Tamiflu

During flu season we have many requests for Tamiflu (oseltamivir) because of flu exposure or disease. I have rarely complied with these requests, though in recent years more often due to the powers that set the guidelines recommending it more. It is more common in my experience to hear negative feedback about side effects than it is to see patients get better faster. (Note: this is a very biased view, since those who are better would not call, but since so many call with side effects it seems fair to say I don't like the drug.)

photo source: Shutterstock

I am not alone in my dislike of Tamiflu. I follow a listserv of pediatricians around the country and many share my views. A recent topic thread on treatment of flu has peaked my interest. One doctor suggested watching a TED Talk by Dr. Ben Goldacre: What doctor's don't know about the drugs they prescribe.  Dr. Goldacre starts talking about Tamiflu specifically about 10:10, but the entire lecture is done in an entertaining and informative manner if you have the time.

I feel deceived. When I practice medicine, I follow standard recommendations and guidelines that are based on peer reviewed articles and data. The question is, what important data is left out? There is a movement to solve this problem of unpublished studies. You can see updates at the Tamiflu Campaign of the British Medical Journal.

Back to influenza treatment...

First, current influenza treatment guidelines regarding the use of antivirals: 

The current guidelines basically say every child should be considered a candidate for an antiviral treatment. I understand the reasoning behind the first two conditions of antiviral use (except that studies don't really support even those indications), but I am very confused about the third highlighted below.

(from http://aapnews.aappublications.org/content/early/2013/09/02/aapnews.20130902-1)

ANTIVIRALS CONTINUE TO BE IMPORTANT IN THE CONTROL OF INFLUENZA.

Treatment should be offered for:

• any child hospitalized with presumed influenza or with severe, complicated or progressive illness attributable to influenza, regardless of influenza immunization status; and
• influenza infection of any severity in children at high risk of complications of influenza.

Treatment should be considered for:

• any otherwise healthy child with influenza infection for whom a decrease in duration of clinical symptoms is felt to be warranted by his or her pediatrician; the greatest impact on outcome will occur if treatment can be initiated within 48 hours of illness onset.

Then look at what a search for "unpublished tamiflu trials" shows.

For those of you unfamiliar with the Cochrane group, I need to take a quick sideline. They are a well respected group that reviews all the studies within certain parameters on one topic to evaluate the overall findings of several independent studies. 

From the Cochrane Group: A review of unpublished regulatory information from trials of neuraminidase inhibitors (Tamiflu - oseltamivir and Relenza - zanamivir) for influenza. These results are from a review of published and unpublished studies that they could find. From the abstract: "The authors have been unable to obtain the full set of clinical study reports or obtain verification of data from the manufacturer of oseltamivir (Roche) despite five requests between June 2010 and February 2011. No substantial comments were made by Roche on the protocol of our Cochrane Review which has been publicly available since December 2010. 

They found several problems with Tamiflu from the studies they were able to review:

• Drug manufacturers sponsored the trials, leading to publication and reporting biases. One of the authors reported that 60% of the data was never published. This is over half of the research, and I suspect it didn't support use of the medicine (remember the company that benefits from selling the medicine was doing the trials...)
• There was no decrease in hospitalization rate for influenza in people treated with Tamiflu.
• There was not enough evidence of prevention of complications from influenza. Design of the trials (again by the people who make the drug) did not report the prevention of complications from influenza, such as secondary infections.
• There is not evidence in the trials to support that Tamiflu reduces spread of the virus. One of the main reasons people request the medication is after exposure to prevent illness! (Note: this might have changed because the indications on the package insert now say it can be used to prevent illness in those over 1 year of age and they were previously not allowed to mention prophylaxis.) 
• Tamiflu reduced symptoms by 21 hours. Yep. Less than one day of fewer symptoms. For the cost of the drug and the potential side effects, is feeling sick for 1 day less really worth it? 
• There was a decreased rate of being diagnosed with influenza in those randomized to get Tamiflu, probably due to an altered antibody response. The authors suspect a body becomes less able to make its own antibodies against influenza when taking Tamiflu. 
• Side effects were not well documented.

