Acne At Different Ages

     Most parents think of acne as being an adolescent problem, but acne can occur at any age.

     Acne in the first few weeks of life is very common. This “newborn” form of acne is mild with small red bumps but no blackheads and minimal inflammation. No treatment is necessary and it usually just goes away with time. It leaves no scars.

     In older infants and toddlers up to age 2, acne can look more like adolescent acne with inflammation, blackheads and pustules. This acne can result in scaring, so the child should be seen by his caregiver and should be treated. The child should also have a good examination to be sure that the child’s growth and development are normal. Acne at this age is much less common than newborn acne, but it does occur.

     Acne in the age group between 2 and 6 years of age is rare and it should always make the parents and the caregiver worry about a hormonal problem. It is probably best to refer children who develop acne in this age group to an endocrine specialist for evaluation.

     Some preteens can get acne. Puberty seems to be occurring at younger ages in this country and acne is often the first sign of puberty. When a preteen gets acne, the child’s caregiver needs to evaluate the child’s growth and development, but, if everything is normal, regular acne therapy should be started.

     For common adolescent acne, there is a product that is heavily advertized on infomercials and in print that is very expensive. This product’s active ingredient is benzyl peroxide, a common acne medicine that can be purchased in any drug store without a prescription and at a much lower cost. The only benefit of the product is that it gives teens a strictly scheduled way of applying it and teenagers are likely to follow it. If the teen would follow the same regimen with the benzyl peroxide from the drug store, it would be every bit as effective.

     If adolescent acne is mild or moderate, their caregiver has ways of treating it that are very effective. If the acne is more severe, a referral to a dermatologist may be necessary. If a teenage girl gets acne at the time of her periods and then the acne improves when the period ends, regular acne therapies may not be effective and she may need to go on a high-estrogen birth-control pill to control the acne.

    

Immersiion In Water During Labor And Delivery

     Immersion in water has become popular in certain circles and many facilities offer it as an alternative way to give birth. The April, 2014 issue of Pediatrics published a joint clinical report on immersion labor and delivery issued by both the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.

     Advocates of immersion during labor and delivery argue that it decreases pain, decreases maternal stress, decreases trauma to the vagina and gives the infant a gentler transition into the world.

     The report in Pediatrics examined the statistical data available for immersion during both the first and second stages of labor and during delivery. They found that immersion in the first stage of labor was associated with a decreased need for epidural, spinal and cervical pain relief. It also reduced the first stage of labor by about 30 minutes. However, there was no difference in vaginal tears and no reduction in the need for cesarean delivery. They found no benefit to the mother with immersion during the second stage of labor. There was no measurable benefit to the infant from immersion during either labor or delivery.

     The report did find that immersion caused an increase in complications for both the mother and the infant. There were higher rates of maternal and infant infections, especially if there had been rupture of membranes. There were reports of infants having severe bleeding from ruptured umbilical cords, infants having hypothermia and infants having episodes of drowning and near-drowning.

     The most serious complications were the drownings and near-drownings. The advocates of immersion birth claim that the infant is protected from inhaling water by the mammalian diving reflex. A Cochrane review in 2009 stated that they found no adverse effects on the infant from immersion, but this study excluded 12% of the infants delivered by immersion who had to be admitted to the Newborn Intensive Care Unit as compared to none in the group delivered without immersion. It also ignored reports of drowning and near-drowning from England in 1995 and a report in 2010 of 4 infants who had severe respiratory distress after water birth. There is a great deal of evidence in both experimental animals and in human infants that the decrease in oxygen which occurs during delivery causes the infant to gasp (which is exactly what Nature intends the infant to do) and the need to take that first breath overrides the diving reflex.

     The conclusion of the 2014 report was that immersion during labor and delivery should be considered an experimental procedure and that the risks involved dictate that it should only be done as part of a closely controlled scientific study.

Super Head Lice

       When I last wrote about head lice in March, 2012, medications that could be purchased over the counter were still effective in treating head lice.  That is no longer true.  The two medications that can be purchased without a prescription, permethrin and pyrethrin, are no longer effective according to an article published in the Journal of Medical Entomology.  The article states that 99.6% of head lice have a gene mutation that gives them immunity to these commonly used medications. Many head lice are also resistant to two other commonly used prescription medications, lindane and malathion.

