Child's Hearing Loss
Children and Facial Paralysis
Facial Sports Injuries
Allergic Rhinitis (Hay Fever)
Child Screening
Children and Facial Trauma
Cochlear-Meningitis Vaccination
Could My Child Have Sleep Apnea?
Day Care and Ear, Nose, and Throat Problems
How Allergies Affect your Child's Ears, Nose, and Throat
Laryngopharyngeal Reflux and Children
Noise-Induced Hearing Loss in Children
Pediatric Food Allergies
Pediatric GERD (Gastro-Esophageal Reflux Disease)
Pediatric Head and Neck Tumors

Pediatric Thyroid Cancer
When Your Child Has Tinnitus
Why Do Children Have Earaches?
Is My Child's Hearing Normal?
Pediatric Sinusitis
Pediatric Obesity and Ear, Nose, and Throat Disorders
Nodules, Polyps, and Cysts
Pediatric GERD (Gastro-Esophageal Reflux Disease)
Pediatric Obesity and Ear, Nose, and Throat Disorders
Tonsillectomy Procedures
Tonsillitis
Tonsils and Adenoids PostOp
Tonsils and Adenoids
Tongue-tie (Ankyloglossia)

Child's Hearing Loss

Your child with a hearing loss can succeed - in school, in work, and in life! It is important to keep this as your focus, whatever your child's age or degree of hearing loss. While you will have the support of many professionals, ultimately you as parents will make many decisions about what is in the best interest of your child. As with all children, there is no magic formula for raising a child with a hearing loss. It helps to maintain a positive attitude, educate yourself about hearing loss, seek out the best resources, and take an active role in your child's education. Most of all, keep in mind that your child is a child first, and a child with a hearing loss second.

This online booklet is written for parents of children of all ages and all degrees of hearing loss. With so much to cover, the information presented here is only a brief overview, supplemented with a variety of reference and resource materials so you can follow up on subjects more thoroughly. In addition, you are encouraged to join the Alexander Graham Bell Association for the Deaf and Hard of Hearing for access to a huge variety of resources, including educational programs for you and your child, a large inventory of books and other publications, video tapes, conferences, and a national support network.

Will your child have a "normal" life? While some mild-moderate losses can be surgically or medically corrected, most hearing loss is a permanent condition. Thus, your child's life will have its challenges. However, these challenges sometimes turn into advantages. For example, the ability to work hard and concentrate more, coupled with the routines of audiologic and language therapy, frequently produces children who are self-disciplined and focused. Moreover, the outcomes for children with hearing loss have greatly improved in the last two decades due to major advances in technology and emphasis on programs of early detection and early intervention.

Emotional Impact of the Diagnosis: Parents can benefit from counseling and support after the diagnosis of hearing loss. Grief, anger, fear and denial are natural responses for hearing parents to feel when they find out their child has a hearing loss. Their expected "normal" child has a problem and this problem is going to present many challenges. We convey love through our words and tone of voice as well as through hugs and kisses. We soothe a child through the sound of our voice, or by singing a lullaby. We teach children that the objects in their room, their toys, their food, and the people around them all have names. We show children how to pronounce words by our example. We discipline and warn children of danger through words as well as actions. How are we going to do this now?

Deaf parents of deaf children are not necessarily prone to grief because they are already familiar with living in a world without sound. Deaf parents may feel more comfortable with a child who is deaf, because this seems natural. But this isn't the case for most hearing parents, who probably know little or nothing about hearing loss and who may never have known a child with a hearing loss. Many deaf parents will teach their child sign language as naturally as hearing parents unconsciously teach their child to speak. But hearing parents must commit themselves to the goal of helping their child listen and speak in order to participate fully in a hearing world, or the equally arduous task of becoming fluent in sign language and learning about Deaf culture.

Grief is a common emotion and an honest expression of disappointment and fear of the unknown. Grief that is not acknowledged or dealt with can lead to denial of a child's problem, which in turn can lead to procrastination in taking constructive action. Unacknowledged grief can lead to unfocused and displaced anger on the part of parents which can last a lifetime. Acknowledging grief, painful as it may be, will clear away anger and denial, allowing parents to most effectively nurture their child.

Children and Facial Paralysis

About 40,000 people in the United States develop facial paralysis each year with children comprising a small percentage of that population. There are more than 50 known causes of facial paralysis but the most common in children is “Bell’s palsy,” the cause of which is not certain. This disorder effects one side of the facial muscles due to dysfunction of the seventh cranial nerve, usually thought to stem from a viral infection; Bell’s palsy is found in 20 out of 100,000 Americans, with the incidence increasing with each decade of life.

What causes Bell’s palsy?

