A child has a brown coating on his tongue: how and why it forms. Causes of black tongue in a child

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A healthy child's tongue is pink. But it happens that a coating of different shades forms on the tongue. This may indicate serious illnesses in the body. If a child has a white coating in the morning, it can be removed with a toothbrush, then there is no need to worry.

You just need to brush your teeth and tongue regularly. But it happens that the thickness of the plaque increases, the structure and color change. In such cases, you should pay attention to the baby’s health, and if plaque cannot be removed with a toothbrush, contact your pediatrician.

The accumulation of bacteria is a factor in the appearance of plaque; the thickness and color of the plaque depends on their type and quantity. They usually accumulate at the root of the tongue. In autumn and winter, the coating is often light; in summer it thickens and becomes yellowish due to a lack of vitamins. You should consult your doctor if yellow, brown, or black plaque appears.

Causes

Possible causes of blackened plaque on a child’s tongue:

  1. Eating coloring foods. It is worth remembering whether the child has eaten black berries, colored candies, or activated carbon. Perhaps an ampoule from a pen or a felt-tip pen has leaked. In this case, the child will most likely have dark spots on his hands and clothes. You need to try to clean off the plaque with a brush, in this case it will come off without special effort in several days.
  2. If the child took liquid iron supplements. In this case, the feces also turn black. The tongue will return to its normal color when the course of treatment is canceled or completed.
  3. After treatment with antibiotics. Molds multiply due to the lack of competition in the form of bacteria. In such cases, the plaque goes away within 2 weeks, and the doctor prescribes antifungal and immune-strengthening drugs.
  4. For acute respiratory viral infections, accompanied by a prolonged increase in temperature, for example, with sore throat. No special treatment is prescribed in these cases, but you need to spend more time on oral hygiene. It is also good to rinse your mouth with infusions of calendula, sage, and chamomile. Do inhalations with fir oil. Eat gentle food to avoid irritation of the throat and tongue - pureed soups, broths.
  5. When the body is dehydrated, the acidity of the blood may increase. First of all, you need to replenish the volume of lost fluid and be sure to consult a doctor.
  6. For gastrointestinal pathologies, disorders of the gallbladder and pancreas, cholestasis, gastritis, enteritis, colitis. Usually accompanied by bitterness in the mouth after eating.
  7. Hypovitaminosis provokes the appearance of black spots on the tongue. Most often due to a lack of vitamins B and PP. They are usually treated with the prescription of complex vitamins and nutritional adjustments.
  8. Cholera– acute infectious intestinal disease. Occurs due to violation of hygiene rules and insufficient heat treatment of products. It manifests itself as loose, profuse stools, maybe more than 10 times a day, and repeated fountain vomiting. There may be severe cramps in the limbs and abdomen. Severe dehydration of the body, the face becomes pointed, folds appear on the skin. The pulse quickens, blood pressure drops. At first there is little urine, then it disappears. The blood thickens. The condition is very serious and requires immediate hospitalization and treatment - replenishment of blood volume, exposure to the pathogen, restoration of electrolyte balance in tissues.
  9. When a chromogenic fungus develops in the mouth, the color becomes greenish-black, and the gums and teeth are also stained. The greenish tint comes from chlorophyll, and the spots are a waste product. Antifungal therapy and oral hygiene are prescribed.
  10. Crohn's disease– chronic gastrointestinal disease – a huge amount of melanin is produced in the mucous membranes and skin. Treated with antibacterial and hormonal drugs, as well as immunosuppressants.
  11. – oral candidiasis. Most common in infants. When immunity decreases or the chemical balance is disrupted, fungi begin to actively reproduce. It manifests itself in the formation of ulcers on the palate, cheeks, tongue, lips, covered with a white coating. Causes pain when touched and when eating. When neglected, the tongue becomes covered with a black coating. Treated with antifungal drugs.
  12. Acidosis– increase in acid-base balance. Occurs as a result of slagging in the body due to excessive consumption of food white bread, baked goods, fats, carbohydrates. And insufficient consumption of raw vegetables and fruits.
  13. – change in the composition of microorganisms living in the intestines. This can occur after taking antibiotics, suffering from infectious diseases, malnutrition, or gastrointestinal diseases. It is treated with anti-disbacteriosis and multivitamin preparations.

