When I hit my 40s, I was happy, healthy and very, very busy. I was a caretaker for someone I loved. I was writing books. I took up golf, learned about scuba diving and participated in my first triathlon, doing lots of TV work, creating my clothing lines… I was really living life, taking care of myself, eating well and getting regular massages was a part of my regimen.

But I started feeling tired after spin classes, my breathing was becoming an issue and I had to stack 5 pillows under my head when I slept, and a cough made voice overs problematic…last but not least, I had developed an uncontrollable itch. At first I blamed my gluten filled diet, and three days before I was to appear on the Montel Williams Show, I recall standing at Whole Foods grocery store and deciding then and there that I needed to be gluten free. I had been feeling so terrible, I really had to dig deep to rethink how I was taking care of myself.

So I started buying rice cakes. I bought all these wonderful flours: tapioca and buckwheat and others. I made the cookies I craved with the new ingredients, and (although they were a little drier), the new cookies… and my new diet… were just fine. I started feeling better, less itchy, less puffy.

But my energy still wasn’t right, and I had a pressure in my chest that made it hard to sleep. My chiropractor would touch my neck in a certain place, and I’d cough every time. Having a past history as a massage therapist, I knew my body was trying to tell me something.

But I was having trouble getting doctors to listen. Some of them mentioned hormones. One doctor started a conversation with, “I know you’re in the media, and you’re used to having a lot of attention, but…” I actually walked out of his office.

When I sat down with the fifth doctor, I said, “Pardon me… I don’t want to seem overly pushy or stubborn or anything, but I want to have a full set of blood tests, and I’m not going to leave your office until you give me a complete chest x-ray.”

I’m not sure if she agreed with me, but she said she could tell I was very serious. “I feel there’s something in my chest,” I said. And I had to find out what it was despite her additional prescription of Nexium for acid reflux (just in case).

The diagnosis was stage 2 Non Hodgkin’s Lymphoma —a form of lymphatic cancer that is thankfully often curable with chemotherapy (and radiation). What I had felt in my chest was a quite a few tumors and one about the size of a banana. When the doctor called, she said, “Thank God you were persistent.”

What is the lesson I learned here?

It took a few months for me to ask this question, and the answer didn’t come immediately. A little time and distance has given me the ability to think about what this diagnosis told me.

1. I realized that I was going too fast, that I needed to make some changes in my life. I was trying to rush through treatment, and I had to rest. I took a step back one day when I realized that I looked forward to my PET scan because I’d have the opportunity to take a 90-minute nap. This was really an eye opener, and I had to train myself to slow down.
2. I recognized that I needed to ask for help. I never ask for help… Rarely do I say to a friend, “Oh, please come with me.” But during treatment, I asked 14 of my best girlfriends to be my cancer buddies, and all of them are dear to my heart because they were there for me when I needed them most.
3. I understood the power of persistence. If I had listened to the first doctor, or had given up after the third, my situation might have gotten a lot worse before it got better. Thus, even though my persistence was sometimes frustrating, I listened to what my body was telling me and used my voice to tell others.

I hope you can take my lessons and apply them to your own lives, to learn how to slow down, ask for help and speak up. You alone have the power to make your life what you want it to be, and I wish you all the strength to do so.

Related concepts:

Precocious puberty

Introduction to early puberty:

When childhood is ending, it often feels like it has all gone by too fast. It’s bittersweet watching our children’s bodies change into those of young men and women. How much more poignant when puberty arrives earlier than expected!

What is early puberty?

The age of onset of puberty varies widely. In girls, the breast bud is usually the first sign, and is seen on average at 10-11 years. Pubic hair usually begins to appear 6-12 months later. Next comes the pubertal growth spurt. Menstruation begins, on average, 2 to 2.5 years after the onset of puberty. The mean age for a girl’s first period is about 12 years. Wide variations are seen in the sequence and timing of these events, but the peak growth spurt always precedes the first period.
In boys, testicular enlargement is the first sign of puberty and is seen on average at 10-13 years. Further testicular enlargement, pubic hair development, and penile enlargement, follow. The peak growth spurt for boys happens around 6 months after pubic hair development and typically occurs later than for girls.
Precocious puberty is often defined as the onset of true puberty before 8 years of age in girls or 9 years of age in boys. (Isolated breast development that doesn’t progress to the rest of puberty is called premature thelarche, and is a different, benign condition).

Who gets early puberty?

Precocious puberty is 10 times more common in girls than in boys.
Most precocious puberty is simply early maturation. Nevertheless, the Lawson Wilkins Pediatric Endocrine Society recommends evaluating for an underlying medical condition in Caucasian-American girls who have development of breast and/or pubic hair before age seven and in African-American girls before age six (Kaplowitz and Oberfield, Pediatrics 1999 Oct;104(4 Pt 1):936-41). Medical conditions that may be associated with precocious puberty include ovarian cysts, thyroid problems, McCune-Albright syndrome, or external sources of estrogen. In girls over age 6, these other causes are quite rare, but should at least be considered by your pediatrician.

What are the symptoms of early puberty?