In Bell’s palsy, facial paralysis results from damage (e.g., possibly from viral infection) to the facial nerve. Adults and children will either wake up to find they have facial paralysis or palsy, or have symptoms such as a dry eye or tingling around their lips that progress to Bell’s palsy during that same day. Occasionally symptoms may take a few days to progress to facial weakness or paralysis. Physical trauma to the head and neck region at birth and during childhood may cause facial paralysis. Other causes are:

• Chicken pox: Chicken pox and shingles are both caused by a single virus of the herpes family known as varicella-zoster virus (VZV). Varicella is the primary infection that causes chickenpox; Herpes zoster is the reactivation of the virus that causes shingles. Research studies suggest that Bell’s palsy may be due to a reactivation of herpes simplex virus (HSV). Between 75 percent and 90 percent of chickenpox cases occur in children under 10 years of age. According to a 2001 study, about 10 percent of children between ages five and nine and about two percent of 10 to 14 year olds get chicken pox each year.
• Infectious mononucleosis: This condition, with a peak incidence in the 15- 17 age group, can be caused by several different viruses. The leading causes are the Epstein-Barr virus and cytomegalovirus, both members of the herpes virus family. The infection is transmitted by saliva, sexual contact, respiratory droplets, and blood transfusions.
• Lyme disease: Lyme disease is an infection that’s spread by Ixodes ticks (black-legged or deer ticks in the eastern United States, and western black-legged ticks in the west). The second stage of Lyme disease usually appears two to three months after the tick bite, and may include facial palsy or paralysis among other symptoms.

What are the symptoms of Bell’s palsy in children?

Not all children react the same to this disorder. However, recorded symptoms include:

• The child may complain of headache or pain behind or in front of the ear a few days prior to the onset of Bell’s palsy.
• Swelling or drooping on one side of the face.
• Drooling, excessive, or reduced production of saliva.
• An inability to blink or completely close one eye.
• The child has either excessive tears or marked dryness and inability to make tears in one eye.
• Sounds seem louder than they really are.
• The child is experiencing sensitivity to light.
• Episodes of dizziness.

Treatments for Facial Paralysis:

If infection is the cause, then an antibiotic to fight bacteria (as in middle ear infections) or antiviral agents (to fight syndromes caused by viruses like herpes zoster (Ramsay Hunt Syndrome) may be used. The prognosis for children with facial paralysis is generally very good. The extent of nerve damage determines the extent of recovery. With or without treatment, studies indicate that most pediatric patients with the disorder begin to get better within two weeks after the initial onset of symptoms and recover completely within three to six months. Adults may find residual symptoms remaining for an indefinite period of time.

What happens during the diagnosis?

After an examination, the otolaryngologist- head and neck surgeon may conduct a hearing test to determine if the cause of damage to the nerve has involved the hearing nerve, inner ear, or delicate hearing mechanism. Additional tests in the physician’s office include a balance test and a tear test, to measure the eye’s ability to produce tears. Eye drops may be necessary to prevent drying of the surface of the eye cornea. In some circumstances, the physician may recommend a CT (computerized tomography) or MRI (magnetic resonance imaging) test to determine if there is infection, tumor, bone fracture, or other abnormality in the area of the facial nerve. An additional diagnostic tool is the Electro neuronography (ENOG), which stimulates the facial nerve to assess how badly the nerve is damaged. This test may have to be repeated at frequent intervals to see if the disease is progressing.

Sources:

National Institute of Neurological Disorders and Stroke

Bell’s Palsy Research Foundation

Facial Sports Injuries

Playing catch, shooting hoops, bicycling on a scenic path or just kicking around a soccer ball have more in common than you may think. On the up side, these activities are good exercise and are enjoyed by thousands of Americans. On the down side, they can result in a variety of injuries to the face.

Many injuries are preventable by wearing the proper protective gear, and your attitude toward safety can make a big difference. However, even the most careful person can get hurt. When an accident happens, it's your response that can make the difference between a temporary inconvenience and permanent injury.

When Someone Gets Hurt:

What First Aid Supplies Should You Have on Hand in Case of An Emergency?

• sterile cloth or pads
• scissors
• ice pack
• tape
• sterile bandages
• cotton tipped swabs
• hydrogen peroxide
• nose drops
• antibiotic ointment
• eye pads
• cotton balls
• butterfly bandages

• Ask "Are you all right?" Determine whether the injured person is breathing and knows who and where they are.

• Be certain the person can see, hear and maintain balance. Watch for subtle changes in behavior or speech, such as slurring or stuttering. Any abnormal response requires medical attention.

• Note weakness or loss of movement in the forehead, eyelids, cheeks and mouth.

• Look at the eyes to make sure they move in the same direction and that both pupils are the same size.

• If any doubts exist, seek immediate medical attention.

When Medical Attention Is Required, What Can You Do?

• Call for medical assistance (911).

• Do not move the victim, or remove helmets or protective gear.

• Do not give food, drink or medication until the extent of the injury has been determined.

• Remember HIV...be very careful around body fluids. In an emergency protect your hands with plastic bags.

• Apply pressure to bleeding wounds with a clean cloth or pad, unless the eye or eyelid is affected or a loose bone can be felt in a head injury. In these cases, do not apply pressure but gently cover the wound with a clean cloth.

• Apply ice or a cold pack to areas that have suffered a blow (such as a bump on the head) to help control swelling and pain.

• Remember to advise your doctor if the patient has HIV or hepatitis.

Facial Fractures

Sports injuries can cause potentially serious broken bones or fractures of the face. Common symptoms of facial fractures include:

• swelling and bruising, such as a black eye

• pain or numbness in the face, cheeks or lips

• double or blurred vision

• nosebleeds

• changes in teeth structure or ability to close mouth properly

It is important to pay attention to swelling because it may be masking a more serious injury. Applying ice packs and keeping the head elevated may reduce early swelling.

