Would you like a brush with that?

Infants and toddlers are like wobbly ninjas, focused maniacally on tasting and mouthing items from coins to blocks to the odd flotsam and jetsam that lives on living room floors. Parents know to beware, to police an area well…as you never know what they’ll pop in their piehole next.  Infant  and toddler oral fixation is considered developmentally appropriate (if not entirely healthy) behavior.  Fortunately, most children outgrow this item-to-mouth impulse by the time they are closing in on their second birthday.

And then, there are those children with pica.

Pica, of course, refers to the old typewriting term of 12 points of line space equal to 1/6 of an inch. However, that has nothing to do with the more intriguing medical definition we’ll discuss here: Children with pica (estimated to be about 10-20% of kids at some point) demonstrate a persistent tendency to ingest or mouth non-food items for more than a month, at an age for which it is not considered developmentally appropriate.

What are we talking about here? The items children and adults with pica may consume range from the everyday (ice, fingernails, batting from stuffed animals, pebbles, and chips of wood), to the unusual (erasers, talcum powder, coins, cigarette butts) to off-putting or dangerous menu items (feces, pins, lightbulbs, batteries, and burnt matches).  Delish?

In some cultures and communities, family members may promote eating non-food items for health, well-being, or enjoyment.  For example, in Turkey and Rwanda, geophagia–the practice of eating soil–occurs in huge segments of the population. Dirt can be bought in marketplaces expressly for eating. In parts of the American South, particularly in African American communities, pregnant women may eat laundry starch, or bits of clay to allay the symptoms of morning sickness.  Children or parents who consume these items report it works, and pass it on down the generations.  But is it ok? More on that in a minute.

Even  after documenting this phenomena for centuries, we don’t have a full explanation for pica, and the compulsion to consume non-food items  in otherwise healthy individuals.   The pre-eminent  theory explains pica as a compensation for nutritional deficiencies–such as iron, zinc, or other minerals– in an individual’s or community’s diet.  Ironically, the consumption of clay and starch block the body’s absorption of iron, and can create or exacerbate a  low iron problem for a woman (not a good thing in pregnancy).

Even in a child who is progressing normally developmentally, pica may be associated with other complex factors. Children with histories of stress, economic hardship, trauma, depression, parental deprivation or frank hunger may consume non food items. Distraction? Boredom? Soothing? Perhaps.  In other situations, pica strongly correlates (for reasons unclear)  with certain mental disorders, such as schizophrenia, or developmental conditions, such as mental retardation or pervasive developmental delay (PDD ).  This can be an important heads up for caretakers, and another challenge in managing these kids as they go through their day.

Pica  behaviors in children and families may go on for years, undisclosed but in plain sight or in secret. For some children and families, shame or embarrassment may hinder discussion with their health care provider. Families may not perceive pica as a health issue, or consider the matter worth mentioning.  For the primary care doc, if there is a suspicion or mention of pica, this is a matter best approached with awareness, sensitivity, and the right questions.

The medical problems from pica derive from what gets eaten. Kids with damaged  or missing teeth from chewing or mouthing unusual materials may arouse suspicion and herald an unrecognized case of pica. Consumed items may exert poisoning effects when swallowed over days or weeks. Lead toxicity is most common, and may be subtle (anemia) or devastating (encephalopathy and brain damage).   Pica behaviors around eating paint chips or contaminated soil may be the source, and observations by parents or astute history taking by health care providers may prove critical in helping manage the acute symptoms and preventing recurrences.

Other children and teens with pica may present with GI discomfort caused by items they’ve eaten. Constipation, ulcers, perforations, and bezoars (wads of undigestible items, such as hair, that are unable to pass out of the stomach) may require special imaging, ER visits, or surgical intervention.

The ingestion of soil or fecal matter in some individuals can also cause bacterial or parasitic infections.   Toxoplasmosis, toxocariasis,  and worm parasites like ascaris can occur, cause havoc, and require prompt treatment and evaluation.  And, they are unpleasant.

Treatment of children and teens with pica requires a team effort.  When the diagnosis is made, the first priority is to determine the health status of the child in question.  Clinicians will perform complete physical and neurological examinations, with  laboratory  or imaging studies, or specialist consultation done as needed.  Medical treatment for pica will be tailored to address any acute problems (infection, GI issues, or toxicity) and longer term, applying a comprehensive and collaborative approach to the family.

Primary care providers, social workers, and mental health experts need to partner with a family to understand their cultural attitudes and health beliefs around pica behaviors to develop trust, communication, and a workabole plan. Ideally, family members learn about the potential risks of pica, and to recognized potential symptoms of ingestion.  With time, families can apply  individualized strategies to redirect and distract from unhealthy mouthing or munching. In most cases, the prognosis is good: healthy children will often outgrow pica by school age, while children with mental or developmental disorders respond well to intervention, but may relapse into the behaviors into their adolescence, and beyond.

So then, while kids may gnaw on this or nibble on that, be mindful. If you are concerned, be careful. And if necessary, talk to your child’s primary doc

about their mouthfuls.

–

Xrays of ingested objects can knock your socks off. (link: http://emedicine.medscape.com/article/801821-overview)

photo above by Schekinov Alexey Victorovich

Cartoon below by me.

In my travels since as a parent and a pediatrician, I’ve come to see that my son’s pre-sleep actions were a variation on a phenomena called headbanging, that causes amusement, curiosity, or frank worry on the part of parents. Can it cause injury? (almost never) What causes it? (good question) What should one do? (read on!)

Headbanging is startlingly common–occurring in up to 1 in 5 healthy infants and toddlers at some point– and is considered a normal habit behavior in healthy children.  Habits like headbanging are known in psychiatric circles as repetitive movement disorders, and they may be described as  behaviors that range from innocuous and quirky, to annoying, and on occasion, causing injury.  Most habits are the stuff that drives grandparents crazy: throat clearing, nailbiting, and teethgrinding. And, then there’s the headbangers.

Headbanging  appears in children after six months of age. It occurs in boys three times more often than in girls.  The textbook case usually goes something like this: Parents may notice that their infants or toddlers tendency to gently wap their head in a facedown position onto a pillow, mattress or blanket as they drift off to sleep. The frequency of these movements can be pretty brisk, occurring about once a second, and can last up to 10-15 minutes until a child falls asleep. In lesser cases, children thump their head or pull on their hair as sleep takes them. Headbanging diminishes and disappears in about 97% of children by their third birthday.  In older kids, who may tap the headboard or wall as they go through these motions, it can make quite a racket.

