Skin and Bones

Dealing with ailing bodies and human foibles all day long, it’s no wonder doctors have a sick sense of humor, me included.  When people show me their kids’ rashes in public, I play it straight and happily consult.  However, occasionally adults will haul up their shirts at parties to show me the latest blemish on their bellies or backs and ask, “Hey Doc, what the heck is this?” I nod confidently: “It’s definitely cancer,” I say. Then I give them a wry smile that says, hey, only kidding!

Given the warm winter we’ve had, the early spring, and the early school closings, I predict a rough summer for rashes.  Children meet the outside world with their skin.  When falling off bikes or monkey bars, not “sticking the landing” as they say in gymnastics, they get scrapes and cuts and bruises.  When they plow through vegetation exploring or searching for stray balls, their skin gets irritated by thorns or poison ivy. Mosquitoes enjoy a blood meal from our children, and later, when the bite itches, they tear at themselves with ragged, dirty fingernails.  Sun cooks hot, exposed skin too.

We’re all learning new habits from Coronavirus concerns, like washing our hands more often and extra carefully, wiping down potentially contaminated surfaces, and trying not to touch our faces.  It’s also a good time to improve skin-care habits for children.  That’s the best prevention for skin injuries and infections that we’ll see in the Emergency Department in the coming months.  Paradoxically, skin is hardest to hurt when it’s soft and pliable.  It bounces back, and heals better.  Hard dry skin cracks under pressure and itches worse when insulted.

Kids should use moisturizing soap. Buy brands like Dove and Caress, which are easy on skin, rather than harsh drying soaps like Ivory, Zest, Dial, or Irish Spring.  Washclothes and vigorous toweling also can irritate, so kids should use only their hands and the soap, and pat dry with towels. Advanced Parenting involves using white lotion to moisturize kids’ skin, putting on sunscreen, and applying bug spray.  When a kid gets a cut or scrape, “rub dirt on it” is just a joke!  Wash broken skin with soap and water, and dress it with neosporin and bandages.  Please keep those grubby ragged fingernails clean and short.

In 2008, New York City mom Lenore Skenazy was shopping with her 9 year-old son.  They had ridden the subway, and that day he begged Ms. Skenazy to let him ride home by himself.  Having taught him how to read subway maps and distinguish between uptown and downtown trains, she decided to let him go.  He got home safely and was ecstatic with his feat.  But when Ms. Skenazy wrote about his adventure in a newspaper column, she set off a storm of controversy.

Some called her the “world’s worst mom.” Child Protection paid her a visit.  Others praised her for giving her child freedoms not allowed by “helicopter parents,” so-called because they hover over their kids’ every move. Ms. Skenazy then briefly had a reality TV series where she coached such parents on letting their kids ride bikes or slice vegetables.  The show’s title: World’s Worst Mom.

Fortunately, we in Acadiana needn’t worry about children navigating crowded cities. But they will be having adventures on bikes and trampolines, or dirt bikes and ATVs.  Most emergencies we’re seeing now are injuries from these. If your child falls off a bike or monkeybars, check the head first.  Head injuries are the most common serious injury in pediatrics.  If the kid has been knocked out or is acting confused, get them into us right away.  Please put helmets on bike-riders before this happens!

If the head checks out okay, limbs are next.  Broken bones are obvious: the child cries and points to the dinged wing.  Sometimes it’s bent in an unnatural way.  The best care for an injured arm or leg is to immobilize it. Preventing the hurt part from moving is the best pain control.  Tape it to a rolled up newspaper or magazine, or a handy board. Give your child some pain medicine, like ibuprofen or tylenol.  DON’T give your child anything to eat or drink.  They’ll need an empty stomach if anesthesia is necessary.

If your child crashes a motorized bike or ATV, you’ll feel like the World’s Worst Mom- these vehicles’ power and speed are too dangerous for little bodies.  Bikes are good enough, and better exercise for their skin and bones.