If any of these symptoms occur, be sure to visit the emergency room or the office of a facial plastic surgeon (such as an otolaryngologist-head and neck surgeon) where x-rays may be taken to determine if there is a fracture.

Upper Face

When you are hit in the upper face (by a ball for example) it can fracture the delicate bones around the sinuses, eye sockets, bridge of the nose or cheek bones. A direct blow to the eye may cause a fracture, as well as blurred or double vision. All eye injuries should be examined by an eye specialist (ophthalmologist).

Lower Face

When your jaw or lower face is injured, it may change the way your teeth fit together. To restore a normal bite, surgeries often can be performed from inside the mouth to prevent visible scarring of the face; and broken jaws often can be repaired without being wired shut for long periods. Your doctor will explain your treatment options and the latest treatment techniques.

Soft Tissue Injuries

Bruises cuts and scrapes often result from high speed or contact sports, such as boxing, football, soccer, ice hockey, bicycling skiing, and snowmobiling. Most can be treated at home, but some require medical attention.

You should get immediate medical care when you have:

• deep skin cuts

• obvious deformity or fracture

• loss of facial movement

• persistent bleeding

• change in vision

• problems breathing and/or swallowing

• alterations in consciousness or facial movement

Bruises

Also called contusions, bruises result from bleeding underneath the skin. Applying pressure, elevating the bruised area above the heart and using an ice pack for the first 24 to 48 hours minimizes discoloration and swelling. After two days, a heat pack or hot water bottle may help more. Most of the swelling and bruising should disappear in one to two weeks.

Cuts and Scrapes

The external bleeding that results from cuts and scrapes can be stopped by immediately applying pressure with gauze or a clean cloth. When the bleeding is uncontrollable, you should go to the emergency room.

Scrapes should be washed with soap and water to remove any foreign material that could cause infection and discoloration of the skin. Scrapes or abrasions can be treated at home by cleaning with 3% hydrogen peroxide and covering with an antibiotic ointment or cream until the skin is healed. Cuts or lacerations, unless very small, should be examined by a physician. Stitches may be necessary, and deeper cuts may have serious effects. Following stitches, cuts should be kept clean and free of scabs with hydrogen peroxide and antibiotic ointment. Bandages may be needed to protect the area from pressure or irritation from clothes. You may experience numbness around the cut for several months. Healing will continue for 6 to 12 months. The application of sunscreen is important during the healing process to prevent pigment changes. Scars that look too obvious after this time should be seen by a facial plastic surgeon.

Nasal Injuries

The nose is one of the most injured areas on the face. Early treatment of a nose injury consists of applying a cold compress and keeping the head higher than the rest of the body. You should seek medical attention in the case of:

• breathing difficulties

• deformity of the nose

• persistent bleeding

• cuts

Bleeding

Nosebleeds are common and usually short-lived. Often they can be controlled by squeezing the nose with constant pressure for 5 to 10 minutes. If bleeding persists, seek medical attention.

Bleeding also can occur underneath the surface of the nose. An otolaryngologist/facial plastic surgeon will examine the nose to determine if there is a clot or collection of blood beneath the mucus membrane of the septum (a septal hematoma) or any fracture. Hematomas should be drained so the pressure does not cause nose damage or infection.

Fractures

Some otolaryngologist-head and neck specialists set fractured bones right away before swelling develops, while others prefer to wait until the swelling is gone. These fractures can be repaired under local or general anesthesia, even weeks later.

Ultimately, treatment decisions will be made to restore proper function of the nasal air passages and normal appearance and structural support of the nose. Swelling and bruising of the nose may last for 10 days or more.

Neck Injuries

Whether seemingly minor or severe, all neck injuries should be thoroughly evaluated by an otolaryngologist -- head and neck surgeon. Injuries may involve specific structures within the neck, such as the larynx (voicebox), esophagus (food passage), or major blood vessels and nerves.

Throat Injuries

The larynx is a complex organ consisting of cartilage, nerves and muscles with a mucous membrane lining all encased in a protective tissue (cartilage) framework.

The cartilages can be fractured or dislocated and may cause severe swelling, which can result in airway obstruction. Hoarseness or difficulty breathing after a blow to the neck are warning signs of a serious injury and the injured person should receive immediate medical attention.

Prevention Of Facial Sports Injuries

The best way to treat facial sports injuries is to prevent them. To insure a safe athletic environment, the following guidelines are suggested:

• Be sure the playing areas are large enough that players will not run into walls or other obstructions.

• Cover unremoveable goal posts and other structures with thick, protective padding.

• Carefully check equipment to be sure it is functioning properly.

• Require protective equipment - such as helmets and padding for football, bicycling and rollerblading; face masks, head and mouth guards for baseball; ear protectors for wrestlers; and eyeglass guards or goggles for racquetball and snowmobiling are just a few.

• Prepare athletes with warm-up exercises before engaging in intense team activity.

• In the case of sports involving fast-moving vehicles, for example, snowmobiles or dirt bikes - check the path of travel, making sure there are no obstructing fences, wires or other obstacles.

• Enlist adequate adult supervision for all children's competitive sports.

Allergic Rhinitis (Hay Fever)

Allergic rhinitis (hay fever) is an especially common chronic nasal problem in adolescents and young adults. Allergies to inhalants like pollen, dust, and animal dander begin to cause sinus and nasal symptoms in early childhood. Infants and young children are especially susceptible to allergic sensitivity to foods and indoor allergens.

