Ask the Pediatrician: Dr. Molly

Category: Private parts

Circumcision pros and cons

Considering circumcision? There are two sides to every argument and let me tell you, both sides of this issue are passionate.

Circumcision has some concrete pros. Firstly, the rate of HIV and penile cancer in circumcised men is lower than those who are not. Secondly, the rate of HPV infection (the virus that causes cervical cancer in women) is much lower as well. Because women get colonized with this virus through sex with men who have it (and are usually without any symptoms themselves) this is a benefit for men and women. Third, hygiene is straightforward in the cirumcised penis. Lastly, boys who are circumcised are much less likely to have urinary tract infections than uncircumcised boys.

Circumcision has some concrete cons, too. It is a surgical procedure and has some small but real risks, including bleeding, damage to the head of the penis and pain. Second, men who have been circumcised as adults report a change in sexual sensation afterward, although reports of sexual enjoyment overall do not differ between circumcised and uncircumcised men.

If boys are taught good hygiene, men use condoms regularly unless they are in a long-term monogamous relationship, the medical advantages to circumcision diminish and what is left are primarily issues of culture. In many cultures, male circumcision is not the norm. Indeed, most of the world doesn't circumcise except for religious reasons. In the United States, however, circumcision has become very common - especially among white middle and upper classes.

I often get asked if an uncircumcised boy is more likely to be the object of teasing in school and my answer is no. I often suggest parents consider the circumcision status of the other male family members in the decision as well as their comfort teaching the hygiene and sexual practices that would minimize risk if they choose not to have their son circumcised.

Circumcision does have medical benefits, but given the fact that the risks can be minimized through good teaching about hygiene and sexual practices, the decision is still on the shoulders of parents.

Category: Viruses

Cold sores: causes, symptoms, strategies to prevent recurrence

Cold sores are a pain in more ways than one. They are ugly, of course, but for many they are numerous enough inside the mouth to cause difficulty eating and sleeping.

Cold sores are actually a viral eruption caused by herpes simplex - yep, that herpes, the one that can cause problems on any mucus membrane including the genitals and mouth. There are two strains of the herpes simplex virus. For a long time we thought type 1 infected the mouth and type 2 the genitals, but in truth both are found in both places.

The first time a person experiences cold sores, they are often accompanied by fever, headache and body aches. Once the virus infects the nerves cells of the mucus membrane once, it lives there forever, dormant and waiting to resurface. Cold sores pop up in the same places because the virus lives in specific nerves and erupts in that nerve's location again and again.

The first symptoms of cold sores are tingling and a sense of swelling that can't be seen. Within a day or two, the characteristic blisters appear on the lips or ulcers appear in the mouth. The blisters and ulcers last about 10-14 days before the body beats back the virus into submission and it returns to its dormant state.

Things that stress the immune system or local trauma can cause the virus to reappear. Incidents such as illness, sunburn on the lips, fever and emotional stress can focus the immune system in other places or weaken it to the point that the virus can come out of its dormancy and cause cold sores.

It makes sense that the best ways to prevent cold sore from recurring is to do things that boost the body's immune system, limit emotional stress and diminish trauma to the lips and mouth.

L-lysine is an amino acid that can boost immune system function and improve the strength and resiliency of the mucus membranes, thereby reducing recurrences. Anyone, including children, can safely take L-lysine and kids who take 500 mg daily and adults who take 1,000 mg each day have significantly fewer outbreaks than those who don't. In addition, if at the first sign of tingling you increase the dose to 2,000 mg daily for kids and 3,000 mg daily for adults, the duration and severity of the outbreak is much less. Zinc and vitamin C also play important roles in mucus membrane health and Vitamin D3 is important in maintaining immune function. So in addition to L-lysine, a multivitamin with these micronutrients should keep your immune system as strong as possible.

Exercising, eating well, getting adequate sleep and encouraging a healthy balance between work and family life along with nurturing yourself can also help decrease the likelihood stress will play a role in cold sore outbreaks.

Lastly, using sunscreen on your lips summer and winter when outdoors for prolonged periods can help minimize sunburn trauma to the lips - a known trigger for cold sore outbreaks.

