Hives Maria McManus, RPAC

May 12, 2015 by admin  
Filed under Allergies, General, Summer

Hives, or urticarial, are itchy pale red swollen bumps or welts. They can appear suddenly, and change location on your body. They can last anywhere from a few hours to six weeks. Sometimes they can also be chronic.

Hives can be caused by many things such as allergy, temperature, infection, or physical pressure. They can be few and mild or become severe and life threatening. Some common causes are secondary to food allergies like egg, nut, shellfish; insects like bees; or medication like ibuprophen. Sometimes the ambient temperature can cause hives known as hot or cold urticarial. Many infections from viruses such as Mono or bacteria such as Strep can cause hives. Some people have what’s called dermatographism where physical pressure on the skin leads to hives developing where the skin was scratched. Chronic hives are usually due to autoimmune disease or chronic illness.

Very often though, we can’t find what is causing the hives. We can do allergy testing or test for Strep and some other diseases but sometimes we can’t pinpoint the cause. We will sometimes need a consultation from an allergist.

In treating hives we first try to avoid exposure to any known trigger. Since hives are formed from the release of histamine from our body, an anti-histamine like Benadryl is recommended to stop the hives. Cool compresses and light clothing help too. Sometimes if hives progress we need to add steroids. In severe cases epinephrine is used.

If your child develops hives, call your pediatricians office for advice. Remove the trigger if possible, give Benadryl, and apply cool compresses. Bring your child to your doctor for evaluation, testing and treatment. If any severe symptoms develop such as wheezing, shortness of breath or mouth swelling call “911” for emergency treatment.

Holiday Hours

December 15, 2014 by admin  
Filed under Office Hours

8 AM – 3 PM


Insect Repellents

June 17, 2013 by admin  
Filed under Summer

     Summer is back and so are mosquitoes.  Before you reach for the insect repellent, review these tips from the American Academy of Pediatrics (AAP):
- The AAP recommends that products containing DEET not be used on children younger than 2 months old.  Instead use mosquito netting with an elastic edge to ensure a tight fit around a stroller.
-Products containing oil of lemon eucalyptus should be not used on children younger than 3years old.
-Avoid products that contians both repellent and sunscreen because sunscreen generally should be reapplied more often than insect repellent.
-Do not use repellent under clothes.
-Never use repellents over cuts, wounds or irritated skin.
-Do not spray directly on the face; apply with your hands.
-Do not allow young children to apply repellents themselves.
-Do not use sprays in enclosed areas or near food.
-Reapply is washed off by sweating or getting wet.
Despite your best efforts your child may still get a mosquito bit.  If this happens, tell your child to try not to scratch the area and dab it with calamine lotion.  In addition keep the area clean to prevent skin infections.
Dr. Visentin

About Those Allergies!

February 26, 2013 by admin  
Filed under Allergies

With spring on the way, trees start to bloom and soon all of us allergy suffers start to sneeze!  Pollen from trees and grass becomes air born and once we breathe it in it triggers a cascade of reactions in our immune system.  This leads to symptoms such as runny noses, itchy watery eyes, coughing and sneezing.  Over the counter antihistamines and allergy eye drops can help counter these symptoms.  Please always check with your doctor regarding proper dosing for your children.

Some other things that help are keeping windows and doors closed as much as possible to limit pollen blowing inside your home. Try to avoid going out during times of high pollen counts.  After being outside consider showering and changing your clothes to physically reduce your pollen exposure.

If symptoms persist despite all these measures, you may need prescription allergy medicine and /or further evaluation for other related problems.  Please call our office for an appointment.

Maria McManus, RPA-C

The Glucose Free Casein Free Diet and Autism Spectrum Disorder

February 1, 2013 by admin  
Filed under Autism Spectrum Disorder

 Autism Spectrum Disorder is being recognized and diagnosed in more and more children. Early behavioral and developmental interventions are proven to be beneficial. Many families struggle with problem eating behaviors and gastrointestinal issues in these patients and look for interventions to help with these and other autism behaviors. Many families try different nutritional interventions. The most popular diet intervention is the Gluten Free Casein Free Diet.  This diet is not supported by evidence, but many families report some benefits. It is a safe intervention to try if care is taken to avoid nutritional deficiencies.