What causes allergic rhinitis?

Allergic rhinitis typically results from two conditions: family history/genetic predisposition to allergic disease and exposure to allergens. Allergens are substances that produce an allergic response.

Children are not born with allergies but develop symptoms upon repeated exposure to environmental allergens. The earliest exposure is through food—and infants may develop eczema, nasal congestion, nasal discharge, and wheezing caused by one or more allergens (milk protein is the most common). Allergies can also contribute to repeated ear infections in children. In early childhood, indoor exposure to dust mites, animal dander, and mold spores may cause an allergic reaction, often lasting throughout the year. Outdoor allergens including pollen from trees, grasses, and weeds primarily cause seasonal symptoms.

The number of patients with allergic rhinitis has increased in the past decade, especially in urban areas. Before adolescence, twice as many boys as girls are affected; however, after adolescence, females are slightly more affected than males. Researchers have found that children born to a large family with several older siblings and day care attendance seem to have less likelihood of developing allergic disease later in life.

What are allergic rhinitis symptoms?

Symptoms can vary with the season and type of allergen and include sneezing, runny nose, nasal congestion, and itchy eyes and nose. A year-long exposure usually produces nasal congestion (chronic stuffy nose).

In children, allergen exposure and subsequent inflammation in the upper respiratory system cause nasal obstruction. This obstruction becomes worse with the gradual enlargement of the adenoid tissue and the tonsils inherent with age. Consequently, the young patient may have mouth-breathing, snoring, and sleep-disordered breathing such as obstructive sleep apnea. Sleep problems such as insomnia, bed-wetting, and sleepwalking may accompany these symptoms along with behavioral changes including short attention span, irritability, poor school performance, and excessive daytime sleepiness.

In these patients, upper respiratory infections such as colds and ear infections are more frequent and last longer. A child’s symptoms after exposure to pollutants such as tobacco smoke are usually amplified in the presence of ongoing allergic inflammation.

When should my child see a doctor?

If your child’s cold-like symptoms (sneezing and runny nose) persist for more than two weeks, it is appropriate to contact a physician.

Emergency treatment is rarely necessary except for upper airway obstruction causing severe sleep apnea or an anaphylactic reaction caused by exposure to a food allergen. Treatment of anaphylactic shock should be immediate and requires continued observation and care.

What happens during a physician visit?

The doctor will first obtain an extensive history about the child, the home environment, possible exposures, and progression of symptoms. Family history of atopic/allergic disease and the presence of other disorders such as eczema and asthma strongly support the diagnosis of allergic rhinitis. The physician will seek a link between the symptoms and exposure to certain allergens.

The physician will examine the skin, eyes, face and facial structures, ears, nose, and throat. In some cases, a nasal endoscopy may be performed. If the history and the physical exam suggest allergic rhinitis, a screening allergy test is ordered. This can be a blood test or a skin prick test. In most children it is easier to obtain a blood test known as the RadioAllergoSorbent Test or RAST. This test measures the amount of specific Immunoglobulin E antibodies (IgE) in the blood responding to various environmental and food allergens.

The skin test results, often immediately available, may be affected by the recent use of antihistamines and other medications, dermatologic conditions, and age of the patient. The blood test is not affected by medication, and results are usually available in several days.

How is allergic rhinitis treated?

The most common treatment recommendation is to have the child avoid the allergens causing the allergic sensitivity. The physician will work with caregivers to develop an avoidance strategy based on the nature of the allergen, exposure, and availability of avoidance measures.

Cost and lifestyle are important factors to consider. For mild, seasonal allergies, avoidance could be the most effective course of action. If pet dander is the offender, consideration should be given to removing the pet from the child’s environment.

Severe symptoms, multiple allergens, year-long exposure, and limited resources for environmental control may call for additional treatment measures. Nasal saline irrigations, nasal steroid sprays, and non-sedating antihistamines are indicated for symptom control. Nasal steroids are the most effective in reducing nasal symptoms of allergic rhinitis. A short burst of oral steroids may be appropriate for some patients with severe symptoms or to gain control during acute attacks.

If symptoms are severe and due to multiple allergens, the child is symptomatic more than six months in a year, and if all other measures fail, then immunotherapy (IT) (or desensitization) may be suggested. IT is delivered by injections of the allergen in doses that are increased incrementally to a maximum that is tolerated without a reaction. Maintenance injections can be delivered at increasing intervals starting from weekly to bi-weekly to monthly injections for up to three to five years. Children with pollen sensitivities benefit most from this treatment. IT is also effective in reducing the onset of pollen-induced asthma.

Child Screening

Why Is Early Childhood Hearing Screening Important For Your Child?

Approximately two to four of every 1,000 children in the United States are born deaf or hard-of-hearing, making hearing loss the most common birth disorder. Many studies have shown that early diagnosis of hearing loss is crucial to the development of speech, language, cognitive, and psychosocial abilities. Treatment is most successful if hearing loss is identified early, preferably within the first month of life. Still, one in every four children born with serious hearing loss does not receive a diagnosis until age three or older.

When Should A Child’s Hearing Be Tested?