A review study done in children exclusively Neuraminidase inhibitors for treatment and prophylaxis of influenza in children: systematic review and meta-analysis of randomised controlled trials focused on treatment of disease and prevention of illness after exposure. Findings included:

• Symptom duration decreased between 0.5 and 1.5 days, but only significantly reduced symptoms in 2 of 4 trials. That means in 2 of 4 trials there was no significant reduction in symptoms.
• Prophylaxis after exposure decreased incidence by 8% of symptomatic influenza. This means for every 13 people given Tamiflu to prevent disease, one case will be prevented. Not great odds.
• Treatment was not associated with an overall decrease in antibiotic use, suggesting it did not alter the complication of bacterial secondary infections.
• Tamiflu was associated with in increased risk of vomiting. About 1 in 20 children treated with Tamiflu had an increased risk of vomiting over the baseline vomiting due to influenza.
• There was little effect on the number of asthma exacerbations or ear infections by treating influenza with Tamiflu.

So what do I recommend during the cold and flu season?

1. Get vaccinated! The influenza vaccines have been shown to help prevent influenza and are very well tolerated with few side effects. If you or your children are due for other vaccines, be sure to get caught up.
2. If you get sick, stay home until you're fever free without the use of a fever reducer for at least 24 hours! Don't spread the illness to others by going to work or school. The influenza virus is spread for several days, starting the day before your symptoms start until 5-7 days after symptoms start-- kids may be contagious for even longer. You are most contagious the days you have a fever.
3. Wash hands well and frequently. If you can't use soap and water, use hand sanitizer.
4. Cover your cough and sneeze with your elbow or a tissue.
5. Avoid close contact with people who are sick. But remember that people spread the virus before they feel the first symptoms, so anyone is a potential culprit!
6. Don't share food, drinks, or towels (such as after brushing teeth to wipe your mouth) with others. 
7. Don't touch your eyes, nose, and mouth -- these are the portals for germs to get into your body. 
8. Keep infants away from large crowds during the sick season.
9. Frequently clean objects that get a lot of touches, such as keyboards, phones, doorknobs, refrigerator handle, etc.
10. Avoid smoke. It irritates the airway and makes it easier to get sick.
11. Remember that many germs make us sick during the flu season. Just because you've been sick once doesn't mean you won't catch the next bug that comes around. Use precautions all year long!

Because the guidelines recommend Tamiflu as above, I will probably be forced to prescribe it by worried parents who hope that their kids will feel better. (You've heard of defensive medicine, right?) 

Influenza is a miserable illness. The key is prevention. I've had my vaccine, how about you? 

Further Reading:

Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children: A link is available to the full text of the study by T Jefferson, MA Jones, P Doshi, CB Del Mar, CJ Heneghan, R Hama, and MJ Thompson.

Update 2016:

The CDC continues to recommend Tamiflu (oseltamivir) and other anti-viral medications. I continue to wonder why.

There continues to be a lot of confusion about unpublished studies. Investigators have documented their discussions with the maker of Tamiflu on Tamiflu correspondence with Roche.

Recent studies have tried to compile all that is known about how oseltamivir works:

• Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. 

Results from this study include:

• In the treatment of adults, oseltamivir reduced the time to first alleviation of symptoms by 16.7 hours, 29 hours in children.
• There was no difference in rates of admission to hospital between treatment groups in both adults and children.
• Oseltamivir relieves symptoms in otherwise healthy children but has no effect on children with asthma who have influenza-like illness.
• Oseltamivir had no significant effect on admissions to the hospital.
• Oseltamivir causes gastrointestinal disturbances in both prophylaxis and treatment roles. In prophylaxis, it caused headaches, renal events (especially decreased creatinine clearance), and psychiatric effects. 

Antibiotic Allergy or Just a Rash?

During the winter months more people get sick, so more people are treated with antibiotics. While antibiotics can help treat bacterial infections, they do carry risks. One of those risks is an allergic reaction. This is one of the reasons pediatricians avoid using antibiotics liberally. Most of the time our bodies can fight off the germs that cause illness and antibiotics don't help treat viruses at all.

When someone is on a medicine and they develop a rash it can sometimes be hard to sort out if symptoms are part of the illness, a non-allergic drug reaction, or an allergic reaction. There are many people who had a rash while taking an antibiotic as a child and were told that they are allergic to that antibiotic, but really aren't. Unfortunately this can lead to more expensive and broader-range antibiotics being used inappropriately and unnecessarily.

