Dr. Greene’s Answer:

A few months earlier, the National Cancer Institute had sent out a letter to physicians in an effort to decrease unnecessary CT scans in children. In the previous decade, the number of CT scans in children each year had skyrocketed 700 percent — into the millions in the US alone. These CT scans had resulted in improved diagnosis, allowed for more effective treatments, and reduced unnecessary surgeries. But we’ve learned that some of these same benefits might now be achieved with fewer CT scans. And CT scans carry their own risk.

Since then, the AAP has continued to look closely at this issue. In September 2007, the AAP published a clinical report on the radiation risk to children from CT scans (PEDIATRICS Volume 120, Number 3, September 2007). Overall, they noted that CT scans use low-level radiation, which may have a small risk of causing cancer. They strongly recommend that pediatric health care professionals, radiologists, and families work together to determine (1) when a CT is indicated and necessary, (2) if there are protocols available to minimize radiation exposure, and (3) that the risks and benefits of the study be discussed with patients and their families.

Read More From This Series:
CT Scan Defined
CT Scan, Ultrasound or MRI?
CT Scan Safety
CT Scans and Radiation Exposure
CT Scan Risks
Higher Risks in Children
Who Should Receive a CT Scan?
X-Ray or a CT Scan?
Alternatives to a CT Scan
When Should a CT Scan be Performed?
Important Tip to Reduce to Radiation
Questions to Ask before Every CT Scan
Other Radiation Exposures
Measures That Radiologists Should Adhere to When Administering a CT Scan
CT Scans and Cancer
When are MRIs not Practical?
What is Ionizing Radiation?
Who are Radiologists?

Dr. Greene’s Answer:

The rattling in the lung could come from extra secretions from the infection itself, or maybe he was describing some wheezing from narrowing of the airways, either from swelling or from tightening of the muscles around the breathing tubes. Albuterol is a smooth muscle relaxant that can open up the airways. It is used both for asthma and for wheezing from other causes. It doesn’t help kids to get over the illness any faster, but it does help if kids are having difficulty breathing or a difficult to control cough. It is generally thought of as a safe drug that is well tolerated by most children when used as prescribed. It can sometimes cause kids to stay awake or become more active when they are on it.

When Albuterol is needed, I favor the inhalers over the liquid–less gets in the body, and more gets to the lungs where it is needed. Albuterol liquid takes longer to act than the inhaler. With the inhaler, it works right away.

Dr. Greene’s Answer:

The most common side effects of Ritalin overall are nervousness and insomnia. In children, trouble with appetite and stomachaches can be even more common. If the stomachaches continue, you will want to report them to your doctor.

If Ritalin is the cause you might want to consider adjusting the dose or changing medications–though sometimes it can be continued as-is. I’m glad you asked this question–many parents don’t know that stomachaches can be a common side effect of Ritalin.

Dr. Greene’s Answer:

Zoloft (Sertraline HCl) is a powerful medicine that has been used to treat depression, panic disorder, obsessive-compulsive disorder, and post-traumatic stress syndrome–all situations that by themselves can have worse side effects than Zoloft.

But, Zoloft can cause irritability and confusion in some, especially if combined with alcohol. Worsening depression and suicidality have been reported in some patients. About one in 20 people on Zoloft feel unpleasant mood changes, especially agitation or emotional instability.

Zoloft can be the best choice for some kids and for some nursing moms. It has brought about many excellent results in treating some serious medical conditions. But it shouldn’t be taken lightly–it is quite a powerful medicine.

Dr. Greene’s Answer:

In many countries, particularly in developing nations, drugs are put on the market that have not been tested according to the standards we are accustomed to in the United States. Many of these drugs are quite safe; however, there is a risk involved in using them. Additionally, during the manufacturing of some of these drugs, safeguards that insure stated dosage levels are not in place. Thus, a package may state a safe dosage for children, but no one is checking to make sure the stated dose is in fact what the medication contains. Usually this is not a problem, but occasionally the results are very harmful and even fatal. Before using over-the-counter drugs from any country, I would recommend investigating their standards for drug testing, safety, and manufacturing. Although safety standards are generally much higher in industrialized countries than in developing countries, I cannot personally comment on the review process for pediatric drugs in other countries.

