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Daily Dose

When Bug Bites Get Infected

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It is the season for bug bites and and I am seeing a lot of parents who are bringing their children in for me to look at all sorts of insect bites. I am not always sure if the bite is due to a mosquito, flea or biting flies, but some of them can cause fairly large reactions. 

The immediate reaction to an insect bite usually occurs in 10-15 minutes after bitten, with local swelling and itching and may disappear in an hour or less. A delayed reaction may appear in 12-24 hours with the development of an itchy red bump which may persist for days to weeks.  This is the reason that some people do not always remember being bitten while they were outside, but the following day may show up with bites all over their arms, legs or chest, depending on what part of the body had been exposed. 

Large local reactions to mosquito bites are very common in children. For some reason, it seems to me that “baby fat” reacts with larger reactions than those bites on older kids and adults. (no science, just anecdote). Toddlers often have itchy, red, warm swellings which occur within minutes of the bites. 

Some of these will go on to develop bruising and even spontaneous blistering 2-6 hours after being bitten. These bites may persist for days to weeks, so in theory, those little chubby legs may be affected for most of the summer. 

Severe local reactions are called “skeeter syndrome” and occur within hours of being bitten and may involve swelling of an entire body part such as the hand, face or an extremity. These are often misdiagnosed as cellulitis, but with a good history of the symptoms  (the rapidity with which the area developed redness, swelling, warmth to touch and tenderness) you can distinguish large local reactions from infection.

Systemic reactions to mosquito bites including generalized hives, swelling of the lips and mouth, nausea, vomiting and wheezing have been reported due to a true allergy to the mosquito salivary proteins, but are extremely rare. 

The treatment of local reactions to bites involves the use of topical anti-itching preparations like Calamine lotion, Sarna lotion and Dommeboro soaks.  This may be supplemented by topical steroid creams (either over the counter of prescription) to help with itching and discomfort. 

An oral antihistamine (Benadryl) may also reduce some of the swelling and itching. Do not use topical antihistamines. Try to prevent secondary infection (from scratching and picking) by using antibacterial soaps, trimming fingernails and applying an antibiotic cream (polysporin) to open bites. 

Due to an exceptionally warm winter throughout the country the mosquito population seems to be especially prolific. The best treatment is prevention!! Before going outside use a DEET preparation in children over the age of six months, and use the lowest concentration that is effective.  Mosquito netting may be used for infants in strollers.  Remember, do not reapply bug spray like you would sunscreen. 

Daily Dose

Skin Lesion: Staph or Pimple?

1:30 to read

I just received an email question from a teenager who happened to attach a picture of a skin lesion she was worried about. I think it is great that teens are being proactive about their health and are asking questions about issues that are concerning to them.  BRAVO!!

So, this “bump” sounds like it started out as a possible “zit” on this 16 year old girl’s neck.  She admitted to lots of “digging” into the lesion and then became concerned that it didn’t seem to be getting any better.  She said that friends told her that it could be scabies, or possibly staph.  Leave it to friends to make you more apprehensive about the mystery bump. Looking at the picture it looks like it could be a simple pimple and in that case the best medicine is to LEAVE IT ALONE. The hardest thing to get teens to do (and also adults) is not to pick at pimples or bumps on their bodies, as this could lead to a skin infection. Many times just washing the “zit” and leaving it alone, it will go away.  When you go “digging” into it you break the skin and allow bacteria to enter the now open wound and you can get a skin infection. 

In many cases this may be due to staph or strep from your hands.  This may sometimes require a topical or oral antibiotic to treat the infection, when it may have been something that should have been left alone. There are skin infections that we are seeing in the community that are due to MRSA (methicillin resistant staph) which have become quite frequent in the last several years. In this case that small “bump” usually arises quite quickly, often times it is confused with an insect bite. But very quickly the bump becomes more inflamed, tender and often quickly grows in size. Many times there will be drainage from the bump which now resembles a boil.  In my experience the hallmark of MRSA infections is how quickly they arise and how painful they are.  They have a fairly classic appearance (see old post on Staph).

