Rashes in kids... a few case studies for parents

I am not a dermatologist, but I see rashes all the time. Some are easy to identify, others I'm not sure what the cause is. In general physicians are taught to treat the symptoms of a rash. The standard dermatology lecture in a nutshell is: If it's wet, dry it. If it's dry, wet it. If it itches, use steroids. If it's infected, use antibiotics.

I'll go over a few made up case studies -- each one is a conglomeration of kids I've seen.

Case 1

Parents bring Itchy in for a well visit but mention that her skin has rashes on her elbow creases and behind her knees. Sometimes she scratches them to the point where they bleed. They've tried applying a pink fragrant lotion that they got as a baby gift, but she says it burns and didn't help.

Advice for this family would not include which of the following?

1. Use the lotion more often since the skin is dry
2. Stop the lotion because fragrant lotions can worsen this condition
3. This type of dry skin can be related to allergies and asthma, having one makes it more likely to have another
4. Controlling the itch is important because scratching worsens the rash

The answer is #1. This rash is most likely eczema, a fancy term for dry skin. It often develops in infants but improves as a child gets older. It is more common in kids with allergies and/or asthma. It can worsen with exposure to irritants (such as a fragranced lotion or soap) and allergens (food allergies and seasonal allergies). I've often heard this called "the itch that rashes". Scratching damages the skin, which allows water to escape, which dries the skin more, leading to more itching. This itch/scratch cycle worsens the rash and can lead to secondary infections. This can be a very frustrating condition because it will come and go for years in some kids. It's important to avoid irritants and use proper skin care. For more treatment, visit Dry Skin / Eczema / Atopic Dermatitis.

Case 2

Parents bring their infant in for her well visit and ask about a rash that's been there "for awhile" but doesn't seem to bother Baby. They aren't sure when it started. They can't recall any new soaps, lotions, foods, or other potential triggers. They describe it as red spots and they aren't sure if they're changing over time. Baby is eating well, gaining weight well, sleeping well, and not fussy. On exam, they show me the rash on the abdomen and arm, but I cannot see any red spots. 

What further questions might I ask and what advice might I give?

1. If this rash would be on your own skin, how would you treat it?
2. Treatment of the rash should be based on symptoms, and since there are no symptoms, no treatment is needed
3. Monitor for signs of itching, fussiness, fever, poor feeding, and other concerns
4. All of the above

The answer is #4 and yes, I see this non-existent rash all the time. It's not just my old eyes that can't see it -- I hear from pediatrician friends about this phantom rash too. I know parents worry more about their children than they worry about themselves, but sometimes they can realize the unfounded concern when I simply ask what they would do if this rash was on their own skin. Most say they wouldn't worry about it. Enough said. 

Case 3

Parents ask about a rash that appears sometimes after their school aged child showers. It doesn't itch or hurt. It is always on the chest and abdomen and sometimes on the legs. It looks like red splotches. They've tried various soaps and shampoos, but changing them doesn't seem to affect the rash. It isn't present on exam because it only happens after showers and lasts less than 30 minutes. They are concerned because it returns so frequently.

My advice to parents includes which the following?

1. Treatment of a rash should be based on symptoms, and since there are no symptoms, no treatment is needed
2. Use only cleansing products made for babies since your child is obviously sensitive to something
3. Turn down the temperature of the water in the shower to see if the rash "resolves"
4. 1 and 3

The answer is # 4. Again, I've been asked this type of question more than once. It also falls into the category of "What would you do if you had this rash?" Most parents would admit they wouldn't do anything since it didn't cause any problems and was brief. If they really think about it, they probably have had this "rash" after a hot shower. It's just flushed skin. If you enjoy a hot shower, it's okay if your skin flushes a bit.

Case 4

Mom brings Kiddo in because her nails are growing "funny." They have a horizontal crack and the tips are peeling off. They don't seem to hurt or bother Kiddo.

What further information would be important to know?

1. Was there any trauma to the nails?
2. Has your child been sick in the past 2 months?
3. Does kiddo use nail polish or fake nails?
4. Does your child pick at her nails regularly?
5. All of the above.