The first opportunity to test a child’s hearing is in the hospital shortly after birth. If your child’s hearing is not screened before leaving the hospital, it is recommended that screening be done within the first month of life. Should test results indicate a possible hearing loss, seek further evaluation as soon as possible; preferably within the first three to six months of life.

Is Early Hearing Screening Mandatory?

In recent years, health organizations across the country, including the AmericanAcademy of Otolaryngology – Head and Neck Surgery, have worked to highlight the importance of screening all newborns for hearing loss. These efforts are working. In 2003, more than 85 percent of all newborns in the United States were screened for hearing loss.  In fact, some 39 states have passed legislation requiring some form of hearing screening of newborns before they leave the hospital. This still leaves more than a million babies who are not screened for hearing loss before leaving the hospital.

How Is Screening Done?

Two tests are used to screen infants and newborns for hearing loss. They are:

• Otoacoustic emissions (OAE) involves placement of a sponge earphone in the ear canal to measure whether the ear can respond properly to sound. In normal-hearing children, a measurable “echo” should be produced when sound is emitted through the earphone. If no echo is measured, it could indicate a hearing loss.
• Auditory brain stem response (ABR) is a more complex test. Earphones are placed on the ears and electrodes are placed on the head and ears. Sound is emitted through the earphones while the electrodes measure how your child’s brain responds to the sound.

If either test indicates a potential hearing loss, your physician may suggest a follow-up evaluation by an otolaryngologist.

Signs Of Hearing Loss In Children

Hearing loss can also occur later childhood, after a newborn leaves the hospital. In these cases, parents, grandparents, and other caregivers are often the first to notice that something may be wrong with a young child’s hearing. Even if your child’s hearing was tested as a newborn, you should continue to watch for signs of hearing loss including:

• Not reacting in any way to unexpected loud noises,
• Not being awakened by loud noises,
• Not turning his/her head in the direction of your voice, 
• Not being able to follow or understand directions,
• Poor language development, or
• Speaking loudly or not using age-appropriate language skills.

If your child exhibits any of these signs, report them to your doctor.

What Happens If My Child Has A Hearing Loss?

Hearing loss in children can be temporary or permanent. It is important to have hearing loss evaluated by a physician who can rule out medical problems that may be causing the hearing loss, such as otitis media (ear infection), excessive earwax congenital malformations, or a genetic hearing loss.

If it is determined that your child’s hearing loss is permanent, hearing aids may be recommended to amplify the sound reaching your child’s ear. Ear surgery may be able to restore or significantly improve hearing in some instances. For those with certain types of profound hearing loss who do not benefit sufficiently from hearing aids, a cochlear implant may be considered. Unlike a hearing aid, a cochlear implant bypasses damaged parts of the auditory system and directly stimulates the hearing nerve and allows the child to hear louder and clearer sound.

You will need to decide whether or not your deaf child will communicate primarily with oral speech and/or sign language, and seek early intervention to prevent language delays. Research indicates that habilitation of hearing loss by age six months will prevent subsequent language delays. Other communication strategies such as auditory verbal therapy, lip reading, and cued speech may also be used in conjunction with a hearing aid or cochlear implant, or independently.

Children and Facial Trauma

What is facial trauma?

The term facial trauma means any injury to the face or upper jaw bone.  Facial traumas include injuries to the skin covering, underlying skeleton, neck, nasal (sinuses), orbital socket, or oral lining, as well as the teeth and dental structures. Sometimes these types of injuries are called maxillofacial injury.  Facial trauma is often recognized by lacerations (breaks in the skin); bruising around the eyes, widening of the distance between the eyes (which may indicate injury to the bones between the eye sockets); movement of the upper jaw when the head is stabilized (which may indicate a fracture in this area); and abnormal sensations on the cheek.

In the U.S., about three million people are treated in emergency departments for facial trauma injuries each year. Of the pediatric patients, five percent have suffered facial fractures. In children less than three years old, the primary cause of these fractures is falls. In children more than five years old the primary cause for facial trauma is motor vehicle accidents.

Our fast paced world of ultra sports and increasing violence puts children at risk for facial injury.  But, children’s facial injuries require special attention.  A child’s future growth plays a big role in treatment for facial trauma. So, one of the most important issues as a care giver is to follow a physician’s treatment plan as closely as you can until your child is fully recovered.

Why is facial trauma different in children than adults?

Facial trauma can range between minor injury to disfigurement that lasts a lifetime. The face is critical in communicating with others, so it is important to get the best treatment possible. Pediatric facial trauma differs from adult injury because the face is not fully formed and future growth will be a factor in how the child heals and recovers. Certain types of trauma may cause a delay in the growth or further complicate recovery. Difficult cases require physicians with great skill to make a repair that will grow with your child.

Types of facial trauma

New technology, such as CT scans, have improved physicians ability to evaluate and manage facial trauma. In some cases, immediate surgery is needed to realign fractures before they heal incorrectly.  Other injuries will have better outcomes if repairs are done after cuts and swelling have improved. A new study has shown that even when injury does not require surgery, it is important to a child’s health and welfare to continue to follow up with a physicians care.

Soft tissue injuries

Injuries such as cuts (lacerations) may occur on the soft tissue of the face.  In combination with suturing the wound, the provider should take care to inspect and treat any injures to the facial nerves, glands, or ducts.

