Valle Verde Pediatrics Blog

Posts for: November, 2012

November 07, 2012
Category: Uncategorized
Tags: Untagged


Concussions in Children

Nathan Rendler, MD

Valle Verde Pediatrics


An increasing concern seen in our office is the growing number of concussions in sports. By definition, the concussion is considered a type of mild traumatic brain injury caused by a bump, blow or jolt to the head that may or may not be associated with a loss of consciousness. At times, the concussion may also occur from a body blow that causes the head to move rapidly back and forth. The athlete often presents with headaches, dizziness, light sensitivity, weakness, lethargy and abnormal mental function, including difficulty with concentration. Unfortunately, even what appears to be a mild injury may be serious, and needs careful evaluation and follow-up. Oftentimes, since the athlete wants to return to competition as soon as possible, he/she minimize the symptoms so that the history may be unreliable, and may not provide enough of a guide as to when it safe to return to play.

Over 300,000 sports-related concussions occur each year at the high school level or below, with 60% of these injuries involving high school football players. Recently, nearly 3,000 former players and players’ family members are in the news for suing the National Football League, claiming the league knew about the dangers of head trauma and concussions and failed to disclose the risks and appropriately manage the consequences. A diagnostic challenge is that concussions are not specifically seen on x-ray, MRI or CT scan, and these tests are used primarily to rule out skull fracture or an intracranial bleed. Therefore, it is recommended that any concerning signs and symptoms be evaluated promptly by a physician.  

In our office, the physician first performs a careful neurological exam to assess the extent of the injury. Complete rest for at least 48 hours after the injury is usually very helpful and may help with an overall quicker recovery. We also work closely with our clinical psychologist, Dr. Jeff Daly, who uses the most-widely accepted concussion evaluation system, called ImPACT testing. It is a standard test that has been used by many professional sport leagues, as well as amateur organizations in college, high school and even elementary schools.

ImPACT testing takes about 30 minutes to complete and measures multiple aspects of cognitive function in the athlete. It is a scientifically validated computerized evaluation system that looks at attention span, working memory, sustained and selective attention time, response variability, non-verbal problem solving and reaction time. It is most helpful when it is administered as a baseline before the concussion occurs, but it remains helpful if the results are abnormal since it may be re-administered at a later time to help determine the extent of injury and the steps needs for recovery. This helps us to improve our ability to manage the recovery process and provide a better assessment for the athlete, parents and coaches as to when it is safe to return to play.

We look forward to helping our patients recover from concussions and focus on their safety and their long term well-being. As always, prevention is the best medicine. Some helpful tips are to teach and practice safe playing techniques, and to encourage athletes to follow the rules of play and to practice good sportsmanship and avoid unnecessary harmful contact. Properly fitting protective equipment is essential and should be well maintained, fit properly and be worn consistently and correctly.

We encourage parents, coaches and athletes to work together as a team to help increase concussion awareness, leading to prompt treatment and improved safe recovery. Please contact us with any concerns you may have. We will schedule an appointment for you quickly and look forward to helping you.

By [email protected]
November 07, 2012
Category: Uncategorized
Tags: Untagged






Hives, or urticaria, are localized pink swellings on the skin that are produced by histamine, a chemical released into the skin from the mast cells that lie along our blood vessels.  They are usually itchy, and may occasionally burn or sting. They vary in size and are quite common in children. Up to 10-20 percent of the population will have at least one episode in their lifetime, and fortunately, most resolve quickly, but some may last for days, weeks or even longer. Occasionally, they may be severe enough to require an emergency visit for associated problems with severe facial swelling with trouble swallowing, wheezing and trouble breathing, severe abdominal pain or severe joint pain/swelling.

By definition, acute hives last less than 6 weeks, and oftentimes, a trigger can be identified and eliminated. Common foods like milk, berries, eggs, tomatoes, shellfish, nuts and chocolate may cause hives.

Any of the over the counter medications can cause hives, and a common cause that pediatricians see involves an allergic reaction to antibiotics, like penicillin and sulfa drugs. We also see hives related to bee stings, viral upper respiratory tract infections, hepatitis and occasionally from bacterial and fungal infections.

Hives that last longer than 6 weeks are considered chronic and are much rarer. It is usually much harder to identify the cause and a referral to a dermatologist or allergist may be needed, with additional blood tests or skin biopsy for diagnosis.

Other physical causes may produce hives, including sensitivity to cold, heat, exercise and pressure. Some healthy patients may even develop hives from firm stroking or scratching of the skin, and though recurrent, these causes tend to be self-limited.

Most patients respond to a short course of daily non-sedating antihistamines, but occasionally a longer course of treatment combining the use of two antihistamines may be needed, as well as the use of steroids, or even an injection of epinephrine in more severe cases. We counsel our patients that the best treatment remains working together to identify an underlying cause and eliminating it whenever possible.