The Gluten Free Casein Free diet involves excluding gluten and casein from the diet. Casein is a protein found in milk and dairy products. Excluding these products removes a major source of calcium, vitamin D, and protein from the diet.  Gluten is a protein found in wheat and other grains including barley, rye, and oats. Excluding gluten eliminates an important source of Iron, fiber, and the B vitamins from the diet.

 If this diet is chosen, it is important to assure appropriate nutrition through alternate sources. The following is a list of various sources of Vitamin D, Calcium, Iron, and protein. The list is not all inclusive and a multivitamin supplement is recommended.

  1. Vitamin D:  Rice, Soy, and  Almond milks are generally fortified with 100 IU per 8 oz serving;

Tofu, eggs, some dairy free fortified yogurts and margarines are available

  1. Calcium:   Fortified Rice, Soy, and Almond milks provide approximately  300mg per serving; beans, almond and hazel nuts, wild rice, greens(spinach and kale), broccoli, green beans, Tofu, and  Calcium fortified Orange Juice
  2. Iron:  Red meats, shell fish, egg yolks, many vegetables, legumes, prunes, and raisins
  3. Protein:  Soy and hemp milk provide 6-8 grams per cup which is closest to the amount of protein in cow’s milk; Rice and Almond milk provide only 1-2 grams per 8 oz and are limited sources; eggs, nuts, seeds, beans, peanut butter

The American Academy of Pediatrics web site provides an excellent discussion on the link between the GFCF diet and autism. This site is a helpful and reliable source for many pediatric health concerns.  The internet is a convenient source of information, some good and some bad.  It is best to consult a reliable source and your health care provider when making health care decisions for your family.

Dr. Kerry Moore

Winter Safety

January 22, 2013 by admin  
Filed under Safety, Wellness

Here we are mid-way through January and up to this point relatively comfortable with the balmy weather we’ve been enjoying –  that is until today! With the recent onset of cold weather and how cold my hands felt this morning (today is the coldest day in two years) it brings to mind the need to be careful when we’re outside in the cold. The American Academy of Pediatrics provides tips for avoiding cold injuries; I’d like to review some of these tips which can go a long way in preventing overexposure.

Remember: An Ounce of Prevention is Worth a Pound of Cure!

Plan ahead – prepare your home and car for the winter – At home, have your fuel company do the preventative maintenance they’re willing to do while things are slow; don’t wait until your furnace breaks down to call them! The use of space heaters and fireplaces to keep the house warm increase the risk of both household fires and the risk of carbon monoxide poisoning. Install both a smoke & carbon monoxide detector in the space being heated. Have a ABC fire extinguisher available.
In your car bring along jackets, hats and gloves, even if you’re not going to wear them. What would you do or how would you stay warm if your car broke down and you were waiting for rescue? Better to have them and not need them than need them and not have them.
Dress warmly – layer your clothing, leave no body parts exposed, tuck in shirts, cover upper chests and neck.  Most important thing to remember is to stay dry.
Eat & drink wisely
Be safe – carry a cell phone, let friends & family know where you’re going, pay attention to travel advisories
Recognize frostbite – easier to treat early on before tissue destruction occurred.

Urban myth: topical emollients applied to the skin do not prevent frostbite and may actually increase the risk of frostbite by increasing water content of the outer layer of skin.

