Head Lice

Q A lot of girls in my daughter's class keep getting lice. How do I know if my daughter has lice? How do you treat it?"

A The human head louse (multiple: lice, singular: louse) is a small insect about 3 mm long. It uses its six legs to scoot around and between human hairs, close to the scalp. Lice feed by sucking up tiny amounts of blood every few hours. The only symptom you're going to notice if your daughter gets lice is itching, caused by an inflammatory reaction to the saliva deposited when a louse bites. Head lice do not cause or transmit any disease.

After an egg hatches, the egg casing remains glued to the hair shaft, moving further out as the hair grows. These little nubs, still glued firmly to a single hair, look a lot like a sesame seed. They can be pulled off by hand or with a nit comb, though it's not essential to remove these at all. If it's more than 1/2 an inch from the scalp, then it has either already hatched or it's dead.

Transmission of lice from child to child occurs almost exclusively from head-to-head contact. Transmission on brushes, combs, hats, and other hair accessories is very rare- healthy, egg-laying lice do not readily leave their warm host. Lice found on floors, beds, combs, and other household surfaces are already dead or dying.

Lice are best diagnosed by a trained person finding live lice running around the scalp. Sometimes, a lice comb can reveal the critters. Lice can also be diagnosed by spotting egg casings or nits less than 1/2 inch from the scalp, glued on to hair shafts. Older nits that have grown further from the scalp are not indicative of a current infestation. The best place to look for eggs is in the nape of the neck and behind the ears. In several studies, laymen and school nurses were unable to tell lice eggs from specks of dirt, dandruff, and flakes of skin. A diagnosis made without actually spotting live lice is often wrong.

First-line treatment for lice should start with permethrin 1%, marketed over-the-counter (OTC) as the brand Nix in crème rinse form. It has very low potential toxicity to mammals, and is very effective when used correctly. To use Nix, first wash the hair with an ordinary shampoo, and towel dry. Then apply, massage in, leave on for 10 minutes, and rinse with water. It's a good idea to repeat the treatment in 7-10 days. Some experts feel repeating the treatment in nine days is ideal; others recommend repeating the treatment twice, each a week apart. The idea behind repeat treatments is to kill any freshly hatched, juvenile lice before they can mature and breed. No lice treatment is 100% effective at killing eggs before they hatch.

There are several other over-thecounter lice killers. Many contain pyrethrins, including Rid, A-200, R & C, Pronto, and Clear Lice System. They're very safe for human use, but probably not as effective as the ingrethent in Nix. LiceMD contains no lice toxins at all, but claims to kill by suffocation. Many home remedies, including mayonnaise and other gooey liquids, might work the same way, but they can be difficult to remove. Limited published evidence shows that home and herbal remedies are less effective than Nix.

Two widely used prescription products are PDA-approved for lice. However, they may be more toxic, and they're certainly more expensive. There is no evidence that any prescription product is more effective than OTC lice preparations.

The most important step in using any lice treatment is to read and follow the directions carefully. Most treatment failures are either caused by a misdiagnosis (that is, the child doesn't really have an active lice infestation), incorrect use of the lice treatment, or a reinfestation after successful treatment. It's also important to follow the instructions for re-treatment 7-10 days later to ensure that freshly hatched juvenile lice are killed off.

Removal of nits and egg casings is not necessary after lice treatment. Only live lice can be transmitted and only live, mature lice can lay more eggs. Still, many families want to remove nits for aesthetic reasons and to avoid future calls from the school nurse. Nits can be picked off by hand, one-by-one, or combed out with patience and a fine-toothed (preferably metal) nit comb.

All household members of a child with lice should be checked for lice, and treated if live lice are found or any egg casings are found on hairs less than W from the scalp. You should also treat children who share a bed with a child with lice. Many families decide to treat everyone in the household. It's a good idea to clean the bedding and hair-care items of the person with lice, but efforts to spray, super-vacuum, and sanitize every item in the house are unnecessary.

Growing Rains

Q My 5-year-old son has a lot o pains at night. He keeps ina u :mg up and crying, and seems to be very upset. He goes back to sleep, but I think there really is something bothering him. Is this "growing pains"?

A It could be, but there are a few other questions to answer to make sure that there couldn't be something else going on.

"Growing pains" are very characteristic, and can usually be diagnosed based only on the pattern of pain. They occur a little more commonly in boys than girls, usually from age 4-8 or so. The pain is almost always limited to the nighttime hours, and often wakes a child from sleep. During the day, children with growing pains do not limp or complain of pain.

At night, when these children wake up, they'll usually complain of pain in one or both legs, and in a vague location that often varies from side to side or site to site on subsequent nights. When children are asked to point at where it hurts, they'll rub over an area rather than point specifically at one exact point.

