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By Andrew J. Carlson, MD
October 02, 2013
Category: Diseases
Tags: virus   cough   adenovirus   cold   cough medicine   illness   medications  

Cough Medicine: Which one's best?

This is the time of year I get a lot of requests for an over the counter cough suppressant suggestion or a prescription cough medicine for kids so they can sleep. Despite my attempts at educating the family about why I don't recommend any cough medicines, many parents are upset leaving without a medicine. I have collected numerous articles that show why I treat cough the way I do. Links are included throughout this blog. Click away to learn more!

First, a little background...


Most cough medicines were studied in adults and the dosing for kids was calculated from the adult dosage. Kids are not small adults. Their bodies handle illness and metabolize drugs differently. But few studies have been done to show if medicines work at all, and if they do, what the best dose is for kids of various ages and sizes.

In 2008 the FDA stated that toddlers and babies should not use cold and cough medicines. Drug makers voluntarily changed the labeling of over the counter (OTC) cough and cold products, recommending them only for children aged 4 and older. The American Academy of Pediatrics says there is no reason that parents should use them in children under age 6 because of the risks without benefit. Despite this, studies show that 60% of parents of children under 2 years have given a cough and cold medicine. Why? In my opinion, they are desperate to help their child and don't think it is enough risk to not at least try.

 

 

photo source: Shutterstock

 



I know it is frustrating when your child is up all night coughing. It is frustrating when my kids and I are up all night coughing. But you know what we do in my house?

  • Humidify the air of the bedroom (unless it's a spring or summer cough)
  • Extra water to drink all day
  • Honey before bedtime in an herbal tea (if my kids will take it... for some reason they don't like honey!)
  • Encourage cough during the day to help clear the airways
  • Nasal rinse with saline (I love this, but my family is not so keen on it)
  • Sleep with water next to the bed to sip on all night long (even when I still had bedwetters)
  • Back rubs, hugs, kisses, reminders that it will get better, etc
  • Nap during the day as needed to catch up on lost sleep
  • Watch for signs of wheezing or distress


That's about it for the cough. If something hurts, we use a pain reliever like ibuprofen or acetaminophen. We use those only if something hurts, not just because and not for fever without discomfort.

Why don't I give my family cough medicines?

Because they don't work.

First the OTC options:


A Cochrane Review in 2007 was done to look at over the counter cough medicine effectiveness in both children and adults. These reviews look at many studies and analyze the data. Unfortunately there are very few studies, and many were of poor quality because they relied on patient report. In studies that included children, they found:

  • Antitussives were no more effective than placebo for kids. (one study) In adults codeine was no more effective than placebo. Two studies showed a benefit to dextromethorphan, but another study did not, so mixed results.
  • Expectorants had NO studies done in children. In adults guaifenesin compared to placebo did not show a statistically different response.
  • Mucolytics more effective than placebo from day 4-10 in kids. (one study) In adults cough frequency was decreased on days 4 and 8 of the cough. (Note: I am not sure what OTC mucolytic was studied. I am only aware of pulmozyme and mucomyst, both used by prescription in children with cystic fibrosis.)
  • Antihistamine-decongestant combinations offered no benefit over placebo. (2 studies) One of two studies showed benefit in adults. The other did not.
  • Antihistamine shows no benefit over placebo. (one study) In adults antihistamines did not help either.


Another Cochrane Review in 2012 once again failed to show any real benefits of cough medicines, especially given the risks of side effects.

What about some specific studies on OTC medicines?

I cannot report them all here, but here's a few:


A study comparing dextromethorphan (the DM in many cough medicines), diphenhydramine (AKA benadryl), and placebo in 2004 showed no difference in effectiveness of controlling cough for sleep. That means the placebo worked just as well as the medicines. Insomnia was more common in those who got dextromethorphan.

Does guaifenesin help? It is thought to thin mucus to help clear the airways. It does not stop the cough. Studies vary in effectiveness and are typically done in adults, but it may be helpful in children over 4 years of age. Do not use combination cough medicines though, for all the reasons above.

In 2007 honey was shown to be a more effective treatment than dextromethorphan or no treatment. Another study in 2012 showed benefit with 2 tsp of honey 30 minutes before bedtime. A side effect of honey? Cavities... Be sure to brush teeth after the honey!

What side effects and other problems are there from over the counter cough medicines?

As stated above, the dosages for children were extrapolated from studies in adults. Children metabolize differently, so the appropriate dosage is not known for children. Taking too much cold medicine can produce dangerous side effects, including shallow breathing and death.

