Category Archives: Common illnesses

My child has an innocent murmur. What do I need to do?

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Suzanne Berman, M.D.

My child has an innocent murmur. What do I need to do?
Actually, nothing. Think of an innocent murmur like freckles. Technically, it’s an “abnormality” in the skin, but practically, it means nothing. Freckles don’t require any special treatment or have any significance. So, children with innocent heart murmurs:

  • do not need any special tests or X-rays
  • can play sports or do any activity they want to do
  • do not have an increased risk of heart problems later in life
  • do need to take antibiotics before dental procedures or surgery
  • should be treated like any other child

Why has no one heard this heart murmur until now?
Parents are sometimes upset when they are told their 4-year-old child has a heart murmur, wondering how the doctor could have “missed it” all this time. However, innocent heart murmurs are often “discovered” much later than the newborn period because:

  • The murmur may not have been there before. Innocent murmurs tend to appear and disappear as children grow.
  • The murmur may be quite soft. and difficult to hear if the child is crying, or if the child’s heart is beating very fast.
  • Certain things (like fever or a change in body position) can make murmurs easier or harder to hear. If the doctor had never listened to the child’s heart during a certain circumstance before, the murmur might not have been audible.

What is causing this murmur?
See our page on what causes murmurs for more details and diagrams.

Will it go away?
Most innocent murmurs do go away as children get older — which is why adults don’t have them, even though so many children do. However, remember that, since it’s harmless, it really doesn’t matter whether an innocent murmur goes away or not.

How can you tell just from listening if the heart murmur is innocent or not?
The characteristics of the sound help classify it as good or bad. For instance, we listen for:

  • How loud the sound is
  • Where on the chest we hear the sound
  • What it most sounds like (a hum, a click, a honk, a whoosh, etc.)
  • When in the cardiac cycle the sound occurs (for example, right after the “lub,” or with the “dub”)
  • Whether the sound comes and goes

Also, there are other things which suggest that a murmur is harmless:

  • An otherwise normal circulation: a normal blood pressure, strong pulses, etc.
  • An otherwise normal body: no other physical problems with the ears, kidneys, limbs, etc.
  • Good growth and development.
  • No symptoms. Children who can run, jump, and play without chest pain, shortness of breath, or heart palpitations are much less likely to have a serious murmur.

Once in a while (about 1% of children), the murmur may sound unusual, or a child may have other issues which make us more suspicious of a heart problem. In those circumstances, we will refer the child to a pediatric cardiologist for evaluation.

For more technical information on the mechanical causes of murmurs, see our page on what causes different kinds of murmurs.

How much acetaminophen (Tylenol) or ibuprofen (Advil) can I give my child?

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Suzanne Berman, M.D.

When dealing with your child’s fever, remember:

  • Acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) can be given every six hours as needed for fever.
  • If your child has a fever but is sleeping, don’t wake him or her up to give medicine for fever! Let your child rest.
  • Fever is not harmful for children. We treat with fever-reducing medications only to make them more comfortable. Avoid the “tyranny of the thermometer” and go more by how your child is acting, rather than the height of the fever.
  • Fever-reducing products, especially those containing acetaminophen, come in different strengths. Be sure to check the label of the product you have, and be sure that you’re giving the right amount for the strength of medicine you’re giving.
  • In 2011, manufacturers are changing the amount (concentration) of acetaminophen (Tylenol) in medicines for infants. These new concentrations will have different dosing directions. During the transition, you may find both concentrations on store shelves and in your home. It is very important that parents look on the label to check the concentration of the product they are giving. If you are unsure, please call our office.
  • Many over-the-counter cough and cold preparations (Dimetapp, Robitussin, Triaminic, etc.) contain acetaminophen as well. Check the label. If you give your child one of these products, do not give extra Tylenol.
  • Call us before giving any fever medication to children under age 3 months. Ibuprofen should never be used in children under age 6 months.

