Gardasil, HPV, and Cervical Cancer – PediaCast 031

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Topics

• Gardasil, HPV, and Cervical Cancer
• Government mandates vs Parental Rights
• An Eczema Primer
• Activity-Enhancing Video Games

Links

• New Mexico Prepares to Pass Compulsory HPV Vaccine
• Eczema Article on Wikipedia
• GNU Free Documentation License

Transcription

Michelle: Hi Dr. Mike and I would like to thank you for your informative podcast. I'm a family medicine resident in Hawaii, I have been listening to you from the start and I have referred several of my patients to your podcast as a useful source for parental information. That said, I was hurt by your comments in your most recent podcast. In spite of your disclaimers to the contrary, I thought that you were unfair to Family Medicine doctors.

Indeed it is true that pediatric residency is spent seeing nothing but children, and Family Medicine receives training in multiple discipline, but I would like to find out some of the main benefits of Family Medicine and Pediatric physicians.

Firstly, we are able to follow moms throughout the pregnancy providing prenatal care, delivery and postpartum care. And as a result, we already know all the prenatal history, any complications and their social situations surrounding that pregnancy.

Secondly, we may already care for the rest of the child's family, including the grandparents, the parents and siblings. As a result, we are often quite fluent in the family's medical history and risk factors and are often privy to important social components of a child's life that may otherwise be less apparent.

01:15

Thirdly, and at no point, will the child ever "outgrow" us and need to find adult doctor. We are able to provide care until either the patient or the doctor outlives the other. As you mentioned in your response, all the Family Medicine train for rounds for seeing in-patient pediatrics and outpatient pediatrics rotation.

In addition, we see babies and children in our clinics daily and at my program, we residents care for all pediatric patients admitted to our hospital whether they are on our Family Medicine service, or under the care of the only pediatrician at our facility. We respond to pediatric and neonatal resuscitation with laws at the hospital as there are no pediatric physicians on-call and we are also board-certified physicians, also required to stay current with literature and re-certify with a written exam every 7 years.

2:05

I certainly feel that when I completed this residency, I will be able to care for children, their parents and their entire family. And as in the key with any primary care specialty, it is very important to recognize a limitation to the training and knowledge and to seek help when you reach that limit.

If a child or any patient for that matter becomes ill beyond my capacity, I would contact a specialist. As I would expect you or any other health care provider to do in this similar situation. I hope that in a future podcast, you would please be kind enough to mention that Family Medicine is indeed comprised of capable physicians, who are prepared to take excellent of you and your whole family. Thank you again for the informative podcast, Dr. Mike. Have a nice day.

Announcer: This is Pediacast.

03:00

[Music]

Announcer: You're listening to the Tripod Network. What's on?

[Music]

Hello Moms, Dads, Grand Moms, Grand Pas, Aunts, Uncles and anyone else who looks after kids.

Welcome to this week's episode of Pediacast, the Pediatric Podcast for Parents. And now, direct from Birdhouse studios here's your host, Dr. Mike Patrick Jr.

Dr. Mike Patrick: Hello everyone! And welcome to Pediacast, the pediatric podcast for parents. This
is Dr. Mike Patrick Jr. coming to you from Birdhouse studio, and I'd like to welcome everyone to the program.

As you can see from our introduction, I've been getting myself into a little bit of trouble. [Laughs] After a member, as I said here in Birdhouse studio which is actually the basement of my home, that there's actually people out there who are listening to what I have to say and I should probably be more careful about how I put things and be a little bit more respectful of others.

04:16

But, Dr. Michelle from Hawaii, I think that you did a fantastic job representing your specialty. I do believe your comments pretty much speak for themselves. So, consider myself corrected on some of those issues.

Alright, let's go ahead and move on. We have a full show for you today so I want to get right into it. We're going to be discussing Gardasil and HPV which is human papillomavirus and it's associated with cervical cancer and its association with cervical cancer.

Gardasil is the new immunization to protect against HPV which again is the virus associated with cervical cancer. So we're going to talk a little bit about a news report about that vaccine, and also talk a little bit about government mandates versus parental rights. And I'm going to give you a little bit of my opinion on that.

05:08

Also then the bulk of the program is going to be spent looking at eczema this week. We have an eczema primer and we had had several questions about eczema in the last few weeks so we're going to sort of combine all those questions together and get to the answers.

And then we'll wrap things up this week with our research roundup. We're going to be talking about the effect of activity-enhancing screen devices on children's energy expenditure. So that's coming up in the research roundup of this week's program.

Let me remind you that if you have a question for us here at Pediacast, it's really simple to get a hold of us. Just go to the website which is www.pediacast.org and click on the contact link. You can also email us at pediacast@gmail.com. If you prefer to send an audio comment like Dr. Michelle did, you can attach an audio file and send it via Gmail or you can call our Skype line at 347-404-KIDS that translates into 5-4-3-7.

06:16

And if you are a fellow Skype user, we are "pediacast." That's our screen name on Skype so you can get a hold of that way as well. I wanted to put in plug here for the blog. the Pediascribe blog. My wife took that over. It's been a couple of weeks ago now and she's done a really good job of keeping it up to date. She's been having posts each weekday for the last couple of weeks and she's done a good job keeping up with it.

It's really not so much geared toward pediatric medicine, but really more on life as a mom, and I think it's a good supplement to the program. The only issue I had with it is [laughs] it really goes into our personal life a little bit more than sometimes my patients may expect.