The answer is #5. The answer is usually in the patient history with this one. I've seen a number of kids with peeling nails recently because we had hand, foot, and mouth in the area about a month ago. Not all kids with that infection lose their nails, but it can happen. For more on this, including pictures, see Four Cases of Onychomadesis after Hand-Foot-Mouth Disease. Other causes of peeling nails include trauma and nail picking, nutritional deficiencies, nail products, chemical irritants, certain medications, infections, and chronic diseases. 

Case 5

Mom brings Snotty in because he's had a runny nose all week. On exam, he's found to have what mom thought was dried mucus under his nose, but the underlying skin is red and it's actually more of a crusting, not mucus. 

Treatment of this includes all except:

1. Using rubbing alcohol to rub off the crust
2. Antibiotic ointment
3. Washing the area
4. Avoid touching the area
5. Oral antibiotics

The answer is #1. That would hurt! This is a classic case of impetigo. Impetigo is a bacterial skin infection. It often happens when the skin is damaged (in this case from Snotty wiping his nose constantly) and if bacteria from the nose or mouth get into the skin. It can be treated with prescription topical antibiotic ointment in most cases, but some cases require oral (by mouth) antibiotics. Wash the area gently and soak crusts with warm wet cloths to help remove the crust. Complete removal of the crust isn't necessary though - that will happen naturally as the infection resolves. Touching the area can spread the infection, so avoid touching it and wash hands well after touching it!

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Dry Skin Tips

With the cold temperatures we've already seen this season, our skin is really taking a hit. Dry skin is often called eczema or atopic dermatitis. Whatever you call it, it's itchy and annoying!

It is really important to keep skin well hydrated or it tends to snowball. The dry skin is broken skin, which allows water to escape, which further dries it, which leads to more evaporation.... Broken skin is more likely to become secondarily infected, which leads to more problems....

Itching dry skin also contributes to its worsening by further damaging the skin and allowing more water to evaporate, so try to keep fingers from scratching! (I know this is easier said than done.)

Eczema is not simply dry skin. It can cause significant distress to infants and children. It can impair sleep. It can distract from learning at school. Children with eczema have higher rates of anxiety and depression.

Eczema doesn't simply go away with good treatment: it can come and go even with the best treatment. It can therefore be a serious problem for families.

Your goal with dry skin is to hydrate it as much as possible to repair the skin barrier. We don't always think about skin as an organ (like the heart and liver), but it is. Its functions are to help keep us at a normal temperature, to keep stuff (such as bones, blood, and nerves) inside our bodies, and it helps to keep some things (such as germs) out of our bodies. When skin is excessively dry, there is inflammation and cracking. This keeps the skin from doing its job. We must try to get it back to normal so it can help keep the rest of our body healthy.

Eczema can be from many factors.

• There is a genetic component, so if a parent or sibling has eczema, it is common for other family members to have it. 
• It is often worsened by environment, both cold dry air and excessive heat. 
• Clothing can irritate some skin, depending on the fabric and the detergent left in the fibers. 
• Any scented lotions or soaps can also irritate skin. (Don't be fooled that "baby" soaps and lotions are better for baby. I usually say to avoid any of the baby products because they are often scented. They make them to sell them, not to be better for baby's skin!)
• Allergies can exacerbate eczema.
• Saliva is very harsh on the skin. Drooling can cause problems around the mouth, chin, and chest. Thumb or finger suckers often have red, thick scaly areas on the preferred finger from the drying effects of saliva.

New eczema guidelines recently released downplay the need to alter foods to treat the skin. There are some kids who have true food allergies that manifest as atopic dermatitis (dry skin), but the large majority of kids do not. Restricting their diet can lead to nutritional deficiencies without any benefit. Talk to you doctor (and be sure they have read the newest on the topic) if you think a food might be exacerbating your child's dry skin.