Many cough medicines have more than one active ingredient. This can increase the risk of overdosing. It also contributes to excess medicines given for problems that are not present. For instance if there is a pain reliever plus cough suppressant, your child gets both medicines even if he only has pain or a cough. Always choose medicines with one active ingredient.

Accidentally giving a child a too much medicine can be easy to do. Parents might use two different brands of medicine at the same time, not realizing they contain the same ingredients. Or they can measure incorrectly with a spoon or due to a darkened room. Or one parent forgets to say when the medicine was given and the other parent gives another dose too soon.

And then there's non-accidental overdose. There is significant abuse potential: One in 20 teens has used over the counter cough medicines to get high. Another great reason to keep them out of the house!

Side effects of cough medicines include:

  • Nausea and vomiting
  • Stomach pain
  • Confusion
  • Dizziness
  • Double or blurred vision
  • Slurred speech
  • Shallow breathing
  • Impaired physical coordination
  • Rapid heart beat
  • Drowsiness
  • Numbness of fingers and toes
  • Disorientation
  • Death, especially in children under 2 years of age and those with too high of a dose

 

What about prescription cough suppressants?


In 1993 a study comparing dextromethorphan or codeine to placebo showed that neither was better than the placebo. Codeine belongs to a class of medications called opiate analgesics and to a class of medications called antitussives. When codeine is used to reduce coughing, it works by decreasing the activity in the part of the brain that causes coughing. It can make breathing too shallow in children. Codeine has several serious side effects which could be life threatening in children. Combination products with codeine and promethazine (AKA phenergan with codeine) should never be used in children under 16 years. In my opinion, why use it in older children and adults, since it hasn't been shown to work?

What about antibiotics for the cough?

Antibiotics may be used to treat bacterial causes of cough (such as some pneumonia or sinusitis illnesses) but antibiotics have no effect on viruses, which cause most coughs. If your child has a cold, antibiotics won't help.

 

By Andrew J. Carlson, MD
September 04, 2013
Category: Parenting
Tags: infant sleep   newborn   sleep  

Common Sleep Myths

As we parent our children in regards to sleep, there is a myriad of information, recommendations, myths, rules and even legends! It can be tough to sort through and make sense of it all. In this article I will respond to 5 of the most common Sleep Myths.
  1. Putting Rice Cereal in a Babies Bottle will help them Sleep Longer-

This one has been around for decades! Many studies have proven that babies who were given rice cereal in their bottle did not sleep any longer than those who did. Some parents have even found the opposite to be true….that babies who were given too much rice cereal or were given rice cereal at a young age suffered from indigestion and tummy upset.

  1. Keeping a baby/child up later at night will make them sleep in.

This one couldn’t be further from the truth. While on the surface this makes sense, we must think biologically not logically when it comes to our child’s sleep. If we allow our children to become overtired they release a hormone called Cortisol, which is similar to adrenaline. This hormone makes it very hard for them to fall and stay asleep. Babies sleep better, longer, and cry less if they are put to bed early in the evening. Babies who go to sleep late in the evening are often "over tired", even though they seem to have energy. A typical and healthy bedtime, depending on how they napped during the day is between 6-8 pm.

  1. A Baby should sleep through the night at 12 weeks-

While this would be nice, and does happen in some cases with some babies, it can be an unrealistic expectation and just cause stress if it doesn’t happen for you. It isn’t unreasonable for a baby to “need” a feeding during the night till around 9 months of age.

  1. My child doesn’t need as much sleep as other children-

I hear this one a lot in my profession and while this might make a parent feel better about how little their child sleeps, it really isn’t true. It is true that some kids need/love sleep more than others but usually this varies by only an hour or two, not huge amounts that I tend to see. It is not uncommon for children to fight sleep but that doesn’t mean they don’t need it. I am confident that all children can be taught to be good sleepers…..and isn’t that what we want?!

  1. You can sleep train a newborn-

In all reality you can’t sleep train or schedule a newborn. Sometimes an infant might appear to be on a schedule until it suddenly changes. This is because our babies Circadian Rythmn or body clock is not biologically mature yet. This maturing starts around 4-5 months of age and this is when we can start scheduling naps, etc.

Most basic baby sleep myths can be busted by remembering to think biologically instead of logically in regards to our children’s sleep. Respecting and encouraging our children’s need for sleep is something every baby deserves!

By Andrew J. Carlson, MD
May 16, 2013
Category: Safety

It's [Sports, School, Camp, Yearly] Physical Time!