07:04

In fact I was in the office late last week and I had a mom come in and say, "Hey I really like reading your wife's blog," and then she went on to say that she tells her husband all these things that are in the blog and her husband said, "Well that's kind of weird that you know so much about our pediatrician." [Laughs]

So there are some personal things in there. But you know we're definitely humans like everybody else, you know. And we have our faults and our pet peeves and our issues and problems and it's all right there in the blog. If you haven't been to Pediascribe, the blog, you want to go to pediacast.org, click on the blog link and you can get to it that way, or go to pediascribe.com, that will get you there as well. So if you haven't checked that out, I included encourage to do so.

Well I had my root canal a week ago today and I just mentioned this in the last podcast that I was kind of anxious about it, but everything went fine, really. You know, I survived.

08:01

And the doctor who did it did a very nice job. So kudos go out to him, or shout-out to Dr. Hingley. Thank you for taking good care of my mouth. See? I still sound pretty much the same. So it couldn't have been too bad.

Alright before we move on, I would like to remind you that the information presented in Pediacast is for educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, call your doctor and arrange a face-to-face interview and a hands-on physical examination.

Also your use of this audio program is subject to the Pediacast Terms of Use Agreement which you can find at Pediacast.org.

We'll be back and get right into the News Parents Can Use segment of the podcast right after this break.

[Music]
09:30

Okay welcome back to the program. In the News Parents Can Use segment, we have an article from Catharine Paddock at Medical News Today. This is "New Mexico Prepares to Pass Compulsory HPV Vaccine." New Mexico is about to pass legislation making it compulsory for girls going into the 6th grade to be vaccinated against the Human papillomavirus.

HPV is a sexually transmitted disease that is known to cause 70% of cervical cancer cases. Cervical cancer is the 5th leading global cause of cancer death in women and it kills 250,000 women each year. In the United States every year there are 10,000 cases and nearly 4,000 deaths from cervical cancer.

10:16

Now in addition to New Mexico, the Virginia State Legislature has passed a bill which their governor [Laughs] I got my lips moving here today, Timothy Kaine has also said that he will sign and in Massachusetts, the governor's budget proposals make provision for a voluntary program for girls age 9 onwards.

Governor of Texas Rick Perry issued an executive order bypassing the state legislature to make vaccination for girls entering the 6th grade compulsory from September of next year.

However, Perry's move in Texas has generated a backlash by conservative opposition and some parent groups who say this was too hasty and it interferes with parents' right to decide when their daughter should be introduced to interventions of a sexual nature.

11:07

Others say that it compromises the state's sex education policy of abstinence. A recent report by health officials in Texas titled, "Cervical Cancer in Texas" says that the cervical cancer rates in Texas are highest among Hispanic women with death rates being highest in Black females.

Cases and deaths have higher rates in rural than in urban populations, say the report which estimates an annual rate of 1,100 cases in nearly 400 deaths in the state. HPV is the most common sexually transmitted virus in the United States and the majority of infections clear up on their own with carriers not even aware they have had it.

The National Cervical Cancer Coalition estimates that about 80% of female Americans are affected by the time they reach the age of 50. The Food and Drug Administration last June approved Merck's 3-dose Gardasil for use as an HPV vaccine for girls and women 9 to 26 years of age.

12:08

Gardasil is so far the only HPV vaccine ready for market that has been approved. Glaxo-Smith Kline is also developing its own brand of cervical cancer vaccine which will be called Cervarix.

So you know, generally speaking, I personally am not big on government mandates. I mean I'm all for parents' rights, and while I believe in the importance of immunizations including Gardasil, I still would prefer in a perfect world you know that parents make educated decisions regarding the immunization of children.

But I would like to make one point that many of these news stories that have been coming out are sort of missing. Gardasil is expensive. And it's 3-dose series that's given over a 6-month period and each of those three doses costs around $150.

13:00

So we're talking $450 for the three doses of the vaccine. Now, when you consider that the highest rates of cervical cancer in a big state like Texas are among Hispanic women and the highest death rates are among Black females, you know you have to wonder, are these groups who are having the most problem with cervical cancer, are they going to be the ones getting the immunization, if it's just up to the parents?

Now, that's not to say that Hispanic and Black moms and dads are more negligent as a rule. It's just that, there is more poverty in these groups and more poverty means less access often to medical care. And so a voluntary fee for service vaccine schedule will really miss the group that needs it the most.

Now the by making the vaccine mandatory, school officials will make sure that kids are protected by notifying the parents of children who haven't had the vaccine so they will require documentation, the kids will take the documentation home and you know parents will have to go to their doctors to get the immunization before their kids get back in school.

14:09

The advantage to that then is that these kids who otherwise will be missing medical care will be sort of forced into getting some of that care. And by and large, I think that the people who don't like the government stepping in the most are going to be the ones who are sort of offended by it, and think "Well I want to make that decision and decide when my kids could go to the doctor," and what we are trying to do, in my opinion is more, make it so people who wouldn't necessarily even think about taking their kids to the doctor, this is sort of an intervention to say, "Well, you need to do it."

The other thing is that state welfare programs and private health insurance plans are more likely to pay for this expensive vaccine, if the law requires it. You know, in general I tend to be a social conservative and I'm all for parental rights. So don't get me wrong here.

15:02

But mandated shots can increase vaccination rates in the group of kids who need those immunizations the most. And if you look at this from a public health standpoint, really we all benefit from less cervical cancer in the community in terms of loss of productivity and the cost of treating cases of cervical cancer in women who are on public assistance.

