Posted in Patient Information

Penile Adhesions in Male Children

Adapted from: Penile Adhesions Parent Information CHOP Website

What are penile adhesions

Penile adhesions in circumcised boys occur when the penile shaft skin adheres to the glans of the penis. There are three types of penile adhesions: glanular adhesions, penile skin bridges and cicatrix.


Some adhesions may develop due to an excess of residual foreskin following a newborn circumcision. Adhesions can also form as an infant develops more fat in his pubic area (the area around the penis and scrotum).


The penis may appear that it is “buried” in the prominent pubic fat pad. Because the penis remains hidden there is a tendency for the shaft skin to adhere to the glans.

With all adhesions you may notice a white discharge coming from the area of the adhesions. This is called smegma. Sometimes smegma can be mistaken for a cyst or pus under the skin, but it is not an infection and does not require antibiotics. Smegma consists of dead skin cells that accumulate underneath the adhesions and help to break them apart.

Diagnosis and treatment

Penile adhesions are generally benign and cause no pain or discomfort to your son. You or your pediatrician may notice them during a physical exam.

Treatment is generally performed by a urologist. They will determine by physical exam the type of penile adhesion and what treatment approach is recommended.

Glanular adhesions

On exam you may not be able to see the complete coronal margin. This is the purple line that separates the glans from the shaft of the penis. This is because the shaft skin has adhered to the glans, covering the coronal margin. Glanular adhesions are benign and when left alone tend to resolve on their own. To help the adhesions separate more quickly, we may suggest applying Vaseline® directly to the adhesions. The Vaseline will soften the adhesions, and with spontaneous erections, the adhesions will begin to break apart on their own.

Penile skin bridge

In some instance, the penile shaft skin will become attached to the coronal margin and develop a thicker permanent attachment that cannot be separated and will not separate on its own. You may notice a band of skin from the shaft adhering to the glans with a small tunnel underneath. In many situations the skin bridge can be divided during an outpatient procedure. Treatment may also involve division of the skin bridge and circumcision revision.


Following a circumcision, the penis may drop back into the pubic fat pad and the surgical area may contract, trapping the penis. In this situation, you will not be able to expose the glans of the penis at all. We have found that cicatrix can be safely and effectively treated with a topical steroid cream. Your child’s doctor will give you instructions on the proper use of the cream. If the steroid cream fails and the penis remains trapped, a circumcision revision and correction of a concealed penis may be necessary.

Posted in Patient Information

Allergy Medication Dosing for Children

Quick reference of allergy med dosing for children.

Zyrtec (cetirizine) dosing:

  • 6-12 months: 2.5 mg once daily
  • 1-2 years: 2.5 mg once to twice daily
  • 2-5 years: 2.5 – 5 mg once daily
  • 6 years and up: 5 – 10mg once daily

Claritin (loratadine) dosing:

  • 2 – 5 years: 5 mg once daily
  • 6 years and up: 5 – 10 mg once daily

Allegra (fexofenadine) dosing:

  • 6 months and < 10.5kg: 15mg twice daily
  • < 2 years or < 10.5kg : 15 – 30 mg twice daily
  • 2 – 11 years: 30 mg twice daily
  • 12 years and up: 180 mg ER once daily

Flonase (fluticasone) dosing:

  • 4 years and up: 1 spray per nostril once daily. If not working, ok to increase to 2 sprays each nostril, but reduce to once daily as soon as possible
  • 12 years and up: 2 sprays each nostril once daily


Posted in Fun

Normal Vitals Wall Decor

Have trouble remembering normal vitals for children of various ages? Try decorating with these wall photos and you’ll never forget again!