About 2% of prescription medications (not just antibiotics) cause a "drug rash". The rash usually begins after being on the medicine for over a week (earlier if there was previous exposure to the medicine), and sometimes even after stopping the medicine. It can look different in different people. Some get pink splotchy areas that whiten (blanch) with touch. Others get target-like spots, called Erythema Multiforme. Often the rash seems to worsen before it improves, whether or not the medicine is stopped. Skin can peel in later stages. It can itch but doesn't have to. Some people have mild fever with these symptoms. In adults this type of rash is often a sign of allergic reaction, but in kids a rash is most often a viral rash - meaning they have a virus that causes a rash but they happen to be on an antibiotic (or other medicine). This is why diagnosing allergy versus drug reaction is tricky. These symptoms can mean allergy to the drug, but (especially in kids) is often just a symptom of a virus (or some bacteria, such as Strep or Mycoplasma).

Up to 10% of children taking a penicillin antibiotic (which includes the commonly used amoxicillin and augmentin) develop a rash starting on day 7 of the treatment. (It can be earlier in people who have had the antibiotic previously.) This rash tends to start on the trunk, looks like pink splotches that can grow and darken before fading. It does not involve difficulty breathing, swelling of the face or airway, or severe itching. Because of this reaction many people live their life thinking they have an allergy to penicillin, even though many of them don't. 

Amoxicillin rash after 17th dose (about the 8th day). Photo source: By Skoch3 (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 4.0-3.0-2.5-2.0-1.0 (http://creativecommons.org/licenses/by-sa/4.0-3.0-2.5-2.0-1.0)], via Wikimedia Commons

Same child, 8 hours after the above photo. Photo source: By Skoch3 (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY-SA 4.0-3.0-2.5-2.0-1.0 (http://creativecommons.org/licenses/by-sa/4.0-3.0-2.5-2.0-1.0)], via Wikimedia Commons

Why does this happen? We don't know for sure. But it can cause a very significant rash, especially with the virus that causes mono.

Up to 80 -90 % of people who have mono develop a rash if they are treated with a penicillin antibiotic (like amoxicillin). This is common since symptoms of Strep throat and mono are very similar, and penicillins are the drug of choice for Strep throat. Some people with mono have a false positive test for Strep throat, meaning they do not have Strep but the test is positive. This is why it is very important for the medical clinician to take a careful history of symptoms and do an exam, even with "classic" Strep symptoms. (If I had a dollar for every parent who says the symptoms are just like all her kids when they get Strep, can't I just call it in...) Always be sure to get a Strep test and full exam to evaluate if it is really Strep or possibly mono. Blood tests for mono can be ordered if clinically indicated. Never treat a sore throat without a full evaluation.

Amoxicillin rash that developed several days after starting amoxicillin with mono. Image from Ónodi-Nagy et al. Allergy, Asthma & Clinical Immunology 2015 11:1   doi:10.1186/1710-1492-11-1

How do we know if it's a real allergy? 

Doctors will take a careful history of all symptoms of the illness, the timing of when the rash developed during the illness and when the medicine was given. If it is a classic viral rash, nothing further needs to be done. If there are symptoms (see below) that help identify a true allergy and make a clear diagnosis, then avoidance of that medication should be done. Be sure all your doctors and pharmacists know of this allergy. If it is not clear then further evaluation can be done. Allergists can do skin testing to see if there is a penicillin allergy, but most antibiotics do not have testing available so an oral challenge (in a controlled setting) is used if there were no clear allergy symptoms with a rash.

Mild to moderate allergic reactions can have the following symptoms:

• Hives (raised, extremely itchy spots that come and go over a period of hours)
• Tissue swelling under the skin, often around the face (also known as angioedema)
• Trouble breathing, coughing, and wheezing

Anaphylaxis is a more serious allergic reaction and can include:

• Difficulty breathing or wheezing
• Swelling of the face, tongue, throat, lips, and airway
• Dizziness
• Loss of consciousness
• Shock
• Death

Final Take Away

As you can see, rashes that develop while on medications can be quite a conundrum. If one develops, be sure to get in touch with your doctor. We usually cannot diagnose rashes over the phone, so an appointment may be necessary.

Thank you to Kressly Pediatrics for posting a comment on Twitter (@KresslyPeds) about drug reactions to give me the idea for this blog!

How To Keep Your Family Healthy This Winter

This blog is short and sweet about avoiding illness this sick season, but has links to dig deeper as desired.

It's not a big secret. We know the best ways to stay healthy, but it takes everyone to participate to make it work.

Practice the following routinely and help stop the spread of illness!