In children with known neurological issues, developmental delay, autism, hearing or visual impairments, and for children who are institutionalized or neglected, headbanging can be much more prevalent, and may be associated with other repetitive behaviors, such as rocking, or humming. And, some of these kids may continue to headbang into their adolescence and beyond.

No, not that kind of headbanging...

What is going on here?

For all those children who headbang, the exact source of the drive of the behavior is not entirely understood. There appears to be something about the gentle, repeating movement that allows the child to relax and organize themselves for sleep, much in the same way perhaps, that a sucking on a binky does for a newborn. Headbanging in children with neurodevelopmental issues, it may provide a source of dealing with overstimulation, or boredom and loneliness.

From a primary care provider’s perspective, I’ll consider each case individually, with an eye to each child’s medical and developmental history followed by a thorough exam. For children without neurologic or developmental concerns, getting a sense of how long a child has been headbanging is important (minutes? weeks? months?), and helps discern if something painful is afoot, such as a bump to the noggin, ear infection or discomfort from teething.  What’s more, it is helpful to establish that these behaviors only occur when going to sleep, and do not carry over into the daytime, and/or occur with movements of other extremities (tapping of the feet, or tics of facial muscles).

In older children, banging one’s head on the floor during a meltdown can be a supreme means of  getting parental attentions.  For parents who encounter episodes of headthumping during tantrums, the best approach is to minimize attention to the outburst.  Make sure a child is safe, but retreat to a distance. Responding repeatedly may actually reinforce the behavior. While headbanging may cause bruises, bumps, calluses, and the occasional scrape, severe injuries are blessedly rare in the vast majority of children.

And what to do? Parents understandably ask if any special preparations should be made for their child when they bang their head at bedtime.  In short, not much past common sense is the best approach. For infants and toddlers, I do not recommend putting bumpers or extra pillows in the child’s crib. There isn’t much danger to begin with, they’re not terribly effective, and the soft objects may pose a hazard to a little one in their bedspace.   For older children, it may be preferable to have the bed moved away from the wall, to avoid the noisy tattoo of head-on-wall.  Otherwise, checking that the bed or crib is secure should do the trick.  All that, and, it’s probably a good idea to tell the grandparents or babysitter so they don’t have a cow when the bedtime rituals begin.

It is absolutely appropriate to see a child’s health care provider if:

• the behavior is causing stress in the household
• there is any difficulty with breathing(such as pronounced snoring or gasping for breath),
• there are concerns for seizures, unrecognized developmental delays, or a risk of injury
• Or, if people are worried.

If warranted, a consultation with a psychiatrist, neurologist, or developmental pediatrician would be just the ticket.

Perhaps, as your charges sleep in their cribs or their beds, there’ll be a half-Bullwinkle,  or someone tip-tapping Night Night in Morse Code. Following the rhythm and the ritual, sleep will come. For most families, headbanging is a funky but benign interlude in their child’s journey. May this lessen your worry. Sweet dreams.

Photo 1 by Alessandro Zangrilli at http://commons.wikimedia.org/wiki/File:A_child_sleeping.jpg

Photo 2 by Lilly M at http://upload.wikimedia.org/wikipedia/commons/9/96/Metalmania_2008_Vader_Maurycy_Mauser_Stefanowicz_01.jpg

Cartoon below by me.

“Aw, man!” said a 5^th grader I know well (my daughter who rules the world) recently, “I thought I had a rock in my shoe, but I have a wart on my foot..and it’s killing me!”

Right. In the main, warts are a visual problem, their stigma causing distress of the self-conscious variety but little more. However, when the little buggers happen on the soles of the feet—so called plantar warts—they can produce a significant, even sidelining amount of pain for kids, teens, and adults. Why do they hurt on the feet and not the hands? (location!) Are there effective ways to rid onself of the scourge? (Maybe). What to do? (read on!)

Nobody has much fondness for their warts.  And in children of school age, of whom about 10-20% may have warts at some point, I’d say they like them even less.

Warts typically peak in incidence at the age when children are most likely to hate them, around ages 10-16 years. The vast majority of non-genital warts are caused by some of the over 100 strains of the human papillomavirus (HPV).

Customarily, kids acquire warts through direct contact (their friends bumpy hands), from one’s own lesions, or indirectly from viral particles shed by another host onto some surface.
In primary care, we diagnose warts with a little bit of history, but mostly from a visual examination of the lesion in question. Plantar warts may begin as shiny bumps as the virus enters and proliferates in the upper layers of the epidermis. Over time, the lesions develop into rough hewn, scaly circles with turtlenecks of callus about them. When they occur over weight bearing areas of, say the heel or forefoot, the warts are pushed deep into the epidermis, and may impinge upon underlying tissues.

Kids can tell you: it can feel very much like having a rock in one’s shoe—and can cause exquisite pain when direct pressure is applied, just so.

So what to do? Treatment for warts in visible areas like the hands or knees is more often a cosmetic issue; they are rarely dangerous in healthy people. Bottomline?

Watchful Waiting. Seriously, less can be more for the non-painful, less dismaying or obtrusive wart as over 60% warts will disappear within a year no matter what one does. This is definitely cost effective, and a preferred mode for littler kids.

For kids with warts that are a bother, or that are causing painful discomfort, over-the-counter salicylic acid products are the first line of treatment, as long as used well, and done right. Note bene: it takes up to 12 weeks or more! The approach I am most impressed by is summarized thusly: (link/reference below)

Other treatments may not be as effective, but may be used in conjunction with the salicylic acid approach.  Liquid nitrogen can be used to freeze warts—as so called cryotherapy—and has elimination rates in the 50-75% range when done with  treatments over 3-4 treatments over a few months. Clinical pearl: this may be more effective if salicylic acid is applied to the wart between treatments.

There are host of other interesting, innovative ideas for wart cures. Duct tape applied to warts got a great deal of traction, so to speak, as a stand alone therapy over the last decade. While followup trials have not proven its singular effectiveness, I use it as a complementary approach, and place it on warts overnight after application with salicylic acid.

Other approaches, such as meditation, prayer, and visualization of the warts provide inspiring but inconsistent cure rates when studied. Hey, these approaches may help, they certainly don’t hurt.

For recalcitrant warts, for kids with warts in unacceptable numbers or unfortunate locations, more high tech and/or invasive approaches come in. Pulse lasers, injections of the warts with immune stimulators or medications, or excision of the warts may be considered by a specialist.