If you have an active cold sore, avoid kissing, sharing towels, drinking glasses, toothbrushe, and eating utensils to minimize spread to others. You can use topical ointments that are available over the counter to decrease symptoms, but if the outbreak is severe or the recurrences are frequent despite the natural strategies outlined above, you should talk to your doctor about the possibility of going on a low dose of acyclovir, an antiviral medication, that can diminish the frequency and severity of attacks. Kids with braces and cold sores often need to do this because the metal in their mouths is causing constant minor trauma.

I learned a lot at pediatrics conference

I recently got back from a five-day meeting of the American Academy of Pediatrics, which hosted its annual National Conference and Exhibition in Washington, D.C. Boy, did I learn a lot! I will have fodder for blogs galore!

I love this meeting. More than 7,000 pediatricians from all over the world attend and there are hundreds of lectures, workshops, plenary talks and meet the expert sessions on topics ranging from genetics to orthopedics to feeding issues to advocacy to obesity to you name it! I was on the planning group for six years and helped put this meeting together so I know the staff, speakers and leadership of the AAP well. This year, however, I didn't help plan it and just got to go, learn and enjoy!

Here are a few of the pearls I learned, some of which will be fleshed out into longer pieces over time:

• High fructose corn syrup (or just fructose) is in everything we eat that we don't make ourselves and is metabolized in ways that are shocking. Consuming fructose leads to fatty liver, high lipid levels in the blood (which can lead to atherosclerosis), excessive insulin production (which can lead to diabetes), and unlike glucose actually sends a message to the brain to eat more even when you have consumed a lot of calories! I am already limiting fructose in my family's diet since coming home!
• Tics in kids really can't be diagnosed until they are around age 5. Before then many kids will have repetitive movements that are tic-like called stereotypies but only a small portion will go on to have frequent tics as older children. Most kids with ADHD on stimulant medication who have tics do not have to stop their medication. Data show that even if the medication increases the tic frequency a bit, the ADHD is worse than that symptom.
• The ability to know how your body will respond to medications based on your genetics as well as whether or not you will go on to have any one of hundreds of diseases is just on the horizon. Primary care docs will have the opportunity to do an even better job guiding wellness.
• Aromatherapy isn't a crock! There is actual data that show it can work for certain things like nausea.
• One in five children in the United States lives in poverty.
• H1N1 live virus vaccine needs to be separated from the seasonal live virus vaccine by only two weeks. The shots can be given simultaneously as can one shot and one live virus.
• The Nuvaring contraceptive is really easy for teens to use and they don't have to remember to do something every day.
• None of the additives to infant formulas (DHA, probiotics, etc.) have been shown to have significant benefit over the old formulations in otherwise healthy term infants.
• When starting infants on solid foods, veggies, fruits, and meats should be first, not rice cereal.
• Babies who see allergenic foods early and often (even before six months) are significantly less likely to be allergic than those whose parents wait to introduce them.
• Developmentally disabled adults who cannot read or do math can be trained to do complex repetitive tasks, so don't sell your cognitively or developmentally challenged child short!
• There is almost no role for soy formula. If a child can't tolerate milk formula, he should go to the extensively hydrolyzed formulas.
• Assistive technology and gadgets for kids with disabilities are amazing, varied, creative and can help almost any child communicate more easily.
• The brains of kids with ADHD and dyslexia are actually wired differently as seen by functional MRIs than typical kids, lending more credence to the concept that these are not deficiencies in parenting or teaching but true physiologic differences.

Whew! I really did learn a lot! And I didn't even mention the sessions on hiring Gen Y, fainting, parasitic infections and sports medicine I attended.

Let me know which of these "pearls" you are interested in learning more about!

Category: Cold and flu

H1N1 update: Michigan is being hit hard now

Iinfluenza has really started to hit our area hard. The following Q&A will help you understand who needs to be seen, when testing should be done and who needs Tamiflu treatment:

Q: When do I suspect my child has influenza? What are the symptoms?
A: Fever higher than 101.5 degrees along with sore throat and body aches is the first sign followed by headache, congestion and cough. The kids look very sick, down and out and are not interested in playing, eating or even really watching TV.