Bone injuries

When a fracture of the bones in the face occurs, the treatment process is similar to that of a fracture in other parts of the body.  Factors that affect how the fracture should be dealt with are the location of the fracture, the severity of the fracture, and the age and general health of the patient.  It is important during treatment of facial fractures to be careful that the patient's facial appearance is minimally affected.

Injuries to the teeth and surrounding dental structures style

Isolated injuries to teeth are quite common and may require the expertise of various dental specialists.  Because of the specific needs of the dental structures, certain actions and precautions should be taken if a child has received an injury to his or her teeth or surrounding dental structures.

• If a tooth is "knocked out", it should be placed in salt water or milk. The sooner the tooth is re-inserted into the dental socket, the better chance it will survive. Therefore, the patient should see a dentist or oral surgeon as soon as possible.
• Never attempt to "wipe the tooth off" since remnants of the ligament which hold the tooth in the jaw are attached and are vital to the success of replanting the tooth.

References:

Stewart MG, Chen AY. Factors predictive of poor compliance with follow-up after Facial trauma: A prospective study. Otolaryn Head and Neck Surg 1997: 117:72-75

Kim MK, Buchman R, Szeremeta. Penetratin neck trauma in children: an urban hospital’s experience. Otolaryn Head and Neck Surg 2000: 123: 439-43

Cochlear-Meningitis Vaccination

What you should know

The CDC and FDA, in partnership with state health departments, have recently completed an investigation that found children with cochlear implants have a higher chance of getting bacterial meningitis than children without cochlear implants. Some children who are candidates for cochlear implants may have factors that increase their risk of meningitis even before they get a cochlear implant. However, this investigation was not designed to determine the risk of meningitis in children who are candidates for cochlear implants but don’t have them.

Because people with cochlear implants are at increased risk for meningitis, CDC recommends that people with cochlear implants follow recommendations for pneumococcal vaccinations that apply to members of other groups at increased risk. Recommendations for the timing and type of pneumococcal vaccination vary with age and vaccination history and should be discussed with a health care provider.

Recommendations for people with cochlear implants aged two years and older include the following:

• Children who have cochlear implants, are aged 2 years and older, and have completed the pneumococcal conjugate vaccine (Prevnar ®) series should receive one dose of the pneumococcal polysaccharide vaccine (Pneumovax ® 23). If they have just received pneumococcal conjugate vaccine, they should wait at least two months before receiving pneumococcal polysaccharide vaccine.
• Children who have cochlear implants are between 24 and 59 months of age, and have never received either pneumococcal conjugate vaccine or pneumococcal polysaccharide vaccine should receive two doses of pneumococcal conjugate vaccine two or more months apart and then receive one dose of pneumococcal polysaccharide vaccine at least two months later.
• Persons who are aged 5 years and older with cochlear implants should receive one dose of pneumococcal polysaccharide vaccine.

Additional facts

Worldwide, there are over 90 known reports of people getting meningitis after getting a cochlear implant. This is out of approximately 60,000 people who have cochlear implants.

Meningitis is an infection. The infection is in the fluid that surrounds the brain and spinal cord. There are two main types of meningitis, viral and bacterial. Bacterial meningitis is the most serious type. It is the type that has been reported in people with cochlear implants. Depending on the cause of the meningitis, the symptoms, treatment, and outcomes differ.

Bacterial meningitis can be caused by several different kinds of bacteria. Four vaccines protect against most of these bacteria. The vaccines are:

• 7-valent pneumococcal conjugate (Prevnar®) (PCV-7)
• 23-valent pneumococcal polysaccharide (Pneumovax® 23) (PPV-23)
• Haemophilus influenzae type b conjugate (Hib)
• Quadrivalent A,C,Y,W-135 meningococcal polysaccharide (Menomune®).

Meningitis in people with cochlear implants is most commonly caused by the bacteria Streptococcus pneumoniae (pneumococcus). Children with cochlear implants are more likely to get pneumococcal meningitis than children without cochlear implants.

None of the children in the investigation had meningococcal meningitis caused by Neisseria meningitidis. There is no evidence that children with cochlear implants are more likely to get meningococcal meningitis than children without cochlear implants.

Could My Child Have Sleep Apnea?

Pediatric Obstructive Sleep Apnea

Sleep disordered breathing (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.

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

Pediatric obstructive sleep apnea

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 sub par academic and social skills may not have SDB, but if a child is a serious snorer and is experiencing mood, behavior, and 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.

Day care and Ear, Nose and Throat Problems

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 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 degrees, 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 unneccessary sickness. If a serious illness occurs, do not hesitate to have your child examined by a physician.

How Allergies Affect your Child's Ears, Nose, and Throat

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. 

Laryngopharyngeal Reflux and Children

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 fiberoptic 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.

Noise-Induced Hearing Loss in Children

The National Institute on Deafness and Other Communication Disorders reports that approximately 28 million Americans have lost some or all of their hearing, including 17 in 1,000 children under age 18. There are three types of hearing loss:

Conductive hearing loss:

This occurs when sound is not conducted efficiently through the outer ear canal to the eardrum and the tiny bones of the middle ear. Conductive hearing loss usually involves a reduction in sound level, or the ability to hear faint sounds. This type of hearing loss can be caused by middle ear infection, impacted earwax, or a benign tumor. This type of hearing loss can often be medically or surgically corrected.