For acetaminophen products

If your child weighs Give this much Infant drops
(80 mg/0.8 ml)		 Children’s syrups
(160 mg/5 ml)		 Chewable tablets
(80 mg/tablet)		 Adult capsule
(325 mg/caps)
6-11 pounds 40 mg 1/2 dropper (0.4 ml) 1/4 tsp —– —–
12-17 pounds 80 mg 1 dropper (0.8 ml) 1/2 tsp —– ——
18-23 pounds 120 mg 1 1/2 droppers (1.2 ml) 3/4 tsp —— —–
24-35 pounds 160 mg 2 droppers (1.6 ml) 1 tsp 2 tablets ——
36-47 pounds 240 mg —— 1 1/2 tsp 3 tablets ——
48-59 pounds 320 mg —– 2 tsp 4 tablets 1 capsule
60-71 pounds 400 mg —– 2 1/2 tsp 5 tablets 1 capsule
72-95 pounds 480 mg —– 3 tsp 6 tablets 1 capsule
96 pounds and up 650 mg —– —– —– 2 capsules

For ibuprofen products

If your child weighs Give this much Infant drops 100 mg/2.5 ml Children’s syrup 100 mg/5ml Children’s tablets
50 mg/tablet		 Jr. strength chewables
100 mg/tab
13-17 pounds 50 mg 1/4 tsp 1/2 tsp —– —–
18-23 pounds 75 mg 1/3 tsp 3/4 tsp —– ———-
24-35 pounds 100 mg 1/2 tsp 1 tsp 2 tablets —–
36-47 pounds 150 mg 3/4 tsp 1 1/2 tsp 3 tablets —–
48-59 pounds 200 mg 1 tsp 1 3/4 tsp 3 tablets 1 1/2 tablets
60-71 pounds 250 mg —– 2 1/2 tsp 5 tablets 2 1/2 tablets
72-95 pounds 300 mg —– 3 tsp 6 tablets 3 tablets
96 pounds and up 400 mg —– —– —– 4 tablets

Due to the risk of Reye syndrome, we do not recommend giving aspirin or aspirin-containing products (such as Pepto-Bismol) to children with fevers.

What causes a heart murmur?

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Suzanne Berman, M.D.

What is a heart murmur?
When we listen to your child’s heart with a stethoscope, we usually hear just the normal two sounds of the heartbeat.

lub dub. lub dub. lub dub. lub dub. lub dub.
Doctors call the first sound (or “lub”) S1 and second sound (or “dub”) S2. These two sounds are caused by healthy heart valves slapping shut.

But once in a while, we hear an extra sound, called a murmur. It could sound like this:

lub [click] dub. lub [click] dub. lub [click] dub. lub [click] dub. lub [click] dub.
Or like this:

lub dubshhh. lub dubshhh. lub dubshhh lub dubshhh lub dubshhh.

Or even like this:

lhonk! dub. lhonk! dub. lhonk! dub. lhonk! dub.
What causes the extra sound?
In both innocent and concerning heart murmurs, the murmur is caused by turbulence in the flow of blood. When blood flows smoothly through a straight vessel, its motion is quiet. When blood hits an obstacle, it starts making noise moving past that obstacle. Think of a water faucet. When you turn it on, water flows out quietly. But if you put your thumb under the spigot, the water starts spraying out around your hand, making lots of noise.

Could a murmur be something bad?

Nearly all children have a heart murmur at some point in their lives, but less than 1% of children have a heart defect. This means that 99% of murmurs in kids are “innocent” — that is, harmless and not caused by a heart defect. Read about innocent heart murmurs for more details. Fortunately, most murmurs which indicate a serious problem are discovered within the first few days after birth.
Why are some murmurs bad and others aren’t?
It depends where the turbulence is coming from. Turbulence occuring inside the heart is what causes most “bad” murmurs; turbulence occuring in the large vessels outside the heart is usually harmless. Note that even if the turbulence comes from a place outside the heart, we still call it a “heart murmur.”

Here’s a diagram of how blood flows through a healthy heart.

  • Blue blood (without oxygen in it) returns to the heart from the body.
  • The heart pushes it out to large blood vessels which take the blood to the lungs.
  • The lungs put oxygen back into the blood.
  • The red blood (with oxygen) returns to the heart.
  • The blood moves through the other side of the heart and out of the heart through the aorta.
  • The aorta branches and divides, supplying blood to the body where the tissues can use the oxygen.

