trying to smell the object.

Symptoms
The most common symptom of a foreign body in the nose is nasal drainage. The drainage often has a bad odor. Parents should suspect a foreign body and not a “cold” when drainage is from only one nostril. In some cases, the child may also have a bloody nose.

Treatment
Foreign objects in your child’s nose should be removed promptly. Sedating the child is sometimes necessary in order to remove the object successfully. This may necessitate a trip to the hospital, depending on the extent of the problem and the cooperation of the child. Some of the techniques that your child’s physician may use to remove the object from the nose include suction machines with tubes attached or instruments such as small tweezers called forceps.

After removal of the object, your child’s physician may re-examine the nose with a special fiber optic light looking for another foreign body or may prescribe nose drops or antibiotic ointments to treat any possible infections.

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

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

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

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

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

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

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

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

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

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

L.P.R. ~ Laryngopharyngeal Reflux

What is laryngopharyngeal reflux (LPR)?

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

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

During the first year, infants frequently spit up. This is essentially LPR because the stomach contents are refluxing into the back of the throat. However, in most infants, it is a normal occurrence caused by the immaturity of both the upper and lower esophageal sphincters, the shorter distance from the stomach to the throat, and the greater amount of time infants spend in the horizontal position. Only infants who have associated airway (breathing) or feeding problems require evaluation by a specialist. This is most critical when breathing-related symptoms are present.

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

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

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

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

How is LPR diagnosed?
Currently, there is no good standardized test to identify LPR. If parents notice any symptoms of LPR in their child, they may wish to discuss with their pediatrician a referral to see an otolaryngologist for evaluation. An otolaryngologist may perform a flexible fiber optic nasopharyngoscopy/laryngoscopy, which involves sliding a 2 mm scope through the infant or child’s nostril, to look directly at the voice box and related structures or a 24 hour pH monitoring of the esophagus. He or she may also decide to perform further evaluation of the child under general anesthesia. This would include looking directly at the voice box and related structures (direct laryngoscopy), a full endoscopic look at the trachea and bronchi (bronchoscopy), and an endoscopic look at the esophagus (esophagoscopy) with a possible biopsy of the esophagus to determine if esophagitis is present. LPR in infants and children remains a diagnosis of clinical judgment based on history given by the parents, the physical exam, and endoscopic evaluations.

How is LPR treated?
Since LPR is an extension of GER, successful treatment of LPR is based on successful treatment of GER. In infants and children, basic recommendations may include smaller and more frequent feedings and keeping an infant in a vertical position after feeding for at least 30 minutes. A trial of medications including H2 blockers or proton pump inhibitors may be necessary. Similar to adults, those who fail medical treatment, or have diagnostic evaluations demonstrating anatomical abnormalities may require surgical intervention such as a fundoplication.

A tonsillectomy (ton-seh-leck-teh-me) is an operation in which the tonsils are taken out of the throat.

What is the procedure for having a tonsillectomy?
After dinner the night before the tonsillectomy, your child won’t be allowed to eat or drink anything — even water!

Upon arriving at the hospital, your child will receive a special bracelet with his/her name on it and hospital clothes. Your child will then meet the doctors and nurses that will be helping his/her. When the doctor is ready, your child will be given a special medicine that makes him/her fall asleep. Then, the doctor and nurses will use special tools to remove the tonsils. It doesn’t take very long – just about 20 minutes!

Upon waking up, the operation will be all over. Your child’s throat may hurt but the nurses and doctors will make sure everything is okay. In a few hours, your child will be ready to go home. Your child’s throat will be sore for a few weeks.

Once home, make sure your child drinks a lot and get lots of rest. It will help to keep his/her throat moist and your child’s body energized. It is okay for your child to eat non-dairy popsicles and other cold treats or soft food that makes the throat feel better, but save ice cream for the next day. Ice cream and other milk products can make your child’s throat worse right after the operation. Within approximately two weeks, your child should be ready to return to school and all normal activities.