It’s Always Sunny in Acadiana

This week’s guest columnist is Dr. Cam Tu Nguyen, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

One spring day, a teenager decided to get a head start on his summer tan.  Like any teen, he didn’t heed his parents’ advice to wear sunscreen. It was a pretty cloudy day at the beach, so to increase his chances of tanning, he applied tanning oil. It had an SPF of 4, so you’d think he was okay between the SPF and the clouds, right?  Wrong!

When he got home and looked in the mirror, he was shocked to see he was red as a lobster!  It really hurt to get a shirt on to go out that night with friends.  Then when he got into the car, he scraped the top of his head on the door sill- YOW!  While his friends killed themselves laughing, he realized he had burned his scalp too.

Sunburns seem to be a rite of passage for kids and teens at the beginning of the summer.  We sometimes see kids in the Pediatric Emergency Department for these burns- they whine and hurt and can’t sleep.  Though teenagers often laugh at their discomfort and cherry red skin, our Dermatologist colleagues shake their heads- they’re contemplating their future skin cancer patients.

How did our teenager burn on a cloudy day?  Sunlight is composed of several wavelengths of radiation, including infrared heat, visible light, and ultraviolet rays.  While clouds stop some sunlight, they don’t stop it completely.  After all, you still have plenty of visible light to see on an overcast day.  Likewise for ultraviolet wavelengths, the ones that burn and lead to cancer. There’s two types of ultraviolet, UVA and UVB.  UVB is the spectrum that causes sunburns. UVA rays are the sun’s “silent killer,” because though you don’t feel them, they penetrate skin and damage skin cells’ DNA, a potential cancer trigger. Like visible light, they get through clouds just fine- burning and injury may take longer, but it happens. This is especially true here in the South, where we’re closer to the sun than the northern parts of the globe.

Dr. Hamilton once took his new 6 week-old daughter to the beach.  His wife loves the beach, and couldn’t wait to get out of the house after recovering from delivery.  They used all the precautions- floppy hat, big baby skirts, even a beach tent with an SPF rating. But that first day when they got home, baby’ face and arms were sunburned.  They learned that sunlight reflected off sand and water, up under tents and hats, can burn just the same!

Babies under 6 months old should be kept out of direct sunlight, in shade.  As Dr. Hamilton discovered, avoid reflected sunlight!  Infants that age are too young for sunscreen, but over 6 months, slather it on liberally.  Babies of any age shouldn’t be in the sun between 10 am and 2 pm, the brightest part of the day, where anyone is most likely to burn.

All kids, when wearing sunscreen, should have it applied 15 minutes before going outdoors, since it takes time to absorb into the skin.  Use SPF 30 or higher-less isn’t enough.  Cover all surfaces- ears and tops of feet and hands.  If your kid isn’t wearing a hat, get that scalp.  You don’t want your kid to be that teenager from above, who burned his scalp sunbathing.  If your children are at the beach or pool all day, re-apply every 2 hours, and after kids get out of the water.  Don’t forget lips- use at least SPF 15 lip balm if you don’t like the taste of regular screen.

This past Mardi Gras, the Scott parade was on a sunny day.  Since it was February, many families didn’t think to use sunscreen.  That night we saw so many sunburned kids in the Pediatric ER that our nurse dubbed it “The Scott Mardi Gras Glow.”  If your kid gets sunburned, you don’t have to bring them in.  Do what we recommended: keep skin moisturized, particularly with an aloe-containing lotion.  Burned skin dries out, and then itches and burns more.  Use ibuprofen or tylenol for pain at bedtime.  Cool baths with moisturizing soap help, but don’t use washcloths, which scrape sensitive skin.  When they get out of the bath, pat dry with towels, don’t scrub dry.  Then slap on that moisturizer!


The Heat Is On!

This week’s guest columnist is Dr. Susila Shanmuganathan, Family Practice resident at the University Hospital and Clinics here in Lafayette.