Now let’s look at two examples of how turbulence causes heart murmurs. The double arrows represent turbulence.

Here’s an example of a non-reassuring murmur caused by a hole between two chambers of the heart. Instead of red and blue blood staying separate, a hole lets blood mix through the middle. Blood bounces around back and forth through the hole. This creates a lot of turbulence and makes a harsh “grinding” sound. Some small holes in the heart can close up on their own, and nothing needs to be done. Large holes in the heart can be bad because, with time, the blood flowing improperly in this way can cause the heart to become misshapen.

Here’s an example of an innocent murmur caused by a curve in a blood vessel. When the blood exits the heart, it’s going at high speed. As it hits a sharp curve in a narrow blood vessel, it makes a “whooshing” sound as it passes. It’s noisy, all right, but harmless, because the blood has no problem getting to where it needs to go. And, of course, there’s nothing wrong with the heart itself.

How do I keep a headache diary?

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Suzanne Berman, M.D.

How do I keep a headache diary?
A “headache diary” is a written record of your child’s headaches: when they occur, what makes them better and worse, etc. On your calendar, write down the following details:

  • The date and time the headache started and stopped
  • What the pain is like (throbbing, stabbing, aching)
  • Where the pain is (left side, forehead, etc)
  • How bad the pain is on a scale of 1 to 10 (1 = barely there, 10 = worst headache ever)
  • Other symptoms before or during the headache (vomiting, blurry vision, etc)
  • Diet and activities that day: stressful exam, skipped lunch, etc.
  • Menstrual cycle (for girls)

Why are these details so important? It seems like a pain to keep up with.
We can do a lot more for the headaches if we know the details surrounding them. People tend to forget details if they aren’t written down. On the other hand, once you keep a written record, you might be amazed at the discoveries you make about the pattern, frequency, and triggers of your child’s headaches.

A two-month headache diary is essential to see if medications are making a difference in the frequency and severity of headaches. Unless you specifically try to keep track of how often headaches occur, you may not notice small differences or improvements in the headaches. (For example, a child may be put on medication that successfully decreases the headaches from 10 headaches a month to 6 headaches a month. 10 headaches a month may seem like “a lot,” and 6 headaches a month may seem like “a lot.” However, going from 10 to 6 is almost a 50% improvement. We might not recognize this unless it’s written down.)

How can I tell if my child is dehydrated?

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Suzanne Berman, M.D.

Here are some guidelines about an all-too-common pediatric problem. If, after reading them, you think your child is dehydrated, let our office know right away.

Why do children get dehydrated?
Basically, a child gets dehydrated when he loses more fluid than he takes in. Ill children don’t eat and drink as much as usual. They also tend to lose more fluid than usual, due to:

  • Lots of vomiting or spitting up.
  • Lots of diarrhea and loose stool.
  • High fever with sweating.
  • Rapid breathing with panting.

A child can have any of these things and do all right as long as fluid input ”catches up” to fluid output. However, if output is greater than input for more than a day or two, a child will get dehydrated.

Is my child dehydrated?
Dehydrated children can have the following:

  • Decreased urination. Infants should urinate at least every 4-6 hours. Older children should urinate 2-3 times a day.
  • No tears with crying.
  • Less saliva, with a tacky, cracked texture to the mouth and lips.
  • Poor skin color: grey, pale or mottled.

How much fluid does my child need?
Minimum fluid requiremenrs are proportional to your child’s weight.

  • 10 pounds: 2 cups per day
  • 20 pounds: 4 cups per day
  • 30 pounds: 5 cups per day
  • 40 pounds: 6 cups per day
  • 50 pounds: 6.5 cups per day
  • 60 pounds: 7 cups per day

A child can get this fluid from any source, including juice, milk, water, Popsicles, lemonade, etc. Even most foods have some fluid content.

Note that these rules of thumb are minimums. A particular child may need more to keep up, depending on his illness and symptoms.

What should I do if my child gets dehydrated?
Have him seen in the office right away. We can determine how dehydrated your child is and recommend a course of action, depending on why he is dehydrated. Most of the time we can treat this at home. Occasionally, we recommend IV fluids in the hospital.

What is neurally mediated syncope?

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Suzanne Berman, M.D.

