Cry It Out, Cuts & Scrapes, Herpes or Hand Foot Mouth – PediaCast 345
- We are back with more news parents can use! This week we explore smoking & schizophrenia, techniques for helping babies sleep at night, and the effect early walking has on bone strength. Dr Michael Dunn stops by to talk about summertime cuts and scrapes. And we answer a listener question related to herpes and hand foot mouth disease. We hope you can join us!
- Maternal Smoking & Schizophrenia
- Babies & Sleeping
- Cry It Out
- Bedtime Fading
- Graduated Extinction
- Early Walking & Bone Strength
- Cuts & Scrapes
- Hand Foot Mouth Disease
- Help and Support to QUIT smoking: SmokeFree.gov
- Instructions for Bedtime Fading and Graduated Extinction
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children’s, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everybody and welcome once again to PediaCast. It’s a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children’s Hospital in Columbus, Ohio.
It’s Episode 345 for June 15th, 2016. We’re calling it “Cry It Out, Cuts and Scrapes, Herpes or Hand-Foot-Mouth”.
I want to welcome everyone to the program.
Yes, we are still making podcasts for moms and dads from Nationwide Children’s Hospital. We had a little sabbatical for the month of May. It’s mid-June actually now, and we are back and moved in to a brand new state-of-the-art recording studio. It took more than a little bit of work for moving everything and getting it set up.
We’re in a different building now on the other end of our sprawling pediatric campus. After all, Nationwide Children’s is the largest children’s hospital in the United States. And this is our first recording of PediaCast in the new digs.
Now, to be transparent, we did record a PediaCast CME prior to this one on pediatric hypertension or high blood pressure. Those are our Continuing Medical Education podcasts for healthcare providers available at PediaCastCME.org.
And I’ve also recorded a few of our Healthcare Communications in Social Media podcast. We’re working on a curriculum designed for healthcare professionals, free, I might add, who would like to learn more about engaging patients and families and colleagues in social media channels like Facebook and Twitter, writing blog posts — just how do you engage in digital space and do it effectively by some folks who have been around the block for a few years?
All of those programs, by the way, are over at PediaCastCME.org. The hypertension or high blood pressure episode is on the Shows & Notes page. And if you’re interested in the social media curriculums, I know we have a lot of pediatric and other healthcare providers who listen to this show. If you’re interested in our social media curriculum, which again is free, just go to PediaCastCME.org and click on the HCSM tab at the top of the page. HCSM stands for Healthcare Communications in Social Media.
All those shows are also in iTunes and most podcast apps. Just search for PediaCast CME and then add an HCSM to the end there as a separate word and you’ll be able to find those.
So. we produced a few of those professional educational podcasts in the new studio, but this is our first show for moms and dads in the new space and I planned it that way on purpose because I wanted to get the technical hiccups out of the way. And, as it turns out, there were a couple that we had to correct. But this show is my baby. It all started right here on PediaCast and I wanted my ducks in order before we released a show recorded here for this audience.
Most of you, if you follow PediaCast closely, know that in our last space, we’re kind of in a temporary space for a while and using portable equipment with headphones. We got the whole studio setup back up and running, so hopefully, the audio quality is back up on par with the excellence that you’ve come to expect.
So, we’re on full swing again. There may have been an extended vacation in the month of May as well, that’s a part of what took so long, because after a long cloudy cold Ohio winter, one needs a little sunshine and there’s not much better way to do that than spending a few days in Florida. So that’s part of our being away. But, we’re back now and have plenty of the material lined up for you, even today.
We’re going to start out with some news parents can use about maternal smoking — so smoking during pregnancy — and schizophrenia. I think we all intuitably know that it’s bad to smoke during pregnancy, right? Nicotine exposure on a developing fetus can have all sorts of effects including, as it turns out, an increased risk of schizophrenia for the baby later in life. So we’ll take a look at a study and the numbers involved.
Now, in a perfect world, we’d say “Well, no one would smoke during a pregnancy, right?” And maybe you have smoked during a pregnancy or maybe you’re pregnant right now and smoking or you know someone who is pregnant and smoking. We can tell you about the risks and warn and say “This is not a good thing to do. Hey, look here’s another thing that can cause schizophrenia among other things.”
So, convincing a mom to stop smoking during pregnancy whether it’s you or someone you know and you’re going to be the one to let them know about the risks, just telling them about it is not enough. It’s also important that we provide support that moms need to stop smoking because it’s a difficult thing to do.
In our story, we’re going to go beyond just telling you it’s bad, but also give you some practical advice on quitting, as well, so as some resources that you can rely on whether you’re the one trying to quit or you’re a healthcare provider supporting someone who’s trying to quit, we’ll let you know where you can go to get information to help and support because we can’t just stop at telling people it’s bad. We have to help them.
And then in our News Parents Can Use segment, we’re going to talk about the cry-it-out method of getting babies to sleep. So in doing PediaCast for nearly a decade — were coming up on our 10-year anniversary next month — and we’ve talked about babies crying at night many times. There’s usually some backlash related to the cry-it-out technique with parents concerned with letting babies cry at night might cause stress and anxiety in their infant and maybe interfere with parent-child bonding and interactions.
So in light of those concerns, this is a reassuring study. It takes a look at two specific techniques, bedtime fading, and graduated extinction, and we’ll define what those are.
And then, the study goes on to measure baby and parent stress as well as bonding and parent-child relationships down the road to see how the babies and the families fare. So does that really cause emotional trauma to let your babies cry at night? So this study takes a look at that. It’s interesting stuff, so stay tuned.
And then, early walking and bone strength. Could early toddler walking and running and jumping, could that lead to stronger bones, a fewer fractures or even a decrease to risk of osteoporosis in later life? So consider those questions and I’ll fill you in with some answers.
From there, we’re going to move on in our interview segment. The summer season is upon us and with it comes cuts and scrapes. Dr. Michael Dunn is a pediatric emergency medicine physician at Nationwide Children’s. He’s going to stop by the studio to explain caring for cuts and scrapes at home — which ones need seen by a medical provider, which ones can you take care of just at home on your own, and how do you take care of them? Which medical provider should you see — your regular pediatrician, an urgent care, an emergency department, how do you choose? What are the skin closure options that are available and how do providers choose which technique to use? And how do you care for closed wounds at home after your visit? So all that is coming your way.
And finally, is it herpes or hand foot mouth disease? A listener in Canada is not sure which one her child had and she has some questions regarding diagnosis and treatment, which will give us the opportunity to explore both diseases in a bit of detail and to get you primed in case your child experiences either one in the future. They’re both fairly common, hand foot mouth disease probably more so. But it should be and enlightening and a practical discussion for you.
I do enjoy answering listener questions on the program. So if you have one, be sure to ask. It’s easy to get in touch. Just head over to PediaCast.org and click on the Contact link. You can also call the voice line 347-404-KIDS, 347-404-5437.
By the way, we’ve had some really good questions lately. No pressure for those of you thinking about writing in. There aren’t really any bad questions, but I’ve had several that were particularly good to regarding cutting behavior in teenagers and another one related to iron deficiency anemia. If you wrote in with those questions, you know who you are.
I wanted to do really well on these, because they’re important topics. I mean, all the topics we cover are important, but I really thought that getting some specialist into the studio to talk about teenage cutting and iron deficiency would be worthwhile, but it takes a bit more time to schedule interviews and get that all set up. But I think the wait would be worth it.
