In my last blog, I mentioned that 6 muscles control the movement of each eye. This is a lot for a newborn’s brain to coordinate. As a result, it’s common for a newborn’s eyes to “wander” in the first few months of life. In most cases, the eyes move inward instead of outward. They are also more likely to wander when a baby is tired.
If the family history is positive for strabismus (lazy eye), the baby’s eyes are constantly out of balance or the baby’s eyes wander after 6 months of age, she should see a pediatric ophthalmologist. Keep in mind that eyes are supposed to converge (come together) if someone is looking at an object close up.
Like all referrals, it’s best not to schedule the appointment during the baby’s nap time because she’s more likely to cooperate with the exam is she isn’t tired.
When children come down with respiratory illnesses, they make lots of noises. The words parents use to describe these noises don’t always agree with how the doctors use the terms. Here’s the lowdown on the noises kids make when they have a cold or the flu.
- Congestion. This occurs with a stuffy nose and sinuses. When a child is congested, he will sound nasal because less air is passing through his nostrils when he talks. Which nostril is clogged varies throughout the day.
- Postnasal drip. If a child has a cold, mucus not only drips out of his nose, but some will also drip down the back of his throat. This can make his voice hoarse or raspy.
- Garbled voice. If a child has enlarged tonsils, he will often sound like he has “marbles” in the back of his throat.
- Chest rattle. Babies and young children don’t do a good job clearing mucus from their nose and throats when they have a cold. As a result, they often produce a rattle-like sound when they breathe. Parents not only hear this noise coming from the baby’s throat, but they may also feel it in the baby’s chest when he’s being held. A chest rattle is not usually a sign of pneumonia.
- Dry cough. This refers to a cough that has a rough, staccato quality.
- Wet cough. This refers to a cough that has a moist quality. It usually happens if a child has postnasal drip or bronchitis. Contrary to what many people believe, bronchitis in children is usually a viral disease and does not require antibiotics.
- Croupy cough. If a child has croup, his trachea becomes swollen below the vocal cords. This creates a hoarse voice and a barky, seal-like cough.
- Stridor. This sound is made during inspiration. It’s a brassy sound associated with a sense of difficulty getting air into the lungs. This is most commonly heard in children with croup: they “bark” when they cough and have stridor when they breathe in.
- Whoop. A classic whoop is heard with pertussis (whooping cough). The whoop is dramatic and occurs after a child has had a prolonged coughing fit. Nowadays, pertussis is more likely to be seen in older children or adolescents rather than babies or toddlers. An older child is more likely to “gasp” than whoop when he takes a breath after a prolonged coughing spell.
- Wheezing. This sound is made primarily during expiration. It’s a medium to high-pitched noise that sounds like the word. It is produced when a child’s bronchial tubes are tight (asthma) or narrowed with mucus (bronchitis, asthma). If a wheezing child is having respiratory distress (difficulty breathing), you may notice certain things when he breathes in: (1) his nostrils flare and (2) the spaces between his ribs pull in (“retract”).
When parents call me about rashes, I often hear that a child has “hives.” In most cases, parents use this term incorrectly. The question is, does that matter?
The factors that cause most rashes in children are environmental (insect bites, heat rash, allergic reactions) or infectious (viruses, bacterial, fungal). Hives are usually caused by viruses, but they can also occur with strep and allergic reactions to foods. (If you suspect that your child has hives because of an allergic reaction to a food, you should give him Benadryl and call the doctor right away. If your child also has coughing or trouble breathing, you should call 911 in case he’s having an anaphylactic reaction.)
The thing that distinguishes hives from other rashes is the margin between the normal skin and the rash. Most of the rashes children get consist of flat areas with or without a scale and small, raised bumps. (Doctors call flat rashes macules, bumps papules and hives wheals.) Papules come in different sizes, but they have one thing in common. The region between normal skin and the lesion rises slowly like a hill. With wheals (hives), the region between normal skin and the lesion rises more sharply, like a plateau. If you’ve ever seen a welt, the raised area at the edge is more characteristic of a wheal than a papule.
Parents often have questions about the things they see in their baby’s mouths. Here are the most common findings you may notice.
- Epstein’s Pearls. These are white spots on the roof of a baby’s mouth. They are usually the size of a sesame seeds. They disappear in a month or two.
- Bahn’s Nodules. These are white spots on the top or sides of a baby’s gums. They are bigger than Epstein’s Pearls, and parents sometimes mistake them for teeth. They disappear by 6 months.
