Summer 2008 Newsletter
WELCOME to our second issue of the Pediatric Specialists newsletter.
Summer Health
Poison Ivy
DEFINITION: Poison ivy, poison oak, and poison sumac are plants that are found in North America.  Poison ivy is common throughout North America, whereas poison oak and poison sumac are found in the Southeast United States.  All 3 plants produce the same rash.  More than 50% of people are sensitive to these plants and will develop an itchy rash 1-2 days after exposure to the oil of the plant.  The rash consists of red streaks or patches and blisters on the exposed parts of skin.  The rash typically lasts for 2 weeks.  The poison ivy rash occurs in areas of skin that have been exposed to the oil of the plant.  It is not contagious and will not spread from one person to another, nor will scratching cause it to spread. 
TREATMENT OF EXPOSURE:  If you think your child has been exposed to poison ivy thoroughly wash the skin with soap (any soap will do) within one hour of exposure.  Shoes and clothing that may have been exposed should be washed as well. 
TREATMENT OF RASH:  Mild poison ivy rash is treated with over-the-counter remedies.  Topical anti-itch creams such as Aveeno or Eucerin may be soothing.  Over the counter 1% hydrocortisone cream will be helpful for itching as well and may be applied twice daily.  Benadryl Elixir or tablets may be given by mouth to decrease itching.  Since Benadryl is often sedating is best used at bedtime. Zyrtec (which is newly over-the-counter) is an alternative antihistamine for itching which is given once daily. 
If poison ivy rash is present on the face, covers a large area of skin, or looks infected (with pus or yellow scabs) an office appointment should be made.  Prescription medications such as steroid cream or oral steroid pills are sometimes used.  If infection is suspected, antibiotics will be prescribed.

Safety:
Sunscreen
Preventing sunburn prevents skin cancer.  Adult skin cancer and premature aging of skin can be caused by sun exposure during childhood.  Sunscreen with UVA and UVB protection should always be used.  Here are some tips for sunscreen use:

• Infants under 6 months are more likely to burn and should be kept out of the sun.  Shade is best, or if sun exposure is unavoidable dress the baby in longer clothing, a hat with a brim, and used sunscreen if needed. 
• SPF 15 sunscreens provide protection against 93% of UVB rays (1/15th of sun’s rays get through).  SPF 30 protects against 97% of UVB rays (1/30th get through).  Generally SPF 30 sunscreen is sufficient.  All sunscreens should be reapplied every 2 hours.  Even “waterproof” sunscreens only stay on for 30 minutes in the water.   Sunscreen should be applied 15-30 minutes before going outside so there is time for it to be absorbed into the skin. 
• Avoid the sun between 10AM and 3PM when the rays are most intense.  Even on a cloudy day, 70% of the sun’s rays get through. 
• Eyes should be shaded with sunglasses that have UV protection. Years of sun exposure increases adult cataract risk. 
• Lips should be protected with lip coating containing PABA.  In fair children, noses may be protected by zinc oxide which blocks sun totally. 
• Do not use combination sunscreen/insect repellent since insect repellent is generally applied once, and sunscreen often needs to be reapplied.  Some experts believe that insect repellent may lower the SPF of sunscreen.

Tanning
Tanning is produced by an increase in the melanin (skin pigment) in skin.  Tanning increases the risk of skin cancer and DOES NOT protect skin against sunburn or other skin damage.  Extra melanin in tanned skin only provides SPF of 2-4 (far below the minimum recommended SPF of 15).  A 1994 Swedish study of women 18-30 showed that those who tanned more than 10 times/yr had a 7 times higher incidence of melanoma.  A 2002 study from Dartmouth Medical School found that tanners had a 2.5 times greater risk of squamous cell carcinoma and a 1.5 time greater risk of basal cell carcinoma

Insect Repellent
To prevent the possibility of being bitten by insects that can transmit diseases such as Lyme disease, there are several precautions that can be taken:

• Be aware that mosquitoes are most active during twilight periods (dawn, dusk, and evening)
• In areas with high prevalence of ticks, wear long sleeved shirts and long pants tucked into socks.  Wear light colored clothing so that ticks are easily seen.
• Inspect your body and clothing for ticks at the end of the day.  Removing ticks right away can prevent some infections.
• Use an insect repellent on exposed skin.  Insect repellent may also be applied to clothing, strollers, and other gear. 
• EPA-registered insect repellents include DEET and Picaridin.  DEET is generally felt to be more effective, and longer lasting. 
• DEET formulations up to 50% are recommended for both adults and children older than 2 months of age.  DEET concentrations of 30% - 50% are effective for several hours.  Picaridin, available at 7% and 15% concentrations needs more frequent application.
• When using sunscreen, apply sunscreen first, then insect repellent.  Repellent should be washed off at the end of the day before going to bed. 
• Infants less than 2 months old may be protected by using a carrier draped with mosquito netting with an elastic edge for a tight fit.   

Nutrition:
Submitted by Leah Spitzer, MD
Here are some quick healthy snacks for summer which kids can have fun helping to prepare: 

Healthy Pita Chips (let kids help cut up pita – these are great to dip in hummus, low fat ranch dressing, guacamole, or salsa).

