Childhood Eczema

Eczema (atopic dermatitis) is a chronic condition caused by inflammation of the skin. It's a component of the "atopic march" which includes asthma, hay fever, and food allergy. Though the exact cause is unknown, the risk of developing eczema is higher in children with dry skin (xerosis) and those with immune dysfunction. 

Additionally, possible triggers reported include:

• irritants (wool, soaps and chemicals)
• contact allergens (latex, metals, perfumes)
• food allergens (cow's milk, eggs nuts, soy, wheat and shellfish)
• house allergens (tobacco smoke, hard water, dust mites, animal dander)
• other irritants (extreme changes in humidity, pollens, molds)

Eczema is most common in children younger than 5 years old. Studies show that 66% of patients first experienced eczema before 7 years of age. The amount of children affected by eczema varies by country and, in the United States, from state to state. Numbers reported are from 1 to as high as 22% of children younger than 18. Studies also show that preterm infants (<37 weeks gestation at birth) have a higher risk of developing the condition. 

Possible risk factors include atopy (positive reaction to at least one skin prick allergen), not breast feeding, immunosuppressants and stress.

Children with eczema are at an increased risk of skin infections caused by staph, strep, herpes simplex 1 and various fungi. Chronic itching may lead to scarring and sleep disturbances. 

The pediatrician will make the diagnosis based on physical examination. It's important to rule out conditions such as parasitic infections (scabies), fungal infections (tinea), metabolic conditions (zinc deficiency), immunological deficiencies (Wiskott-Aldrich Syndrome, dermatitis herpetiformis, lupus, HIV dermatitis), systemic disease (primary biliary cirrhosis, polycythemia vera and renal failure) and other skin conditions (contact dermatitis, ichthyosis, psoriasis and seborrheic dermatitis).

Most cases of childhood eczema improve with age, and up to 70% of cases clear by teenage years. 

The secret to managing eczema lies in both controlling the dryness of the skin and minimizing any inflammation. This includes:

• Use moisturizing soap (Dove brand preferable) at very END of bath to avoid irritation
• Moisturizing cream (such as Vaseline or Eucerin) applied immediately after bath (while still damp) to affected areas 
• An anti-inflammatory (steroid cream such as triamcinolone) may be prescribed. Use twice a day.
• Avoiding irritants or triggers

Reference

Atopic dermatitis. Dynamed database. Updated January 21 2014. Accessed July 2, 2014.

Asthma in children

Asthma is a condition of the small airways of our lungs in which hypersensitive cells are aggravated by environmental substances, leading to inflammation, swelling and poor air flow. It is estimated that 70% of cases are caused by allergic substances such as dust, pollen and pet dander. Other causes include viral illnesses, exercise and cough.

It’s estimated that in the United States, 1 in 10 children younger than 18 years suffer from asthma. Many children with asthma have experienced what is known in dermatology as the “atopic march”, which is essentially a trifecta of asthma, atopic dermatitis (eczema), food allergy and allergic rhinitis (hay fever). Additionally, having asthma makes airways of children vulnerable, putting them at increased risk for diseases like pneumonia, influenza and obstructive sleep apnea.

Signs of asthma in children younger than 2 years old include noisy breathing, grunting and cough while the classic signs in children with are wheezing, chest tightness, cough and difficulty breathing.

Pediatricians will attempt to get specific information regarding the asthma in order to both determine the level of severity and prescribe the most appropriate course of treatment. Questions asked include daytime or nighttime cough, possible triggers (such as viral illness, changing seasons, exercise, etc) and previous episodes. This can reveal special cases such as cough-variant asthma and exercise-induced asthma. Additionally, the pediatrician will want to rule out other conditions such as viral bronchiolitis, cystic fibrosis (CF), bronchopulmonary dysplasia (scarring of the lungs in premature babies) and aspiration of a foreign body. Tests ordered may include spirometry in children >5 years old (blowing into a tube to test lung strength/capacity) and/or a sweat chloride test in children younger than 3 (to rule out CF).

The treatment for asthma depends on the severity. All asthma patients, regardless of severity, are placed on a short-acting beta agonist (SABA, an inhaler) on an as needed (prn) basis. The child’s response to the treatment will be reassessed at follow up in 2-6 weeks.

There are 4 levels of asthma, organized by their level of severity:

Intermittent (episodes < 3 d/week, no nighttime awakenings)

Mild persistent (episodes 3+ d/week)

Moderate Persistent (daily episodes)

Severe Persistent (episodes throughout the day with weekly nighttime awakenings)

The treatments for each are as follows:

Intermittent: SABA prn

Mild persistent: SABA + low-dose Inhaled corticosteroids (ICS)

Moderate Persistent: SABA + medium-dose ICS

Severe Persistent: SABA + high-dose ICS + long acting beta agonist (LABA)

An oral corticosteroid, such as prednisone, may be added in very severe cases where the inhaled medication isn’t working well. The reason for this is that if the airways are severely blocked, the inhaled medication will not be able to reach the tissues to be absorbed.