Of course, all urgent questions should always go to your child’s doctor, not me, right? We don’t practice medicine here and in each of these cases, the folks involved mention they’re working with their child’s doctor already. They just had some questions that would benefit the rest of the audience. So we’ll explore those with some specialists here from Nationwide Children’s in upcoming episodes.
I do want to also remind you that the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you do have a concern about your child’s health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.
So let’s take a quick break and I will be back with news parents can use, an interview with a pediatric expert and an answer to a listener question. That’s all coming up right after this.
Dr. Mike Patrick: Smoking during pregnancy increases the risk of developing schizophrenia for the babies who are exposed to nicotine while in the womb. This, according to the researchers at Columbia University, the New York State Psychiatric Institute and the National Institute of the Health and Welfare in Finland and recently reported in the American Journal of Psychiatry.
Investigators evaluated nearly 1,000 cases of schizophrenia and matched controls among offspring born in Finland from 1983 to 998 who were ascertained from the country’s national registry. Results showed that a higher maternal nicotine level in the mother’s blood was associated with an increased risk of schizophrenia among her offspring. And, the findings persisted after adjusting for important confounding factors including mom and dad’s psychiatric history, socioeconomic status, and the mother’s age.
Researchers say heavy nicotine exposure while in the womb raise the odds of developing schizophrenia by 38% , which they add is the most definitive evidence to date that smoking during pregnancy is associated with schizophrenia.
Dr. Alan Brown, senior author of the study and professor of Epidemiology and Clinical Psychiatry at Columbia says, “To our knowledge, this is the first biomarker-based study to show a relationship between fetal nicotine exposure and schizophrenia. We employed a nationwide sample with the highest number of schizophrenia cases to date in a study of this type.”
Researchers analyzed data from two sources, the Finnish Prenatal Study of Schizophrenia and the Finnish Maternity Cohort, which has archived over one million blood samples from pregnant women drawn during the first and early second trimesters since 1983. The Hospital and Outpatient Discharge Registry of Finland was used to identify all recorded diagnoses for psychiatric hospital admissions and outpatient treatment visits.
So how did the investigators identified heavy smoking during the pregnancy given the fact that the folks diagnosed with schizophrenia in the control group without schizophrenia were inside the womb so many years ago? Well, they went back and tested those blood samples looking for the chemical cotinine, which is a reliable marker of the blood nicotine level when the samples were obtained.
And here’s what they found, the cotinine level was consistent with heavy smoking during pregnancy in 20% of those in the schizophrenia group compared with 14.7% of those in the control group.
Smoking during pregnancy is known to contribute to significant problems in utero and following birth, including low birth weight and attention difficulties. Nicotine readily crosses the placenta into the fetal bloodstream and it specifically targets fetal brain development, causing short- and long-term changes in cognition, and potentially contributing to other neurodevelopmental abnormalities.
Dr. Brown says, “These findings underscore the value of ongoing public health education on the potentially debilitating, and largely preventable, consequences that smoking may have on children over time.” He adds, “Future studies on maternal smoking and other environmental, genetic and epigenetic factors as well as animal models should allow identification of the biological mechanisms responsible for these observed associations.”
Researchers would also like to examine maternal cotinine levels in a similar fashion as they relate to bipolar disorder, autism and other psychiatric conditions.
In a previous study from a different birth cohort, which was also reported in the American Journal of Psychiatry, Dr. Brown and colleagues found that offspring of mothers who reported smoking during pregnancy do have an increased risk of bipolar disorder as well.
So lots of reasons not to smoke during pregnancy, but we’ll add another association to the pile and that is an increased risk in developing the mental illness, schizophrenia. Of course, this is just one co-factor and the genetics and the environment likely play very important roles. After all, 80% of those with schizophrenia did not have mothers who smoke heavily during pregnancy. So abstaining from nicotine will not absolutely prevent schizophrenia, but smoking during pregnancy does appear to increase the risk by about 38%.
So please don’t smoke during pregnancy for this reason and many many others. In fact, it’s best not to smoke at all for your kid’s sake and for your sake. So lots of risk associated with smoking. You know this.
But, another really important point, I think, for all of you, but also for the medical providers out there is, for all of us to realize it can be very difficult to stop smoking. I think medical providers do a disservice to our patients and families when our message of don’t smoke and here’s why you shouldn’t smoke, we do a disservice when the message stops there. So we have to recognize the difficulty and then go on to provide help and support.
So moms and dads who smoke, it’s tough to quit. We get that, but you really do need to for your own health and for the health of your children, and particularly, if you’re pregnant. But please, don’t be afraid to ask for help and providers offer that help and support with a concrete plan, not pie-in-the-sky words of encouragement, but an actual practical plan. That’s what our patients and our families need.
A great place to start quitting is a website from the US Department of Health and Human Services called SmokeFree.gov. Lots of great hints and tips for our patients and providers in terms of helping folks to quit smoking. Again, that’s SmokeFree.gov, and I’ll put a link to it, so you’ll find it easily in the Show Notes for this episode, 345, over at PediaCast.org
Letting babies cry themselves to sleep may not cause the emotional, behavioral, and parent-child attachment issues that many parents fear. This, according to a new study led by investigators at Flinders University and recently published by the journal, Pediatrics.
Study findings promised to help parents who have babies with night-time sleep problems to rest a little easier and they can promote better sleep for babies as well.
Dr. Michael Gradisar, study author, sleep expert and Associate Professor of Psychology at Flinders University in Australia says the research shows that controlled crying or ‘graduated extinction’ and another sleep education method called ‘bedtime fading,’ can actually improve babies’ and parents’ sleeping patterns.
In fact, the sleep training routine promises to provide bedtime-resistant infants with better sleep without any adverse effects on the family.
He adds, “It’s natural for parents to worry about having their babies cry at bedtime, and while it’s well documented that sleep deprivation can cause family distress, including maternal depression, we’re hoping these results will add another element to how parents view their responses and how they manage their own and their babies’ sleep behavior.”
Researcher used two sleep education methods, graduated extinction and bedtime fading. Both methods appear to improve sleep without detrimental effects on the child or the family, but Dr. Gradisar says more independent trials are required to validate the findings.
These infant sleep training interventions were conducted during a randomized controlled trial involving 43 infants who had persistent night-time sleep problems at around 6 months of age.
The graduated extinction method allows babies to cry for increasingly longer periods of time, while the bedtime fading routine has parents gradually delaying bedtime each night with a hope that sleepier babies will doze off more easily.
Compared to a control group, researchers reported that infants whose parents used the graduated extinction method fell asleep an average of 13 minutes sooner and woke up significantly less often during the night.
At the same time, there were no significant differences in babies’ stress levels based on salivary cortisol readings of the infants. So, they got some of the infants drool and test it for cortisol which is an indicator of stress levels. Parental stress, parental mood and measurements of parent-child attachment were also unaffected by the cry it out interventions.
However, Dr. Gradisar says for parents who remain anxious about letting babies cry, the bedtime-fading group showed nearly as large of a decrease (ten minutes) in the amount of time it took for babies to fall asleep. Although this group saw no change in the number of night-time awakenings compared to the control group.
Despite there being solid evidence of these sleep training techniques improves infant sleep and improve the mood and stress levels of mothers, parents still have concerns regarding short-term and long-term psychological effects. However, at a 12-month follow-up, no significant differences were found in emotional or behavioral problems, or in attachment styles.