MRSA infections often have to be drained and require different antibiotics than ”regular” skin infections. In most cases it is necessary to obtain a culture of the drainage so that the appropriate antibiotic may be selected. In some circumstances the infection is quite extensive and may even require surgical drainage and IV antibiotics, requiring a stay in the hospital.  MRSA is a serious infection and is often seen in teens who share articles of clothing or participate in sports where they are showering, using equipment etc that is shared. Remember to use your own towels, and athletic equipment when you can.

This teen also asked “if you have staph would you have it forever?” In actuality, many of us harbor staph in our noses and we all rub our noses throughout the day and then touch other parts of our body as well as other objects. This then passes the bacteria from person to person, sometimes via another object. If you are not symptomatic, don’t worry about whether you have staph in your nostrils, but do adhere to good hand washing and try to keep your hands away from your face. For patients who have had recurrent skin MRSA infections, I often prescribe an antibiotic cream to be put in the nostrils as well as in the nostrils of all close contacts (family members). I also recommend that the patient bath in an anti-bacterial soap and take a bleach bath every week to help decrease the bacterial colonization with staph. It seems that this has helped prevent reoccurrences of staph for the individual as well as for other family members. Lastly, this is certainly not scabies, but we have an older post on that too with pictures!

That’s your daily dose for today. We’ll chat again tomorrow. Send your question or comment to Dr. Sue!

Daily Dose

Stomach Virus

1:30 to read

What a week in the office as there has been an outbreak of presumed Norovirus in our community, and we are seeing tons of sick kids. I guess the virus does not realize that it is still in the 90’s in Texas, as this virus is more often seen during the winter months….but it seems there are occasional outbreaks throughout the year.

Norovirus is EXTREMELY contagious…and you may already be shedding the virus (expose others) before you even get sick. At the same time…you may also be contagious for 2 -3 days after you are better. Norovirus is the most common cause of the “stomach flu” or “food poisoning.” 

Knowing this, it is difficult to know when you have been exposed to this virus. But, a day or two after exposure, your child (or the parents ) may suddenly develop abdominal cramping, vomiting (more common in children) and diarrhea  more common in adults). Some children and their parents are “lucky” enough to get both!!  

The mainstay of treatment is to stay hydrated. This illness is typically “fast and furious”, but you have to make sure that you are replacing the fluids that you are losing ( from both ends).  After your child has vomited you want to wait for at least 30 minutes before offering your child sips of CLEAR FLUIDS, some sort of liquid with electrolytes ( very important to replenish what you are losing) ….and I mean SIPS. If you  give the fluid too quickly and in too large a volume you may see it come right back up.  As your child tolerates sips you may advance to a larger volume each time.  If they are doing well for several hours, but then your child vomits again…start back over with smaller volumes. Continue to make sure your child has tears when they cry, wet diapers ( they may not be soaked), urine when asked to go try and “potty” and drool or a  moist mouth. These are signs that your child (and you) are hydrated.

Once the vomiting has subsided you can let your child begin to eat, but I would avoid all dairy. It is important to offer foods with some protein as well.  I start with crackers, noodles and rice and then add in chicken or beef. Veggies and fruit are okay as well ….as your child is feeling better their appetite will return…don’t push them. You probably don’t want a big meal either if you have been sick. Fluids are more important than food. Adding probiotics is also helpful to put “good bacteria” back into a damaged gut. 

Prevention is key, but difficult as there are millions of viral particles in your child’s stool and vomit….and these particles can be spread via the air as well.  Clean surfaces with a dilute bleach solution, wash your hands and “don’t breath??”

Daily Dose

Ear Infections

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The American Academy of Pediatrics (AAP) has released new guidelines for the diagnosis and treatment of acute otitis media (AOM) which is ‘doctor speak’ for an ear infection.  

