medicine

#067 HOW A COMMON BABY RASH CAN BE MISTAKEN FOR CHILD ABUSE

Hey, friends, today I wanted to delve into a topic about which many of you have questions.  We're going to discuss rashes in young children and babies.  Specifically, why do babies and young children seem to have sensitive skin?   Why might your child be more prone rashes than you are?  Why do they get rashes when they are wearing a diaper, for instance?  When you wear underwear, you don't get a rash from wearing underwear.  If you wore a diaper for whatever reason, you might not get a rash either.  Yet, your child might develop a diaper rash.  How come ?  Is it all your fault? Of course not but I want to give you the reason why it's not.  Then I also want to discuss to discuss what to do with these rashes.  In the end, I'm going to end with a special treat.  I'm having my first guest on this show, and she's a dermatologist.  

To give you some background, as a family doctor, I see rashes a lot, but you know what?  As a family doctor, I have the opportunity to refer out to specialists if I have questions about a specific medical topic.     Let's say that I have really evaluated a rash.   I've done a skin biopsy.  I've treated it on my own.  I've really worked this rash up and down, and the rash doesn't seem to be improving. The patient is unhappy, and I just want to help them and their rash.  Guess what I do? I refer my questions about rashes to my colleagues - the dermatologists.   Thus, over the series of the next few posts - all marked with #023 and corresponding to podcast #023 - not only will I talk about rashes, but I will also bring on a skin doctor - a dermatologist - to discuss them.

The topic of skin rashes is important to me for several reasons.  First, if your child has food allergies, chances are that they also have rashes. Not always but often enough!  Second, if your child has challenges around food or picky eating, what might be doing instead of eating their food?  How about putting it in their mouths, moving it from side to side, spitting it out, and drooling... if you can even get it in their mouths?  Third, what if your child has a feeding tube?  Children with G-tubes often develop rashes around the site of the tube.  Fourth, there's some stigma associated with rashes.  Even the common diaper rash can bring fear to the eyes of some parents, and I'll explain how.  

In medical school, I was taught that it was my duty to report any suspected cases of child abuse.  If I did not report them, then I could be held medically liable especially if something happened to the child...  If I suspected child abuse, did not report it, and the child eventually died or had some tragic injury, I could be held partially responsible.  The professors would tell us, "You must report!  You  must report!  You see this is or that symptom, and you must report or else...."    The professor would go through a list of symptoms that could potentially signify chid abuse.

One of those symptoms was a diaper rash.  Yes, a diaper rash!  If you are anything like the mom version of me, then your child developed a  diaper rash at some point.  The thought of you being reported to child protective services for your child having a diaper rash seems a crazy.  It's seems like crazy talk!   People, if you are anything like the doctor version of me, then you have seen tons of children with diaper rashes, and you likely haven't reported a single child with a diaper rash.  Quite honestly, I do not think that a doctor is going to report a parent to child protective services if their child has a diaper rash.  It would have to look very suspicious.   As doctors, we're pretty sure that our professors told us in medical school that the rash has to look very suspicious for child abuse for us to do any kind of reporting.   Like really suspicious! 

What would a very suspicious diaper rash look like?  It would be one that is accompanied by other signs of parental neglect.  For instance,  little John goes to daycare, and at daycare, the staff notice a severe diaper rash They call mom and ask her, "Can we put a special cream around your child's buttocks to help prevent the diaper rash from getting any worse?"  Mom answers, "Sure!"  With daily treatment with the cream at daycare,  the rash goes away.  It comes back again after little John takes a break from daycare.  It gets treated again at daycare.  Then little John again doesn't go to daycare, and the rash comes back.  To the person at daycare, it appears that the only place where little John's diaper rash is treated is at daycare.  The daycare starts to wonder, "Is the mom not taking care of her child?"  They might call child protective services for parental neglect.  This was a situation where the cream almost resolved the diaper rash, and once the cream seemed to have been stopped, the diaper rash came back.  Then again, in this situation, the daycare might be more likely to call child protective services than a physician.  We tend to really like and believe our patients.  (By the way, shameless plug!  My book - "The FPIES Handbook" - has a whole chapter dedicated to child protective services.)  