Dr. Gradisar says, “A combination of using bedtime fading first, then moving on to graduated extinction could be another good approach. We hope parents of children who are 6 to 16 months of age can become more aware of bedtime fading which helps babies fall asleep at the start of the night.”
“Unfortunately, this technique may not resolve awakenings during the night, so if a child is waking up several times a night, then there is now some evidence that graduated extinction is a technique that may be more beneficial and not harmful to the child.”
He also encourages parents to seek medical advice if there are sleep problems in the home whether it’s the infant, children, older children or adults who are having the problem.
He says, “If sleeplessness is associated with some form of daytime impairment, not just in the individual having trouble sleeping, but also on other family members, then this is an indication of a sleep problem.”
Other sleep enhancing methods such as bed-sharing were not included in the research due to serious safety concerns with that practice.
However, room-sharing with baby in his or her own crib, that can be another option for introducing the sleep behavior training techniques.
Further instructions on how to accomplish both bedtime fading and graduated extinction are available from the researchers, sort of in recipe card format that you can print and hang on the fridge or the bathroom mirror or the door to your baby’s room so you can just see step by step on how you could do bedtime fading, how do you do graduated extinction, what d they look like in practice.
I’ll include links to both of those in the Show Notes for this episode, 345, over at PediaCast.org.
Children who start walking and jumping earlier are more likely to have stronger bones in later life. This, according to researchers at Manchester Metropolitan University and the University of Bristol and recently published in the Journal of Bone and Mineral Research.
Investigators demonstrated an association between children’s ability in common movements like jumping, running and walking at 18 months of age with stronger bones as adolescents. It is thought that these movements in toddlers place a stress on the bones, causing the bones to react by becoming wider and thicker, thereby making them stronger than the bones of children who may not be moving as much.
Findings from the study may help to identify who is at a greatest risk of bone fractures and even in osteoporosis in later life.
However, the scientists say the results could also be partly attributed to children with good early life movement being more physically active as they get older. These children had bigger muscles which previous work by the Bristol group has shown to be associated with greater physical activity.
In the current study, researchers demonstrated that around half of the differences in bone strength at 17 years of age is associated with movement that could be explained by differences in muscle size.
Dr. Alex Ireland, lead investigator on the project says, “The findings are intriguing as they provide a link which wasn’t previously understood, primarily that how we move as a young child can have ramifications for our bone strength even 16 years later.”
“We believe that stronger muscles could act as a ‘marker’ for this. Being more active gives you stronger muscles which can then apply bigger forces to the bones as they walk, run or jump, which helps to strengthen bones as we grow.”
Dr. Ireland adds, “Importantly, the results could have implications for later life by helping medical practitioners to anticipate and detect those who are at greatest risk of fractures or osteoporosis down the road. This will help practitioners devise prevention and coping strategies. For example, attainment of movement skills at an early age and otherwise sedentary children can be easily improved even by simple parent-led walking practice at home.”
Researchers analyzed data from 2,327 participants from Children of the 90’s, a lifelong study of health and wellbeing that has been charting the lives of 14,500 people since they were born in the early 1990s. Movement was assessed at 18 months, and hip and shin bone size, shape and mineral density was measured at 17 years of age, for both males and females, by performing X-ray absorptiometry and peripheral CT scans.
The study found the effect was more pronounced in males than in females, suggesting early movement plays less of a role in female bone strength. This fits with previous studies by the Manchester and Bristol groups showing that effects of physical activity and exercise on bone are greater in males than females.
Previous studies from Dr. Ireland, published in the journal, Bone, in 2014, showed that babies who started to walk earlier could have up to 40% higher bone mass in their shinbone compared to toddlers who were still crawling at 15 months of age.
So the take home message here, get those toddlers walking and running, and jumping, and moving as much as possible right from the get-go. Early movement may help establish a lifelong pattern of healthy physical activity and they may contribute to the building of stronger bones which may reduce the risk of fractures and osteoporosis.
And, this is important too — moms and dads, move around with your toddlers because it’s just plain fun.
Dr. Mike Patrick: All right, we are back. Dr. Michael Dunn is a Pediatric Emergency Medicine Physician at Nationwide Children’s Hospital and an assistant professor of Pediatrics at the Ohio State University College of Medicine. Dr. Dunn serves as the Medical Director of the Orthopedic and Suture Tech Program at Nationwide Children’s — meaning, he trains and supervises the folks who care for the majority of cuts and scrapes seen in our busy emergency department and urgent care centers.
That’s what we’re here to talk about today, cuts and scrapes. So, let’s give a warm PediaCast welcome to Dr. Michael Dunn. Thanks for joining us today.
Dr. Michael Dunn: Thanks.
Dr. Mike Patrick: Really appreciate you stopping by.
I think parents sort of have in mind cuts and scrapes. When would you say a scrape becomes a cut? Where is the dividing line between those things?
Dr. Michael Dunn: It’s really about how deep the cut goes through the skin. There are a couple of layers of skin, the epidermis and the dermis. The dermis layer is the part of the skin that bleeds, but when you get through that, that’s when you can let the cut gape apart and you can see maybe some of the fatty tissue underneath.
Dr. Mike Patrick: Yeah. So if you see fat or structures underneath, then it’s a cut. That’s something that’s going to need to be dealt with.
Dr. Michael Dunn: Right. Or if you could like pull it apart. If it gapes when you pull it, that’s it.
Dr. Mike Patrick: And if it’s more superficial and just an abrasion or a scrape, then that’s probably something that they’ll be able to take care of at home unless it’s extensive in terms of the size.
Dr. Michael Dunn: Exactly.
Dr. Mike Patrick: And these are very common that kids fall and skinned up elbows and knees.
Dr. Michael Dunn: Especially this time of the year.
Dr. Mike Patrick: Yeah. Definitely. So how should parents treat those at home?
Dr. Michael Dunn: With the scrape, the best way is just to clean it with soap and water and then put some antibiotic ointment like Neosporin or Bacitracin. A lot of times we talk about Bacitracin, which is single antibiotic as supposed to Neosporin which is triple antibiotic, because between 10% and 5% of people are actually allergic to Neosporin.
Dr. Mike Patrick: So if you use that, it may delay healing or it may get some more inflammation that’s just more from the allergic reaction which you can confuse with an infection if you’re using the Neosporin. If you’re in that 10%, but 90% of the folks are going to be able to do fine with the triple antibiotic.
Dr. Michael Dunn: Yeah. Right.
Dr. Mike Patrick: Is that one easier to find?
Dr. Michael Dunn: Bacitracin is right in the aisle where the pharmacy keeps Neosporin, and it’s about half the price. So, I generally tell people just use Bactitracin.
Dr. Mike Patrick: Yeah. That absolutely makes sense. Just look at the ingredients. You just want the one ingredient rather than the triple. Got you.
And so you do that immediately with cleansing it gently. Do you use soap?
Dr. Michael Dunn: Soap and water, for sure. And then once you put the antibiotic ointment on, cover it with a Band-Aid or other kind of bandage. The first couple of days, the first 48 hours is actually the most important time when the skin is growing back over the scrape. So you really want to keep that covered. There’s this fallacy that you should leave it open and let it dry out, and that’s exactly the opposite of what you should do.
Dr. Mike Patrick: Got you. So want to keep it covered for how many days would you say?
