Diaper Rash, Pink Eye, and Acne – PediaCast 005
- Diaper Rash
- Hand, Foot, Mouth Disease
- Can Sutures Get Wet?
- Pink Eye
- Measles Outbreak In Indiana
Announcer: This is Pediacast, Episode 5 for August 16th, 2006.
Hello, moms, dads, grandmoms and grandpas, aunts, uncles and anyone else who looks after kids. Welcome to this week's episode of PediaCast, a pediatric podcast for parents. And now, direct from Birdhouse Studios. Here is your host, Dr. Mike Patrick Jr.
Dr. Mike Patrick: Hi, everyone. This is Dr. Mike Patrick Jr coming to you from Birdhouse Studio and I'd like to welcome you to Episode Number 5 of PediaCast, a pediatric podcast for parents.
This week, we're going to continue with the format that we started last week. So we're going to divide the program up into four segments. We'll start with infants and we'll be discussing thrush and then diaper rash.
In our Toddler Segment, we will talk about hand, foot and mouth disease. And we're also going to answer the question, "Can you get sutures wet?" So if your child get stitches, does it increase the risk of getting an infection in the wound if the sutures get wet? There was a research study that looked at that recently, and we're going to discuss that.
And then in our School Age Segment this week, we're going to discuss pink eye. Especially with school getting back in session, there will be some cases of that running around the school. So we'll talk a little bit about how you treat it and when kids can go back to school if they have pink eye.
Also, in our School Age Segment, there was a measles outbreak last year in Indiana. So we're going to look at the historical events that happened with that — how exactly it occurred and why the children who got measles had the disease and sort of what happened to them, how many ended up in the hospital and what kind of complication you can get from the measles. So, just sort of a general discussion about measles.
And then, in our Teenage Segment this week, we're going to discuss acne. I think that's another good back-to-school segment as the teenagers get ready to go back to high school. Certainly everyone is going to have some concerns about acne and what the best way to treat it and prevent it. So, we'll discuss that coming up in the Teenage Segment.
If you like the way we are structuring PediaCast now, if you wouldn't mind giving us a little bit of feedback on that, it would be appreciated. There has been some discussion of continuing about a 45 to 55-minute weekly program that divides it up into these four segments with about 15 minutes each. I know we went over a little bit last week to an hour and 10 which was a bit on the long side, but I had trouble cutting some things out. So we'll try to keep it a little bit shorter.
But the question I have for everybody out there is, do you think it would be better to continue to do basically about an hour long show with a 15-minute segment devoted to infants and toddlers, school-aged, and teens? Or do you think we should break up the program and have an infant program, a toddler program, a school age program, and a teen program each week that comes out each one probably be in more like 15 to 20 minutes each? And in that way parents could just listen to the ones that affect their kids. &
I'll be honest, I'm a little bit hesitant to do it that way only because a lot of these topics do sort of cross age group. Now, certainly diaper rash, you're not going to see that in school-aged kids or teenagers, hopefully, and acne doesn't really affect toddlers too much. But there are definitely some topics that if you are the parent of a school-aged kid that might get addressed in the toddler or the teen section that you might miss if you only listen to the school-age segment. Of course, you could always look at the Show Notes and then pick out the ones that you want to see.
So, again, I'm kind of torn about what the best way to go with that is. And I would like some feedback on that if you wouldn't mind. You can contact us at firstname.lastname@example.org or you can go to our website www.pediascribe.com/podcast and click on the Contact link and reach us that way as well. We also have a new way to reach us and that's with our telephone line. Our phone number now is 347-404-KIDS. That's 347-404-5437, which spells out KIDS. So you could also call and leave us a voice mail with some feedback that way, too. &
And the reason the feedback is so important is really the goal of this program is for the parents. And we want to discuss some topics that you may be interested in and that you don't have a chance to talk to your own pediatrician about in too much length, just to give more explanation in the why we do the things we do in pediatric medicine. And I want this to be as user-friendly as possible and whatever the general consensus out there is we'll probably go with that.
So some feedback again would be helpful. Also, if you have a topic that you would like to see addressed in the future episode of PediaCast, you could give us some feedback that way too and we'll try to get your topics lined up.
OK, so let's go ahead and move on into our Infant Segment this week. Our first topic up for discussion is infant thrush. Now, thrush in its simplest form is a yeast infection in the mouth and it is pretty common in young infants. Symptoms of it, and if you have infants out there, almost all infants get it in at one point or another. So it is a pretty common infection. And again, it's caused by yeast or fungus.
Symptoms of it are irregular white patches inside the mouth. And these patches don't wipe away if you try to rub at them. Most commonly, you're going to see these in the inside portions of the lips and the cheeks. So if you kind of stretch the mouth opening around and look at the inside portions of the cheeks, and then up in the gum line and on the inside portion of both the upper and lower lip, that's where you're going to most commonly see these irregular wipe patches that don't wipe away very well. And that's& what thrush looks like.
Sometimes, it can also be seen as a coating on the tongue. Although if it is on the tongue, it's usually kind of patchy looking and normally, you also see it on the inside of the cheeks and the inside of the lips,& as we discussed before. So if you only see a white coating on the tongue and it's no place else and it's a pretty uniform white coating, then that's probably not thrush. That's more likely just to be some breast milk or formula. Babies' tongues are kind of sticky and it's easy for the formula and breast milk to stick to it and kind of get inside the nooks and crannies and stick to the taste buds. And then, you get this white coating that's kind of difficult to go away. But if it's just a uniform white coating on the tongue, it's probably not thrush.
Thrush is also associated with a little bit of mouth discomfort. So, sometimes, babies will be a bit fuzzy and may have some trouble eating when they do have thrush. However, it's usually not terrible discomfort. So, if you have a baby with thrush and they're really irritable or difficult to console or just refusing to eat, there's probably something else going on with them and they at least deserve to be checked out in the office by your doctor.
OK, so what causes thrush? Well, you have to keep in mind that the mouth is a warm moist environment and thrush or yeast or fungus, they like warm-moist environments to grow. And if you think about a bathroom, it's easy for a mold to grow in there and in basements, and again, that's because they're moist environments, and moist environments that are also warm really do help the funguses to grow. Now, the yeast that causes thrush is everywhere and it's opportunistic. And really, all the yeasts and molds are opportunistic and that just means they grow wherever they can. If you think just about old bread, sitting there in your counter& and as it ages a little bit, the mold starts to grow on it. So it grows easily even if you keep a clean house. You can't get rid of it, it's in our environment.
