In my daily pediatric practice, I see many children with repeated infections especially common cold , that presents with cough, dry or phlegmy, runny nose, may be sore throat, sometimes diarrhea, with fever or no fever at all . Many of these children are attending daycare or school where there is a close physical contact among children which favors the transmission of infectious diseases especially upper respiratory tract infection and increased risk of chest infection and gastroenteritis or maybe hepatitis A or even some parasitic infestation. Most of these infections are viral, at least in the beginning and the period of sickness last for average of seven to ten days, they mostly get well with no antibiotics .The question which is usually asked by parents is whether or not the child has some sorts of immune deficiency.

Answer:
Apart from being in contact with other sick children, age is another factor, and the younger they are especially less than 3 years of age, there is more chance of getting repeated infections. There are of course other contributing factors, like poor nutrition, environment, anatomical defect or allergy but the chance of immune deficiency is much less. However, the warning signs of immune deficiency are as follows:
1) Six or more ear infections within one year
2) Two or more sinus infections in one year
3) Two or more months on antibiotics with little effects
4) Two or more pneumonia infections within one year
5) Failure of the infant to gain weight and grow normally
6) Recurrent deep skin or organ abscesses
7) Persistent fungal infections in the mouth or skin after one year
8) Two or more deep seated infections such as meningitis, osteomyelitis, cellulitis or sepsis
9) Family history of primary immune deficiency

In my pediatric practice like in many other medical centers, the most common problem among children visited is the infectious disease which are mostly viral in origin and to lesser extend bacterial . Of course there are many other causes or living pathogens that can make a child sick like fungus or mycoplasma, etc.. which are much less common.
Both bacteria and viruses are very small living pathogen which cannot be seen by naked eyes and you need a microscope to be able to see them. Bacteria can reproduce on their own and can survive in any environment including extreme heat and cold, most of them are not only harmless but even helpful for the body and actually lives in a harmony in the host and only 10% of them can cause disease in human , some time minor and occasionally life threatening infection.
Viruses are the most common cause of infection in children and are too many in types, maybe over 200, sitting around waiting for opportunity to enter the body , multiply and making the child sick. Viruses are tinier than bacteria in size and unlike bacteria, cannot survive without a host and can only reproduce by attaching themselves to the body’s cells. Generally a viral disease or illness is usually mild and the symptoms which they present can be multiple in types and not related to one organ this is unlike bacterial illness, like the common cold which is caused by a virus and the child may have evidence of tonsillitis, conjunctivitis and even diarrhea at the same time but bacterial infection usually involve only one system or one organ like tonsillitis of streptococcal origin which is the usual bacterial infection of tonsils or meningitis which is infection of central nervous system. So when a child with infection present with multiple unrelated symptoms it is more likely to be of viral origin. However there are some viral illnesses that make the child severely sick and differentiation with the bacterial cause can be difficult, or the symptoms of a bacterial infection some times are similar to those caused by a viral infection. This is one reason why occasionally it is difficult for the physician to decide about the causative agent and use antibiotics when it is not indicated . Also presence or absence of fever or even if temperature is really high it does not help to differentiate a viral from bacterial infection for sure but the medical history and physical examination of the patient helps a lot to differentiate the two and sometime some laboratory tests will help to make this differentiation easier.
Antibiotic can kill bacteria but is not effective against viruses like common cold or influenza viruses, beside using antibiotics without being almost sure of the diagnosis can harm the child .Over use of antibiotics also create resistant strains of bacteria in the body and the community, can kill the good bacteria in the body and help to over grow the harmful bacteria. For prevention of many viral infection vaccination stand the first such as polio , measles and chicken pox or flu, hepatitis A and B and Human Papiloma Virus which is the only vaccine available to prevent some cancers. Treatment of viral infections has also been improved and for some viral infection like herpes, HIV and Influenza antiviral medication are now available. However many times the only way to treat a viral infection is to wait and let the illness to run its course.