Yet, what if the cream did not treat the diaper rash?  What if the daycare put the cream on little John and nothing happened?  What if he continued to have  diaper rash?  What now?   Perhaps not all diaper rashes are due to excessive moisture in the diaper area, increased pH, friction, and chemical irritation of the skin inside the diaper from urine or stool.  Perhaps not all diaper rashes are due to diarrhea that is more likely to happen if a young child who has food allergies.  There are multiple medical conditions that might mimic a diaper rash.

I will give you a list of five medical conditions that look like diaper rash but are not.

1.  Psoriasis.  This can be hard to diagnose and is uncommon in babies since most people get psoriasis when they are teenagers or adults.  Psoriasis consists of red scaly patches on the skin, but in a baby, it might show up as red, non-scaly rashes around the folds in the groin area.  Babies with psoriasis might also develop scaly red rashes on the scalp which are not to be confused with dandruff or cradle cap.  

2.  Langerhans cell histiocytosis. This condition is rare.  The rare baby who has Langerhans cell histiocytosis develops scaly, red "pimples" in skin folds.  

3.  Biotin deficiency which is otherwise known as deficiency of vitamin B1 or vitamin H.   Testing for this might be part of newborn screening, and it's rare for babies to have a biotin deficiency.  If they have one, a diaper rash is usually not the only symptom.  There might be hair loss, trouble breathing, seizures, and weak muscle tone.  

4.  Infection due to yeast (Candida).  This condition is different from a regular diaper rash.   First, it doesn't respond to the standard skin barrier creams used to treat a diaper rash.  The rash can have additional spots outside of the border of the main rash, but really, if it's been a while and the diaper rash isn't getting better with standard diaper creams, this is a condition to consider.  It's more common than the other ones.  

5.  Diaper dyes and fragrances to which the child has an allergy or sensitivity.  Yes, a baby has sensitive skin, and that skin can have a "allergy" to chemicals found in some diapers.  

OK... You got 5 different medical conditions that aren't your regular diaper rash. Each of these medical conditions requires different treatment - not just use of the cream that helps with a diaper rash that tends to go away on its own.    If you are not sure if your child has one of these other conditions, make sure to see your child's doctor.  I'm sure that many of them have seem quite a number of babies or young children with rashes or "sensitive skin".  

This brings us to my next question.  Why do babies get so many rashes?  What do these rashes say about food allergies?  We'll discuss this in the next blog post as I'll have a guest come on my blog and talk about rashes in babies.  




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medicine

#015 HOW TO GET A CHILD TO TAKE MEDICINE

I will give you three ways to increase the chances that the child will take medication.  I cannot promise you that these ways will certainly help your child with taking the medicine each and every time, but I am hopeful that they will help.  Anyway, let's get started with these three ways.  

1. The first way is to meet the child where their oral motor skills happen to be.  Make sure that the medication is given to the child in a way that they can actually ingest.  How do you do that?  One of the easiest way to do this is to talk to a compounding pharmacist - especially one who specifically helps children.   These pharmacists can put drugs into forms in which the manufacturer might not necessarily put them.  Compounding pharmacists can make specially flavored liquids,  skin creams or gels, suppositories or rectal enemas, or other dosage forms that are specific to what the child is able to ingest.  If your child has a food allergy to one of the inactive ingredients that would normally go into the medication, compounding pharmacies may be able to further help and perhaps change the inactive ingredients.  Remember that most medications show up as a recipe.  A tablet or a capsule doesn't just have one thing in it.  A medicine in solution form doesn't just have one ingredient in it;  it has more than just a liquid like water.  In that medication, you will find the active ingredient - the ingredient that does what the medication is said to do.  In that same medication, you will also find inactive ingredients - inactive compounds that help the active ingredient stay in a specific form.  

You can learn more about this through a compounding pharmacist.  Just wanted to stress this point!   Talking to a compounding pharmacist can truly be helpful because this is where a lot of caregivers go when they cannot get their child to take a medicine in the way that it is made available by the manufacturer.  They ask the compounding pharmacist to put it in a form that the child may be more likely to ingest.  The compounding pharmacist might not be able to do this with every medication, or what they create might - or might not - be more expensive than getting the medicine in a way that it would otherwise be available  at a regular pharmacy.  However, these pediatric compounding pharmacists - especially the good ones who really listen to the patients and the caregivers - can be great trouble shooters to help you figure out how to get the medication into your child.