Dr. Greene’s Answer:

Blood pressure varies with the age of the child, and is closely related to height and weight. A one-year-old with a blood pressure of 110/70 has hypertension; a ten-year-old with 110/70 is normal.

One of the most common reasons for “high blood pressure” in children is a false reading obtained by using an inappropriately sized cuff. Children come in a wide variety of sizes; cuffs come in five: 3, 5, 7, 12, and 18 cm widths. (The lengths are not important as long as they fully encircle the arm.) The tables for normal blood pressures for children were compiled using cuffs of only these five widths, so while a reading obtained using the appropriate cuff may not reflect precisely the actual pressure in a child’s artery, it will tell you whether or not her blood pressure is in the normal range.

There are multiple varied recommendations for how to pick the appropriate blood pressure cuff size. Some experts recommend using the length of the upper arm to determine the cuff size. Others recommend using the circumference of the upper arm. (Pediatrics 1999;104;e30) While the exact calculations of size of cuff vary between these experts, all agree that a too-large cuff will underestimate blood pressure and a too-small cuff will overestimate blood pressure.

Whenever there is suspicion of cardiovascular disease in children, or if there is documented high blood pressure, blood pressure should be measured in both arms and in one leg. Underlying causes such as coarctation of the aorta (a congenital narrowing of the largest artery in the body) are often overlooked until a leg blood pressure is taken.

Your question is an excellent example of a much more far-reaching problem. In pediatrics we see people who vary as widely as a 2-pound premature infant differs from a 200-pound teenage linebacker. Children are not just little adults. Their development is complex. The disorders affecting growing humans are also complex — and often different from those affecting adults.

When children are examined and treated, they deserve equipment and personnel that are appropriate to them. Many clinics and emergency departments are not equipped with the proper sizes of tools. When children are sick and need to see a specialist, they are often taken to adult specialists who do not have either the tools or experience to optimally treat children. We would not think of sending an adult executive with a stroke to a pediatric neurologist, but children with seizures are often forced to see adults’ neurologists. Children are a large segment of our population; they represent our hope and our future. We must organize our healthcare delivery systems and health insurance protocols to insure the same quality of care we would give to an adult.

Dr. Greene’s Answer:

Dear Lesley, Last night I had bad dreams about fungal nails. Your story reminded me of the seemingly interminable battle I have had with them. Mine began when I was in college and rowed on the crew team. I had athlete’s foot that eventually spread into the toenails.

The nails of our fingers and toes are tremendously effective barriers. This barrier makes it quite difficult for a superficial infection to invade the nail. Once an infection has set up residence, the same barrier that was so effective in protecting us against infection now works against us, making it difficult to treat the infection.

Fungus rarely invades an intact nail. Usually, there is some kind of trauma such as that experienced by your son. Prolonged wetness can also allow the barrier to be breached. Sometimes a prolonged athlete’s foot condition can even breach an intact nail. Usually, it is some combination of these methods. Fungal infections can also be a problem for people wearing acrylic nails. This happens because the fungus becomes trapped next to the natural nail in a warm, dark, moist environment for a prolonged period of time. Long-term bandages over the nails can have the same effect.

Fungal nails usually begin with an opaque white or silvery area at the distal (outside) edge of a nail. The fungus gradually works its way inward. As the fungus grows, the nail thickens and can become quite painful.

My Own Story (I) – Frustration

When I first noticed that I had a fungal nail, I began treating myself with over-the-counter athlete’s foot medicines — one after another. It soon became evident that while they were effective in treating the athlete’s foot, they were of no value in helping the nail condition. I went to see a physician and eventually went through a large number of more potent anti-fungal creams, including Nizoral, which you’ve used so liberally. Sometimes this seemed to slow the progression of the fungal infection, but the onward march across the nail was relentless. I later learned that the treatment was a little more effective if I gently filed the outer surface of the nail, thus making the barrier less complete, and immediately applied the Nizoral. This was much more work, and resulted in a small improvement in efficacy. Later, I learned from a podiatrist that this could be enhanced further by using an electric tool, called a dremel drill, to gently buff the outermost layer off the nail before applying the Nizoral. I tried this, but was also disappointed with the results. I have, however, known people who have had success with this method.