If a child experiencing an asthma exacerbation is not responding to his or her treatment, experiences a late night attack or has had a severe episode in the past, it’s important to bring them to the emergency room for monitoring. They may require endotracheal intubation, IV antibiotics and/or an IV theophylline drip.

The goals of the parent should include both prevention and preparedness:

• Be sure to limit your child’s exposure to cigarette smoke, pollution, aerosol chemicals and any known triggers

• Some studies have shown that breastfeeding reduces the risk of developing asthma, and others suggest that swimming helps improve lung function and reduce the severity of exacerbations

Reference

Asthma in Children. Dynamed Database. Updated May 7, 2014. Accessed July 1, 2014.

Sleepwalking and Night Terrors in Children

Sleepwalking and night terrors are not uncommon events in developing children. Though they can be quite frightening and worrisome for parents, there is little danger to the child. Both conditions are known as parasomnias, or events that occur during sleep. Knowing what do during your child's episode will put you at ease while reducing the amount of danger to your loved one.

Sleepwalking occurs most commonly in children 11-12 years old. The disorder is relatively common: a 2007 Canadian study estimated that 14% of children aged 3-13 years have had at least one episode. Similarly, night terrors occur between ages 2-10 years old, though it is estimated that 39.8% of children aged 2.5-6 years old have had at least one episode. 

A sleepwalking episode typically lasts 30 seconds to 30 minutes, and is characterized by clumsy and purposeless movements while the eyes remain open. Occasionally, additional parasomnias will occur such as enuresis, bruxism (grinding of teeth) and body rocking. The child will never remembers the event in the morning.

Night terrors are commonly misdiagnosed as nightmares, though there are distinct differences between the two. While nightmares occur in the second half of the night and can be remembered the next morning, night terrors occur about 15-90 minutes after falling asleep, cannot be recalled the next morning, are combined with sleepwalking in a third of cases, and involve autonomic nervous system activation such as high heart rate (tachycardia), profuse sweating (diaphoresis) and fast breathing (tachypnea). Additionally, reports of 390 pairs of twins suggest that night terrors may be genetic in origin.

What can you do?

If you're concerned about your child's sleep walking or night terrors, it may help to know that most cases do not have an underlying disorder. Medications such as lithium, valproate and zolpidem have been associated with sleepwalking, but most cases are likely caused by stress or sleep deprivation. A major danger to children suffering from a sleepwalking episode lies in their surroundings- if you're witnessing the event or noticing recurring events, be sure to minimize any potential hazards by reducing any access to stairs or sharp objects. 

If your child is having multiple episodes of sleepwalking, be sure to mention it to your pediatrician. An important cause to rule out is seizure disorder with post-ictal activity. There are significant differences between seizure and sleepwalking, however, in cases of seizure the patient is unable to find his or her way back to their bed. Other medical illnesses, such as overactive thyroid, migraine, anxiety and Tourette syndrome may be to blame.

The treatment for sleepwalking may lie in hypnosis or scheduled nightly awakenings prior to each episode, though these methods have not been completely validated in the medical community. Medications such as benzodiazepines (clonzaepam) for sleepwalking and L-5 hydroxytryptophan for night terrors may help reduce the number of episodes. As a parent, it is important to remember to stay calm during the event and not to confront the child about the episode in the morning. Additionally, be sure that your child is getting quality sleep throughout the night. The following pediatric sleep requirements may be useful to you:

Newborn: 16-18 hours

6 months old: 14.5 hours

12 months old: 13.5 hours

2 years old: 13 hours

4 years old: 11.5 hours

7 years old: 10.5 hours

10-12 years old: 9 hours

Teenagers: 8-9 hours

References

Night Terrors. Dynamed Database. Updated May 13, 2014. Accessed June 23, 2014.

Sleepwalking. Dynamed Database. Updated May 13, 2014. Accessed June 23, 2014.

Heart Attacks in Children? The Kawasaki Disease Epidemic

A recent study out of Australia published in the Journal of Pediatrics revealed that cases of the potentially deadly Kawasaki Disease are steadily increasing. Kawasaki Disease (KD) is a poorly understood condition known as vasculitis, which is the inflammation of small blood vessels. The disease is known for attacking the coronary arteries of children, the vital blood vessels supplying the heart muscle with oxygen and other nutrients. The child suffers from an acute fever and severe pain, essentially symptoms of both infection and a heart attack.