Q: What's the difference between H1N1 and seasonal influenza?
A: The symptoms are the same and both can give illness that ranges from mild to severe. Deaths in healthy and high-risk children occur with both, but early information indicates because none of us has immunity to the new H1N1 virus, lots more kids are getting sick with it.

Q: What if there's a case at my child's school - should I keep him home or what should I do?
A: I would not keep your healthy child at home. This situation will be the case every day for the next few months and unless you plan to homeschool your child this year, he should go. We will not be putting high-risk kids on Tamiflu when the only exposure is a classmate. Only 20 percent to 30 percent of household contacts will get the flu when exposed within the family, so the risk is even smaller for contact with classmates.

Q: When do I need to take my child to the doctor's office?
A: If your child is at high risk for complications from influenza you should take your child in within 48 hours of the start of symptoms. If your child is low risk, you should bring him in if the fever lasts more than three days to make sure there is not a secondary bacterial infection, or if the fever goes away for a full day and then returns at 101 degrees or higher.

Q: How do I know if my child is high risk?
A: High risk kids are those younger than 5 or any child with asthma, diabetes, heart conditions requiring daily medication, cystic fibrosis or any condition that affects ability to breathe easily (cystic fibrosis, very low muscle tone, etc.).

Q: What if I have a child who is high risk but it is the sibling of that child who is sick?
A: In that case, take the sick child to the doctor for assessment. High-risk siblings of likely influenza cases will need medication to try to minimize their chance of getting the illness or lessening the symptoms.

Q: Are you going to test for influenza in the office?
A: Most offices have a rapid test for influenza available. All high-risk kids (or siblings of high-risk kids) should be tested, but the test is not foolproof. About 30 percent of the time the test will be negative even with influenza present. So even if the test is negative, your high-risk child should be treated with Tamiflu to be on the safe side if the clinical presentation is consistent with influenza.

Q: Should all kids who have a positive test be treated with Tamiflu?
A: No. Only those children at high risk for complications should be treated. For the vast majority of children, the illness will be uncomfortable but not dangerous. To discourage the H1N1 virus from morphing and becoming resistant to Tamiflu, it is not recommended that otherwise healthy children receive it.

Q: How do you know that the influenza cases you are seeing now are H1N1? Can you do the test to know for sure?
A: Only hospitalized cases are being tested specifically for the H1N1 strain. Across the nation, more than 98 percent of all of the influenza seen and typed is H1N1 so it is safe to assume every case seen now is the swine flu. This will get tricky in late December or January when the seasonal flu will start to get mixed in, especially because the seasonal flu is not made better with Tamiflu because it is resistant to it.

Q: What if my child was exposed to another child with influenza during a sleepover or other intense and prolonged contact? Should he receive the medication to help minimize the chance he will get sick?
A: Only if he is high risk.

Q: We stood in line to get the H1N1 vaccine at the health department clinics last weekend. When can we get the seasonal vaccine?
A: When your child can get the seasonal vaccine depends on the type of H1N1 vaccine he received. If he received the live virus intranasal vaccine and you want to get the intranasal seasonal vaccine, you will need to wait two weeks. If you got the intranasal vaccine but are willing to get the seasonal flu shot, you can get that at any time. If you got the H1N1 vaccine as a shot, you can get either the intranasal or the shot for the seasonal flu vaccine at any time. Remember, the intranasal vaccine can only be given to children older than 2 without a history of wheezing or asthma and cannot be given when an infant younger than 6 months or anyone with an immune-compromising illness is in the household.

Q: Should we be taking our kids to CVS or Wal-Mart to get the seasonal vaccine?
A: Retail-based pharmacies will not administer the vaccine to anyone younger than 4 years of age and because the seasonal flu is still a ways off, I think it is more than safe to wait and get the vaccine at your doctor's office when it comes in.

More information is available on the CDC flu site as well as the Michigan Department of Community Health site. You can also read my other blog posts on seasonal and H1N1 flu, too.

Category: Cold and flu

Croup season is here!

It is 2 a.m. and you hear your 3-year-old in her bedroom awake and coughing. This cough doesn't sound like any cough you have heard before.

Your child is agitated, sounds like she is gasping for air and even when she is just breathing you can hear her air moving in and out. When you look at her chest and neck they seem to cave in oddly as she tries to breathe more deeply. Her voice is hoarse and she may even have a fever. The amount of distress you are seeing as she breathes is very concerning and you call your doctor who encourages you to calm her down and perhaps take her outside where the cool air can help her swollen airway.