My best tips for treating dry skin:

• Avoid exposures to soaps because they further damage skin. Non-soap cleansers that are fragrance free are much more mild on the skin.
• Soaking in bath water or in the shower can help hydrate the skin. After bathing the skin should be only briefly dried (remove large water droplets, but allow the skin to still be moist with water) and moisturizers (with or without steroids) must be applied immediately afterwards to prevent water from evaporating out of skin.
• Moisturizers should be hypoallergenic, fragrance free, and dye free. A good place to review if a product is good is on the National Eczema Association website. I really like the moisturizers with ceramide. This has been shown to help heal the skin barrier without steroids. Use moisturizers at least twice per day, more often as needed on the really dry spots.
• After the moisturizer soaks into the skin, cover extremely dry spots with petrolatum jelly. 
• Steroids can be used for flares. Steroids are available in 7 different strength categories. The stronger the steroid, the less often it should be used. Over the counter hydrocortisone is a very mild steroid and can be used twice a day with mild flares. Stronger (prescription) steroids should be discussed with your doctor if the eczema is more severe, but they can be safe and effective when used appropriately.
• Bleach baths have been shown to help in moderate to severe eczema. Add 2 ounces of bleach to the bath water and soak the body (not the face) for 20 minutes a few times a week.
• Oral antihistamines, such as zyrtec, allegra, or claritin (or any of their generics) can help control the itch. I recommend the long acting antihistamines over the short acting ones, especially overnight, to avoid gaps in dosing leading to the itch/scratch cycle. Avoid topical antihistamines due to variable absorption from disrupted skin.
• Add water to the air during the dry months. If your air conditioner is running you shouldn't need (or want) to add humidity. If your heat is on, you might have an attached humidifier, which is great. You can also buy a room humidifier or vaporizer to add water to the air. When there's more water in the air, the skin will have less evaporation.
• Use wet water cloths on dry patches. This can help get a child through an itchy time with a cool compress. It also helps hydrate the skin. Since it might remove the moisturizer, re-apply moisturizer when the wet cloth is removed. Some kids benefit from wet wraps (see link). This is time intensive, but very effective, so worth trying for more severe eczema patches. 
• If your child just can't stop itching, be sure nails are clipped to help avoid scratching. Sleeping with socks or mittens helps the inadvertent scratching during sleep. Many kids remove these, so sewing an old pair of socks onto the arms of long sleeve PJs can help. (Don't forget to put moisturizer on first!)
• If your child drools or sucks a finger, wipe the saliva off regularly and protect the skin with petrolatum jelly.

At times prescription medicines are needed. These can include steroids, immune modulators, and antibiotics. If your doctor recommends them, don't be afraid to use them. Many parents under utilize medical treatments out of fear of side effects. Yes, there are risks to all medicines, but there are also risks to having eczema untreated. Discuss fears with your doctor to come up with a good plan that you both agree with. Don't just not use the prescriptions.

Get control of your child's eczema. If you can't seem to do it alone, schedule an appointment with your pediatrician to see what else can be done.

For more information, see the American Academy of Pediatrics clinical report on eczema management and the American Academy of Dermatology's Guidelines.

Starting Solids-- The Old and the New and the Myths

Many parents are excited yet apprehensive to start foods with their infants.  So many questions, so many fears.  So much food introduction guidance has changed in recent years, that what you did with your older kids might not be current.  Change takes time, so not everyone agrees on the "new" rules.  Talk to your own pediatrician to see their take on it all!

The older "rules" for starting foods were so confusing... different sources will vary on these rules.

photo source: Shutterstock

• don't feed before 6 months is now ok to feed at 4 months if baby's ready

• don't give nuts, eggs, and other "allergy" foods until ____ (2/3/5 years, varying by expert) is now it is okay to give allergy foods unless there is a family history of food allergy

• don't start more than one food every 3-5 days is now  introducing multiple foods at one time is ok

• start with rice, then add vegetables, then meat., wait until last for fruit is now begin with any foods, but try to make nutritious choices, such as meat which is high in iron and protein

Variations of this were plenty, depending on the provider's preferences.  

No wonder there is so much confusion!!!!

New rules are much easier.  I like easier.