Dr. Michael Dunn: At least 48 hours.
Dr. Mike Patrick: So couple of days, keep it covered and then you can let it be open to air after that?
Dr. Michael Dunn: Yeah.
Dr. Mike Patrick: Depending on the kid, right?
Dr. Michael Dunn: And depending on how deep it is and how big it is. I mean, you really don’t want things to scab over. The scab itself will slow down the amount of time that it takes for it to heal.
Dr. Mike Patrick: Got you. And if you have a kiddo who is going to play with it, or they’re prone to getting it dirty, then maybe just leave it covered a little longer in that case.
And then on a daily basis, do you want to continue that same cleaning and antibiotic ointment on the wound everyday or…
Dr. Michael Dunn: Everyday for at least about a week or so.
Dr. Mike Patrick: And couple of times a day?
Dr. Michael Dunn: Couple of times.
Dr. Mike Patrick: And still general soap and water, and then pat it dry, and a little bit of antibiotic ointment on it again?
Dr. Michael Dunn: Yeah.
Dr. Mike Patrick: Okay. Do scrapes ever need to be seen by a doctor?
Dr. Michael Dunn: You know if they’re really large, then that would be a good reason. Sometimes, really extensive scrapes like if you fall off your bicycle and you got it all over your face or all over your legs, it could actually be a little bit like a burn. So if it’s really extensive area, then you definitely want to go see a doctor.
Dr. Mike Patrick: And then if there’s underlying tenderness, you got to think about the bones under there, too. So sometimes a kiddo’s initial complain is just with the abrasion. But then, if a few hours later, it’s still really hurting more than you think it ought to or there’s any swelling that starting to develop or difficulty in moving that area, think about fractures underneath because the scrapes happens with falls, too.
Dr. Michael Dunn: Exactly, yeah.
Dr. Mike Patrick: And then what about cuts? Do those always needs to be seen by a medical provider or can parents take care of cuts sometimes at home as well.
Dr. Michael Dunn: Yeah, I think if a cut is very superficial or very small, very superficial, doesn’t really gape open, you could probably get away with washing it with soap and water and putting a Band-Aid over it. And by small, I mean like less than a quarter of an inch if it were on the leg or the foot or something like that. If it’s on the face, for scarring reasons, you should probably see a doctor.
Dr. Mike Patrick: And if you are going to take care of it at home, it’s still going to be really important to treat it. Again, this is really small ones. They’re not gaping. They’re not continuing to bleed. In fact, some of those just start to heal so quickly when they’re tiny like that, but you’d take care of those the same way that you would take care of a scrape just the same way that we’d talked about.
Dr. Michael Dunn: And the thing you’d worry about the most is infection.
Dr. Mike Patrick: And foreign bodies sometimes, of course, not so much with the small ones, I mean that’s another one of the reasons why you want a medical provider to take care and really examine it, look, and make sure that there’s not something in the wound.
Dr. Michael Dunn: Exactly. Like if you stepped on glass. Especially if you fall and you’re on a lot of gravel, sometimes you can get little bits of gravel in those scrapes.
Dr. Mike Patrick: So anything gaping more than a quarter of an inch, continuing to bleed, you’re worried about a foreign body — gravel, debris, glass — that sort of thing, then you going to want to have a medical provider to look into it.
How long is too long to wait on those? How quickly do you want someone to take a peek?
Dr. Michael Dunn: That’s a great question. On the face and the scalp, you got 24 hours to fix it because there’s just such a great blood supply there, but everywhere else on the body you’ve only got 12 hours. After 12 hours on the body, 24 hours on the head, the risk of infection increases greatly. So after that amount of time, you don’t put stitches.
Dr. Mike Patrick: Because skin bacteria just gets down into the wound and even when you try to clean it, you don’t get all of them and then when you close it, you’re closing those in.
Dr. Michael Dunn: Those germs in. Exactly.
Dr. Mike Patrick: And then, that can definitely be a problem. In terms of if you don’t make those time frames, what happens then?
Dr. Michael Dunn: Then you just have to let them heal. Again, you still wash them out really well and you could put a Band-Aid on them, but you don’t bring them in together really tight for the reason you just said. You don’t want to trap those germs inside.
Dr. Mike Patrick: Yeah, So you just have to let it heal and realize you might have a little bit of a bigger scar there, but that’s just the way it goes.
Now, the next question then in terms of you think about how long before you see a medical provider, I guess the next question is which medical provider should you see? So, as we think about a kid’s primary care doctor, versus going to an urgent care, versus an emergency room, how do you make those decisions on where your child should be seen to have a cut looked into?
Dr. Michael Dunn: So I think if they’re relatively small cuts, an inch or so, you can call your physician first. A lot of physicians will do minor lacerations in their office whether if it’s with Dermabond, the medical super glue. Or, if they can do little stitches, you could try them first. I’d say the majority don’t, but some do.
And then, at least here in Columbus, we have our Ortho-Suture Tech program at all of our urgent care facilities.
So just about every cut can be taken care of in the urgent care and as well as the emergency department. Now, if it gets to be a very extensive cut, it’s on the hand, on the foot, that might have cut a tendon, or if you think there’s a badly broken bone at the same time, that would be when you want to go to the emergency department.
Dr. Mike Patrick: Or if it’s a bleeding, difficulty controlling the bleeding, or like a serious blood trauma, like your kid fell off of a tree, or there’s a significant car accident. And you’d want to have low threshold of those situations for calling 911, activating EMS, don’t try to get him to the emergency department on your own if those kind of things are going on.
And I like that you said call your regular doctor and not only because that your regular doctor may be able to take care of it in the office, but they may have some insight on where you should go depending on what resources are available in your particular community, the places that they know about.
Do you think specific pediatric urgent care is an important thing if it’s available?
Dr. Michael Dunn: I think it is. I think because pediatric facilities are used to dealing with the little ones especially under five years old. It takes a lot of effort to make those kids calm to be able to give them the stitches without having to hold them down forcibly.
Dr. Mike Patrick: Yeah. There’s definitely an art involved. And, it’s one of those things, the more the people do it, the more comfortable they are with it. It’s just going to be probably a better experience all around for you and your kids. Although in communities where there aren’t pediatrics specific urgent cares then the regular urgent cares get lots of pediatric experience because that’s where everyone goes and that really it’s all about.
So once you do make your way into a medical provider who’s going to close the laceration or cut, what are some of the options available for closing the skin and how do you decide which ones to use?
Dr. Michael Dunn: So it really depends on where the cut is on the body. Most of the times we like to use absorbable suture that disintegrates by themselves. There are a few places on the body where we like to use what we call permanent sutures where they have to be taken out later. Those are really rare, I should say. Things like dog bites really dirty wounds, very extensive wounds that we know have to follow up with the doctor. Sometimes we put in permanent sutures, but most of the time we put in the absorbables.
Dr. Mike Patrick: If they are the permanent ones, how long do they usually stay in?
Dr. Michael Dunn: So on the face, it would be five days. Most other places in the body, it’s seven. If it’s over a joint, it’s usually about 14 days.
Dr. Mike Patrick: The more tension that’s there, the longer they need to stay in?
Dr. Michael Dunn: The more the skin moves, yeah.
Dr. Mike Patrick: Yeah. And then it just takes a little bit more longer to heal the farther it get away from the central part of the body. We just need to keep those in a little bit longer.