Now, why does it grow in the inside of baby's mouth? Well again, the mouth is a warm-moist environment but the reason it doesn't grow in most people's mouths is there's really two reasons. Number one is, our mouths are full of bacteria. So there simply is not room for the thrush to grow inside the mouth if it's full of bacteria. But little infants, they don't have a lot of mouth bacteria colonized inside their mouth yet, and so there is space to grow and it's warm and moist. And that's why young infants are more likely to get thrush.
Now, when you have older infants, if they're on antibiotic, for instance, for an ear infection, well, what the antibiotic does is that it kills off the normal mouth bacteria, and so they may not have much room for the yeast to grow. But now that they're on their antibiotic and you killed off the normal mouth bacteria, now, the yeast that's in the environment can come in and grow. So again, it's opportunistic. It just gets inside the mouth. It's warm and moist that likes to grow there, and if there's not a lot of bacteria, then it's going to grow.
Now, another thing that can cause this is if you have a problem with your immune system, sometimes even if there's not a lot of space for the thrush to grow, if there's a tiny bit of space that might start growing, but it's in such small amount that your immune systems able to take care of it. But if you have someone who has an immune disease, they could get thrush a little bit more easily. And you'll particularly worry about that when you have older infants or young children who keep getting thrush over and over again, especially if they haven't been on an antibiotic recently. So that's something that would make you a little bit concerned.
OK, so let's say you have a young infant and they get a little bit of thrush, maybe just for the very first time. Usually, the first medicine that we used for it is one called Nystatin, which is anti-yeast or anti-fungal medicine. It works topically. So usually the dose for infants of pretty much any size is going to be about 2mm which is just less than half a teaspoon. And you put that in a little dropper and then four times a day you try to drip it as best as you can on the irregular white patches. And generally, you have to do that for one to two weeks. The longer the better, really, because thrush if you leave a few of the yeast particles behind, it's easy for it to start growing back a few days after you stop the treatment. So most doctors would recommend treating one to two weeks with the emphasis being more on the two-week time period.
It's definitely labor-intensive because you've got to do it four times a day. And certainly, when you have a baby who's moving around, opening and closing their mouth, trying to drip it on the white patches, I do realize it's easier said than done. And then, once you drip it on the white patches, you go ahead and let them swallow it. But it's going to work best if you do get it right inside on the white.
You could also take a cotton ball and put the 2ml of the Nystatin on there and kind of swipe over the white areas. But then, you want to sort of wring out the cotton balls so that the Nystatin drips into the baby's mouth after you swabbed those irregular white patches. That way, they're swallowing some of the medicine as well.
Now, there's another medicine that you can use for thrush that actually works a lot better. It definitely works faster. Well, the brand name is Diflucan and the generic name is fluconazole. It actually works through the bloodstream. So this medicine you only have to give once a day and you don't have to drip it on the white patches. You just put it on their mouth and go ahead and let them swallow it. So, it's much easier to give and works a lot faster. So you think, "Well golly, why don't we just use that right off the bat?"& Well, the reason that we don't is because it's very expensive compared to Nystatin. And it also has more side effects associated with it, including vomiting and diarrhea and very rare instances of liver disease and anemia as well. Again, those are extremely rare. But when you have something like Nystatin, even though it's more labor-intensive, it usually does work and then you're eliminating some of those more dangerous side effects that are possible and also saving some money, too, which is important in this day and age.
OK, that's how you treat thrush. Now, how do you prevent it so you don't get it in the first place? Well, even with the best effort, you might not be able to prevent it. And again, if you look at the example of bread getting moldy, you can understand why it's difficult to prevent. So if you have a baby who doesn't have a lot of bacteria in their mouth and just in any normal environment, they could get it.
Now, some things that you can do to help prevent it, especially re-infection with it, is you want to make sure that you sterilize nipples and pacifiers. Hot dishwasher is probably fine but if you are putting those things through a hot dishwasher and thrush is happening recurrently, then you might want to boil those things for a few days after the thrush is gone.
Also, breastfeeding moms can sometimes get the yeast growing on their breast. And so, if your baby has recurrent thrush, then you might want to, with the Nystatin, not only give it to the baby but also put some on the medicine on the cotton ball and apply that to the nipples, too, after the baby nurses. So that way, if there was any yeast inside the baby's mouth that gets unto the mom's skin, you can kill that off with Nystatin. In that way, when they go to nurse the next time, hopefully, the yeast won't be there anymore.
Also, and this sounds easier said than done as well, kind of like with dripping the Nystatin on the thrush. And that's to limit antibiotic use if it's not necessary. Now, if you're seeing a trained pediatrician, that probably is not an issue because most pediatricians are trained to only treat known bacterial infections with antibiotics. So, if you really think it's a viral infection, you want to avoid antibiotics. And we'll talk about in the future at Pediacast, especially as we get into the winter months. But one of the things that can happen is, you're treating with the antibiotic and you don't know for sure what you're treating or it's really a virus, one of the side effects is you're going to kill the normal good mouth bacteria. And then, it's going to be more likely that your baby will get thrush. So you want to avoid unnecessary use of antibiotics.
OK,& we talked also about some of the issues with thrush that won't go away or if it's recurrent thrush, especially in older children and infant, might be a sign of immune system problems you'd want to talk to your doctor. And also, if you're unsure if thrush is really the problem, make an appointment. Most doctors, if you describe thrush pretty well on the phone and it's not something that's recurrent and you have a young baby, a lot of doctors will just call in some of the Nystatin for you. But if you have a question about whether it really is thrush or not, by all means, make an appointment for your baby to be seen. You're certainly not going to offend anyone or put anybody out. As pediatricians, there's no silly questions and, really, if you want us to look, we'd rather look. So, just call your doctor and ask for an appointment if you think it might be thrush but you just aren't certain about it.
OK, moving on along, in our Infant Segment this week, we're going to talk about diaper rash. Really, this topic goes hand in hand with the thrush topic basically because the most common cause of diaper rash is going to be yeast, just like the thrush in the mouth. So once again, the diaper area is a warm, moist environment and so it's a place that yeast can grow.
Also, little babies don't have as much skin bacteria as you do. As you get a little bit older, the skin starts to get colonized with normal good bacteria and then there is not as much room for yeast to grow. So if you have a little baby, you got the diaper on, it's warm and moist, there's not a lot of bacteria there and the yeast can pretty much thrive. And so, also, antibiotic use is going to make it more likely to get a yeast diaper rash as well. And again, because the antibiotics are killing off the normal good bacteria that live on the skin.