An ear infection is one of the most common infections of early childhood and is also one of the most common reasons that antibiotics are prescribed.  Guidelines from 2004 recommended that pediatricians use “watchful waiting” before prescribing antibiotics for an ear infection in some children. 

The new guidelines for treating an ear infection with oral antibiotics are even more specific than those in 2004, and further clarify who are the best children to observe and those that should be treated right away.  This will reduce the number of unnecessary antibiotics that are prescribed, which in turn may help prevent antibiotic resistant bacteria. 

Many parents worry that their child may develop an ear infection after having a cold, but for a child between 6 months and 12 years of age, a mild ear infection found during a visit to their pediatrician may now be observed for 72 hours.  

According to the new AAP guidelines, children need to receive immediate antibiotics if they have a severe ear infection (with a fever of 102.2 degrees or higher or significant pain), have a ruptured ear drum with drainage or an ear infection in both ears in a 2 year old or under.  This will really change current treatment and the number of antibiotics prescribed. 

As both pediatricians and parents know, there are all sorts of things that cause ear pain:  an erupting new molar, a cold, or a sore throat can all result in ear pain and a “cranky” child.  But if the eardrum is not bulging the best treatment is pain control. This can be accomplished with acetaminophen or ibuprofen and watchful waiting to see if a child’s symptoms worsen or if the pain and symptoms resolve.  In studies, 2 out of 3 children get better without an antibiotic. 

More and more parents are responsive to using fewer antibiotics for their children and these recommendations reinforce that antibiotics don’t treat viral infections or pain.   Save the antibiotics for use when there is evidence of a bacterial infection. 

The next time your child has a cold and complains of an earache, try this approach and you may see that the ear pain resolves in 24-48 hours and you have one less trip to the pediatrician!

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Daily Dose

Salmonella Scare

1:30 to read

I have been watching the news about the ongoing salmonella outbreak. Unfortunately, there have now been two reported deaths, and over 300 people have been infected. This outbreak has been linked to American cucumbers imported from Mexico. Over 50% of those infected have been children younger than 18 years.

Salmonella infections are a bacterial infection, and cause fever, diarrhea (it may be bloody) and abdominal cramping.   In most cases you develop signs and symptoms 12-72 hours after being exposed to the bacteria. For most people the infection is self limited and the diarrhea resolves after 4-7 “uncomfortable days”.

While contaminated foods are the biggest cause of salmonella infections, children may be exposed from sources other than food. This includes pet turtles, baby chicks, ducks and hamsters. Having your child wash their hands with soap after handling these pets, even if the animal has no symptoms, is an important way to prevent an infection. 

In some cases, especially in a young child, the diarrhea may be so severe as to cause dehydration which requires hospitalization and IV re-hydration. The signs of dehydration are dry mucous membranes (mouth, eyes), increased thirst, decreased urine output and lethargy.  

Dehydration is often more difficult to diagnose in a baby as they obviously cannot tell you how they are feeling. Look for a dry mouth and tongue and when you put your finger in your baby’s mouth it should always be moist.  If your baby is drooling that is a good sign that they are not dehydrated.  They should not have sunken eyes or a sunken fontanelle (soft spot), but these are late signs of dehydration. Wet diapers are also a good sign that your baby is getting enough fluids, but with the new diapers which are “super absorbent” it is sometimes difficult to tell if your child has a wet diaper or not. For an older child you can look at the color of their urine….it should always be clear to light yellow, and never amber or cola colored which means you are dehydrated.

In order to maintain hydration in the face of prolonged diarrhea it is important to drink a lot of fluids including an oral electrolyte solution such as Pedialyte. Many children (and adults) will not drink Pedialyte and then I would recommend gatorade over other “sugary” juices or carbonated drinks as you need to replenish the salt and electrolytes that are being lost in the stools.  It is important to offer frequent small amounts of fluid. Parents often worry if their child is not eating,  but fluids are the most important way to maintain hydration. You can also try popsicles of Pedialtye pops as a way of getting fluids into your child.