                       

It's that time of year when school aged children and teens need physicals for school or camp entry or to participate in sports. Parents often want to work in a last minute "quick physical" for a form to be signed before a sport season starts or a child goes to a new school. Plan ahead so you can get an appointment at your preferred time!

Unfortunately some parents calling at the last minute are unable to get an appointment that fits their needs so they decide to go to a walk in clinic to just get the form signed. Keep reading to learn why this isn't a good substitute for a yearly physical in your child's medical home (AKA regular doctor's office).

Some parents don't think a yearly physical is important, and if not required to present a form to a school, sport, or camp, they simply don't do them. Their kids miss out on the benefits of a yearly physical.

Even when you think your child is healthy, there are several things that should be discussed, reviewed, and evaluated during the physical, so the visit isn't quick and it should be done in your child's medical home. If your child's regular physician is not available, there is still benefit to scheduling with another provider at your doctor's office as allowed by their policies. Past records are available to be able to compare current height to past growth. We can review vaccines and update as needed. We can update your child's record as needed since the last visit with new family medical history, changes in the home or school, and with your child's overall health.

Over the years I have "cleared" many student athletes by signing a pre-participation form required for high school sports or camps. On occasion I have not been able to sign the form, and this can lead to frustration for the athlete and his/her family. If a physician or other licensed medical provider does not feel requriements have been met to "clear" an athlete for safe participation in sports, parents and their athlete often do not understand the "why" behind the need for further evaluation or treatment.

Common reasons to not clear an athlete for participation include recent concussion or a history of passing out that hasn't been fully evaluated. I had one patient upset that I wouldn't sign the form because of a current broken bone... you can't play a sport in a cast! From the mother's perspective, she just wanted the form done today because the physical was today. From my perspective, the form can be signed when the child is able to play. I can't in good conscience say the student is able to play today if he is not. You don't want me as your child's pediatrician if I am able to attest to something I know is not true.

Please don't go to an urgent care or chiropractor to get the form signed when your regular doctor refuses due to a medical concern. I have seen parents do this -- omitting the fact that their child has passed out and needs further testing or had a concussion. That undermines the reason for the form in the first place! It is for your child's safety!

A glance at the Connecticut  Pre-Participation Physical Evaluation  form's first page highlights many of the important topics to investigate. It would be impossible to completely cover every recommended topic at every physical, but standard recommendations include:

  • Review of health history, including chronic conditions (such as asthma, diabetes, learning disabilities etc), hospitalizations, surgeries
  • Review of family medical history
  • Height, weight, Body Mass Index (BMI), vital signs (blood pressure, pulse, respiratory rate) - comparison to previous values is most helpful
  • Puberty status
  • Nutrition, exercise, and weight management issues - including performance-enhancing substances
  • Sleep
  • Risk factors (safety, smoke exposure, violence, alcohol use, screen time, internet safety, and more)
  • Mental health (depression screening, drug/alcohol use, bullying)
  • Physical exam (special attention to cardiac system, musculoskeletal, neurologic and other sport's preventing problems)
  • Update vaccines as needed
  • Laboratory evaluation as needed: cholesterol screening, anemia screening, and other risk-based testing

Not included in this list is following up chronic conditions, addressing the issues raised at the physical, refilling all medicines, etc. There are times that addressing one or two specific issues is appropriate, but often there isn't enough time to adequately address all concerns. A separate visit may be needed to be able to devote appropriate attention to each issue. Please don't save up a year's worth of concerns to discuss at one visit each year.

 

A well visit is recommended every year for all children over the age of 3 years (more for younger children). If your child hasn't had a well visit in the past year, call today or request a physical through our portal! Don't wait until the last minute... summer physicals book quickly.

The yearly well visit can be used to address all sports and camp physical forms that need to be done. Please bring them to your visit with the appropriate sections pre-filled out to save time in the office.

 

Labels:cardiac,concussion,heart,physical,preventative medicine,sports

 

By Andrew J. Carlson, MD
May 01, 2013
Category: Diseases
Tags: virus   allergies   allergy   itch   nasal washing   runny nose   saline  

 

It's allergy season! Prevention and treatment is important if you have seasonal allergies so you can enjoy the great outdoors.