Once you calm down and she does, too, her breathing is still noisy. When she coughs it sounds like a seal barking, but otherwise the distress and agitation are improved and both of you can return to sleep.

This is the classic presentation of croup. Croup is caused by swelling in the airway just below the vocal cords in response to a viral illness or more rarely a bacterial illness. Occasionally croup swelling can be the result of allergy, but this, too, is very uncommon. The fall viruses, parainfluenza viruses and adenovirus, and the winter influenza and RSV are the most common causes of croup. I am seeing a fair amount of it and I suspect adenovirus is the cause.

When the virus causes swelling, the airway that is usually wide open (like a wide hose) gets constricted to a narrow tube (like a straw) and as a result there is a lot of distress, noise and work to get the air through the smaller tube into the lungs. If you suck hard on a straw, especially if you are having a milkshake, the tube will collapse due to the negative pressure. When croup causes swelling, the airway doesn't collapse but it takes a lot more negative pressure to move the air past the area that is narrow. This work to breathe deeply is what causes the distress and the retractions seen as the chest seems to cave in against the narrowed airway.

The swelling of the airway is worse at night (isn't everything?!) and as a result, kids will appear to have a hoarse voice and a cold during the day, but at night the symptoms escalate. Older kids and adults who get infected with these viruses get laryngitis and a very sore throat along with a harsh cough, but because the airway is much wider to begin with, the swelling doesn't compromise the air movement as much. Older kids and adults report the sore throat feels like they have swallowed glass and unfortunately there is little more than pain relievers, cool liquids and time to cure this illness.

There are lots of strategies to use when the symptoms get bad at night to relieve the symptoms of croup: steamy showers, going outside in the cool air and running humidifiers. Few of these actually make much difference. What is the biggest help is remaining calm and helping your child relax. Sometimes cool air or steamy air can help and they are not harmful so try those, too, but getting your child to relax and realize she can breathe is most important. It may take up to an hour to calm down your child enough to return to sleep, but hang in there; calming and soothing and most often the cough and agitation will lessen and you can all rest again. You may need to go to the ER during the night if your child is turning blue or cannot seem to relax despite your help and the breathing distress continues.

After a bad night and the noisy breathing is still present during the day, even if the child isn't agitated, I know it will be even worse at night so I often will prescribe a three-day course of an oral steroid to help shrink the swelling in the airway more quickly.

The good news is that croup symptoms are bad for only about three nights and then within 10 days the cold symptoms that accompany it are gone and the child feels back to normal.

Croup is contagious and as such if kids have fevers or are having really rough nights due to the cough, they shouldn't go to school or daycare the following day.

Category: Weight

Handling the prepuberty bulge in kids

Everybody goes through puberty whether they want to or not and most kids weather the changes and adjustments quite well. One of the changes has to do with weight.

In the year or so before puberty kicks in, many kids get a little roun, especially their faces and bellies. This can cause worry for parents and children alike. Most often I encounter this concern as I am pulled aside in the hallway as I am about to enter the exam room to see an 11- or 12-year-old when the parents whisper to me they are concerned their child is getting fat. Most of the time I can reassure these parents after looking at the growth curve and the child that this round look is nothing more than the body's prelude to puberty.

Most parents remain somewhat concerned, though, because most middle school-aged kids aren't known for their love of healthy eating. Most kids will eat candy and chips with abandon even if they are somewhat concerned about their bodies, and this worries parents. With obesity rates so much higher, nipping things in the bud is increasingly important. The challenge is that this is a fine line to walk. Parents understand that everything we say and do can have one of two effects at this age: no effect at all or profound and devastating effects. OK, I understand this is a wild exaggeration but it is the way things seem, isn't it? If we say too much about our child's round appearance and eating habits, we worry we will make her so self-conscious she'll stop eating and become anorexic, but if we don't say enough she will end up obese! Quite a conundrum. Here's my advice on how to approach kids this age:

Start by weighing and measuring the height of your child and then plotting that data on the CDC growth curves based on your child's gender or age. If the height percentile and weight percentiles match (or are pretty close) you can be even more sure that this is not concerning and strictly cosmetic. Even if the height percentile is 50th and the weight is 70th, there is little need for concern. Only when the percentiles are significantly off (50th for height and more than 90th for weight for example) do you need to be concerned that issues of true overweight are present. If that is the case, see your pediatrician to talk about this issue.