For most kids, a tincture of time or a bit of a salicylic acid does the job. Never, I tell my patients, elect to ‘remove’ a wart oneself via ‘home surgery’, including by teeth, tweezers, knives or hot objects –I’ve seen some unhappy ‘botched’ outcomes there. Always contact your child’s health care provider if you just aren’t sure.

In the case of my 5^th grade friend: she found quick relief by sliding a soft insert in her shoe, and she and her family are attacking that wart with topical treatments.  Slow and steady wins the wart race!

Treatment recommendations adapted from this very nice review :

ELIE MULHEM, MD, and SUSANNA PINELIS, MD, Treatment of Nongenital Cutaneous Warts Am Fam Physician. 2011 Aug 1;84(3):288-293.

Cool video of someone applying cryotherapy to a wart here. (link http://www.youtube.com/watch?v=ACbYqha551Q)

Photo above by Chicagopodiatry

Cartoon below by me.

Croup.  Here it comes. Oh, that stop-you-in-your tracks cough makes it that most anomatopoeic of illnesses.

Variously described as barking, brassy, or seal-like, the cough of croup and its accompanying noises are most frequently heard–at a great distance–during the late fall and early winter.  Almost always, parents are understandably distressed by croup and seek urgent or emergency care for their charges when they get it. Questions abound: what causes it ? (you might be surprised) have treatments gotten better? (kinda, sorta) And, is it true that a walk outside on a cold night for a croupy kiddo could fix troublesome symptoms? (read on and find out)….

The name “croup” is apt, and is a centuries-old contraction of the words croak and whoop. (Interestingly, and quite of another subject, croup is also the term for the hindquarters of a quadriped–which happily has no clinical significance here).  Croup affects the youngest set, ages 6 months to 3 years, most often. However, it does occur occasionally in children up to school age and older.  Parents typically describe a few days of mild cough and cold symptoms, with unremarkable runny nose, sore throat, and perhaps a hoarse cry or voice at the start. However, it is when the infection attacks the upper airway on the second or third night (always at night for some reason) of illness in these children that things get exciting.

Croup’s medical aliases– laryngotracheitis or laryngotracheobronchitis –reflect the zip code of a child’s airway affected  by the viral infection and inflammation.  Parainfluenza virus most often is the culprit here, causing about 80% of cases in kids. The other 20% of viral bad guys causing croup are an infamous lot, including RSV, adenovirus, rhinovirus (the common cold), and influenza (aka the flu).  Irritation and swelling of the airway above and below the vocal cords begins as that sore throat or raspy voice, and may progress to that sea-lion’s cough, and perhaps it’s pal, stridor.

Stridor is the hallmark of a more dramatic case of croup, and is caused by noisy turbulence in breathing through a narrow, inflamed airway. Stridor creates a harsh, musical sound, reminiscent of a squeaky wooden drawer being pulled from a jammed position.  When taken in combination with the croupy cough, things can get quite symphonic and can seem pretty freaky. Fortunately, the vast majority of croup cases are mild, and stridor may be absent altogether. Parents can be reassured if their child is coughing noisily, but acts playfully, smiles, and can be consoled easily. All that, no stridor? Mild croup.

In moderate or severe cases of croup, stridor may be audible during inspiration and exhalation. As cases become more serious, kids may appear to work harder to breathe, seem cranky and uncomfortable, and show puckering (retracting) between the spaces of their ribs.

Parents will note that stridor often becomes more pronounced (and thus be more distressing) when children breathe more quickly. For this reason, finding ways to keep kids calm (comfort, hugs, and reassuring whispers) during bad croup flares is always a good idea.  Medications like acetaminophen (Tylenol) or ibuprofen (Motrin) may help in fever control and for throat discomfort. Steaming up the bathroom with a hot shower may offer some temporary relief.

What’s more, there may be something to this clinical pearl:  bundling up and going outside in the winter chill and breathing that cold air for a few minutes may soothe and improve a child’s airway inflammation.  ER docs I have worked with insist they have seen multiple cases of kids hacking and barking at home, only to appear much better by the time they reach the hospital after travelling through a December night.

For any family member or caretaker who suspects a case of croup is progressing past the noisy cough stage towards some degree of respiratory distress–or if they are just worried–a STAT checkin with their child’s primary care doc is called for, so to speak.  If circumstances allow, and if a child seems more bothered than sick, a phone call may suffice. Having that child within earshot of the clinician on the line to hear some coughing/barking may help clinch the diagnosis and allow for appropriate triage: manage at home? come in tomorrow? go right to the ER?

Treatment for croup has evolved a fair amount in the last twenty years. Some parents today may remember in their childhood that hospitals used to have ‘croup tents’, filled with misty water vapor.  These were a mainstay of therapy for croup dating back to the 19th century. However, research by the late 90s proved these devices were not terribly effective for more severe symptoms, and placing children in the plastic-shrouded cribs may have done more to make them anxious and their stridor worse.

In the office or ER, clinicians can usually assess a child quickly and make the croup diagnosis by taking the history and performing an exam.  First order of business: determine the severity of the disease. Steroid medications are the first line treatment for children with advancing symptoms of discomfort or distress for croup, and may even be given in milder cases to head off badness.  These medications may be administered orally or by injection, and work to reduce the viral inflammation and swelling of the airway.  For many, this may do the trick and will work well combined with the comfort and care measures described above.  For a few, a checkback and even a second steroid treatment the next day may be recommended.

Children who have more extreme symptoms of cough, stridor, may be given aerosolized treatments of epinephrine. This is dramatic, potent stuff—typically given in an emergency room versus a doctor’s office–and can work in minutes to open things up.  Heliox (a blend of oxygen and helium used by scuba divers for deep dives, among other things) has been used for children who have been unresponsive to epinephrine, and tends to be reserved for children admitted to hospital. Fortunately, the effectiveness of these treatments have contributed to faster recoveries and lower rates of hospital admissions for croup over the last decade. That’s nothing to cough at.

Before we wrap up, an important question to consider: Can you get croup again? About 5% of children can have a recurrent episode of croup. Most of these will be another, unfortunate viral illness.  Note: a second bout will place a patient on watch to be sure nothing else is going on. Clinician and family may consider if something else is afoot. So-called spasmodic croup, for example, includes a subset of kids who have precipitous bouts of stridor and barking cough absent fever and signs of illness. In short, they customarily awake from sleep in full croupy splendor with little warning. These kids, and others may have other causes at work, including unrecognized allergy, acid reflux disease, or anatomical issues that trigger brassy coughs and noisy breathing.  For these children, imaging or the use of special scopes to look at the airway by a specialist may be warranted.