• Start new foods between 4 and 6 months, when your baby shows interest and is able to sit with minimal support and hold the head up.
• Don't give honey until 1 year of age.
• Don't give any textures your baby will choke on.

Done.  

That's it.  Nothing fancy.  Any foods in any order.  Multiple new foods on the same day are okay. Common sense will hopefully guide types of foods.  Nothing too salted. Try nutritious foods, not junk.  

These minimal rules can make parents weary.

What about food allergies if foods are given too early?

Research does not support the thought that starting foods earlier lead to allergies.  In fact, there is research to support that starting foods earlier might prevent food allergies.  A full 180 degree change!  Pregnant women and breastfeeding mothers no longer have to avoid nuts or other allergy foods in most cases.  If there is a close family member with a food allergy, it might still be beneficial to wait to introduce that food.  Talk with your pediatrician in that case.

I admit that I was initially nervous about telling parents it was okay to give nut products in infancy.  Not just the allergy aspect, but also choking risks.  ~ Back to the no textures your baby will choke on... nuts are hard and round-- two no-nos, peanut butter is thick and sticky-- another choking risk.   

Any of the more allergy prone foods should first be offered in small amounts at home.  These foods include nuts, egg, and fish.  Do this only if there is no one in your house who is allergic to that food.  Have diphenhydramine allergy syrup around just in case, but remember most kids are NOT allergic, and starting younger seems to prevent (not cause) allergy.  In the case of nuts, since there is also a choking risk, you can try a food cooked with nuts or nut oil.

What about saving the fruit for last so they don't get a sweet tooth?

Babies who have had breast milk have had sweet all along! Breast milk is very sweet, yet babies who are graduating to foods often love the new flavors and textures with foods.  Formula babies haven't had the sweet milk, but they can still develop a healthy appreciation of flavors with addition of new foods. Saving fruit for last simply doesn't seem to make a difference. Adding fruits alone is not very nutritious though, so fruits should be added along with other more nutritious foods.  The more colors on our plates, the healthier the meal probably is!

I thought they couldn't have cow's milk until after a year?

Cow's milk is not a meal in itself (like breast milk or formula). It is missing many vitamins and minerals, so babies need to continue breast milk or formula until at least a year.  Cow's milk may lead to allergies or eczema, including formulas made with cow's milk.  Milk products, such as cheese and yogurt can be given to babies as part of an otherwise well rounded diet as long as they don't show any allergy risks to milk.  Regardless of dairy intake, it is recommended for infants under 6 months to have 400 IU Vitamin D/day and those over 6 months to take 600 IU Vitamin D/day as a supplement.

I thought they should have cereal first...

Rice cereal has been the first food for generations, probably because grandma said so.  There has never been any research supporting giving it first.  With white rice and other "white" carbohydrates under attack now, it is no wonder the "rice first" rule is being debated. Despite being fortified with vitamins and iron, it is relatively nutrient poor, so choosing a meat or vegetable as first foods will offer more nutrition.  

Shouldn't we wait on meat?

Waiting on meat due to protein load was once recommended, but no longer felt to be needed. Pureed meats (preferably from your refrigerator... baby food meats are not very palatable!) are a great source of nutrition for baby!  Some experts recommend meat as the first food due to its high nutritional value and low allergy risk.  

How do we know what they're allergic to if we start several new things at once?

First, most kids are not allergic.  

Second, if they are allergic to a food, it is often days/weeks/months before the allergy is recognized. Waiting 3 days between food introduction simply doesn't allow recognition unless it is hives or anaphylaxis, and there are a small number of foods that account for most of these reactions. If your child has one of these reactions we can test to see what the offender was.  This is recommended with severe allergies since people with one allergy might have other allergies, and identification for avoidance is important.  

Allergy symptoms can be broad and often are not specific: dry skin (eczema), runny nose, hives, swelling of lips, difficulty breathing, vomiting, diarrhea, or blood in the stool.  If you think your child is allergic to a food, discuss with your doctor.  Severe symptoms (anaphylaxis) demand immediate attention!

How do we know when to start foods? I wanted to start to help baby sleep through the night, but I heard starting too soon increased obesity and diabetes.