Doctors do not know the cause of KD, but they believe it may be infectious in origin because most cases occur between the winter and spring, and epidemics occur frequently.  KD most commonly affects Japanese children and those of Japanese ancestry: the incidence in Japan has been steadily increasing, from 102 per every 100,000 children <5 years old to 188 in 2006.  In the United States, it is 17.1 per 100,000 children <5 years old, but clinicians fear this number will continue to increase.

85% of children suffering from KD are <5 years old, and the median age is 2 years old. The symptoms begin with a high fever that lasts a minimum of 5 days and lasts as long as 4 weeks. The child typically experiences redness and swelling of his or her hands and feet and a morbilliform rash of the face and extremities. The lips and mouth will typically dry out, crack and blister.

Meanwhile, inside the coronary arteries, the body is attacking the vascular smooth muscle and causing inflammation that will lead to scarring and poor vessel integrity.  It is for this reason that coronary artery aneurysm (ballooning and tearing) occurs in 25% of cases, particularly if the child is less than 6 months or older than 6 years old. Other complications include myocardial infarction, cardiac arrest, heart failure, myocarditis and pericarditis. Two reports have noted children becoming insulin dependent diabetic within 4 months of the vasculitis.

When the pediatrician recognizes these harrowing symptoms, he or she will order an echocardiogram to visualize the heart.  When a blood test reveals high white blood cells (leukocytosis), high erythrocyte sedimentation rate (ESR) and high C-reactive protein (CRP), a diagnosis can be made.

The treatment for KD is intravenous immunoglobulin (IVIG), which is an injection of IgG (long-term) antibodies pooled from over 1,000 blood donors. High dose aspirin with or without corticosteroids is also administered to help reduce swelling and prevent a heart attack. The child should follow up with a cardiologist for repeated echocardiograms and long-term monitoring, since the highest risk for a heart attack is in the first year after diagnosis.

Until more is learned about KD and its origins, it will be added to a long list of autoimmune diseases that are poorly understood but well respected in the medical community.  

References

Saundankar J1, Yim D, Itotoh B, Payne R, Maslin K, Jape G, Ramsay J, Kothari D, Cheng A, Burgner D. The epidemiology and clinical features of Kawasaki disease in Australia. Pediatrics. 2014; 133(4):e1009-14.

Kawasaki Disease. Dynamed Database. Updated June 9, 2014. Accessed June 13, 2014.

Protect Your Baby From Bronchiolitis

Bronchiolitis is a relatively common respiratory condition seen in children younger than 2 years old.  According to a recent study out of Finland published in the Scandanavian journal Acta Paediatrica, bronchiolitis is a major cause of lower respiratory tract illness and hospitalization in babies, especially those younger than 6 months old. The condition is mostly caused by the respiratory syncytial virus (RSV), which is the infectious agent in over 75% of cases.  Other viruses, including influenza (flu) and adenovirus represent the remaining 25% and in many cases exist as co-infections.

RSV season typically begins in October and ends in April.  The virus is spread via the hands of caregivers and other inanimate surfaces (fomites), and can stay alive on them for several hours. The virus enters the respiratory tract and infiltrates the top cell layer of the lungs, known as bronchiolar epithelium, causing inflammation and swelling and obstructing the small airways. Once this happens, air passing through these small spaces emits a whistle-like sound that can be heard as a wheeze outside of the body.

This wheeze, along with a runny nose (rhinitis), cough, and fever, is suggestive of  RSV bronchiolitis. It is important, however, for the pediatrician to rule out other disease processes, such as pneumonia or foreign body aspiration. Studies have shown that infants <12 weeks old, particularly those who were premature at birth, have an increased risk of requiring hospitalization and medical intervention. For many babies, though, this disease is self-limiting and no tests or treatments are necessary.

There are established risk factors for RSV that you can’t avoid; childcare attendance, school aged siblings, prematurity, congenital cardiopulmonary disease and immunodeficiency. But the steps listed below have been shown to reduce the risk of spreading RSV:

• When in a group setting such as daycare or doctors offices, be sure that you and others caring for your children decontaminate their hands with alcohol-based sanitizer before and after direct contact with children or inanimate objects

• Do not smoke tobacco or wear clothing that has been around cigarette smoke unless it has been thoroughly washed

• Avoid exposing your infant to air pollutants

• Always breastfeed your infant whenever possible to allow your infant's immune system to strengthen

• Always follow current vaccination guidelines, including the flu vaccine

References

Bronchiolitis. Dynamed Database. Updated 2014 May 12 02:17:00 PM. Accessed June 6 2014. 

Pruikkonen H1, Uhari M, Dunder T, Pokka T, Renko M. Infants Under Six Months With Bronchiolitis Are Most Likely To Need Major Medical Interventions In The Five Days After Onset. Acta Paediatr. 2014 [Epub ahead of print]