So, my wishes for the best of luck for all of you with a super crouper, the illness with a bark that bites.

photo by jaQinthebox84

diagram link at   http://commons.wikimedia.org/wiki/File:Throat_Diagram.svg

Cartoon below by me.

I’m covering this topic on the occasion of the opening of NIDA’s National Drug Facts Week  to raise awareness — for teens and the adults in their lives — of something about which there are a lot of myths: prescription drug abuse, including ADHD meds.

Not too long ago, a patient of mine, an 18-year old named Martin, came back from college break for a checkup. He is an enterprising fellow, and I was glad to see he had settled in nicely for his first semester at college. However, he became upset when he reported that his roommate had found his ADHD medication, and had convinced him and his friends to take two or three pills each to stay up and study through the night just before midterms. This was a kid who’d been taking prescription medications responsibly since 9^th grade  and had always been careful to follow the correct dosages.

“Does this mean I’m addicted?” he asked sincerely, before adding, “Is taking these meds for fun really that dangerous?” Good kid. Tough questions.

As a pediatrician, you can bet that nearly every day I’m asked about treatment and medications for attention deficit/hyperactivity disorder (ADHD), such as stimulants Ritalin (aka methylphenidate) and Adderall (or amphetamine salts).  Do no harm, right?

After alcohol, marijuana, and tobacco, prescription medications are the next most commonly abused drugs by adolescents. This happens more than you might think. Upwards of one in five high schoolers reported using prescription meds for nonmedical purposes.  In cases like Martin’s, where prescription  medications are used for purposes for which they were not intended.  Ritalin or Adderall are often readily available drugs of abuse.

The Good?

Stimulant medications boost the effects of neurotransmitters in the brain such as dopamine and norepinephrine and allow more distractible and hyperactive folks to concentrate and focus. When used to treat a medical condition such as ADHD, the goal of the health care provider is to prescribe the lowest dose of stimulant for the best effect, then adjust meds until a desired degree of attention improvement or impulse control is achieved.

The Bad.

In the medicine universe, stimulants are potent stuff. Adolescent and adult users can take them in pill form, or crush them for snorting (ick), or inject them (yikes).  Higher doses of stimulants can derange the normal actions of neurotransmitters like the aforementioned dopamine, producing a euphoric-like high. Stimulant highs can be bewitching to those who seek them, heightening the risk of addiction. Ironically and rather cruelly, these medications decrease responses to normal dopamine, and require abusers to use more of the drug to get high over time.

The Ugly!

Taking stimulants at higher doses, or in combination with over-the-counter medications or anti-depressants gets scary quickly. Short-term reactions to high dose stimulants can include potentially dangerous changes in heart rhythms, heart attacks, stroke, or seizures. Any of these can lead to devastating injury or death. Some users may become dangerously hostile or paranoid and pose a threat to themselves or others. Longer term, chronic abusers of stimulants may experience drug withdrawal symptoms with severe disorders of mood, declines in academic performance, depression, thoughts of suicide, and engaging in illicit or high risk behaviors to feed their drug craving. It ain’t pretty.

Like many adolescents and adults, Martin perceived a prescription medication as being a less risky prospect than a street drug.  Prescription drugs, omnipresent in so many medicine cabinets and dorm rooms, render them familiar and less scary.  Further, Martin fell under the spell cast by his roommate about the performance-enhancing aspect of “a little extra” Adderall. Other kids may take stimulants, or other prescription drugs to self-medicate (to relax or feel better), or out of curiosity (everyone else is doing it).

How do we prevent or respond to instances when family members, friends (or for that matter, patients in clinic) are considering or actively abusing prescription drugs? For starters, everyone benefits by including prescription medications on the agenda of any discussion about substance abuse. Stimulant medications, pain killers, and other prescription drugs should also be recognized for their potential for benefit for treating medical conditions when done right.

Research has continued to demonstrate that parents often share with their teens the perception that prescription medications are less risky, or that their kids would not engage in their misuse. It ain’t necessarily so. Martin was not the first teen I’d met with such a story, nor will he be the last. I have encountered more than a few instances where a relative poaches a child’s prescription for their own use or profit. Sad, but true. Potential prescription drugs of abuse–including pain-killers, stimulants, or other psychiatric meds–should be kept in secure places and supplies monitored no matter who they are for.

Likewise, it continues to be the responsibility of health care providers like myself to ensure that prescribed stimulants are being used correctly, for the right reason. These medicines are considered ‘controlled substances,’ and so may only be given out in limited amounts to any one person for specific amounts of time. As in any medical concern, we consider each case individually and consider the need to review drug use if an individual or family appears to be refilling a prescription too quickly, or ‘losing’ their pills once too often.

And so, back to Martin. Does this one time dalliance render him an addict? Unlikely, I told him, but his action did put him at risk–and could do so again. He pondered this while I reviewed how the abuse of prescription stimulants could pose a real threat to his well being, or that of his friends. He had a lot to think about.

Before we left, we refilled his Adderall medication. We’ve met a few times since. (And, for the record, he’s made his refills on time!) Martin reports he’s declined other offers from friends to have another “ADHD Pill Party.”  And, for good measure, he keeps his own pills in a safe place.

And so we all do well to remember: the prescription drugs in our everyday medicine cabinets can help those for whom they are meant when used correctly.  And we all must pay attention to this key fact:  their abuse happens, and can lead to dangerous, or tragic results.

==

For more information on the misuse of prescription drugs or other questions on youth and adolescent substance abuse see the following links:

Great resource for teens: The Sara Bellum blog : http://teens.drugabuse.gov/blog/

NIDA’s National Drug Facts Week:  http://teens.drugabuse.gov/index.php

Referrals to treatment programs: 1-800-662-HELP (a confidential hotline), or www.findtreatment. samhsa.gov

Cradle cap aka milk crust, or honeycomb disease: looks like dried mayo, right?

It doesn’t really matter how old you are, but an itchy, flaky, or itchy-flaky scalp can be a drag. Seborrhea dermatitis is often the culprit here. What makes it interesting to skin geeks and horrifying to infant parents (eek! cradle cap!), or teens dusting hairsnow off their shoulders(Drat! dandruff!) is how it can happen throughout childhood for some, and not at all for others. Before you rush to the mirror and check your scalp, let’s scratch below the surface a bit.