Adapted from materials by Joel Hardin, M.D.

What is syncope?

“Syncope” refers to a brief loss of consciousness, usually related to temporarily insufficient blood flow to the brain: a fainting spell. It may be caused by many different things, including emotional stress, sudden pain, sudden changes in body position, or dehydration (e.g. after heavy sweating.) Rarely, syncope can be caused by heart disorders, but fortunately these are very rare in children and young adults.

What is neurally mediated syncope?
Neurally mediated syncope (NMS) is a harmless form of fainting that is common in children and teenagers. In fact, it’s the most common cause of fainting, or near fainting, in young people. It seems to be particularly common in tall, slim teenage girls, although boys and girls of all body types can have it.

NMS happens when blood pressure or heart rate drops, reducing circulation to the brain. It can cause dizziness, lightheadedness, or loss of consciousness. Children having an episode of NMS often describe it as feeling weak or dizzy, “seeing white” or seeing spots, feeling shaky or trembling. Parents or other people watching the episode often comment that the child seemed to be pale and sweaty appearing before passing out. If the fainting is prolonged, it can even trigger a seizure. (Placing the child in a reclining position will restore blood flow to the brain, resulting in return of consciousness and an end to the seizure.) Over two-thirds of children with NMS will have it more than once. NMS is not caused by a weak heart or heart problems.

What can I do for NMS?
Most of the time, NMS can be avoided by:
  • Lying down before losing consciousness. Fortunately, most children have symptoms which signal a spell is about to happen: nausea or vomiting, turning pale, lightheadedness, dizziness, visual disturbances, sweating, and shortness of breath. These let the young person know that it’s time to lie down and take a break.
  • Wearing elastic hose or tights to prevent venous pooling in the legs.
  • Increasing salt and water intake. Adding an extra gram of salt per day and an extra liter of fluids per day help maintain good blood volume.
  • Eating regularly. Poor diet also precipitates a “faint” feeling. Anemia from poor diet can also be a contributing factor.
  • Avoiding situations that trigger syncope, such as pain, fear, exhaustion, hunger, prolonged standing, or crowded/poorly ventilated rooms. Acute illness (colds, “flu,” etc.) is also a stimulus.
  • Intermittently contracting leg muscles when standing to increase venous return.
  • Avoiding drugs that can increase the likelihood of NMS, like alcohol, beta-blockers, and tricyclic antidepressants.

In cases where NMS continues to be common and disruptive in spite of doing the above, medications like hydrofluorocortisone or pseudoephedrine can be given to raise blood pressure. Fortunately, though, this is pretty unusual.

What is vulvovaginitis, and what can I do about it?

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Suzanne Berman, M.D.

Vulvovaginitis refers to a red, itchy irritation of the labia and vaginal area. Often, there is a film or discharge from the raw tissue which can be foul-smelling. Sometimes vulvovaginitis can be so severe that it hurts to urinate, even though there is no urinary tract infection (UTI). Many young girls have this condition from time to time.

What causes vulvovaginitis?

In teen girls and adult women, a yeast infection is the most common cause — especially after a course of antibiotics. Fortunately, in little girls, vulvovaginitis usually isn’t caused by yeast or other infections. More often, it’s caused by salt and acid from chemicals, sweat, urine, and other secretions.

How do I treat vulvovaginitis?

To soothe vulvovaginitis, we recommend the following:

  • Don’t use bubble bath in the tub.
  • Don’t let a bar of soap sit in the tub with your child.
  • Have your child get out of the bathtub right after washing and rinsing her hair — shampoo can also irritate this sensitive area.
  • Have your child take time to fully empty her bladder when using the toilet. Children who don’t empty fully tend to “dribble” urine in between trips to the restroom.
  • Little girls should wipe gently from front to back after using the toilet.
  • Be sure little girls do not have vaginal reflux of urine.
  • Wear clean cotton underpants every day. Underpants should be changed during the day if they get damp from urine or sweat.
  • Wash underpants in a mild, fragrance-free detergent such as Dreft.
  • After getting out of the swimming pool or lake, get out of the wet swimsuit quickly.
  • Avoid tight pants and shorts.
  • Use plain toilet paper without color or scent.
  • If your child is toilet trained at night, let her go without underwear at night. This will let air circulate around the skin.
  • Unless we specifically recommend it, don’t use any ointments or creams on the area. Many creams have chemicals in them that make irritation worse.
  • Discourage your child from rubbing or scratching the itchy area. Just like repeatedly scratching an itchy bug bite can infect it, scratching can introduce bacteria.
  • Use sitz baths two or three times a day to soothe and cleanse the area. Fill the bathtub with a few inches of warm water and let your child sit in it for about 10 minutes. Don’t put any soap or bubble bath in the water. (However, adding a few tablespoons of baking soda is OK.) After getting out of the bathtub, gently pat dry.