Hypothermia is a condition in which core temperature drops below the required temperature for normal body functions (95.0 °F). Because children are smaller than adults their body temperature will drop faster than an adult, especially when playing outdoors in extremely cold weather in wet clothes or ill fitting clothing. Symptoms include shivering, lethargy, clumsiness; if they get really cold they may not shiver and may actually take off their coat. Treatment includes keeping them indoors, remove wet clothing and dress them warmly.
Frostbite is the condition where localized damage is caused to skin due to freezing. Because some parts of your body have a large surface area, frostbite tends to occur there (fingers, toes, ears, nose) which may become pale, gray, and blistered. The child may complain of itchiness or burning. Treatment involves putting warm washcloths over the cold parts. Do not rub the frozen areas. After thawing the frost bitten part must be kept warm, dry, and loosely covered. Elevating the affected part may help reduce edema (I’m talking about hands and feet). Children should be kept warm and dry and given something warm to drink.
In either case (hypothermia or frostbite) call your pediatrician or local emergency department to discuss proper management of overexposure.

I hope this gives you some insight into preventing injuries due to cold weather. Please feel free to discuss this blog with your provider of choice the next time you are in our office.

Dr Forletti

Toilet Training

January 20, 2013 by admin  
Filed under Teaching Children

Many times during the 18 month Well Visit parents ask me when is the best time to begin toilet training. The answer is actually simple, although the implementation may not be; training begins when both the child and the parent are ready! The approach to toilet training has changed over time and currently there are two main approaches to training:

Child-Ready approach (Toilet Training – the Brazelton Way) – The focus is on parent training and picking up on cues from the child; and
Parent-Ready approach (Toilet Training in Less Than a Day, Azrin & Foxx) – The focus is on conditioning the child to respond to cues from their body and to reinforce this behavior.

Both methods encourage child mastery of a skill set on a step-by-step basis; both approaches seem to be equally effective; the American Academy of Pediatrics currently recommends the Brazelton method. I’d encourage parents to read either book before embarking on this journey so as to minimize failure and navigate pitfalls, and both books read very easily.

Your child’s readiness for toilet training should be based on their development not their age; with that said, most children will start training by 2 to 3 years of age. Training should also take into account their temperament & personality. Your child must become aware of an urge, your child should be able to get to the bathroom, and your child should be able to know what a potty is and what it is used for. This all takes time and cannot be rushed: don’t start on this quest a few weeks before your child starts day care; and don’t let day care force you to undertake training unless you are both ready to do so. Children are great imitators so have them accompany you to the bathroom (dads – if you are the model – sit to void, it’ll be easier for your child to start off sitting rather than standing, and it segues into stooling). Success at each step should be rewarded with lots of praise and some small reward – kids love stickers! When a step is not successful parents need to stay positive (sometimes challenging) and never punitive – punishment is very counter productive, does NOT work, and can lead to stool withholding.

A few behaviors to look for that tell you it is NOT the time to start (or it is time to stop) training:

1) withholding – if you child is holding their legs & buttocks together, standing stiffly up on their toes, or looks frozen or hides, chances are they don’t want to pass urine or stool – you might as well back off and wait.
2) constipation – if your child is passing hard and/or large stools that can be painful to pass – you should get their stool into a more comfortable form to pass. Constipation, which leads to pain with defecation, is probably the biggest hurdle to toilet training. If your child is having infrequent, hard, or large stools this must be addressed sooner than later! Speak with us about normalizing their stool.
3) temperament – if your child is less adaptable, has a negative mood or they’re trying to exert their independence, they just started school, or have developmental delays – you might want to wait or go with the method outline by Azrin & Foxx.

Tips for Toileting:

1) break down the steps, focus on what the child can do (very effective) not on what they can’t do (counterproductive).
2) no matter what – stay positive and minimize the stress! All things being equal, your child will be trained. Getting yourself all in a twist won’t help – give your child and yourself a break!
3) schedule a toilet time – most children & adults have an urge to defecate 10 – 20 minutes after eating (the gastrocolic reflex) so use nature to aid in the toileting process. But don’t fight with them to sit too long; maybe keep a special toy in the bathroom to help with compliance. (Very Important: This toy could be a vector for infection so keep it in the bathroom, and wash those hands afterward!)
4) reward your child after achieving each step in the path to self sufficient toileting.

And did I mention Stay Positive and Don’t Stress?

I hope this gives you some insight into teaching your child to toilet train. Please feel free to discuss this blog with your provider of choice the next time you are in our office.

