Head lice
Most patients will present with scalp itching due to an allergic response of the scalp to the saliva of the lice and can take weeks to develop. However, only a third of patients experience itching.
What you need to know?
1. Have live lice been seen?the easiest detection method of live lice is to comb damp or wet hair forward using a fine metal-toothed comb over a pale or white piece of paper. If live lice are present then one or more will be visible on the paper.
2.Empty egg shells (nits); egg shells are not removed by insecticides and patients need to be reassured that the presence of egg shells does not mean treatment failure.
3. Presence of itching; itching is not always present with head lice.
Management;
Dimeticone and the insecticides malathion, permethrin and phenothrin are available OTC, while carbaryl is a prescription-only medicine (POM). All are effective treatments for head lice. If insecticide treatment fails then another preparation from a different class of insecticides is used next. Herbal treatments (e.g. teatree oil) and aromatherapy have been triedbut there is little evidence of their effectiveness.
*Bug busting method; involves combing wet hair with a fine toothed comb every 3-4 days for 2 weeks. This removes all the lice as they hatch and ensures that none reach maturity and lay the next generation of eggs.
*Dimeticone; is thought to coat the lice and prevent the insects from excreting excesswater. It is applied to dry hair and scalp, left for 8 h and then rinsedoff. A second application is used after 7 days. Detection combing at 4and again at 8–10 days is recommended. Dimeticone has a good safetyprofile. Adverse effects are not common and include itchy or flaky scalpand irritation if it gets into the eyes. It is particularly useful for peoplewith eczema or asthma as it is less irritating to the scalp.
*Malathion; is available as liquid, lotion or shampoo. Liquids and lotions are applied in exactly the same manner as phenothrin. Shampoos, if used, should be applied to wet hair and left on for 5 min before rinsing. After rinsing the process should be repeated. Two further treatment courses then have to be applied at 3 days intervals.
*Permethrin; before the application, the hair should be washed with a mild shampoo and toweled dry. Enough amounts should be applied to the hair to ensure the hair and scalp is thoroughly saturated. It should be left on the hair for 10 min. before rinsing the hair thoroughly with water.
*Phenothrin; is available as liquid, lotion or mousse. Liquids and lotions are rubbed into the scalp until all thehair and scalp is thoroughly moistened and then allowed to dry naturally. They should be applied as close to the base of the hair and scalp as possible. Twelve hours later the hair should be shampooed in the normal way. The mousse isapplied to dry hair at several points on the scalp and massaged into the scalp, ensuring no part of the scalp is left uncovered. After 30 min. the hair can be washed with normal shampoo.
Note;
- When applying the products, particular attention should be paid to the areas behind the ears and at the nape of the neck, as these areas are where lice most often found.
- There are two issues to consider when choosing a formulation: the first is the concentration of insecticide that will be in contact with the scalp; the second is the length of time the insecticide will be in contact with the scalp. Lotions are the preferred treatment for head lice. A lotion is applied to the scalp and the hair left to dry for 12 h or overnight to increase the likelihood that eggs are killed. The insecticide is therefore in contact with the hair for a long period of time and at a high concentration. By contrast, a cream rinse or shampoo is diluted by water, so that the concentration of insecticide is lower. After shampooing, the hair is rinsed so that the insecticide is in contact with the scalp for only a short time. Because several applications of shampoo are needed, compliance may not be achieved and treatment failure can result. A cream rinse is left on for 10 min and foam (mousse) for 30 min before shampooing off, so the contact time is short.
- Malathion and carbaryl are available as alcoholic and aqueous lotions. Alcohol-based formulations are generally useful but are not suitable for all patients because they can cause two types of problems. Firstly, alcohol can cause stinging when applied to scalps. Secondly, in patients with asthma, it is thought that alcohol-based lotions are best avoided, as the evaporating alcohol might irritate the lungs and cause wheezing, perhaps even precipitating an attack of asthma. The NHS Clinical Knowledge Service recommends that aqueous lotions should be used first line because of their lower potential for adverse effects.
- Shampoos are not recommended. Their clinical effectiveness is less than that of lotion and cream rinse formulations. In the past, shampoos were an alternative where alcoholic lotions were not suitable. However, aqueous versions of treatments are now available.
- Hair driers or other heat sources should notbe used with carbaryl and malathion because both are inactivated byheat. In addition, where an alcoholic lotion is used, the hair should bekept away from fire and naked flames.
Threadworm (Enterobiusvermicularis)
Night-time perianal itching is the classic presentation ranging from a local tickling sensation to acute pain. Itching can lead to sleep disturbances resulting in irritability and tiredness the next day. Complicating factors such as excoriation and secondary bacterial infection of the perianal skin can occur due to persistent scratching.
What you need to know?