Vaccinating a population with a proven vaccine will be cheaper than treating the cases of cervical cancer that would otherwise result, both in terms of money spent and of course, the emotional impact of the disease.

Government mandates would force the inclusion of the vaccine in the National Vaccine Injury Compensation Program which protects vaccine manufacturers and doctors from vaccine liability by providing compensation to families for adverse effects from vaccines. Without this protection,
large lawsuits may diminish the incentive for future vaccine development and may also keep some doctors for providing vaccines because of liability concerns.

16:01

I received a number of emails asking my opinion on this matter, and while I keep the politics out of Pediacast, I'm going to include it this week. I am for mandated immunization against HPV, the virus associated with cervical cancer not because I am for governments telling parents what to do. Frankly I hate that! But government mandates will ensure protection for these kids who need the vaccine most. And the kids with the least access to vaccines and the kids will most likely to need public assistance later in life during their expensive treatments of cervical cancer. So there you have it. An opinion! [Laughs] If you have a different one, let me know and we may include it in a future show because we all know how much I like to put different opinions out there — you know, opinions on sleep issues, opinions on speech therapy, opinions on family practice doctors. [Laughs] Opinions get me in trouble sometimes, but look, opinions open up dialogue and in the end that's an important thing. Alright we'll
be back with our listeners' segment right after this break.

17:08

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Okay this week, our let listeners' segment is going to focus on eczema. So here we have a topic show. We're just going to talk about eczema during the listeners' segment. It's a very common skin condition seen in babies, children and adults. And I've had several recent questions pertaining to eczema so I thought we could lump them all together and just have a grand eczema discussion. And I hope this will answer all your questions about the disorder.

18:05

So, without further ado, let's move on to your questions.

First up is Jennifer from Indiana.

"Alright, first let me say thank you for the service you provide for parents through this podcast. It's a wonderful resource and I really enjoy listening to your answers to listeners' questions. I have a 6-month-old daughter who seems to have some food allergies or intolerances. My 4-year-old son was the same way and is dairy allergic and my husband also has food allergies. My daughter is nursing and does not tolerate any dairy among other things in my diet. She also has terrible eczema which we know can also be related. Even though it may not be pleasant to talk about, one of my questions is actually about her poop. Everything I have read says breastfed babies' poop should be seedy and smell like buttermilk. That is how my son's was. But my daughter's smells horribly like rotten eggs. It's a very strong sulfur smell and it's been that way for several months. Is this possibly related to an allergy or something that she is not digesting appropriately? Also if we see a specialist for the eczema, would you recommend an allergist or a dermatologist? Thanks again for all your insight."

19:13

Okay next is Carrie from Michigan.

Carrie writes, "Hello again, Dr Mike. I wrote you previously regarding the car seat and my tall skinny son who is outgrowing it lengthwise. I'm happy to announce he's finally been approved into a big boy car seat. Thanks for the information you provided. I really appreciated it. I do have another question, though, if you have time." Of course I do. "Due to the cold weather, my son has developed really bad eczema. He has it on his face, neck, chest, stomach, back, arms and legs, you name it. My mother-in-law said my husband had it just as bad when he was a child if not worse. I took my son to the doctor for it earlier but at that time, he only had two small spots on his legs so the doc said to put some cortisone on it, and that should take care of it."

20:01

"Since then it's gotten way worse and we've been using Eucerin lotion since his skin gets so dry and we'd go through a tube of cortisone a day and if we coat his whole body in it. We don't take him outside unless we have to since it's so cold out which seems to make it worse. Do you have any other suggestions? Should we stick with the cortisone and just buy the family-size tubes? Just curious if you might have any ideas. Thank you for your time and I am still listening. Have a great day."

Then next we have Lindsey from Florida who says, "Hi, Dr. Mike! First of all I absolutely love the show. Please keep up the great work. Anyway, I was wondering if you could take a little bit of time to talk about eczema. I'm a new subscriber to your podcast and haven't had a chance to listen to all of the episodes but I looked in the show notes and didn't see where you had talked about it before. My 3-year-old son has suffered with eczema since he was a baby but bit has gotten worse in the last 6 months or so. It used to be just on his buttocks but now it's down to his legs and the backs of his knees and his neck and can pop up pretty much anywhere else."

21:03

"He takes a bath every other day and I slather him up with extra moisturizing lotion and when he is particularly itchy in a certain area, I use hydrocortisone, but I'm not sure what else to do. I've read that the prescriptions that are available are only used in very serious cases because of the side effects. The worst part is that since he is only 3 it's very difficult to make him stop scratching and it frequently breaks the skin. I was wondering if you had any suggestions and if you could talk about the causes and symptoms of eczema. I really appreciate all you do."

And finally Brenda from Indiana says, "Hi Dr. Mike still listening, love the podcast. My 9-year-old daughter has tiny red bumps on her lower cheeks and jaw area and the back of her arms. They are not very noticeable. She has had these since she was a toddler, maybe an infant. When she was smaller the doctor gave us a prescription for a lotion — sorry I can't remember what it was, just in a big, white bottle" well that should help, "but he indicated it might only minimally help and that she would eventually grow out on him in adulthood. "

22:08

"The bumps are apparently fairly common and that nothing in particular causes the rash. Should I take her to a dermatologist or let time play its role? I certainly would not want to ignore this if there was something else I could or should be doing. Also, on the podcast, you have mentioned the second chicken pox inoculation. Will children who have had the first shot at some point need to have a second shot? Also please clarify regarding the commitment to flu shot, once they are initiated. Is this only for egg-intolerant children or all children, not that I plan on not getting them their flu shot. Will children who have had a vaccine and miss a year run a high risk of getting the flu and getting it with more severe symptoms?"