It helps a lot if leading up to this time your family already has well-established, good eating habits in place. These include scheduled meal and snack times and limited unplanned snacking. In other words, have breakfast, lunch and dinner as regular parts of your day (even if they can't all be shared together as a family) and have scheduled snack time(s). If your kids get used to being able to go to the pantry and grab a snack whenever they feel like it, controlling it later is tough. In addition, have certain foods available for snacks and others available only on special occasions. For example, if your family pattern is to have an afterschool snack, offering fruits, yogurt or peanut butter crackers as the choices will make life easier later than routinely offering cookies, ice cream and chips. These other foods can of course be a part of life, but on special occasions rather than whenever the child chooses. If you haven't scheduled snack times and exerted some control over the choices, now is the time to do this. Put aside a basket in the pantry with the snack choices and put the junky food out of sight. That way no matter what your child chooses, you won't need to comment or criticize.

Another suggestion, with Halloween fast approaching, is to let your child eat several pieces of candy when first received (some parents even let the child eat as much as they want at that one time) and then give the rest away. Another alternative is to have the child put aside enough candy to have a piece every day for a specific time frame and give the rest away. This allows the child some control and pleasure but limits the total amount consumed. It is important to apply these guidelines to everyone in the family, not just the child in question.

Don't point out the fact that you think your child is gaining too much weight or looks chubby. Believe it or not, many kids who are just about to enter puberty are blissfully unaware and if you can gently encourage good snack choices and regular meal times (along with good portion sizes) you can achieve what you are trying to do without encouraging your child to focus on his appearance in this way. If your child brings up the subject of his weight with you, this can be a time to talk about controlling portion sizes and snacks and come up with a plan together. Make sure you communicate that you love your child no matter what and that we all have things we need to work on at times. If your child is significantly overweight and brings it up with you, ask him if he wants to talk to his pediatrician about strategies to get healthier.

Lastly, remember most kids will adjust their eating patterns on their own as they progress through puberty and after as a result of peer pressure or self image. The less you do to focus on the specifics of what your child is eating, the less apt he or she will be to see food as a method of power and control in the relationship between the two of you and use eating (or not eating) as a method of passive rebellion. Most children who are normal weight for height all through grade school who appear to bulk up before puberty will use that extra bulk for the huge growth spurt to come and will end up just as well balanced as they were before puberty started.

Category: Sleep

Sleep solutions for school-aged kids

How much sleep do kids need? About a third of our lives are spent asleep and the amount and quality of that sleep is essential to a sense of well being, immune system function and school and sports performance.

Whenever I do a checkup I talk about sleep. There are lots of barriers to good sleep including homework, TV, texting, chatting, after school and evening activities and video games. Others kids have difficulty falling asleep, snoring, frequent night waking and lack of a nighttime routine with a consistent bedtime.

Kids aged 6-9 need about 10 hours of sleep, children 10-12 need on average a little more than nine hours each night and teenagers need about eight-nine and a half hours of good quality sleep to ensure a sharp mind and healthy body. Not all kids fit these guidelines but most do and it is a good place to start.

Children and teens who routinely get fewer hours of sleep than they need may appear unfocused or hyper, have difficulty focusing in school and/or have periods of excessive sleepiness during the day. Many kids who aren't getting enough sleep will have more illnesses than their healthy sleeping peers and are more likely to be overweight because sleep deprivation results in carbohydrate cravings. So there are many good reasons to encourage healthy sleep.

Here are strategies to help your child get the sleep he needs:

Make sure all media (TVs, phones, computers, iPods, etc.) are off about a half hour before bedtime. Try to have the same bedtime each night with minor variations when needed and keep the wakeup times about the same, too, which will create a rhythm in the body to ready it for sleep naturally. Some kids benefit from light reading or listening to instrumental music as they wind down to go to sleep. Even relaxation techniques can be helpful. Recent data suggests online cognitive behavioral therapy when used in adults can work almost as well as medication at improving symptoms of insomnia.