1. Wash hands or use hand sanitizer (sanitizer is not helpful at eliminating all germs - see the link for more information on how and when it is appropriate) 
2. Eat healthy and drink water (infants under 6 months should drink breast milk or formula)
3. Sleep
4. Get vaccinated
5. Don't touch your face - this is where germs enter our bodies!
6. Probiotics might help (recent meta analysis)
7. Wipe down objects regularly: learn the difference between cleaning, disinfecting, and sanitizing.
8. Safely prepare and serve food 
9. Cover your cough and sneeze with your elbow.
10. Avoid sick people
11. Stay home when sick

Things that haven't been shown to help:

1. Mega doses of vitamins
2. Cough and cold medicines have limited benefits, if any at all
3. Homeopathic medications
4. Essential oils
5. Antibiotics for viral illnesses (most cold and coughs)
6. Using an improper medication dosing device

Related blogs:

How Long Will a Cough or Cold Last?

Cough Medicine: Which one's best?

My Child's Cough Sounds Like...

But the snot is green...

Sick, sick, and more sick

Holidays and family spoiled by illness... It's that time of year!

To Tamiflu or Not to Tamiflu?

Tamiflu: Guest Blogger Dr. Mark Helm

Adenovirus Infections

Evolution of Illness

Fever Is...

New High Risk Child RSV Prevention Guidelines

What are the most common risks after shots?

Parents want to keep their kids as healthy as possible, but with the overwhelming amount of information found in media these days, it is hard to know what is safe and what risks really are when it comes to vaccines.

Nothing we do is without risk. The most risky thing most of us do daily is to get in a car and drive somewhere. We can minimize the risk by wearing a seat belt and putting our kids in the proper sized car seat, obeying the traffic laws, and adjusting our driving to the road and weather conditions, but there is always the chance of an accident. For most of us, the risk of an accident is outweighed by the benefits of getting to where you need to go. 

Vaccines are no different. The benefits are many, including preventing early death from infection. The risks are often overblown, but do exist.

You might have read somewhere that you should read the package insert of vaccines before allowing your child to get a vaccine. This advice is somewhat misguided. The package insert has a lot of information, but it is designed for legal reasons, not consumer information sharing. Anti-vax groups encourage the reading of them to learn risks of the vaccines, but this can lead to undue fear and confusion. Not all problems recorded in the adverse reactions section of the package insert are due to the vaccine. If someone fell out of a tree and broke his leg after a vaccine and reported it during vaccine trials, "broken leg" will be listed as a reaction. It does not mean that the vaccine broke the leg or caused the broken leg in any way, but it is reported in a way that can make it look like there is a cause and effect relationship. For a more detailed description of package inserts, see Package Inserts - Understanding What They Do (and Don't) Say. 

The risks of all vaccines are similar. Specific risks can be found on the Vaccine Information Sheets (which are designed to educate consumers about risks and benefits), but in general the risks of any vaccine may include:

• Pain with injection. This is very subjective. Most babies cry, but typically as soon as they are cuddled by a parent they quickly calm down. Toddlers are more prone to longer crying times, but that often starts unrelated to the vaccine and is not solely due to pain. It is often due to their frustration and/or fear of being in the doctor's office. Older kids often will say the pain was less than they feared, but some do complain for several minutes. Moving the arms or legs that were injected can help ease this pain. 
• Fever. A mild fever can occur for a day or two after many vaccines. Most kids do not need any fever reducers for this. The fever reducers might even reduce some of the effectiveness of the vaccine, so are not routinely recommended after vaccines. If the temperature is over 102F or the child is very fussy with the fever, it is okay to use a fever reducer. These higher fevers are not common after vaccines, but are possible.
• Fussiness or feeling mildly ill. Infants can be fussy for a few days and older kids might say they feel tired or have a headache. Some kids (and adults) will feel like they're getting sick, but it never evolves into an illness and it stays mild. Extra sleep would be beneficial, but typically no treatment is needed. 
• Non-stop crying. While unusual, it is possible that an infant will cry for hours after one or more vaccines. If this occurs, you can try a pain reliever. If the crying doesn't stop, it might be wise to have your child examined since it might be that something significant is going on causing the crying. 
• Seizure. It is not common to have a seizure after a vaccine, but whenever a child under 5-6 years of age has a fever, it is possible to have a fever seizure. Most fever seizures are from viral illnesses, some of which are prevented by vaccines. Vaccines rarely cause fever seizures, but if the temperature increases rapidly after a vaccine in a susceptible child, it is possible. If a child has a fever seizure, it is scary to watch but does not lead to permanent brain damage.  
• Pain, tenderness and swelling of the injection site for several days after the injection. Some vaccines, such as DTaP and Tdap, are more prone to swelling and redness than others. The most swelling tends to happen after several doses of these vaccines, such as with kindergarteners, tweens, or adults. My son's arm was so swollen after kindergarten shots that he couldn't fit into some of his shirts with narrow arms, but it was a normal shot reaction. With a shot reaction the inflammation begins a few hours after vaccination, peaks 24 h to 48 h afterward and resolves within one week. Tenderness is usually at its worst during the first few hours and resolves as the reaction enlarges. The amount of swelling and redness is more significant than pain or tenderness with a classical vaccine reaction. 
• Infection of the injection site. Very rarely the area can become infected (cellulitis) but this is exceedingly rare now that most childhood vaccines come in single dose syringes. Cellulitis can evolve rapidly -- often within 12 h to 24 h. Diagnosis is based on the symptoms of redness, pain, swelling and warmth, usually with fever and ill appearance. Most redness and swelling is a normal shot reaction and not a sign of infection, but if your child seems ill along with a painful red and swollen area where the vaccine was injected, it might be wise to have your doctor take a look at it. 

