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• Colds
• Earwax Problems
• Hay Fever ( Allergic Rhinitis )
• Lymph Node Infection In The Neck ( Cervical Adentis )
• Lymph Nodes Or Glands, Swollen
• Nosebleed
• Sinus Infection ( Sinusitis )
• Sore Throat ( Pharyngitis )
• Strep Throat Infection
• Swimmer's Ear ( Otitis Externa )

• Runny or stuffy nose.
• Usually associated with fever and sore throat.
• Sometimes associated with a cough, hoarseness, red eyes, and swollen lymph nodes in the neck.
• Also called an upper respiratory infection (URI).

1. Vasomotor rhinitis. Many children and adults have a profusely runny nose in the winter when they are breathing cold air. This usually clears within 15 minutes of coming indoors. It requires no treatment A cold or URI is a viral infection of the nose and throat. The cold viruses are spread from one person to another by hand contact, coughing, and sneezing - not by cold air or drafts. Since there are up to 200 cold viruses, most healthy children get at least six colds each year.

2. Chemical rhinitis. Chemical rhinitis is a dry stuffy nose from excessive and prolonged use of vasonconstrictor nose drops (more than 1 week). It will be better within a day or two of stopping the nose drops.

A cold or URL is a viral infection of the nosed and throat. The cold viruses are spread from one person to another by hand contact, coughing, and sneezing - not by cold air or drafts. Since there are up to 200 cold viruses, most healthy children get at least six colds each year.

EXPECTED COURSE:

Usually the fever lasts less than 3 days, and all nose and throat symptoms are gone by 1 week. A cough may last 2 to 3 weeks. The main things to watch for are secondary bacterial infections such as ear infections, yellow drainage from the eyes, sinus pressure or pain (often indicating a sinus infection ), or difficulty breathing (often caused by pneumonia). In young infants, a blocked nose can interfere so much with the ability to suck that dehydration can occur.

Not much can be done to affect how long a cold lasts. However, we can relieve many of the symptoms. Keep in mind that the treatment for a runny nose is quite different from the treatment for a stuffy nose.

Treatment for a Runny Nose with Profuse Discharge:

Suctioning or Blowing:
The best treatment is clearing the nose for a day or two. Sniffing and swallowing the secretions are probably better than blowing because blowing the nose can force the infection into the ears and sinuses. For younger babies, use a soft rubber suction bulb to remove the secretions gently. Nasal discharge is the nose's way of eliminating viruses. Medicine is not helpful unless your child has a nasal allergy.

Warm-Water or Saline Nose Drops and Suctioning (Nasal Washes):
Most stuffy noses are blocked by dry mucus. Blowing the nose or suction alone cannot remove most dry secretions. Nose drops of warm tap water are better than any medicine you can buy for loosening mucus. If you prefer normal saline nose drops, mix 1/2 level teaspoon of table salt in 8 ounces of water. Make up a fresh solution everyday and keep it in a clean bottle. Use a clean dropper to insert drops. Water can also be dripped or splashed in using a wet cotton ball.

• For the younger child who cannot blow her nose: Place three drops of warm water or saline in each nostril. After 1 minute use a soft rubber suction bulb to suck out the loosened mucus gently. To remove secretions from the back of the nose, you will need to seal off both nasal openings completely with the tip of the suction bulb and your fingers. You can get a suction bulb at your drug store.
  
• For the older child who can blow her nose: Use three drops as necessary in each nostril while your child is lying on her back on a bed with the head hanging over the side. Wait 1 minute for the water or saline to soften and loosen the dried mucus. Then have your child blow her nose. This can be repeated several times in a row for complete clearing of the nasal passages.
  
• Errors in using nose drops: The main errors are not putting in enough water or saline, not waiting long enough for secretions to loosen up, and not repeating the procedure until the breathing is easy. The front of the nose can look open while the back of the nose is all gummed up with dried mucus. Obviously, putting in nose drops without suctioning or blowing the nose afterward is of little value.
  
• Use nasal washes at least 4 times per day or whenever your child can't breather through the nose.

• Fever: Use acetaminophen or ibuprofen for aches or mild fever
  (over 102 degrees F).
• Sore throat: Use hard candies for children over 4 years old and warm chicken broth for children over 1 year old.
• Cough: Use cough drops for children over 4 years old and corn syrup for younger children. Run a humidifier.
• Red eyes: Rinse frequently with wet cotton balls.
• Poor appetite: Encourage fluids of the child's choice.

