Prevention Strategies Critical for Child Safety During Summer

As warmer weather begins to sweep the nation, heralding the official start of summer, children are exposed to elements such as the sun, grass, and water. Melody L. Berg, PharmD, MPH, BCPS, editorial director, American Society of Health-System Pharmacists, explains the most common exposures and treatments related to sunburn, insect bites, and waterborne infections.

SUNSCREENS

Joshua Fitch, editor, Contemporary Pediatrics®:

First, what vehicle for sunscreens is preferred for pediatric use?

Melody L. Berg, PharmD, MPH, BCPS:

There are several different…ways that we can give sunscreen to children. We have lotion, we have sprays, and we have sticks that can be applied as well. Most commonly we see lotions and sprays. Typically, lotions are recommended for children rather than sprays. There are some concerns about whether spray is as effective as lotion, because we tend not to do a great job of spraying on and applying, whereas [with] lotion we can see the film and know that we’re rubbing it in. Also, there are some concerns about safety of spray…and the damage it can do if we inhale it.

Fitch:

In what areas are chemical sunscreens recommended over mineral sunscreens, and why?

Berg:

There are no areas where chemical sunscreen is recommended over mineral. Either…is recommended at this point…. There are some situations where mineral would be preferred over the chemical. Mineral sunscreens are those that contain zinc oxide or titanium dioxide, so they tend to work more like sunblock. So rather than absorb the sunrays, they block the sun from entering the skin. So those are the ones back in the day that used to be the thick white ones we saw, but now they make them so they rub in way easier and you don’t see that thick paste. Chemical sunscreens have a variety of…chemicals and active ingredients in them and they…do absorb into the skin. So, a lot of [individuals] are concerned that chemical sunscreens aren’t as safe for use, but that’s not really been found to be true. However, chemical sunscreens can be irritating to the skin, so sometimes we would recommend the mineral sunscreen over the chemical sunscreen for patients who have sensitive skin or may be prone to breakout or allergy. Even though there’s no reason to recommend chemical over mineral, a lot of our patients like to use the chemical because it’s easier, it rubs in easier, and you don’t see it.

Fitch:

Are there different recommendations for very fair-skinned children when it comes to sunscreen, or any specially designed sunscreen for this population?

Berg:

Nothing specific for those children. Some [individuals] may think you want to use a higher SPF [sun protection factor], so the sunproof for the SPF we recommend as a minimum of 30, but 30 sunproof blocks out about 97% of UV rays. Going up higher on [sunproof] only increases the percentage slightly, not to a large degree, so there’s really no benefit on going up much higher than 30. You may want to consider [higher than 30 SPF] in a fair-skinned child, just for that reason. Really, the best thing you can do is, if they are fair skinned and prone to burn, make sure they are using nonsunscreen measures to block the sun, such as wide-brimmed hats or long-sleeve shirts or rash guards that are going to be better at keeping the sun out. Those are the only things that are 100% effective at keeping the sun out.

Fitch:

Lastly, on sunscreen, what are some clinical pearls pediatric health care professionals can use when discussing proper sunscreen use or treatment with their patients?

Berg:

Make sure that you advise them to put the sunscreen on before they head outside. Also, it takes about 15 minutes for the sunscreen to fully absorb and work, so you want to make sure you’re waiting at least that long; 15 to 30 minutes before you get into the water after applying. Otherwise, you risk that water just rinsing the sunscreen off and it not working as well. Also, it’s important to reapply every 2 hours while out in the sun…even more frequently if you’ve been in the water a lot or [experience] excessive sweating, because even though it may say “water-resistant sunscreen,” it’s not really water resistant per se; it…still washes off some of the sunproof properties. If they do use the spray, avoid spraying the face and instead put it on your hands and apply it to your face. Additionally, make sure you apply it to the skin until the skin glistens, so they can see the actual sunscreen on the child’s skin and then rub it in thoroughly so it gets absorbed into the skin.

BUG BITES

Fitch:

What are standard care practices when a child comes back up to their parents with a bug bite, and you don’t know where it came from? What are first steps health care professionals need to advise parents to do?

Berg:

Think about your environment and where you are. Typically, if you are out in the woods, you’re going to think about mosquito bites. Most frequently, you’re going to know if mosquitoes are in the area, because you will have seen them flying around. The child may also report…having seen a spider or having a spider or some other type of bug on their skin and that may be how you can identify what the type of bite is. There [are] bug repellents with DEET [N,N-diethyl-meta-toluamide] or picaridin, [which] are both highly recommended when you’re going to be outside in the woods or in areas that have infestation with mosquitoes.