If you have prolonged symptoms or are worried about dehydration call your doctor’s office. In the meantime, I guess I won’t be having cucumbers from Mexico in my salads! This is when I wish I had a green thumb and a garden!

Daily Dose

Facial Rash

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Lots of babies and toddlers have problems with recurrent rashes around their mouths. It is most bothersome to their parents…who think it is “unsightly, especially in pictures”.  The problem is,due to the fact that babies and toddlers drool and they also always have their fingers and/or hands in their mouths.  Remember, a child is in their “oral phase” from birth through the toddler years….and everything goes into their mouths.

On top of the safety issues with a child putting everything into their mouths and the risks surrounding choking….all of this hand to mouth often leads to a rash which is a type of “peri-oral” dermatitis. It is usually a bit red (erythematous) and bumpy (papular) and will have good and bad days.   So how do you get rid of it?

It is not and “easy” fix but here are some things that help. Pacifiers are one of the biggest rash causing culprits as a child sucks and the drool accumulates around the outside of the mouth and under the pacifier.  I love pacifiers for younger children (<12-18 months), but if your child (like the one in the picture) still has a pacifier and is over 12 months of age taking away the pacifier (another post ) will absolutely help.  

Another reason for the rash is frequent face washing and wiping.  What parent is not constantly wiping their child’s face?  In fact, one night when I was seeing a mother with her child for this very rash and I “suggested” that she wipe his face less frequently she said to me rather emphatically “I do not wipe his face!! “  Well, I wonder why he did not have all sorts of leftover carrot, pears, peas and yogurt on his face?  At any rate, the less frequently you wipe off the “schmutz” the less drying and irritation to the skin.  Still hard to do as your child finger feeds often missing their mouth.

So the mainstay of treatment is a barrier/moisturizer as well as a topical steroid cream. I usually recommend something like Aquaphor or Vaseline and I apply it often and generously. Especially when your child is heading to bed, coat the area…even under that pacifier if necessary.  On days that it looks especially inflamed, I add an over the counter steroid cream, such as Cortaid or Cortizone.  When using the steroid a tiny amount “pea sized” is all you need, put that on first, followed by the layer of Aquaphor or Vaseline. The steroid cream will help “get the red out” but it is not to be used daily.  Use the steroid for several days, take the Christmas card picture and stop the steroid for awhile. I use the steroid “as needed” rather than daily. 

I recently learned that an occasional child is “allergic” or reacts to the lanolin alcohol in Aquaphor and the rash might get worse instead of better. If that seem to be the case and you have been using Aquaphor you might switch to simple pure petrolatum like Vaseline.  

The best news is that most of these rashes clear up on their own over time when your child moves out of the oral, messy mouth stage and won’t be drooling and having their face wiped all of the time….but next up is the “anal phase”!

Daily Dose

Teens And Sexually Transmitted Infections

An alarming study in Pediatrics reveals a rise in STD among sexually active teens. Recently, I was reviewing an alarming study in an issue of Pediatrics. Although I use the word alarming, unfortunately it is better stated as “sobering reality” as the statistics only corroborate what I have seen in my own pediatric practice where I take care of many adolescents.