Okay these are the questions and as you can see a bulk of them deal with eczema, so I'm going to take a short break and then we'll return with a comprehensive pretty discussion on dry skin and eczema.

23:05

Oh and of course there some other questions thrown in there you know dealing with poop smells and flu shots and of course we'll address those issues as well. So we'll be back and address all of these things right after this break.

[Music]

Okay so let's talk about eczema. Now before we begin, I would like to mention that portions of this discussion come from Wikipedia and these portions have been modified by me to ensure accuracy, to clarify points, and to suit the needs of my audience.

24:10

My use of this material and any modifications I make are in accordance with the Wikipedia GNU free documentation license and any re-use or further modification of this material must comply with the terms of this licensing agreement. There are links to any and all articles I used from Wikipedia and a link to the GNU free documentation license in the show notes at Pediacast.org.

So let's start with the definition. Eczema is a form of dermatitis or inflammation of the upper layers of the skin. The term "eczema" is broadly applied to a range of persistent or recurring skin rashes characterized by redness, skin edema, itching and dryness with possible crusting, flaking, blistering, cracking, oozing, or bleeding. Areas of temporary skin discoloration sometimes characterize healed lesions and scarring can sometimes result; however, this complication is rare.

25:03

So let's talk first about the common forms of eczema. The first one would be what we call atopic dermatitis, and this form is believed to have a hereditary component to it and often runs in families whose members also have hay fever, or allergic rhinitis and asthma. Itchy rashes particularly noticeable on the face and scalp, neck, insides of the elbows, behind the knees and the buttocks. Experts are urging doctors to be more vigilant in weeding out cases that are in axiality irritant contact dermatitis. It is very common in developing countries and rising.

Okay so what's contact dermatitis? Well, it's kind of another form of eczema. Contact dermatitis has basically two forms of it. There's allergic contact dermatitis which results from what we call a delayed reaction or delayed sensitivity to some allergen such as poison ivy or nickel and then there is irritant contact dermatitis which results from a direct reaction to say, a solvent.

26:08

Some substances can act as both an allergen and an irritant and an example of that is wet cement for some people. Other substances cause a problem after sunlight exposure bringing on phototoxic dermatitis. About three quarters of cases of contact eczema are of the irritant type which is the most common occupational skin disease.

Contact eczema is curable provided the offending substance can be avoided and its traces removed from one's environment. And then the third type of eczema is seborrheic dermatitis. And we discussed this last week when we talked about cradle cap in babies. And just to remind you, this form of eczema is seen as dry or greasy scaling of the scalp, cheeks and eyebrows and scaly pimples and red patches sometimes also appear on affected skin. In newborns, we often see a thick, yellow, crusty scalp rash commonly referred to as cradle cap.

27:05

Okay so those are the forms of eczema. Now how do we diagnose it? Well eczema diagnosis is generally based on the appearance of inflamed itchy skin in eczema-sensitive areas such as face chest and skin crease such as the insides of elbows and the back of knees.

Given the many possible reasons for eczema-like flare-ups as well as other disease processes — you know they can look like eczema. Doctors should see your child to diagnose this skin condition and initiate a treatment plan. Here are some of the things in the history portion of the visit
that your doctor will likely ask.

They want to know about the family history — you know is there are a lot of eczema in the family, psoriasis, people who see dermatologists or allergists or take medicine for their skin, also dietary habits lifestyle habits, allergic tendencies, any prescribed drugs that you may be taking and a potential chemical or material exposure at home, school, or for teenagers, in the work place.

28:03

To determine whether an eczema flare is the result of an allergic reaction to a particular substance, your doctor may test the blood for the levels of antibodies and the numbers of certain types of cells. In eczema, the blood may show a raised IgE, just a type of immunoglobulin or eosinophilia,
which is shown up in the blood count as a certain type of white blood cells that are seen in higher percentage.

The blood can also be sent for RAST tests which we talked about before when we discussed food allergies and in these tests blood is mixed separately with many allergens and the antibody levels are measured. High levels of antibodies in the blood signify an allergy to that particular substance.

Another test for eczema is skin patch testing and the suspected irritant here is applied to the skin and held in place with an adhesive patch. Another patch with nothing on it is also applied as a control.

29:00

After 24 to 48 hours, the patch is removed and if the skin under the suspect patch is red and swollen, the result is positive and the person is probably allergic to that particular substance. And then very rarely, diagnosis may involve a skin biopsy or removal of a small piece of affected skin for microscopic evaluation in a pathology laboratory.

Now blood tests and biopsies are usually not necessary for the diagnosis of eczema. However, they are useful if the symptoms are unusual, severe or if you need to identify particular triggers. In the case of run-of-the-mill eczema, the diagnosis can often be made based simply on the history and a quick physical examination by your doctor.

Okay let's say that your child does have eczema, you'll take him to the doctor and they'll look at it, they'll say, "Yup, it looks like eczema," what do you do for it?

Well the basic treatment, the first one is going to be moisturizing the skin. I mean dermatitis and eczema basically is a dry skin problem.

30:04

And you want to keep the affected area moist and that can promote healing and retain natural moisture and this is really the most important self-care treatment that one can use in atopic eczema.

