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Dedicated to PediatricsQ u a r t e r l y N e w s l e t t e r – H i m a l a y a H e r b a l H e a l t h c a r e – P e d i a t r i c s

Vol. 4 No. 3

EditorialGastroesophageal reflux (GER) is the most common gastroenterological problem that leads referral to a pediatric gastroenterologist during infancy. Although minor degrees of GER are experienced in both children and adults, the degree and severity of reflux episodes are increased during infancy. Thereby, GER represents a common physiological event in the first year of life. Studies have reported that approximately 60% to 70% of infants experience emesis during at least one feeding per 24-hour period by 3 to 4 months of age. This issue of Pediritz discusses about the etiological factors, clinical manifestations, and complications of GER in children. Bonnisan and Bonnispaz, phytopharmaceutical formulations of The Himalaya Drug Company are effective in the management of common digestive complaints in infants and children.

This issue also focuses on renal colic in children, an excruciatingly painful event resulting from the presence of calculi in kidney or ureter. An exclusive article on nappy rash, a skin problem commonly affecting children below 3 years of age, highlights on the causes, treatment, and management of this condition.

In addition, this issue also includes other interesting features such as “Upcoming Events,” Picture Quiz,” and “Difficult Case.” We look forward to receiving your valuable feedback/suggestions on this issue as well as your answers to the “Picture Quiz.” Do write to us at [email protected].

Happy reading!

– Editor

2 | Pediritz • Vol. 4 • No. 3

Gastroesophageal Reflux in ChildrenGastroesophageal reflux (GER), an effortless retrograde movement of gastric contents into the esophagus, is considered as a normal physiological process when lasting for less than 3 minutes, occurring in the postprandial period, and causing few or no symptoms. Transient lower esophageal sphincter relaxation (TLESR) is the primary mechanism allowing reflux to occur. Gastric distension is the main stimulus for TLESRs. Straining during a TLESR makes reflux more likely, as do positions that place the gastroesophageal junction below the air–fluid interface in the stomach.

Other factors such as increased movement, straining, obesity, large volume or hyperosmolar meals, and increased respiratory effort as during coughing and wheezing can have a similar effect. Diagnosis of gastroesophageal reflux disease (GERD) is performed when the reflux of gastric contents causes troublesome symptoms and/or complications.

GER in infants is evident in the first few months of life, peaks at 4 months, resolves in most by 12 months, and nearly all by 24 months. Symptoms in older children are chronic, waxing and waning, but completely resolving in about half of them. GERD likely has genetic predisposition, with complex inheritance involving multiple genes. A pediatric autosomal dominant form has been proposed on chromosome 13q14.

Clinical manifestation of GERD in infants is most often with postprandial regurgitation, and signs of esophagitis like irritability, arching, choking, gagging, and aversion to feeds. There may be failure to thrive. In preschool children, there may be regurgitation. In older children, substernal and abdominal pain may occur. Respiratory manifestations include obstructive apnea, stridor, bronchospasm, in which reflux complicates primary airway disease like laryngomalacia or chronic lung disease.

GERD that occurs during infancy has a tendency to improve spontaneously during the first few years of life. This may be due to alteration in feeding habits and improved function of the lower esophageal sphincter.

Complications of GERD include esophagitis and its sequelae like stricture, metaplastic transformation of the normal esophageal squamous epithelium into intestinal

columnar epithelium, termed Barrett esophagus, which is a precursor of esophageal adenocarcinoma.

Failure to thrive is common due to calorie deficit. There may be a variety of otolaryngologic symptoms like infections, postnasal drip and allergies, and pulmonary symptoms like chronic cough and wheezing. Stridor triggered by reflux generally occurs in infants anatomically predisposed to stridor like those with laryngomalacia and micrognathia.

Thorough history and physical examination suffice most of the times in reaching a diagnosis of GERD. Focused diagnostic testing can then supplement the initial examination. Barium radiographic study of the esophagus and upper gastrointestinal tract can help make a diagnosis of GER and rule out other conditions that form differential diagnosis of vomiting and dysphagia.

McCauley, et al in 1978 had published a useful classification or grading based on the extent of retrograde flow of barium. Although it is simple to understand, it is not used in day-to-day practice. The grading is as follows:

y Reflux into the distal esophagus only y Reflux extending above the carina, but not into

cervical esophagus y Reflux into cervical esophagus y Free persistent reflux into cervical esophagus with a

widely patent cardiac sphincter (chalasia)

Pediritz • Vol. 4 • No. 3 | 3

y Reflux of barium with aspiration into the trachea or lungs

These grades were classified into minor reflux (grades 1 and 2) and major reflux (grades 3 to 5).

A radionuclide study using technetium 99 m labeled milk feeding has been described in literature for the detection of GER and aspiration in children.