- White or irregular gums. Some babies have smooth gums. Others have tiny ridges. The sides of a baby’s gums sometimes look white instead of pink. These are all normal findings.
- White coating on the tongue. Most parents are aware that newborns can get a yeast infection called thrush. However, if all you see is a thin, white coating on your baby’s tongue, it’s most likely from breast milk or formula. With thrush, you usually see cheesy-looking material on the inside of the cheeks and lips and on the roof of the baby’s mouth.
- Tongue-tie. This is hard for parents to see, but most have heard about it. The bottom of the tongue attaches to the floor of the mouth with a thin band of tissue called the lingual frenulum. In some cases, the frenulum is tight, thick or attaches near the tip of the tongue. If this happens, it may be harder for your baby to nurse properly. Doctors and nurses routinely check for this at newborn visits. In some cases, the baby will be referred to an oral surgeon or an ENT doctor to “clip” the frenulum.
In my last blog, I mentioned that it takes 6 months for testicles to descend from the abdomen into the scrotum. If this process doesn’t occur properly, a baby will be born with an undescended testicle. (If the testicle can be felt in the inguinal canal, it’s referred to as a partially undescended testicle.) In many cases, an undescended testicle will drop to its normal position by 2 to 3 months of life. If this fails to occur, the baby will be referred to a pediatric urologist.
Prior to puberty, a boy’s testicle is roughly the size and shape of a peanut. This fact, combined with an active scrotal reflex, often pulls the testicle into the lower part of the inguinal canal. We call this a retractile testicle. It’s not the same as a partially undescended testicle. In pre-adolescents, testicles commonly “hide” when boys giggle during the genital exam.
The way doctors differentiate between a partially undescended testicle and a retractile testicle is to see what happens when the boy squats. During a squat, a retractile testicle will drop down so it can be easily pulled into the scrotum; a partially undescended testicle will not. If there is any question about this, your child will be referred to a pediatric urologist.
If your child can’t get through the genital exam because he’s ticklish, there is a way parents can identify a retractile testicle without seeing a urologist. Have your child sit in a warm bath for about 5 minutes. Because the testicles are meant to be cooler than the body, retractile testicles will almost always drop down into the scrotum, which itself gets “baggy” in warm water. If you see or feel the testicles in the lower scrotum, you don’t need an appointment with a urologist.
Children are encouraged to get regular checkups. In addition to answering a parent’s questions, these visits are meant to reinforce a healthy lifestyle and to screen for certain conditions based on the child’s age. For babies and toddlers, screening questions focus on nutrition, growth and development, and safety. For school-aged children, this focus is broadened to include exercise, academic readiness, and the management of common childhood problems. Adolescents need more independence and should spend some time alone with the doctor.
Every checkup includes a physical examination where the doctor ensures the child is growing well and does not have any problems that could interfere with his health. Checkups are also accompanied by vaccinations to prevent the large number of serious diseases that children are at risk for.
Each question or test a doctor does has a purpose. For example, screen vision and hearing is screened yearly for two reasons:
- Children may not notice if they are not seeing or hearing well.
- Research has shown that vision and hearing can change over a span of six to twelve months.
The reason most pediatricians do not do blood tests every year is because the situation is different when it comes to blood work. Doctors routinely check for anemia (low blood count) at nine months and two years of age because the rapid growth of early childhood is a risk factor for developing iron-deficiency. However, if a child is healthy and has a healthy diet, the likelihood of developing anemia in elementary school is very low. This does not mean a doctor will not do blood work throughout this time period, however. But research does not support doing yearly blood counts on most children. Adolescent girls need blood counts more frequently because menstruation puts them at increased risk for iron-deficiency.
Other blood tests you may have heard of include:
- Cholesterol levels
- Liver and kidney tests
- Lead tests
- Vitamin D levels
While each of these tests is important, there is no reason to do them on a yearly basis. Each doctor will decide when to do them based on the child’s age and certain risk factors, which include family history, if the child has an underlying medical problem, and where the child lives.
I have an article on helping children cope with doctor’s visits and shots elsewhere on the website. (Link: https://howardjbennett.com/medical-articles/help-your-child-cope-with-doctors-visits/) Today, I wanted to mention a simple technique that can improve the way medical visits go for toddlers and young children. For this to work, you need three things.
- An older child who likes seeing the doctor.
- A schedule that allows you to bring the older child to the toddler’s visit.