Sensorineural hearing loss:

This hearing loss, caused by damage to the inner ear or to the nerve pathways from the inner ear to the brain, is permanent and cannot be medically or surgically corrected. Sensorineural hearing loss not only involves a reduction in sound level, or ability to hear faint sounds, but also affects speech understanding, or ability to hear clearly. Causes of this disorder include drugs that are toxic to the auditory system, and genetic syndromes. Sensorineural hearing loss may also occur as a result of noise exposure, viruses, head trauma, aging, and tumors.

Mixed hearing loss:

Hearing loss can be both conductive and sensorineural. For example, there may be damage in the outer or middle ear and in the inner ear (cochlea) or auditory nerve. When this occurs, the hearing loss is referred to as a mixed hearing loss.

Incidence of this disorder increases with age. For example, approximately 314 in 1,000 people over age 65 have hearing loss and 40 to 50 percent of people 75 and older have a hearing loss.

Although 10 million Americans suffer irreversible noise-induced hearing loss, with 30 million more exposed to dangerous noise levels each day, very little has been reported on children’s risk for this type of impairment.

This may soon change. Preteens are attending music concerts with increasing regularity. Additionally, the portable MP3 player, successor to transistor radios and the walkman, is a portable device that can provide up to 15,000 songs through headphones.

Should MP3 player use be limited?

Ear specialists say a whisper is 30 decibels and that a normal conversation is 60 decibels. The sound from an iPod Shuffle has been measured at 115 decibels. A survey sponsored by the Australian government found that about 25 percent of people using portable stereos had daily noise exposures high enough to cause hearing damage. And further research from the United Kingdom determined that young people, ages 18 to 24, were more likely than other adults to exceed safe listening limits.

Researchers at Boston Children’s Hospital determined that listening to a portable music player with headphones at 60 percent of its potential volume for one hour a day is relatively safe.

Why earplugs are important at concerts

Parents should be aware that various medical studies have found sound levels at rock concerts often to be significantly higher than 85 dBA, with some reports suggesting that sound intensity may reach 90 dBA to as high as 122 dBA.

To experience 85 dBA, listen to an electric shaver or a busy urban street. Experts agree that continued exposure to noise above 85 dBA over time will cause hearing loss. Clearly, if levels are maintained at values greater than 85 dBA for long periods of time, this may lead to a significant noise exposure and frequent concertgoers may experience some potentially irreversible hearing loss from this experience.

A research study, “Incidence of Spontaneous Hearing Threshold Shifts during Modern Concert Performances,” from the University of Minnesota Medical Center in Minneapolis examined sound intensity throughout a well-known concert venue and the effectiveness of earplugs.

The findings, presented at the 2005 annual meeting stated that sound pressure levels appeared equally hazardous in all parts of the concert hall, regardless of the type of music played. Accordingly, you should use earplugs at every type of musical concert, regardless of your vicinity to the stage.

A good rule of thumb: When a child accompanies a parent to any activity or location with excessive noise, ear protection should be worn by the entire family.

Pediatric Food Allergies

Dust, mites, pet dander, and ragweed are not the only allergic threats to your child. Food allergies and sensitivities may cause a wide range of adverse reactions to the skin, respiratory system, stomach, and other physiological functions of the body.

Determining what foods are the cause of an allergic reaction is key to treatment. Before you identify the culinary culprit you must consider what type of food allergy your child has. There are two types of food allergies. They are classified as:

• Fixed food allergies: A fixed food allergy may be very apparent, such as the child whose lips swell and throat itches immediately in response to eating peanuts. The cause for this type of food allergy is similar to that of inhalant allergies, so the diagnosis is more easily reached. Blood testing (i.e., RAST test) is typically used to verify fixed food allergies. Approximately five to 15 percent of food allergies are of the fixed variety.
  
• Cyclic food allergies: These allergies are far more common but less understood. Delayed food allergy symptoms can take up to three days to appear. This type of reaction is associated with the body’s immunoglobin G (IgG) or antibodies. Unlike fixed food allergies, this allergic response is cyclical in nature. As an example, a child may be IgG sensitive to milk. Consequently, symptoms might appear if the child increases the intake and/or frequency of milk consumption.

Both children and adults are susceptible to food allergies. The bad news for children is that they often have more skin reactions to foods, such as eczema, than do adults. But the good news for the young patient is that a child often outgrows his or her food sensitivities, even those that are positive on a RAST test, over time. Food allergies may fade, and then inhalant (e.g, dust, ragweed) allergies may begin to manifest.

Diagnosing and treating the cyclic food allergy

If your child is experiencing allergic reactions to food of unknown origin, you should ask yourself, “Are there any foods that my child craves or any food that I avoid offering?” These foods may be the ones that are causing difficulties for the young patient.

Your physician may also suggest the Elimination and Challenge Diet.

This dietary test consists of the following steps:

1. Keep a detailed food diary tracking what was eaten (including ingredients), when it was eaten, medications taken, and any symptoms which developed.   Be honest! Some well-meaning parents or caregivers often create a food diary to look healthier than it typically is. Your child can receive the best diagnosis if the diet records are accurate, timed precisely, and truthful. The diet diary can be evaluated by an ear, nose, and throat specialist to identify one or several food items that may be the culprits.