A day without demographics is like a day without sunshine
A day without demographics is like a day without sunshine
Fever = 100.4 F
Fever = 100.4 F
Minimum wet diapers in 24 hours: 3
Minimum wet diapers in 24 hours: 3
Newborn to 6 months: 120-150 bpm
Newborn to 6 months: 120-150 bpm
6 to 12 months: 110-140 bpm
6 to 12 months: 110-140 bpm
1-2 years: 90-130 bpm
1-2 years: 90-130 bpm
3-5 years: 80-120 bpm
3-5 years: 80-120 bpm
6-12 years: 70-110 bpm
6-12 years: 70-110 bpm
13+: 60-100 bpm
13+: 60-100 bpm
0-12 months: 30-50 breaths per minute
0-12 months: 30-50 breaths per minute
1-2 years: 25-40 breaths per minute
1-2 years: 25-40 breaths per minute
3-5 years: 20-30 breaths per minute
3-5 years: 20-30 breaths per minute
6 to 12 years: 16-25 breaths per minute
6 to 12 years: 16-25 breaths per minute
13 years and older: 12-20 breaths per minute
13 years and older: 12-20 breaths per minute
Posted in Patient Information

Sleeping Difficulties in Infants

Adapted verbatim from:
Am Fam Physician. 2009Jul15;80(2):139-142.

Guidance for Parents

Newborns usually wake up every two to three hours. Each baby will have different sleep habits. Babies will sleep longer as they get older. Most babies sleep through the night by one year of age, but some babies start sleeping through the night by four to six months of age.

If your baby is not sleeping through the night by the end of the first year, you can try some things to help him or her sleep longer. Responding less often to your baby’s cries may help. For example, at first go to your baby within five minutes of crying, then wait for 10 minutes the next time, and then a little longer each time. After awhile, your baby will learn to calm down and go back to sleep.

Having your baby wake up at the same time each morning and go to sleep at the same time each night can help. Waking up your baby before expected middle-of-the-night awakening times also might help. For example, if your baby usually wakes up at 1:00 a.m., 4:00 a.m., and 7:00 a.m., wake him or her 15 minutes earlier each time. Your baby may eventually sleep through his or her predicted times.

More Info: Development of Normal Sleep Pattern

An important part of the childhood development process is gaining independence, and one way in which an infant works toward this goal is by sleeping through the night. Approximately 80 percent of children sleep through the night by six months of age, and 90 percent by one year of age. The definition of “sleeping through the night” is variable, because sleep schedules for each family and person are unique. Some children sleep through the night at an early age, but temporarily revert to nighttime awakenings. These awakenings are usual in the nine- to 18-month age group, when separation anxiety is common.

American Academy of Sleep Medicine 2006 Recommended Methods for Prolonging Sleep in Infants (5 years and younger):

The Parental Guidance above is from on these recommendations. These recommendations were based on a review of 52 articles on sleep in children. There is insufficient evidence to favor one method of sleep intervention over another. There is also insufficient evidence to support a combination of methods as more favorable than one sleep intervention alone.

Unmodified extinction

Lay the infant down to sleep at a designated time and do not respond to any crying until morning

Graduated extinction

Gradually respond less frequently to the infant’s cries (e.g., initially respond within five minutes of crying, then space out the response to every 10 minutes, then longer)

Bedtime routines

Maintain the same sleep and wake schedule daily

Scheduled awakenings before expected awakening time

If the predicted awakening times for the infant are, for example, 1:00 a.m., 4:00 a.m., and 7:00 a.m., awaken the infant 15 minutes earlier than the predicted time; the infant will eventually sleep through the predicted times

Note: Some methods listed may not be feasible for some families; for example, a family that lives in a thin-walled apartment complex may have complaints from neighbors if they attempt to let their infant cry through the night. Parents can try a method that fits with their values, culture, and living arrangement.

Avoid Medications

Trial of Infant Response to Diphenhydramine (TIRED)
The TIRED study showed that diphenhydramine (Benadryl) was no more effective than placebo in reducing nighttime awakenings in infants. Medication should not be used to treat this normal developmental stage. Parents can be reassured that regardless of the method used, there is no difference in family functioning between children who have and do not have sleep issues.