In girls, the signs to watch for are the development of the breasts, the growth of pubic hair or underarm hair, a change in the appearance of the external genitals, and the beginning of menstrual periods.
In boys, watch for enlargement of the testicles or penis, the appearance of pubic hair or underarm hair, acne, and the deepening of the voice.
Increased height and weight may be seen in boys or girls.
Early maturation may be divided into three main types: rapidly progressive, slowly progressive, and unsustained. Most girls who begin puberty early (especially those who begin before age 6) have the rapidly progressive variety. They go through each of the stages (including closure of the growth plates of the bones) at a very rapid pace, and thus lose much of their adult height potential. About 1/3 of these girls will end up shorter than the 5th percentile of adult height. Many girls, however (particularly those beginning puberty after their 7th birthdays), will start puberty early, but still go through each of the stages at a more typical pace. While their “adolescent” growth spurts are over early, they will continue to grow until their bones reach final maturity at about age 16.
A few have unsustained early puberty: the changes of puberty begin and then stop.

Is early puberty contagious?

No

How long does early puberty last?

Sexual development may begin at any age. Pregnancy has been reported as early as 5 1/2 years old.

How is early puberty diagnosed?

Early puberty is suspected on the basis of the physical examination. Laboratory tests are important to determine which puberty hormones are present, and where they are coming from. Sometimes X-rays of the hands to look at bone growth help determine the cause of early puberty.

How is early puberty treated?

Medicines are available to slow or stop early puberty. Sometimes surgery is needed to remove ovarian cysts, or other ongoing sources of puberty hormones.
Children with early puberty tend to have the mental development of their chronologic age clashing with the emotional surges of adolescence. These children deserve extra understanding and support.

How can early puberty be prevented?

Often early puberty cannot be prevented. We do know that exposure to puberty hormones such as estrogen can trigger some types of early puberty. Reducing children’s exposure to estrogen or other sex hormones is wise.

Related A-to-Z Information:

Depression, HIV, Inconspicuous Penis, Labial Adhesions, Lanugo, Nightmares, Obesity, Sexual Abuse, Sexual Curiosity in Young Children

Dr. Greene’s Answer:

Having the belly fill up with stool is more common than most people think. The scenario is so common that I created my own name for the downward spiral that leads to it. I call it the “D3 cycle” (discomfort, dread, delay).

Children can enter the D3 cycle at any point. Sometimes it begins with an uncomfortable experience passing a hard stool created by a change in diet or a brief illness. Sometimes the starting point is simply the fear of sitting over the gaping hole in the potty to poop. Sometimes children are engaged in playing and choose to ignore the urge to poop, holding the stool in just to delay interrupting a vitally important game.

Whatever the starting point, they end up having a painful experience. When the next urge arrives, the child decides to delay going to the bathroom in order to avert what happened last time. The longer she delays, the firmer the next stool becomes. When she finally does poop, the event is even more uncomfortable-confirming her fears. What she dreaded was true!

She vividly learns from this experiment, but it’s the wrong lesson. So next time she is even more determined to hold in the stool. Discomfort leads to dread; dread leads to delay; delay leads to discomfort. The rectum stretches internally so that more stool can be held, and soon urges to defecate are not often felt. The D3 cycle becomes a powerful trap.

But this trap can be undone. Kids should not have to learn to live backed up with stool.

You said that she has been on a program to reverse this for 3 weeks. That sounds like the right place to begin. It can take a while to get the bowels regular. Once kids are having daily soft stools, it takes another 2 weeks for the intestines to shrink back to normal.

Cramping pain during this process is not unusual. If the pain persists after the stool problem is resolved, a long list of other possible causes should be considered. Food intolerances, celiac disease, inflammatory bowel disease, parasites, or other infections could cause it-to name a few possibilities. Further workup may be indicated to find out what else is going on. Children with these conditions deserve to have them identified and treated.

Dr. Greene’s Answer:

Lice have been a nuisance to humans since ancient times. They have thrived almost wherever humans have been in prolonged close contact with each other. One notable exception to this has been in areas where the pesticide DDT is in widespread use. In the United States, for a period of about 30 years, lice outbreaks were uncommon. Since DDT was banned in 1973, the number of cases of lice has risen steadily. Today, there are about 12 million cases per year in the United States alone. Each year, many day care centers, schools, neighborhoods, extended families, and small family units face problems with lice. You are not alone.

Two myths:

Myth: Head lice restrict their activities to unclean houses, unclean heads, and unsavory sorts of folks.
Fact: Having head lice is not a sign of poverty or poor hygiene.

Myth: All heads of hair are equally attractive to lice.
Fact: Lice seem to prefer children to adults, long hair to short hair, and they particularly like the hair of females. Interestingly, lice only rarely afflict African Americans living in North America. The lice in Africa and South America have adapted, however, and cases are common in every group on those continents. Cases of lice are most common in children 3 and 10 years old, but can occur at any age.

Adult lice are six-legged, wingless insects 2-4 mm long. They have translucent grayish-white bodies, and look a bit like a grain of rice with six legs. Their heads have two tiny eyes (too small to be seen without magnification) and two small antennae (usually visible). Six pairs of hooks surround the mouth parts, by which they attach themselves to the skin of the scalp for feeding. The mouth contains two retractable, needle-like tubes that pierce the scalp. Salivary juices are injected into the scalp to prevent blood from clotting, and then the lice feed happily, sucking blood through these same tubes. Their translucent bodies turn reddish brown when engorged with blood. Lice completely depend on the blood extracted from humans for existence, and thus will starve to death after 55 hours without blood.