If the tongue turns black, you need to show the child to a pediatrician and gastroenterologist. Complaints with black plaque: itching, dry mouth, sour breath, bitter taste, decreased taste.

Usually in children the plaque is located in the middle of the tongue or at the root. Often the papillae of the tongue become thicker, coarser, and look like villi. dark color- hairy tongue. To quickly remove the darkened layer, keratolytic substances are used - prescribed by the dentist. Vitamins are also prescribed.

Plaque looks like small black dots in case of: fungal diseases, diseases of the gastrointestinal tract, lead poisoning - the gums are covered with a black rim, there is a metallic taste. Plaque has the form of a spot - gastrointestinal problems, complications after infectious diseases.

Prevention

When plaque appears, it is important to change toothbrush. Brush your teeth and tongue in the morning and before bed. Drink tea with herbs: plantain, linden, oregano, yarrow. Drink flax seed decoction. Rinse your mouth with oak bark, chamomile, sage, mint, and strawberries.

If the plaque cannot be removed with a brush, you need to consult a doctor, he will review your diet and prescribe treatment according to the reason. It is important to ensure drinking regime - at least two liters of water.

Looking into the baby's mouth, you may find that the child has a black tongue. A competent pediatrician does exactly this at every appointment - examines the little patient’s oral cavity. Perhaps the child drew and licked a felt-tip pen the day before or chewed on an ink pen? This is the safest, but take a closer look, is it just a coating or does the tongue itself have dark color?

Many diseases have no symptoms, but the tongue, in addition to its basic functions, is one of the main indicators of health conditions. He can tell not only verbally, but also physically about problems and disturbances in the functioning of the body. The normal appearance of the most muscular and mobile organ of the human body is an even pink color with a slightly whitish coating. Any other shade, spots, strange consistency is a reason to think about your health. If yellowish and white coating is a very common occurrence on the tongue and should not cause much concern, then its darkening is a fairly rare situation and needs to be discussed in more detail, especially when children are the focus.

In infancy and at a younger age, a black coating on the tongue may indicate very serious malfunctions and problems in the body little man, which he himself cannot talk about. But it’s too early to panic; first of all, let’s figure out the reasons for this deviation and try to find ways to solve this problem.

Nutritional reasons

The mucous surface of the tongue shell tends to become stained as a result of exposure to food coloring(synthetic or natural). In this situation, a child’s black tongue is an absolutely safe phenomenon. It is necessary to temporarily exclude from the children's diet foods and drinks that can give the tongue a dark color. These include: various berries (blackberries, blueberries, currants, prunes, mulberries, chokeberries), juices and compotes based on them, all kinds of candies, chewing gum, candies, dark-colored drinks (including black tea, coffee). Then regular oral cleaning will restore your tongue to a healthy appearance.

Careful oral care is as follows. After each meal, you should rinse your mouth - this will remove food debris and reduce the growth of bacteria. You also need to teach your child to use a special tongue scraper; a regular toothbrush can replace this tool.

In infants, if complementary foods are introduced prematurely, a dark coating on the tongue may also appear, which signals that the baby's stomach is not ready for food other than mother's milk. IN in this case It’s worth putting off introducing new products for a while or changing your approach to the food system.

Medicinal reasons

Taking iron-containing medications (especially in liquid form), activated carbon, treatment with antibiotics can cause a dark color on the surface of a child’s tongue. A whole arsenal of medications can cope with all kinds of diseases, but sometimes they deal a big blow to the body, weakening the immune system. And the language, like a mirror, reflects the state of human health.

Prolonged and uncontrolled use of antibiotics is especially dangerous; it leads to disruption of the microflora not only of the intestines (dysbacteriosis), but also of the oral cavity; candidiasis may develop (in other words, thrush or stomatitis), as a result of which, if treatment is not started in time, gray plaque on the child's tongue. Detecting this problem and eliminating the causes, following the instructions and prescriptions of your local doctor will help you cope with the frightening plaque. You should not try to remove plaque yourself. The use of antifungal medications together with treating the oral cavity with antiseptic solutions and following a gentle diet will give a positive result.