Tonsils are the two pink lumps of tissue found on each side of the back of the throat. Each grape-size lump fights off the bad bacteria or germs living in the human body. Tonsillitis refers to inflammation of the pharyngeal tonsils. The inflammation may involve other areas of the back of the throat including the adenoids and the lingual tonsils (areas of tonsil tissue at the back of the tongue). There are several variations of tonsillitis: acute, recurrent and chronic tonsillitis and peritonsillar abscess. Viral or bacterial infections and immunologic factors lead to tonsillitis and its complications. Nearly all children in the United States experience at least one episode of tonsillitis. Because of improvements in medical and surgical treatments, complications associated with tonsillitis, including mortality, are rare.

Who gets tonsillitis?
Tonsillitis most often occurs in children; however, the condition rarely occurs in children younger than two years. Tonsillitis caused by streptococcus species typically occurs in children aged five to 15 years, while viral tonsillitis is more common in younger children. A peritonsillar abscess is usually found in young adults but can occur occasionally in children. The patient’s history often helps identify the type of tonsillitis (i.e., acute, recurrent, chronic) that is present.

What causes tonsillitis?
The herpes simplex virus, streptococcus pyogenes (GABHS) and Epstein-Barr virus (EBV), cytomegalovirus, adenovirus, and the measles virus cause most cases of acute pharyngitis and acute tonsillitis. Bacteria cause 15-30 percent of pharyngotonsillitis cases; GABHS is the cause for most bacterial tonsillitis.

What are the symptoms of tonsillitis?
The type of tonsillitis determines what symptoms will occur.

• Acute tonsillitis: Patients have a fever, sore throat, foul breath, dysphagia (difficulty swallowing), odynophagia (painful swallowing) and tender cervical lymph nodes. Airway obstruction due to swollen tonsils may cause mouth breathing, snoring, nocturnal breathing pauses, or sleep apnea. Lethargy and malaise are common. These symptoms usually resolve in three to four days but may last up to two weeks despite therapy.
• Recurrent tonsillitis: This diagnosis is made when an individual has multiple episodes of acute tonsillitis in a year.
• Chronic tonsillitis: Individuals often have chronic sore throat, halitosis, tonsillitis and persistently tender cervical nodes.
• Peritonsillar abscess: Individuals often have severe throat pain, fever, drooling, foul breath, trismus (difficulty opening the mouth), and muffled voice quality, such as the “hot potato” voice (as if talking with a hot potato in his or her mouth).

What happens during the physician visit?
Your child will undergo a general ear, nose and throat examination as well as a review of the patient’s medical history.

A physical examination of a young patient with tonsillitis may find:

• Fever and enlarged inflamed tonsils covered by pus.
• Group A beta-hemolytic Streptococcus pyogenes (GABHS) can cause tonsillitis associated with the presence of palatal petechiae (minute hemorrhagic spots, of pinpoint to pinhead size, on the soft palate). Neck nodes may be enlarged. A fine red rash over the body suggests scarlet fever. GABHS pharyngitis usually occurs in children aged 5-15 years.
• Open-mouth breathing and muffled voice resulting from obstructive tonsillar enlargement. The voice change with acute tonsillitis usually is not as severe as that associated with peritonsillar abscess.
• Tender cervical lymph nodes and neck stiffness (often found in acute tonsillitis).
• Signs of dehydration (found by examination of skin and mucosa).
• The possibility of infectious mononucleosis due to EBV in an adolescent or younger child with acute tonsillitis, particularly when cervical, axillary and/or groin nodes are tender. Severe lethargy, malaise and low-grade fever accompany acute tonsillitis.
• A grey membrane covering tonsils that are inflamed from an EBV infection. (This membrane can be removed without bleeding.) Palatal petechiae (pinpoint spots on the soft palate) may also be seen with an EBV infection.
• Red swollen tonsils that may have small ulcers on their surfaces in individuals with herpes simplex virus (HSV) tonsillitis.
• Unilateral bulging above and to the side of one of the tonsils when peritonsillar abscess exists. A stiff jaw may be present in varying severity.