Seborrhea dermatitis refers to the ‘-itis’ (inflammation) that happens to areas rich in sebum-producing oil glands on the skin, including the scalp and folds of the groin, diaper area, as well as the underarms and thighs. The cause of this rash and its many forms is unknown, but there are suspects. Naturally occurring skin yeasts (some implicate species of Malassezia , and others point fingers at Pityrosporum varieties) appear to kick off an inflammatory response with the fatty acids produced on these areas of the body, in certain hosts. GIven the right conditions–boom! Rash city.

Flares of seborrhea dermatitis can occur in response to exposure to medications, stress, and certain kinds of medication. In children, it tends to arise from fluxes in hormones, such as in the infant’s exposure to maternal hormones during childbirth, or with the onset of puberty.

Normally, skin cells all over the body are constantly shed and replaced, unnoticed and too small to be seen. In areas of ‘seb derm,’ the cycle of irritation deranges this process a bit, causing rafts of skin cells to fall off in larger pieces. When present, the cycle of itching and scratching the scalp only amplifies this process. Soon enough, there are the drifts of white flakes on a shirt or blouse. And here’s the thing: in terms of scalp flakiness, parents can see one variety of seborrhea dermatitis on the heads of infants and small children, and then a very different version during the teen years and into adulthood. From preschoolers to preteens, seb derm of the scalp generally goes on hiatus. Thus, we might consider other diagnoses when we encounter 5-10 year olds with scales and flakes in their hair.

Any way you dice it, in my humble opinion, cradle cap is pretty funky. Known as” infant seborrheic dermatitis,”  cradle cap appears as white, creamy, yellow-brown, or (gag) yellow-green greasy patches. Infant seb derm of the scalp appears on the crown of the head, and doesn’t itch, ache, or bleed. Most commonly, the babies who have it (about 1 in 10)are untroubled, but their  parents driven to distraction by it. In some babies as in older kids and adults, seborrhea dermatitis manifests elsewhere as reddish, or cream-colored patches crop up in other areas of skin folds (neck, armpits, diaper area). For the examining clinician, this combo of scalp rash and body distribution can help clinch the diagnosis.

Generally, cradle cap peaks in frequency at about at 1 to 2 months of age. It is not unusual to see it on kids through their first birthday. And, less often, it can be found in kids through preschool age. Happily, most cases are mild and do not require treatment beyond regular passing of a soft bristle hairbrush over the affected area of the scalp at bedtime. Easy enough.

For the more obstinate patches of cradle cap, parents can massage an unfragranced, neutral oil–such as mineral oil (aka ‘baby oil’) or even (yes!) olive oil–onto the scalp before bedtime or nap. You might find the babies love the head rub so much, you do it whether they have a patch of cap up there or not. After the oil has softened the patches of crud (at least 10-15 minutes), parents can gently make small circular motions with a (repurposed) soft bristle toothbrush to help it break up the patch and slough it off. Daily cleansing with baby shampoos is also appropriate and may help clear things up as well. Gentleness is key; no elbow grease here!

If the cradle cap continues to advance in spite of all these efforts, it might be a good idea to check in with the baby’s child care provider to take interventions to the next level. Recalcitrant cradle cap may require some store-bought dandruff shampoo. If you use it, leave it on for a few minutes and keep it out of  baby’s eyes!

In extreme cases, bacterial infections can take root, can make babies pretty miserable, and require an evaluation. If ever in doubt, call. Or, kindly suggest that you email a photo of the eruption in question to help the clinician assess the level of severity. That may save time and possibly a trip in to the office or clinic. Of course, if there is a concurrent body rash that is unresponsive to your best efforts at home, I recommend family’s let their primary care clinician know: there may be a (skin) app for that, too.

Next post: Flakes in Kids, part 2: Dandruff.

Link to photo above

Cartoon: pending. We are experiencing technical issues!

Oh, me achin' knees! classic painful bump just under the knee in OSD

“Osgood-Schlatter disease?” the athletic teen asked me, turning pale, “What is that, some sort of cancer? Is it something I’m going to have for the rest of my life?”

Alas, medicine is full of conditions named for their long-dead discoverers. Some of them sound misleadingly but downright jolly–e.g. Chvostek’s sign (a term for the lockjaw of tetany). Others sound obscure, like McBurney’s point (the point on the lower right abdomen known for tenderness during appendicitis). And then there’s Osgood-Schlatter.  It has enough syllables to sound life-ending, or perhaps describing some sort of Bavarian side dish. No, on both counts.

Rather, Osgood Schlatter disease (OSD) is the most common cause of knee pain in adolescents. In one survey, Osgood Schlatter was found in about 1 in 5 teen athletes (versus less than in 5% of a comparable group of non-athletic kids). Oh, and it isn’t cancer either.

Most often, the stories go a little something like this: An eighth grade basketball player comes into my office about 8 weeks into the season. He complains it feels like some little leprechaun has run up and bashed upon upon his knees with a ball peen hammer at the end of every practice or game. And, wouldn’t you know it? Our hero walks without a limp, but has telltale swelling on the upper aspects of both shin bones that are tender to the touch. These areas ache when he goes down stairs, squats, or kneels. The pain comes and goes, in general, but is usually always worse after a workout.  For the few severely affected kids, the pain may render them unable to play.

The area of interest

Fortunately for my panicked patient in clinic that day, and for the vast majority of those I see with it, OSD causes a mild to moderate amount of discomfort, and responds well to proper treatment and a tincture of time.  What is it, exactly? Take a knee, I’ll explain.

The growing knee of early adolescence is a busy place. Roll up your pant legs and play along as I go. Osgood Schlatter disease can be explained by age, growth, and teen lifestyle. As the old song says, the knee bone (aka, patella) is connected to the shinbone (or tibia). The  workhorse muscle of the thigh, the quadriceps, slings across the kneecap and inserts onto the upper aspect of the tibia via the patellar tendon. For a girl aged 8-12, or for boys around 12-15, the upper aspect of the shinbone where the patellar tendon anchors is a growth plate, and is especially vulnerable to stress and inflammation.

And here we have the setup. Middle school and high school athletes who have rapid periods of growth, and frequently, who engage in high impact sports with prolonged sessions of running and jumping are those who are most vulnerable to developing Osgood Schlatter discomfort.