Symptoms of Allergies:

Allergies can impair sleep (leading to all the problems associated with not enough sleep) and can lead to the annoying symptoms of itching, coughing, sneezing, runny nose, and watery eyes. Some kids get a crease across their nose from wiping. Others get purple circles under their eyes called allergic shiners. These symptoms last longer than the typical cold, which usually resolves after 1-3 weeks. Fever is a sign of infection, not allergies. Other than fever, it is very difficult sometimes to decide if it is a virus or allergies until a seasonal pattern really develops. Even then it is possible to get colds during allergy season some years!

Treatments:

It is best to treat before the symptoms get bad. I registered on (and recommend) Pollen.com for free alerts at the beginning of the season to anticipate the need to treat before symptoms begin. Treatments include medicines and limiting exposure.

Medications:

I don't want kids with outdoor allergies to be afraid to go outside, so taking medicines to keep the symptoms at bay while out can help. Types of medicines:
 

  • Antihistamines work to block histamine in the body. Histamine causes the symptoms of allergies, so an antihistamine can help stop the symptoms. Some people respond well to one antihistamine but not others. In general I prefer the 24 hour antihistamines simply because it is impossible to cover the full day with a medicine that only lasts 4-6 hours. Different antihistamines work better for some than others. Personally loratadine does nothing for me, fexofenadine is okay, but cetirizine is best. I have seen many patients with opposite benefits. You will have to do a trial period of a medicine to see which works best. If they make your child sleepy, giving at dinner time instead of the morning might help. Prescription antihistamines are available, but usually an over the counter type works just as well and is less expensive.
  • Antihistamine and decongestant combinations are available but are not usually recommended by me. Once control of the mucus is achieved, a decongestant isn't needed.
  • Nasal spray antihistamines are available over the counter and as a prescription. An office visit to discuss the value of these for your child and proper use is recommended.
  • Eye drops can help alleviate eye symptoms. They are available both as over the counter allergy drops and prescription allergy eye drops. If over the counter drops fail, make an appointment to discuss if a prescription might help better. Tips to administer eye drops include washing hands before using eye drops, put the drop on the corner of the closed eye (nose side) and then have the child open his eyes to allow the drop to enter the eye.
  • Singulair (Montelukast) works to stop histamine from being released into the body. It helps control both allergies and asthma and is best taken in the evening. It is available only by prescription, so make an appointment to discuss this if your child might benefit.
  • Steroids decrease allergic inflammation well. These can include both oral steroids for severe reactions (such as poison ivy on the face or an asthma attack) and inhaled corticosteroids for the nose (or lungs in asthma). These require a prescription, so a visit to your provider is recommended to discuss proper use.


Limiting Exposure: The longer your airway is exposed to the allergen (pollen, grass, mold, etc) the more inflammation you will have.

  • Wash hair, eyelashes, and nose after exposures -- especially before sleep. They all trap allergens and increase the time your body reacts to them. I have found the information and videos on Nasopure.com very helpful to teach kids as young as 2 years to wash their noses. (Note: I have no financial ties to Nasopure... I just love the product and website!)
  • Remove clothing and shoes that have pollen on them when entering the house to keep pollen off the couch, beds, and carpet.
  • Wash towels and sheets weekly in hot water.
  • Vacuum and dust weekly. Consider cleaning home vents. Consider hard flooring in bedrooms instead of carpeting.
  • Wash stuffed animals and other toys regularly and discourage allergic children from sleeping with them.
  • There are many types of air filters that have varying benefits and costs. For information on air filters see this pdf from the Environmental Protection Agency: Aircleaners.
  • Keep the windows closed. Sorry to those who love the "fresh air" in the house. For those who suffer from allergies, this is just too much exposure!
  • Keep pets out of bedrooms. If you know a family member is allergic to an animal, don't get a new pet of this type! If you already have a loved pet someone in the home is allergic to, consider allergy shots against this type of animal.
  • If itchy eyes are a problem for contact lens wearers, a break from the contacts may help. Talk with your eye doctor if eye symptoms cause problems with your contacts.

 

What if all of the above isn't helping?