When can my child return to day care or school?

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Suzanne Berman, M.D.

Reasons to keep a child out of day care or school include:

  • The child is lethargic, irritable, tearful, or acting such that he or she is unable to participate in the usual activities.
  • The child’s illness is complex or severe enough that he or she takes all the time of a staff member or teacher.
  • Fever over 101 F.
  • Respiratory difficulty.
  • Diarrhea not contained by diapers or the toilet, stools containing blood or mucus, or bacterial diarrhea (such as E. coli)
  • A contagious bacterial illness until the child has been on antibiotics for at least 24 hours. Contagious bacterial illnesses include conjunctivitis (pink eye) and strep throat. (Bacterial illnesses such as ear infections and urinary tract infections are not contagious.)
Children shouldn’t be excluded for day care simply for:
  • Ear pain
  • A runny nose, even if the mucus is green or yellow
  • A viral sore throat
  • Cough.
  • One or two loose stools a day, contained in diapers.

When should I worry about fever?

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Robert Berman, M.D.
Suzanne Berman, M.D.

What qualifies as a fever?
A child’s body temperature is not a constant 98.6 degrees. During the course of a typical day, body temperature may vary almost two degrees above or below the 98.6 average. Fever is considered to be present if the body temperature is outside of this normal range. As measured by a rectal thermometer, a temperature of 100.5 or higher is considered to be a fever. Less than this is not a “low grade fever;” it’s simply within the normal temperature range.
Why does the body make fever?
When a healthy child begins to fight an infection, natural chemicals called pyrogens are produced. These pyrogens cause the body’s temperature to go up, resulting in a fever. A fever means that the body has found an infection and is trying to fight it. In fact, we know the immune system works better when the body is at a higher temperature.Fever is a symptom of most common illnesses of childhood, including: colds, gastroenteritis (“stomach virus”), flu, sore throats, sinus infections, ear infections, chicken pox, and roseola. Fever can also be seen with more serious infections, such as pneumonia and meningitis. High fevers, up to 106o F, can be present in both simple infections and in complicated infections. So, fever alone (or the height of the fever) can’t tell us whether a child has a mild infection or a more serious one. Read our information sheet on how to take a child’s temperature. Instead, we look at other things to find out what type of infection is causing the fever:

  • How long has the fever been going on? Most simple illnesses have fevers which last about 72 hours, or three full days from the time the fever started. Fevers can be quite high during this time, but will go away after about 72 hours because the body will start to eliminate the infection. Fevers which last longer than this can still occur with simple illnesses. However, if a child has fever more than three full days, we recommend getting the child checked to make sure there is no complicating problem.
  • What other symptoms does the child have? Cough, congestion, runny nose, vomiting, diarrhea, ear pain, rash, sore throat, stomachache, wheezing, rapid breathing, bladder pain, and muscle pain are other symptoms which help us figure out what type of infection the child has.
  • How is the child acting overall? Children with simple, common illnesses may not feel much like eating big meals, may be cranky, and will sleep more than usual – just like sick adults. However, these children should also be able to play a little bit, drink some liquids, and communicate how they feel. Worrisome signs include: refusing all food or drink, lethargy, inconsolable crying, lying very still for a long time, not seeming interested in usual people or things, etc. As you might expect, we are less concerned about a child with a high fever who is acting okay than a child with a low-grade fever who is very lethargic.

Sometimes, the only way to rule out a more serious infection is to have the child seen in our office, and we will carefully examine the child for a source of infection. If you feel concerned that your child is acting very sick, let us evaluate him or her. However, if your child is otherwise okay besides the fever, it is usually fine to wait and let it run its course.