Dr Forletti

Lab Tests: Urine Analysis and the (dreaded) protein in my child’s urine!

January 14, 2013 by admin  
Filed under Lab Tests

In our office urine is tested to determine the amount of specific substances (sugar, protein), cells (red, white) and properties (specific gravity). We accomplish these measurements by utilizing urine test strips (a plastic strip with chemical pads that react with urine) and a device to read the strips and print out the results.

This type of testing is referred to as “screening”; with the aid of routine screening three groups of problems may be identified before symptoms become evident: 1) disorders of the urinary tract (kidneys, bladder); 2) disorders of metabolism (diabetes); and 3) disorders of the liver. The most common parameters we screen for are protein and glucose; you are probably most familiar with these terms from school forms and having to repeat the urinalysis because of protein in your child’s urine. We look for protein in urine as a sign of inflammation or damage to a specific part of the kidney called the glomeruli. This damage may go unnoticed for a long period of time leading to extensive kidney damage; screening is a fundamental step in identifying kidney damage at an early stage. Now you can see why this test is important and why you wouldn’t want to ignore a positive result (even if every year your child’s urine is initially positive for protein only to subsequently negative).

Some common reasons for protein in your child’s urine are: they were up and about before their urine was tested (technically called ‘orthostatic proteinuria’); or their urine was concentrated (the specific gravity was greater than 1.020). To minimize the effect of being up and about we ask that you collect your child’s urine 1st thing in the morning; assuming your child has been asleep all night their kidneys have had time to get use to them being recumbent. To minimize the effect that concentrated urine has on the amount of protein we ask that several days prior to re-testing you encourage your child to take a drink of water after each time they void, thus using their bodily function as a reminder to drink; since this is something they probably do not do, their urine will become more dilute and less likely to be falsely positive for protein. If despite these measures your child’s urine still has protein, we’ll ask that the collection take place once more (that is, test the urine 3 times) before sending their urine to a lab – this is the recommendation stated in pediatric reference texts.

I hope this gives you some insight into why we test for protein in urine. Please feel free to discuss this blog with your provider of choice the next time you are in our office.

Dr Forletti

Raising Self-Confident Children

December 22, 2012 by admin  
Filed under Teaching Children

Teach by example.

If you must hold yourself up to your children as an object lesson…hold yourself up as an example and not as a warning.

George Bernard Shaw

How we think about ourselves and whether we find value in our selves, translates into how we teach our children.  Our ability to parent our children well is directly related to our ability to ‘parent’ ourselves.  If you are going to do something around the house no matter how trivial you may think it is, insist your children accompany you.  While you can, be their role model.

Teach them to think on their own.

Give a man a fish and you feed him for a day.Teach a man to fish and you have fed him for a lifetime.

Chinese Proverb

Starting at an early age, give your children responsibilities and accountability.  Set age appropriate goals for your child and lay out the steps needed to reach that goal.  Make the task within each step fit your child.  Keep raising the bar but not too high!  Remember your child’s age and stage of development.  Always pay attention to their emotional limitations and monitor your response for appropriateness.  Confidence comes about through experience; give your children the opportunities to experiencing their own achievements – step back and allow your children to get the experience for themselves.  Give them every opportunity for responsibility in the home so they learn to be responsible outside of the home.

Teach them to learn from their mistakes.

I have not failed.  I’ve just found 10,000 ways that won’t work.

Thomas A. Edison

In addition to encouraging your children to commit to a project, you must also allow them to experience disappointment when it occurs.  Everyone can learn from their mistakes; if we carefully monitor our child’s activities and pay attention to whatever unfolds, we will be able to provide our children with great opportunities for understanding life’s unexpected twists and turns.

Teach them resilience.

Inside of a ring or out, ain’t nothing wrong with going down.  It’s staying down that’s wrong. Muhammad Al

Don’t step in too quickly and rescue your children when you see disappointment coming.  Instead be there to give them a hand up.  Be there for them and help them take stock of the situation.  Listen as they talk about their feelings of disappointment.