This is one of the most serious reasons, the black color of the tongue may indicate problems in the digestive system; in some cases, other internal organs are also affected. If you have problems with the gastrointestinal tract, most likely only the root of the tongue will be dark, the edges and tip will invariably be Pink colour. Such chronic diseases, such as colitis, enteritis, gastritis, are most often accompanied by constipation, diarrhea, nausea and heartburn. But diseases of the pancreas and gall bladder begin asymptomatically, occasionally accompanied by a bitter taste in the mouth.

If gastrointestinal problems are suspected, it is necessary to visit a pediatric gastroenterologist, conduct ultrasound and other necessary examinations of internal organs, and identify the sore spot.

Further, with proper comprehensive treatment and compliance healthy image in life, do not be afraid of relapses. But most often adults, rarely children, experience blackening of the tongue due to pathologies of the gastrointestinal tract.

Causes in other diseases

  1. Various infectious diseases of the respiratory tract (tonsillitis, acute tonsillitis, ARVI), inflammation of the tonsils with increased body temperature, acid-base imbalance (acidosis) can also lead to the formation of a dark coating on the tongue in children. When inflammation is healed and subsides, the oral mucosa will return to its normal state without additional effort. Rinsing the mouth with decoctions of pharmaceutical herbs (sage, chamomile, calendula) only with the approval of the pediatrician.
  2. Complex vitamins will help boost immunity and avoid hypovitaminosis. Very often you can observe dark spots on the tongue in children whose bodies do not receive enough vitamins from groups PP, B. You should never resort to folk methods treating children without the supervision of a doctor, it is necessary to follow his prescriptions and not exceed the dosage of medications.
  3. Remak syndrome (lead poisoning of the body) can cause a black tongue. This disease is accompanied by additional symptoms (darkening of the gums, metallic taste in the mouth). Under treatment combination drugs and eliminating patient exposure to lead.
  4. Crohn's disease, when the patient experiences autoimmune processes. The content of melanin in the skin and mucous membranes increases, the functioning of the adrenal glands is disrupted, and the amount of hormones decreases. This disease is treated long and difficult under the close supervision of doctors.

Physiological features

It happens that a dark coating appears in the middle and basal part of the tongue, forming a triangle or oval in the direction of the pharynx. This occurs as a result of multiple growth of the papillae of the tongue. Their keratinization is similar to villi; they are dark in color. This condition is rare and is called a hairy or villous tongue.

If the child is feeling normal, and there are no complaints of discomfort or dryness, there is no need to focus on this. The cause of this phenomenon is often impossible to establish and restoration of normal appearance Tongue problems occur in children on their own, without unnecessary treatment, within a couple of weeks.

It is worth remembering that in case of any deviation from the norm, it is still worth visiting a doctor, getting a consultation and drawing up an observation and treatment plan. Do not resort to self-medication and do not try to independently look for the causes of black tongue in children. Only a specialist (possibly a combination of a pediatrician, a gastroenterologist, and a dentist) can determine why a child has a dark coating on the tongue, help cope with the problem and avoid its recurrence.

Maintain hygiene, adhere to proper diet nutrition, avoid bad habits, undergo routine examinations with doctors - this is the main thing in maintaining the health of you and your children. Be healthy – and your tongue will thank you!

The tongue is considered an indispensable organ for communicating with people and plays a large role in digestion. But besides this, it is a kind of indicator indicating the development of various diseases.

A child’s black tongue should be a signal for an early examination and identification of the reasons that provoked the color change.

Causes of darkening of the tongue

In most cases, the causes of darkening of the tongue are its external coloration. For example, a change in color can be caused by consumption black currant, chokeberry, blueberry, blackberry, blueberry or.

If the baby has been in the room unattended for some time, then you should pay attention to surrounding objects that can change the color of the tongue. Perhaps the child tasted ink, gouache, decorative cosmetics or newspaper.

The above reasons are short-term and disappear after treatment of the oral cavity. Special attention It is worth paying attention if the black color on the surface of the tongue does not go away within three days.

