Hand Washing, Sacral Dimples, Vaginal Pain – PediaCast 054
- The Importance of Hand Washing
- Sacral Dimples and Tethered Spinal Cords
- Vaginal Pain in a Three Year-Old
- Salmonella (CDC)
- Hepatitis A (CDC)
- E. Coli O157:H7 (CDC)
- Tethered Spinal Cord Info (Neurosurgery4Kids.net)
- Labial Adhesions (DrGreene.com)
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents — The Listener Edition. And now, direct from Birdhouse Studios, here is your host, Dr. Mike.
Dr. Mike Patrick: Hi, everyone. It is PediaCast, Episode Number 54, The Listener Edition for Tuesday, September 25th, 2007.
This is the episode where we answer your questions each and every week. And I get lots of good questions and, unfortunately, and I can't get to all of them. We try to do a mix of ages and a variety of diseases so that it's a nice variety and we touch babies and children and teenagers. But I will say this, you have a better chance of getting your question answered in one of these Listener Editions if you ask about a specific disease process. So, it's really better if you go see your doctor and your doctor says your child has XY or Z, and you write in and say, "Hey, I want to know a little bit more about this disease," and then, I can answer your question. That's little bit better than saying "Hey, what's wrong with my kid?" Because we're not able to do a complete history and physical exam in the course of a podcast. So, it's a little hard to say what's wrong with your child. We can talk about what some of the different things might be. But it's still important, of course, to see your doctor.
So, in our lineup today — hand washing, why is it important? I mean, it seems obvious, but is it? And then sacral dimples. Now, some of you out there know what I'm talking about. If you have a child who has a sacral dimple as an infant, you probably know exactly what I mean. On the other hand, this is not something people tend to discuss when they're talking about their kids or out of dinner or at family reunions. So if your child doesn't have a sacral dimple, you may have no clue what I'm talking about. So you can learn about it here.
Also, a three-year-old with vaginal pain, what could be the cause? Now, OK, it's a "What's wrong with my kid" question. So, it's not the best one. But I'm going to take this opportunity to discuss a common condition. So, we'll have to just sort of assume that's what it is, but of course, it might not be. And we'll talk about that in a little bit when we get to the question that I'm talking about.
All right, don't forget to get a hold of me. Just go to pediacast.org and click on the Contact link. You can also email firstname.lastname@example.org or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.
Let me also remind you the information presented in PediaCast just for general educational purposes only. Again, we do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands-on physical examination.
OK, first up in our Listener Episode is Geraldine from Israel. And Geraldine says, "Greetings from the Middle East. We were supposed to wash our hands after going to the bathroom and wash fresh produce before eating it and so on. My question, just out of curiosity, is what do bacteria that you find in veggies or feces do exactly to human bodies? Thank you a lot and have a good one — Geraldine. PS: Do you know your show has fans in Uruguay, South America?"
No, really, I had no idea. I don't think anyone from Uruguay — Uruguay, "Urugway…? — I'm embarrassed to say I don't know which one it is. So if you're from that country in South America, please drop me a line and let me know the correct way to pronounce your country, probably a good thing.
OK. So, let's talk about hand washing. Now, again, it seems obvious on the surface, but if you look at it this way, you could say, look, bacteria that's in the intestine is already in your body, right? So why would you have to wash your hands after you go to the bathroom if the fear is just that you're going to ingest bacteria from your hands. Let's say you pick something up, you eat it. Well, now, the poop germs are on your hands. But isn't it just going back where it came from? So, I guess from that point of view, you have to say, well, maybe it's not such a bad thing.
However, there are some issues. And the first issue we're going to talk about is just with your own body. Of course, there is the issue of spreading your poop germs to other people, which you may not want your neighbor's poop germs in your body even though they're pretty much the same bacteria. But it's just the thought of it.
So let's talk about your own body first. Well, if you have these bacteria that is OK to live in your intestine on your hands, you do run the risk of that bacteria getting to places on your own body where it shouldn't be. So, if you rub your eyes, the bacteria can end up causing a conjunctivitis if you're not careful. It could get on the skin in "colonate……
"Colonate…, listen to me. I have vacation coming up, you got to cut me a little slack. Colonize, hey, I'm like George Bush, I can make up words. OK. We're not going to get political.
So I can colonize my skin with bacteria that's not suppose to live on the skin. And then, if I have eczema or I get a scratch or an abrasion and then, that bacteria that's supposed to be in the intestine now is on the skin, then that can cause a problem that way as well.