Now, another type of diaper rash you can get other than the yeast is sort of what I call an irritation rash. And this is just from urine and stool and the actual diaper itself touching the skin. Stool is the biggest problem because it can have some digestive enzymes from the intestinal tract in it and those digestive enzymes not only break down food but they can break down skin as well. So you can get pretty bad irritative-type diaper rashes if babies have stool in their diaper for a long period of time without getting it cleaned up.
Another cause of diaper rashes could be a bacterial infection. This is usually on top of the other rashes, so it may start out as a yeast rash or irritation rash, then you get some broken down skin and then you get some poop in there and then you get some bacteria from the stool that starts to infect the broken down skin. So you can get sort of impetigo or even some skin abscess kind of rashes that are bacterial infections.
Usually, you can tell the difference between these different kind of diaper rashes by looking at them and it's important to see what it looks like to be able to tell which type of diaper rash it is. Because the way you treat it is going to be a little bit different, depending on what you have. So, in order to successfully treat it, you have to know what it is, and to know what it is, you have to know what it looks like. And so, if you are in doubt, make an appointment. Even if your doctor says "Hey, we'll just call something in, some cream for you." Well, what cream are they going to call in if they don't know if it's a yeast rash, an irritative rash. or a bacterial infection rash?
Now, if you're an experienced parent, you're working on your second or third baby, they've had a couple yeast diaper rashes in the past or you dealt with the bacteria one or an irritative one, you know it's common, well, then you're going to trust mom to say "Yeah, this looks like yeast again," and be more likely to call in the yeast medicine for the parent.
But if you haven't seen a lot of diaper rash, don't be embarrassed to say, "I'd rather not have you call something in. Why don't you make me an appointment so you can come and you can tell me for sure what kind of rash that we're dealing with." There's certainly nothing wrong with doing that.
Now, in terms of what they look like — and this is generalization — there are variations on what all of these looks like and that's why the experience of a pediatrician is good, because we see so many diaper rashes, you get an idea of sort of what all the variations are. But in general, the yeast rashes are going to be sort of a solid red color that tends to be worse in the creases, inside the butt crack and inside where the legs fold in the groin is, and then the red area tends to be surrounded by little red dots. So if you have solid red, worse in the creases and then some dots around it, that sort of the classic look of the yeast diaper rash. Now again, you can have yeasty rashes that look a little bit different than that. That's just the classic. &
An irritative diaper rash, the one caused by contact with pee and poop and the diaper, this just tends to be more sort of blotchy,& broken down skin. You have some areas that look sort of, yeah, almost like the beginning of skin ulcers where the skin's sort of rubbing off. And then, sort of the next step beyond that is the infection-type rash and now you can get some sort oozing and crusting lesions. It can sort of scab over. You might feel some firm knots in the skin or you might even see some pus. Again, there's lots of variations on this. And, again, if you're in doubt, make sure you make an appointment.
Now, in terms of treatment, depending on& which of those rashes you have, you're going to have different type of treatments. So the yeast rashes, we also tend to use Nystatin like you do for thrush. But in this case, instead of using the liquid kind, it comes in a cream and that's a prescription medicine. You can also get over-the-counter Lotrimin cream which is also a yeast medicine and the yeast medicines, Nystatin cream and the Lotrimin cream, you use usually about four times a day. And again, one to two weeks with the preference being more toward the two-week time period.
In terms of the irritated kind of rashes, really the best thing for that, first you want to make a thick barrier that protects the skin against contact. So if you used Desitin or A&D ointment or Balmex or basically whatever your choice of diaper rash cream is, by putting it on really thick, you're making an actual physical barrier. So the pee and the poop and the diaper instead of touching the skin, will touch these creams instead and in that way you avoid the contact dermatitis or the breakdown because of that stuff touching the skin. It will touch the cream instead.
There's also a medicine that tends to help a lot of children's hospitals called this Magic Butt Cream. I just love that name. And it's Aquaphor which is a moisturizing cream, and then what you can have the pharmacist do is pour in some Maalox, the antacid inside of that and mix it all together. I've tried this at home before. It's very tough to get it to mix together on your own. But the pharmacist has the equipment necessary to really get that into a nice cream.
Now, the reason that that works is, in the stool, there's digestive enzymes. Those digestive enzymes in order to work and break down the skin, they can sort of need an acidic environment in order to work. If you just think about the stomach and the upper portion of the small intestine, if you have a baby with some loose stool and those digestive enzymes are making it all the way through in to the poop inside the diaper and they're starting to break down the skin, well, those enzymes are going to thrive, so to speak, in an acidic environment. So if you put an antacid cream which is what the Maalox is, it's an antacid, you basically decrease the acidity of the poop and then those enzymes don't work as well. So it helps prevent further damage of the skin by inactivating the digestive enzymes that normally need an acidic environment in order to work.
OK, if you have infection rash with impetigo or any kind of abscesses or pus, then you're going to need a topical antibiotic. If it's really mild, just some Neosporin would probably work. There's also Bacitracin and Bactroban little more higher strength types of topical antibiotics. And if it's a serious infection even in the diaper area, it might require an oral antibiotic, especially if there's a cellulitis or deeper skin infection or if there's an abscess.
Also, if there is an abscess and it's a deep one, it might have to be drained. So your pediatrician might have to actually sterilize the skin and then poke it with the needle and get some of the pus out and send it off for a culture and put your baby on an oral antibiotic. That's possible. Sometimes, they're also large enough that you actually have to get a surgery referral because it's going to need a little bit of a bigger incision to drain. So it's rare but sometimes you do see that.
Also, you can get some abscesses right next to the anus and you do worry a little bit about a connection from the inside of the anus to the surface of the skin like a little fistula we call them, and you don't want to miss that because those would need to be closed or they're going to keep getting infected. So if you do have an abscess that's right around the anus, usually we refer them to the pediatric surgery folks as well.
Something you also can do really for all of these types of diaper rashes to help with the treatment, whether it's a yeast rash, an irritated rash or infection, and that's, of course, change their diaper quickly after they go, especially after they stool. You don't want to them sitting on that stool long, so check them often. And then as soon as they go, get them cleaned up and if alcohol wipe seemed to be irritating their skin, you can always just use warm water and paper towels. And once you get them cleaned up just if you can leave their diaper open to the air, that will really help dry things out, make it not be so moist inside there. Also make it not be as warm, so yeast is less likely to want to grow because it's not a warm-moist environment if they're just kind of laying around and open to the air.
Of course, you're taking the chance of making a pretty big mess when you do that. So that's another reason to try to catch them right after they go, get them cleaned up and then leave them out of the diaper for as long as you dare to do so. And then put your thick barrier cream on — Desitin A&D or Balmex, really whichever your preference is — and put it on really thick so it's a nice barrier, so the diaper and the pee and poop don't touch the skin. And that will help you to get rid of the diaper rash a little bit faster.
