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Daily Dose

Summer Skin Infections

1:30 to read

I have been seeing a lot of skin infections and many of these are due to community acquired methicillin resistant staph areus (caMRSA). The typical patient may be a teen involved in sports, but I also see this infection in young children in day care, or summer camp. The typical history is “I think I have a spider bite” and that makes your ears perk up because that is one of the most common complaints with a staph infection, which is typically not due to a bite at all.

The poor spider keeps getting blamed, and how many spiders have you seen lurking around your house waiting to pounce? The caMRSA bacteria is ubiquitous and penetrates small micro abrasions in the skin without any of us every knowing it. The typical caMRSA infection presents with a boil or pustule that grows rapidly and is very tender, red and warm to the touch. The patient will often say that they “thought it was a bite” but the lesion gets angry and red and tender very quickly and typically has a pustular center.

For most of us pediatricians, you can see a lesion and you know that it is staph. It is most common to see these lesions in athletes on exposed skin surfaces such as arms and legs, but lesions are also common on the buttocks of children who are in diapers in day care. The area is angry looking and tender and the teenage boy I saw the other day would not sit on the chair, but laid on the table on his side as he was so uncomfortable. If the lesion is pustular the doctor should obtain a culture to determine which bacteria is causing the infection, but in most cases in my office the culture of these lesions comes back as caMRSA or in the jargon Mersa. When I say Mersa, I often cause widespread panic among my patients, but in most cases to date these infections may still be treated with an oral antibiotic that covers caMRSA, such as clindamycin or trimethoprim-sulfa. Many of the lesions improve dramatically once the site is drained and cultured. I will reiterate that if possible you want your doctor to obtain a culture to identify the bacteria that is causing the infection.

To prevent caMRSA remind your student athlete not to share towels, clothing or other items. Make sure that common areas are disinfected and once again encourage good hand washing. The closure of schools or disinfecting an entire football field or area with turf is not recommended. Lastly, this is a good reminder that you only want to take an antibiotic for a bacterial infection and that overuse of antibiotics leads to resistance. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

Breastfed Babies & Diaper Rash

1:30 to read

I was shopping at Target just the other day and happened to be in the “baby aisle” looking for one of those snack cups with the lids to let little fingers get in and not let the puffs fall out.  I needed it as part of a baby gift basket.  Useful for sure!!

So…while I am browsing, I see a young mother and her mother looking at diaper creams and obviously trying to decide which one to buy. I could’t resist offering help (always worry about being intrusive). When I asked what they were trying to treat the mother said, “ my new baby has this raw and red diaper rash right around his bottom”.  “He is just 12 days old and I change his diaper all of the time….how could he possibly get a diaper rash? What am I doing wrong?”

As we say in Texas, “bless her heart”!!! I asked if she was breast feeding,  and she was,  then I immediately knew what she meant. A breast fed infant will poop ALL OF THE TIME.  Many times you change a new diaper and as soon as the next diaper is put on the baby stools again. There are many times when your infant may poop a bit of stool during sleep and when you get them up they have a dirty diaper…all normal. No new mother guilt!!

The good news is that a newborn who is stooling a lot is probably getting plenty of breast milk as well…and that means they are gaining weight too!  The flip side is that it is not uncommon for a newborn to get that raw red bottom during the first month or so of breast feeding.  After that time, the stools do slow down a bit and diaper rash is less common.

The best remedy I have found for treating that tender new bottom is a combination of a diaper cream that contains zinc (Destin, Dr. Smith’s, or Boudreaux’s Butt Paste) and a bit of a liquid antacid (Mylanta, Maalox, Gaviscon). I put  a blob of diaper cream in my palm and then pour a bit of the antacid into it and mix….you can’t use too much of the liquid or it will run off.  Then I take that combo and coat the baby’s bottom. You can’t over do it. Use it with each diaper change.   It seems to do the trick and is easy. Several years ago I told a mother about the concoction (she had 4 children and was very sleep deprived) and I  just said use some antacid if you have some. She called later in the day and said she had tried to crush up the tablets and mix it with diaper cream and it wasn’t working.  I have since learned to be a bit more specific about a LIQUID antacid.  






Daily Dose

Diagnosing Online

1:30 to read

 recently saw a child in the office who had been well until a few days prior to the visit when his mother noticed that he had a purplish rash on his ankles which she initially attributed to bug bites.  But then she noticed that the rash seemed to be spreading as well as becoming darker in color. The rash was flat to slightly raised and did not seem to bother the child initially, but had now become painful and itchy.  Interestingly, the mother had GOOGLED “weird purplish red rash on lower extremities” and she told me as I sat down to take his history that she thought he had Henoch-Schonlein purpura (HSP).