  • Maybe it's really not allergies.
  • Allergies to things other than foods are rare before 2 years of age.
  • Viruses can cause very similar symptoms to allergies.
  • Allergy testing is possible by blood or skin prick testing, but can be costly. In most cases I don't find it very helpful for environmental allergens because you can't avoid them entirely and you can always limit exposures as above. I think that tracking seasonal patterns over a few years can identify many of the allergens. You can still treat as needed during this time. Reports of pollen and mold counts are found on Pollen.com. Note also animal exposures and household conditions. Write symptoms and exposures weekly (or daily). It often doesn't take long to see patterns. Testing is important if allergy shots are being considered.
  • Need help tracking allergy symptoms? There's an app for that! Here's one review I found of allergy apps. I don't have any personal experience of any, so please put your favorite in the comments below to help others!
  • Wrong medicine or wrong dose.
  • Some people have more severe allergies and need more than one treatment. Allergies tend to worsen as kids get older. Switching types of medication or adding another type of medicine might help. If you need help deciding which medicine(s) are best for your child, an office visit for an exam and discussion of symptoms is advised.
  • Some kids outgrow a dose and simply need a higher dose of medicine as they grow.
  • Consider allergy shots (immunotherapy) to desensitize against allergens if symptoms persist despite your best efforts as above. Schedule an appointment to discuss if this is an option for your allergy sufferer.
By Andrew J. Carlson, MD
April 09, 2013
Category: Diseases

 

The Limping Child

A limp in children is a fairly common problem that has many causes. Many of these causes are not dangerous, but all limping children should be evaluated by a health care provider to be sure there isn't anything more serious requiring treatment. Our office has recently seen a surge of limping kids from various causes, so I thought I'd review many of them here. They are in order of body location, but symptoms of all may include a limp. This list is not comprehensive... although it is long, there are other causes I have left off. I have linked many of the causes to more information, just click on the diagnosis name.

Fever, weight loss, poor feeding, or night sweats suggest infection or malignancy and should be evaluated as soon as possible. History of trauma of course increases the likelihood of traumatic injury and if stable, can wait overnight to avoid an ER trip, but if any gaping open skin, excessive bleeding, disfigurement, or excessive pain warrants immediate evaluation and treatment.

 

Hips:

Developmental dysplasia of the hip involves the abnormal formation of the hip socket and a flattening of the top of the thigh bone (femur). Babies who are born breech, especially females, are at increased risk. Family history and some genetic conditions also can show a predisposition to this condition. All babies are routinely screened with a hip check during their physical exam until they are well into walking. Sometimes even with a shallow hip socket the exam can appear normal, so high risk infants are often sent for hip ultrasounds (sonograms) or x-ray (if over 6 months). If this condition is recognized, these babies should be treated by a pediatric orthopedic surgeon.

Transient synovitis (also called toxic synovitis) is found in children 3-10 years of age. It typically follows an infection. They have pain in the hip and don't want to move the hip in its full range of motion. It self-resolves in about a week. Non-steroidal anti-inflammatory medications can help with the pain. Although it resolves without treatment, a thorough physical exam by a medical provider is important to evaluate for other causes.

Septic arthritis, on the other hand, is an acute infection of the hip joint. This is a very serious condition because without treatment the hip joint (or other affected joints) is destroyed by the infection. Several bacteria can cause this type of infection, so culture of the pus is obtained and antibiotics are required. Classically these infants and children hold their leg at a flexed position and don't want to move the leg. This helps reduce the pain by giving the hip joint as much open space for the pus to decrease the pressure and relieve the pain.

Legg-Calve-Perthes disease is found in males more than females, typically 4-10 years of age. It is usually on one side, and results from an interrupted blood supply to the top of the femur (thigh bone). This leads to a flattening of the top of the femur and cysts in the bone. Physical therapy, casting, traction, or surgical correction are various treatment options, depending on age and severity. Pediatric orthopedists are consulted to manage the treatment of this process.

Slipped capital femoral epiphysis (SCFE) tends to occur in early teen years, males more than females, and obese children are at increased risk. It often happens in both hips and is caused by pressure on the growth plate at the top of the femur (thigh bone). Pain can be felt at the hip, thigh, or knee. It can be sudden or gradual. It requires surgery to pin the top of the bone (above the growth plate) in line with the rest of the bone, so pediatric orthopedists are consulted to treat this condition.

 

Knees:

Osgood-Schlatter disease is fairly common in athletic teens. Knee pain is caused from traction on the growth plate on the tibia (one of the shin bones). Pain is felt directly below the knee at the top of the shin bone. Many people have a boney bump that doesn't hurt after growth is complete and the growth plate is no longer present. Rest, ice, and non-steroidal anti-inflammatories are the treatment. Unfortunately symptoms can last for several years until growth is complete, but it is not a concerning process for overall bone health.

Sprains involve stretched or torn ligaments. Often a popping sound is heard at the time of injury and pain is immediate. Swelling from fluid behind the kneecap is common. The knee can seem unstable and weight bearing is painful. Strains are a tear of the muscle or tendon. Symptoms are similar to sprains but also involve bruising. For more information on both sprains and strains see KidsHealth.

