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Thursday, September 17, 2015

Heat Illness in Children

Pediatricians often caution their patients to "drink more water" on hot days or while exercising, but what is the reasoning behind this? 

Children and adolescents have two disadvantages when it comes to heat illness, which makes them more susceptible. Both their decreased sweat response (we cool off by sweating) and their poor thirst response (the feeling of being thirsty) when compared to adults. It is for this reason that heat illness is the 3rd leading cause of death in athletes in the U.S. The illness is categorized by the degree of temperature elevation:

Heat Cramps
Mild dehydration leads to cramps in the hamstrings or calves, and responds well to electrolyte fluid replacement. 

Heat Exhaustion
Characterized by a 100-103 degree body temperature, along with headache, weakness, nausea and vomiting. The treatment is to remove the clothes, apply ice packs to the body and to place the patient under cooling fans. Fluids are given for rehydration, whether by mouth or via an IV. 

Heat Stroke
A medical emergency characterized by a body temperature of >104 degrees paired with intense sweating caused by overexertion. The patient is immediately cooled to prevent organ damage, and IV fluids are administered. Unfortunately, the result is death in 50% of cases,

Athletes are encouraged to drink water every 20 minutes, and if exercise exceeds 1 hour then an electrolyte-rich sports drink is indicated.

Wednesday, September 16, 2015

Your child's sports injury: the foot

Ankle injuries are considered the most common type of athletic injuries. If your adolescent or teen has suffered an injury, the most likely cause is a sprain. The treatment for a sprain is RICE (rest, ice, compression and elevation) for the first 48 hours, followed by rehabilitation. However, here are a few lesser known injuries that may be to blame:

Stress Fractures
Metatarsal Stress Fracture
This is a small crack in one of the metatarsal (toe) bones, usually the 2nd or 3rd toe, and typically occurs in runners. There will be point tenderness over the area on examination. Treatment is rest for 6 weeks and using shoes with good arch support.

Navicular Stress Fracture
This is a tricky fracture of the upper bone in the foot called the navicular bone that occurs in athletes in running sports. They complain of vague, non-localizing pain at the dorsum (top) of the foot. These do not show up on imaging right away, so after a few weeks an MRI may be needed to make the daignosis. Treatment is casting and immobilization for 8 weeks

Calcaneal Stress Fracture
Fracture of the heel bone. Occurs in athletes engaging in running sports, and is characterized by pain in the heel with walking or running. Pain can be elicited on exam by squeezing the heel bone. Imaging may be needed to make the diagnosis, and treatment is 8 weeks of immobilization.

Sever Disease
Inflammation of the bottom of the Achilles tendon where it attaches to the heel bone (calcaneus). It occurs in prepubescent boys, during exercise, in both lower legs. The treatment is RICE and shoes with good arch support, and will heal in about 2 months.

Plantar Fasciitis
Athletes will report morning heel pain after several hours of rest or during the first few steps of the day. The treatment is rest, and pain is gone after about 6 months.

Tuesday, September 15, 2015

The Newborn Foot Examination

One of the most common questions asked by new parents concerns their newborn's feet. "Is this normal?" is an appropriate question to ask when a body part on your child doesn't quite look right. 
Though changes in the angles of the feet are typically normal, it is imperative that the pediatrician rules out conditions that require closer observation and management. Here is the "differential diagnosis" for oddly shaped baby feet:

Metatarsus Adductus
The "forefoot" or front part of the foot is turned in (adducted) toward the center, while the middle and hint foot portions are normal. Typically caused by "intrauterine molding", or the way the baby was positioned in the womb. The physician will perform a quick test to be sure the forefoot can be moved to midline without resistance. If the feet are too rigid, a referral to a pediatric orthopedist is warranted. There, the feet may be placed in special "reverselast" shoes and reevaluated in 6 weeks. If this does not fix the problem, serial lower leg casting may be required. The last step would be surgery, which isn't done until 4 years of age. 

Talipes Equinovarus (clubfoot)
The whole foot is adducted. As with above, a quick test for rigidity is performed. If correctable, it is referred to as "positional clubfoot" and is simply observed over time. The more serious diagnosis is congenital clubfoot, which occurs in 1 out of every 1,000 births. Congenital clubfoot requires x-ray imaging, referral to pediatric orthopedics and treatment with special casting referred to as the "Ponseti method". Surgery may be required between ages 3-12 months. 


Pes Planus (flat foot)
The lack of an identifiable arch in the foot. This is quite common, seen in approximately 1 in every 4 children. This condition is simply observed over time, since arches typically develop by age 10. If the child complains of pain in the feet as they get older, they may require stretching exercises or special shoes. 

Congenital Vertical Talus (rocker bottom foot)
Rocker bottom feet are characterized by elevated, dislocated, midfeet. The condition is typically associated with genetic syndromes or single gene deletions. Referral is made to pediatric orthopedics.