Now, another issue is that, you could have some bacteria in your intestine that could cause a problem. It just isn't causing a problem at the moment for you because there's a limited number of them. Maybe the exact place in the intestine where they're living is not hospitable to growth, where the immune system is keeping it in check. So you could have salmonella, shigella, clostridium difficile or CDIFT. You could have the bad E.coli, E.coli O157:H7. That's the one you hear about with food poisoning that can cause severe disease and death.
So, you could have those bacteria in your intestine. They just aren't causing a problem at the moment because your immune system has them in check or they're in an area of the intestine that's not very hospitable to them growing. But then, if you have those on your hands and you reingest them, well now you can reintroduce those bad bacteria to a place in the intestine where growth is a little bit more hospital so you get more of them. They overrun the immune system's ability to keep them in check and then you could make yourself sick even though you're just ingesting things that were already in your intestine to begin with. So that's one reason.
Now, of course, as I alluded to, it's kind of yucky to think about not washing your hands after you go to the bathroom and then the germs or bacteria that are normal in your body are now in a door knob. Or they're on a telephone receiver and then you're spreading them that way. And again, even though it typically is going to be the same bacteria that all of us are exposed to and have in our intestine, it's still just not very nice to think about being exposed to it. So I guess just that a courtesy to your fellow human, hand washing is important.
Now, what about vegetables? Well, vegetables do not inherently have any bad bacteria. The problem is that depending on where the vegetables were grown. Do they have fertilizer that could have been contaminated with human feces? Now, that's disgusting to think about but it happens. Also the people who pick the food, who package the food, distribute the food, do they wash their hands very well after they go to the bathroom? And so their poop germs can be on vegetables. So that's good reason to wash them off is just to be sure that there aren't any bad bacteria and or even good bacteria on the surface of the vegetables because it's someone else's poop germs. You don't necessarily want those entering your body.
Also fruits and vegetables may also have chemical pesticides and fertilizers and things that aren't necessarily biologic in nature, but chemical that could potentially cause problems if you're exposed to enough of it down the road. So those would be the reasons.
The bacteria, again, are not necessarily going to be bad for your body if that's the kind of bacteria that's supposed to live there and in the right amount. But there is always that potential to get sick either from yourself or from someone who is harboring a bad bacteria. And again, some examples of that would be salmonella, E.coli O157:H7 and hepatitis A. Hepatitis A is a virus, so that one is a little bit different, but it is spread in the same kind of way and that can get in your body and cause a hepatitis.
So there, I do know, in the Show Notes, if you're interested in those diseases, a little bit more about them, there are some links to some information sources from the Center for Disease Control or the CDC on salmonella, hepatitis A and the bad E.coli.
Sometimes, I do have people mistake the bad E.coli for the good E.coli. I mean, E.coli lives pretty much in everyone's intestine. If it gets in the urinary tract, it's really the most common cause in women of urinary tract infections just because of the close proximity to where those bacteria are coming out and the urinary tract. But that's regular E.coli. That's not the O157:H7 which can cause bloody diarrhea and hemolytic-uremic syndrome, which is basically the bad E.coli is making a toxin that breaks apart red blood cells, so you become anemic. And then, you also have the breakdown of the inner products of those red blood cells and those can cause kidney damage and it can lead to death in some cases. So it's something that is serious and you be definitely want to avoid having that in your body.
So again, if you have or if you like to know more information about those particular bacteria, just look in the Show Notes.
OK, so let's move on, Listener Question number 2. This comes from Liam's mum in Melbourne, Australia. And she says, "Good day, Dr. Mike. Greetings from down under. I love your show and really look forward each week to your updates. My four-month-old son was born with a sacral dimple indent at the base of his spine. The doctors and nurses checked it and advised that the dimple was closed, and hence unlikely to cause him any discomfort in the future. It still concerns me, however. My husband and I will be seeking to have this monitored for our son over the coming years. In the meantime, we would be grateful if you could please shed some light on A, the likely causes of sacral dimples; and B, the variety of complications that are known to arise from this condition, if any. Thanks for your valuable time. Cheers. Liam's mum."
All right. So greetings to you, too, from down under. I'd like to go there someday. In fact, there is Adventures by Disney trip that they're organizing to go down to Australia but the price is just so expensive. And so, I think we're going to hold off now but, boy, I would like to go to Australia someday.