Adult lice can freely move around a head of hair and travel to another person, clothing, plastic combs or brushes, or upholstered furniture. Adult lice usually live for about a month on a human host. During this time, the females generally lay from three to 10 eggs per day (although some female lice have been known to lay up to 5,000 eggs in their lives when in an environment to their liking).

Lice eggs are called nits. These white, translucent, pinpoint-sized eggs are laid near the base of hair shafts, and move outward as the hair grows (nits found near the tips of long hairs suggest a longstanding infestation). Nits are glued tightly to the side of the hair shafts, and cannot be moved along the shafts or knocked off with fingers. The eggs hatch between ten to fourteen days after they are laid. The empty eggs remain attached to the hair shaft. The newborn larvae must feed on human blood within 24 hours, or they will starve to death. The larvae become sexually mature adult lice within about one week.

During this whole life cycle, larvae and adult lice deposit their feces in the scalp, which eventually causes itching as the person develops an allergic reaction to the lice stool. The hallmark symptom of head lice is itching, but a person may have lice for months before the itching begins. For me, just thinking about lice makes my head itch.

Now, a moment of silence to be grateful that lice can’t fly…

Lice spread from person to person when heads touch. Because they can live independent of a person for up to 55 hours, they are also commonly spread via stuffed animals, hats, headphones, combs, brushes, towels, clothing, car seats, sofa cushions, and bedding.

The best way to diagnose head lice is to inspect the head of anyone who might have been exposed to them using a bright light (full sun or the brightest lights in your home during daylight hours work well). A magnifying glass can make the job easier. Part the hair all the way down to the scalp in very small swaths, looking both for moving insects and nits. The entire head must be inspected to make sure there is no problem. Careful attention should be given to the nape of the neck and around the ears, the most common locations for nits. Even one nit in the hair should be treated. The egg might be empty, or contain a dead larva but — then again, it might not!

Frequently, people find “pseudo-nits” and panic unnecessarily. Bits of hair spray, dead skin scales, or loose debris may be seen on hair shafts. These move with pressure from the fingers — nits do not. Also, live nits glow when exposed to a black light (we use black lights in pediatric offices for inspection) and dead nits and empty nits do not.

Historically, the main method for getting rid of lice has been mechanical — physically removing the nits, or “nit picking,” such as apes do for each other during their daily grooming routine. About 30 years ago, powerful pesticides were introduced as lice treatments. For a time, they made treating lice much easier. Over the last several years, however, the lice have become increasingly resistant to these medicines. The resistance is growing. Now, once again, mechanical nit removal is the cornerstone of lice treatment, although the medicines can still be a real help.

Treatment for head lice can be effective, but it is not simple, easy, or inexpensive. A key to success is making sure that ALL individuals who may be potentially affected by the outbreak complete a radical eradication. If 99.99% of the lice are killed, but .01% are not, you already have the makings of another outbreak!

So, you can check easily for lice without going to the doctor, but you do not need to feel embarrassed or ashamed. Your doctor will understand and I do too — from personal experience.

Dr. Greene’s Answer:

Lumps of one kind or another are a common reason for a visit to the doctor’s office. The lump might be in the neck (that the parents suspect is just a swollen gland), in the knee (that the parents think is from sliding into third base last month), or under the nipple (that the parents hope is due to puberty). I often enjoy seeing parents with these concerns in my own office. Sometimes the parents feel that they shouldn’t even bother their doctor with this because it’s probably normal. But underneath these hopeful, at-home diagnoses lies a common fear–it might be a tumor!

Most lumps in children are not cancerous and are not serious. Thankfully, childhood cancer is uncommon. But parents’ fears are not unfounded. Childhood breast cancer is quite rare, but it certainly does occur, even in boys. In males of all ages, breast cancer accounts for less than 1% of all cancers (American Surgeon, 1999; 65:250–253). But if it is your son, any chance of cancer seems too much. And a lump might be the first sign noticed.

Breast lumps in children often give rise to two immediate fears–Could it be a tumor? Or could something be going wrong with puberty? (A third fear–Will my child be teased?–arises if the first two turn out to be no problem.)

I’ll give you some guidelines for when to be concerned about a breast lump and when you can relax.

Puberty is a time of dramatic changes in the body, especially in the reproductive system. These transformations are brought about by surges of complex and precisely balanced hormones. The last time your 12-year-old had these tides of hormones was when he was a newborn–but then the hormones were yours. Coursing through his blood, your hormones matured his lungs, made him ready for life in the big outside world, and along the way may have given him baby acne and breast enlargement–even nipples that leaked milk. This precious newborn season was gone in a blink.

Now your 12-year-old is making surges of these same hormones on his own as his body turns into an adult’s–a miracle not unlike when you helped turn his body into a newborn’s.

There are five stages of the changes that occur during puberty, called Tanner stages or Sexual Maturity Rating (SMR) stages. Breast lumps in boys are common during SMR 3 and SMR 4.

In boys, SMR 3 usually begins at about age 12 or 13 years and lasts a year or so, although it can be normal in our culture to begin as early as 10 years or as late as 14.9 years, according to Tanner (Journal of Pediatrics, 1985; 107:317). SMR 3 is the time when the testes get clearly larger, the penis gets noticeably longer (then thicker in SMR 4), and the pubic hair (though still small in amount) gets darker and starts to curl.