It’s summer time, and the heat is on…on your child’s skin!  With the sun out, her soft and beautiful skin is at risk for sunburn.  Sunburn is very common, with more than 30% of adults and 70% of children and adolescents getting at least one sunburn per year.  Although most aren’t severe, a lifetime of sun exposure significantly increases the risk of skin cancer, and wrinkles.  And it hurts!  When kids hurt, they whine, and no one wants that on vacation.

Sunburn can be sneaky.  Unlike other types of burns, sunburn may not show immediately, because it takes three to five hours for redness to develop after being out.  Redness peaks at about 12 to 24 hours after sun exposure and fades over 72 hours.

What increases your risk of sunburn?  One factor is the amount of pigment in your skin, called melanin.  Melanin protects from burns, so really pale kids burn easier than their darker skinned friends.  Also, where you are in the World counts.  The close you are to the equator and the higher your altitude, the more rays you get and risk increases.  So if you’re heading to Central America or the Caribbean with the kiddos, or hiking in the Rockies, pack the sunblock!

Another thing we often forget is that certain medications make skin more sensitive to burning.  These include certain antibiotics, some blood pressure medications, and even something as simple as ibuprofen.  So before you go the beach, make sure your 15-year-old on Doxycycline for his acne is okay with having a red face for a few days. Better still, put on the block!

If your child does get sunburn, there are treatments.  First, stay out of the sun until the redness and pain resolve.  Ibuprofen (Motrin, Advil, or generic) or acetaminophen (Tylenol) can relieve the pain.  These should be started as soon as the burn is noticed, since the benefits tend to decrease after 24 hours.  Cool compresses, aloe-based lotions, and lotions with local anesthetic may help too.

A friend of mine once went on a misson trip to the Philippines.  He schlepped his snorkeling gear half way around the world because he had heard about the beautiful coral reefs there.  When his day at the beach came, he forgot about sunblock or wearing a sunshirt.  While snorkeling the cool water kept him from realizing what the near-equatorial sun was doing to his skin.  The next morning he had sunburn so bad it blistered his back and shoulders- a second degree sunburn!  Sleeping was tough, but fortunately aloe was handy and he smeared that on generously.

Lesson to be learned: when in the beam, use the ‘screen!  Here are some tips to using sunscreen most effectively.  Put it on 15 minutes before going out in the sun: the better it dries, the harder it is to rub or sweat off.  Be sure to cover all surfaces, including ears. I remember an old OB/GYN attending, an avid sailor, who had notches in his ears where pre-cancerous growths had had to be cut out.

Applying sunscreen just once isn’t enough.  Sunscreen is washed off by water, rubbed off by towels and sand, and sweat off when your kids run around in the heat. You need to re-apply at least every 2 hours during peak burning times (roughly 10 am to 5pm) to properly protect your kids.  Apply more often for the very active swimming and running and toweling kids.

Another strategy is to avoid sun exposure in the first place.  Shade is your kid’s friend- umbrellas, beach tents, leafy trees, shaded porches.  Some fair-skinned kids just can’t get enough sunblock, they burn so easily.  These kids benefit from protective clothing- long sleeve shirts, long pants, big brimmed hats, and sunglasses. They now make shirts and pants that are light enough to be cool and have SPF (Sun Protective Factor) ratings just like sunscreen.

Fun in the sun is something that even the littlest ones look forward to, but be prepared for the damage that can be done.   Remember: cover that beautiful baby skin with protective clothing and high SPF sunblock to keep the fun, in the sun!

Heat And Light

If you think pediatricians don’t make mistakes raising their own kids, think again!.  My wife and I had just had our first baby.  When our girl was 6 weeks old, my wife was getting cabin fever, stuck home breast feeding around the clock.  We lived in eastern Maryland then, and decided to take a weekend at the beach for some fresh air and sunshine.  Being a pediatrician and a pediatric nurse, we were careful about the sun- big hat, sun tent, plenty of fluids.

We didn’t put sunscreen on baby and unfortunately, didn’t count on sunlight reflected off the sand and off the water.  Baby was lit up from below where her hat and tent didn’t protect and when we brought her home, she was the color of a cooked lobster.  Some experts!