At this point, you might ask yourself, "How do I find a compounding pharmacy that specializes in children"?  One option is to call your insurance company and ask to speak to the nurse's line or even customer service and see what they could suggest.  Another option is to ask neighbors or friends; I tend to do this by asking other people in our town through the town's social media page.  If that doesn't work, an an online search may help. Remember that there are also compounding pharmacies in this country who ship nationally and can help children throughout the country.

2.  Now we are on to the second way that you can help a child to take medication that they otherwise refuse.  Remember how we had talked about how the sensory experience that a child has with a medication can contribute to its refusal?  You need to find a way to improve the sensory experience that a child has to the medicine.  

Let's talk about the senses.  The senses include the sense of sight, touch, smell, taste, and hearing. The body's sensing organs take in information from the environment and send that information to our brains where it can be used to understand and be aware of the world around us.  Let's talk about each of these senses and some of the ways that they could potentially contribute to refusal to take a specific medication.   

a.  Let's talk about the sense of SIGHT.  The way that a medication look can affect whether a child can take it.  I remember one toddler who hated the color yellow!  Just hated it!  She hated all things yellow.  No explanation about why the color yellow was not to be liked.  However, you can imagine how she reacted to yellow medications. Thankfully, each manufacturer of the same type of medication has a different way of making that medicine look.  An internet search under images should be able to give you a sense of what different forms of the same type of medication may look like.  Some websites like rxlist.com and webmd.com in its "pill identifier" section can help you identify medications based upon a specific shape or color.  Perhaps this can help steer you to certain looks and away from certain looks.  You can also ask the pharmacist, "Hey! Do you have forms of the same medicine from different manufacturers?  Can you tell me what each form looks like?"

b.  Now let's discuss the sense of TOUCH.  If you recall my example of the young child who refused to take seizure medication in the form of sprinkles,  one of the reasons that she didn't take them is because the sprinkles felt like sand in her mouth.  She didn't want to eat the sand.  Luckily, there are other ways to take seizure medications - in the form of oral solution, rectal enemas, and so on.  However, let's say that the family needed to stick with these sprinkles whose sand-like texture was not pleasant to the young child.  Can you imagine a way to make sand feel pleasant to taste?  One option that the mom considered was to make edible sand using a recipe that she found on the internet.  This sand did not have any of the medication.  It just allowed for sensory exploration.  Her child would play with the sand, and eventually over time, some of the sand would wind up in her mouth.   Then she would proceed to eat it or to try it.  The hope that was that eventually this sandy texture in the mouth would feel OK, and the child might then be more likely to take medication that had the texture of sand.

c.  Let's talk about medication refusal from the perspective of your EARS and HEARING the medication.  I'm sure that there are sounds that medications make that can be not-so-pleasing.  I think about this in terms of hard crunchy things that I eat.  My mouth makes loud mouth noises when I chew on them, and this loud noise may be unpleasant to some. However, there's another way to look at HEARING.  What does the child hear when the medication is given?  Is there dead silence, and are the caregivers holding their breaths when giving the medicine to the child?  Do the caregivers usually hold their breaths, and is there usually dead silence in the home?  A change in routine may seem uncomfortable to the child... like there is some different about taking the medications that changes the noises that they hear in the environment.  That change may be scary for some. 

d.  Do you think that the sense of SMELL could affect how a medicine is taken?  Absolutely!   Not every medicine smells very pleasant.    I remember an experiment that was done on a number of physicians.  They were told to smell a medicine that they often prescribe to patients with diabetes. There are a lot of positive aspects of taking metformin, but there was something surprising when the doctors smelled the metformin.  To some of them, metformin smelled like dead fish.  It's not the only medicine that can smell unpleasant.  Another such medicine is cyclosporine that can smell like a skunk.  Interesting, right?  These smells make turn off some patients from taking the medications.  What do you do about the smell of certain medications?  You could try to hide it.  Lemon is one smell that tends to help mask other smells, and most people like the smell of lemons. 

e. Last but not least, we can talk about the TASTE of the medicine.  We had previously discussed how so medications taste better.  Even if you add flavorings to these medications, the bitter taste may still be present - although perhaps to a lesser extent.  What's another way to mask the bitter taste of some medicine?  One way to do this is to squirt small amounts of liquid medicine in a syringe into the back of the mouth.  This is not to be done in a way that the child may choke.  We are talking about squirting in one to two milliliters of the medicine at a time in hopes that the squirting helps the medicine to go past some of the taste receptors in the front and the sides of the tongue. Taste receptors can be present anywhere, but they seem especially prevalent in these areas.  