Sperm is first produced during SMR 3.

Boys grow at their fastest during SMR 3 and SMR 4 (girls get their growth spurts earlier). With your son, you’re probably seeing him outgrow his beginning-of-the-year school clothes already–especially his shoes. During SMR 3, the feet and hands usually grow first, then the arms and legs, and finally the trunk–giving them that adorable adolescent gawky look (don’t tell my 12-year-old son I said that).

SMR 3 also marks the beginning of significant underarm perspiration (the odor, as you’ve probably noticed, can start much earlier).

And teenage acne usually begins at SMR 3, continuing on until the end of puberty.

In newborns, baby acne and breast buds often occur at about the same time. In the same way, many adolescent boys develop gynecomastia–true mammary breast tissue in a male–during SMR 3. The firm lump may occur under only one nipple, under both nipples, or under the two at different rates or sizes. The lumps are often tender when they are growing the fastest. In at least 90% of kids, these will go away on their own. They may disappear as quickly as in a few months, but it is not unusual for them to last up to 2 years (Nelson Textbook of Pediatrics, WB Saunders, 1996). In some children, they may persist without being a problem. Gynecomastia occurs in at least 40% to 60% of boys (Fortschritte der Medizin, 1998; 116:23–26).

Gynecomastia can run in families, and when it does, the disappearance pattern tends to be similar in the family. Gynecomastia can happen in boys of any size but it is more common in bigger teens–either taller, heavier, or both. Obesity can certainly be a cause of gynecomastia in some children (Clinical Pediatrcs, 1998; 37:367–371).

Gynecomastia is different, though, than fatty tissue in the breast area. Boys tend to store extra fat in the upper body (breast and abdomen area), but girls are much more likely to store it in the lower body, particularly the thighs (Pediatrics, 1998; 102:e4). This is the first place it goes on and the last place it comes off. If girls’ breasts do enlarge by storing fat, this is usually one of the first places it disappears with weight loss.

Here are times to worry about lumps in a boy’s (not a newborn’s) breast:

• If they begin before age 10 years or after age 15 years (especially after puberty is complete)
• If they are not directly under the nipple
• If there is overlying dimpling of the skin, skin ulceration, or change in the color of the skin
• If the they feel fixed to the skin
• If they are large–over 1.5 inches (4 cm) in diameter
• If they don’t go away within 2 years
• If the nipples leak milk, blood, pus, or other fluid
• If there are other signs of disease–night sweats, fever, or weight loss, for example

These are all situations in which a breast lump should definitely be examined, in addition to the important regularly scheduled physicals during the puberty years. These children should have a careful physical examination right away. They should probably have an endocrinology (hormone) workup and perhaps an ultrasound or a mammogram, depending on the exam. I would also consult with a health care provider if a breast lump is associated with any signs of infection, such as sudden increased size, warmth, tenderness, drainage, redness, or fevers.

In a recent study at Johns Hopkins University of 60 high-risk boys with large lumps (> 4 cm), most of the boys–45 of them–turned out to be fine, but 15 did have significant medical problems, including one who had a serious cancer. Most of the problems were genetic (such as Klinefelter’s syndrome–XXY boys) or hormonal problems that needed to be treated (Clinical Pediatrics, 1998; 37:367–371). Gynecomastia can also be a side effect of taking steroids or other medications. It can come from liver disease, testicular disease, or neurologic diseases.

If you are ever unsure whether a breast lump is normal, it is always wise to seek the advice and opinion of your child’s doctor.

Good breast health practices for teens include:

• Avoiding steroid supplements
• Avoiding steroid medicines where possible (e.g., keep asthma well controlled with preventive measures)
• Avoiding cigarette smoking and exposure to second-hand smoke
• Avoiding alcohol
• Being physically active daily (exercise)
• Eating a healthy, whole food diet
• Maintaining ideal weight
• Avoiding piercing and tattooing

If normal, benign gynecomastia is bothersome, either because it is large or because it doesn’t go away as puberty progresses, treatment is possible. Sometimes hormones are given to try to shrink the breast tissue. Alternatively, the mammary breast tissue can be removed. A tiny incision is made under the armpit, and the tissue is removed with a fiberoptic scope. The results are great, and the scar is small and inconspicuous (Annals of Plastic Surgery, 1998; 40:62–64).

Normal, small gynecomastia is yet another reminder of the wonderful changes in your son’s body as he becomes a man. While teenagers can be quite trying to live with at times, savor every moment you can as you enter the last few years of having your son in your home.

Did this article help answer your questions on Breast Lumps in teens? Do you still have questions? Let us know in the comments below.

Dr. Greene’s Answer:

Vonda, I’m so glad you asked! Most people are not aware of this medical condition. Hemihypertrophy, also called hemihyperplasia, is a greater-than-normal asymmetry between the right and left sides of the body. This difference can be in just one finger; just one limb; just the face; or an entire half of the body, including half the brain, half the tongue and the internal organs, or any variation in between. Someone with hemihypertrophy might have acne on only one side of the face. The skin is often thicker, and there may be more hair on the head, on the larger side. Rarely, children can have crossed hemihypertrophy (one leg and the opposite arm are larger than their partners).