Factors that provoke darkening of the tongue:

  1. A change in the color of the organ mucosa can be caused by long-term use of iron supplements.
  2. Often, with a sore throat or other respiratory diseases, the attending physician may prescribe antibiotics to the child.
  3. Long-term use of drugs causes oral thrush, in which yeast-like fungi begin to actively grow and secrete a specific pigment. Therefore, after a few days you may notice small dark spots on the tongue.
  4. Chronic diseases of the gastrointestinal tract (gastritis, enteritis) occur with a change in the color of the tongue. With these diseases, the baby’s appetite disappears, but there are cases of its unreasonable increase. This can cause sudden weight loss or gain. The child experiences frequent abdominal pain, nausea, vomiting, and changes in the color of stool.
  5. Lack of vitamins in the body is the most common cause of darkening of the tongue. Most often this occurs due to a lack of vitamins B and PP.
  6. The greenish-black tint of the tongue mucosa is the consequences of the proliferation of a chromogenic fungus in the oral cavity. Dark spots are a product of their vital activity. The disease may occur with mild pain and changes in the child’s behavior. After trying to remove it yourself using a toothbrush, the plaque appears again after a while.
  7. Lack of oral hygiene can cause cholera, an acute infectious intestinal disease. The disease manifests itself with copious loose stools (up to ten times a day) and frequent vomiting. About a day after infection, the child may experience minor twitching of the limbs and small folds throughout the body. The main symptoms of cholera are dehydration, rapid heartbeat, and low blood pressure.
  8. Use by a child large quantity white bread, fats and carbohydrates provokes an increased acid-base balance of the intestines. The slagging of the body manifests itself as black spots on the surface of the tongue.
  9. Very rarely, the attending physician can diagnose Saturnism. Lead poisoning can occur after a child licks objects painted with lead paint. The disease is characterized by severe abdominal pain, anemia, convulsions, decreased intelligence and the presence of a lead border.
  10. Black hairy tongue syndrome has not been fully studied to date. The child feels well and has no complaints. Small villi on the tongue do not cause any discomfort other than cosmetic ones.

Treatment

Oral hygiene

Treatment of the disease depends on the cause that caused the change in the mucosa. When contacting, the pediatrician must prescribe the necessary diagnostics, which includes urine and blood tests, and various examinations.

Only after receiving accurate results is therapy prescribed, which is aimed at treating the underlying disease:

  1. If the cause of darkening of the tongue is iron-containing objects, then stopping their use on the recommendation of a doctor will return the organ to its former healthy color.
  2. For gastrointestinal diseases, antisecretory and herbal choleretic agents, antacids, and bile thinners are prescribed.

To restore intestinal microflora, eubiotic preparations are required. The most effective in this group are considered to be Linnex, Lacidophil and Bifidumbacterin. It is very important during treatment to carefully heat treatment products and a diet that is gentle on the baby’s body. Most of which should be fermented milk products.

It is impossible to get rid of fungal plaque on your own or remove it. For complete recovery, it is necessary to take antifungal drugs and, if the child’s age allows, frequent rinsing of the mouth with antiseptic agents.

The problem of hypovitaminosis can be quickly solved with the help of complex vitamin preparations. After the necessary course of treatment, the signs of a black tongue will disappear.

Black coating or dark spots on the tongue

When taking antibiotics, mold fungi begin to multiply quickly. This is due to the fact that the number of bacteria to fight them decreases sharply. If the drugs cannot be stopped, the attending physician prescribes antifungal drugs.

To maintain the baby’s health, it is necessary to simultaneously take medications that help improve immunity. After about two weeks of treatment, the tongue will acquire a healthy pink tint.

Treatment of acute respiratory diseases does not require special treatment methods. At this point, it is very important to pay great attention to oral hygiene. At the same time, you can rinse your mouth with decoctions based on sage, chamomile or calendula.

During a sore throat, you need to follow a gentle diet to avoid mechanical damage larynx. It mainly consists of meat broths, porridges or pureed soups. Rapid recovery can occur after inhalation with fir oil. But before the procedures you need to consult with your doctor.

Acidosis or increased acidity eliminated with a diet based on raw vegetables and fruits.

In case of lead poisoning, special antidotes are prescribed. Detoxification therapy is carried out based on colloid and crystalloid drugs.

For quick fix black plaque can be rinsed daily:

  1. Finely chop the zest of fresh lemon and add to a glass of water.
  2. A teaspoon of salt and five drops of oil tea tree dissolve in 200 ml of warm water.
  3. Pour baking soda onto gauze, bandage and wet. Use the resulting lump to clean the surface of the tongue.

Prevention of the disease also plays an important role in the treatment of black tongue:

  • daily brushing of teeth, gums and cheeks with a soft toothbrush and scraper spoon;
  • using good toothpaste;
  • rinsing the mouth after every meal;
  • eating bran, fruits and vegetables;
  • replacing black tea with herbal teas: linden, strawberry.