Despite our parental and societal “admonitions” not to have sex before marriage, teenagers are engaging in sexual activity, and they are also developing sexually transmitted infections. The statistics continue to show that somewhere between 60 to 70 percent of high school seniors have had “sex”, and by 12th grade, more girls than boys admit to having had intercourse. More than 15 percent have had multiple partners. In this study, which was done by the Centers for Disease Control and Prevention (CDC), 838 girls ages 14 to 19, who were participating in the National Health and Nutrition Examination Survey 2003 – 2004, provided specimens that were tested for gonorrhea, Chlamydia, trichomonas, herpes, and HPV (human papilloma virus). The prevalence of any of the five sexually transmitted infections (STI) was 24.1 percent. When results were broken down further those teens who reported only one lifetime sexual partner had 19.2 percent prevalence of any STI and for those teens who had more than three sexual partners the prevalence increased to 53.3 percent for an STI. Once again, as in previous studies the most common STI was HPV (types 6 and 11), followed by Chlamydia. HPV infections accounted for nearly three- quarters of the overall STI prevalence. Both of these infections may be silent, in other words, young girls may not have outward evidence of these infections but HPV may lead to cervical cancer and Chlamydia may cause problems with infertility. Unfortunately, I don’t think many teens are thinking about long-term consequences when they engage in pre-marital sexual behaviors. Teens are impulsive, live in the moment and typically feel that “these things happen to other people.” Even when talking about these issues with my own teenage sons I often hear “Mom, we get it we are smart!!” Smart kids get STI’s too. We need to continue discussing sexuality with our children, even at young ages. The more knowledge the better and while still supporting abstinence, they need to learn how to protect themselves if they do have sex. Abstinence only education has not been successful as we see our teen pregnancy rates rising and now the rate of sexually transmitted infections are even more prevalent and occur quickly after a girl’s sexual “debut”. All girls (and now boys) ages 11 – 26 should receive HPV vaccinations and sexually active adolescent females need to be screened yearly for Chlamydia. We need to ensure that all of our adolescents have access to sex education and sexual health care.  Keep up the dialogue. That’s your daily dose, we’ll chat again tomorrow. Send your question to Dr. Sue!

Daily Dose

How to Treat a Baby With Thrush

I have received some recent e-mails and now an office visit regarding the possibility of a baby having thrush. Thrush is a yeast (fungal) infection that involves the mouth, and is most typically seen in infants.I have received an email via our iPhone App and now an office visit regarding the possibility of a baby having thrush. Thrush is a yeast (fungal) infection that involves the mouth, and is most typically seen in infants.

The yeast infection usually involves the inside of a baby’s cheeks and lips and occasionally the tongue. It appears as white, almost cottage cheese like patches, and is often visible when a baby is yawning or crying. A baby who only has a white tongue typically does not have thrush, but just a milk coated tongue (see if you can wipe some of the milk off of the tongue, as yeast is usually more adherent). Thrush is fairly common as we all have yeast in our digestive tracts, and babies are often colonized with yeast as they travel through the birth canal. For unknown reasons, in some infants there is an overgrowth of yeast and thrush may develop. Many mothers feel guilty that they “gave their baby” a yeast infection. They worry that thrush has something to do with cleanliness (NOT) and somehow that maternal guiles thing is already beginning. (Dads have already cut to the chase and say, how do you treat it?!) Thrush can happen to any infant. In a breast feeding baby it may also cause a mother to have inflamed and tender nipples, and the baby and mother actually pass the yeast back and forth during feeding (no guilt, as breastfeeding is good!) In most babies thrush does not cause a lot of problems and may go away by itself. But if the infection becomes extensive it may become painful and cause an infant to be uncomfortable when nursing or taking a bottle. If you notice that your baby has white plaques in their mouth or under their lips it may be worth a phone call to your pediatrician. (This is not an emergency and can wait till office hours.) There are several prescription preparations that may be used to treat thrush. The most common being Nystatin, which is a liquid medication that is given to the baby after they have been fed, and is squirted into the mouth on the inside of the cheeks, to treat the yeast infection.  It is also beneficial to treat a nursing mother’s nipples with an anti-fungal agent. I usually tell patients to use the medications for at least seven days or until the white patches have been gone for several days before stopping treatment. It is not uncommon to get thrush again, so don’t fret if your baby develops another infection, at least you know what it is and how to treat it. A yeast infection in the mouth may often lead to a yeast infection in the diaper area (candidal diaper dermatitis), because as you know what goes in the mouth comes out in the poop. But that rash is for another day…. That’s your daily dose, we’ll chat again tomorrow. Send your question to Dr. Sue!

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