3.  All right!  I wanted to talk to you about the third way to help children take medicine.  This has to do with fear or anxiety around taking a new medicine.  What is one of the ways to help the fear or anxiety to dissipate?

I like to think of time.  The natural progression for most children is to move forward in their development and to try new things that they have not tried before. If we expose a child to the same anxiety-provoking medication over and over again, as times go on, the hope is that the medication isn't so anxiety provoking.  As times goes on, the child gets used to taking the medicine.

You would hope that the path from refusal to acceptance is a straight line, but that isn't always the case.  Sometimes the situation gets worse before it gets better. Sometimes the child really acts out or really refuses first.   Yet eventually they turn the corner.

Just make sure that the acting out is behavioral because there's always a concern that it may be medically-induced. For instance, the child may be refusing to take the medicine as the medication makes them feel sick with all kinds of side effects.  In that case, the behavior isn't necessarily a direct response to the change in the child's comfort zone - the new medication.  It may be a response to feeling sick when taking the medicine.  In that case, it's good to try to ask your child what those symptoms may be.  Not all medications within a specific category of medications are going to have the same side effects, and perhaps there are things that can be done to improve those side effects.   That deserves a conversation with your child's doctor.

In any case,  I hope that this was helpful for you.  I hope that you learned some of the reasons why a child may refuse medication and some of the techniques that can be tried so that a medication is more likely to be ingested by the child.  Hopefully this may be helpful for you.

In case you are asking yourself, "So what happened to the young child who refused to take the seizure medication?" Well, I am hoping that the child's mom eventually comes on the air to tell you in a future podcast.  We will see what happens, but I have asked her to.   (She can stay anonymous.) 

UPDATE : Finally heard back from the family!  They visited with a compounding pharmacist and decided to give the medication to the child in an easily-dissolvable form under the tongue while asleep.  



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medicine

#014 CHILD REFUSING MEDICAL TREATMENT

Today, I spoke to a mom whose child refused to take medications that were necessary for the child's health. The child had a seizure disorder and really needed her seizure medications. Without these medications, she would go into these prolonged episodes of having one seizure after another after another.  Prolonged seizures have the ability to damage multiple body parts including the muscles, the lungs, and the heart.   Prolonged seizures are not something that any parent wants for her child.  It is especially hard when the medications that is available to treat seizures is effective for the child - which it isn't always- but the child refuses to take the medicine.  Then what?  What does the caregiver do?  If you know someone who's young child refuses to take medications, what  has been your experience?  If you have successfully gone through that experience, what would have been helpful for you to know at the time that you were going through it?   If your young child is currently refusing to take a particular medicine, what would be helpful for you to know right now?

Let us say that you have found yourself in a similar situation than the one that  just described.  Although, by and large, pharmaceutical companies try to create pleasant-tasting  versions of a medications and to make them easy for even babies and toddlers to digest, this is not always the case.  Some medicine just is not made in that particular early-to digest  way. If the medication is nasty tasting, unpleasant in texture, or foul smelling, there is no fail-proof way to completely hide the medication's taste, texture, or smell.  

What is a caregiver or a parent to do when the medicine must be taken, but the child refuses to take it?  What happens if that medicine is crucial in that it helps decrease the frequency of life-altering seizures?  What if the seizure medicine actually works to decrease the frequency of seizures in a particular child, but the child refuses to take it?  What if it is another type of very importance medicine? For instance, the child has a sore throat, goes to the doctor's office, and is found to have Strep throat.  The doctor needs to prescribe antibiotics for Strep throat not because these antibiotics will stop the sore throat but because untreated Strep throat can lead to complications in the heart and the kidneys.   Cases of great A beta-hemolytic Strep really do need that antibiotic, but what if the child refuses to take it?   You - as the caregiver - might understand exactly why your child needs to take the medication, but  you just can't get your child to take it.  