Now in terms of preventing a diaper rash, again, you want to avoid unnecessary antibiotic use because if your baby gets antibiotic that they don't need, that's going to kill off their normal skin bacteria and it will be more likely for the yeast to grow. And then, again, use a thick barrier cream. For some babies, you might have to try a different brand of diapers depending on the types of chemicals that are used in the diaper-making process. You definitely have some kids who seem to tolerate one brand of diaper over another.
And I have never found any correlation with a specific brand. You don't see everybody has more diaper rashes with one brand or another. Really, it runs the gamut. For one kid, you see Pampers are the only thing they can wear. And the kids in the next room, you put him in Pampers and they're going to break out in a bad rash and their moms say, "Oh, no, they have to have Huggies." Just sort of try one brand or another and if you find one that seems to ward off diaper rashes a little bit better and it's a contact kind of diaper rash, that's something to think about.
And then the cloth versus plastic. For most babies, it doesn't really matter, but there's going to be a few who do better with one versus the other. And then, of course, changing their diaper frequently and trying to catch it just soon as they go is another way to prevent diaper rashes from happening in the first place.
All right. Well, that wraps up our Infant Segment this week with the thrush and the diaper rash. If you have a little baby at home and you have a question that you're interested in hearing us discuss here in PediaCast, just let us know.
This week on our Toddler Section, we're going to talk about hand, foot, and mouth disease. And this is one that if you have a toddler at home, you probably heard of it and if you haven't heard of it at some point in the next year or two, you probably will hear about it. It's an infection caused by a virus. It's usually caused by the Coxsackie A16 virus. It's a big word, I know. But the Coxsackie group of viruses are usually the ones that cause hand, foot, and mouth disease.
Other types of Coxsackie virus other than A16 can also cause it. There are also some enteroviruses that can cause hand, foot, and mouth disease as well. Now the reason that's important is because there's not just one virus that causes hand, foot, and mouth disease. So that makes it what we call sort of a syndrome, meaning there's a group of different viruses that can cause the same looking disease. And that also means you can get it more than once because if you have the Coxsackie virus A16 and you get hand, foot, and mouth disease, well it's likely you won't get it from that virus again but there other Coxsackie viruses that could cause it plus the enteroviruses that can cause it. So you can get it more than once.
It's most common in children who are six months to about four years of age but you certainly can see it in older kids than that, and particularly if you consider that they can get it from more than one virus. It's going to span a little bit longer the time period that you can get it. But for the most part, by the time that you're school-aged or so, you've had most of the viruses that can cause it and so you generally aren't going to catch it much after that. But they'll be the rare teenager that gets it as well and sometimes adults get it, too.
Also,& you may get sort of milder form of the disease if you've had one of those particular strings of virus. So let's say for example, you were two years old and you had the Coxsackie A16 virus and had a rip roaring case of hand, foot, and mouth disease, then you're exposed to it again years later, rather than having a really bad case of it, you might just have a real mild form of it. Just a couple of little sores in your mouth and it all goes away in a few days because your immune systems, they're there to attack it, but you still do get some symptoms from it.
Well, what are the symptoms? Well, you're going to get scattered red spots or blisters and they're usually small. I mean, usually smaller than a pencil eraser and they're most commonly seen on the hands, feet, and inside the mouth. That's why it's called hand, foot, and mouth disease. It's also common in the groin area. That's probably the second – I'm sorry — the fourth most common place that we'd see it. So, some people think it ought to be called hand, foot, mouth and groin disease because you can see it down in the diaper area also.
When it does happens on the hands and the feet, it usually on the palms and soles and between the fingers and toes, but it can be on top surfaces as well. And sometimes, you see it even on the ankles, up on to the legs. They can be on the trunk. Less common on the face but you can have it there as well.
Usually, you're not covered with these like you are with really bad chickenpox or measles or something of that nature. Generally, you have just maybe five or fewer of these little blisters per hand or per foot. So it's just a few scattered ones, and then you also get the mouth blisters and those can be pretty painful — almost like burns inside the mouth. So those do hurt and in fact, when we talk about complications, the most common complication is going to be dehydration because they won't eat or drink because their mouth hurt so much.
Now, the other spots other than inside the mouth usually aren't too painful. Sometimes babies will kind of scratch at them a little bit. But they're not really itchy like chickenpox lesions are and the older kids who get it tend not to complain too much about the spots hurting other the ones inside the mouth.
There's also fever usually associated with hand, foot, and mouth disease. It typically is not really a high fever, more on the 100 to 102 range. Every now and then, you'll see a kid who gets a higher fever with it, but a higher fever should make you think to look elsewhere for a source of infection like inside the ears or sinus infection or apparent strep throat which can go along with hand, foot, and mouth disease sometimes.
OK, one of the things that's important to know about hand, foot, and mouth disease, it is not related to hoof and mouth disease that you see in cattle. This is strictly a human disease. So if the doctor tells you your kid has hand, foot, and mouth disease, they did not catch it from a cow.
& I have had a question about that here recently but it seems like a couple of years ago. There was a lot of this hoof and mouth disease going around from cattle that were coming from other countries or people who had traveled to other countries and then were coming back into the United States of America, and there was a question of whether they're bringing in hoof and mouth disease with them. And then a lot of parents thought their kids with hand, foot, and mouth disease were catching it that way.
But no, this is strictly a human disease. Usually last about seven to ten days or so. Fever for the first three or four days and the mouth ulcers last about a week and then the rash in other places usually lasts about seven to ten days. And again, the most common complication is dehydration because of the mouth sores and kids not wanting to drink so much.
Treatment is really just supportive. Antibiotics will not treat hand, foot, and mouth disease but if a kid has a concurrent bacterial infections, so if they have ear infection with their hand, foot, and mouth disease or they have a pneumonia or a strep throat or sinus infection, then might need an antibiotic for that component. But the hand, foot, and mouth disease part of it — because it's a virus — the antibiotics are not going to treat it and will not make you get better any faster.
So, how do you treat it? Well again, supportive. So, Tylenol or Motrin for fever and mouth pain. Sometimes, the mouth pain can be so much that you need some Tylenol with codeine to help calm that down. Although, that's going to be more common with some other diseases that cause just mouth sore like herpangina or herpes virus inside the mouth. Those things usually cause just tons of ulcers in the mouth and those kids are much more likely to get dehydrated and need some Tylenol with codeine to help with their pain control.