- A doctor who is willing to “examine” the older child first.
It’s common for children to bring a “lovey” to doctor’s appointments to make the visits less stressful. Over the years, I have examined hundreds of stuffed animals from dogs to sharks to giraffes. The purpose of this fake exam is twofold. First, it shows the child you like to play. Second, it empowers the child so the visit is less threatening.
During my 30 years in pediatric practice, I have noticed that an older brother or sister can do an even better job reassuring toddlers that a medical checkup isn’t the worst thing in the world. A cooperative sibling can help in situations where a stuffed animal cannot. Here’s why.
- Toddlers know stuffed animals aren’t real. However, if an older sibling says the ear exam doesn’t hurt, it may carry more weight.
- Younger siblings generally look up to their brothers and sisters and want to be like them. This encourages the toddler to overcome his fear of the examination.
- The presence of the older child may act as a distraction making it easier for the toddler to stay still during the examination.
Although older siblings can help with the medical exam, they are less effective when it comes to blood tests or shots. Consequently, unless you have remarkable kids, I wouldn’t ask the older one to tackle that task.
This blog post is really for adolescent males. If you are a parent, copy the information or send a link to your son. Concerned aunts, uncles and grandparents can do the same thing.On May 14th, I wrote a blog about testicular torsion. [Link: https://howardjbennett.com/2012/05/14/have-you-ever-heard-of-testicular-torsion/
] The purpose of the blog was to inform kids and parents about a serious condition that can happen at any age, but is more common in teens.
I educate all of my adolescent patients about testicular torsion so they will act quickly if they develop the sudden onset of testicular pain. I also encourage them to check their testicles on a monthly basis to look for other problems. They don’t always listen.A few months ago, I saw a 16-year-old for a routine checkup. During the genital exam, I found a large inguinal (groin) hernia. When I asked Jeremy (not his real name) how long the bulge had been present, he got quiet and said, “I’m not sure, four months maybe.”The reason Jeremy didn’t tell me about the swelling is because he had hoped it would go away. This is an example of denial, something that can happen to anyone. Males of all ages, but especially teenagers, are reluctant to report problems in this particular location.
I referred Jeremy to a surgeon who repaired the hernia without complications. But the take-home message is clear. If something else had been causing the swelling, such as testicular cancer, not telling anyone about it for months might have had a different outcome.
Although testicular cancer is rare (5.4 cases per 100,000 males), it is the most common cancer in males aged 15 to 39. Because the incidence of testicular cancer is low, there is disagreement among medical professionals regarding the value of monthly screening. That being said, the survival rate for Stage 1 testicular cancer is better than advanced disease.
The best time to do the exam is after a shower when the scrotum is relaxed.
- Examine one testicle at a time.
- Using gentle pressure, roll each testicle between your thumb and fingers. Testicles are egg-shaped and should feel smooth and firm. One may be slightly bigger than the other, but they should be about the same weight and consistency.
- Feel for small lumps, swelling, hardness or other changes in the shape of the testicle.
- The epididymis is a spongy, tube-like structure that is attached to the top and back of each testicle. It is a normal finding.
- If you notice a change in either testicle, see your doctor promptly.
Doctor’s visits can be unsettling for children so I usually examine infants and toddlers on the parent’s lap. However, once boys reach the age of three or four, it’s important to do the testicular examination while they are standing.
Prior to adolescence, the main problem we look for is an inguinal hernia. Although parents may notice a bulge in their child’s groin before the checkup, the finding can be missed if a child isn’t standing when he’s examined. The reason for this is because an inguinal hernia is the result of a small opening between the abdominal cavity and the scrotum. If a person is standing, gravity “pushes” intestinal contents downward making the hernia easier to find.
Doctors look for inguinal hernias in adolescents as well, but this age group can also develop something called a varicocele. A varicocele is a painless swelling in the scrotum due to enlarged veins. (It feels like the scrotum is partially filled with worms or cooked spaghetti.) Like hernias, the problem can be missed if the testicles are examined when a person is lying down because the swelling goes away in this position.
If your child’s genital exam isn’t done while he’s standing, tell the doctor you know someone whose hernia or varicocele wasn’t found until he was checked in this position. Also, because adolescents usually ask parents to leave during the genital exam, make sure your son knows about the importance of being examined while standing.
Although inguinal hernias are much more common in boys, they can occur in girls as well. Therefore, it’s a good idea to do a brief genital check in girls when they are standing.