Dr. Michael Dunn: And then there are three or four types of absorbable features that we use, and we use a different type depending on how long it needs to stay in.
Dr. Mike Patrick: So some of them will dissolve more quickly than others?
Dr. Michael Dunn: Exactly.
Dr. Mike Patrick: And the face, you want to use the more quicker dissolving liquid paste.
Dr. Michael Dunn: Right. Which is actually called fast absorbing.
Dr. Mike Patrick: And that’s because the face heals so quickly compared to the other parts of the body.
What about staples?
Dr. Michael Dunn: So staples are a great tool to use. I think staples are fine in older kids, in adults. I don’t like to use staples in the really young kids. I’ve had a lot of patients that will pick up their staples, maybe turn them around upside down and makes it really difficult to get out. Not that it’s a bad choice. It’s just personally, I don’t like it as much.
Dr. Mike Patrick: What about the glue you have mentioned Dermabond, the medical super glue? It seemed like that’s such a good thing, just use that on everybody. But it does have some limitations, right?
Dr. Michael Dunn: It does have some limitations. I like to use it where the skin doesn’t move a lot and I like to use it on a face, especially. It only last about five to seven days, maybe as long as eight sometimes. So, it’s really not useful on over joints of the fingers, but you could use in the hand. A lot of times, you have to use stitches underneath, and then sometimes you can use Dermabond on top. It really depends on how comfortable you are with using the Super Glue.
Dr. Mike Patrick: Got you. But it certainly not for everyone. There’s going to be cuts that take longer than five days to heal and then large gaping ones with tension that the glue just not going to really be able to keep it together as long.
Dr. Michael Dunn: And the other reason not to use would be in one that is a little bit dirty or it was from an animal bite that locks the germs in there. So if you’re worried about infection, that’s a reason not to use it.
Dr. Mike Patrick: What about the old Steri-Strips? Is there ever a reason to use those? So just bandage it together.
Dr. Michael Dunn: I don’t think they really are any better than today’s bandage, frankly.
Dr. Mike Patrick: Yeah, yeah, right. Exactly. And kids are going to pick at them and the thing falls apart and now you’re past the point of when you could do sutures. So a lot of parents just try to bandage it together and hope for the best. But then, you’re worried that you could go out past that 12- to 24-hour window.
Dr. Michael Dunn: So I think, like I said before where if it’s less than a quarter of an inch, it’s super tiny, that would be a reason to use Steri-Strips just like a bandage.
Dr. Mike Patrick: And I like what you said about comfort level, too. So ultimately, the person who’s fixing up your kid, you want them to be comfortable with the materials that they’re using. And so, you may say, “Hey, I heard this podcast, why don’t use in a glue?” But you really want the person taking care of your kid to use what they’re used to using and what they’re comfortable with to some degree.
Dr. Michael Dunn: Yeah, because actually, the different stitches tie differently. And so, in order to do it correctly, you have to be really familiar with the material.
Dr. Mike Patrick: And then, in terms of numbing the skin before you do any of these options, if you’re using a needle to close with sutures, that’s going to be more of a concern than it is with glue for instance. But what are some of the options for numbing, making sure kids are comfortable when we’re closing these wounds?
Dr. Michael Dunn: So in pediatrics, we’d like to use something called LAT which is a gel that goes over the wound. It’s mostly used in the face, on the scalp, because there’s such great blood supply there. The numbing gel can kind of absorb into the skin there a little bit better. We don’t use this much over the extremities of the trunk, especially the back as the skin is so thick there. So it doesn’t really work there. If it doesn’t work there, then you have to use injectable lidocaine.
Dr. Mike Patrick: Got you. And then, that’s going to cause a little poke and ultimately, it just last a few seconds, and then the area is numb and the kids are feeling better.
Dr. Michael Dunn: That’s right. I like the way…
Dr. Mike Patrick: Just a way to distract them.
Dr. Michael Dunn: I like to always tell the kids that the stitches never hurt. That part never hurts but the numbing medicine does.
Dr. Mike Patrick: I think, my own experience has been it’s best to be honest with kids. It’s going to hurt a little bit. But it’s going to be for a few seconds. Instead of, “Oh, no, this won’t hurt at all,” and then it does and they don’t trust you.
Dr. Michael Dunn: Exactly.
Dr. Mike Patrick: And then, they’re more likely to kind of I don’t want to say go off, but you know have a meltdown.
Dr. Michael Dunn: What I like to say, is right up front, “I’m not going to lie to you and I’m not going to trick you. If something’s going to hurt, I’m going to tell you it’s going to hurt. But I tell you it won’t hurt, it won’t hurt.”
Dr. Mike Patrick: And if it does, let us know so that we can make sure that it’s not…
Dr. Michael Dunn: Give more medicine.
Dr. Mike Patrick: Yeah, absolutely. Tetanus is always a concern with cuts. Tell us, what is tetanus and why is that an issue?
Dr. Michael Dunn: So the more common name for tetanus is lockjaw, and it’s a bacterial infection that can actually close your windpipe. So we always like to give the tetanus vaccine if you haven’t had the vaccine within the last five years.
Dr. Mike Patrick: We’ve talked about some of these organisms before on PediaCast, and the one with tetanus is clostridium tetani which lives in the soil, so that’s why wounds are a concern especially if you get them outside. You hear like rusty nail. But the rusty nail just means it was probably out in the elements where there’s soil that made the nail rust. But it’s really the bacteria in the soil.
And then, it produces toxin that causes muscles to contract — and like you said, lock jaw — can make it so that you can breathe because the muscles all contract. And so, you have to have muscles that relax in order to get air into the lungs during the breathing cycle. So, it can lead to respiratory failure and death.
It’s really a nasty disease and if you do get it, you’re on a ventilator for usually prolonged period and then you get complications like pneumonia and sepsis, so folks really can die from this without support. And even if they are in the hospital, I see they can still die from complicating infections, too.
Dr. Michael Dunn: Right. You almost always a tracheostomy tube in order to survive.
Dr. Mike Patrick: So definitely something that you want to avoid. The tetanus vaccine has been around for a very long time, has a great safety profile. Most kids get it at two, four, six months and then they get a booster dose at 15 to 18 months and then before they go to kindergarten and then another one at age 12, just to make sure everybody is protected against tetanus because it is so severe and the shot works so well.
So if you have a kid who is behind or lapsing, what are the rules in terms of when you would need a shot around the time of your injury.
Dr. Michael Dunn: So, again, it’s usually just if you haven’t had the tetanus within the last five years, then you just get the booster for whatever would have been appropriate that they’re behind on.
Dr. Mike Patrick: Got you. And then, there’s also, if you have a really dirty wound and deep, and you’re really worried about the possibility of tetanus, then you can also give tetanus antibodies as well. So the shot stimulates your immune system to make antibodies against tetanus but you can also give those antibodies if it’s a particularly… This is tetanus one… This is like second level of knowledge, but that’s also something that you may come across if you have a particularly large and dirty wound.
Dr. Michael Dunn: Right.
Dr. Mike Patrick: What are the complications do we have to think about? Tetanus would be one. What are others as we think about skin trauma?
Dr. Michael Dunn: The biggest complication is just general bacterial infection. And so, when you’re closing the wound, we always wash it out really good, really well and place that antibiotic ointment over the wound just to make sure it doesn’t get infected.