WOW!! - so let’s review his history and symptoms that led her to this diagnosis.  He was an otherwise healthy child who had recently had a few days of fever, cough and runny nose that had gotten better before she noted the rash. He had also complained of some joint pain before the rash appeared and she thinks he had some diarrhea. She thought all of this would “just get better on its own”, until the rash developed, then she became concerned.

Once I examined the boy and saw the different sized purpuric looking lesions on his ankles, legs and up to the buttocks as well as new emerging rash on his arms I too was thinking HSP.  HIs exam was otherwise normal and he did not complain of any joint pain or abdominal pain that day.

HSP is a vasculitis (inflammation of the blood vessels) which may cause bleeding into the skin and other organs.  It is typically seen in young children who have had a recent viral infection. The exact reason for its occurrence is not clear…which is line that parents don’t like to hear (I get that). Although skin involvement is typically the first thing you notice, children may also complain of abdominal pain and joint pain.  

Because this illness affects the blood vessels you can see involvement of the kidneys and sometimes blood in the urine. Some children will get severe abdominal pain and even bloody diarrhea.  Parents need to know what to watch for as there is no specific treatment for uncomplicated HSP…it is another one of those illnesses that has to get better with time. The rash of HSP fades over weeks to a month or two as well. 

During the watching and waiting it is important to monitor a child’s blood pressure and to check the urine for blood (even if not visible), as some children may go on to develop more extensive kidney involvement. 

So this clever mother really did Google a symptom and amazed me that she came up with her son’s diagnosis.  (I am not a big fan of Dr. Google ). Her son did well and has not had any kidney involvement. He was back at school fairly quickly, albeit with his “spots” and is being followed for the next several months.  Good work Mom!

Daily Dose

Hand, Foot & Mouth Disease

1.15 to read

They say a picture is worth a thousand words and I believe it, especially as it pertains to rashes and pediatric illnesses. My iPhone has become a wonderful educational tool for my patients in the office, online and via social media.

It seems rather late in the season for Coxsackie virus to be occurring (typically more late summer early fall) but I am seeing so many little patients with the classic skin findings of “hand-foot and mouth” disease (HFM).  Some of the cases have been so classic that I took pictures of the rash, as once you see HFM you tend to know it!  Unfortunately, you may see this rash and think you won’t see it again, but you can get HFM more than once, so you will definitely know what you are dealing with once you have seen it.

HFM disease is a viral illness which typically occurs in younger children, although I occasionally see a miserable teenager who has classic Coxsackie virus findings.  In most cases the rash is preceded by a few days of fever and malaise and then the viral papules appear on the hands and soles of the feet. At the same time those papules and vesicles are often in the child’s throat, so you may see a toddler who is drooling more as it hurts to even swallow their spit!

Most kids with HFM don’t feel well and are irritable and fussy.  Occasionally you will see a child who appears totally happy, never had a fever and only has the classic Coxsackie rash on the hands, feet. The rash often occurs on the buttocks as well and may be equally as uncomfortable for those in diapers.

Because HFM is a viral illness there is no treatment per se.  This is where the TLC becomes important. You can use acetaminophen or ibuprofen for the fever or even for the throat discomfort. I am also a fan of things like popsicles, pudding, ice cream and Slurpees to help with the throat pain. Just make sure your child stays hydrated during the illness, they will eat their meals once they are feeling better.

The virus is contracted from person to person as well as from contaminated surfaces. This means that it is not uncommon to see “outbreaks” in daycare and preschools as the toddler set shares their germs better than their toys. The incubation period after exposure is about 3–7 days.

Once your child is fever free for 24 hours they may return to school as the rash may last anywhere from 5 – 7 days. Best prevention is still good hand washing.

Thanks to all of my little patients who were so helpful in letting me take pictures of their rash! I am getting better with the iPhone camera all of the time.

That’s your daily dose for today.  We’ll chat again tomorrow. 


Daily Dose

Hot Hand-Foot Syndrome

I was recently reading a dermatology article that I found quite interesting. The article was discussing “Hot Hand-Foot Syndrome” and showed a picture of a child with bright red palms and soles. It made me stop and read the article, as I am sure I had recently seen a child that looked like that picture. This puzzling syndrome presents with the sudden (acute) onset of warm, tender, red nodules and plaques on the palms and or soles.