     There are three new medications that are available by prescription and are effective in treating head lice. Benzyl alcohol comes in a lotion that is applied for 10 minutes to the hair and scalp and then rinsed off and repeated in a week. (“nits” – the lice eggs - hatch in a week). Spinosad is a lotion that is used in the same way.  Both can cause irritation to the scalp. Ivermectin is available in both a hair/scalp preparation and as an oral medication. Ivermectin kills both lice and eggs, so no repeat dose is necessary. Sulfa-based antibiotics are also used to treat head lice, but they can cause serious allergic reactions.

     Wet combing – using a fine-toothed nit comb after lubricating the hair with a substance to make the comb pass more easily – is now considered the best way to make the diagnosis of head lice. If live lice are obtained by passing the wet comb through the hair., the child has an infestation. However, if a parent sees the child itching the scalp and then notices nits or lice on the hair, the child almost certainly needs treatment. However, simple inspection is not adequate to tell whether a child has been treated successfully. It is thought that after treatment, 28% of children still have lice on their hair and 63% still have nits. This is important because schools bar children with lice from coming to school and many schools have a “no-nit “ policy for allowing the child to return to school – if the nurse sees a nit, the child goes home. This results in millions of needlessly lost school days every year.

     Repeated wet combing is also used as a treatment for head lice for people who don’t want to use medications. The lubricated hair is combed for up to 30 minutes every 3 to 4 days until no live lice are found and then continued for about 2 weeks after that to ensure successful treatment.

     There are many other treatments commonly recommended but without any real scientific proof of effectiveness. Smearing olive oil, petroleum jelly or mayonnaise in the hair doesn’t really “suffocate” the lice. Heat applied through an electric comb or a hair drier doesn’t work, either.

     Finally, many of the recommendations about how to clean the house when a child has lice are part of the general overreaction that we all have as parents when we think of bugs crawling on our child’s head. Lice that fall off the head probably don’t live more than 48 hours and any head louse that would crawl off a nice, warm, bloody scalp in order to attach to a stuffed animal probably wasn’t going to live long anyway. It is reasonable to hot-water wash hats and linen that were used for two days before the diagnosis was made, but putting all the stuffed animals in a bag for two weeks or spraying the furniture with anti-lice spray aren’t necessary. Also, don’t blame the family dog or cat – they don’t carry human lice.  

When To See A Doctor For A Child's Cold And Fever

            When babysitting for a niece recently, Grandma and I were told, “If he gets a fever of over 100.3, take him into the Emergency Room”. Her toddler son is perfectly healthy and has no medical problems, but our niece had been told by a medical person that “any fever over 100.3 was dangerous.”

            Toddlers, especially toddlers in day care, seem to catch a new virus about every two weeks. In this era of poor insurance and high co-pays, it is important that young parents know how to tell if a child needs to examined in a medical facility or if observation at home is appropriate.

            Most viral infections start with an evening fever. The child is crabby, tired and has a poor appetite at the end of the day and then develops a fever. The height of the fever is unimportant – fever that comes with a viral infection is never dangerous. If, after an age-appropriate dose of a fever/pain reliever is given, the child seems to feel better, the parents should just watch to see if the child acts any sicker.

            Within the next twelve hours, the virus will declare itself – the child will develop runny nose and congestion or perhaps vomiting and diarrhea if it is a gastrointestinal virus.

            With an upper respiratory virus (a “cold”), the child can feel pressure and fluid build-up in the middle ear because the swelling in the nose causes blockage of the drainage tube out of the ear. The child complains of mild ear pain and pulls on the ear. The child’s eye can develop some crusting mattering from a similar blockage of the tear duct. The ear pain can be treated with a dose of fever/pain reliever and the mattering in the eye treated with cleansing with a warm washcloth. The nose drainage can be thick or thin and can be about any color. The fever will be up and down for three days. The child will be coughing and feel bad, but will not be severely lethargic or ill-appearing. No cold medications or antibiotics are necessary. The symptoms improve over three days, even though the cough can last for two weeks.

            A complication of a cold is that bacteria can infect the blocked fluid in the ear or the eye. These infections usually develop later in the course of a cold. Daytime fever with a common cold should be gone by the third day. If the daytime fever lasts longer than three days, or if the fever goes away and then returns, it could be a sign of bacterial infection. If a prolonged or late fever is accompanied by more severe or continuous ear pain, the ear may need antibiotic treatment. If the mattering in the eye is persistent or becomes pus-like, it also could be a bacterial infection. If the fever returns on the fourth or fifth day and the cough is getting worse, pneumonia could be developing.

            But, if the child continues to act only mildly ill, the fever goes away in three days and the symptoms slowly get better, the child is probably going to be fine and the parents have made it through one more viral infection.