When babies are able to sit with minimal support and hold their head up and when they show interest in food by reaching for it they might be ready.  They can wait until 6 months to start foods, but some studies show poor weight gain and nutritional balance as well as resistance to foods if started after 6 months.  

In formula fed babies it has been shown to increase the risk of obesity at 3 years (6x!) if foods are started before 4 months of age.  That risk is not seen in exclusively breast fed infants or those who begin foods after 4 months of age.

It is still an old wive's tale that starting solids will help baby sleep through the night.  Babies tend to sleep longer stretches at this age, so it is no wonder that this myth perpetuates.  Start foods because you see signs that baby is ready, not because you want longer sleep patterns!

How do I know how much to feed my baby?

Babies will let you know when they are full by turning away, pursing their lips, spitting out food, or throwing foods.  As they eat more food, they will need less breast milk or formula.  In general a baby who is gaining weight normally will self regulate volumes.

What's better: baby foods bought at the store or home made foods?

Marketing and ease of preparation has made pre-prepared foods for us all common place.  It does not mean they are any better.  They cost more than home made foods.  I didn't make baby foods when my kids were babies because I thought it would be too hard, but now I puree foods to put into recipes (my kids are like many who aren't fans of veggies and I want to improve their nutrition).  It really isn't hard.  You can take whatever you are cooking for your family and put it in a food processor or some blenders and with a little water to get it to a texture baby can eat: voila!  Home made food.  There are of course many baby food cook books and ideas of how to freeze meal-sized portions so you can make multiple meals at one sitting. There is help for parents who want to safely prepare baby food at home on How to Make Your Own Baby Food from What to Expect. (link updated 9.16.17)

My baby only wants table foods. Is that okay? Don't they need pureed foods first?  He doesn't have many teeth!

Pureed foods are what most babies start with due to the easy texture, but some babies quickly develop the ability to pick up small pieces of food with the pincher grasp (finger/thumb) and want to feed themselves.  If they are able to get the food in their mouth, move it to the back safely with their tongue, and swallow without choking, they are ready to  feed table foods... at least with some textures. Beware of chewy or hard foods as well as round foods ~ these all increase the risk of choking.  

Most babies will be able to eat table foods between 9 and 12 months.  They tend to not have molars until after 12 months, so they grind with their gums and use all their saliva to help break down food.  They need foods broken into small enough pieces until they can bite off a safe bite themselves.  

Don't put the whole meal on their tray at once... they will shove it all in and choke! Put a few bites down at a time and let them swallow before putting more down.  Rotate food groups to give them a balance, or feed the least favorite first when they are most hungry, saving the best for last!

This is a great time for parents, sitters, and other caregivers to take a refresher course on CPR in case baby does choke.  Infants and young children are more likely to choke on foods and small objects, so it is always good to be prepared!  

How much juice should my baby drink?

In general I think babies don't need juice at all. They can practice drinking from a cup with water.  Juice adds little nutritional value and a lot of sugar.  Eating fruit and drinking water is preferable.  If they do drink juice, it should be 100% fruit or vegetable juice, not a fruit flavored drink!  No more than 4 ounces/day of fruit juice is recommended. 

What about organic? 

There is not enough evidence to recommend organic food, since the nutritional components of the foods are similar regardless of how they were farmed.   

Organically grown foods do have lower pesticide residues than conventionally farmed produce, but it is debated if this is significant or not to overall health.  Conventionally farmed produce have the pesticide levels monitored, and they fall within levels that are felt to be safe.

Organic farming rules also dictate no food additives or added hormones, which is also an area of study for health risks and benefits, but not enough data is available to give an educated opinion yet.  

Organic farming is generally felt to be better for the environment, but the sustainability of that is questioned.  

Organic farming might increase the risk of bacterial and fungal contamination or heavy metal content, so it is very important to wash fresh fruits and vegetables well prior to cutting or eating (as you should with all fresh foods).  

For more information, see the USDA site.

A backyard garden can be inexpensive, organic, and a great way for your kids to learn about growing and preparing healthy foods!