It's hard to see, but this is my arm 2 days after a Tdap. The area was swollen, warm and red. The redness has irregular borders, looking lacy in appearance, which is common in shot reactions. I didn't take any pain relievers. I tried moving my arm around a lot and that helped. 

If a child's temperature is usually low, how do we define fever?

My child typically runs a temperature around 97°F, so if the temperature is 99°F, is that a fever?

We get a variation of this question all the time.

Sometimes it's the opposite, such as my child usually runs hot, so can you write a note saying 101°F isn't a fever for him?

Short answer (both questions): No.

Long answer: Our body temperature is very complex. Your school district will define a fever with a number, but your doctor might have a different number. A fever is not defined by the change from a person's baseline temperature.

Disclaimer: All information on fever given is for healthy, vaccinated children over 3 months. Young infants, children with chronic disease, or undervaccinated kids do not apply to standard fever discussion and advice.

Most people think of a "normal" body temperature as an oral temperature of 98.6°F. Your temperature may normally be a degree or more higher or lower, which means 99.6°F is normal despite the fact that some daycares define this as a fever. Most often we associate high body temperatures with illness, but elevated temperatures also can be caused by environment temperatures being too high (or over bundled babies), dehydration, medications, poisons, cancer or overactivity. Your normal body temperature changes by as much as 1°F throughout the day, depending on how active you are and the time of day. Body temperature is very sensitive to hormone levels, so may vary with women’s monthly cycles. Our temperature tends to lower as we age - kids tend to have slightly higher temperatures than their parents, even when healthy. It is very common for children to get a fever when sick, but less common for adults. And the thermometer itself can vary in readings significantly, so the number may or may not be reliable, depending on the thermometer.

It is said that a child has a fever when his or her rectal temperature is 100.5°F or higher, which is about 99°F under the arm and 99.5°F and in the mouth. [This was edited 6/21/17 after some perceptive pediatricians found a typo.] This is by convention, but in actuality children’s normal temperatures may be higher than adults so these temperatures might be normal and only higher temperatures may actually indicate fever.

Parents often use the term "low grade fever" to indicate something less than 100.5°F. There is really no such thing. It's either a fever or it's not. A low fever in my mind means a temperature over 100.5°F that doesn't make the kid feel pathetic. Any temperature less than that simply isn't a fever. The child might be sick and temperature doesn't define illness, but it's not a fever.

There also isn't a medical definition of high fever. The temperature is the temperature and illness is better defined by describing all symptoms, not just the temperature. I guess if I had to define a high fever, it would be one that makes a person feel absolutely miserable. There is no magic number that defines this high fever or that tells us when to worry more. It's more important to look at the child than the thermometer to know if they're really sick or not.

Many parents have fever phobia, a condition where they worry that the fever itself will do damage. While a rapidly increasing temperature can cause fever seizures, these are more scary than dangerous. Fever seizures can occur with relatively low fevers if the change in temperature is rapid. It's not necessarily the high high temperatures that cause seizures. The brain will not be permanently damaged from most fevers (even high temperatures), though a fever can be a symptom of serious illness that can damage the brain, such as meningitis. But you would recognize that your child is more sick than the typical illness if they are having symptoms of such a significant illness. You would not use a thermometer to tell you that.