Childhood Sleep Information from UM Pediatrics

Posted in Patient Information

Hand Foot Mouth


What is hand, foot and mouth disease?

Hand, foot and mouth disease (HFMD) is a common infectious disease of infants and children. It is characterized by fever, painful sores in the mouth, and a rash with blisters on hands, feet and also buttocks. It is prevalent in many Asian countries.

Is it the same as foot-and-mouth disease in animals?

No, HFMD is not to be confused with foot-and-mouth (also called hoof-and-mouth) disease which is caused by a different virus and affects cattle, sheep, and pigs.

Where does HFMD occur?

Individual cases and outbreaks of HFMD occur worldwide. In tropical and subtropical countries, outbreaks often occur year-round.

Outbreaks of HFMD occur every few years in different parts of the world, but in recent years these have occurred more in Asia. Countries with recent large increases in the number of reported cases in Asia include: China, Japan, Hong Kong (China), Republic of Korea, Malaysia, Singapore, Thailand, Taiwan (China) and Viet Nam.

What causes HFMD?

Viruses from the group called enteroviruses cause HFMD. There are many different types in the group including polioviruses, coxsackieviruses, echoviruses and other enteroviruses.

HFMD is most commonly caused by coxsackievirus A16 which usually results in a mild self-limiting disease with few complications. However, HFMD is also caused by Enteroviruses, including enterovirus 71 (EV71) which has been associated with serious complications, and may be fatal.

How serious is HFMD?

Most people with HFMD recover fully after the acute illness.

HFMD is usually a mild disease, and nearly all patients recover in 7 to 10 days without medical treatment and complications are uncommon.

Dehydration is the most common complication of HFMD infection caused by coxsackieviruses; it can occur if intake of liquids is limited due to painful sores in the mouth.

Rarely, patients develop “aseptic” or viral meningitis, in which the person has fever, headache, stiff neck, or back pain, and may need to be hospitalized for a few days.

HFMD caused by EV71 has been associated with meningitis and encephalitis, and on occasion can cause severe complications, including neurological, cardiovascular and respiratory problems. Cases of fatal EV71 encephalitis have occurred during outbreaks.

How soon after exposure do symptoms appear?

The usual period from infection to onset of symptoms is 3–7 days.

Fever, lasting 24-48 hours, is often the first symptom of HFMD.

What are the symptoms?

The disease usually begins with a fever, poor appetite, malaise, and frequently with a sore throat.

One or 2 days after fever onset, painful sores develop in the mouth. They begin as small red spots that blister and then often become ulcers. They are usually located on the tongue, gums, and inside of the cheeks.

A non-itchy skin rash develops over 1–2 days with flat or raised red spots, some with blisters. The rash is usually located on the palms of the hands and soles of the feet; it may also appear on the buttocks and/or genitalia.

A person with HFMD may not have symptoms, or may have only the rash or only mouth ulcers.

In a small number of cases, children may experience a brief illness, present with mixed neurological and respiratory symptoms and succumb rapidly to the disease.

How do you get HFMD?

HFMD virus is contagious and infection is spread from person to person by direct contact with nose and throat discharges, saliva, fluid from blisters, or the stool of infected persons. Infected persons are most contagious during the first week of the illness, but the period of communicability can last for several weeks (as the virus persists in stool).

HFMD is not transmitted to or from pets or other animals.

Who is at risk for HFMD?

Everyone who has not already been infected is at risk of infection, but not everyone who is infected becomes ill.

HFMD occurs mainly in children under 10 years old, but most commonly in children younger than 5 years of age. Younger children tend to have worse symptoms.

Children are more likely to be susceptible to infection and illness from these viruses, because they are less likely than adults to have antibodies and be immune from previous exposures to them. Most adults are immune, but cases in adolescents and adults are not unusual.