Theories abound as to the cause of hemihypertrophy- perhaps it is increased blood flow or decreased lymph drainage, or nerve or hormone abnormalities. To date, not enough research has been conducted to choose between the theories. We don’t know the cause, but we do know that hemihypertrophy is usually not inherited. People with hemihypertrophy can go on to have healthy, normal children (Genetic Counseling, 1993; 4:119–126).

Hemihypertrophy is a key warning to be on the lookout for several kinds of cancers. Sadly, hemihypertrophy is often not looked for and not diagnosed until after the cancer has been discovered.

None of us is exactly symmetric. I recall seeing a series of fascinating magazine photos of famous movie stars. The photos were made by putting together 2 right sides and 2 left sides of their faces. It was surprising how much this changed their appearances. I had not noticed the asymmetry until it was removed.

During World War II, a series of United States Army recruits was carefully measured, and only 23% were found to have legs of equal length. The average difference was a little more than 1/4 inch (American Journal of Roentgenology, 1946; 56:616–623). One of our ears is usually higher than the other. The two eyes are slightly different. Only rarely are two nipples at the same height and the same distance from the midline.

All of us are asymmetric, and where normal variation ends and hemihypertrophy begins is controversial. Nevertheless, the distinction is very important because hemihypertrophy carries real risks. A definition first proposed over 20 years ago still seems to me to be the best general guideline: hemihypertrophy is a 5% or greater difference in size or length between some aspect of the right and left sides of the body (Clinical Orthopedics, 1979; 144:198–211). This translates into a leg-length difference of about 1/2 inch for a 1-year-old, about 1 inch for a 5-year-old, and about 1-1/2 inches for an adult.

As children with hemihypertrophy grow, the discrepancy between the two sides increases, but the relative proportions between the two sides usually remains the same over the long haul. Variations are found among different children, but in most children, the discrepancy about doubles between the first and fifth birthdays, which sounds like what has happened in Jemma.

Hemihypertrophy can occur as an independent condition (isolated hemihypertrophy) or as a part of a genetic syndrome (i.e. Beckwith-Wiedemann syndrome). Isolated hemihypertrophy is thought to occur in about 1 in 86,000 people, but this number may change as there is more agreement on a definition and more people looking for it. Some children with hemihypertrophy also have a genetic syndrome, such as Beckwith-Wiedemann syndrome, neurofibromatosis, Klippel-Trenaunay-Weber syndrome, or Proteus syndrome. Although these occur in the minority of children, each child with hemihypertrophy should be evaluated by a geneticist to look for associated conditions. Inguinal hernias, undescended testicles, and unusual kidneys (renal cysts or horseshoe-shaped kidneys) are more common in children with hemihypertrophy whether or not they have other syndromes.

Because hemihypertrophy is a disorder of the body’s normal controls of growth, it is not surprising that people with this condition can also have a higher rate of cancer. In one study, 168 children with isolated hemihypertrophy were very carefully followed to try to determine the true rate of cancer in children with this condition. Just under 6% developed childhood tumors (American Journal of Medical Genetics, 1998; 79:274–278). The most common cancer is Wilms’ tumor (of the kidney), followed by adrenal carcinoma and liver cancer (hepatoblastoma).

Because most of the cancers occur in the abdomen, the recommendation has been made (by the participants of the First International Conference on Molecular and Clinical Genetics of Childhood Renal Tumors–among others) that children with hemihypertrophy receive a screening abdominal ultrasound every 3 months until age 7 and, at minimum, a careful physical examination every 6 months until growth is completed (I prefer ultrasound). One proposed exception to this recommendation is in hemihypertrophy due to Klippel-Trenaunay Syndrome– the risk of Wilm’s tumor does not appear to be increased in these cases (Pediatrics 2004; 113:326-329).

Some argue that screening for cancer in children with hemihypertrophy is not cost effective because most children do not get these tumors and, even for those who do, these tumors are fairly easy to treat even if caught late. Be that as it may, if it were my child, I would insist on the screening.

The next most immediate concerns are the orthopedic problems that result from any leg-length discrepancy. Over time, scoliosis, or curvature of the spine, commonly develops. This disappears when the leg lengths are equalized, either with surgery or with special shoes or lifts. Close contact with a skilled pediatric orthopedist is a must.

Plastic surgery for facial discrepancies is sometimes warranted. The best people to contact are a craniofacial team or perhaps the people who repair cleft lip and palate in your area if no one has experience with hemihypertrophy. Computed tomography (CT) scans and computers can now be used to plan the repair for the best outcome (Journal of Oral and Maxillofacial Surgery, 1987; 45:217–222).

These, Vonda are the major issues. I’d be happy to talk with you more about them in chat.

Dr. Greene’s Answer:

Current lab tests to detect pertussis are either slow, cumbersome, not readily available, or often fail to pick up the disease. For this reason, the number of proven cases reported to the health department vastly underestimates the number of cases in the community. Many physicians rely on the working definition of pertussis. According to the Centers for Disease Control and Prevention, people are considered to have pertussis if they have a cough lasting for at least 14 days (with no other confirmed cause) and any one of the following symptoms (even if they have been immunized):

• Coughing spasms or fits (coughs comes in clusters).
• A whooping noise while breathing in.
• Vomiting caused by the cough.

The case is called confirmed pertussis if there is a positive lab test or if there has been exposure to someone with a positive lab test. During a pertussis outbreak, anyone who has a cough lasting at least 14 days (with no other known cause) probably has pertussis, even in the absence of other specific symptoms.