But sometimes, you get a kid with hand, foot, and mouth disease that his mouth hurts so much you have to use little Tylenol with codeine. Also popsicles are good. Even if they're young infants and they're going to make a mess with a popsicle, just having something cold in their mouth will help numb the surface of the inside of the mouth and help them to be able to drink a little bit better. And then, of course, clear liquids are going to help soft foods. And then, the rare kids are going to need IV fluids because they get dehydrated because they're not drinking.
Hand, foot, and mouth disease is a very contagious disease. And again, you can get it more than once. Its incubation period is going to be in the three to seven-day range. So about half-a-week to a week. It's most contagious during the fever stage, so it's going to be during the first three to four days of it. But then it's going to really be mildly contagious from about two days before they get the rash until about two days after the rash is completely gone.
In terms of staying away from day care, definitely stay away during the fever stage. In terms of after that, it sort of depends on the day care's policy. They are still mildly contagious until the rash is completely gone. But with good sort of semi-isolation procedures and hand washing, you might be able to get away with them going back to day care when the rash is in its very last fading away stage.
It's also important to note that they are mildly contagious two days before the rash, which is usually a day or two before they even have fever. Which is why it spread so easily, because you're going to have kids at day care who don't have the rash yet, they don't have the fever, you don't even know that they're sick and they're contagious with it to a mild degree. So you can go to day care centers and schools, even though there aren't kids who were going to school with fever and rash, so you can still get it that way.
OK, so that's our discussion on hand, foot, and mouth disease. Hopefully we covered all the different aspects of it. If we missed something though and you have a question, just go ahead and shoot us an email at email@example.com. Or you can go to www.pediascribe.com/podcast and use the Contact link and get to us that way. Or you can use our telephone comment line 347-404-KIDS, 347-404-KIDS.
OK, moving on in our Toddler Segment this week, we're going to discuss sutures. Now, this is actually a study that was done. It was reported in the British Medical Journal on May of this year. So May 6th, 2006 is when it came out.
And the study questions the usual guidelines of keeping surgical wounds dry and covered for the first couple of days after the surgery. Now, this study, it's important to know what we're talking about here is surgical wounds. So this is not kids who necessarily get a laceration. They fall down, get a cut and need some stitches. We're talking about kids who actually had surgery and they had a wound that was made with a surgical knife and then sewn up with sutures. That's what we're talking about with this study. That's what they did with this particular one.
It's still an important issue for toddlers because they're the ones that are most likely, if they've had surgery somewhere, to remove the dressing and the wounds get wet. They're the ones least likely to listen to you. And they're taking the bandage off and the next thing you know they're running their hand in the faucet and they're putting their hand in their mouth, and that's where the suture was. So I think it is an important issue for the toddler age group.
Now, this study was done in North Queensland, Australia. And there were 16 doctors who participated in the study. Between the 16 doctors, they had a total of 857 patients who were having what they describe as a minor skin incision. So, I'm guessing that these are things like taking off the mole, sort of a larger one that's going to need a stitch or two after you take it off or some other kind of skin lesion that they had to remove. So if they had a minor skin incision and had it stitched up afterward, they were included in the study.
And again there were 857 total patients divided into two groups: 442 of them would keep the wound and the sutures dry and covered, and 415 of them were to remove the dressing during the first day or two and wet the wound with some water.
Now, patients who already taking antibiotics, whether it was by mouth or topical antibiotics for some other reason, were excluded from the study and patients who are on medications that suppressed the immune system were also excluded. And also, both groups were advised not to use any antibacterial medicine, washes or soap of any kind on the wounds. So, it was basically just they made the wound, sewed it up and then one group covered it and told them to keep it dry, don't put anything on it. And the other group told them, in the first day or two take the dressing off, get the wound wet but then don't wash it or use any antibacterial medicine. Just leave it alone and then they would see these patients back in one week and inspect it for signs of infection.
And what they found was the group who left it dry — so they left the dressing on and they kept it dry — the infection rate was 8.9%. In the group that took the bandage off and let the wound get wet that had the sutures in it, the rate of infection was 8.4%. So basically, there was no difference between the two groups, not a statistically significant difference. So, one group 8.9% infection rate and the second group 8.4 infection rate. So it didn't seem to matter whether it got wet or not. So uncovering the wound and getting it wet did not increase the infection rate that was basically the result of the study.
Now again, this was for surgical wounds. Also the age of the patient was not mentioned in the study. I'm guessing it was probably adult patients. And if it were adults, how wet they did get the wound? Did they get the wound with the same intensity of wetness as a playing toddler would get it?
And also the diagnosis of infection was very subjective. The doctors just looked at it and one doctor may have called a mild infection of the wound, another doctor may have said "No, that redness is just from the healing process." So, there wasn't really a good definition of what the doctors would call infection and not call infection. So it wasn't a perfect study. It definitely had some issues with it.
But it does raise the question of is keeping sutures, saying they absolutely cannot get wet at all, is it just another one of our blind routines? Do we have a real definite reason for saying "You can't get it wet at all"? So, it looks like this is going to need further study.
It would be nice to have a study involving kids. And then, also does this translate into minor traumatic lacerations? So kids who fall down, have a couple of stitches from a minor scrape, if they get the bath and their sutures get wet every other day, is that going to increase the risk of infection? According to this study, that's less likely to be the case. But I think further studies are needed to look into that.
Now, this sort of thing, is it worth spending money on? These kind of studies though, you have to understand, generally are not multimillion dollar studies sponsored by a governmental agency. These kind of studies can be done by a surgical resident who needs to fulfill a research component of their residency. And they may not have a huge number of kids but they can recruit other doctors to be involved with it. And these are the kind of things that you don't have to spend a lot of money to do.
And if nothing else, it helps to determine some of the things we do in medicine are just so blind. We say you can do this, you can't do that, but there's no good reason to know for sure if that is something you can or can't do. So that's another reason why these studies are important, to sort of see the blind routines that we do are really something you need to do or are we just continuing to hand down old wives' tales, so to speak.
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Speaker 3: Children under 4'9" need to be in a booster seat, because they aren't ready for adult safety belts alone. Remember that 4'9" is the magic number and get your little bumpkin there safely in a booster seat.
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Dr. Mike Patrick: Welcome back to the program. This is Dr. Mike Patrick Jr with you on PediaCast, the pediatric podcast for parents.
We're going to start our School Age Section now and our first topic is pink eye. Pink eye is what we call viral conjunctivitis. Now, the conjunctiva is a clear membrane-like covering that covers the white part of the eye also known as sclera. Conjunctivitis just means inflammation of the conjunctiva. So, this clear membrane that's covering the white part of the eye gets inflamed and the blood vessels inside the mucus membrane swell and that's what gives it the pink appearance. Symptoms of pink eye are going to be pink appearance covering over the white part of the eye. You can have some clear or thin, yellow discharge and the eyes are itchy and maybe mildly puffy eyelids.