I do not recommend taking a child's temperature frequently. That causes excess worry in parents when the temperature increases by 0.5 degree, which could be a real change or just the thermometer's reading. Respond to your child, and don't rely on the thermometer. Never wake a comfortably sleeping child to take the temperature. Don't use sticky strip thermometers that tell your cell phone if there's a fever (yes, that exists, and it will lead to more parental anxiety than help keep children healthy.) Knowing the temperature helps to know if it is a true fever or not, but it should not direct you to give medicine or not. A temperature can be taken at times you need to know if there's a fever, since schools and daycares have rules to keep kids with fever away (though fever is not the only sign of illness and if your child's sick he might need to stay home despite temperature). It is sometimes helpful to know if a warm or hot child has a true fever, but you don't need to take it every hour to follow the trend with most illnesses. It's not even helpful to see how much medicine brings the temperature down. If a child doesn't improve, you will be concerned regardless of the thermometer reading. Taking a temperature once or twice a day is sufficient. I'd recommend taking it at times that it is likely to be its highest, such as in the evening or when fever reducing medicine has worn off.

The American Academy of Pediatrics recommends treating sick children for comfort, which is typically when the temperature reaches about 102°F or if they have pain somewhere. Not all earaches or sore throats cause fever, but you might consider a pain reliever to help symptoms. Most people feel uncomfortable as their temperature approaches 102°F. Only give fever reducers if the child needs it for comfort because the fever is actually helping the child fight off an infection - don't inhibit the immune system if your child is comfortable enough to sleep and drink without significant pain.

Never give a fever reducer to hide a fever so you can send your child to school or daycare. If they don't feel well, they shouldn't go because they'll spread the illness to other kids. A normal temperature because of a fever reducer does not mean that the child is fever free. You can only be fever free if the medicine has worn off and the temperature remains normal. The temperature should be normal off medicines for 24 hours before returning to school or daycare (or work for adults with fever).

So, with the original question, if a child is usually cooler than 98.6°F, when do they have a fever?

A temperature over 100.5°F is the general definition of fever, regardless of baseline temperature. In practical terms though, parents really want to know if a child is sick or not. You can tell when a child is uncomfortable by looking at him ~ you don't need a thermometer. It is not necessary to treat based on the thermometer reading. It is important to give a fever reducer/pain reliever when the child is uncomfortable so he can drink to stay hydrated and sleep. The goal is not to lower the temperature to “normal”, it's to make the child more comfortable.

If you are concerned about your child's illness, especially if he looks dehydrated, is having trouble breathing, is in uncontrollable pain, has symptoms you think might need antibiotics (such as UTI symptoms or Strep throat), or if the fever lasts more than 3-5 days (depending on age of child and overall symptoms), bring him to have an exam to look for sources of fever. 

Related blogs:

Fever is... 
Evolution of illness
But the snot is green
Adenovirus infections
To Tamiflu or Not to Tamiflu
Tamiflu: Guest blogger Dr. Mark Helm
Urgent cares for routine illness: Yes or No?
New Guidelines for treating Strep throat
Updated sinusitis guidelines
All about ears
Menthol for sore throats and cough
My child's cough sounds like...
Cough medicines: Which one's best?
How long with a cough or cold last?

P.S. I'd love to meet you on Twitter. Stop by and say "hi"!

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When should my child shave?

In my last blog I discussed the common question about when it is appropriate to start using deodorant or antiperspirants, which led me to think of all those questions beginning, "When is my child old enough..."

Photo source: Wikimedia

One of these questions: When is my child old enough to shave?

This is another question without a one-size fits all answer.

Girls and boys differ in needs and ages of puberty.

I told my own daughter that she could shave her legs when she needed to shave under her arms, since I know that under arm hair becomes longer during puberty, which is also when leg hairs thicken and grow. This just seemed like an easy answer to me. We are born with hairs on our legs, so deciding when those hairs are too long is tricky. It's not of a question of age, but one of quantity, color, and thickness of hairs.

When a boy starts to get visible peach fuzz on his upper lip it may be time to consider shaving, but it depends on the hair color, length, and his desires. Some schools include a "no facial hair" policy, which forces the issue.

Some kids are naturally hairier than others. Some have dark hair, others light hair. Puberty increases hair growth on the arms, legs, armpit, and in the groin in both sexes, and on the face in boys, but the age of puberty varies widely. Culture plays a part in the family's decision whether or not to shave body hairs.