Dr. Greene’s Answer:

Almost every day, Shelley, concerned parents ask me about lumps in their children’s necks or scalps. Most of the time, these turn out to be normal. Occasionally, though, they are an early sign of a serious infection or malignancy. No wonder, then, lymph nodes are such a cause of concern — particularly for those who have had a previous experience with cancer.

All of us have hundreds of lymph nodes scattered throughout our bodies as a critical part of our immune systems. This network of nodes functions as a powerful, intelligent filtration system to keep the insides of our bodies clean and healthy.

Tiny vessels called lymph vessels carry germs, foreign particles, and unhealthy or malignant cells to the lymph nodes, where they are trapped. Active lymph nodes enlarge as they attempt to destroy the unwelcome material.

The lymph nodes also function as schools. Lymphocytes, a type of white blood cell, study the foreign material so that they can produce antibodies, killer cells, and other substances to protect the body from the threat.

Sometimes the lymph nodes are overwhelmed in the process. Our defenders can be taken over by a cancer or an infection. These enlarged nodes can become a refuge where the invaders can hide and proliferate.

In a newborn infant, the lymph nodes are often small enough and soft enough not to be felt. But by the time a baby is several months old, healthy, growing, learning lymph nodes are frequently obvious enough to be noticed by parents — to their alarm.

When evaluating enlarged lymph nodes the first consideration is whether these nodes are localized (in one or two adjacent regions of the body) or generalized (spread throughout the body, often including the spleen — the largest lymph node — which is found just under the rib cage in the left upper part of the abdomen). Generalized enlarged lymph nodes suggest that the body is responding to a whole-body problem, such as an infection (bacterial, viral, or fungal), an autoimmune disease (arthritis or lupus), a drug reaction, or a malignancy such as leukemia. The infection might be very mild, or might be as serious as HIV.

Localized enlarged lymph nodes are responding to events in the part of the body filtered by those nodes. A scratch on the finger can produce swollen nodes at the elbow and /or the armpit. Minor trauma to the foot is filtered by nodes behind the knee and in the groin.

The localized nodes most often noticed by parents are those around the head (especially near the base of the skull) and neck. They frequently grow in response either to the mouth organisms that enter the body during teething, or to the tiny particles that get into the scalp from a baby’s lying down most of the day, or to respiratory infections of all kinds (ear infections, colds, sinus infections, etc.) — or, to some combination of these.

Much less commonly, head and neck nodes can grow from cat-scratch-fever, tuberculosis, drinking unpasteurized milk (mycobacterial infections), or eating undercooked meat (toxoplasmosis). They can also grow from an isolated malignancy, such as a lymphoma.

Many people have a sunny attitude toward “swollen glands,” not believing they will really be serious. Others believe these lumps to be harbingers of doom. The truth is somewhere in between. Most of these situations turn out to be fine, but enlarged lymph nodes should be respected.

When should you be concerned?

When examining your child, your physician will pay attention to several important signs:

• Location — enlarged lymph nodes just above the collar bone but below the neck often indicate serious disease.
• Character — nodes that are hard, non-tender, and irregular are very suspicious. Normal nodes are mobile beneath the skin. Fixed nodes, those that are firmly attached either to the skin or to deeper tissues, are often malignant. Nodes that are tender, inflamed, or rubbery in consistency usually represent an infection.
• Growth — enlarged nodes that continue to enlarge rapidly should be evaluated rapidly.
• Associated symptoms — fever, night sweats, or weight loss accompanying enlarged lymph nodes should be investigated thoroughly.
• Size — size does matter! The definition of an enlarged lymph node is size larger than one centimeter (0.4 inch) in diameter. Pea-size lymph nodes are not enlarged, even if you didn’t feel them there before. Any node that is larger than 1cm in diameter should be followed closely by a physician. It should shrink noticeably within 4-6 weeks, and should be less than one centimeter within 8-12 weeks. High-risk enlarged nodes are those larger than 3cm (more than an inch) in diameter.

If lymph nodes remain truly enlarged for more than 2 weeks, or if other worrisome signs are present, then the next steps of evaluation include a complete blood count with a manual differential (CBCd)l. This test looks at the number and type of cells in the blood. Isolated anemia is not usually a problem, but anemia with an unusual white blood cell count or platelet number is worrisome. An abnormal CBC can be diagnostic of leukemia and lymphoma, but it is important to note that most children with neck malignancies have normal CBC’s.

Other simple tests include a sedimentation rate (a general blood test that indicates whether something significant might be going on in the body as a whole), blood chemistries (LDH is often elevated in malignancies, AST and ALT are often elevated in infections that cause enlarged lymph nodes), and a tuberculosis skin test. Depending on the results, other studies might include tests for specific illnesses (mono or HIV), and an x-ray or an ultrasound to get a better picture of what is going on.

If the node remains enlarged (greater than 1cm) for 2 to 3 months, or continues to grow after 2 weeks, then a biopsy of the lymph node may be indicated, unless the physical exam and lab tests are convincingly reassuring. At least half of the time, a biopsy does not reveal a definite cause for the enlargement, but the biopsy can rule out cancer and other serious problems.