Over time, tension placed on the patellar ligament by growing bones and the increased stress of athletics can cause microtrauma to the insertion point of the patellar tendon at the bump under the knee, called the tibial tubercle.  In some cases, the cycle of injury and re-healed bone can lead to prominent little goose eggs (see photo above) on one or both of these areas (about 3/4 of all cases are one-sided) that hurt when doctors or parents poke them.

For the treating primary care provider, Osgood Schlatter disease tops our list of diagnoses when we have a so-called classic case, such as a tennis, basketball player, or runner of cross country with sore, bumpy knees. However, before we ever rush to a conclusion, it remains a part of our job to go over parts of each story, and consider and eliminate other possibilities.

Consider: Hip pain can be referred to the knee, oddly enough, and it is key to ensure there is no problem with that big joint, or any other muscles, bones or tendons (anyone for jumper’s knee?). A clinician will perform a leg and knee exam, looking for suspicious rashes, swelling, fluid in the joint, tenderness or limits in strength or movement. To assist in this process, parents or teens who may suspect they have a case of OSD, should be clear about the timing of the onset of pain, triggers for its recurrence, and activities or positions that offer relief of any symptoms.  Most often, a good history combined with a physical exam clinches the diagnosis.

Most teens with Osgood Schlatter disease may continue their sports activity with proper care and treatment. Indeed, whether I meet kids with OSD who’ve undertaken a sport to address their obesity issues or to perform at the elite level, my approach is to keep them playing and to minimize downtime. Kids and parents should discuss with the child’s primary care provider if they would benefit from patellar tendon straps or knee pads.

Customarily, applying ice to painful shins post-workout for 20 min every 2-3 hours after  a workout can suppress swelling and inflammation. Pain relievers, such as Ibuprofen or other non-steroidal anti-inflammatory medications, may take the edge off the owie, but do not tend to shorten the overall course of the problem. Some teens may benefit from some certain stretches to promote quadricep and hamstring flexibility. For those so inclined, acupuncture may also help with pain and inflammation. Happily, the prognosis is excellent for over 90% of kids with Osgood Schlatter disease, and the knee pain typically resolves within a year or when their growth spurts ends–whichever comes first.

For those who encounter more profound pain or disruption of their performance, a respite from play (up to a couple of months!) may be recommended.  For tougher cases, I’d recommend a consultation with a specialist in orthopedics or sports medicine.

So, the next time a 14 year old talks about a leprechaun whacking his knees with hammer after practice, take heed! You need not believe in the wee people part, to be sure, but knee pain? growing kid? athlete? Consider if you might have a case of Osgood Schlatter disease…and getting it checked out for good measure.

Photo #1 by Berg/Worzala,from this nice article; Photo 2 by bonecareatrbjcc

Cartoon below by me.

More Faster Pediatrics:

Sweating It: Understanding Kids, Armpits, and Body Odor

Sunblocked? Keeping Kids Safer in the Sun

That's the stuff!

“Is swaddling my baby a bad idea?” asked a mom, just the other day, “Or should I be doing it?” Great question. For the parents of sleep-proof or fussy newborns, finding ways to improve their infant’s shuteye—longer? better? –may be their highest priority. Is swaddling safe? (yes, if done right) Does it work for all babies? (Not always) Until what age is it appropriate? (Read on!)

Contrary to what certain claims may suggest, swaddling isn’t new.  Rather, in Europe and North America, the practice has been rediscovered as a way of soothing crying infants or promoting better sleep. Wrapping infants snugly in cloth has been done worldwide for centuries. Recall the swaddling clothes used at Christ’s birth? Consider also the variety of approaches to swaddling used around the world: from the papoose-style cradleboards in rural China (35 days) and the Navajo (for 5-6 months), to the use of cloth wraps in Holland (12 weeks), Mongolia (5-6 months) or rural Turkey (up to a year). In warmer climes as in Africa, babies require less clothing, and may be placed in a sling instead.

In the US, interest in swaddling intensified, with the 2002 book by Dr Harvey Karp, The Happiest Baby on the Block. What has followed has been a fascinating resurgence in this practice, with a raft of studies to assess anew swaddling’s effectiveness and safety. And here’s the thing: for some younger infants, swaddling seems to work, and when done right, it can be downright beneficial. Tuck in, and I’ll explain.

Proper swaddling technique is key.  Babies need to be properly wrapped (nice video here)—not too tight!–with the snugness of the blankets as one article suggests, just under that of the elastic band on a pair of gym shorts. Lastly and most importantly, a swaddled babe can be placed in her crib in the supine, or face up position. Why? Babies placed on their backs to sleep have substantially lower rates of Sudden Infant Death Syndrome (aka SIDS, or crib death).

Research has confirmed some clearly positive aspects of good swaddling on sleep. Properly swaddled infants generally have fewer startles and arousals during sleep than their unswaddled peers, allowing them (and their parents!) to sleep longer.  That’s pretty sweet. What’s more, swaddling helps infants who seem to prefer prone or face down position do better in sleeping on their backs. That’s a good thing, too.

Other studies have shown that swaddling decreases fussiness and crying for infants, at least in the first couple of months. Much in the way a pacifier can soothe an infant who is upset or in distress, swaddling exerts a calming effect on most young and premature infants. For example, research and practice demonstrates swaddling proves effective in decreasing crying time after babies get stuck for blood draws. Premature infants who are routinely swaddled demonstrate improved neuromuscular development, and soothe more easily than their unbundled peers.

In a more profound example, infants born to narcotics-using mothers often undergo treatment for withdrawal. These babes do far better—with less irritability and crying–when swaddled snugly. So much so, in fact, that bundling these infants thus has long been considered a cornerstone of their care, and helps them recover faster.

For the first several months of life, swaddling helps babies do what neurologists would describe as “organize better,” and decompensate less with the stresses of newborn life: eating, sleeping, waking, and pooping. Before we start swaddling our inattentive adult co-workers to see if it helps them any, let’s consider a few more issues.

Are there downsides to swaddling?  A number of studies have attempted to answer this question, but only a few have had convincing results. Investigators have posited unconvincingly that swaddled babies may have higher rates of chest colds, or issues with rickets and vitamin D deficiency. For most babies, I don’t see this as a problem.