Pink eye is usually caused by a virus and especially if the redness is moderate to severe. Mild redness could actually be an allergic conjunctivitis. And if you have thicker eye discharge that's yellow or green, then that can indicate a bacterial conjunctivitis. And those are treated differently.
So again, if you have a question about this, it's best to see your doctor and let them take a look to see whether it's viral, allergic or bacterial pink eye conjunctivitis, because you're going to base your treatment on how it looks.
Now, pink eye is not really a medical term. It's just sort of generic term that we usually use to describe a severe viral conjunctivitis. The only treatment for pink eye, really, is your body's immune system and that takes anywhere from usually three to seven days.& Sometimes, three at the absolute minimum. Usually more along the lines of five to seven days and every now and then, you have one that last 10 to 14 days.
But because it's a viral infection, antibiotic eye drops will not treat pink eye. And we do often use antibacterial eye drops in kids that have pink eye, but the reason is because if your eyes are watering all the time and they're itchy, it's pretty hard to tell the kid not to rub his eyes. And even though you don't want them to rub their eyes, you look away from them for two or three minutes and you look back and they're rubbing their eyes. And then they get their fingers in their mouth, and then they're rubbing their eyes. And next thing you know, you have skin bacteria or mouth bacteria growing inside the inflamed pink area. Now, you're getting the thick green and yellow stuff come out. So we use the eye drops more when we use them as a way to prevent a bacterial conjunctivitis happening on top of the pink eye that's already there.
Now, if you have an older kid with pink eye and you're pretty sure they're not going to rub their eyes a lot even if you tell him not to and you trust that they're not going to do it, you don't have to use antibiotic eye drops for those kids. It's really more for the younger children who you think they're probably going to have their hands in their mouth and rub their eyes regardless of what mom tells them. And those are the kids that you usually use an antibacterial eye drop.
But again, the important thing here is, using those eye drops is not going to make the pink eye get better any faster because it's a virus. Antibiotic don't treat viruses. Also, it is going to be contagious the entire time that they're using those eye drops. So this is really an important point, because a lot of school nurses will say, "As soon as you get on the eye drops, you can come back to school." Well, if it's a viral conjunctivitis, that's just craziness because it's caused by a virus and antibacterial eye drops are not going to cause this to decrease the contagiousness of it.
Now, the question becomes do you have to stay out of school until the pink is completely gone? And that's up for debate. A lot of people think, for the most part, pink eye is a fairly mild infection, usually does not have much long term effects. And so there is more and more of a push to get these kids back in school even though they may still be contagious and try to keep them from rubbing their eyes or try to have them wash their hands frequently or carry around some antiseptic hand gel and use very frequently at school.
Some schools however would say kids with pink eye cannot come to school if it's still contagious and if that's the school's policy, that's fine. There is certainly an argument to be made for not having a class of 30 kids all with pink eye. But it is fairly harmless. And yeah, more and more schools are allowing kids to come back even though their pink eye may still be a little bit contagious. But if your school's policy is no pink eye in the school, if the school nurse says once you start the drops you can come back, well, that's again, they're still going to be contagious even with the eye drops if it's a viral conjunctivitis.
Now, if it doesn't have a viral component and it's a bacterial conjunctivitis, so this is more with the thick green and yellow stuff coming out constantly. You use a wet compress and sort of wipe the goo away and within half an hour, it's just all gooey again. Now that's going to be more of a bacterial conjunctivitis. And, so those, once you start the antibiotic eye drops or the ointment, usually within 24 hours or so, that's probably not going to be very contagious anymore. Because it's a bacteria and now you can use something to treat it.
If it's an allergic conjunctivitis, if you go outside and your eyes get red and itchy and watery or around cats or unknown contact with something, obviously, that's not going to be contagious and you don't want to use antibiotics for that as well. There are some antihistamine-type eye drops that can be used for that kind of conjunctivitis.
So again, if you have any questions about it, see your doctor. They'll be able to take a look and give you better idea of which kind of conjunctivitis it is. If it is a bad viral conjunctivitis, that's what you'd call pink eye.
Now, any pain in the eye definitely requires a visit to your doctor because pain in the eye is more likely to be associated with the corneal abrasion in the eye. Also, there are certain kind of infections particularly herpes kind of infection that can cause ulcers in the eye. So you really do need a good eye exam by your doctor if there's a lot of pain associated with conjunctivitis.
OK, moving on in our School Age Segment, the next topic is little bit of a historical story. There was a measles outbreak in Indiana. This was reported by the New England Journal of Medicine just a week and a half ago or so. It was just August 3rd of 2006, the story was reported.
And basically it goes like this, in 2005, there was a 17-year old unvaccinated girl — so she did not have the MMR vaccine — and she returned to Indiana from a trip in Romania. She'd gone there on a mission trip. And while she was over in Romania on her mission trip, she was infected with measles.
Now, the first symptoms of measles which is going to be like cough, runny nose, congestion and a little bit of conjunctivitis, it began just right around time that she was returning but everyone just thought she had a cold and a little pink eye. Well, two days after her return — so now, she's got this cold-like symptoms full blown but no rash yet — she attended the large church gathering in Indiana and there were lots and lots of unvaccinated children present there.
Two weeks later, a six-year old also unvaccinated the girl was hospitalized with measles. So she actually had the rash now and she was in another state but she attended that church gathering and the Public Health Department was able to track her back. And actually, within the next six weeks, 34 more cases of measles were confirmed from this particular outbreak.
So, it all started with the 17-year old unvaccinated girl. She went to Romania, came back, went to church gathering and, basically, 34 cases of measles came out of this and this was last year.
Now, stats on the confirmed cases are interesting, 94% of the folks who got measles were unvaccinated. So, 94%, 88% of them are under 20 years of age and of those who were school-aged, 71% of them were home schooled and about 9% of them required hospitalization, which is a pretty big number. Almost 10% of everyone who is infected was sick enough to have to go in the hospital because of it. And really with any disease, that's a pretty high number.
So what can we say about this? Well, the cases were largely confined to unvaccinated children whose parents had refused vaccines due to a fear of the side effects. And their fear of the vaccine was perpetuated by their religious community. So, they went to this church to where there was largely unvaccinated kids and when the health officials talk to these folks, the reason that they did not have the MMR vaccine was basically a fear of what the vaccine would do to their children. And they had a lot of support within their church community, everyone else was not wanting the MMR. So the parents felt like everyone else at church is doing it, so I'd feel more comfortable also refusing the MMR.