The use of anything that may dry out the skin should be discontinued and this includes both some normal soaps and bubble baths which remove the natural oils from the skin. Now right there you know, this is something that a lot of parents, when I see kids with bad eczema, that really catches them by surprise. You would think that washing would actually help because you are applying water to the skin but the use of soap disrupts the fat layer on outside of the skin and then when you get out of the bath, the bath water evaporates, and because you're missing now that fatty layer of protection or that oily layer of protection, skin water evaporates with the bath water that's on the surface of the skin, so you end up drier than you were before the bath.

31:01

So definitely frequent daily bathing in kids who have bad eczema typically will make the eczema worse. So what you want to use for a moisturizing agent is not water which is going to evaporate and take skin water with it. But you want to use a moistening agent that's called an emollient and the rule to use is you want to use a thick ointment to the areas where the eczema is the worst. You want a thick cream that's very fatty or oily in nature and what that's going to do is basically make a fat layer on top of the skin that's going to keep skin water from evaporating.

Now the nice smelling creams and ointments and lotions, those typically have more of a water component. So if you can get the cream or the moisturizing ointment out of a pump bottle or a squeeze tube, it's probably more of an aqueous cream even though it smells good, once you rub it in, it's going to evaporate and not really work as well.

32:08

So what the kind of cream that you want is going to be the thick creams that are in jars. And the Aquaphor Eucerin cream, which is E-U-C-E-R-I-N, these are all good ones. And they are almost tough to put on because they are greasy. They can be sort of thick so it's almost like rubbing a greasy dough on the skin. Even Vaseline works better than the water-based creams.

So you want something that's in a jar that you scoop out that's really thick and kind of greasy, and not so much the thin creams that have a nice smell and come out of a squeeze tube or a pump bottle. So you want something thick.

Now you want to apply that a couple of times a day and even when the skin is looking good in the areas that are prone to getting eczema or getting dried out, even when the skin looks good, you really want to use these moisturizing creams on that to prevent the eczema flare-up in the first place.

33:09

Now, let's say, and really, the maintenance therapy for most people are just going to be these thick moisturizing creams. That's really all that you need to do. But what about when you actually have flare up and your child is itching. Well in that case, antihistamine medicines are going to be useful. If they're really itching a lot, you can give them some Benadyrl, which is an antihistamine that can make you sleepy. It's a really strong antihistamine, but if they are itching a lot, that's going to help. Of course you want to consult your doctor before you do that and talk to your doctor about what kind of dose that you need to use. Now, another type of antihistamine that we've talked about before are the ones that don't make you so drowsy and they are not quite as strong, things like Zyrtec, Claritin, Allegra, Claritin the generic, over-the-counter form is called the loratadine.

34:01

And with some folks with eczema who have just sort of a mild itch associated with eczema may very well be that a daily dose of Zyrtec or Claritin or Allegra, these kind of things, loratadine, may help to prevent some of the itching associated with dry skin. So that's something else you know you want to talk to your doctor about if itching is a particularly bad component with your eczema.

Now the next portion of treatment of acute flare-ups of eczema is going to be the corticosteroids and the most common one is going to be the 1% hydrocortisone cream that you can get over-the-counter. Now how that works is with most of these atopic eczemas, there's some allergen that your body is making antibodies against and then the antibodies and the immune reaction result in inflammation and the hydrocortisone cream basically interferes with the body's ability to make the inflammation. So usually it really calms down allergic type eczema by breaking that inflammation cycle.

35:02

So it seems like "Wow, hydrocortisone cream, it works so well. We should just use that all the time, and instead of using moisturizing cream, you know just get the big family sized bottle of hydrocortisone cream or tube and just use that constantly." Well the problem is too much hydrocortisone cream can have issues of its own. It can cause damage to the skin, thinning of the skin. It can increase and decrease skin pigmentation. That's generally more of an issue with African-Americans, Hispanics, and other darker-skinned races but you know then again, uncontrolled inflammation from the eczema itself can also cause increased or decreased pigmentation. So you know sometimes it is a no-win situation. You are going to have some pigment changes because of the uncontrolled eczema or because of the constant use of steroid creams.
You know you also worry about total body steroid exposure over long periods of time.

36:01

The steroid does get absorbed and goes into the blood stream and if you are using too much of it over too long of a period, there are issues with the growth that can be a problem and other immune system issues and also what we call the adrenal axis which your body is making its own corticosteroids and hormones and if you are putting too much of it own, your body kind of shuts down its own production and begins to rely on the steroid that you are providing so then if you stop, you can have sort of a low steroid type of crisis.

You know, you don't want to use too much steroid because that can cause problems of its own like we've just mentioned. So if it's really mild eczema, you don't want be slathering hydrocortisone cream on it day and day out and you know if it's not really itchy, it's not real disfiguring, sometimes it's better I think you know just to do the — cut back on bathing and also use the moisturizing creams but you know, don't do the hydrocortisone cream unless it's really a flare.

37:04

Now in some cases, the eczema is really bad and the 1% hydrocortisone cream is not quite enough and there are prescription strength steroid creams that you can use — things like Westcort, Elocon cream, Locoid is another one and then those come and cream form and they also come in ointment form which is even more potent. Now for some folks you know we're saying, well, don't use too much steroid, it can cause all these bad things but again, uncontrolled eczema particularly if the broken down skin is starting to get infected and you got impetigo, I mean those are also issues and you really need it to get under control so in those cases, brief uses of the higher potency steroids sometimes are required. And then in really bad cases, sometimes we even have to use small bursts of oral steroid prednisolone Orapred like we've talked about before with asthma, sometimes these are needed more to really calm down a very severe outbreak of eczema.