Most fevers in otherwise healthy children are caused by viruses.There are hundreds of viruses that cause fever, congestion, cough, runny nose, and sore throat. Since there are no vaccines for these viruses, getting them and letting them run their course is just part of childhood. Children can get six to eight colds and one to three episodes of vomiting and diarrhea a year. (That averages almost an illness a month!) For children in day care, this number can be even higher. Your doctor can confirm what viruses are “going around” the community at the time.

Fevers do not cause brain damage. In order to have brain damage due to overheating, the body’s core temperature must exceed 107oF. Fevers do not cause temperatures this high; brain damage due to overheating is caused by environmental causes (e.g. sunstroke.)

Fevers can cause harmless seizures in a small percentage of children. In 3-5% of children, a rapid rise in body temperature (rather than the height of the temperature itself) can trigger a brief, harmless “febrile seizure.” While scary to watch, these seizures usually stop after just a few minutes. It is well documented that these children do not have any brain damage, mental retardation, or learning disabilities as a result. Febrile seizures tend to run in families, and 97% of children with them have no more seizures after age 6.

Fever only warrants immediate physician evaluation in four cases. If your child gets a fever in the middle of the night, you do not need to take him or her to the emergency room unless:

  1. Your child is acting very sick.
  2. Your child is an infant under the age of 2 months.
  3. You have refused to get recommended vaccinations for your child, putting him or her at increased risk for invasive bacterial disease.
  4. Your child has a weakened immune system, from cancer treatment, HIV infection, immunodeficiency, etc.

Unless one of the above cases is met, it is safe to treat fever at home. You can use either ibuprofen (Advil, Motrin) products or acetaminophen (Tylenol) products. Do not use aspirin, which in children with certain infections can cause a dangerous condition cause Reye Syndrome. Check to be sure you are giving the right dose for your child’s weight. If you are also using a cough/cold product (Dimetapp, Robitussin, etc.), check the label to see if it contains acetaminophen. If so, do not give additional acetaminophen.

When should I worry about swollen lymph nodes?

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Suzanne Berman, M.D.

What are lymph nodes?
Lymph nodes are like your body’s infection policemen. They are found all over the body, looking for any sign of infection that they can “arrest.” Each set of lymph nodes has its own “beat” that it monitors. For example:

  • Lymph nodes in the sides of the neck watch over the nose and throat.
  • Lymph nodes behind the ears and on the back of the neck watch over the scalp skin.
  • Lymph nodes in the armpits watch over the arms and chest.
  • Lymph nodes in the groin watch over the legs.

If an infection in one of these body zones occurs, the associated lymph nodes get busy. This causes those lymph nodes to swell up. For example, if you catch a cold virus, which causes an infection in your nose and throat, there may be swelling in the lymph nodes of the neck. They often swell to about the size of a quarter.

So a big lymph node means that there’s an infection?

No, not necessarily. (These policemen make a lot of false arrests!) Lymph nodes will swell up when the body suspects there’s an infection – even if there’s not really one there. Frequently, they swell up when there’s irritation of the area when no infection is present.

For example, lymph nodes behind the ears or on the back of the neck will grow in response to an irritation of the scalp, caused by:

  • a bug bite on the head
  • a cut or abrasion on the scalp
  • a fetal scalp monitor during labor
  • a harsh shampoo
  • bad eczema, cradle cap, or another skin condition

All of these things are really harmless. But the body isn’t sure at first, so it activates those lymph nodes – just to be sure. As a result, you’ll feel a small knot – usually the size of a pea or kernel of corn – on the back of your child’s neck.

When should I worry about a big lymph node?

Let us check it out in the office if:

  • if the lymph node is painful to the touch
  • if the skin over it is hot or red
  • if there is pus draining from the skin around the lymph node
  • if the child has other concerning symptoms, like unexplained fever, loss of appetite, weight loss, etc.
  • if there are lots of big lymph nodes, instead of just one
How long will the big lymph node last?

Sometimes weeks to months. The lymph nodes can swell up quickly, but usually take much longer to resolve.