Dr. Mike Patrick: Yeah. And really just watch for signs of infections, so increasing… There’s going to be some redness around it as it heals but if it’s more of a beefy redness or it’s getting more red, if it increase in tenderness, once the bleeding had stop and now, it’s bleeding again or there’s drainage associated with it, fevers, vomiting, any of those things with infection, you want to have someone take a look at them again right away.
Dr. Michael Dunn: Oftentimes, I talk about ingrown toenails, people seem to know how painful that is. And so, I say, “If it starts to get painful like an ingrown toenail, that’s infection. You need to come back.”
Dr. Mike Patrick: Yeah, absolutely. And then, animal bites are a particular concern with infection, right?
Dr. Michael Dunn: And so, for those we have to wash out the wound a lot, with a lot of liquid. Usually, we use saline but water works as well. And then, we always have to give those wounds antibiotics…
Dr. Mike Patrick: So, antibiotics by mouth, not just ointment. Just to really make sure that they don’t get infected. Because they can get infected quickly and very severely.
Dr. Michael Dunn: That’s six hours.
Dr. Mike Patrick: And then, with dog bites, rabies is… Really, I think you have to talk to the medical providers in your community to see is there rabies and dogs in your area, like in where we practice here. I think it’s been since the 1960s since there was a documented dog with rabies. So it’s not as big of a concern with dogs. But other animals, it can be a concern. And certainly in your area, that may be different. Then your health department would know and the doctors who practice in your area would know if dogs are a concern.
Dr. Michael Dunn: Right.
Dr. Mike Patrick: But, other animals, what are some other animals that we have to worry about rabies?
Dr. Michael Dunn: Especially here in Columbus, bats are the biggest vector I think with rabies. Foxes can get rabies as well.
Dr. Mike Patrick: So, there are other things to think about. And then, we mentioned underlying fractures and you said tendon disruption that can go along with best skin trauma that you want to think about.
Dr. Michael Dunn: Exactly.
Dr. Mike Patrick: Once parents are at home then with a wound that’s been closed, is the instructions still the same as we had talked about with scrapes and small cuts that you take care of yourself in the house?
Dr. Michael Dunn: It really is again. The first 48 hours is the most important time where the skin closes over the wound, and if you can keep that area moist, you’re going to really decrease the scarring that happens.
Dr. Mike Patrick: And again, wash couple of times a day with soap and water, pat it dry, a little antibiotic ointment over the top of it, watch for infection and hopefully, should heal nicely for you.
Dr. Michael Dunn: The only difference is that when you do get sutures, you have to wait about 12 to 24 hours before you get it wet at all because sometimes the water can go down the line of the stitch and bring germs down in there.
Dr. Mike Patrick: And before they actually do the sutures, they’re going to have to wash it for you so it’s OK to wait that 12 hours or so.
You mentioned scars, is there a way to prevent scar formation?
Dr. Michael Dunn: The biggest thing to prevent scar formation is to prevent infection. If a wound gets infected, it always has a worse scar. But assuming it hasn’t gotten infected, keeping sunrise, ultraviolet light away from it is the most effective way to decrease scarring.
Dr. Mike Patrick: Yes, so it’s really important to use sunscreen right on top of the scar. It’s important to use sunscreen anyway. But in particular, if you have an injury in the last six months that has little scar there, you want to definitely put sunscreen over it to reduce the ultraviolet light exposure.
Dr. Michael Dunn: Right. Somewhere between six months and two years is where we know that it stops making as much the difference. So it’s really important to do it for, I usually say, up to two years.
Dr. Mike Patrick: Sure. Vitamin A and D products that are out there?
Dr. Michael Dunn: They’re OK. There’s not been a lot of science that shows that it works. If there’s anything that might work, Vitamin E might work. There was a time when where we thought that a lot of people were allergic to vitamin E, so we kind of step away from vitamin E. But the newest study show that most people are not allergic to vitamin E and that might actually help.
Dr. Mike Patrick: And then, there’s a product Mederma which has onion extract. Does that do anything?
Dr. Michael Dunn: I used to always tease that no one thought that mashed-up onion would help the scarring until this guy came up with this product, but the science shows that Mederma is a really expensive placebo.
Dr. Mike Patrick: Yeah, absolutely. I also want to mention with scars that sometimes it will look like it’s going to be a bad scar but just give it a couple of years, and it really fades.
Dr. Michael Dunn: Yeah, in the first six months, the scar formation is just trying to keep the skin strong. And then, over about two years is when the scar changes and will become a lot smaller.
Dr. Mike Patrick: Finally, you mentioned our Suture Tech Program here at Nationwide Children’s. Tell us a little bit about that. Who are suture techs?
Dr. Michael Dunn: So our suture technicians are licensed practitioning nurses, LPNs. They have a year of training with me and other suture technicians. They go through several stages where they start, where they can only do stitches on the arms and the legs where scars aren’t as important. And then, they graduate up to really complex scars or complex cuts. And it’s one of only a few programs in the nation, and it’s really fantastic. It’s all they do all day long and they’re fantastic at it.
Dr. Mike Patrick: Yeah, if my kid had a wound, I would definitely would want one of them closing it up, because they… If I had a wound, I would want one of them closing it up because it’s all they do all day long is sew up kids. They do a great job and we’re really lucky to have them and to be able to work with them here at Nationwide Children’s.
Dr. Michael Dunn: And they’re really good with working with children as well. It’s amazing to me when I think we’re going to have to sedate this child for this really complex cut and they walk out of confinement.
Dr. Mike Patrick: It takes a special person to sew up kids all day long.
Dr. Michael Dunn: Some of them squirm a little bit.
Dr. Mike Patrick: Yes, yeah, definitely. Well, we really appreciate you stopping by and talking to us. Again, Dr. Michael Dunn, pediatric emergency medicine physician here at Nationwide Children’s Hospital. Thanks for stopping by.
Dr. Michael Dunn: Thanks for having me.
Dr. Mike Patrick: In our listener segment this week, we have a question from Jennifer in Canada. Jennifer says, “Hello. I think my son may have been misdiagnosed with herpes rather than hand foot mouth disease. Will giving him the antiviral Acyclovir be bad for him? Why would they not have tested to be sure? Would having the virus or giving this medication cause any long-term damage and will this affect his already dilated kidneys? Thank you very much.”
Thanks for the question, Jennifer. Lots there, as always. It’s very much appreciated. Those of you who write in and ask questions. Because if you have that question, it’s probably likely that other parents out there have similar questions, so we can talk about these things and hopefully get everyone satisfied who may have been thinking about herpes or hand foot mouth disease.
The first point I want to make related to all these questions — and a long-time PediaCast listeners can predict what I’m going to say here — I cannot confirm the cause of your child’s rash. So Jennifer, I’m not going to be able to tell you what is wrong with your child. And because of that I won’t be able to comment on the appropriateness of using Acyclovir in your child’s specific situation because I don’t have enough information or the ability to examine your child. In other words, we don’t practice medicine or telemedicine by way of podcast on this program.
But we can talk in general terms. We can look at herpes and hand foot mouth disease, talk about ways they are similar and other ways they are different. It doesn’t mean that your child has either one of those things. So, don’t take it that way, we can talk about these things in general. We can talk about how you make the diagnoses including tests and we can talk about Acyclovir, when it’s used, what to expect when it’s used, its safety profile including risks and adverse effects.