1. Age; very common in schoolchildren.
2. Signs of infection;the first sign that parents notice is the child scratching hisor her bottom. Perianal itching is a classic symptom of threadworminfection and is caused by an allergic reaction to the substances inand surrounding the worms’ eggs, which are laid around the anus.Sensitization takes a while to develop, so in someone infected for thefirst time itching will not necessarily occur.Itching is worse at night, because at that time the female wormsemerge from the anus to lay their eggs on the surrounding skin. Theeggs are secreted together with a sticky irritant fluid onto the perianalskin.
3. Appearance of worms;the worms themselves can be easily seen in the feces as white- orcream-colored thread-like objects. Males are smaller than females. The worms cansurvive outside the body for a short time and hence may be seen to bemoving. Sometimes the worms may be seen protruding from the anusitself.
4. Other symptoms; in severe cases of infection, diarrhea may be present and, in girls,vaginal itch.
5. Duration; if a threadworm infection is identified, the pharmacist needs to knowhow long the symptoms have been present and to consider this informationin the light of any treatments tried.
5. Recent travel abroad; if the person hasrecently travelled abroad, this information should be passed on to thedoctor so that other types of worm can be considered.
6. Other family members.
7. Medication; the pharmacist should enquire about the identity of any treatment already tried to treat the symptoms and shouldalso ask how the treatment was used, in order to establishwhether treatment failure might be due to incorrect use.
When to Refer?
- Medication failure.
- Secondary infection of perianal skin due to scratching.
- Infection other than the threadworm suspected.
- Recent travel.
Management:
Treatment should ideally be given to all family members and not only the patient with symptoms, as it is likely that other family members will have been infected even though they might not show signs of clinical infection. A repeated dose 14 days later is often recommended to insure worms maturing from ova at the time of the first dose are also eradicated.
*Mebendazole (Vermox®, Ovex®); inhibit the worm's uptake of glucose. It has been reported to cause abdominal pain, diarrhea and rash.The drug is formulated as a suspension or a tablet,which can be given to children aged 2 years and over and to adults.
*Piperazine;the mode of action of piperazine seems to be paralysis of the threadworms in the gut. The incorporation of a laxative (senna) in the sachet preparation helps to ensure that the paralyzed worms are then expelled with the feces.However, if paralysis wears off the worm might be able to migrate back into the colon and thus treatment would fail. It is available as sachets and elixir.Its use is contraindicatedin epileptic patients since it has been shown to have the potentialto induce fits in patients with grand mal epilepsy.
Notes;
- Transmission and re-infection by threadworms can be prevented bythe following practical measures:
(a)Cutting fingernails short to prevent large numbers of eggs beingtransmitted. Hands should be washed and nails brushed after goingto the toilet and before preparing or eating food, since hand-to-mouthtransfer of eggs is common. Eggs may be transmitted from the fingerswhile eating food or onto the surface of food during preparation. Eggsremain viable for up to 1 week.
(b)Children wearing pajamas to reduce the scratching of bare skinduring the night. Underpants can be worn under pajama bottoms.
(c)Affected family members having a bath or shower each morning towash away the eggs that
were laid during the previous night.
Colic
Wessel (1954) proposed a definition for colic known as the 'rule of threes' meaning that an infant could be considered to have colic if it cries for more than 3 hours a day for more than 3 days a week for more than 3 weeks. A number of theories have been put, from an immature digestive system to problems in under- or over feeding. Pain and crying in an infant might be due to excessive wind caused by air swallowing during crying or feeding. If the infant is bottle fed this is almost always due to the teat hole being too small. If the infant is breast fed then air swallowing can be due to sucking too long on the breast or sucking on an empty breast.
Besides the obvious crying, the infant might show signs of abdominal pain, having a rigid abdomen with the legs drawn up towards the chest. Fists may be clenched and the infant resists acts of comfort and cuddling. Attacks appear to be more common in the early evening, giving rise to the name 6.00 p.m. colic.
What you need to know?
1. Age;Colic generally starts in the early weeks and may last up to the age of 3–4 months.
2. Duration of crying; the baby usually cry for more than 3 h per day, for more than 3 days per week.
3. History of crying.
4. Feeding; establish whether the baby is bottle- or breastfed (or a combination)and the type of formula milk being used.
5. Does the mother smoke?There does seem to be an association between maternal smoking andcolic in the baby.
6. Any advice already sought?It is useful to ask whether advice has been sought already either fromhealth professionals or other sources.
When to Refer?
- Infants that are failing to put on weight.
- Medication failure.
- Overanxious parents.
Management;
Dimethicone(semithicone) is reported to have antifoaming properties, reducing surface tension and allowing easier elimination of gas from the gut by passing flatus or belching. It might be a useful placebo for anxious and irritable parents who want to give their baby some form of medication.