IMMEDIATELY if :

• Breathing becomes difficult and no better after you clear the nose.
• Your child starts acting very sick.

Within 24 hours if :

• The nasal discharge lasts more than 10 days.
• A fever lasts more than 3 days.
• The eyes develop a yellow discharge .
• There is any suggestion of an earache or sinus pain.
• You have other questions or concerns.

Everyone has earwax. The color can normally vary from light yellow to dark brown. Earwax is not dirty or abnormal; in fact it contains natural chemicals that can kill germs. It also keep dust off the eardrum and protects the lining of the ear canal. The ear canal is designed to clean itself. Earwax is produced in the outer third of the ear canal. Earwax moves outward naturally during chewing and the normal growth of the ear canal's lining. Every day or two, you may notice a little earwax at the opening of the ear canal. If you do nothing, this earwax will fall out on its own.
Unless there is a blockage, it is best to leave earwax alone. If you push the earwax back into the ear, as usually happens when you try to remove the wax from the inside of the ear canal, it becomes more difficult for the wax to come out naturally.
Proceed with the guideline if earwax is completely blocking one of the ear canals and your child can not hear on that side. If the hearing seems normal on that side, that means the blockage is only partial and you can leave it alone.

Flushing Out Packed Earwax :

• If the wax is hard, soften it first. Mineral oil or baby oil is a good earwax softener. Put in 5 drops. Leave the oil in for 1 to 2 hours.
• When the wax is soft, wash it out with a rubber ear syringe or Water-Pik at the lowest setting. The water must be at body temperature to prevent dizziness. If the earwax does not seem to be coming out, flush it with the head tilted so that the involved ear is down. Gravity will help the water wash it out ( the waterfall effect ).
• Flush out the ear several times, until the water that comes out is clear and the ear canal seems open when you look in with a light.
  Caution: Never put water in your child's ear if there is any chance the eardrum has a hole in it or if your child has ventilation tubes.

Prevention
Nothing should be put inside the ear canal to try to hurry the earwax process along. Using cotton swabs just ends up packing the wax deeper. Earwax does not need any help getting out. Cotton swabs also carry the risk of damaging your child's eardrum if they turn their head suddenly. Tell everyone in your family that the most common cause of earwax buildup is putting cotton swabs into the ear canal. Another common cause is wearing earplugs of any type.

Removing Visible Earwax
In general, leave it alone. On special occasions if earwax is right at the opening of the ear canal and you feel compelled to remove it for cosmetic reasons, flick it out with a bent paper clip or little foiled piece of paper.

During regular hours if :

• Flushing out the ear canal does not return the hearing to normal
• Any discharge other than earwax comes from the ear canal
• Blockage from earwax recurs after you stop using cotton swabs
• You have other questions or concerns

• There is a clear nasal discharge with sneezing, sniffing and nasal itching
• Symptoms occur during pollen seasons
• Similar symptoms occurred during the same month of the previous year
• Previous confirmation of this diagnosis by a physician is helpful
• Itchy, watery eyes ( eye allergies ) are commonly associated
• Sinus or ear congestion is sometimes associated

Hay fever is an allergic reaction of the nose ( and sinuses ) to an inhaled substance. This allergic sensitivity is often inherited. During late April and May the most common offending pollen is from trees. From late May to mid-July, the offending pollen is usually grass. From late August to the first frost, the leading cause of hay fever is ragweed pollen. Although the inhaled substance is usually a pollen, it can also be animal dander or other agents that your child is allergic to. Hay fever is the most common allergy; more than 15% of the population have it.

This is a chronic condition that will probably recur every year, perhaps for a lifetime. Therefore it is important to learn how to control it.

Oral Antihistamine Medicines
The best drug for hay fever is an antihistamine. It will relieve nose and eye symptoms.
( There are many effective nonprescription antihistamines such as chlorpheniramine and brompheniremine. )
Symptoms clear up faster if antihistamines are given at the first sign of sneezing or sniffing. For children with occasional symptoms, antihistamines can be taken on days when symptoms are present or expected. For children with daily symptoms the best control is attained if antihistamines are taken continuously ( several times each day ) throughout the pollen season.
The main side effect of antihistamines is drowsiness. If your child become drowsy, switch to a combination product that contains an antihistamine with a decongestant ( such as pseudoephedrine or phenylpropanolamine ). If your child remains drowsy, continue the drug, but temporarily decrease the dosage. Tolerance of the regular dosage should occur
1 to 2 weeks. Newer prescription antihistamines cause much less drowsiness and are approved by the Food and Drug Administration for use in children over age 6.