The maturity of a child should be considered. A girl with thick, dark hair entering puberty at 9 years of age who is getting teased at school about her hairy legs might have a strong desire to shave, but if her fine motor skills are weak and she cannot safely handle a razor, it might not be appropriate for her to shave yet - at least not with a standard razor.

If a child has body hair that is bothersome and they want it removed but they are not able to safely use a standard razor, options might include other forms of hair removal, such as the chemical hair removal products, waxing, electric razors, or allowing a parent to help them shave. Each of these has it's own issues to consider.

Chemical hair removal products generally work by weakening the hair so that it is easily broken off at the skin level. Chemical products might lead to skin irritation or allergic reaction, but are well tolerated by most people. If you are planning to use it on the face, be sure to get a product specifically for the face and test a small area first to be sure they don't react to it negatively. Chemical hair removal products are relatively easy to use, can be done at home, and last for several days. Young children should be supervised so that the chemical does not get on other body parts or all over the bathroom...

Waxing is an option for many girls and women. It can also be used for boys and men, though is less commonly used by men. It's benefits are that it lasts several days and over time might cause the hair to grow in thinner (or not at all- which might not be a great idea for a boy who one day might want a beard). It can be painful, which might not be tolerable for some kids. You can go to a salon for a professional wax, but this is more expensive than the many do-it-yourself kits you can buy at local stores. You can look online for tips on how to find the best waxing product for your needs and how to wax.

Electric razors offer the benefit of a safer cut, but can take more time and often don't get as close to the skin as a standard razor. If your child is using an electric razor, (s)he must be warned about the hazards of using something electric next to a water source (such as the sink or tub). There are many types available, and I would recommend searching for reviews online prior to purchasing. Follow package directions on keeping the razor clean.

If you allow your child to shave with a razor be sure to get a new one just for that child. Never share razors, since this can lead to sharing of germs that cause infection. The choice of using a shaving gel or cream or just shower soap is a personal choice. Also talk about when to change the razor blade. It depends on how often (s)he shaves, how large of an area being shaved, and the body hair type. Someone with thick, coarse and curly hair that grows super fast will need more frequent blade changes than someone who is shaving fine peach-fuzz hair off every few days. Any blade that’s rusted must be changed immediately. When a blade feels like it’s tugging on the hair instead of gliding smoothly, it is time to change. If you’re using an older blade and notice nicks or rashes or razor-burn bumps, it's past time to change it. After each use a razor should be rinsed clean of all hairs and soaps/creams and allowed to dry. Don't lay it in a soap dish because it will stay wet. Wetness allows germs to grow and encourages rust, both of which are dangerous.

If you would be most comfortable shaving your child's skin, you can certainly try this with his or her permission. Be careful though, because if you nick the skin, you will never be forgiven! Kids are like that...

When it comes down to when it is the best time to shave, I think it is a very personal decision.

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When should my child start wearing deodorant?

I get asked all the time when kids should start wearing deodorant or antiperspirant.

There's no standard answer since kids have different needs. Some kids are active outside and simply carry the smells of the great outdoors and sweat on their body. This isn't puberty sweat, just musty body odor in most young smelly children. Sweat in general makes conditions ripe for bacteria to grow on our skin, and the bacteria make us smell. Kids enter puberty at different ages, and puberty affects how we smell in addition to many other obvious things because sweat glands become more active.

Image source: Wikimedia

First things first: get clean!

Body odor is often related to bathing, since some early elementary school aged kids shower independently, but don't do the best job at actually using soap in all the areas it's needed. Or they argue about needing to get clean daily. Every other day might work in the winter (if they don't sweat a lot with play) but in the summer, they really need a daily cleansing if they smell offensively.

The first step I always recommend is making sure kids who have that funky smell shower (or take a bath) daily with the same soap that the parents use, not a baby wash. Many families buy baby washes for the first year of life and keep using them during toddlerhood and childhood out of habit. Baby washes don't lather up well (which leads to less body surface areas getting lathered up) and aren't designed to get the oils, dirts, and smells off like regular soaps. There really is no need to continue to use these washes for kids beyond infancy and it might contribute to body odors.

Talk to your kids about getting soap suds on all body parts. I think using a shower pouf with a body wash makes it fun for kids to see all the bubbles - and it helps them to see what parts are done and which need suds. If your child likes to play in the bath tub, it might help for them to end with a quick wash and/or rinse in the shower, since they are sitting in the dirty water during the bath. It is hard to wash the submerged body parts with soap, since the cloth or pouf rinses out under water. They will need to stand to wash the lower half of their body properly.