Black plaque or dark spots on the tongue are most often the result of external staining. If symptoms do not go away after several days, you should consult a specialist. After a thorough examination and identification of the causes of changes in the color of the organ, effective therapy is prescribed, after which the tongue will acquire a healthy appearance.

When you need to rush to the doctor if you have problems with your tongue, watch the following video:

Looking into the baby's mouth, you may find that the child has a black tongue. A competent pediatrician does exactly this at every appointment - examines the little patient’s oral cavity. Perhaps the child drew and licked a felt-tip pen the day before or chewed on an ink pen? This is the safest, but take a closer look, is it just a coating or is the tongue itself dark in color?

Many diseases have no symptoms, but the tongue, in addition to its basic functions, is one of the main indicators of health conditions. He can tell not only verbally, but also physically about problems and disturbances in the functioning of the body. The normal appearance of the most muscular and mobile organ of the human body is an even pink color with a slightly whitish coating. Any other shade, spots, strange consistency is a reason to think about your health. If yellowish and white coating on the tongue is a very common occurrence and should not cause much concern, then its darkening is a rather rare situation and needs to be discussed in more detail, especially when children are the focus.

In infancy and at a younger age, a black coating on the tongue may indicate very serious malfunctions and malfunctions in the little person’s body, which he himself cannot tell about. But it’s too early to panic; first of all, let’s figure out the reasons for this deviation and try to find ways to solve this problem.

Nutritional reasons

The mucous surface of the tongue tends to become stained as a result of exposure to food dyes (synthetic or natural). In this situation, a child’s black tongue is an absolutely safe phenomenon. It is necessary to temporarily exclude from the children's diet foods and drinks that can give the tongue a dark color. These include: various berries (blackberries, blueberries, currants, prunes, mulberries, chokeberries), juices and compotes based on them, all kinds of candies, chewing gum, candies, dark-colored drinks (including black tea, coffee). Then regular oral cleaning will restore your tongue to a healthy appearance.

Careful oral care is as follows. After each meal, you should rinse your mouth - this will remove food debris and reduce the growth of bacteria. You also need to teach your child to use a special tongue scraper; a regular toothbrush can replace this tool.

In infants, if complementary foods are introduced prematurely, a dark coating on the tongue may also appear, which signals that the baby's stomach is not ready for food other than mother's milk. In this case, it is worth temporarily postponing getting to know new products or changing your approach to the nutrition system.

Medicinal reasons

Taking iron-containing medications (especially in liquid form), activated carbon, and antibiotic treatment can cause a dark color on the surface of a child’s tongue. A whole arsenal of medications can cope with all kinds of diseases, but sometimes they deal a big blow to the body, weakening the immune system. And the language, like a mirror, reflects the state of human health.

Prolonged and uncontrolled use of antibiotics is especially dangerous; it leads to disruption of the microflora not only of the intestines (dysbacteriosis), but also of the oral cavity; candidiasis may develop (in other words, thrush or stomatitis), as a result of which, if treatment is not started in time, gray coating on a child's tongue. Detecting this problem and eliminating the causes, following the instructions and prescriptions of your local doctor will help you cope with the frightening plaque. You should not try to remove plaque yourself. The use of antifungal medications together with treating the oral cavity with antiseptic solutions and following a gentle diet will give a positive result.


This is one of the most serious reasons; the black color of the tongue may indicate problems in the digestive system; in some cases, other internal organs are also affected. If you have problems with the gastrointestinal tract, most likely only the root of the tongue will be dark; the edges and tip will always be pink. Chronic diseases such as colitis, enteritis, gastritis are most often accompanied by constipation, diarrhea, nausea and heartburn. But diseases of the pancreas and gall bladder begin asymptomatically, occasionally accompanied by a bitter taste in the mouth.

If gastrointestinal problems are suspected, it is necessary to visit a pediatric gastroenterologist, conduct ultrasound and other necessary examinations of internal organs, and identify the sore spot.

Further, with proper comprehensive treatment and maintaining a healthy lifestyle, there is no fear of relapses. But most often adults, rarely children, experience blackening of the tongue due to pathologies of the gastrointestinal tract.