Adapted from the educational pamphlet: Urticaria-Hives

A 2005 publication from the American Academy of Dermatology






Atopic dermatitis is the most common type of dry, itchy skin known as eczema. It affects 10-20 percent of kids and from 1-3 percent of adults.

Patients may scratch uncontrollably leading to redness, swelling and cracking of the skin, with crusting and scaling, and even “weeping” of clear fluid. Patches of the affected skin may be widespread and the constant scratching can lead to skin damage, secondary infection and loss of sleep.

In kids, we often see this condition develop in the first year of life, and it develops in 80 percent of those affected before age 5. In infants, itchy patches are often noted on the scalp, forehead, and cheeks. Many of these younger children get better with time, but it may be a clue for the “allergic march”, with a risk for the development of allergy and asthma. Therefore, we carefully monitor for any associated wheezing and persistent congestion, and at times, test for associated food allergies, including milk products, nuts and shellfish. Controlling asthma symptoms and environmental allergies and hay fever will also help clear up the skin. If the condition doesn’t resolve early on, a childhood phase develops with skin involvement that usually appears on the inside of the elbows or the back of the knees. We often see this in older children and teens, and they may also show patches on the face, hands, feet, wrists and ankles, and neck and upper chest. With time, the patches may become discolored, scaly and thick, as well as emotionally distressing. Fortunately, the itchy skin tends to improve with time, but it may be a lifelong condition for those severely affected.  For example, hand eczema is an especially bothersome form of dry skin that can become chronic and interfere with everyday activities. The use of prescription ointments and creams with frequent use of moisturizers is helpful, but it is especially important to avoid harsh soaps and irritating cleansers, and even use gloves for protection. This presents a good example of the effectiveness of combining of good medical treatment with environmental control.

While the treatment and control of atopic dermatitis may be challenging, it is very rewarding to see patients improve when we educate them and their families about controlling the condition. I recently attended a medical conference with lectures from a noted dermatologist who taught us that the use of bleach scrubs for certain challenging cases is helpful, and I’ve had some good success with this treatment. By working together with patients and their families, we look to identify and avoid allergen and environmental triggers, and develop an effective long-term treatment and prevention plan, including the use of approved corticosteroid creams and ointments, breaking the itch cycle with non-sedating antihistamines, and the use of aggressive moisturization. We can make a difference and stop the “itch cycle” in our patients with eczema.


Adapted from the pamphlet:

Eczema/Atopic Dermatitis, a 2009 publication of the American Academy of Dermatology.







Since I started practice, I have shared a special interest in helping patients with attention deficit and learning problems.  It is one of the most common concerns that I evaluate  and treat daily, and it is especially gratifying for me to treat these patients  and watch them grow and succeed in the long term, from the early school age years and all the way through the college years. The parent usually brings in the child with a history of worsening attention problems, hyperactive and impulsive behavior, and poor social interactions with his/her peers and other family members. While most kids present in early school age, I also see teens come in with similar concerns that have not been addressed previously.

Oftentimes, the child is easily distracted, has problems focusing and paying attention, is forgetful, and has trouble listening and following directions both at home and at school. Along with the attention problems, parents are concerned about hyperactivity, where the child has trouble sitting through a class and has poor self-control. Impulsivity is also very common and is marked by trouble waiting or taking turns, frequently interrupting others and getting into trouble at school. The combination of these behaviors significantly affect academic performance and the way teachers, parents and peers view and interact with the child, and may lead to school failure and poor performance in day to day life activities. It may also lead to feelings of poor self-esteem that makes the problems even worse for the patient and family.



Conservative estimates suggest that at least  3-7% of school-aged kids have ADHD. Studies now show that up to 80% of kids with ADHD will still have symptoms as teens and well into adulthood. Fortunately, we can help them adjust and succeed for the long term.



While no specific cause has been identified, research suggests that an imbalance  in the neurotransmitters (chemical messengers) in the brain, specifically dopamine and norepinephrine, contribute to the symptoms of ADHD. Please see the ADHD Helpful Diagram that is included. One of the challenges  we face is that no single blood test or imaging study, such as an MRI or CT scan of the brain, is diagnostic.

We do  know that ADHD runs in families, and immediate family members like parents and siblings may have up to a 3 time greater risk of having it than other non-related strangers. Therefore, while helping the child, we may also have an opportunity to help another affected family member undergo evaluation and treatment.

Researchers have also learned that many factors have not been proven to cause ADHD. These include poor parenting, bad teachers, poor schooling, family problems, food allergies, too much sugar, and even too much television. Nevertheless, it’s always important to address parental concerns about these factors and take the time to address these particular concerns.