Now it’s summer and kids should be outdoors swimming and playing, having fun and using their brains in healthier ways than with a phone, computer, or TV.  However, kids need protection from too much heat and light from the summer sun.  The most dangerous problem is children and teens overheating.

The heat-related tragedies are already making the news.  The story typically goes like this: the parent is in a rush, goes into a store and leaves the child in the car.  The parent is detained somehow and by the time he/she gets back to the car, the child is dead.  They always say, “I was only going in for a few minutes,” but unfortunately anything longer than a few minutes is all it takes.

Consider this: How long could you sit in a parked car in the sun, engine and A/C off?  Five minutes?  Ten, if you’re strong?  It takes about 40 minutes to bake a cake, about 20 minutes to bake a cupcake.  Now if you’re the cake and can only stand five minutes in the car before you are drenched with sweat and gasping and overheated, how long do you think your cupcake toddler can last?  The lesson is clear: don’t leave kids in a car in the summer at all, for any length of time!

Fortunately, these episodes of kids dying in hot cars is rare.  Much more common is heat injury with older kids during summer sports practice.  August is coming and with it, football practice.  I can count on seeing some kids in the Emergency Department with heat cramps, heat exhaustion or worse, heat stroke.

Heat cramps are the mildest of the sports heat injuries, where the kid athlete is working out hard, not stretching enough, not drinking enough, and not resting enough between bursts of activity.  He begins to get painful muscle cramps, and this means it’s time to stop, recover, stretch, and hydrate.

The next level of injury is heat exhaustion.  In addition to cramps, these kids begin to have dizziness, headache, and weakness from dehydration and over-heating.  If the child-athlete doesn’t take a break at this point, the next, worst, stage is heat stroke: the child becomes confused, lethargic, may stop sweating, and then is at risk for muscle and kidney and brain injury, and death.

To prevent heat injury, coaches and team captains should take these precautions: First, athletes need to adapt to the heat.  Start with work-outs of lighter intensity and shorter duration.  Football players should spend the first weeks of summer practice in shorts and t-shirts only; then progressively add intensity, duration, and equipment.

The second strategy is adequate hydration and recovery.  Athletes should drink before, during, and after practices.  There should never be limits on access to drink; coaches who restrict fluids are only hurting their kids, hurting their kids’ performance, and should be fired.

Finally, direct sun exposure should be minimized.  Teams should have a shady spot to rehydrate between work-outs.  Practices should be scheduled for earlier morning, like for 7am to 10 am instead of 8 to 11.  Afternoon practice should start at 4 or 6 pm instead of 2 pm.

Finally, coaches should have an action plan to handle heat injury.  Like surveillance for concussions, coaches should be watching players for signs of cramping, sleepiness, and headaches.

We all make mistakes, like when my wife and I accidentally sunburned our new baby at the beach.  Just please don’t make bigger mistakes by not taking heat seriously.


Sun Exposure

This morning Tracy Wirtz and I talked about sun exposure and preventing sun burns.  Skin cancer is more common than people think, and is quite preventable.  Also, sun burn hurts and few things are more miserable than a child unable to sleep at night because of sun burn pain.

Do you wear a seat belt?  Do you lock your doors at night?  If you care enough to do these safety measures, then you should put sunscreen on you and your kids.  Put it on ten minutes before the kids get into the water.  Re-apply it once or twice if you are out more than four hours, or if your kids are in the water more than 30 minutes.

Babies need sunscreen too.  Adult sunscreens are ok.  However, babies (and particularly babies under 6 months-old) should be kept out of the sun, under an umbrella, hat, and long loose clothes.  Beware!- reflection off water or sand can cause sunburn- I’ve made this mistake myself when my oldest child was 6 weeks old!

If your child gets sunburn, the best treatment is moisturizer lotion and ibuprofen or tylenol for pain.  If the sunburn develops blister, red streaks, or pus, see your doctor.