We are going to discuss this next.  What if a child refuses to take medicine that is super important to take?  As the caregiver you're doing the best you can.  You're trying your best, and it is super hard to get anyone to do anything that they do not want to do.  This is also the case with that young child.  This child has free will.  You're caught in a very tough situation.  You can't force your child to do anything... well, actually, you can but there could be psychological impacts to the child....  Thus, yeah, I guess that you could force a child, but could there be an easier way?  You still need to figure out how to get your child to take the medicine.   Hard, huh?  A young child doesn't have the abstract reasoning skills that you probably do and can't understand the need for the medicine in the same way that you can.  The  young child experiences the world more through their senses.    

What do I mean by that?  Is it really part of that sensory experience that contributes to a child refusing to take a particular medication? While there are multiple reasons why a child may refuse to take a particular medicine, some common reasons have to do with the senses.  The taste, smell, texture, and sight of a medicine can contribute to refusing to take it, but so can a child's oral-motor skills and their level of anxiety.  Let's discuss some of these common reasons for why a child may refuse to take a particular medicine.  By understanding some of the common reasons, perhaps we can better understand what to do about them.  

I'm going to give you three reasons why a young child might refuse medicine. I'm sure that there are other reasons, but I'm going to just give you these three.   The first reason is oral motor skill development. The second reason is the sensory experience that the child has with that medicine - whether it to be the taste, smell, texture, or sight of the medicine.  The third reason is the newness of taking that medicine and the change that comes with it.  I will discuss what each of these three reasons mean.  I'm sure that there are other reasons, but I'm going to just give you these three.  We're going to go through each of these reasons.  Once we've finished with that, I'll give you some suggestions on how you might be able to get your child to take a medicine a little bit more easily.  

1.  The first reason has to do with oral motor skill development.  Let's talk about it from an oral motor skill standpoint.  For many of us as adults,  swallowing medication might not seem that hard.  You can move your mouth, use saliva to form a bolus around a capsule or tablet, and then swallow.  Not that hard for most of us. Right?  It's just something that we have learned to do, but doing these actions with our mouths was harder for us when we were little.  While we now take these learned skills for granted as they have become so automatic, for a young child, these "put a tablet or capsule in your mouth and swallow" activities might be hard.

A baby is born with only some oral motor skills, and other oral motor skills take a while to develop. You're not going to expect your three month old to chew a piece of steak effectively. It's just not going to happen. There are stages and ages for learning different movements within the mouth, with the tongue, and so on.  These movements serve to propel food forward in the digestive tract while preventing food from going into the lower airways.   In fact, according to a few studies that I read,  the average age at which a child is able to achieve enough mouth coordination to  swallow tablets or capsules is around the age of six years.   Between the ages of birth and six year many children just don't have the full ability to swallow a small capsule or a small tablet.  Even then, at age six, we are talking about small tablets.  There are some guidelines that tablets should be no larger than about five millimeters or about half a centimeter for children under the age of six.  However, not all tablets are manufactured to be that small, and taking them could present challenges to the young child.   Luckily, most pharmaceutical companies are keenly aware that they can't offer half-inch tablets to 3 year olds and come up with liquid forms of medications but this is not always the case.  What can we do about it?  I'll discuss that later in this week's episode. 

2.  The second reason why a child may not want to take a medicine is because of the sensory experience associated with it.  The way that the medicine feels, tastes, smells, or looks may be unpleasant in some way to the child.  Let me give you some examples.

Most children are programmed since birth to like salty and sweet foods, but bitter tastes take a little bit of getting used to.  Unless a baby who is a few months old is continuously exposed to a particular bitter taste, he might not particularly like it.  There's a window of time during which - if a child is continuously exposed to bitter tastes - he learns to tolerate them.  However, unless this exposure to bitter has frequently occurred at a young age, the somewhat older child who tastes something bitter might find the experience to be uncomfortable.  

At this point, you might ask yourself, "What's the deal with bitter? Do medicines need to be bitter anyway?"  Unfortunately, yes, some medicines happen to taste bitter, and there's no getting around that.  There are some medicines whose active ingredient - the ingredient that absolutely has to be in the medicine - has a strong bitter flavor.  Examples of these include prednisone;  this steroid is used for cases of asthma.  Another example of a bitter-tasting medicine is the antibiotic clindamycin.  There are others.  These medicines can leave an unpleasant bitter taste in the mouth.  