Most children will also complain of low-grade fever, malaise and tenderness of the palms and soles that may even restrict walking or use of the hands and fingers. The presentation of this often looks like some sort of viral infection (fever, malaise) with a “weird” rash, but in actuality this is an illness caused by the bacteria Pseudomonas aeruginosa. This bacterium is found in water and soil and can enter the skin through hair follicles, sweat gland ducts, or micro-breaks in the skin. The most common place to be exposed to this bacterium is in hot tubs, saunas or swimming pools. You do not realize that you have even been exposed, but with a good history you may find that the child had been in a hot tub in the last 24

Daily Dose

How to Treat Poison Ivy

1.15 to read

With the long weekend here, many families are enjoying the outdoors. But with outdoor activity, your children may develop summer rashes like poison ivy, poison oak or poison sumac. Each plant is endemic to different areas of the country, but unfortunately all 50 states have one of these pesky plants. Teach your children the adage “leaves of three, let it be”, so they come to recognize the typical leaves of the poison ivy.

The rash of poison ivy (we will use this as the prototype) is caused by exposure of the skin to the plant sap urushiol, and the subsequent allergic reaction. Like most allergies, this reaction requires previous exposure to the plant, and upon re-exposure your child will develop an allergic contact dermatitis. This reaction may occur anywhere from hours to days after exposure, but typically occurs one to three days after the sap has come into contact with your child’s skin and they may then develop the typical linear rash with vesicles and papules that are itchy, red and swollen. Poison ivy is most common in people ages four to 30. During the spring and summer months I often see children who have a history of playing in the yard, down by a creek, exploring in the woods etc, who then develop a rash. I love the kids playing outside, but the rash of poison ivy may be extremely painful especially if it is on multiple surface areas, as in children who are in shorts and sleeveless clothes at this time of year. The typical fluid filled vesicles (blisters) of poison ivy will rupture (after scratching), ooze and will ultimately crust over and dry up, although this may take days to weeks. The fluid from the vesicles is NOT contagious and you cannot give the poison ivy to others once you have bathed and washed off the sap. You can get poison ivy from contact with your pet, toys, or your clothes etc. that came in contact with the sap, and have not have been washed off. If you know your child has come into contact with poison ivy try to bath them immediately and wash vigorously with soap and water within 5

Daily Dose

Spring Weather Brings Spring Rashes

Tonight I saw a little girl who had a hive like (urticarial) rash on her trunk, arms, legs which seemed to migrate from place to place.Sunday evening at our house if often house call night. It is rather fun for my husband (and me) to have young children in our very quiet house. Seems I miss my college boys most on Sundays too, so house calls are therapy for everyone. Tonight I saw a little girl who had a hive like (urticarial) rash on her trunk, arms, legs which seemed to migrate from place to place.

Her parents had noticed the rash the night before and the father had given her some Benadryl before bed. She seemed fine, they didn't think much about it, and then the rash returned later the following day. She was otherwise totally well. No fever, cough, breathing problems etc. and she was racing around pointing out her blotches that seemed to itch. She was otherwise oblivious. This kind of rash is common in early spring as the pollens start to fly. Although parents rack their brains trying to figure out the instigating allergen, we typically never know. These are not hives that are associated with breathing problems and allergic reactions to foods or drugs. The treatment of choice is to keep the child from being overheated (hives will be more prominent and itch more), start an antihistamine like Benadryl, or a non-sedating medication like Claritin or Zyrtec. You can take these on a daily basis for several days and see if the rash goes away. If it does, I recommend staying on the antihistamine for several days even after the hives have resolved, then stop the medication and see if the hives return. These rashes are typically short lived, although on occasion the child may need to stay on antihistamine throughout the spring at which time you should have your child see their doctor. That's your daily dose, we'll chat again tomorrow.

Your Baby

Starting Baby on Solid Foods

Your goal over the next few months is to introduce a wide variety of foods. If your baby doesn't seem to like a particular food, reintroduce it at later meals. It can take quite a few tries before kids warm up to certain foods.Starting baby on solid foods can be an exciting and perplexing time for parents. What foods should I start with? How much? How often?