Some kids will still have trouble falling asleep at an appropriate time despite these things and as such may benefit from a natural product called melatonin. Prepubertal kids can take 1-3 mg and while teenagers will need the whole 3 mg. Melatonin is great because it is natural and doesn't act the way a sleeping pill would. It merely sends the message to the brain that it is time to release the hormone that quiets the body and brain and readies it for sleep. It cannot be addictive nor can you develop a dependency on it. It doesn't change your sleep cycles and as such you wake as refreshed as you always would.

Some kids don't have trouble falling asleep, but have trouble staying asleep either because they are snoring and having intermittent waking as a result, are over-caffeinated or are having emotional issues that are impairing sleep. When snoring is the cause, seeing an Ear, Nose and Throat specialist for evaluation is very important. Removing tonsils and adenoids when needed can result in dramatic changes in behavior, school performance and even eliminate bed wetting for some kids. For those kids with frequent waking due to stress, depression or emotional challenges, addressing these head-on can often have significant improvements in sleep quality relatively quickly.

It may be that with some minor adjustments the eight or more hours of sleep your child needs is within your grasp.

Category: Cold and flu

H1N1/swine flu on pace to kill more kids than seasonal flu

The H1N1 (swine flu) virus is hitting many states hard, but lucky for us Michigan has yet to see widespread infection. As predicted, children are the most likely to have complications. In the last week, 19 deaths were reported among children with the infection.

Of the more than 75 children in the United States that have died of the illness thus far, 20 percent were otherwise healthy children with no risk factors. If the number of children dying of this virus remains at this pace, the H1N1 virus will surpass the seasonal influenza in deaths among children this year. Over the last several years, the number of children who have died as a result of the seasonal influenza have ranged from 46-88 deaths each year.

The good news is that so far all of the influenza seen this fall is H1N1 and remains very susceptible to the antiviral medications. More good news is that the Michigan Department of Community Health will begin distributing the vaccine in the coming weeks and we may be one of the few states that will be able to get most people vaccinated before the illness takes over. The H1N1 vaccine is highly recommended for all people 6 months-24 years of age, pregnant women and adults with chronic health conditions.

What about squalene?
Previous blog entries have addressed the safety of the H1N1 vaccine, its formulations and side effects, but one more question has been posed by several patients: what about squalene? Squalene is a naturally occurring substance that is made by all of us in our livers and used as an adjuvant in the vaccine to boost immune response. The squalene in the vaccine is culled from ocean fish and purified. Squalene has been well studied and is a safe and desirable way to boost response to the vaccine.

• Michigan gets first batch of swine flu vaccine

Category: Skin

Teen acne can be managed with variety of treatments

This past weekend was homecoming at my daughter's high school and because I see a lot of teenagers in my practice, it was a busy week. Some came to the office to try to rid themselves of an illness in time for the dance while others arrived with the hope that I would be able to cure their acne quickly. If only the acne-laden kids had come in a few weeks earlier there would have been some hope for smoother skin by the weekend.

Almost everyone will have acne at some time and puberty brings on a hormonal storm that makes acne nearly ubiquitous at this time. Acne isn't caused by dirt or oil on the top of the skin but rather the small hair follicles (pores) in the skin get clogged with dead skin causing a blackhead or whitehead. Sometimes those blackheads will have bacteria growing in them causing a lumpy feeling under the skin. Usually the bacteria causes the body to respond with inflammation and that's what causes the redness and pus of a pimple.

Because there are three distinct components to acne (clogged pores, bacterial growth and inflammation) treating it can be complex. The first step in any regimen is to wash the skin twice a day with mild soap and warm water. Use very mild soaps without antibacterial properties because these will be too drying. Don't use a rough cloth or over scrub because this will actually worsen acne. Washing your face twice a day will remove the dead skin cells that clog the pores and are the primary set up for acne. If that alone isn't enough but if you aren't having red raised pimples, using an over the counter 10 percent benzoyl peroxide product twice a day after washing may make all the difference.