Nasal Sprays
Severe hay fever can now usually be controlled by new cromolyn or steroid nasal sprays rather than allergy shots. Since these sprays must be used when the nose is not dripping, antihistamines must be given first to stop the drainage.
Nasal sprays do not help eye symptoms. Therefore they are usually used with oral antihistamines.

Pollen Remove to Decrease Symptoms of Hay Fever
Pollen tends to collect on the exposed body surfaces and especially in the hair. Shower your child and wash their hair every night before going to bed. Avoid handling pets that have been outside and are probably covered with pollen.

Prevention of Hay Fever Symptoms
Your child's exposure to pollen can be reduced by not going on drives in the country, not sitting by an open car window on necessary drives, not being near someone cutting the grass during pollen season, staying indoors when it is windy or the pollen count is especially high and closing the windows that face the prevailing winds. If your child's hay fever is especially bad and you do not have air-conditioning, you may wish to take them to an air-conditioned store or theater for a few hours. Avoid feather pillows, pets, farms, stables and tobacco smoke if any of them seem to bring on symptoms of nasal allergy.

Eye Allergies Associated with Hay Fever
If your child also has itchy watery eyes, wash their face and eyelids to remove pollen. Then apply a cold compress to their eyelids for 10 minutes. An oral antihistamine will usually bring the eye symptoms under control. If not, instill 2 drops of long-acting vasoconstrictor eye drops ( a nonprescription item ) every 8 to 12 hours for a few days. Ask your pharmacist for help in choosing a reliable product.

During regular hours if

• Symptoms are not controlled in 2 days with antihistamines
• Your child develops sinus pain or pressure
• You have other questions or concerns

• A bacterial infection of a lymph node in the neck
• Abrupt onset of a tender, firm mass on one side of the neck
• Usually located below the angle of the jaw ( the tonsillar node )
• Large node, usually over 1 inch across ( can be size of walnut or egg )
• Sometimes the overlaying skin is pink
• Fever is usually present

Lymph nodes are part of our immune system, which helps fight infections. Although viral infections or even a " strep throat " infection usually cause several nodes on both sides of the neck to become swollen, when bacteria actually invade a lymph node, usually only one lymph node is involved. Bacteria present in the nose, tonsils, or adenoids can spread to a lymph node and cause an infection. Also, cavities in the teeth can become infected and the bacteria may then spread to a lymph node under the jaw. The infected lymph node then becomes enlarged, warm and tender.

Most lymph node infections heal well with oral antibiotics, but sometimes a lymph node needs to be opened and drained. Lymph nodes that need to be drained become soft in the middle or come to a head ( form a large pimple ).

Oral Antibiotics
Antibiotics are used to treat the bacterial infection.

Local Heat
Apply a heating pad or warm, moist washcloth to the lymph node for 20 minutes, three times a day.This will help deliver the antibiotic to the infection and bring the infection to a head.

Fever and Pain Relief
Give your child acetaminophen or ibuprofen if they develop a fever over 102° F ( 39° C ) or has pain from the neck swelling.

Fluids
Make sure your child is drinking plenty of fluids.

Follow-up Visits
All children with lymph node infections should see their doctor at the end of the antibiotic treatment to make sure the lymph node is no longer infected. It may take 1 or 2 months for the node to return to normal size. However, the node will not ever completely disappear.

IMMEDIATLEY IF :

• Your child has any difficulty swallowing liquids or breathing
• The lymph node is rapidly enlarging even though your child is taking antibiotics
• The fever is not gone 48 hours after starting an antibiotic
• Your child is acting very sick

During regular hours if :

• The lymph node becomes soft in the middle
• The swelling is enlarging after 48 hours of antibiotics and your child is not getting any better
• You have other questions or concerns

• Normal non infected nodes are less than 1/2 inch across ( often the size of a pea or baked bean ).
• Nodes infected by a virus are usually 1/2 to 1 inch across. Slight enlargement and mild tenderness mean the lymph node is fighting infection and succeeding.
• Nodes severely infected with bacteria are usually more than 1 inch across and tender to the touch. If they are over 2 inches across or the overlaying skin is pink, the nodes are not controlling the infection and may contain pus.