However, tight wrapping of some babies may contribute to higher rates of abnormal development of the hip, called developmental hip dysplasia (DDH).  This is less a concern for healthy babies. However, for parents whose children have been identified with DDH, or to those who are at risk for having it (e.g. children born in breech position), I recommend that they discuss if/how they swaddle their babies with their child’s primary care provider. In general, better techniques involve bundling that is snugger on top, and permits some leg and hip movement on the bottom.  Clinical pearl here: if you need a live demo in your doctor’s office, ask a nurse. They do it SO much better than the physicians.

I advise parents to use a bit of common sense, as well. On hot days, or in stuffy, unairconditioned homes, swaddling can overheat babies. Increased ruddiness, fussiness or sweatiness on the babies face or hands or feet may suggest it’s better to refrain from using clothing or heavy blankets, and that a light cotton blanket will do, if at all.

Otherwise, the other, more concerning downside of swaddling is a moot point for the watchful parent following healthful bedtime procedures. In short, swaddled infants should NEVER be placed prone (face down) to sleep. For reasons not entirely clear, this setup places these infants at a substantially higher risk of SIDS. ‘Nuff said.

And so: how long should someone swaddle their baby? As noted above, experts, studies, and world cultures differ on this point. Here’s my bottomline: I encourage parents to swaddle their infants for as long as it seems to work. For most infants, this seems to run about 2-3 months. Some babies seem to want to wean from it sooner, and will let you know by fussing more when wrapped. For other babies, swaddling becomes a trusty part of the glidepath to bedtime, and helps them relax before they cork off for the night, up to 4 or 5 months. In my case, I’ll tell parents it’s probably time to wind down their child’s swaddling when the baby is consistently busting out of the wrap like some teeny Incredible Hulk, or when they are able to flop from their back to their front.

And lastly, there is the Truth that keeps we parents and pediatricians humble. Kids vary. Some infants never take to swaddling, finding it neither relaxing nor enjoyable. These parents will come to this conclusion quickly, as evidenced by the crescendo of fussiness when these kids are wrapped snug as a bug in a rug. And, that is ok. There’re still kisses, hugs, and binkies!

That’s a wrap.

Photo above by tsdelvis; cartoon below by me

Not so long ago, a most astute colleague of mine did what the very best clinicians do: she pieced together parts of a patient’s story  to make an elusive and important diagnosis. In this particular case, a young teen reported feeling crummy for several weeks.  That a teenager was complaining was neither unusual nor particularly concerning. That’s their job, right? However, this young girl’s litany of woes included some vague belly pain and more alarmingly, a new, blistery rash on her palms and soles.  Abdominal upset for more than two weeks? An odd skin eruption? Hmmm.

dermatitis herpetiformis

Her clinical spidersense tingling, my colleague confirmed her suspicions with the rash’s peculiar appearance and distribution first by a crosscheck of a dermatology textbook (rash: dermatitis herpetiformis) and clinched the diagnosis with a blood test. Bingo!  This young woman had celiac disease.  Such clinical sleuthing saved that girl a potentially long road fraught with complications that  might have gone unrecognized for years. More good news: there’s treatment for celiac disease. The bad news? Celiac disease is on the rise, and recognizing this entity with its protean (or, you might pun, ‘protein’) manifestations isn’t so easy.  And there’s the rub: when does one suspect it? What to do if you think your child has it?

Celiac disease (aka sprue, wheat allergy, or gluten intolerance) may be one of the most common chronic conditions globally, affecting upwards of 1% of the US population. That is a lot. It is more common in females than males, and is far less common in people of African, or Asian ancestry.  Celiac disease can appear at any time in the lifespan, but is more common in adults over the age of 60.

Celiac disease arises from the inability of a child or adult to digest proteins, called glutens, contained in wheat, rye, and barley.  Oats are sometimes included on this list, but research suggests that they do no themselves contain glutens, but often become contaminated with these proteins as they mix with other grains during processing, as they journey from the farm to the dinner table. Unhappily, certain genetically predisposed individuals develop an autoimmune disease against their own gut tissue, with massive antibody attacks triggered by ingestion of gluten-containing materials. Quite literally, these wheat products become toxic to their intestines. Please hold my order of beer and pretzels while we explain what that looks like.

In medicine, a ‘classical’ presentation is considered to be the most obvious and/or typical manner in which a disease process brings a patient to a doctor’s office or ER. In it’s classical form, celiac disease appears in an older infant or young toddler as they wean off formula or breastmilk, and begin to take gluten products in their diet.  Susceptible infants may develop some number of persistent or increasingly severe GI symptoms (notably without fever), including bloating, abdominal discomfort, flatulence, vomiting, or watery diarrhea.  In extreme cases, infants may come in with profound dehydration and malnutrition due to the inability of their damaged guts to absorb nutrients and fluids. See? It can get serious!  In addition, pediatric care providers are recognizing that celiac may also be a cause of constipation that doesn’t respond to the usual treatments. See? It can be tricky. And, then, there’s the older kids.

In upwards of 2/3 of cases of celiac disease in older children (say, school age and older), the connection between celiac and GI symptoms is a bit more tenuous. Stomach upset, feelings of bloating or loose bowel movements may come and go, and be harder to nail down as something triggered by stuff in the diet. It can look like a bazillion other entities we see in primary care that lend themselves to such constitutional malaise in this age group: nerves? carsickness? sicking out of a tough exam by a 4^th grader? Monthly menstrual discomfort in a 14 year old?

And that is where history can be key: persistence of these complaints over weeks or months should be a flag. In addition, older children and adults may have a host of seeming vague and disconnected symptoms that occur with so-called ‘silent, intermittent celiac disease.’ Outwardly, a child or teen may not look sick at all for some time—if ever. Meanwhile, internally, their intestines may be suffering reversible but mounting damage from the celiac-induced autoimmune process.

Eventually, this inflammatory cascade may render a child less able to absorb key nutrients like iron, or zinc, or over time, they become unable to digest lactose, and must avoid dairy products.  Some children or teens with celiac may be brought in for medical care due to recurring canker sores, weight loss, changes in appetite, poor growth or delayed puberty. Sharp-eyed dentists may suspect the diagnosis when they encounter poorly formed dental enamel. Other celiac-related issues can include moodiness and depression that must be discerned from the usual sturm and drang of adolescence.