Causes in other diseases

  1. Various infectious diseases of the respiratory tract (tonsillitis, acute tonsillitis, ARVI), inflammation of the tonsils with increased body temperature, acid-base imbalance (acidosis) can also lead to the formation of a dark coating on the tongue in children. When inflammation is healed and subsides, the oral mucosa will return to its normal state without additional effort. Rinsing the mouth with decoctions of pharmaceutical herbs (sage, chamomile, calendula) only with the approval of the pediatrician.
  2. Complex vitamins will help boost immunity and avoid hypovitaminosis. Very often you can observe dark spots on the tongue in children whose bodies do not receive enough vitamins from groups PP, B. You should never resort to traditional methods of treating children without the supervision of a doctor; you must follow his prescriptions and not exceed the dosage of medications.
  3. Remak syndrome (lead poisoning of the body) can cause a black tongue. This disease is accompanied by additional symptoms (darkening of the gums, metallic taste in the mouth). It is treated with combination drugs and stopping the patient's contact with lead.
  4. Crohn's disease, when the patient experiences autoimmune processes. The content of melanin in the skin and mucous membranes increases, the functioning of the adrenal glands is disrupted, and the amount of hormones decreases. This disease is treated long and difficult under the close supervision of doctors.

Physiological features

It happens that a dark coating appears in the middle and basal part of the tongue, forming a triangle or oval in the direction of the pharynx. This occurs as a result of multiple growth of the papillae of the tongue. Their keratinization is similar to villi; they are dark in color. This condition is rare and is called a hairy or villous tongue.

If the child is feeling normal, and there are no complaints of discomfort or dryness, there is no need to focus on this. The cause of this phenomenon often cannot be determined, and restoration of the normal appearance of the tongue occurs in children on their own, without unnecessary treatment, within a couple of weeks.

It is worth remembering that in case of any deviation from the norm, it is still worth visiting a doctor, getting a consultation and drawing up an observation and treatment plan. Do not resort to self-medication and do not try to independently look for the causes of black tongue in children. Only a specialist (possibly a combination of a pediatrician, a gastroenterologist, and a dentist) can determine why a child has a dark coating on the tongue, help cope with the problem and avoid its recurrence.

Maintain hygiene, adhere to a proper diet, avoid bad habits, undergo routine examinations with doctors - this is the main thing in maintaining the health of you and your children. Be healthy – and your tongue will thank you!

The tongue is not only an organ involved in speech and digestion. It can be called an indicator of the state of the body. Some diseases do not manifest themselves at all. And only the tongue can change its color. He will tell an experienced doctor a lot. Therefore, parents should pay attention to the color of the tongue in order to contact a pediatrician if something happens. After all, in such a matter as the health of your own child, every little thing can be important. A healthy toddler has a pink tongue. And if a dark, black coating appears on it, naturally, this is not the norm. So why does the child have a black tongue?

Black tongue in a child - reasons

Black tongue coloring is not always associated with diseases. This happens when you eat foods dark colors, for example, after the baby has eaten blackberries or mulberries or drinks made from them. In this case, after several brushings, the plaque will disappear and the tongue will become pink again.

Additionally, if your baby has iron deficiency anemia and takes liquid iron supplements, you may notice that his tongue turns black. Soon after stopping the medicine, the child's tongue will return to its normal color.

However, most often the reasons why a black tongue occurs are pathological conditions child's body. It is characteristic that not the entire surface darkens, but the root of the tongue becomes black. The edges and tip of the organ remain unchanged, that is, light pink. The appearance of dark plaque is associated with diseases of the gastrointestinal tract and other internal organs. This may be gastritis, colitis, enteritis, dysbacteriosis, as well as disorders in the liver or biliary tract. Pathogenic microbes develop not only in the stomach or intestines, but also on the tongue.

If you find a black tongue on a baby, then in addition to dysbacteriosis, suspicion may also fall on candidal stomatitis, or simply thrush. Recognizing the infection is not difficult, because darkening of the tongue is accompanied by a whitish, uneven coating in the oral cavity.

Sometimes the appearance of a black coating on the tongue is associated with taking antibiotics for acute respiratory infections. Darkening usually appears a couple of days after starting medication.

If a black coating occurs on a child’s tongue, you should make an appointment with a pediatric gastroenterologist. To exclude pathologies digestive system Most likely, you will be prescribed an ultrasound.

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