38:07

Now another medicine that's used in eczema treatment is what we call the non-steroidal immunomodulators and these are nonsteroids that also have an effect at treating and preventing eczema outbreaks and these are medicines like Elidel and Protopic and I think these are the prescription medicines that we were talking about with some of these questions that I have mentioned from listeners. These types of medicines, Elidel and Protopic and others suppress the immune system by a different mechanism than the steroids do. And daily use of these have been
shown to really be a good preventative type program for many folks so in addition to using a moisturizing cream every day, a couple of times a day, using a medicine like Elidel or Protopic everyday really does a great job of suppressing the immune system and keeping the eczema flare-up from happening.

39:02

Now of course, whenever you have advantages, there are issues. And there have been some studies that show a relationship with certain kinds of cancers including lymphoma with the use of medicines like Elidel and Protopic. Now before we get too crazed about this finding, let's think about the cause of eczema, you know is your immune system going a bit haywire. So you know, you'll have these antibodies that you sort of overreact and cause a lot of inflammation and the allergens whatever it is that you are allergic to stimulate the antibodies and the antibody attack causes the inflammation which we see as eczema. Now if you look at lymphoma, lymphoma is a cancer caused in part by an immune system gone haywire. So the question is this, you know if you have folks with more severe cases of eczema, they are more likely to need fancier medications like Elidel and Protopic. So do these medications cause lymphoma or is it the people with bad eczema, caused by immune systems gone haywire, have a higher risk of lymphoma because that's also caused by immune systems going sort of haywire?

40:16

So we're still sorting out the answer to the question but I do think that these probably are some of the prescription medicines that Lindsey in Florida had asked about these and the higher potency steroid creams. So I mean, yes these medicines are reserved for the most severe cases because of the possibility of this adverse reactions but you know sometimes, again you have to look at risk versus benefit and if you have someone who is just miserable with itching and nothing else is working, or the skin is getting infected, then you do have to take those risks and use the higher potency steroids and or use steroid creams over a longer period of time or use the Elidel or the Protopic despite the fact that there could be this association.

41:01

But you know, if you don't get the really bad eczema under control, you know we can get skin infection which could go to the blood and you can become septic so you really have to look at the advantages and disadvantage of everything you do and that's why you want a doctor who you trust and who will explain these things to you and say yes, the studies show that maybe there's a relationship between lymphoma and these medicines but let's explain why and is it worth us taking that risk for this particular problem and the answer to that may be yes, it may be no. That really depends on your particular situation and the discussion that you have with your doctor.

Okay I also want to mention some seasonal issues with eczema. The amount of humidity in the air also plays a big role with eczema. So here in Ohio, we definitely see worse eczema during the winter time and the reason is that the air is drier in the winter and inside your house, it's also drier because as the heaters kick on during the cold season, that generally dries out the air.

42:04

So in my practice, I see lots more eczema problems in the fall, winter, and early spring and a lot less of that problem in the late spring and into the summer because there's a lot more humidity and moisture in the air and that really seems to help out a lot. I suspect that if you live in a place where there's a lot of humidity, like the southeastern United States — Florida, Georgia, Alabama, you know these places — there is not quite as much of an eczema problem as there is up north. So you know, that's the time of the year in you may just have to do your eczema treatment more in the winter and the fall, and the early spring than you do in late spring and summer. And if you're a parent with a child with eczema you probably already know that. Also since humidity in the air is helpful as seen by the fact that in the summer there's less eczema, it stands to reason that during the dry season, a humidifier in the bedroom may help out a little bit because if your child is at least sleeping in a moist environment, that may help their skin out as well.

43:08

So, in addition to the emollients and the moisturizing cream to keep moisture in the skin, having your child sleep in a moist environment with a humidifier probably helps a little bit too. Jennifer in Indiana had asked about allergist versus a dermatologist. First let me say that your primary medical doctor, whether that be your pediatrician or your family practice doctor can treat most cases of eczema. Severe cases that are not responding to several modes of treatments like antihistamines, the moisture therapy, possible intermittent use of steroids and those immunomodulators such as Elidel and Protopic, if none of these things are working, then you know there may be some benefit from a referral to a specialists to see if they have any other tricks up their sleeve. Most common reason to send a child like this is for the skin testing so you can try to figure out what it is that they are allergic to or what might be the factors that make them have the so they can figure out what to avoid.

44:11

If skin is the only problem, now I think the dermatologist would be fine. But a lot of times, these kids with really bad eczema also have asthma and or allergic rhinitis along with it and if that's the case, I'll probably go more with an allergist than with a dermatologist. Now of course it's going to depend on who's available in your area and what particular doctors your primary doctor trusts and refers to so all in all I think either is probably fine but again but it's more of just a skin issue, you know a dermatologist is okay, and if it's more of an asthma and allergy type thing with the eczema which is very often the case, then the allergist or an immunologist is also someone that you could go see. And a lot of allergists also had immunology training as well.