Throat pain is one of the frequent complaints in children, most of which are caused by viruses like common cold viruses and less frequently by bacteria, the most common of which is streptococcus bacterium. Differentiating viral from bacterial cause is very important because of modality of treatment and is possible in most cases based on a good history and physical examination supported occasionally by doing some laboratory tests and waiting couple of days before blindly treating the child sore throat with antibiotic.
Tonsillitis is inflammation of tonsils, the two oval shaped tissues at the back of the throat one on each side. Bacterial type is usually caused by streptococcus pyogenes beta hemolytic, occurs rarely in less than 2 years of age and more common between 5-15 years. Patients suffer from fever, may look sick with swollen tonsils and in minority with some exudates on the tonsils. Throat pain is one of the prominent symptom as well as tender cervical adenopathy on the sides of the neck and occasionally abdominal pain. In old time we used to treat the patient with bacterial etiology immediately with antibiotics preferably using penicillin but nowadays in doubtful cases we can even wait 4 or 5 days before starting antibiotic depending on the case and the condition of the patient, this is in order to make sure of the cause viral or bacterial and even if it is bacterial this delay does not hurt the patient but it gives a better protection immunologically.
When we deal with tonsillitis at any age it is very important to consider the possibility of other causative agents meaning the differential diagnosis of the Acute Tonsillitis or Pharyngitis which are as followed:
1. Viral infection , which is the most common cause of tonsillitis
2. Bacterial, Streptococcus Group A Beta hemolytic which is the most common offending agent although other strain of strep like Group C and G beta hemolytic can also cause the same picture.
3. Mycoplasma Pneumonia ,is a small bacteria and common respiratory pathogen
4. Fusobacterium necrophorum which is anaerobic gram negative bacillus and the leading cause of peritonsillar abscess and also of the Lamierrre’s syndrome or suppurative internal jugular thrombophlebitis which is a potentially lethal form of sore throat.
5. Staphylococcus aureus, not that uncommon cause of tonsillitis
6. Diphtheria, very rare because of vaccination program
7. Tuleremia, very rare, a bacteria, need contact with infected animal like cat, deer or rabbit
Sometimes patient complains of chronic sore throat which can have anyone of the following causes (Differential diagnoses):
1. Tonsillitis
2. Allergy
3. Infectious Mononucleosis
4. Inhaling air pollutant
5. Smoking
6. Influenza
7. Inhaling through the mouth instead of nose

Many parents have doubt in giving flu vaccine to their children and consider it as optional; some complains that even after receiving flu vaccine children still get common cold sickness.
This is the answer to the parents doubt:
First of all flu sickness (Influenza) is different from common cold illness. There are more than 200 viruses around and many of them can cause the common cold symptoms like running nose, cough, fever etc….., symptoms are usually mild and many of the patients get well even with no treatment . Influenza is also a viral disease caused by only two other types of viruses namely Influenza A and B , symptoms although are same as in common cold but are usually more severe presenting with high fever, muscle and bone pain, child looks more toxic and complication is more serious. So we need to know that when you receive flu vaccine it doesn’t prevent the children from catching common cold and it only protects you from catching influenza. The reason for repeated episodes of cold in children especially below2 or 3 years of age is the fact that there are too many viruses causing the common cold sickness and the fact that each episode does not produce permanent immunity, also when attending kindergarten or school there are many sick kids in there plying and passing the virus to each other mainly through touching, coughing and sneezing.
In 2012 – 2013 flu season many children died, 5 times the number of children died because of influenza in the previous season especially in children with chronic medical condition such as bronchial asthma and 90% of those who died missed one thing that could have save them and that was the flu vaccine. So fear of getting sick after flu vaccine and misinformation cause some families to take their chance with this potentially fatal respiratory viruses.The tragedy is that this illness is largely preventable. .
In fact an average of 20000 kids aged 5 and younger are hospitalized with the flu in USA every year and more than a third of the children who died during the 2012-13 flu season were under age 4 because their immune system was not mature enough to have antibodies to fight off sickness. This is why kids 5 years and under should receive two separate doses of flu vaccine at least 28 days apart. Getting vaccinated early and good hygiene habits are the best way to prevent flu complication, however it takes 2 weeks after receiving the vaccine for the body to develop antibodies to fight flu. Pregnant women especially in the second and third trimester and breast feeding mothers can receive the flu vaccine because catching the flu while pregnant increases the risk of miscarriage and premature birth. Besides you pass flu-fighting antibodies on to your baby that can protect him up to 4 month after birth. Influenza vaccine is also needed for people over 65 years of age because of their poor immune system and the chance of getting in to complication For those children, who are not vaccinated and catches influenza antiviral medications will be more effective if started in 48 hours of the first symptom in order to decrease the risk of serious complications