Notes;
- For breastfed infants it may be worth the mother considering the exclusionof cow’s milk from her diet. There is a theoretical rationale forthis in that breast milk contains intact cow’s milk proteins. This means that the mother needs tostop eating all forms of dairy products. If there appears to be someimprovement, referral to the health visitor for further advice on diet isappropriate.
- Where the baby is being bottle-fed and symptoms are severe andpersistent, the mother might consider trying hypoallergenic formula(casein-free) milk. Studies indicate that this mayreduce crying by over 20%. A trial of such milk for 1 week could besuggested. If there appears to be a response, referral for further adviceon diet from the health visitor is appropriate.
- Complementary therapies; A study of herbal tea in colic showed a large reduction in crying. Furthermore, the safety ofherbal teas in infants has been questioned, probably because of questions about the possiblepresence of other ingredients.
- Behavioral approaches; In the past it was thought that overstimulation of the baby might bea cause of colic. Therefore there have been studies to test avoidingcarrying or holding the baby unnecessarily and not intervening toorapidly when the baby cries.
- Baby massage;Although baby massage seems to have become more popular as amethod of managing colic, the evidence of benefit is uncertain.
Other childhood conditions
Rashes that do not blanch
As a general rule all rashes that do not blanch when pressed (using glass tumbler test) thought to be referred toa doctor. These rashes are caused by blood leaking out of a capillary,which may be caused by a blood disorder. It could be the first sign of leukemia or a much less serious condition.
When to Refer?
- Flulike symptoms
- Vomiting
- Headache
- Neck stiffness
Fever
Moderate fever (raised temperature up to 40◦C from normal 36.5–37.5) is usually not harmful and some experts believe it could even havebeneficial effects in some illnesses. The NIHCEGuideline onFeverish Illness in Children advises against routine use of antipyreticto solely reduce temperature if the child is otherwise well.Sponging with lukewarm water used to be recommended as a methodof reducing fever but can cause goosebumps and shivering and is nowviewed as potentially causing discomfort to the child.Paracetamolor ibuprofen can be used if a high temperature ispresent.Many babies develop a raised temperature after immunization. Somepreparations containing paracetamolor ibuprofen can be used OTC to reduce post-immunization fever.
Itching
Crotamiton cream or lotion may help tosoothe itchy skin. Calamine lotion has been used traditionally but it isnow thought that the powdery residue it leaves may further dry andirritate itchy dry skin. If itching is very severe, chlorpheniraminecanbe effective in providing relief, can be given to children 1 year and overand is licensed for use OTC in chicken pox rash. Such treatment wouldbe likely to make the child drowsy but may be useful at night time.
Teething
Teething can start as early as 3 months and continue up to 3 years. The appropriate management of teething is local discomfort reliefusing application of cold and the use of analgesics (paracetamol suspension)or topical gels. Parents should be encouraged to clean their baby’s teethfrom their first appearance using a baby toothbrush. Dummies shouldbe avoided, but if used then it is important not to dip them or teethingrings into honey, fruit juices or syrups. Further advice on preventionof teething problems can be obtained from the health visitor.
Napkin rash
Most babies will have napkin (nappy) rash at some stage during theirinfancy. Contributory factors include contact of urine and feces withthe skin, irritant effect of soaps and maceration of skin dueto infrequent nappy changes and inadequate skin care. you need to know
What you need to know?
1. Nature and location of rash;Nappy rash, sometimes called napkin dermatitis, appears as an erythematousrash on the buttock area. Other areas of the body are not involved.
2.Severity;if the skin is unbroken and there are no signs of secondarybacterial infection, treatment may be considered. The presenceof bacterial infection could be signified by weeping or yellow crusting.Secondary fungal infection is common in napkin dermatitis andthe presence of satellite papules (small, red lesions near the perimeterof the affected area) would indicate such an infection. Referral to thedoctor would be advisable if bacterial infection were suspected, sincetopical or systemic antibiotics might be needed. Secondary fungal infectioncould be treated by the pharmacist using one of the azole topicalantifungal preparations that are available.
3. Duration;If the condition has been present for longer than 2 weeks, the pharmacistmight decide that referral to the doctor depending on the nature and severity of the rash.
4. Previous history;The pharmacist should establish whether the problem has occurredbefore and, if so, what action was taken, e.g. treatment with OTCproducts.
5. Other symptoms;Napkin dermatitis sometimes occurs during or after a bout of diarrhea,when the perianal skin becomes reddened and sore. The pharmacistshould therefore enquire about current or recent incidence of diarrhea. Sometimes thrush in the nappy area may beassociated with oral thrush, which causes a sore mouth or throat. If this is suspected, referral to the doctor is advisable.