The authors conclude that the high vaccination rate in the surrounding communities and the low rate of vaccine failure in those communities really prevented an epidemic. So it was isolated to this group of unvaccinated children and the children's surrounding communities who still had contact with these kids did not come down with measles. So their vaccines worked very well for them.
This shows just how quickly and easily though measles can spread in an unvaccinated population. And,& really, had it not been for the MMR in the surrounding communities, all of those kids were also unvaccinated, they probably would have been many, many, many more cases of measles. And if that 10% requiring hospitalization held up, well, the hospitals would have been inundated with kids.
So in our discussion of, let's just talk a little bit about what measles is. It's caused by a virus. So antibiotics are going to treat it. Again, the prodrome is what we call the beginning of the measles before you have the rash and that consist of a cough, runny nose, little pink eye and fever for three or four days prior to the rash breaking out. And then, you get this little white spots on the inside of the cheeks, inside the mouth, opposite the molars. Those are called Koplik's spots.
And then, the rash starts on the face and it spreads the entire body usually within about three days. The rash is very intense. It's all over, it's red, it's blotchy. It's really impressive when you see it. And then measles is very contagious in unvaccinated kids and incubation period is going to be about seven to ten days usually.
Now, OK, you got a fever, you got a cold, you got this bad looking rash, what's the big deal? Well, the big deal with measles is the complications that can happen because of it. The most common ones are going to be diarrhea, not eating, dehydration kind of stuff, need an IV fluids. Ear infections are also common but the serious complications are going to be two things. One is a type of pneumonia caused by the virus itself. They can be very severe and the kids can require time in the intensive care unit on a ventilator because of how severe the bronchial pneumonia can be.
Also, you can get encephalitis which is brain inflammation. And that actually, the encephalitis that goes along with measles, so this brain inflammation, results in death in about two of every 1,000 cases of measles in developed countries and about 150 in every 1,000 cases in undeveloped or third world countries. So, two out of every thousand kids with measles dying from encephalitis is pretty serious.
Prior to the MMR vaccines used in the early 1960s, about 300 kids in the United States died each year from measles. If you correct for population growth, that would translate to about 500 to 750 kids a year today. So if you look at the percentage of kids who got measles and then died from it and then you correct for the current population, you could expect between 500 and 750 deaths a year in children from measles if we didn't have the MMR vaccines.
Now, there are some things that can affect that a little bit. Number one, modern medicine may be able to decrease that death rate because a lot of those kids may have died from severe dehydration and we certainly are better at IV fluids and helping kids out who are dehydrated. Also, some of them may have had secondary bacterial infections. So, they may have had bacterial pneumonia along with their viral pneumonia caused from the measles. And so, those kids have better antibiotics today and be less likely to die. Also, we have better intensive care units, ventilator support than we did back in the 1950s.
So you could argue that maybe that 500 to 750 kids is a little bit on the high side when you consider the advances of modern medicine compared to the kids who were getting measles and dying from it back in the 1950s. Now, having said that, though the kids who get encephalitis from the measles, those kids, even with modern medicine today there's little that can be done for them and many, many of those would die who would get encephalitis from their measles.
So the bottom line is with advances in medicine, we really don't know how many kids would die from measles these days if there was another epidemic. We just don't know for sure. But it doesn't really matter how many if your child is one of them. And so, I would definitely encourage moms and dads out there to get your kids vaccinated against MMR or against measles, mumps, rubella vaccine so that we can prevent that sort of thing from happening again.
Incidentally, if you do get measles, the treatment is pretty much supportive. Tylenol, Motrin, cough medicine, lots of fluids. If they have secondary bacterial infection, antibiotics, then later support for pneumonia. And, of course, the best prevention for measles is going to be getting that MMR vaccine. Also, limited exposure if possible. So if you go to church with a bunch of unvaccinated kids, if one of them gets measles and your kids, even if they had their vaccine, if they have a vaccine failure, then they're be more likely to get measles.
Now, there is a pretty low rate of vaccine failure with the MMR but there is a small degree of it. So if your children are in a large group of unvaccinated kids, even if they've had vaccines, they're a little bit of a higher risk for getting that disease if their vaccine is one of the few that fails.
Dr. Mike Patrick: This week in our Teenage Segment, we're going to talk about acne. And almost all teenagers get acne at one point or another. Its cause is number one, hormones. The hormones of puberty caused glands in the skin, particularly in the back and on the face and on the chest, cause these glands to sort of wake up and start making more oil. The cells that line oil duct get larger as they make the oil. And then they also tend to slough off. As your body sort of regenerates itself, you're making new cells and the old ones get slough off the skin, fall off the skin, basically.
But these larger cells that are making the oil, if they sort of break up, they can actually clog the duct and if that duct gets blocked and the oil becomes trapped inside the gland itself, then that's how you get the white and black heads. And then some skin bacteria tend to invade these clog gland area and then causes redness and swelling.
Things that will make acne worst is pinching or popping that forces the oil that's in the gland now to penetrate surrounding skin that can cause a little bit of immune response, because that oil is not supposed to be there and you get more redness and swelling in the area of the acne. Hard scrubbing can irritate the skin and anything that has prolonged close contact with the skin and is irritating it, you're more likely to get pimples or acne on those areas. So if you're wearing hats frequently, your hair accessories, even hair itself rubbing up against the skin, chin straps, with support helmets, bras, eye glasses — anything where there something touching the skin and the skin is getting a little bit irritated — you're more likely to have a bit of an outbreak on those areas.
Also, things like makeup, creams, hair products are all things that can block the oil ducts and that can cause more acne. And then, there's also some medications such as steroids that can increase gland, can cause the glands to make more of the oil. And changes in hormone level during monthly cycle for females can contribute to it. Also, emotional stress and nervous tension can cause fluctuation in hormone levels which then those glands respond to.
Now, things that won't make acne worst — food, soft drinks, greasy foods, chocolate, none of those things in studies have ever been shown to cause acne or to aggravate acne. Also dirt or being unclean, these glands are not blocked by dirt or any other kind of uncleanliness. It's caused by the skin cells that are big because they're making more of these oil. But then, in turn, those bigger skin cells kind of break away and then clog the actual duct and then the oil gets trapped down in that glands. So that's how it happened. It's not from dirt blocking the ducts. Not ducks, duct.
OK. Acne is not contagious. It doesn't spread from one person to another. And then, also we want not have to do an explicit rating here but sexual thoughts, sexual activity, masturbation, none of those will cause the acne.