Fitch:

Are there any first steps regardless of bug by type?

Berg:

I think identifying…the type is important first. Mosquito bites and chigger bites may be bothersome, but they are not going to be harmful. They’re self-limiting and will resolve in a few days but may just be uncomfortable. Pediatricians should advise caregivers that if it’s a tick bite, make sure that the tick is no longer on the skin, so the first step is to immediately remove that tick if it is a tick bite. Tell parents not to squeeze the tick but use tweezers and remove it from the area close to the skin, which is where the head would be, and pull out. Then, ask them to try to save that tick if they can, by taping it to a piece of paper so that they can show you, especially if symptoms develop.

Fitch:

What are some common treatment options for mosquito bites?

Berg:

For mosquito bites or chigger bites, the child is just going to be itchy for a few days and…uncomfortable. Those can be treated at home, so pediatricians usually recommend any type of anti-itch cream like calamine lotion or a Benadryl [diphenhydramine] cream [and] in some cases, even a low-strength hydrocortisone cream to help relieve that itch. Pediatricians should also remind parents that if the child starts to scratch a lot and it’s appearing to be infected—a little bit warmer, it’s not getting better—then it may become a secondary infection. Then they would want to go to their doctor, where they may need an antibiotic. We really want to encourage the nonscratching of those bites, and clinicians can recommend cool compresses, in addition to those creams mentioned earlier. Also, encourage patients to make sure they’re washing their hands and the bug bite area with soap and water. If it’s a tick bite, you want to watch it to see how the bite progresses. The small bump or the tick is more than common, but in some cases, bacterial infection can occur after the tick bite, which then translates to Lyme disease. You want to see if that rash progresses at all in the area outside of the bite, which is known as a bull’s-eye rash, or any other area of the body where a rash may progress. If this is the case, the provider will put them on an antibiotic that will help stop the bacterial infection.

Fitch:

Lastly, on this subject, what are some rare but serious bites or infections that you know of, or treatment options for these that you’ve seen come up in summertime?

Berg:

Illness that can occur with ticks is often Lyme disease but with mosquitoes we talk about things like West Nile virus or Zika virus, chikungunya virus—those are all things that…aren’t treatable with any type of direct medicine. Those are treated symptomatically. All those viral illnesses look like fever, headaches, joint aches, and are treated like a typical viral infection; and if patients come in with those, in…rare cases, they need hospitalization and symptomatic treatment.

WATERBORNE INFECTIONS

Fitch:

What are some of the most common parasites or waterborne infections a child can get in saltwater or freshwater environments?

Berg:

Parasite-wise, we have Cryptosporidium; that is one we get most concerned about in the summers. That is a parasite that causes a gastrointestinal illness. So pediatric health care providers should urge caregivers not to let their children swim if they’ve had a diarrheal illness recently; not to change diapers near a pool, as these are where we tend to see this happen, [when there is] contaminated water from fecal matter; and, of course, it doesn’t hurt to remind caregivers to wash their hands before getting back in the pool. Also, advise parents to visit pools and freshwater sources that are…tested regularly and treated appropriately.

The other types of infections we tend to see with swimming [are] bacterial in nature. There are more…parasite infections that are…very rarely seen such as malaria, as well as cyanotoxins that can occur with blue-green algae [cyanobacteria] when you swim in water that’s contaminated.

Fitch:

For treating some of these rare infections, is it as simple as a prescription? How are they treated?

Berg:

For things like Cryptosporidium there actually is a…medicine that can be prescribed for patients…[nitazoxanide], for a lot of the bacterial gastrointestinal diseases that you can get from swimming in contaminated water. There are also going to be other antibiotics that you can treat them with: the cyanotoxins [found in lakes and oceans] tend to be a little more self-limiting, so we must just wait for those to run their course. The [rarer] Naegleria fowleri…does not have a treatment; it is almost always fatal. So, the key, rather than treatment, is really focusing on prevention, making sure families know where safe water sources are. Providers can advise them to not swim in freshwater sources, like ponds that are low. Maybe it hasn’t rained in a long time so it’s low on sources, and it’s superwarm water, in which case [individuals] should certainly avoid those types of areas.

Fitch:

What are some of the biggest takeaways from this conversation that physicians should know for overall pediatric summer safety?

Berg:

One of the biggest things is to make sure we’re pushing and recommending sunscreen. Bringing a bug repellent to an insect-heavy area. Make sure caregivers know their sources when swimming and choose safe environments; pools and freshwater sources where the water is tested and treated regularly. So, although there are treatment options available if your patient does get sick, really the key is to help families get to know their prevention strategies.

This article originally appeared on Contemporary Pediatrics.