Treatment
Tonsillitis is usually treated with a regimen of antibiotics. Fluid replacement and pain control are important. Hospitalization may be required in severe cases, particularly when there is airway obstruction. When the condition is chronic or recurrent, a surgical procedure to remove the tonsils is often recommended.

The tonsils are two pads of tissue located on both sides of the back of the throat. Adenoids sit high on each side of the throat behind the nose and the roof of the mouth. Tonsils and adenoids are often removed when they become enlarged and block the upper airway, leading to breathing difficulty. They are also removed when recurrence of tonsil infections or strep throat cannot be successfully treated by antibiotics.

The procedure to remove the tonsils is called a tonsillectomy; excision of the adenoids is an adenoidectomy. Both are usually performed concurrently; hence the procedure is known as a tonsillectomy and adenoidectomy (T&A).

T&A is an outpatient surgical procedure lasting between 30 and 45 minutes and performed under general anesthesia. Normally, the young patient will remain at the hospital or clinic for about four hours after surgery for observation. An overnight stay may be required if there are complications such as excessive bleeding or poor intake of fluids.

When the tonsillectomy patient comes home
Most children require seven to ten days to recover from the surgery. Some may recover more quickly; others can take up to two weeks for a full recovery. The following guidelines are recommended:

Drinking: The most important requirement for recovery is for the patient to drink plenty of fluids. Milk products should be avoided in the first 24 hours after surgery. Offer juice, soft drinks, popsicles and gelatin. Pudding, yogurt, ice-cream and other milk products can be offered after 24 hours. Some patients experience nausea and vomiting after the surgery caused by the general anesthetic. This usually occurs within the first 24 hours and resolves on its own. Contact your physician if there are signs of dehydration (urination less than two to three times a day or crying without tears).

During first 24 hours

Weight of Patient - Minimal Fluid Intake

over 20 pounds - 34 ounces

over 30 pounds - 42 ounces

over 40 pounds - 50 ounces

over 50 pounds - 58 ounces

over 60 pounds - 68 ounces

Eating: Generally, there are no food restrictions (other than milk products) after surgery. The sooner the child eats and chews, the quicker the recovery. Tonsillectomy patients may be reluctant to eat because of sore throat pain; consequently, some weight loss may occur, which is gained back after a normal diet is resumed.

Fever: A low-grade fever may be observed several days after surgery. Contact your physician if the fever is greater than 102º.

Activity: Bed rest is recommended for several days after surgery. Activity may be increased slowly, with a return to school after normal eating and drinking resumes, pain medication ceases, and the child sleeps through the night. Travel away from home is not recommended for two weeks following surgery.

Breathing: The parent may notice abnormal snoring and mouth breathing due to swelling in the throat. Breathing should return to normal when swelling subsides, 10-14 days after surgery.

Scabs: A scab will form where the tonsils and adenoids were removed. These scabs are thick, white, and cause bad breath. This is not unexpected. Most scabs fall off in small pieces five to ten days after surgery and are swallowed.

Bleeding: With the exception of small specks of blood from the nose or in the saliva, bright red blood should not be seen. If such bleeding occurs, contact your physician immediately or take your child to the emergency room. Bleeding is an indication that the scabs have fallen off too early, and medical attention is required.

Pain: Nearly all children undergoing a tonsillectomy/adenoidectomy will have mild to severe pain in the throat after surgery. Some may complain of an earache (because stimulation of the same nerve that goes to throat also travels to the ear), and a few may incur pain in the jaw and neck (due to positioning of the patient in the operating room).

Pain control: Your physician will prescribe appropriate pain medications for the young patient such as codeine, hydrocodone, Tylenol^® with codeine liquid, or Lortab^® (hydrocodone with Tylenol^®). Generally, an acetaminophen (Tylenol^®, Tempra^®, Panadol^®) teaspoon solution is recommended for regular administration to the patient for three or four days after surgery.

If you are troubled about any phase of your child’s recovery, contact your physician immediately.