Shelley, you bring to this situation your love as a mother, your difficult experience with the misdiagnosis of your own mother, and your determination to seek the best information available about swollen glands. Your pediatrician brings a wealth of knowledge, a practiced objectivity, and the experience of examining and following many lymph nodes. Together you have what it takes to insure the best care for your daughter, as you keep the lines of communication open.

Dr. Greene’s Answer:

Even the unbridled energy of childhood can be squelched by a pounding migraine headache. As the pain mounts, a normally curious and active child will slow and then stop playing, brought down by the migraine. Migraines are not just any type of bad headaches — they are a specific condition. And they are much more common than most people suspect. Migraines are the most important and frequent type of headache in children, affecting more than one in twelve kids — yet only 20 percent of children with migraines are ever properly diagnosed and treated (Headache, May 1997).

Migraines are caused by an inherited extra-sensitivity of certain blood vessels to the nerve and chemical signals that normally cause these vessels to dilate or constrict (especially to serotonin, norepinephrine, and substance P). When these over-exuberant blood vessels expand and contract, the resulting changes in pressure produce pain (Pediatric Annals, September 1995). The medicines for migraines decrease the responsiveness of these vessels.

Migraines are defined as recurrent headaches (in which the child is well between episodes) accompanied by at least 3 of the following symptoms:

• abdominal pain
• nausea or vomiting
• throbbing headache
• specific location of pain
• sensitivity to light and sound
• associated “aura”
• relief with sleep (headaches that awaken children, or early morning)
• family history of migraines

Before puberty, migraines are more common in boys than in girls (the reverse is true afterwards). Most kids do not have an aura (changes in vision or tingling hands or feet), but most do have a throbbing or pounding headache, often at both temples, accompanied by nausea and vomiting. The headaches typically last for one to three hours — but they can last for 24 hours or longer. Kids often appear pale and are sensitive to light during a migraine. They feel crummy!

Helping kids with migraines begins with carefully observing the circumstances when the headaches begin. A big difference in kids’ lives can be made by identifying and avoiding their migraine triggers.

A number of foods have been shown to be the triggers for some individuals. The most common of these are nuts, chocolate, cola drinks, hot dogs and luncheon meats (probably the nitrates and nitrites), pepperoni and sausage (thought, perhaps, to be the spices), kippers (though I have never yet seen a kid eat kippers!), and MSG (found in Chinese food and in restaurant salads — another non-issue for most kids). Both alcohol and birth control pills are associated with migraines, but there are better reasons than headaches to avoid these in young children.

Bright flashing lights can also trigger migraines. This happened recently on a large scale to many children watching a cartoon in Japan (this cartoon also triggered seizures in many children, which of course captured more attention than the migraines).

Children who get migraines are more likely to get them when they are over-tired or have gone too long without eating. In addition to fatigue and hunger, other known triggers are sun exposure, excessive physical exertion, motion sickness, loud noises, head bumps, stress, and anxiety.

Even if the triggers can’t be avoided, children who learn what their triggers are often experience a great reduction in the number of headaches. Perhaps their brains are more ready to deal with the surges of serotonin or other substances.

Exciting new drugs have been developed for adults with migraines. These have not yet been approved for use in children, but thankfully kids are much more responsive than adults to available, gentle medicines.

Ibuprofen (Motrin or Advil) is more than twice as effective as acetaminophen (Tylenol) at stopping a migraine — but acetaminophen starts working twice as fast. I recommend giving a child a dose of both ibuprofen and acetaminophen when the headache starts, and then having him rest in a quiet, darkened room. Most kids get quite sleepy with migraines, and want to lie down. They usually awake refreshed and headache-free.

If vomiting is a major symptom, giving a prescription anti-vomiting medicine at the beginning of the headache can be the most important part of treatment.

These simple measures will give effective relief to most kids. Stronger medicines (such as ergotamine or sumatriptan) might be used if pain continues to be a problem. Multiple studies have demonstrated the safety of triptans (such as sumatriptan) in children and adolescents; only the nasal form of sumatriptan has demonstrated efficacy in adolescents. However, the triptans (as well as ergotamine) have not been approved by the FDA for pediatric use. They are usually used “off label” in consultation with a neurologist (Pediatrics in Review, February 2007).

If the migraines are very frequent, or are interfering with school, then a continuous, daily medication might be prescribed to prevent the migraines. Options for this include propranolol, phenytoin, phenobarbital, amitriptyline, cyproheptadine, and methysergide. Newer antiseizure medications are now being used for migraine prevention, such as topiramate and leviteracetam; they generally have less side effects than phenytoin or phenobarbital. Propranolol is the one most frequently used by experts in the field. These are all strong medicines with significant side effects, so I would only use them if the headaches are seriously impacting your child’s life.

I prefer teaching children either self-hypnosis or biofeedback to control their headaches. These techniques can be mastered by most kids in second grade or above. They have been shown to be even more effective than propranolol at preventing migraines (Nelson Textbook of Pediatrics, Saunders, 2004) — and without side effects! Cognitive-behavioral therapy and relaxation techniques have been shown to be effective as well (Cephalalgia, 2006).

Most children’s hospitals have experts who can teach these techniques to children. Pediatricians in behavioral pediatrics departments should be able to direct you to the appropriate people.