As a caregiver, you now might be asking, "Well, isn't there something that I can put in the medicine to remove some of the bitter taste?"  Of course, you could mix the medicine with a flavor like vanilla, banana, or white grape juice. You could ask a pharmacist to add a special flavoring to the medicine.  However, even if you add a different flavor to the medication, that doesn't mean that the taste of bitterness will go away.  You may be left with two different flavors.  One flavor doesn't necessarily mask the other flavor. Think of it as if you're eating salt and vinegar potato chips.  The saltiness of the potato chips is not going to mask the vinegar taste.  That vinegar taste is quite distinct.  You can put tons and tons of extra salt on those potato chips, but that vinegar taste is going to stay.  It's the same thing with adding these flavorings.  The bitterness is still going to be there in a lot of cases. The bitter taste is not going to be completely gone just because there's another flavoring that's been added.  At least, it won't be for a lot of people.  Everyone's taste buds are different.  

OK... one more example when it comes to our sensory perception of certain medications. Remember how we had talked about the mom of a young child who refused to take seizure medication?  The doctor prescribed a seizure medication in sprinkle form, but the sprinkles of medicine tasted a little bit like sand to the child.  Sand is not something that many of us would generally eat.  If I had a sandy texture in my mouth that reminded me a lot of sand, my natural reaction might be to spit out the sand.  It would be to take out the sand and not to eat it.  It would take a whole lot of tries for me to get used to eating something that reminded me of sand because I am so conditioned to remove sand out of my mouth and not to eat it.   That sand just seems weird on the mouth. It seems weird to swallow.  If I am asked to take a medicine that reminds me of eating sand, I'd have a hard time with that. 


3.  OK.  So far, we have two  reasons why a child might not want the medicine. The first reason is because of oral motor skills. The second reason because of the look,  taste, smell, or  texture of a  medicine.   The third and final reason why some children may refuse medicine is anxiety or fear around taking the medicine. Not everyone is completely brave and willing to try anything that's out there. Some people get more anxious especially when asked to do things that are new.  

The child might being used to a specific routine. Then all of a sudden that routine changes.  The child has to take the medicine.  Perhaps the child will even be OK with taking the medicine the first few times or can be "tricked" into taking the medicine the first few times.  Then eventually something clicks for the child.  The child thinks, "Not only is taking this particular medicine a new activity in my life, but now it seems like that activity is here to stay.  It's not going to go away?  This is a new change to my routine.  Oh gosh... oh gosh... what do I do?"  The parent understands the importance of taking the  medicine, but the child does not have all that abstract reasoning to be able to figure it out.  For the child,  this is something new, and the child may develop some level of fear. 

Of course, there are other reasons for anxiety around taking a particular medication, and a child might refuse to take the medicine from the beginning - not just after a specific period of time.  

Let's repeat the story of the mom who is trying to get her young child to take seizure medication.  In this case, initially, the child  took the seizure medicine in the form of sprinkles with applesauce and yogurt.  Then she started refusing.  Then they had to hide it in food such as cream cheese, but the young child also started refusing that.  What changed?  It's hard to know why the  preschooler went from initial acceptance to refusal.  As I speculate, one of my thoughts is that the child might have felt a certain way after taking the medication... a certain way that felt uncomfortable.  Maybe she was left with an unpleasant feeling in her mouth.  Maybe she felt nauseous after taking the medication as one of the side effects of that medication is nausea; it can happen to almost half of people taking the medicine.  Initially, the child might not have made the connection that the medication was contributing to the nausea.  It just didn't click.  However, when it clicked that A might be contributing to B, she started refusing some of the medication.  

There you have it. Three reasons why a child might not want to take medication.  They are their oral motor skills, fear or anxiety around the medication, and the sensory experience with the medication.   I am sure that there are other reasons as well, but these are some of the more common ones.  However, knowing why a child might not want to take a medicine doesn't necessarily help you.  It also helps to know the "how".   What can you do to help a child take a medicine that they are just not willing to take?  

That, my friend, is the subject of the next blog post.  

This episode is a section of the



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