1. Intramuscular route offer a faster rate of absorption than subcutaneous injection, it can hold a volume of fluid in children which is 0.5-2ml depending on the child size.
2. In children age less than 2 years the recommended site of injection is the leg muscle vastus lateralis, middle part and the lateral aspect of the muscle; shown in the figure. Insert the needle at 90 degrees to the long axis of the femur with the skin compressed between the index finger and the thumb.
3. Do the injection with a dart like motion to quickly pierce the skin and administer at a rate of no more than or faster than1ml/10 second in order to minimize the pain
4. For children more than 2 years, upper arm, deltoid muscle site is the recommended site of injection, 2-3 fingers (2.5-5cm) below the lower acromion process and the volume of injection should be limited to 0.5-1ml. This site is not used for injection for large volume of drugs especially for less than 5 year old kids.
5. The ventrogluteal muscle (upper outer part of buttock) is the site of choice for injection in adolescent and adult and not used in children, this site provides greater thickness of gluteal muscle.
6. Needle size Gauge 25 (1 inch, in length, 0.6 mm) is the most appropriate size for intramuscular injection to minimize local irritation and pain in children.
7. Use of longer needle (1inch) significantly reduces the local reaction instead of short needle except in neonate, when 16mm needle is suitable. Longer needle has been associated with reduce redness or swelling compared to shorter needle because the injection is deeper.
8. For cleaning the site of injection I believe using alcohol swab is better than normal saline.
9. Aspiration immediately before administration should be done, it takes only one second and you are sure you’re not hitting a vessel.
10. It is very important to minimize injection induced pain and the child distress. This issue has not been solved yet but there are some technique that can lessen the pain like topical anesthetic (Emla Cream) which takes about half an hour to start of its effect, positioning of the child ,good communication and also distracting the child attention.
Conclusion: The vastus lateralis (tigh muscle) is the site of choice for intramuscular injection in children under the age of 2 years followed by deltoid muscle (arm) for children 2 years and above. Ventrogluteal (buttocks) muscle being the site of choice in I.M. injection in adolescent and adult. Compressing or holding the skin between the index finger and the thumb can help to lessen the injection pain. The needle size of choice is Gauge 25 (1 inch, in length, 0.6 mm) is the choice for I.M. injection. Piercing the skin should be in dart like motion very quick, with quick aspiration prior to administration.

Questions: Is there any risk in exposing children to x-ray? My child is coughing for last 2 weeks and my pediatrician ordered a chest x-ray for him. Is it completely safe?
Answer: When your child is ill or injured you want to do whatever the tests is needed as soon as possible. Sometimes this test like x-ray or CT scan exposes child to radiation which can link to cancer later in life in some individual, especially the growing child is more sensitive to radiation. There is no doubt that x ray and scan are helpful and even sometime life saving but no one should be expose to radiation that is not wisely ordered and benefit of the test should outweigh the risk of radiation exposure.
So before any imaging study is done for your child you should ask several questions from your doctor:
1. Does this imaging test uses radiation; does he really needs this imaging test? And if yes what type?
2. Are there any options or alternatives like ultrasound rather than using ionizing radiation?
3. If the test ordered is a CT scan which exposes the child to much more radiation compared to a simple x-ray, parents should consider going to a children hospital rather than a general hospital which are more likely to adjust the scanner to deliver a child size dose of radiation for that particular image. It is very important to use the lowest dose possible when scanning a child.
The amount of radiation exposure depends on the type of imaging test used, for example a single chest x-ray exposes a child to about 0.1 mSv (millisieeverts which is a measure of radiation exposure). This is about the same amount of radiation people are exposed to over the course of about 10 days naturally or a mammogram exposes a woman to 0.4 mSv which is the amount of a person should expose in nature over 7 weeks and a CT scan of abdomen or pelvis can expose a person to 10 mSv. Radiation exposure to all these sources can add up over the life time and increases the chance of cancer in future. So in any child that may need to be exposed to radiation or x-ray, is better to reconsider its necessity or at least to see if other imaging test which uses no radiation like sonography or MRI can be substituted. Dental x-ray is one of the lowest radiation dose and a routine exam which include 4 bitewings is about 0.005mSv, which is less than one day of natural background radiation or about the same amount of radiation exposure from a short airplane flight (1-2 hours). American Dental Association also recommends the kids and teens get bitewing x-ray not more frequent than every 6-12 months if they have cavities, of course the frequency depends on medical and dental history and current condition.
One way to lessen repeated exposure of children to unnecessary radiation is to concentrate on clinical skill of the physician like taking a good history of patient, a good physical examination, and sometime keeping the child in the hospital for few hours of observation before submitting him to radiation if clinical situation permits. Follow up of the case during period of observation may also help to choose a better option and save the kid from receiving unnecessary radiation. This type of thinking along with parent not wanting an answer right away and putting too much pressure on the doctor can be very helpful.