Lymph glands stop the spread of infection and protect the bloodstream from invasion
( blood poisoning ). They enlarge with cuts, scrapes, scratches, splinters, burns, insect bites, rashes, impetigo or any break in the skin. Try to locate and identify the cause of the the swollen gland by remembering that the groin nodes drain lymph from the legs and lower abdomen, the armpit nodes drain the arms and upper chest, the back-of-the-neck nodes drain the scalp, and the front-of-the-neck nodes drain the lower face, nose and throat. Most enlarged nodes in the neck are due to colds or throat infections. A disease such as chickenpox can cause all nodes to swell.

With the usual viral infections or skin infections, nodes can quickly double in size over 2 or 3 days and then slowly return to normal size over 2 to 4 weeks. However, you can still see and feel nodes in most normal children, especially in the neck and groin. Do not check for lymph nodes because you can always find some normal ones.

Facts About Nodes
The body contains more than 500 lymph nodes. They can always be felt in the neck and the groin. Normal nodes are largest at age 10 to 12. At this age they can be twice the normal adult size. Minor skin infections and irritations can cause lymph nodes to double in size. It may take 1 month for them to return to normal size. However, they will not completely disappear.

Treat the Cause of the Swelling
In general, no treatment is necessary for swollen nodes associated with viral infections
( e.g., upper respiratory infections ). For bacterial infections, the underlying disease that is causing the node to react needs to be treated. For example, remove the splinter, treat the ingrown toenail, or have a dentist treat the tooth abscess. Many children with swollen lymph nodes due to a skin infection also require an oral antibiotic.
For pain or fever above 102° F ( 38.9° C ), give acetaminophen or ibuprofen in the appropriate amount.

Do not Squeeze the Nodes
Poking and squeezing lymph nodes may keep them from shrinking back to normal size. Remember that it may take a month for the nodes to return to normal, and they will not completely disappear. There is no need to check them more than once a month. If your child fidgets with them, discourage it if they are old enough to cooperate.

IMMEDIATLEY IF :

• The node swells to more than 2 inches across
• The overlying skin becomes red
• Your child is acting very sick

During regular hours if :

• The node swells to 1 to 2 inches across
• Your child also develops a sore throat
• A fever persists more than 3 days
• You have other questions or concerns

• nose picking
• injury
• dry air
• asprin

Nosebleeds are scary but not usually serious ( bad ).

• Your child must rest.
• The child should not lie flat.
• Have your child keep the head up for 2 days.
• Keep the head on more pillows for sleep.
• Make the home air more moist ( wet ). Use a humidifier.
  

DO NOT give asprin.

Teach an older child NOT to pick or blow the nose.

Put Vaseline® in the nose 2 times a day. Do this for 2 days. ( Use a Q-tip® . )
DO NOT do this if your child fights you.

If the doctor says to, use medicine like Afrin® for a child 6 years old or more. Buy it at the drug store. Use the dose on the lable. Use it for 3 days only.

If the nose bleeds, pinch the soft part of your child's nose. Do this for 20 minutes.

• fever of 101 °F or more
• a skin bruise ( with no cause )
• persistent nosebleeds

DANGER! Come back now for :

• bleeding that lasts longer than 20 minutes
• feeling faint or dizzy
• trouble breathing ( by the mouth )

A sinus infection is a bacterial infection of one of the seven sinuses that normally drain into the nose. Sinus congestion can occur without an infection if one of the sinus openings becomes blocked from a cold or hay fever. As bacteria multiply within the sinuses, pain and pressure occur above the eyebrow, behind the eye, or over the cheekbone. Other symptoms can include a profuse yellow nasal discharge, postnasal drip, a blocked nose, fever, and bad breath. Until recent years, we did not recognize that a chronic cough can be caused by a sinus infection. Swallowing sinus secretions is normal and harmless but may lead to some nausea. Most sinus infections can be diagnosed without sinus x-ray studies. The following treatment should reduce pain and fever within 48 hours or less.