OK. So having said that, let's talk about sacral dimples. These are basically little pits or a dimple deeper pit down at the base of the spine, as Liam's mom said. And again, if you have a kid with this, you know exactly what I'm talking about. It, basically, is if you look at the fold that's just between the two butt cheeks, it's going to be in the midline of the back just right above that, or even in between the fold at the top part of the fold. And you just have basically a little puckering in. And we do sort of differentiate, is it's a shallow dimple or is it a deep dimple?
Now, when I trained, the issue was this — if it was a shallow dimple, you just watch them. If it was a deep dimple, then you do some kind of imaging to make sure that there wasn't a structural defect of the spinal cord in the lower back. And the structural defects that we're talking about would be spina bifida and tethered spinal cord. Now, what these things are — the spina bifida, I think we touched on this in other podcast in the past. And really, that really sort of deserves its own episode because it is complicated. So, I'm not really going to get in too much detail with that. But it's an abnormality of the formation or development of the central nervous system and it can be at the base of the skull or high up in the neck and it can also be down in the lower back.
So that's something that you do have to worry about with the sacral dimple, especially deep one. But more commonly, and still it's not very common, but the other thing that we worry about is something called a tethered spinal cord and what that is, it's a developmental issue where the spinal cord has ligaments that attach it at the bottom of the canal that it rests in. So basically what happens then, as a child grows, the spine, the bones becomes elongated but because the spinal cord is attached down at the bottom, it starts to get stretched. And because of this stretch, you do have some damage and as the child grows in mid to late childhood, they can start to get leg weakness, constipation, incontinence with the urine and then incontinence with stool.
And so, basically, just the nerves that are coming off of the spinal cord that go to the bowel, the bladder and the lower extremities aren't working properly because the spinal cord is getting stretched. And once that stretch happens — you can have surgery to release that tethered cord — but once the stretch has occurred, the damage tends to be more permanent. So it's best to find out if the child has this before the damage takes place, that you can release that tethered cord to prevent problems down the road.
Now, the thought is that if it's a shallow dimple, then there's a lot less risk than if there's a deep dimple that you can't really see the base of very well. And so, the way I was trained is that you just only do the imaging studies if it's a deep one, and if it's a shallow one, the chance is so low, you don't really do much with it at all.
Now the issue becomes, as doctors, we have to practice by what's considered the standard of care in our individual community. So what would other pediatricians do in a certain circumstance, you're sort of held to that same things. So where I practice, it generally is accepted that even if it a shallow one, you go ahead and do some kind of imaging study to rule out a tethered cord. So that typically is what I do for it. But other doctors who practice in an area that's a little more conservative and likes to wait and see, certainly that is an option as well. But certainly, a kid, even with the shallow dimple, if they started to have leg weakness, constipation issues, incontinence, then an imaging study to screen or look for a tethered spinal cord is certainly something that you would want to do.
OK. So what kind of radiology procedures are we talking about? The easiest one in terms of doing it on a child is going to be an ultrasound where you can look at the spinal cord with sound waves. Now, the only issue with this is it's difficult. It's difficult to visualize a spinal cord with an ultrasound. And so, a lot of radiologists are not trained to do this. So you have to really have it done in a place where the radiologist do this quite often. And, unfortunately, there is not a lot of places where that can happen. And you can order it, but the radiologist, if they're not really good and experience reading spinal ultrasounds, they're going to say, "Well, I don't see any evidence of the tethered cord. However, it can't be ruled out based on the study, and I would suggest getting an MRI."
So an MRI is going to be the best way – universally, the radiologist is going to see a nice clear picture of the spinal cord and would be able to diagnose a tethered spinal cord based on the MRI, a little bit easier than with the ultrasound. Now the problem with the MRI is that in children, they often need sedation and there is a risk that goes along with sedation. And I guess, that's really the issue — do you do the MRI on everybody that even has a shallow dimple? The risk of the sedation from the MRI, how does that compare to the risk of having a tethered spinal cord with just the shallow dimple back there?
So, the malpractice lawyers are going to come after a doctor, really, regardless of which way this goes. If you say, "Well, the risk of the sedation with the MRI outweighs the risk of having a tethered spinal cord, we're not going to do it. We're just going to watch closely." And then, they have a tethered spinal cord and they start to have problems. And you'd catch it as soon as they have problems but some permanent damage has been done. There's a possibility that you're going to get sued for malpractice because you didn't get that MRI.
On the other hand, if the same kid, same exact kid and you do the MRI and they have a problem. Let's say they arrest during the sedation, they have a bad allergic reaction or just an idiopathic reaction, something that just happens because of their body chemical makeup that doesn't agree with the sedation. And they arrest and maybe suffer brain insult because they go without oxygen or die. And then, they're going to say, "Why did you do the MRI? You know sedation is dangerous and it was unlikely they had a tethered cord." So my point with this is, just sometimes, as a doctor, you can't win. OK. It's not funny.