2. Conduct an unblinded elimination and challenge diet at home based upon your physician’s assessment of your child’s diet diary. It is best if you carefully maintain a new diet diary for your child during the period of elimination and challenge. During this elimination and challenge diet, your child must abstain from one, and only one, of the possible food culprits at a time for a period of four days. This can be difficult to carry out if the food is very common, such eggs or cereal, so you need to pay strict attention to your child’s diet during the elimination phase. Any “cheating” will invalidate the results.

3. On the fifth day, you will be asked to feed your child the suspected culprit food item. This is the challenge! Provide your child an average-sized portion of the food in question to be eaten in five minutes. In one hour the child should eat another 1/2 portion if no symptoms have developed. Any symptoms that develop are then timed and recorded. With a true cyclic food allergy, you would expect a significant worsening of the symptoms described in the original diet diary, although the challenge symptoms may vary as well. Fixed food allergies should never be deliberately challenged unless under the direct supervision of a physician. For minor, moderate discomfort from the testing, the patient may take: 1) a child’s laxative to decrease the transit time through the digestive system, 2) Alka Seltzer Gold, 3) Buffered Vitamin C (one gram).

If the Elimination and Challenge Diet confirms a cyclic food allergy, then you will be asked to abstain from feeding your child this food for a period of three to six months. After this time you can slowly reintroduce the food on a rotary basis; it is not to be eaten more frequently than every four days (once or twice a week).

Pediatric GERD (Gastro-Esophageal Reflux Disease)

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 stenoses, 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 narrowings 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.
• Fiberoptic 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

Pediatric Head and Neck Tumors

Tumors or growths in the head and neck region may be divided into those that are benign (not cancerous) and malignant (ie., cancer).  Fortunately, most growths in the head and neck region in children are considered to be benign. These benign growths can be related to infection, inflammation, fluid collections, swellings, or neoplasms (tumors) that are non life-threatening.  The malignant growths, on the other hand, may be life-threatening and cause other problems related to their growth and spread.  Even the malignant growths in the head and neck are usually treatable.

Benign Tumors

It is very common for children to have enlarged tonsils and adenoids.  These are almost always from an infection or inflammation.  It is very rare that children develop a cancer, lymphoma, or sarcoma of these areas.  When the tonsils, adenoids, or other areas of the mouth or throat remain enlarged or are enlarged on only one side, it is important to have an evaluation by a specialist in ear, nose and throat or otolaryngology-head and neck surgery.

The lymph nodes of the neck region may become enlarged during childhood.  Most of the time, this is reactive in nature and related to inflammation or infection.  However, if the lymph nodes remain enlarged for a period of time without going away, it is important to have an otolaryngologist-head and neck surgeon evaluate the problem.

Other benign growths in the face and neck include cysts (fluid collection) such as branchial cleft cyst, thyroglossal duct cyst, cystic hygroma, and dermoid cysts.  These often require removal due to their continued growth and potential for infection.  Growths of blood vessels often are seen in the face and neck and these are often referred to as hemangiomas, vascular malformations, lymphatic and arteriovenous malformations (AVM).  Some of these may require removal or treatment depending upon the type and location.

Sinus and Nose Growths

Although most children have nose bleeds and occasional allergies and sinus infection, sometimes tumors of the nose and sinus present with similar symptoms.  It is generally recommended that a child with continuous sinus problems or nose bleeds be evaluated by an otolaryngologist-head and neck surgeon to be sure it is not a tumor or other treatable condition.

Non-epithelial neoplasms constitute the majority of sinonasal (sinus) tumors in children and adolescents.  Among these, rhabdomyosarcoma (RMS) or undifferentiated sarcoma and non-Hodgkin lymphoma account for the majority of cases. Among head and neck RMS 14 percent arise from the nasal cavity and 10 percent from the paranasal sinuses.  Nasopharyngeal carcinoma accounts for one third of the nasopharyngeal neoplasms in children.  As is the case in adult patients, it is associated with Epstein-Barr virus (EBV) infection as demonstrated by EBV DNA presence in malignant cells.  Less frequently, Ewing’s sarcoma/PNET can present in this location. These tumors have also been described as secondary malignancies following treatment of retinoblastoma and other neoplasms. Esthesioneuroblastoma is a rare sinonasal tumor historically related to Ewing/PNET, although more recently comparative genomic hybridization analysis disputes this relation.  Other less common sinonasal tumors presenting in children include hemangioma and hemagiopericitoma, fibroma and fibrosarcoma, malignant fibrous histiocytoma, and desmoid fibromatosis.

Salivary Gland Tumors

There are three paired sets of salivary glands in the head and neck region.  These include the ones in front of the ears (parotid), below the jaw (submandibular), and underneath the tongue (sublingual).  Additionally, there are numerous very small salivary glands throughout the mouth and throat.  Although tumors can arise in these areas, they are rare.  Thus, any child with a growth in these areas should be seen by an otolaryngologist-head and neck surgeon.

Thyroid Tumors

The thyroid gland is found in the front of the lower part of the neck just above the chest area but below the Adam’s apple on both sides.  Although tumors can arise in this area, they are rare.  Thus, any child with a growth in this area should be seen by an otolaryngologist-head and neck surgeon.

Pediatric Obesity and Ear, Nose, and Throat Disorders

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 age of two-to-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 has identified 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.

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.