A note about the poufs: Be sure to show your kids how to rinse the bubbles out of the pouf after the shower or bath and hang it to dry between uses. You'll also want to wash the poufs weekly. I sometimes throw them into the washing machine with the towels, but that takes the life out of them more quickly than soaking in vinegar and water.

Go over all the body parts to wash. I looked for a video that they could sing along to (there are a lot for washing hands and brushing teeth), but couldn't find a good one to remind kids of all the body parts. If anyone's musically talented, this would be a great project to help many kids (and parents)! If you find a good video, please share the link in the comments below!

• Hair - It is tricky for kids to massage all parts of their scalp when washing hair, so show them to use their fingertips up and down then side to side to cover all parts of the head. The frequency of how often hair needs to be washed can be debated. Hair can trap pollen and other outdoor smells and the scalp's sweat can lead to funky odor, so hair needs to be washed at least a couple days per week and daily for those with allergies to pollens that are in the environment at that time.
• Face - Kids won't want to get soap in their eyes so many parents just have them rinse with water, but many kids need to actually wash with a mild soap or cleanser. Eyelids can get what my parents used to call "sleep dust" - little crusties - if they are never washed. You can use a baby "no tears" shampoo to wash eyelashes if needed or a mild soap or cleanser with closed lids and careful rinsing. When kids start getting oily skin on the face they should wash it twice a day. A quick reminder not directly related to cleaning: A daily moisturizer with sunscreen is great all year long for our faces, which are exposed to the sun and elements every day.
• Armpits - While it seems obvious when you've talked to your kids about having smelly pits, you'd be surprised that it doesn't always equate to kids being conscious of washing those pits. With soap. Kids just don't make the connections you think are obvious. 
• The whole back - It is hard for any of us to wash our own back, so show your kids how to use a back scrubber or wash cloth to reach all areas.  
• Belly, arms, and legs - Again, have them look to see where the suds are and where they're missing to hit all the areas.
• The bottoms of the feet - Show kids how to hold on to something when washing their feet and consider adding a non-slip surface to your shower or tub. Have them wash one at a time so they can stand on the non-soapy foot. Soapy feet are slick!
• Between the legs - Kids need to be taught to wash between the buttocks and around their genitals, with special care given to rinsing these areas well. Trapped soaps can irritate the skin and cause rashes, so rinsing should get special attention in these sensitive areas. I really like removable shower heads that can come down to help rinse, but kids can also use several cups of clean water to rinse hard to reach areas. Girls might need to sit in the tub to do this rinsing with a cup because it's hard to splash the water up between skin folds sufficiently.

Clothing 

Kids might have a favorite shirt that they want to wear every day, but clothing (especially shirts, socks, and underwear) must be washed regularly. Putting stinky clothes on a clean kid just makes the kid stinky. Avoid polyester (except the special polyester in performance wear- designed to wick sweat away) and rayon clothes, since they do not absorb the sweat well. Cotton is a great choice: it absorbs sweat well and is relatively inexpensive. 

If kids have sweaty feet, white socks might be better than colored ones due to the coloring irritating the feet. Changing socks when the feet get sweaty, such as after playing a sport, can help. Changing shoes and allowing each pair to dry thoroughly between wears can help too.

Deodorant vs Anti-perspirant?

Deodorant is used to cover up smells. It is often what I recommend for those younger kids who sweat during active play or outside in the heat. 

Anti-perspirant is designed to decrease sweating and often is mixed with a deodorant. Before puberty a deodorant is probably sufficient, but during puberty our sweat glands are activated and we sweat a lot more, especially under the arms, on hands and feet, and in the groin. It is personal choice if one wants to decrease underarm sweating with an antiperspirant. 

Over the years I have seen many concerns with the aluminum in antiperspirants - everything from it causes Alzheimer's to it causes cancer. Studies do not support those claims. You can read more about the proposed risks of antiperspirants on WebMD.

When is sweating abnormal?

Sweating is abnormal if it is excessive for the body's needs or if a child has other signs of puberty before the normal ages (8 years in girls, 10 years in boys- some sources say 7 years in girls and 9 years in boys). 

There are many reasons for excessive sweat that are relatively uncommon, so I won't go into detail here. If you think your child sweats excessively or is entering puberty too early, please take him or her to their doctor to be evaluated. (A phone call isn't sufficient because they will need to look for associated signs and symptoms on an exam.)

Next up...

I will cover "When should my child shave?" next, since it is also a very common question!