A combination of helpful information leads to the diagnosis of ADHD.  First, a thorough medical history and physical exam is important to rule out any organic causes, including hearing problems and metabolic disorders.  Our practice combines the history and physical with an easy to use ADHD checklist, based on  well-established criteria  from the  most current  edition of the  Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association, as well as observation rating scales from parents, teachers and other objective observers.  These helpful handouts are included for your review.  As needed, we  also have an experienced psychologist, Dr.  Jeff Daly, who can perform psycho-educational testing to rule out  any associated learning problems, since up to  20-30% of kids with ADHD have associated learning disorders. We also assess for any associated mood disorders, including anxiety, depression, oppositional defiant disorder and conduct disorders. While we perform the evaluation, we provide the parents and caregivers with useful educational resources that make them more comfortable with understanding the disorder and options for treatment. These resources are also included for your review.



After careful assessment and diagnosis, I meet with the parents and patient and design a personalized and total treatment plan. Such a plan includes behavior management, counseling and support, and medical treatment. Careful and consistent follow-up with outcome progress reports are especially important for assessing the success of treatment, and making any needed adjustments. I’ve also included this outcome progress report for your review.

The American Academy of Pediatrics has a very useful Tips Sheet for Parents of Children with ADHD which I have also included. It can be used to encourage improvement in behavior through positive reinforcement and addresses solutions to the common everyday problems that parents face, from getting ready for school, to dealing with homework challenges, as well as  helping deal with potential medication side effects. Dr. Erikah Holtermann, our behavioral psychologist, is always willing to meet with parents and patients and help teach  parenting and social skills that help the patient learn to control anger and impulsivity, improve communication skills and learn problem solving skills. As needed, we also work closely with the schools to encourage additional help through specialized programs, like a 504 plan, special education classes, AVID or an individualized educational plan (IEP).

Over the years , we’ve enjoyed helping many of our patients succeed in school and in their personal lives, protecting their self-esteem and watching them thrive as they learn to successfully  deal with  their attention problems and learning challenges.

We’ll be happy to share contact information for families of patients who have benefited from our treatment plan, and look forward to helping you with any specific concerns. Working together, we look forward to helping your child succeed and thrive, socially and academically.

Please note, as stated above, I have included several of the important resources that I use to help evaluate and treat ADHD. These are on the website page and include the following:

  • The Diagnostic Checklist for ADHD
  • ADHD Diagram and Pathophysiology
  • ADHD Resources
  • SNAP Rating Scales
  • Tips for Parents of Children with ADHD






Concussion Blog

By Dr. Jeff Daly, Clinical psychologist

So what exactly is a concussion? A concussion is a type of brain injury caused by a bump, blow, or jolt to the head that can change the way your brain normally works.  Concussions can also occur from a blow to the body that causes the head to move rapidly back and forth.  Even a “ding,”  “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.

I have evaluated many concussed athletes, most recently a high school football athlete who was knocked unconscious during practice. After getting his “bell rung,” he experienced balance problems, nausea, irritability, dizziness, light sensitivity, and difficulty concentrating. The coach referred the student to me for neuropsychological evaluation to determine the extent of his injuries and to help determine when he can return to play. Medically he looked fine. Imaging by MRI was normal, which is common with concussions. I put him through a series of tests and found deficits in memory, processing speed, and impulse control, areas often affected by concussion. My question after testing him was, “did these deficits exist prior to concussion?” This is always a difficult question to answer.  Fortunately, we have the technology to measure an athlete’s cognitive ability before and after a suspected concussion, which is crucial towards understanding the effects of concussion on the brain and when it is safe to return to play.  

I have adopted ImPACT neuropsychological testing, which is testing an athlete before potential injury. This way, should the athlete suffer a concussion or other brain injury, I can retest them to determine the extent of the injury. ImPACT testing provides baseline information of neurocognitive ability in areas quite sensitive to concussions. This technology is adopted by the NFL, NHL, MLB, MLS, NBA, professional auto racing, professional rugby, Olympic sports, and even at the college and high school level. I advise anyone participating in contact sports to receive a baseline neurocognitive evaluation, because if you receive a concussion, this information is essential for determining the extent of your injuries as well as when it is safe  to return to play.

Here at Valle Verde Pediatrics, we have a dual approach to concussion prevention and management.  Our physicians provide the necessary medical evaluation and treatments of concussions and I provide the neuropsychological testing and examination, all of which ensure that your child receives the best and most comprehensive care. 

300,000 sports-related mild traumatic brain injuries occur each year; at the high school level or below, with high school football players acquiring 60% of concussions.  Because of this, it is recommended that any person participating in contact sports receive a baseline neurocognitive evaluation.  Please feel free to contact me directly should you have any questions or would like to schedule an appt. for ImPACT testing.  I look forward to meeting and helping you.

Office: 858-376-0230      Twitter:@Drjeffdaly