OK, so what do you do if you have it? Well, home treatment, the first thing is benzoyl peroxide containing products and that just helps to get rid of the sloughed skin that's plugging the ducts. So if you have any of the skin cells that are blocking the entrance to the gland, benzoyl peroxide helps to unplug them by loosening those skin cells that are blocking the entrance. Benzoyl peroxide also can kill skin bacteria. So it helps in that way.
Generally, you want to start with the low percentage of benzoyl peroxide. So 2.5% is the lowest and it goes up to 10%. So you go from 2.5% up to 5% and then up to 10% and you can use it once or twice a day. So you start out with a low dose using it once a day. You can advance that to twice a day, then go from 2.5% up to 5%. Do that once a day, go up to twice a day. If that's not working, then you could go up to 10% and do that once or twice a day.& But you can't use too much of it. The skin will start to dry out and get some redness associated with just too much benzoyl peroxide. So you want to start low and then slowly work your way up to a higher percentage and using it more frequently.
Also, just a little hint about benzoyl peroxide, it does act as a bleach. So if you put it on the skin and then, put clothes on right afterward, it can bleach out color in the clothes. So you want to wear something white with not a lot of color, if it's going to be touching where the actual application of the& benzoyl peroxide was placed. Or you want to wear an undershirt or something underneath there to act as a barrier between the benzoyl peroxide and your good clothes. And, of course, using it at night time will help you out there as well, because you can just wear something old to bed that you don't mind if it bleaches out a little bit.
Another medicine that you can start with the home treatment is soap washes that contain triclosan. Triclosan is an antibiotic that's in some soaps and it also kills skin bacteria, so it helps to decrease the amount of acne that way. It can be used once or twice daily. You can use that in the shower and an example of that is like Clearasil Daily Face Wash.
So, an example of a good place to start with acne treatment is going to be something with benzoyl peroxide in it and then a soap with triclosan and using those things once or twice a day. And that's a good place to start. Now,& let's say you start with that and it's not working. Well, you want to see your doctor because if that home treatment isn't working, there's a lot more that we can do.
So, if you have really severe acne or you're trying these home treatments for a few weeks and you're not getting anywhere, then you do want to see your doctor. And some things your doctor can do, one is to do a prescription-strength benzoyl peroxide with an antibiotic combination. Example of that is BenzaClin. It has an antibiotic in it along with the benzoyl peroxide and that tends to work pretty well for lots of kids.
Also the Retin-A products, those unplugged the ducts probably a little bit better than benzoyl peroxide does but they're a lot more expensive to use. Also, if you use Retin-A products, you want to avoid sun exposure because there'll be some sensitivity to that and you'll get sunburn a lot easier.
Also, oral antibiotics, low daily dose of tetracycline, that can also help reduce the number of skin bacteria and that, in turn, decreases the amount of acne. But, again, you need to see your doctor because that's a prescription. And once again, with tetracycline, you have to avoid the sun because you have some sun sensitivity with that as well.
And then, the big gun is going to be Accutane which is a vitamin A derivative. Accutane is very good at eliminating acne. It mostly works by helping these skin cells not to make as much oil, not to get so large and clog off the entrance to the glands. So it works really well. But the problem with Accutane is that it can be associated with very severe birth defects and even fetal death. And so, girls really need to make sure that they're not going to get pregnant while they are on Accutane. And a lot of doctors would want to do a pregnancy test before they'll put a girl on Accutane, plus have the girls sign a contract saying she won't get pregnant and she understands the risk. And someone argued that they won't even use Accutane in teenage girls unless the girls are also on birth control.
So, usually, it's a pediatric dermatologist who sees a lot of kids. They may not be a pediatric specialist but does have a large teenage practice. Those are going to be the ones that are most likely to use Accutane. Because you've already tried your prescription-strength benzoyl peroxide, your Retin-As, your oral antibiotics and if you get into that point, dermatology referral to look into Accutane is probably appropriate.
Some reminder points with acne, you got to be patient. It can take several weeks to see improvement. This is not one of those things you're going to slap on a little benzoyl peroxide and see an improvement in a day or two. It's going to take a little while. Also, you have to use any acne medicine consistently. Even if it seems not to be working, you just got to keep at it. You don't want to overdo the medicine. Hard scrubbing or using acne medicines more than once or twice a day can actually make things a little worse and cause more skin redness and swelling.
Also, and this is really important. Don't use medicine that's prescribed for your friends. Go see your own doctor if the over-the-counter stuff is not working. There had been some cases out there where a teenager will use their friend's Accutane but that teenager didn't know she had an early pregnancy and then, it's just a disaster. So whenever you use prescription medicine that's prescribed for someone else, you want to see your doctor and find out what's going to be the best medicine for you.
And then, make sure you follow all the directions on the labels, whether it's an over-the-counter medicine or one that your doctor gives you, you got to follow all the directions on the labels. And then, if things aren't working, you got to let your doctor know that the treatment is not working. I can't tell you how many kids you see who have some really bad acne, and you mention it at their well checkup and you look back and you say, "Well, golly, we started BenzaClin back a few months ago." And they said, "Yeah, it wasn't working so we stopped it." Well, but you didn't come in. You go to go back in to see the doctor if things aren't working so that we can try something a little different that helps in a better way.
Dr. Mike Patrick: Well,& that concludes this week's edition of PediaCast. This is Dr. Mike Patrick Jr coming to you from Birdhouse Studio and I'd like to thank everyone for joining us this week.
Once again, if you have a question that you would like us to address here on the show, you can get a hold of us by going to www.pediascribe.com/podcast. Click on the Contact link and you can send us a message that way. You can also email us at firstname.lastname@example.org. And then, we have our brand new phone number, you can leave a voice message at 347-404-KIDS. That's 347-404-K-I-D-S. And if you call that number, you can leave us some voice mail and leave your message that way and next week, we'll try to get to some more Listener Mail.
Also, if you could let us know how you like the show in terms of keeping it with the four age groups like we're doing, divided up into about an hour show, 15 minutes each age group. Or if you'd rather have four separate 15 to 20-minute shows based on age range, just some feedback on that would be helpful as well. Because, once again, we want this program to be the topics that you want to talk about and in a way that is most convenient for you to listen to.
Also, if you have some good things to say about PediaCast and want to give us a shout out at the iTunes Music Store, that would be most appreciated. Also, we're on Podcast Pickle. And on our website, it's also sort of like a blog as well. So any comments that you want to make on an individual show, you can leave at the website as well.
And also, tell your friends and other parents about PediaCast, so the more people we have listening, the more topics we'll be able to generate and discuss and of course, that benefits everyone.
So once again, thank for joining us this week and until next week, this is Dr. Mike Patrick Jr saying, so long everybody!