With the many options now available, most kids can cut down both the frequency and severity of migraines. Whatever course of treatment you choose, most children with migraines can look forward to spontaneously outgrowing them by the 10th birthday — just in time for the new challenges of puberty

Dr. Greene’s Answer:

Some children have seizures or convulsions when they have fevers. Although febrile seizures are fairly common, many parents have never seen one until it happens to their child. Febrile seizures occur in 3% to 5% of otherwise healthy children between the ages of 6 months and 5 years. Toddlers are the most commonly affected.

The seizure begins with the sudden sustained contraction of muscles on both sides of a child’s body — usually the muscles of the face, the trunk, the arms and the legs. Often a haunting, involuntary cry or moan emerges from the child, from the force of the muscle contraction. The contraction continues for seemingly endless seconds, or tens of seconds. The child will fall, if standing, and may pass urine. He may vomit. He may bite his tongue. The child will not be breathing, and may begin to turn blue. Finally, the sustained contraction is broken by repeated brief moments of relaxation — the child’s body begins to jerk rhythmically. The child is unresponsive to the parent’s screams.

This is usually one of lifetime’s most frightening moments for the parents. Most parents are afraid that their child will die or will have brain damage. Thankfully, simple febrile seizures are harmless.

Febrile seizures are brought on by the sudden stimulation of many brain cells at once. Experts argue over whether febrile seizures are triggered by the height of the fever or by the rate of rise. I suspect that both play a role. Most febrile seizures occur well within the first 24 hours of an illness, not necessarily when the fever is highest. Often the seizure is the first sign of a fever, making febrile seizures hard to prevent.

A simple febrile seizure stops by itself within a few seconds to 10 minutes, sometimes followed by a brief period of drowsiness or confusion. Anticonvulsant medicines are generally not needed.

A complex febrile seizure is one that lasts longer than 15 minutes, occurs in an isolated part of the body, or recurs during the same illness.

During the seizure leave your child on the floor, although you may want to slide a blanket under him if the floor is hard. Move him only if he is in a dangerous location. Loosen any tight clothing, especially around the neck. If possible, open or remove clothes from the waist up. If he vomits, or if saliva and mucus build up in the mouth, turn him on his side or stomach. Don’t try to restrain your son, or stop the seizure movements. Don’t try to force anything into his mouth to prevent him from biting his tongue, as this increases the risk of injury and choking. Be sure that your child is breathing during the seizure. If he appears blue around his lips, you should call 911 immediately.

Focus your attention on bringing the fever down. Inserting rectal acetaminophen (Tylenol) is a great first step — if you happen to have some. Don’t try to give him anything by mouth.

Apply cool washcloths to the forehead and neck. Sponge the rest of his body with lukewarm (not cold) water. (Cold water or alcohol may make him shiver and make the fever worse). After the seizure is over and your son is awake, give him the normal dose of ibuprofen (Motrin or Advil) or acetaminophen (Tylenol). Children should see a doctor as soon as possible after their first febrile seizure. If the seizure ends quickly, drive him to an emergency room when it is over. If the seizure is lasting several minutes, call 911 to have an ambulance bring him to the hospital.

After the seizure, the most important step is to identify the cause of the fever. Most febrile seizures are brought on by fevers arising from viral upper respiratory infections, ear infections, or roseola. Meningitis causes less than 0.1% of febrile seizures but should always be considered, especially in children less than one year old or who still look ill when the fever drops.

About one third of the children who have had a febrile seizure will have another one with a subsequent fever (about 2/3 won’t). Of those who do, about half will have a third seizure. Few have more than three. Sometimes febrile seizures run in families. If there is a family history, if the first seizure happened before 12 months of age, or if the seizure happened with a fever of <102, a child is more likely to fall in the group that has more than one febrile seizure.

To try to prevent future febrile seizures, many health care providers recommend using acetaminophen (Tylenol) and/or ibuprofen (Motrin or Advil) at the first sign of a fever. However, researchers have found that these medications may not necessarily prevent febrile seizures. Despite the question of their utility in preventing febrile seizures, these medications can make children more comfortable when they are feverish and are worth trying for that reason(Eur J Pediatr (2008) 167:17–27).

Other things to try include sponging your child with lukewarm water. Also give him cool liquids to drink — both to lower the temperature and to keep him well hydrated. Since febrile seizures can occur as the first sign of illness, prevention is often not possible. Neither an initial nor a recurrent febrile seizure suggests second-rate care of your child.

Sometimes children who have had a febrile seizure are subsequently treated by their parents as weak or vulnerable children. This does not help anyone. Simple febrile seizures should not hold a child back from his normal activities.

There is no evidence that febrile seizures cause death, brain damage, epilepsy, mental retardation, a decrease in IQ, or learning difficulties.

A small number of children who have had a febrile seizure do go on to develop epilepsy, but not because of the febrile seizures. Children who would develop epilepsy anyway will sometimes have their first seizures during fevers. These are usually prolonged, complex seizures. Previous neurologic problems and a family history of epilepsy also make future epilepsy more common (about 2% of these high risk children will develop epilepsy, compared to about 1% in the general population). The number of febrile seizures has no correlation with future epilepsy.

I have no doubt that your son’s febrile seizure was a moment of terror for you. For many families, these seizures shake more than the children’s bodies. The seizure can shake up the routine of being a parent. For parents of toddlers, the battles of the wills can get exasperating. The work can be exhausting. The seizure can shake off the layers of weariness and frustration to reveal the intense love you have for each other.