In short, celiac disease can look like almost anything. On the medical side, Ideally, careful observations by the family, skilled listening and examinations by a primary care provider familiar with a child’s ‘big picture’ allow for the dots to be connected when things don’t seem right (as in my colleagues case). The blood tests to measure the antibodies to glutens can be done in any primary care setting allow for a preliminary diagnosis. Children, teens or adults whose results that suggest the condition are customarily referred to a gastroenterologist to confirm the diagnosis definitively via intestinal biopsy. It may sound drastic, but it’s worth it. The profound genetic component of celiac disease have made it essential to screen the nearest relatives of individuals who have been diagnosed. Up to 5% of first degree family members are identified with celiac disease in this manner—the majority of these people being asymptomatic.  What’s more, celiac disease keeps company more often in individuals with diabetes, thyroid disease, and kids with Down syndrome, Williams Syndrome or Turners syndrome. Accordingly, kids and adults with these conditions may be watched closely and screened accordingly.

While celiac disease ain’t curable (yet), it is treatable. Moreover, the vast majority of celiac related problems eventually resolve when a child makes appropriate lifestyle and diet changes.

Treatment for celiac disease is the gluten free diet, and is a lifelong commitment.  Avoiding ingredients that are ubiquitous in the Western diet may be overwhelming at first, and can run up the family grocery bill. No more standard breads, pastas, or handy snack foods! For many, that’s the hard part. The upside to the soaring rates of celiac disease is that books, websites, grocery stores and eateries increasingly provide gluten-free options and resources.

What’s more, we health care providers team with pediatric nutritionists and specialists to orient the family (not just the kiddo!) on how to go gluten free: how to shop, prepare food, and to read labels fastidiously.

And until medical science delivers us a cure of celiac disease, affected children and adults need to stick to a gluten free diet to heal up and stay well. No cheating, no sneaking. Period. Kids who stray back to wheat products—even if they feel well and are asymptomatic—risk reinjuring their gut and reigniting the vicious circle of problems that arise from it.

Kids and parents become expert at spotting the key words on ingredient lists that contain wheat, rye or barley (eg dextrin is a form of wheat flour used to thicken certain foods, like gravy).  Even with steep learning curves that this may present, I find families ably navigate the gluten free universe with stunning rapidity.  What’s more, alternative nutrients abound, (like corn, rice, soy, chick peas, or quinoa) and offer food options that are no less delicious.

And so, the next time a clinical conundrum rolls your child’s way, if there seems to be a smattering of unhappy and persistent complaints of misery, lassitude, disenchanted bowels, or somesuch….Sharpen your eyes, channel Sherlock Homes, Dr House, and my astute colleague, and have a chat with your child’s healthcare provider. Maybe what’s up is celiac disease down there.

For any readers who have tips on celiac disease related resources for families, please share your favorites below!

Photo 1 by roarnkatt

Photo 2 by ncbi

Photo 3 by PRWeb_04_2011

Cartoon below by me

The classic, much hated HP rash!

I see this every day. Some parents and kids are really freaked out by it. Most of the population has it. It may have an inherited component, and run in families. Many are unaware they are walking around with it. By and large, this is a painless phenomena, but causes a fair amount of consternation. It has a horrible, bad diagnosis-sounding name, and it is no big deal. I am talking about hyperkeratosis pilaris, of course.

What is this exactly? Take a second to look at the outer and posterior aspect of your upper arm, and tops of the thighs, and you will get a better idea. In around 40% of the population, and up to 80% of all adolescents, you will find zones of regularly spaced, red or skin colored bumps on these surfaces. Those with hyperkeratosis pilaris (HP) rashes will note they are painless, and may mildly itch from time to time. Hot weather or tight clothing or sports gear may predispose these teeny lesions to some irritation, but it usually subsides without fanfare. However, there is something about this ubiquitous eruption that drives mothers crazy.

I get this a lot, with a mom spinning her 12 year old around and hiking up a sleeve: “What is this? My daughter has goosebumps all the time, just here! Can you treat this?” Well put. Let’s delve.

Normally, adults and children shed their outermost skin cells—our keratinocytes–all the time. Eventually, this becomes dust on our floor, or fodder for the dust mites in our bed. Yum. Keratin is a fibrous protein found in hoofs, claws, feathers, and in this case, in our skin’s keratinocytes.

A little red, maybe not. Bumpy, not clustered rash.

In hyperkeratosis pilaris (HP), keratin plugs the hair follicles most pronouncedly in certain areas of the body; especially the arms and thighs, as noted, and less often the neck, cheeks and buttocks.  A quick check shows patches of bumps with a distribution mapped to hair follicles (regularly spaced apart, not clustered together). For those most curious, lesions may sometimes have hair growing out of them, or have a trapped coil of a growing hair inside.

Debate has raged (in sleepy, derm-y circles) over the years as to whether there is an association between HP and eczema. Seems not. However, HP may intensify with with periods of increased hormone production, as during puberty. HP also seems to occur more in females than males. Sorry, girls. And, kids and adults with hyperkeratosis pilaris note it tends to be more pronounced in dryer, colder weather.

As medical conditions go, hyperkeratosis pilaris rates as a classic ‘annoying but not dangerous’ category—joining such celebrated maladies as long nose hair, newborn acne, and chapped lips. But, for those truly bothered, either by cosmetic concerns or a bit of itching, there are ways to reduce or dampen the rash’s symptoms and appearance.

Taking a page from the eczema playbook, kids and teens with HP should avoid steaming hot showers, and use warm to tepid water, and dab dry afterwards. This averts cycles of inflammation that can make it worsen. Mild, unfragranced soap should be used while bathing (Dove rocks), and a greasy, emollient ointment (e.g. petroleum jelly) can be applied to the affected area once or twice a day.

For kids who have more extensive cases, including redness, irritation, or a concern that the rash has become tender or infected, a check-in with a health provider is a good idea. Inflamed or widespread rashes may require a topical steroid ointment, and/or a pricey salve (a lactic acid, or retinoid cream) to break down the keratin plugs on the troubled patches of skin and allow things to heal up.

Hyperkeratosis pilaris will eventually go away by the late teens in about a third of cases. For the majority of children, teens and adults (and, I’d venture, for people reading this piece), HP is something one can live with and not worry about, if understood and treated right. Getting treatment for flares of inflammation or questions of infection is important. And, consider the bright side.

This newfound medical knowledge can enhance a tried and true backseat game for siblings on long car rides. Instead of older siblings one-sidedly bamboozling younger brothers by teasing: “Your epidermis is showing…”, the battle equation can be rebalanced. Now, you can prepare the little sibling to retort: “Maybe so, but your hyperkeratosis pilaris is erythematous and papular!”

That’s so cool, it’ll give you permanent goosebumps!

nice photos by kp

cartoon below by me