Can you be infected with HFMD more than once?

Yes, infection only results in immunity to one specific virus, other episodes may occur following infection with a different virus type.

What about pregnant women?

Ideally pregnant women should avoid close contact with anyone with HFMD and pay particular attention to measures that prevent transmission.

Enterovirus infections, including HFMD are common and pregnant women are frequently exposed to them. They may cause mild or no illness in the pregnant woman and currently there is no clear evidence that maternal enterovirus infection, including HFMD, is associated with any particular adverse outcomes of pregnancy (such as abortion, stillbirth or congenital defects). However, pregnant women may pass the virus to the baby if they are infected shortly before delivery or have symptoms at the time of delivery.

Most newborns infected with an enterovirus have mild illness, but rarely may develop an overwhelming infection of many organs, including liver and heart, and die from the infection. The risk of this severe illness is higher for newborns infected during the first two weeks of life.

How is HFMD treated?

Presently, there is no specific treatment available for HFMD. Patients should drink plenty of water and may require symptomatic treatment to reduce fever and pain from ulcers.

Can HFMD be prevented?

There are no specific antiviral drugs or vaccines available against non-polio enteroviruses causing HFMD. The risk of infection can be lowered by good, hygiene practices and prompt medical attention for children showing severe symptoms.

  • Preventive measures include:
    frequent handwashing with soap and water especially after touching any blister or sore, before preparing food and eating, before feeding young infants, after using the toilet and after changing diapers;
  • cleaning contaminated surfaces and soiled items (including toys) first with soap and water, and then disinfecting them using a dilute solution of chlorine-containing bleach;
  • avoiding close contact (kissing, hugging, sharing utensils, etc.) with children with HFMD may also help to reduce of the risk of infection;
  • keeping infants and sick children away from kindergarten, nursery, school or gatherings until they are well;
  • monitoring the sick child’s condition closely and seeking prompt medical attention if persistent high fever, decrease in alertness or deterioration in general condition occurs;
  • covering mouth and nose when sneezing and coughing;
  • disposing properly of used tissues and nappies into waste bins that close properly;
  • maintaining cleanliness of home, child care centre, kindergartens or schools.
Posted in Patient Information

Circumcision Care for the Newborn

What might I see after the circumcision?

Your baby may be restless for about 2 to 3 hours after the circumcision and may refuse a feeding. For the next day or two, you can comfort him by giving him extra cuddling, extra feeding (if he wants) and letting him suck whenever he wants.

While the site is healing, you might see crusted blood, or a white or crusted yellow-colored tissue around the circumcision site. This is a normal part of healing. It is not an infection and it will go away on its own. Do not try to rub it off. The head of the penis may be black and blue or in some cases, bright red. The shaft of the foreskin may swell and become black and blue as well. All of these are normal findings.


  1. Change your baby’s diaper and check the circumcision site at least every 4 hours.
  2. At each diaper change, gently wash the penis with warm water and pat dry. Do not rub. Do not use soaps, lotions or powder.
  3. For the first 24 hours, apply petroleum jelly to the penis and diaper at each diaper change. This will keep the diaper from sticking to the penis. Continue applying the jelly, until the redness of the penis goes away. If the gauze dressing or diaper is stuck when you are trying to remove it, do not pull it off. Soak the area with a warm, wet cloth, until it comes off easily.
  4. At each diaper change, check for bleeding at the circumcision site, blood on the diaper, or swelling of the penis.
  5. If the circumcision site is bleeding, put gentle pressure on the area with a clean cloth.

Reasons to call your doctor:

  • There is bleeding that does not stop with the gentle pressure. Keep gentle pressure on the area as long as the bleeding continues.
  • If there is a greenish or bad smelling discharge from the circumcision site or the penis looks red or swollen. There may be an infection in the circumcised area.
  • If your baby does not pass urine in 8 hours. Your baby should have at least 3 wet diapers in 24 hours.