When a person has more than blackheads and whiteheads though, prescription medications might be needed. When the acne lesions are filled with pus or are red and raised, there is enough inflammation that benzoyl peroxide and washing alone won't be enough. To avoid scarring from the inflammation, using the prescription products regularly is very important. Most doctors will start with a topical cream or gel called Retin-A. The upside to Retin-A is that it is very effective; the downside is that it can cause some redness and irritation to the skin for the first few weeks it is used. This can be minimized by choosing the weakest strength needed to control the symptoms. Anyway you slice it, Retin-A takes a few weeks before the skin is clear. Retin-A works well because it is an anti-inflammatory product and as such, the pus and redness are greatly diminished. When used with a benzoyl peroxide wash to gently fight bacteria and clear away dead skin, the combo is a real winner.

Sometimes, the pimples aren't red and raised and when that is the case an anti-inflammatory like Retin-A isn't the first choice. Instead, a combination of benzoyl peroxide and an antibiotic to fight bacteria makes sense. In this case, topical antibiotics (usually clindamycin) and benzoyl peroxide are used to manage the acne. Retin-A can be added later if these aren't enough.

When acne is scarring or when the topical treatments aren't enough, low dose oral antibiotics like clindamycin and/or oral anti-inflammatory medications like Accutane are up for consideration. Usually it is at this point that I refer kids to the dermatologist.

Acne can be embarrassing for kids and often they won't even bring it up to me despite the fact it is effecting their self-confidence and esteem. Sometimes parents will bring it up but often I am the one to break the ice and talk about acne and its management. The good news is that it doesn't have to be a right of passage that must be weathered without treatment. Most of the time acne can be managed with a commitment from the teen to do the prescribed skin care regime twice a day and everyone will be happier.

Category: Skin

Hives in kids are not always a sign of allergy

It's 2 a.m. and your 4-year-old climbs into bed with you, squirming and irritated. He doesn't feel like he has a fever and hasn't had a bad dream and yet he can't seem to stop moving around. Exhausted yourself, you get frustrated with his constant movement and walk him back to his own bed for the night. As you pass by the bathroom with the nightlight on you notice something odd: your child has spots - everywhere! Quickly you turn on the big light and see he has hives all over his body and face.

Your tired mind starts racing: What did he have for dinner? Could it have been from the peanut butter cookie he had for dessert even though he's had peanut butter all along? Are those new PJs? did he take a bubble bath last night?

You get out the Benadryl and give him a dose. As he finally gets relief from the annoying itch, you and he fall asleep again. At 7 a.m., when you both get up for the day, you notice his hives are still there and the itching is back so as soon as the doctor's office opens you call for advice and an appointment.

By the time you get to the appointment at 11 a.m., his hives are barely visible and all seems well again. You feel a little silly talking to the doctor with no evidence of the rash anymore and yet you worry if this is the first sign of a serious allergy. After all, more kids seem to have food allergies and because nothing else has changed in his clothes or soaps, you figure this must be the cause.

Your doctor asks a bunch of questions: any new foods? (no), new soaps? (no), any family history of allergies? (yes), any diarrhea or vomiting? (no), new exposure to animals the day before? (no), any recent diarrhea or cold symptoms? (no).

After examining him and finding nothing more than the remnants of the hives you have been seeing, she tells you these are not likely due to allergy at all. In fact, most often the cause of hives in children is never determined and thought to be due to a viral illness. More than 70 percent of the time the exact cause is never known and the hives peter out after about two days.

Hives are caused when the body overreacts to something and the immune system responds as if it is an allergy. Because many viruses will turn on the immune system, sometimes things go a bit awry and hives are the result. Other times, hives can be caused by a food, medication or something in the environment like molds or even something innocuous like cold temperature. If hives are the only symptom of the reaction, whether it be to a virus or a true allergen, there is no need to worry. Benadryl for a day or two will take care of the itch although the rash will continue to come and go. The rash will look much worse at times during these couple of days and anything that makes the child hot (like a bath, sleeping under cozy blankets or running around outside) will make the rash look even worse.

Unless your child has joint swelling, breathing trouble or is vomiting a lot, this is not going to progress to a serious reaction. Sometimes hives will appear off and on for weeks. If that's the case, seeing an allergist is warranted.

Bottom line: Hives alone are no big deal. Use some Benadryl antihistamine if the itching is bad and let nature do its job.