In the beginning, I was told that two oral agents were available for treatment of fungal nails. One of them is called griseofulvin. It requires daily treatment — 6 months for fingernails and 12 to 18 months for toenails. Even prolonged therapy does not always lead to a cure. With griseofulvin, recurrences are quite frequent. I eventually tried this medication, but was not able to tolerate it due to nausea. I also tried the other oral medication that had been suggested, ketoconazole (Nizoral), the oral form of the same medicine you have been trying as a cream. Oral Nizoral is another long-term, daily treatment. This is more effective in treating fungal nails, but it can have even more side effects than griseofulvin. I needed to stop taking this medicine because of the effect on my liver. Both of these oral agents are available for children.

My Own Story (II) – If At First You Don’t Succeed…

After a long and painful struggle, I became frustrated with all of the  conventional medicine approaches and looked at alternative medicines. A promising solution was a natural remedy called Australian Tea Tree Oil. It is a naturally occurring anti-fungal compound that can penetrate the nails. Full of hope, I began gently filing my nails and applying the Australian Tea Tree Oil two times daily. I found this to be about as effective as the Nizoral cream. It did slow the progression of the fungal nail, but it did not reverse the condition.

I finally accepted the fact that the fungus would never go away.

My Own Story (III) – Success At Last!

A few years after that, a pharmacist friend suggested I try a newer oral medication called fluconazole (Diflucan). This is taken once a week until all the infected nail grows out. Fluconazole is far safer and more effective than any of the previous oral preparations. I took the oral Diflucan as suggested and was giddy to see the fungal nails heal almost effortlessly! As the nail grew out, it was replaced by a perfect-looking nail. Fluconazole was developed as a result of AIDS research and is now available in a pleasant-tasting liquid for children. It is also being marketed as a single-dose medication for yeast infections in women.

Current Treatment

Two newer, more effective oral medications have now become the standards. Itraconazole (Sporanox) and terbinafine (Lamasil) are both FDA approved for the treatment of nail fungus. The most frequent side effects include nausea, diarrhea, and rash. As with other medications used to treat nail fungus, liver enzyme abnormalities can occur and should be monitored. The medicines work even better if part of the fungus-filled nail is filed away.

Effective Prevention

I have since learned that, unfortunately, I am prone to fungal problems. If I fail to keep up a preventive regimen, and my feet get moist for a prolonged period, then the fungal infection starts up again (for which I use Sporanox). Because your son’s infection was precipitated by an abrupt injury, we don’t know how prone to fungal infections he is. I would still recommend — at least while he has this infection — keeping his fingers as dry as possible. When his fingers do become wet, they should be dried thoroughly, perhaps with a hair dryer.

I have found an effective preventive routine for my feet: shoes that breathe, cotton socks, athlete’s foot powder (any brand) in my shoes, Fungoid Tincture on the nails before bed, and Lamisil cream to the whole foot once a week. The latter two may be useful for your son’s hands.

You have had a long battle with an annoying problem. I wish you the best in days to come.

Dr. Greene`s Answer:

Septra and Bactrim are both brand names for a combination antibiotic called trimethoprim-sulfamethoxazole. This antibiotic is in widespread use. In children, the most common uses are for ear infections and urinary tract infections. It also has a role in the treatment of chronic bronchitis, traveler’s diarrhea, shigella, and in both the treatment and prevention of pneumocystis carinii pneumonia.

We all need folic acid (a B-complex vitamin) to survive. Most bacteria must manufacture their own supply of folic acid or folate. Animals (and some bacteria) depend on outside sources of folic acid, getting what they need from what they eat. Trimethoprim and sulfamethoxazole are both compounds that block the internal production of folic acid. Thus these compounds are relatively safe for humans, yet lethal to many bacteria. The combination product, Septra, is far more effective than either ingredient alone.

The sulfamethoxazole component of Septra is a sulfa (or sulfur containing) drug. It causes fewer side effects than the other sulfa drugs, but its side effects should be respected.

The most common significant adverse effects are allergic skin reactions. Most of these are mild, but occasionally they are quite severe. Septra should be discontinued at the first sign of a skin rash. Excess sun exposure should be avoided by anyone taking Septra.