45:01

But there are some infectious disease doctors who are immunologists too. If there is a big asthma component that you're having trouble getting under control, you could consider a pulmonologist or a lung doctor as well. But the bottom line, eczema type stuff, here's sort of a take home, you know if your child has bad dry skin, start with your regular doctor. The first thing you're going to advise is increased skin hydration, decreased bathing, lots and lots of thick emollient, you know the kind that's really thick and comes in a jar, and then for the flares, 1% hydrocortisone cream that's over the counter twice a day for five to seven days. I mean you may need to use it more often longer, even daily in some cases, but you want to consult your doctor before you do that again because of the adverse effects that are possible. Of course, antihistamines for the itch, the big guns — Benadryl, Atarax or hydroxyzine as a prescription antihistamine that's strong like Benadryl and then there's the sort of milder non-sedating type antihistamines that you could consider like Zyrtec and Claritin.

46:05

With seborrheic dermatitis we have some scalp involvement. We talked about this last week. Selsun Blue shampoo is helpful because oftentimes, there's a yeast that's associated with cradle cap and seborrheic dermatitis of the scalp. Also, not just soap because it disrupts the fat layer but also just as an allergen, a lot of times soap will cause some eczema flares. So you want to use hypoallergenic soap and might want to consider Dreft as a detergent. Also a lot of patients I have them double rinse their wash so that you use a little less laundry soap for your kinds who have bad eczema, use less laundry soap, double rinse so that you really get all the detergent out and then don't use any dryer sheets because the dryer sheets, as they tumble with the clothes, basically coats the clothes with the chemical that yet makes it not have static cling, but this chemical touching the skin can cause some allergic type reactions and result in eczema.

47:04

Also, if there are certain foods — again, this is where some of these blood tests may come in handy if there's a food, milk in particular can do this so can dairy where you have eczema flare-ups from food. Also I wanted to mention too — I know a lot of the dermatologists that I had trained with recommend unscented Dove so that's something that's pretty hypoallergenic soap that you might want to try. And then also watch out for impetigo, or skin infection associated with eczema and in that case you may need some Neosporin or a prescription antibiotic ointment or even oral antibiotics if there's a bad eczema related impetigo or cellulitis.

And then again the more advanced treatment are going to be prescription steroid creams, prescription steroid ointments and oral steroids. So I hope that this discussion was helpful for most of you out there. Our four ladies this week had some other questions and we'll address all of those things right after this break.

48:06

[Music]

49:16

Alright, welcome back to the program. In addition to the eczema questions, our listeners had some other issues and I didn't want to address those quickly. Jennifer from Indiana asked about baby poop that smells like sulfur instead of a buttermilk [Laughs] and you know, I just want to say that I don’t see a lot of kids whose poop smells like buttermilk so I think you just had a really good experience with your first daughter because buttermilk-like poop is not very common. [Laughs] Okay. The smell of poop is really going to depend on the types of gases and liquid chemicals in the stool which in turn are a product of bacterial breakdown of the food and the unique mix of bacteria in your baby's gut may not be the same as in another baby's gut. And since this mix of bacteria will lead to a unique combination of byproducts, the smell of a baby's poop is also going to be somewhat unique from one baby to another.

50:13

And this of course is true in the animal world. I mean when you think about it, many animals use poop smell to identify one another, you know, butt sniffing dogs — you know it's kind of like a finger print, you know, you recognize them by the smell of their poop [Laughs] that's because depending on the exact bacterial mix in the gut, that's going to determine what byproducts get made when the bacteria is breaking down food and whichever gases and chemicals are made is what results in the smell. So if your baby has smelly sulfury stool, you can blame the bacterial mix that's inside the gut and this is not a problem if your child is healthy and growing well. On the other hand, if they have chronic diarrhea, where there's blood in the stool or extreme fuzziness or vomiting, fever, poor growth, and they have really smelly poop in combination with any of those things, then that may be a concern.

51:07

But if smell is the only issue, I'm less concerned about that. But as always, check with your doctor. Okay and finally Brenda from Indiana — she asked about the second chickenpox shot. It is now recommended that all children receive two chickenpox shots at least one month apart. Most doctors are giving one at 12 to 15 months with the MMR vaccine and there is now a MMRV that combines the MMR with the chickenpox vaccine and then we do the second one usually before the kindergarten at 4 or 5 years of age and again you can do that with the MMR and the Varivax, which is the chickenpox shot separately or in the form of the combined MMRV. Now kids who have had a significant case of natural chickenpox infection do not need the vaccine and kids who have had one vaccine and then maybe a minor case of chickenpox maybe they just had a few pox lesions, scattered around but it wasn't really bad and they seem — your doctor said, "Well it wasn't this bad because they had the chicken pox shot."

52:14

For those kids probably getting the booster is advised. Older kids, with no vaccine history and no natural disease should get two chickenpox shots one month apart. And then with regard to the flu vaccines, my point from a few episodes back was if a child gets natural flu, there is evidence to suggest that a kid's naturally obtained immunity against the flu is stronger and lasts stronger than the protection you get from a flu shot. Therefore if children get flu shots, it's important that they get them year after year because the shot from the year before will be wearing off and there maybe a new strain in the new shot each year anyway and with no history of natural flu and natural protection, then you're sort of setting them up to get a bad case of the flu when their body sees a particular strain for the very first time and they don't have the protection from last year or the year before's flu shot.

53:08

Now having said that, I do think it's important for kids to get flu shots every year because natural flu disease is significant you know with a week of high fever, potential for dehydration and pneumonia as complication. So, my saying, once you start getting flu shots keep getting them, was not to suggest you shouldn't do it. I was simply trying to explain why you should get them year after year. And those with egg allergies should not get flu shots at all because of egg exposure year after year in the vaccine even though it's a very small amount, can lead to serious reactions down the road as they keep getting exposed to the egg year after year after year.