So I think we’ll be able to provide some answers for you, Jennifer, but how well the answers translate and relate to your child really depends on your child’s condition, which may or may not be either of these disorders at the end of the day. Which is why it’s so important to talk with and see your child’s regular doctor when you have an acute health concern.
So let’s dive in to this. Herpes is a viral disease that is caused by the herpes virus. That’s pretty easy. Hand foot and mouth disease is also a viral disease. This one’s caused by a different virus called the coxsackievirus, which is a type of enterovirus.
So, we have two different viral diseases, caused by two different viruses. And, in most cases, they can be easily distinguished clinically. Meaning, I don’t need tests to tell them apart. I can distinguish between them most of the time based on a careful history and physical examination.
Now, you noticed I said most of the time which doesn’t mean always, and I’ll explain the situations where it may be difficult to tell the two apart in just a moment. So let’s consider hand foot and mouth disease first. It is just so common especially this time of the year in the summertime.
So, it’s a viral disease that most kids get during childhood. There are several strains of coxsackievirus that cause it, so you can get it more than once. It results in typical enterovirus symptoms because, again, the coxsackievirus is a type of enterovirus. So you can get a little fever, sore throat. You actually can get a high fever. Sore throat is possible, nasal congestion, a little vomiting, a little diarrhea. Any of these are possible. All of them are possible, but sometimes you see none of those.
So that’s possible as well. So there’s a variability in the presence and degree of the symptoms that you see. But something that you always have if you’re going to call the infection hand foot mouth disease is skin lesions and/or lesions inside the mouth. Now, if the lesions are inside the mouth, they tend to be small vesicles or little blisters which can ulcerate. So you get little blisters or ulcers scattered in the mouth in the back of the throat.
Now, in terms of how does that feel, it makes your mouth burn and uncomfortable, kind of like you drank a hot cup of coffee or a piece of pizza you ate that was too hot and you burn the roof of your mouth. It kind of has that feel or sensation to the inside of your mouth. But you don’t get swollen tonsils with pus on your tonsils like you can see with strep. Strep throat, so that’s something that’s a little bit different too.
The skin lesions tend to be little bumps that also have a vesicular component. So we call them papulovesicle. So papulo means bump, vesicles mean a little blister. So you have small red bumps with little blisters on top.
But there’s a variety of appearances and sizes that these can have. The blister component can be very small and then pop and scab. So you may or may not actually see the blister. And again, depending on what stage they’re in, the size, how much of a little blister there is, it can have a variety of appearances along a spectrum, but an experience pediatric provider is going to be able to identify those. Once you’ve seen hundreds of cases of hand foot and mouth disease , you start to realize what the whole spectrum looks like and it makes it easy to tell them that apart from other things.
The point there is that the lesions don’t always look exactly like the picture you’re mostly likely to pull up on the Internet or see in a textbook. But again, pediatric providers who have a good idea that hand foot mouth disease is the problem because we’ve seen all the varieties of appearance.
These lesions when they’re on the skin are generally found around the mouth, on the hands, in the feet. Hence the name, hand foot and mouth disease., Now, here’s where things get tricky. You don’t have to have the lesions in all of these places. In fact, you don’t have to have the lesions in any of these places including the ones inside the mouth. They can be anywhere, but those are the most common places — inside the mouth, around the mouth, on the hands and on the feet — and that’s why we call it hand foot and mouth disease.
The buttocks and the remainder of the diaper and underwear region is another common location. You can call it hand foot mouth and groin disease because you do see it there often. And you can see them on the neck, other places on the face, the trunk, further up on the arms and legs, not just the hands and feet. So, they really can’t be anywhere, but again the classic appearance is in and around the mouth and the hands and feet.
The rash and symptoms last a few days and then they go away. No treatments required or even available for hand foot and mouth disease except for supportive care, so rest, fluids, fever reducers, that sort of thing.
So what about herpes? So how is herpes different than what I just described. Well, again, herpes is caused by a different virus, the herpes virus. And like the coxsackievirus, we have some different types of herpes viruses including Herpes Simplex Virus 1 which is more common in younger children and usually affects the mouth, and Herpes Simplex Virus 2 which is more common in older folks and usually responsible for the genital form of the disease which is usually sexually transmitted.
The herpes virus also causes papulovesicles. So red bumps with fluid filled blisters that pop and scab. Now, this tend to be a bit larger than the papulovesicle seen with hand foot mouth disease. Although, again, there’s variation and overlap, so small-ish herpes lesions may be similar in size to large-ish coxsackievirus lesion, if that makes sense.
So in general, the lesions with hand foot and mouth are smaller. With herpes, they are a little bit bigger, but again there can be some overlap. Herpes also tends to be confined to a specific region. So like the mouth, for Herpes Simplex Virus 1 and the genitals for Herpes Simplex Virus 2.
Again, in general, the lesions with herpes tend to hurt more and tend to be more concentrated compared with hand foot mouth disease. Rarely would you see herpes lesions at the same time at distant locations, like the hands, the feet and the mouth. You’d expect to see the herpes virus lesions centered around one location, not scattered, all of these locations at the same time.
Now, there are exceptions to that. If you’re dealing with an immunocompromised patient, so they don’t have an intact immune system and that includes young infants, then you could see herpes lesions in multiple places scattered throughout the bodies. That’s one of those instances where it can be a little bit hard to tell the two apart, if you have an immunocompromised patient or a very young infant.
So the appearance of it, of herpes, there can be some overlap in terms of what the distribution looks like between herpes and hand foot mouth disease. So both viruses are common in and around the mouth, although herpes is more likely to only be in and around the mouth and not scattered elsewhere, again, unless you have an immune system problem.
But then again, you can also see a hand foot mouth disease that only involves the mouth or just around the mouth, or another enterovirus infection we tend to call herpangina, which also causes these lesions just in the mouth and the lips and the skin around the mouth.
Now, herpes in the mouth also tends to be worse than hand foot mouth disease causing something that we call gingivostomatitis which is widespread painful blisters and ulcerations of the oral mucosa, the gums, the lips and the skin around the mouth. And often, it’s very impressive and pretty easy to distinguish from a hand-foot-and-mouth disease based on appearance.
So you just have a lot more of them, more concentrated, the kid’s mouth hurt a lot more. So it’s not just like you burnt your mouth on a piece of pizza or drink hot coffee. Your whole mouth is just on fire, usually if you have a primary herpes infection. And a lot of times, these kids won’t drink, they can’t get dehydrated. They’ll drool because they don’t want to swallow their spit because it hurt so much.
But again, milder cases of herpes and more severe cases of hand foot and mouth disease, those could overlap a little bit, in terms of what they look like. Now, if you see lesions elsewhere, like the hands, the feet, the groin, extremities and trunk, then it’s more likely that it’s hand foot and mouth disease. Again, unless the child has a compromised immune system or is a very young baby.
Now, it is useful to tell them apart because we do have an antiviral agent for herpes, Acyclovir, which Jennifer mentioned. It doesn’t work as well as an antibiotic works for bacterial infections however. So rather than stopping the infections in its tracks, Acyclovir slows it down. So, the viral infection hopefully won’t get as bad as otherwise might have become but it doesn’t take care of it, and usually boom like an antibiotic does.
And the other thing with Acyclovir is you have to get it started in the first couple of days of infection for it to really have a chance of having a good effect. The longer that you wait to start it, the less likely it is that it’s going to make a big difference. So, there is a treatment for herpes. It’s not as good as an antibiotic and the longer you wait to start it, the less likely it is to work.