This medicine will kill bacteria that are causing the sinus infection. Try not to forget any of the doses. If your child goes to school or to a babysitter, arrange for someone to give the afternoon dose. If the medicine is a liquid, use a measuring spoon so you give the right amount. Also, an antibiotic should not be saved from one illness to the next because it loses its strength. Even though your child will feel better in a few days, give all the medicine to prevent the infection from flaring up.

Nasal Washes
Use warm water or saline nose drops followed by suction or nose blowing to wash dried mucus or pus out of the nose. Do nasal washes at least four times a day or whenever your child can not breathe through the nose. If the air in your home is dry, run a humidifier.

Decongestant Nose Drops or Sprays
To drain the sinuses, use a generic, long-acting vasoconstrictor nose drop or spray ( such as oxymetazoline ), which is nonprescription. The usual dose for adolescents is 2 drops or sprays per nostril twice daily. For younger children use 1 drop or spray each day. Use the medicine routinely for the first 2 or 3 days of treatment. Thereafter do not use the spray or nose drops unless the sinus congestion or pain recurs. Stop the drops or spray after 5 days to prevent rebound swelling.

Pain Relief Medicines
Acetaminophen or ibuprofen may be given for a few days for sinus pain or any fever over 102° F ( 38.9° C ).

Oral Antihistamines
If your child also has hay fever, give their allergy medicine. Otherwise, avoid antihistamines because they can slow down the movement of secretions out of the sinuses.

Contagiousness
Sinus infections are not contagious. Your child can return to school or day care when they are feeling better and the fever has gone.

IMMEDIATLEY IF :

• Redness or swelling occurs on the cheek, eyelid or forehead
• Your child is acting very sick

Within 24 hours if :

• The fever or pain is not gone after your child has taken the antibiotics for 48hours
• You have other questions or concerns

• The child complains of a sore throat
• In children too young to talk, a sore throat may be suspected if they refuse to eat or begin to cry during feedings
• When examined with a light, the throat is bright red

Most sore throats are caused by viruses and are part of a cold. About 10% of sore throats are due to the strep bacteria. A throat culture or rapid strep test is the only way to distinguish strep pharyngitis from viral pharyngitis. Without treatment, a strep throat can have some rare but serious complications. Tonsillitis ( temporary swelling and redness of the tonsils ) is usually present with any throat infection, viral or bacterial. The presence of tonsillitis does not have any special meaning.
Children who sleep with their mouths open often wake in the morning with a dry mouth and sore throat. It clears within an hour of having something to drink. Use a humidifier to help prevent this problem. Children with a postnasal drip from draining sinuses often have a sore throat from frequent throat cleaning.

Sore throats with viral illnesses usually last 3 or 4 days. Strep throat responds well to penicillin. After taking the medication for 24 hours, your child is no longer contagious and can return to day care or school if the fever is gone and they are feeling better.

Local Pain Relief
Children over 8 years of age can gargle warm salt water ( 1/4 teaspoon of salt per glass ). Children over 4 years of age can suck on hard candy ( butterscotch seems to be a soothing flavor ) or lollipops as often as necessary. Children over age 1 can sip warm chicken broth or warm apple juice.

Soft Diet
Swollen tonsils can make some foods hard to swallow. Provide your child with a soft diet for a few days if they prefer it.

Fever
Acetaminophen or ibuprofen may be given for a few days if your child has a fever over 102° F ( 38.9° C ) or a great deal of throat discomfort.

• Avoid expensive throat sprays or throat lozenges. Not only are they no more effective than hard candy, but they also may contain an ingredient ( benzocaine ) that may cause a drug reaction.
• Avoid using leftover antibiotics from siblings or friends. These should be thrown out because they deteriorate faster than other drugs. Unfortunately, antibiotics only help strep throat. They have no effect on viruses, and they can cause harm. They also make it difficult to find out what is wrong if your child becomes sicker.