Tendonitis is an inflammed tendon. It is a common overuse injury. Pain or tenderness with movement of the joint or walking is noted. Rest, ice, wraps, elevation of the leg, and anti inflammatory medications can help. Physical therapy to strengthen muscles to support the knee is recommended for most of these overuse injuries, but surgery is sometimes required.

Meniscal tears are common sports injuries from sudden change in speed or side to side movement. Tenderness, tightness, and swelling of the knee are noted. Initial treatment is the same as the tendonitis treatment above, but surgery is required for large tears.

Osteochondritis dessicans (OCD) occurs when a piece of bone or cartilage breaks off the bone and causes long-term knee pain. It often occurs with swelling, inability to extend the knee fully, stiff knee, and popping of the knee. Treatment involves casting and sometimes surgery.

Feet and Ankles:

Tarsal coalition is a condition where 2 or more bones are joined in the midfoot or hindfoot. Pain in the midfoot or a spastic or fixed flatfoot are symptoms. This is a congenital (birth) condition, but symptoms don't develop until late childhood or adolescence. It is sometimes found incidentally on xray for another issue. Conservative treatment involves splinting, and surgical correction is also available.

Plantar Fasciitis is pain in the bottom of the foot or heel pain. Tight calf muscles or Achilles tendons often are associated with this. It occurs in toe-walkers, overweight people, people who wear shoes without sufficient support, and athletes who fail to adequately stretch. Stretching, non-steroidal anti-inflammatory medications, and heel inserts often help relieve pain. Physical therapy can be helpful.

Achilles Tendonitis is an overuse injury of the Achilles tendon. Runners and jumpers are often affected. Pain tends to worsen with time, especially after running or jumping. It is treated with rest, ice, wrapping, elevation of the foot, anti-inflammatory medicines, stretching, and shoe inserts.

Sprained ankles are very common. They happen when the ligaments of the ankle get stretched. Elevation of the foot, ice, non-steroidal anti-inflammatories, and rest help it heal.

 

Bones:

Fractures (see also fractures) after injury are not always easily identifiable in young children who are not able to state what happened. Initial xrays might appear normal if there is only a subtle fracture. If limp persists, follow up xrays in one week can show signs of a healing fracture more readily than the initial fracture.

Overuse injuries and stress fractures are becomming more common as younger kids are getting into more highly competitive sports. X-rays may be normal or show mild changes. If history of training and pain/limp is consistent with stress fracture, MRI or bone scans might be required to show bone injury.

Bone tumors can originate in the bone or from other cancers metastasizing to the bone. Leukemia involves production of abnormal blood cells in the bone marrow, and leg pain is often a common finding. Bone pain, fracture from mild trauma, and other symptoms of the primary cancer are all presenting signs.

Leg length discrepancy can cause a limp that typically does not hurt. Most of these can be managed with shoe inserts to "lengthen" the short leg. Surgery is sometimes recommended.

 

Multiple joints:

Arthritis can affect a single or multiple joints. Morning stiffness that gradually lessens as the day progresses and the joint "warms up" is common. Swelling might be minimal or great. Family history is often a clue, but some kids have no family history of arthritis. Other symptoms, such as rash, fever, eye changes, are possible.

 

Abdominal and back issues:

Constipation, appendicitis, abdominal muscle (psoas) abcess, tumors in the abdomen, inflammation of the disc spaces in the vertebral column, and tumors of the spinal cord are other possible causes of limp or refusal to walk. History and exam will help to identify these causes.

 

Muscles:

Hamstring strain happens when muscles in the back of the leg stretch and tear. Sudden thigh pain, sometimes with a popping sensation and bruising, are symptoms. Treatment involves rest, ice, wrapping the muscle, elevation of the leg, and non-steroidal anti-inflammatory medications.

Quadriceps contusion happens after a hit to the muscles of the thigh. Rest, ice, wraps, elevation of the leg, massage, and non-steroidal anti-inflammatories can help relieve pain. Physical therapy can be initiated when swelling is decreased. Slow return to sports is important to allow complete healing.

Post-viral myositis is muscle inflammation after an infection with a virus. Affected kids will have severe pain in the calf muscles, typically within a couple of days of a resolving viral illness (often influenza, but other viruses too). This is a condition that resolves over about 10 days, but medical providers should help with the evaluation of this to be sure the kidneys are not involved. If the urine is very dark it should be evaluated immediately.

 

And one more thing...

A cause of leg pain that doesn't cause limp is Growing Pains.

 

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