My son is 2 years old and has been in contact with a child who has chicken pox . He as not received chickenpox vaccine so far. Can I give him chicken pox vaccine now for his protection ?
Answer: chicken pox vaccine is highly effective ( 95% for the prevention for moderate to severe disease) when used within 36 hours of exposure in an environment involving close contact . It should be given as soon as possible after the exposure but is recommended up-to 5 days after exposure. The reason for high efficiency is that naturally acquired varicella-zoster virus usually takes 5-7 days to propagate in the respiratory tract before primary viremia and dissemination occur , where as vaccine virus may elicit humeral and cellular immunity in significantly less time.
Question: Is MMR vaccine effective in preventing measles if given after exposure to the illness?
Answer: The measles vaccine if given within 72 hours of measles exposure will provide protection in some cases , so vaccination within 72 hours is recommended for all unvaccinated contact including children as young as 6 months. In children less than 1 year this vaccine should not count as part of primary service, which should continue as usual ( with the minimum of 28 days of separating vaccines).

Parents often worry a lot and losses sleep, when their children have fever in spite of fever being helpful and harmless. Sometimes the child does not have really fever but feels warm when touched, which could have many other reasons like the temperature of parent’s hands when touching the kid or when child is playing hard or crying or getting out of a warm bed or in a hot weather because in these cases the child is giving off heat. In fact measuring the child’s simply by touching skin is shown to be misleading in at least 40% of cases.
Parental concerns usually rises because of the belief that fever is a disease rather than a symptom of illness. This misconceptions and unrealistic concerns about the fever which ranges from thinking about the brain damage, losing their children and the disease causing the fever is potentially dangerous rather than relatively benign is termed fever phobia, and I hope the following details can help the parents to be more realistic when their children is febrile:
1) Temperature should be measured by thermometer, and the most accurate is the mercurial thermometer, putting under axilla, in mouth or rectal depending on the age of the child. Axillary temperature above 37.5 deg Celsius, rectal temperature more than 38 deg Celsius and oral or mouth temperature more than 37.7 degree Celsius is considered as fever.
2) Fever is a friend and is a body’s way of fighting infection by activating immune system of child.
3) Fever rarely goes above 40.5 – 41 degree Celsius and by itself doesn’t cause brain damage; only temperature above 42.2 degree Celsius can cause brain damage. It also does not increase the risk of speech delay or learning problem.
4) Fever only needs to be treated if they cause discomfort and this usually doesn’t happen unless it gets above 38.8 degree Celsius. Usually the brain has a thermostat and help for the fever not to go about 40 degrees Celsius.
5) The level of fever doesn’t indicate the type or severity of the disease causing the fever but other symptoms such as extreme fatigue or loss of appetite , how the child looks, does he play when his temperature is down ,is he playful or looks sick are important but the level of temperature is not , exception is when the child is less than 6 months old and fever specially high temperature can be the indication of a serious problem in some of them.
6) Some parents are worried about fever causing convulsion or seizure. Only 4 % of children can have seizure with fever and these are mostly special cases with a family history of seizure, child with hypoxic insult in the past or one who had once febrile seizure before. Most febrile seizure is really harmless, it may look scary to watch but it stops within 5 minutes and don’t cause any permanent harm.
QUESTION No. 2: When do I need to get worried about my febrile child and to seek immediate contact with my doctor?
1- Fever of any degree especially high fever in infant less than 6 month of age.
2- If the fever persist for more than 3-4 days and the cause of the fever is not clear
3- When your febrile child looks really sick, does not like to play, has poor appetite and is getting listless and weak.
4- If your child had already once febrile convulsion in the past.
5- If your child cries constantly and is very sensitive to touch especially in infants less than 1 year of age.
6- If you’re febrile child is also having difficulty in swallowing , have respiratory distress ,or is having diarrhea.