The American Academy of Pediatrics currently recommends gradually introducing solid foods when a baby is about 6 months old. Your pediatrician, however, may recommend starting as early as 4 months depending on your baby's readiness and nutritional needs. Be sure to check with your pediatrician before starting any solid foods. Is your baby ready? Breast milk or formula is the only food your newborn needs. Within four to six months, however, your baby will begin to develop the coordination to move solid food from the front of the mouth to the back for swallowing. At the same time, your baby's head control will improve and he or she will learn to sit with support — essential skills for eating solid foods. If you're not sure whether your baby is ready, ask yourself these questions: •       Can your baby hold his or her head in a steady, upright position? •       Can your baby sit with support? •       Is your baby interested in what you're eating? If you answer yes to these questions and you have the OK from your baby's doctor or dietitian, you can begin supplementing your baby's liquid diet. What Foods to Start With. Continue feeding your baby breast milk or formula as usual. Then: •       Start with baby cereal. Mix 1 tablespoon (15 milliliters) of a single-grain, iron-fortified baby cereal with 4 to 5 tablespoons (60 to 75 milliliters) of breast milk or formula. Many parents start with rice cereal. Even if the cereal barely thickens the liquid, resist the temptation to serve it from a bottle. Instead, help your baby sit upright and offer the cereal with a small spoon once or twice a day. Once your baby gets the hang of swallowing runny cereal, mix it with less liquid. For variety, you might offer single-grain oatmeal or barley cereals. Your baby may take a little while to "learn" how to eat solids. During these months you'll still be providing the usual feedings of breast milk or formula, so don't be concerned if your baby refuses certain foods at first or doesn't seem interested. It may just take some time. Do not add cereal to your baby's bottle unless your doctor instructs you to do so, as this can cause babies to become overweight and doesn't help the baby learn how to eat solid foods •       Add pureed meat, vegetables and fruits. Once your baby masters cereal, gradually introduce pureed meat, vegetables and fruits. Offer single-ingredient foods at first, and wait three to five days between each new food. If your baby has a reaction to a particular food — such as diarrhea, a rash or vomiting — you'll know the culprit. •       Offer finely chopped finger foods. By ages 8 months to 10 months, most babies can handle small portions of finely chopped finger foods, such as soft fruits, well-cooked pasta, cheese, graham crackers and ground meat. As your baby approaches his or her first birthday, mashed or chopped versions of whatever the rest of the family is eating will become your baby's main fare. Continue to offer breast milk or formula with and between meals. Foods to Avoid for Now. Some foods are generally withheld until later. Do not give eggs, cow's milk, citrus fruits and juices, and honey until after a baby's first birthday. Eggs (especially the whites) may cause an allergic reaction, especially if given too early. Citrus is highly acidic and can cause painful diaper rashes for a baby. Honey may contain certain spores that, while harmless to adults, can cause botulism in babies. Regular cow's milk does not have the nutrition that infants need. Fish and seafood, peanuts and peanut butter, and tree nuts are also considered allergenic for infants, and shouldn't be given until after the child is 2 or 3 years old, depending on whether the child is at higher risk for developing food allergies. A child is at higher risk for food allergies if one or more close family members have allergies or allergy-related conditions, like food allergies, eczema, or asthma. Introducing Juice. Juice can be given after 6 months of age, which is also a good age to introduce your baby to a cup. Buy one with large handles and a lid (a "sippy cup"), and teach your baby how to maneuver and drink from it. You might need to try a few different cups to find one that works for your child. Use water at first to avoid messy clean-ups. Serve only 100% fruit juice, not juice drinks or powdered drink mixes. Do not give juice in a bottle and remember to limit the amount of juice your baby drinks to less than 4 total ounces (120 ml) a day. Too much juice adds extra calories without the nutrition of breast milk or formula. Drinking too much juice can contribute to obesity can cause diarrhea. Infants usually like fruits and sweeter vegetables, such as carrots and sweet potatoes, but don't neglect other vegetables. Your goal over the next few months is to introduce a wide variety of foods. If your baby doesn't seem to like a particular food, reintroduce it at later meals. It can take quite a few tries before kids warm up to certain foods.

Daily Dose

Treating Diaper Rash

1:30 to read

Diaper rash is one of those nasty little problems that most infants and toddlers will experience at some time and that means their parents will have to deal with it. In most cases diaper rash is due to the fact that children in diapers have skin that is in constant contact with urine and stool. Despite frequent diaper changes, and hypoallergenic, fragrance free wipes, diaper rash can happen to any baby. Some children have very sensitive skin and are more prone to diaper rashes.

Diaper rash does not mean that you are not changing diapers enough, or that you need to change brands of diapers or wipes. It most cases it just means that your child's "butt" needs to be more protected. Diaper rash "potions" come in many forms, creams, lotions, ointments. I prefer a diaper cream that is thicker and has zinc oxide as a base as it is more protective and acts as a barrier to the skin. Others may prefer a petrolatum based diaper cream like A&D or even Aquaphor.

Many times you may try several different products and each parent/your-baby duo has their preference. If a diaper rash is persistent despite using a diaper cream, then your your-baby may have developed a secondary yeast (candidal) diaper rash. This often looks like diaper rash with small red bumps that are spreading, "satellite lesions", as they are called. But sometimes, a yeast infection does not look like classic, but may just be a red diaper rash that does not get better. In either case, try an over-the-counter yeast medication in duo with the regular diaper cream. In most cases the over the counter product will clear it up.

If the rash does not improve, it may require a visit to your pediatrician for a prescriptive anti-fungal cream. Yeast diaper dermatitis is quite common and the ultimate cure? Potty Training!

That's your daily dose, we'll chat again soon!



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