It's important to stress that the pain itself is very real- "growing pains" is not a euphemism for "faking it." These kids are genuinely uncomfortable, and often scared. Fortunately, it's easy to treat. Gentle massage or a heating pad works very well, or a single dose of a pain medicine like ibuprofen oracetaminophen will help. Though they may seem to be very uncomfortable, growing pains usually subside in 20-30 minutes, so everyone can go back to sleep.

Recent research has shown that in some cases, vitamin D deficiency can contribute to nighttime muscle and bone pains. Parents of children with apparent growing pains may want to try a vitamin D supplement. The AAP currently recommends a vitamin D supplement of 400 ID/day for almost all children, anyway.

I ask parents of children with growing pains to beware of the following "red flags." If any of these are present, it's not typical of growing pains, and further evaluation may be necessary:

* Pain or limp during the day.

* Pain that persistently affects one specific joint or place.

* Associated fever, weight loss, or other symptoms of potentially serious disease.

* Pain that's become more and more intense as weeks go by.

Growing pain itself is quite common, and usually falls into such a specific pattern that it's easy to diagnose and treat. You should discuss your child's discomfort with your pediatrician, and go through the history in detail to make sure that there aren't any "red flags" that could signal a more serious problem.

Sports Injuries

Q A friend of my son's is having "Tommy John" ligament reconstruction surgery on his elbow. I keep hearing about more and more children and teenagers having serious sports injuries like this one. What can I do to keep my son safe? He is a baseball player.

A It's not your imaginationmany pediatricians believe that children are experiencing more sports injuries, and more serious sports injuries, at a younger age than ever before. And despite the impression given in the media, if a child needs surgery then it's very doubtful that he or she will ever be in the kind of perfect shape needed to become a professional athlete.

There are several factors that put children at risk. They're still learning proper techniques, and may not always be fully trained or trained well. Often, their equipment is ill fitting, or not really designed for kids. Children ortheir parents may not be as quick to recognize an early injury that can affect a child's mechanics, leading to further injury.

More subtle influences are probably important, too. Sports seasons have gotten longer, with extended pre-training and prolonged "post-seasons." Many children do not specialize in a single sport, or even a single position, which dramatically increases their risk of over-use injuries, and doesn't allow their bodies to heal from repetitive trauma. There may also be pressure from coaches, peers, and parents for the best-performing children to stay in the game despite pain and injuries.

To some degree, injuries may be an inevitable part of competitive sports. Still, many could be prevented with some simple steps. Concentrate on the basics of learning good techniques and sportsmanship. Insist on proper, well-fitting equipment that's kept in good shape. Encourage children to play multiple positions in different sports during different times of the year.

Most importantly, teach your child to pay attention to signals from his body. Pain means injury, and a child should not "play through pain." If something hurts, then the child ought to be able to sit out for evaluation by a trainer; if pain persists, then consult a pediatrician, orthopedist or sports medicine specialist. Depending on the cause and kind of injury, reasonable restrictions might be needed to allow healing- rarely is absolute restriction from all sports necessary, but children need to know in any case that their parents are supportive of their taking a break from a sport in order to heal.

Urinary Problems

Q My four-year-old daughter has sometimes complained of pain with urination, and she also has some accidents. She seems to have to run to the bathroom a lot. Urine tests have been negative, so the doctor says there is no infection. What could be going on?

A Assuming that her physician has already run a standard urinalysis and urine culture, we know that there is no infection or diabetes. The most common cause of her symptoms, once infection has been ruled out, is a process called "dysfunctional voiding."

Dysfunctional voiding begins with a child developing a habit of urinating infrequently or incompletely. Sometimes she's just rushing off the toilet, or sometimes she's unwilling to stop doing something fun so she can go to the bathroom.

Over time, chronic urine "holders" develop a thickened bladder wall that doesn't empty well, and can start to have painful "bladder spasms." These children have the urge to urinate frequently (though the amounts will be small), and often have to run to the bathroom in a rush, seemingly at the last minute.

Sometimes, there are little dribbly accidents, and bedwetting can occur. Many children with dysfunctional voiding also have constipation-they hold both urine and stool. Both of these habits have to be addressed together.

Fixing dysfunctional voiding takes patience and consistency. Gently encourage your daughter to void completely at every trip to the bathroom. She needs to relax and take her time. Make sure that the family knows that all fun activity stops during bathroom breaks, so she doesn't rush or feel left out. A kitchen timer can be a helpful reminder of potty break times (a timer is better than just pointing to your watch- with a timer, it's not Dad's fault that it's potty time.)

Girls can be encouraged to sit backwards on the toilet, facing the tank, to slow them down and help completely empty the bladder. If your daughter is reluctant to use the bathroom at school, then talk with her teacher about making this less unpleasant for her. If there is co-existing constipation, a safe stool softener should be used.

Also talk with your daughter's pediatrician to confirm that this is the correct diagnosis, and for guidance with the treatment plan. If necessary, a consultation with a pediatrie urologist can be helpful.

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By Roy Benamati, MD