IMMEDIATLEY IF :

• Your child is drooling, spitting or having great difficulty in swallowing
• Breathing becomes difficult
• Your child is acting very sick

During regular hours if :

• To make an appointment for a throat culture for any other child with a sore throat present for more than 24 hours.
  ( Exception: If the sore throat is very mild and the main symptom is croup, hoarseness, or a cough, a throat culture is probably not needed. Throat cultures are recommended for all other sore throats because a resurgence of acute rheumatic fever began in 1987. Rheumatic fever is a complication of strep infections that can lead to permanent damage to the valves of the heart. )
• A fever persists more than 3 days
• You have other questions or concerns

Your child has a strep throat infection if diagnosis is confirmed by a throat culture or rapid strep test. The treatment of strep throats can prevent some rare but serious complications, namely, rheumatic fever ( heart disease ) or glomerulonephritis ( kidney disease ).
In addition, treatment usually eliminates the fever and much of the sore throat within 24 hrs.

Antibiotics:

• Antibiotics will be prescribed after the diagnosis of Strep has been confirmed by a strep test.
• Try not to forget any doses.
• If the medicine is a liquid, store the antibiotics in the refrigerator and use a measuring spoon to be sure that you give the right amount.
• Give the medicine until all the pills are gone or the bottle is empty. Even though your child will feel better in a few days, give the antibiotic for 10 days to keep the strep throat from flaring up.
• A long-acting penicillin ( Bicillin ) injection can be given if your child refuses oral medicines or if it will be impossible for you to give the oral medicine regularly.

Local Pain Relief :
Children over age 1 can sip warm chicken broth or warm apple juice. Children over age 4 can suck on hard candy or lollipops. Children over 8 can gargle with warm salt water ( 1/4 teaspoon of salt per glass ).

Soft Diet :
Since swollen tonsils can make some foods hard to swallow, provide your child with soft diet for a few days.

Fever :
Acetaminophen or ibuprofen may be given if your child has a fever over 102 °F ( 39 °C ) or a great deal of throat discomfort.

Contagiousness :
Your child is no longer contagious after he or she has taken the antibiotic for 24 hours. Therefore your child can return to school after 1 day if the fever is gone.

Throat Cultures for the Family :
Strep throat can spread to others in the family. Any child or adult who lives in your home and has a fever, sore throat, runny nose, headache, vomiting, or sores; does not want to eat; or develops these symptoms in the next 5 days should be brought in for a throat culture. In most homes we need to culture only those who are sick. We will call you if any of these cultures are positive for strep infection.
( Exception : In families where relatives have had rheumatic fever or frequent strep infections, everyone should come in for a throat culture. )

Follow-up Visits :
Repeat cultures are unnecessary if your child receives all of the antibiotic.

IMMEDIATLEY IF :

• Your child develops drooling
• Your child develops great difficulty with swallowing
• Your child is acting very sick

Within 24 hours if :

• The fever lasts over 48 hours after starting an antibiotic
• You have other questions or concerns

• Itchy and painful ear canals
• Currently engaged in swimming
• Pain when the outer ear is moved up and down
• Pain when the tab of the outer ear overlaying the ear canal is pushed in
• A feeling that the ear is plugged up
• Slight, clear discharge initially; without treatment, it becomes yellowish

Antibiotic-Steroid Ear Drops :
Run the ear drops down the side of the ear canal's opening so that air is not trapped under them.

Soft Diet :
Swollen tonsils can make some foods hard to swallow. Provide your child with a soft diet for a few days if they prefer it.

Fever :
Acetaminophen or ibuprofen may be given for a few days if your child has a fever over 102° F ( 38.9° C ) or a great deal of throat discomfort.

• Avoid expensive throat sprays or throat lozenges. Not only are they no more effective than hard candy, but they also may contain an ingredient ( benzocaine ) that may cause a drug reaction.
• Avoid using leftover antibiotics from siblings or friends. These should be thrown out because they deteriorate faster than other drugs. Unfortunately, antibiotics only help strep throat. They have no effect on viruses, and they can cause harm. They also make it difficult to find out what is wrong if your child becomes sicker.

IMMEDIATLEY IF :

• Your child is drooling, spitting or having great difficulty in swallowing
• Breathing becomes difficult
• Your child is acting very sick

During regular hours if :

• To make an appointment for a throat culture for any other child with a sore throat present for more than 24 hours.
  ( Exception: If the sore throat is very mild and the main symptom is croup, hoarseness, or a cough, a throat culture is probably not needed. Throat cultures are recommended for all other sore throats because a resurgence of acute rheumatic fever began in 1987. Rheumatic fever is a complication of strep infections that can lead to permanent damage to the valves of the heart. )
• A fever persists more than 3 days
• You have other questions or concerns