Extended esophageal pH monitoring is helpful in quantitative documentation of acid reflux episodes. Normal values of distal esophageal acid exposure are generally established as 5% to 8% of the total monitored time. Indications for esophageal pH monitoring are assessing efficacy of acid suppression during treatment, evaluating apneic episodes, chronic cough, stridor, and wheezing. Impedance testing is useful for diagnosis of nonacid reflux, but is cumbersome to perform. Endoscopy allows diagnosis of erosive esophagitis, strictures, and Barrett’s esophagus.

Management includes primarily conservative therapy. Modification of feeding techniques, volumes, and frequency can be advocated like giving small frequent feeds. Thickening of formula with rice cereal may reduce regurgitation and increase calorie density.

A short trial of hypoallergenic diet can be used to exclude milk or soy protein allergy before the intake of medications. Positioning the infant upright or with the head end inclined up from supine posture may help minimize reflux. Pharmacotherapy includes antacids, histamine-2 receptor antagonists such as ranitidine, proton pump inhibitors like omeprazole, lansoprazole, and prokinetic agents like domperidone and erythromycin. Intractable GERD may necessitate surgical procedures like fundoplication. The availability of potent acid suppressing medication mandates more rigorous evaluation of the relative risks and benefits of therapy.

Some conditions in children predispose to or cause higher incidence of GERD. They include prematurity with bronchopulmonary dysplasia, cerebral palsy, hyperactive airway disease, congenital diaphragmatic

hernia, cystic fibrosis, and tracheoesophageal fistula.

Premature babies with extremely low birth weight who have required prolonged mechanical ventilation are the ones prone to develop bronchopulmonary dysplasia, in which there may be tachypnea, increased anteroposterior chest diameter, altered lung mechanics, all of which cause frequent symptoms of GERD.

GERD can cause chronic, intermittent cough and masquerade as hyperactive airway disease like asthma. Reflux can also worsen asthma by macro- or micro-aspiration and vagally mediated reflex bronchospasm. Occult GER should be suspected in children who have hyperactive airways, the symptoms of which are difficult to control.

More than 50% of children with congenital diaphragmatoic hernia have GERD. It is more common in those children whose diaphragmatic defect involves the esophageal hiatus. About 25% of these children with GERD are refractory to medical management and require a surgical antireflux procedure.

In children with cystic fibrosis, several factors raise intra-abdominal pressure, including cough and obstructed airways, causing repeated aspiration and wheezing reflex. These signs and symptoms overlap with those of GERD. In infants with tracheoesophageal fistula, GERD may develop due to intrinsic abnormalities of esophageal motility, and anastomotic strictures following surgical correction.

Cow’s milk protein allergy can mimic or aggravate all signs and symptoms of severe GERD during infancy.Feeding difficulties, vomiting, and recurrent chest infections associated with poor growth and nutrition are common in children with cerebral palsy. In the Institute of Child Health, Birmingham, it was proven with 24-hour ambulatory esophageal pH monitoring, that there is a significant incidence of gastroesophageal reflux. The recommendation from that study and several others is that reflux is common and should be treated in symptomatic, neurologically handicapped children as effective treatment is likely to improve quality of life.

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Efficacy of Bonnispaz in Abdominal ColicA study conducted to evaluate the clinical efficacy and safety of Bonnispaz drops in abdominal colic in infants and children reported significant relief from abdominal bloating and tenderness. The study was an open clinical trial where all infants and children suffering from abdominal colic were included. Of the 105 patients enrolled, 103 patients had excessive crying problem and abdominal bloating; 105 patients had reduced food intake; and 67 patients were suffering from uncleared bowels. After 5 days treatment with Bonnispaz, a 100% significant symptomatic relief from excessive crying, abdominal bloating, and abdominal tenderness was observed. All the infants who had reduced food intake and uncleared bowels showed improvement.

– Parmar BJ, et al. Antiseptic. 2007;104(10):524-528.

Bonnisan for Gastrointestinal Disturbances in ChildrenA study conducted to evaluate the efficacy of Bonnisan in infants and young children with gastrointestinal disturbances showed significant improvement in conditions such as dyspepsia, infantile colic, and nonspecific diarrhea. The study included 150 children aged ≤3 years. Bonnisan was administered at appropriate doses three to four times a day to children aged between 1 and 36 months. Bonnisan treatment resulted in a significant improvement in 116 (77.3%) children with gastrointestinal symptoms. Bonnisan was also effective in majority of the children with postantibiotic dyspepsia (100%), nonspecific constipation (93.3%), infantile colic (86.6%), teething problem (80%), failure to thrive and vague illness (70%–75%), and anorexia, vomiting or regurgitation, and mild nonspecific diarrhea (60%–67%).

– Sethi T, et al. Med & Surg. 1982.

Picture Quiz No.14QuestionWhat is your diagnosis?

Please send in your answers by May 15, 2012 to:The Editor – Pediritz The Himalaya Drug Company Makali, Bangalore 562 123, India T +91 80 2371 4444. F +91 80 2371 4480 [email protected] • www.himalayahealthcare.com

Cong

ratu

latio

ns!