So, in any case if you find a tethered cord, surgical correction usually is the course that you follow. And I do have a link in the Show Notes on tethered spinal cord from neurosurgery4kids.net. They have a great information sheet about the tethered spinal cord so you can read more about it. Again, just look in the Show Notes for that.
OK. And our third question, this comes from Natalie in Georgia. Natalie says, "Hi, Dr. Mike. I apologize if you covered this before. I would appreciate some guidance. In January of this year, my three-and-a-half-year-old daughter who turned four last May started complaining that her vagina was bothering her, not hurting, burning or itching. She described it as a tickling feeling on the inside. This bothersome feeling exploded to meltdowns when having to sit down anywhere including the car seat. She even had a night terror at one point and I thought she was going to really injure herself. We went to our pediatrician three different times for urine test and cultures, they always came back normal. I was basically told by several different physicians that this is typical body awareness and potentially triggered by anxiety.
After close to three months, it drastically improved. She would mention a tickle and urinating seem to solve the problem. We were relieved but now the problem has started up again to where using the bathroom is not solving it. I know it's a very physical symptom for her. She can be totally calm, involved in playing or watching the show and it can start up with her. We've wracked our brains trying to eliminate possible triggers and there don't seem to be any. We switched detergents, monitored foods, monitored stress levels.
I took her back to the doctor for another urine test a week ago just to cover that possibility, and again it was normal. As a mom, I want to fix this. I can't imagine how annoying and bothersome this feeling must be for her. The latest doc said she may be very sensitive down there. We're supposed to acknowledge that our daughter is experiencing something real but calmly tell her that "it's normal and it will get better and not to bring too much attention to the problem" to quote our doctor.
I feel like a broken record to my little girl, not to mention feeling helpless to make this problem go away. I just cross my fingers it will improve soon as it did the last time. Have you encountered this problem or anything similar in your practice? Again, no fevers, no signs of trauma, no discharge. I tried to research this online but really can't find anything. Any advice you can give would be greatly appreciated. Your information on this podcast has been invaluable to me. Keep up the great work and thank you."
All right. Well, when you have a little girl, toddler age, who's complaining of a discomfort down in the private region, obviously the first thing you have to make sure they are not having is urinary tract infection. And, Natalie did that. So, it's really important to check the urine to make sure that they don't have the urinary tract infection because that can lead to a kidney infection, can lead to then to blood infection and sepsis. So, bad things can happen if they have urinary tract infection that you are not addressing. Now usually that's going to have bad belly ache along with it and vomiting and fever but not always. So anytime my kid is complaining a pain in the private area, especially the girls, you have to make sure that they don't have a urinary tract infection.
The other thing that's very common and it sounds like you addressed this as well is basically what I would call a contact urethritis. So, it's basically pain in the urethra area down below, sort of with the urethra which is the tube traveling from the bladder to the outside of the body. Anything chemical-wise that can irritate that could cause a problem — so things like bubble bath, soap, shampoos.
In some kids, you think, "Why, I don't let them take bubble baths." But if they take long baths and you let them wash first and they're playing in that soapy water, it's just that soap, it's not bubbles. But you know what I'm talking about, there's just soap on top of the water and in the water and they're playing in that for a while, that can cause a contact issue as well.
So, probably the best thing to do with the kid who's sensitive in that area is to let them play just in clean clear water, supervised. And make sure they're at appropriate age to be in the bath by themselves. And then, basically, let them play and then wash, rinse, and get out. So that they're not playing in soapy or shampooey water at all.
Also for some kids, really, just using a little bit of soap in that area is going to cause a problem. So, even if you do it real quick at the end of the bath and then rinse them real good, so for these kids, you don't just don't use any soap at all. You just kind of spread them apart and swish the water up in that area to clean just with water. So that's something, too, for some kids who are really sensitive.
Also, white cotton panties are going to be the best. Because sometimes the synthetic underwear polyester or dyes in the underwear — so different colors — especially when kids are sweating, they're playing real hard or warm at night time or during the summer time and they're sweating, sometimes, little particles of the dye or synthetic fiber can come off and cause irritation. So, white cotton pennies are going to be the best for kids who are sensitive in that area.