Many parents ask if influenza vaccine is absolutely needed for children or is influenza one of the basic vaccines that the child should receive.
The answer is yes, influenza is a serious disease and children need to receive it once a year during cold season from October to March. Influenza virus is more pathogenic in two extreme of life, in small children and old ages .Every year many children die in different countries because of not having enough immunity against influenza viruses , they develop lung infection ( broncho pneumonia) and other complications like ear infection and sinusitis specially kids less than 3 years old.. It is part of routine vaccination program in some countries like United Kingdom and Finland.
There are many types of influenza vaccines but the one usually used in children and adolescents is an inactivated vaccine that covers for 3 strains of influenza viruses giving protection 2-3 weeks after vaccine given. It is recommended for all individual aged 6 months and above unless child is febrile or suffering from an acute infection. There is no age limit for receiving the vaccine and the one used used in older age above 60 has added adjutants which makes it stronger to more enhance the immune response.
Side effect is rare and mostly is the cold symptoms which disappear in 1-2 days. It can be given to all pregnant ladies at any time and during breast feeding too which apart from protecting the mother it will help for transmission of transplacental antibody and protects the baby. If mother is not protected, influenza viruses may cause premature delivery,still birth and even neonatal death. Influenza vaccine is absolutely needed in high risk children with special conditions like brachial asthma, chronic pulmonary or cardiac diseases and those with Immune suppressive disorder.

Childhood trauma can initiate from anything that makes the child helpless and disrupts the sense of safety and security including sexual, physical or verbal abuse, unstable or unsafe environment, separation from parents, neglect, bullying or serious illnesses. Anyone of the mentioned emotional trauma or wound can have a devastating effect on the child future life in adulthood and can impact a young person’s sense of self (false self) and the world around him. An individual undergoing trauma during childhood may not be aware how it is impacting their life but any specific childhood events is buried somewhere in the subconscious and it will show its bad effect later in life.
Stress, assault and tension especially if it gets chronic during childhood cause the stress hormone such as cortisone and nor-epinephrine to flood the body in order to defend itself. This is when the body automatically tenses up itself. Childhood trauma can result to social anxiety disorder. Parental abuse like insulting , disrespect, swearing, denigrating and emotional neglect (not feeling cared for, or loved) relate directly to social anxiety disorder and social withdrawal and intense persistent feeling of fear to be judged by others. It is human nature to circumvent the things we fear but childhood trauma takes this avoidance to the extreme. Like you may have an innate fear of going to dentist but you will probably still go because the benefit of taking action overrule the fear response but far too often adult with history of stress trauma in childhood allow fear to dictate their action and they may avoid the dentist allowing fear to cripple their intention and on occasion can seriously impede the quality of life.
There is a link of childhood traumatic stress to poor life outcomes, social economic status, academic under achievement often leading to deviant behavior and difficulty in earning living. People who come from disadvantage background are 65% more likely to have experience trauma as a child than someone from middle class background.
Trauma disrupts your natural equilibrium, freezing you in a state of hyper arousal and fear. In essence your nervous system gets stuck. Children who have experienced complex trauma often have difficulty identifying, expressing and managing emotions and may have limited language or feeling states. They often internalize and /or externalize stress reaction and as a result may experience significant depression, anxiety and anger.