So, how about testing, especially in cases where there’s overlap of appearance? So, if it’s clearly hand foot mouth, that’s one thing. If it’s clearly herpes, that’s another. But as we mentioned, there are some overlap in terms of how they can look in the distribution. So, in those cases, how about testing? And this really gets to the heart of Jennifer’s question, I think.
You can test for both of these viruses. However, they’re not cheap rapid tests that we’re talking about. It’s not like rapid strep test for strep throat or a rapid flu test. These are expensive tests for coxsackievirus and herpes virus and they’re not available everywhere, only through advanced labs. And they may take awhile to come back, depending on the exact test ordered and the laboratory in question.
So you don’t get a rapid answer on these things, and considering that most of the time, you can’t tell them apart clinically. And most of the time, both of these diseases get better on their own, then you have to ask, do I really need to perform an expensive test?
Now, if the patient is sick enough to be in the hospital or they’re immunocompromised or they’re young infant, then sure, you test because if it’s decimated or widespread herpes, that can be life threatening and you’re going to need hospitalization and the medicine Acyclovir through an IV.
However, if we’re talking about outpatient treatment, you can test, but if you wait on the test to come back to decide whether you’re going to give Acyclovir or not, by the time you get the test back, it may be too late for the Acyclovir to really make a significant difference. Because remember, Acyclovir works better and best the sooner that it started.
So it’s really better to make these diagnoses clinically especially in the outpatient setting and the kid who’s not that sick, and then treat based on that.
We generally don’t test for coxsackievirus or hand-and-foot-mouth disease in the outpatient setting. Sometimes, we do for herpes depending on the situation but again, you wouldn’t want to wait on the result to treat with Acyclovir. You treat first and see what the result is, when the lab test comes back. That may help you to decide to stop the Acyclovir if the test comes back negative, but you generally start the Acyclovir before the test comes back again. Because if you really think it could be herpes, then it’s best to get the medicine started.
Now, if you decide to use Acyclovir based on the clinical diagnosis, and all the little factors that go into making a treatment decision which again is why you need a flesh and blood provider walking through this stuff as it actually happens rather than some guy on a podcast, regardless how knowledgeable or likeable he sounds, right?
You want someone who’s making these decisions and walking you through what the doctor thinks it is, what you got to do for it, whether you should test or not. It’s really best to do that right in the office.
And, don’t be afraid to ask questions. And don’t be afraid to say, “Hey, why are doing this? Why aren’t you testing?” So, if you have a question, “Hey, why aren’t we testing? And is Acyclovir going to be a problem? Is it dangerous?” Ask those questions, don’t feel like, I get it. You wait for a long time in the doctor’s office and then the doctor seems a little rush because there’s a big long wait in the waiting room. But you still deserve to get your questions answered. And if that means other people have to wait a little bit longer, this is not fast food. It’s better to wait and really get good care and have things explain to you. So ask the questions right there when you’re in the exam room.
By the way, in the case of oral herpes or gingivostomatitis , even then, if you’re sure of the diagnosis, you don’t have to test for it. You can make the diagnosis clinically and decide whether you’re going to treat with Acyclovir based on the clinical diagnosis because, again, most experienced pediatric providers are going to be able to tell the difference between these things.
So the situation you described, Jennifer, it’s really not far-fetched. And, although, you aren’t sure if you’re child had hand foot and mouth disease or herpes, it sounds like your doctor felt pretty comfortable about that diagnosis.
Also, keep this in mind, if your doctor isn’t completely sure which one it is, although again we can’t tell by appearance, it all still comes down to risk versus benefit as you think about the possibility of starting Acyclovir, without knowing for sure what the diagnosis is.
So in other words, if it really is herpes, especially early herpes and you don’t start the Acyclovir, then things could get worse. On the other hand, why don’t we start the Acyclovir but in reality the child had hand foot and mouth disease.
So it comes down to thinking about the risk of each of these conditions, the benefits of the medicine, the risks of the medicine, and then balancing out risk and benefits. And, again, your doctor in the flesh and blood right there in the exam room should walk down that path with you explaining as he or she goes. And again, if she or he doesn’t ask for explanations, ask about the risk and benefits, educate yourself right then and there in the exam room, and if the question comes to mind after you go home, by all means, call your doctor and ask. You have every right to know.
Now, as it turns out, Acyclovir has an excellent safety record in children. Adverse reactions are possible, as is the case with most medications. And you do want to make sure the benefit of using outweighs the risk, and that has to be evaluated on a case by case basis.
Now, you mentioned dilated kidneys, Jennifer. I’m not a 100% sure what you mean by that. If you’re talking about reflex of urine back up to the kidney and that causing a back flow of urine and dilated kidneys from urine, but your child’s kidneys themselves are functioning normally, so they have normal kidney function, then Acyclovir’s effect would be expected to be the same as it is for any other child’s kidneys.
Now, if your child truly has renal insufficiency, so not only is there dilation but the kidneys aren’t working like they should be working or a degree of renal failure, then sure that may well play into the risk-benefit discussion. And in that case, your child’s probably seeing a pediatric nephrologist or a kidney doctor, a renal doctor, and it would be helpful for your primary care provider and the nephrologist, the kidney doctor, to communicate, or for you to call your child specialist. If you have a concern, you call the kidney doctor, if you’re concerned about a particular medicine and it doesn’t seem like your regular doctor and the specialist are communicating well.
So I hope that helps, Jennifer. I think the biggest thing here is just empowering parents to ask this… Of course, I appreciate you asking me, and you probably did this, Jennifer. You probably asked your regular doctor already and hopefully got answers and explanations that satisfied you. But I don’t mind you asking the question here because it gives us the chance to talk about these things, but absolutely ask your regular doctor who knows your child well and the ins and outs of your child’s particular condition.
I know, I think folks are always hoping for a black-and-white answer. Yes, do this. No, don’t do that. But the reality is, there are lots of factors to consider as we make diagnostic and treatment decisions. And we doctors, I think sometimes need to do a better job of answering these questions and concerns right there in the exam room at the point of the decision, so that parents feel more comfortable and really view themselves as partners because that’s what they are in the decision-making process.
Thanks, again, for the questions, Jennifer. Really do appreciate you sharing your concerns with us on PediaCast.
Dr. Mike Patrick: All right, we are back with just enough time to say thanks to all of you for taking time out of your day to make PediaCast a part of it. Really do appreciate that.
Thanks for your patience during our little sabbatical there. Really appreciate it. It gave us the chance to get the studio moved and set up, and I think we’re ready to get back into the groove. So we hopefully have shows for you week in and week out now on a regular schedule.
I also want to thank Dr. Michael Dunn, pediatric emergency medicine physician here at Nationwide Children’s for stopping by and talking with us about cuts and scrapes.
That is all the time we have today. PediaCast is a production of Nationwide Children’s.
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And while you have your providers’ ear, please tell them we have a podcast for them as well — PediaCast CME. It’s similar to this program, we turn the science up a couple of notches and provide free Category 1 Continuing Medical Education Credit for those who listen. Shows and details are available at PediaCastCME.org.
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Thanks again for stopping by, and until next time, this is Dr. Mike, saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.
Announcer 2: This program is a production of Nationwide Children’s. Thanks for listening. We’ll see you next time on PediaCast.