2 large (12 inch) or 4 medium (6inch) whole wheat pita rounds
Olive oil for sprinkling
Coarse salt to taste
Optional toppings: chopped fresh herbs (rosemary, oregano, or thyme) or freshly grated Parmesan cheese
Preheat oven to 375 degrees.  Separate two layers of pita with kitchen scissors.  Cut pita up into wedges (i.e. one 6 inch pita makes 12 chips).   Place them on baking sheet rough side up.  Sprinkle them lightly with oil and salt.  If you’d like to add herbs or parmesan sprinkle those on top.    Toast the chips for 8 – 10 minutes until they are golden brown.  Watch carefully for last few minutes of baking as they can burn quickly. 
Eat after cooling slightly, or cool completely before storing in plastic ziplock bag for up to 2 days. 

               

Banana Berry Smoothie
(This is a great way to use up old bananas.  When they are too brown to eat, peel them and store in Ziploc bags in the freezer)
1 container light vanilla yogurt
3/4C skim milk
½ frozen banana
6 whole frozen strawberries
Combine all ingredients in blender and puree.  Makes 2 large smoothies. 

Fruit Cream Popsicles
1 banana
10 oz package frozen sliced strawberries and juice, thawed
8 oz can crushed pineapple and juice
¼ cup milk
Popsicle molds or 3 oz disposable cups and popsicle sticks. 
Mash up banana and strawberries with a fork.  Mix in remaining ingredients.  Pour into popsicle molds and freeze.
Makes 6-8 servings.

Staff Update
We continue to benefit from our association with Heather Stone, RD, LDN.  Heather is available to meet with patients in our office for nutritional counseling.  Appointments may be arranged by contacting her directly at 508- 577-3765.

Ask the Doctor

Question: Are generic medications equivalent to name brand drugs?
Answer:  The FDA requires that all GENERIC medications have the same quality, strength and efficacy as brand name medications.  Lower cost GENERICS benefit everyone.  Using generic medications results in lowest co-payments to patients, lower health plan premiums for your employer, and lower taxpayer costs for tax supported programs.  There are many common pediatric medications which have equivalent generics.  These include most commonly used antibiotics as well as  Flonase, Allegra, Prilosec, and Yasmin or Yaz.   
Question:  Does my child need antibiotics for his ear infection?

Answer:  In this era of increasing antibiotic resistance, the recommended policy for treating ear infections has changed.  In May of 2004, the American Academy of Pediatrics issued a policy statement about ear infections and antibiotics which changed common practice.  The policy states that for children older than 2 years old, most ear infections will resolve without antibiotics and may be treated solely with analgesics for pain control.  We do still recommend antibiotics for children who have any of the following:

• Underlying chronic illness or immune deficiency
• Chronic fluid in the middle ear
• Recurrent ear infection (previous infection within 30d)
• Severe illness (i.e. severe pain or fever > 102

For children with an ear infection that is not severe, the majority will improve within 48 hours without antibiotics.  Children should show signs if improvement within 48 hours such as decreased fever, decreased irritability, improved sleep and improved appetite.   We do recommend pain control with analgesics such as acetaminophen or ibuprofen.  Eardrops that numb the ear (benzocaine) may also be used for pain control.  If there is no improvement or there is worsening illness within 48 – 72 hours, antibiotic treatment should be started. 
There is some evidence that ear infections may be prevented by the following measures:

• Breast feeding for at least the first 6 months of life
• Eliminating pacifiers after 6 months
• Avoiding second hand smoke
• Avoiding supine bottle feeding (bottle propping with infant flat on his/her back)
• Annual flu vaccines

Question:  What is Coxsackie virus?
Answer:  Coxsackie virus (also known as hand, foot, and mouth disease) causes a common summer illness.  The symptoms include: small, painful ulcers in the mouth; red blistered bumps on palms, soles, and occasionally on the buttocks; and fever. The fever generally lasts 3-4 days, the mouth sores take about 7 days to heal, and the rash may take about 10 days to resolve.   The mouth sores can be painful and some children will refuse to eat or drink because their mouth is sore.  Treatment includes: acetaminophen or ibuprofen to control pain and fever; cool drinks and soft foods; also a mixture of Benadryl and Maalox (combined 1:1) can be applied to mouth sores to help with the discomfort.  The biggest concern is the risk of dehydration, so careful attention should be paid to how frequently your child is urinating, and to encouraging your child to take fluids.  There is no relation between hand, foot, and mouth disease and hoof and mouth disease of cattle.  Most children are contagious from 2 days before the rash appears, until 2 days after.  They may return to day care once their fever is gone. 

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We always appreciate your help in improving our practice, and welcome any feedback you provide.  Please let us know if there is any way we can improve your experience at Pediatric Specialists. Feedback can be sent by the email link on our website www.pediatricspec.com . Feed back for the Foxboro office should be sent tocustomerservicefoxboro@pediatricspec.com and for the Wrentham office to customerservicewrentham@pediatricspec.com.  
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