Lab Tests: Strep Test and the (dreaded) Stick!

December 21, 2012 by admin  
Filed under Lab Tests

Strep (or Streptococcus species) are bacteria that are responsible for a variety of illnesses such as meningitis, pneumonia, heart disease (endocarditis), and skin infections (erysipelas, cellulitis); many species are normally found on our skin, in our mouths and intestines and upper airways; and some species are necessary for producing cheese!

I’ll limit this blog to Group A Strep because I want to talk about tests we do for sore throats.  Sore throats can be caused by many factors (infections, irritations, etc).  Strep throat as a cause of sore throat is an infection in both children and adults that has plagued us for a very long time.  Although if left untreated a “strep throat” will resolve on its own, it can also cause some grievous illnesses such as inflammation of the heart (carditis), inflammation of the kidneys (nephritis), inflammation of the brain (corea), and inflammation of the joints (arthritis).  These are the very good reasons you do not want to leave a sore throat alone, even if it goes away.

Although there are criteria for the clinician to follow to determine if a sore throat is likely to be caused by Group A Strep (Children’s Hospital of Pittsburgh scoring system, for example) they are not all that helpful.  For example if your school aged child has a sore throat and all the other criteria are met, there is a 25% chance they do not have a “Strep Throat,” and if your school aged child has a sore throat and no other criteria there is a 1 out of 5 chance they do have a “Strep Throat.”  You can see these are not the odds you want when it comes to being on an antibiotic for 10 days or putting your heart, kidneys, joints, or brain in harm’s way.

Years ago the only test to help determine the cause of a sore throat was a throat culture.  A throat culture is a test where organisms from your tonsils and the back of your throat are placed on a gel, allowed to grow (this takes about 48 hours), and then inspected by eye to see if the organisms form colonies that look like group A streptococcus colonies.  Because of this lag time a common practice was to treat the patient with antibiotic until the culture result was available; if the result was positive treatment would continue for 10 days, if the result was negative treatment would be discontinued.  The downside of this practice is you are on an antibiotic unnecessarily if the result comes back negative.  (At some point in the future I’ll blog about the pros and cons of antibiotic treatment.)

Recently another test was developed to help determine the cause of a sore throat, the Rapid Antigen Detection Test (or Rapid Strep Test).  A rapid strep test is where organisms from your tonsils and the back of your throat are placed in a chemical and this ‘soup’ is put on a special strip, if group A strep is present, the strip turns pink, if the sugar is absent the strip does not turn pink.  Because a result is available in about 5 minutes, treatment can be initiated if criteria are met and the test is positive, and the patient does not have to be on an antibiotic unnecessarily waiting for the test result.

Some caveats to the test: 1) depending on how long you are sick (if the strep has had enough time to multiply in your throat) the rapid test can be falsely negative; given a similar time frame the throat culture will rarely be falsely negative; 2) sometimes treatment will be initiated despite a negative rapid strep test if we’re concerned about the condition of the patient; and 3) both tests require “the stick!” and the associated gagging sensation and anxiety brought about by something tripping your gag reflex. For those reasons and others, we try to obtain both samples (use 2 swabs) at the same time.  Of course if the rapid test is positive the culture is usually discarded.  If the rapid test is negative the culture is sent to a lab for culture and identification; treatment with an antibiotic may be held until a result is obtained.

Some other caveats: 1) some insurance companies require the guarantor to pay a fee for the tests, we have no control over which insurance companies do, which don’t and how much of a responsibility is borne by the guarantor; 2) if a rapid test is done and it is positive and the culture is not sent to a lab; the guarantor may be responsible for 1 test; and 3) if the rapid test is negative the culture is sent to a lab; the guarantor may be responsible for 2 tests even though one was negative (whether truly or falsely negative is not important to the insurance company).

I hope this gives you some insight into why we test for strep, why we use 2 swabs, and why we send a culture to a lab if the rapid strep test is negative.  Please feel free to discuss this blog with your provider of choice the next time you are in our office.

Dr Forletti