So, during flu season if you have an egg allergy and you haven't gotten your flu shots, the first sign of the flu or high fever, get right in to see your doctor because if you start a medicine like Tamiflu early on in the flu cycle, then that may help diminish the severity of the disease and also how long the disease is lasting.

54:08

Alright I think we have everything covered and then we'll be back with our research roundup right after this break.

[Music]

Okay welcome back to the program. This week in our research roundup, the effect of activity-enhancing screen devices on children's energy expenditure. [Laughs] Okay. This comes from the Mayo Clinic in Rochester, Minnesota and it was published in the December 2006 edition of the medical journal, Pediatrics. So the effect of activity-enhancing screen devices in children's energy expenditure. Sitting in front of a television, video game or computer screen is consistently associated with low levels of physical activity and the average US home has a TV on for 8 hours per day. Since several activity-promoting video games now exist, investigators at the Mayo Clinic Rochester Minnesota undertook to measure energy expenditure in 25 children ages 8 to 12 years under four different conditions. The first was watching TV seated. The second was playing a video game seated. The third was watching TV while walking on a tread mill at 1 and a half miles per hour. And the fourth was well playing activity-promoting video games.

56:00

The energy expenditure during each activity was measured with a high-precision indirect calorie meter built specifically for use with children and the activity promoting video games that they use were EyeToy made by Sony and there was a game called NickToons Movin'. And then they also used Dance Dance Revolution UltraMix 2 on the Xbox. Now during each of the four activities, energy expenditure was measured over a 15-minute period. Watching TV or playing a video game, well, seated increased expenditure by about 20% or above resting values for watching TV and about 22% above resting values for playing a video game in a seated position. Now in contrast, walking on a treadmill while watching TV increased energy expenditure not by 20% or 22% but by 138% over resting values and playing the EyeToy Nicktoons Movin' by Sony, that increased energy expenditure by just 108% over resting but playing Dance Dance Revolution UltraMix 2 increased energy expenditure by 172%.

57:16

So the researchers concluded that activity promoting video games have the potential to increase children's energy expenditure to a significant degree. Okay, well this of course seems like common sense. I mean after all, physical exercise equals energy expenditure. We all know that. And we also know that energy expenditure equals calories out which is an important part of weight reduction and a heart-healthy lifestyle. So I say hurray to the game companies for coming out with products that combine gaming with physical activity. I mean as a parent I know how enthralled my kids are with video games and I'm enthralled with them as well at times. [Laughs]

58:00

So if we can combine this interest with something good for physical well-being then I think it's a great thing and hopefully these kinds of studies will help spread the word about the importance of physical activity and how it can be linked to activities that kids enjoy. If parents and teens begin to preferentially buy games that encourage physical activity, then there will be more incentive for the game companies to make them and everything considered, that really would be fine by me. Personally, I've got my eye on one of these Wiis the new Nintendo gaming system that requires plenty of physical activities. So Karen, my wife and personal financial guru and author of the Pediascribe blog, if you are listening to this and need an idea for father's day, you know keep the Wii in mind. After all, research shows, it's good for our family's physical well-being. [Laughs] There now, how's that for a plug. Alright we'll wrap up the show and do that right after this break.

[Music]

59:00

You have no idea I've been standing here all this time. [Shouts]

Okay we're going to wrap up the program. I want to say that Nick did a great job this week. I mentioned last week in the show that he was in the Wizard of Oz as a munchkin and he did a wonderful job. Little problem though, we figured out he was at the Palace theater with all the tech rehearsals and then all the different shows, he was actually at the theater for 40 hours plus last week and when you get together 30 to 40 munchkins for 40 hours in a week, it equals strep throat.

1:00:06

So he woke up this morning with a bad sore throat, we swabbed it and he had streps [Laughs]. Sorry, Nick. Well the Wizard of Oz is over and now we can concentrate on Kathy. Kathy, I want to say break a leg. She is in Kabuki Sleeping Beauty; she plays one of the ghosts which if you remember the Disney version of Sleeping Beauty that sort of translates into one of the fairies. So she's playing that role in Columbus at the Davis Center and her tech week is this week and opening performance will be this Friday and then that performance is actually done over the course of two weekends. So, break a leg to Kathy. There was Nick's turn last week and now it's your turn.

Alright thank yous this week go out to Dr. Michelle from Hawaii. Thanks for calling in and setting the record straight regarding Family Practice doctors. Also, Jennifer and Brenda from Indiana, Lindsey from Florida, and Carrie from Michigan, thanks for bringing up the eczema type questions. Also I want to thank all the rest of the listeners out there and also my family for letting me do this.

1:01:10

And Vlad, over at Vlad Studio for providing the artwork for the website. If you go to vladstudio.com, you'll see his work there. Reminders, www.pediacast.org. Click on the contact link if you'd like to contact us with your own question. You can also email pediacast@gmail.com and if you'd like to send an audio request, you can attach an audio file to your email or call the Skype line at 347-404-KIDS.

Promotional materials are on the poster page of the website and don't forget reviews in iTunes are very helpful as are digs at digg.com. So be sure to tell your friends, family, co-workers and neighbors about the show so we can empower more parents to make great choices about their kids. This is Dr. Mike, till next time, saying stay safe, stay healthy, and stay involved with your kids. So long everybody.
[Music]

01:02:011

The Tripod Network. What's on?