Also, you want to make sure that when you wash their underwear, I will do it separately, a separate load. Use a tiny amount of detergent, something that's really hypoallergenic, something like dye-free, hypoallergenic Tide or Dreft, those kinds of things. So just a really mild soap, use a small amount of it, double rinse, no fabric softener, no dryer sheets. You really just want to try to make sure that there's no chemical on the underwear that's going to be in contact with the skin in that area.
Also make sure you use in a white toilet paper. You don't want to any dyes or prints on the toilet paper itself because again that could cause some irritation. And for some kids, if you switch from toilet paper to using those flushable wet wipes, sometimes that helps, too. In other kids, that makes it worse. So you just have to sort of experiment with your own kid.
Now, let's say you've considered all of these things, and again as I mentioned, this is not diagnosis-and-treatment-plan time as we say over and over on this podcast, but something else that someone in the situation could consider is intermittent labial adhesions. And what this is, is where the labia minora or the inner lips in the private area of girls and little girls sticks together. So I could imagine that if that was starting to stick together a little bit that the kid would feel sort of tickling down there especially if it unsticks. It's kind of like pulling a Band-aid off and so the times when you're having more serious pain could be when the labia adhesion is coming apart.
So what do you do for that? Well, first, let me say if you have a baby or a toddler young girl who is having labial adhesions, you don't necessarily have to treat them, unless they are having pain associated with it or they're getting frequent infection — whether that be urinary tract infection, frequent yeast infection in that area or bacterial infections — or if they're having difficulty with urination. Then, in that situation, you do want to do something to help these labial adhesions to go away.
And we talked a couple of weeks ago about foreskin adhesions in boys with circumcision. So this is going to be something that sort of the same as that but with girls where the inner lips that on the inside are sticking together.
And so what do you do about this? Well, if you're having pain with it or infection or urinary difficulty, there is an oestrogen cream that you can put in that area. And basically, what this does is it simulates puberty just in that region briefly. And the reason that's important is because the type of skin cells that line the labia are changed with puberty. So that before puberty, they tend to be more of a sticky type of outer layer and so those two layers can stick together and cause the issue. Whereas once puberty, they become more of a slippery type of skin cell that doesn't stick together. And this is the reason that, mostly, labial adhesions are going to take care of themselves as girls get older. So the skin cells themselves change to more of a slippery type. So with the oestrogen cream, you're basically just making it more slippery.
Now, you never want to actually purposely pull that area apart because it's going to be very traumatic and hurt quite a bit especially in older girls. And so you just put this oestrogen cream on a couple times a day for a few days and usually it will come apart. And once it comes apart, you're going to want to coat that area with Vaseline or K-Y Jelly or something to keep it slippery and make it not stick together. You may have to actually do that several times a day to keep it well lubricated and slippery.
So, for your situation, Natalie, you may want to try just putting some Vaseline or K-Y Jelly down there just in case that's the issue and will help keep the labia from sticking together with the labial adhesion. So I suspect that could be one of the things that's happening. But again, not seeing her, knowing more of the history and doing the examination, we can't say for sure.
I also should mention with the oestrogen cream, you're going to have some side effects. You can get more sort of development down in the private area. You can start to get some breast development because of the oestrogen and when you stop it, sometimes you may have a little vaginal bleeding like a mini period. And really, it's just the body responding to the hormone and as soon as you stop using it, those side effects are going to go away.
And remember, you think "Oh, I don't want that to happen," but if the alternative is pain or recur infection or difficulty with urination, then it's worth doing. But again, if you're not having those issues with labial adhesion, it's probably not worth doing the estrogen cream causing those side effects when there was really no problem to begin with. Because we know when kids go to puberty, it's probably going to go away on its own.
I do have a link in the Show Notes to DrGreene.com. It's a site we've talked about before, has lots of great information from moms and dads and he has a nice write-up on labial adhesions there. So I would encourage you to check up the Show Notes if you want to know more about labial adhesion.
All right, we're going to go ahead and take a quick break and wrap things up right after this.
All right, I want to thank all of you for tuning in today to PediaCast. Also, thanks go out to my family for letting me do this crazy project because it does take up a little bit of time.
Also, thanks to Vlad over at Vlad Studio. He's the artist that does the artwork at our website and on the Feed and you can support him by visiting vladstudio.com.
Also iTunes reviews continue to be very important because the more reviews that we have — and especially positive reviews — the higher we go in the rankings and that helps to get exposure so we can let more and more moms and dads know about PediaCast.
Tomorrow, we're going to have an In-Depth Edition and talk about childhood alopecia which is just a fancy word for hair loss. So that's coming up tomorrow and until next time which is tomorrow, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids.
So long, everybody!