Winners* ofPediritz Picture Quiz No. 12

Correct answer:Diagnosis: Tracheoesophageal fistula

X-ray shows coiled feeding tube in the esophagus (anteroposterior view) suggesting blind end (lateral view). Gas in the abdomen (lateral view) suggests that the lower segment of the esophagus is connected to trachea.

Pediritz Picture Quiz No.12

Each winner gets a gift hamper consisting of a Littmann stethoscope and Bluebeam no contact thermometer*Winners are chosen by lucky draw

Dr Priyanka Jain, MBBS, DNB (Paed) Neonatologist, Child Specialist & Pediatric Dermatologist, Indore, Madhya pradesh

Dr Prashanth Patil, MBBS, DCHPediatrician, Patil Hospital, CIDCO, Aurangabad, Maharashtra


Renal Colic in ChildrenRenal colic is the intermittent and acute pain usually resulting from the presence of one or more calculi in the kidney or ureter. The pain typically begins in the abdomen and often radiates to the hypochondrium or the groin. Most of the pain receptors of the upper urinary tract responsible for the perception of renal colic are located submucosally in the renal pelvis, calices, renal capsule, and upper ureter. Acute distention seems to be more important in the development of the pain of acute renal colic than spasm, local irritation, or ureteral hyperperistalsis.

Stimulation of the peripelvic renal capsule causes flank pain, while stimulation of the renal pelvis and calices causes typical renal colic. Mucosal irritation can be sensed in the renal pelvis to some degree by chemoreceptors, but this irritation is thought to play only a minor role in the perception of renal or ureteral colic.

Renal pain fibers are primarily preganglionic sympathetic nerves that reach spinal cord levels T-11 to L-2 through the dorsal nerve roots. Aortorenal, celiac, and inferior mesenteric ganglia are also involved. Spinal transmission of renal pain signals primarily occurs through the ascending spinothalamic tracts.

In the lower ureter, pain signals are also distributed through the genitofemoral and ilioinguinal nerves. The nervi erigentes, which innervate the intramural ureter and bladder, are responsible for some of the bladder symptoms that often accompany an intramural ureteral calculus.

Development of Renal Colic Pain—Clinical AspectsThe colicky-type pain known as renal colic usually begins in the upper lateral midback over the costovertebral angle and occasionally subcostally. It radiates inferiorly and anteriorly toward the groin. The pain generated by renal colic is primarily caused by the dilation, stretching, and spasm caused by the acute ureteral obstruction. (When a severe but chronic obstruction develops, as in some types of cancer, it is usually painless.)

In the ureter, an increase in proximal peristalsis through activation of intrinsic ureteral pacemakers may

contribute to the perception of pain. Muscle spasm, increased proximal peristalsis, local inflammation, irritation, and edema at the site of obstruction may contribute to the development of pain through chemoreceptor activation and stretching of submucosal free nerve endings.

The term “renal colic” is actually a misnomer, because this pain tends to remain constant, whereas intestinal or biliary colic is usually somewhat intermittent and often comes in waves. The pattern of the pain depends on the individual’s pain threshold and perception and on the speed and degree of the changes in hydrostatic pressure within the proximal ureter and renal pelvis. Ureteral peristalsis, stone migration, and tilting or twisting of the stone with subsequent intermittent obstructions may cause exacerbation or renewal of the renal colic pain.

The severity of the pain depends on the degree and site of the obstruction, not on the size of the stone. A patient can often point to the site of maximum tenderness, which is likely to be the site of the ureteral obstruction.

A stone moving down the ureter and causing only intermittent obstruction actually may be more painful than a stone that is motionless. A constant obstruction, even if high grade, allows for various autoregulatory mechanisms and reflexes, interstitial renal edema, and pyelolymphatic and pyelovenous backflow to help diminish the renal pelvic hydrostatic pressure, which gradually helps reduce the pain.

Acute renal colic is probably the most excruciatingly painful event a person can endure. Striking without

Kidney stones

warning, the pain is often described as being worse than childbirth, broken bones, gunshot wounds, burns, or surgery. Renal colic affects approximately 1.2 million people each year and accounts for approximately 1% of all hospital admissions. Most common cause of renal colic is renal stones. Urinary tract stone disease has been a part of the human condition for millennia; in fact, bladder and kidney stones have even been found in Egyptian mummies. Some of the earliest recorded medical texts and figures depict the treatment of urinary tract stone disease.

The four main chemical types of renal calculi, which together are associated with more than 20 underlying etiologies:

y Calcium stones y Struvite (magnesium ammonium phosphate) stones y Uric acid stones y Cystine stones

Drug-induced Stone DiseaseA number of medications or their metabolites can precipitate in urine causing stone formation. These include indinavir; atazanavir; guaifenesin; triamterene; silicate (overuse of antacids containing magnesium silicate); and sulfa drugs including sulfasalazine, sulfadiazine, acetylsulfamethoxazole, acetylsulfasoxazole, and acetylsulfaguanidine.

Approximately 80% to 85% of stones pass spontaneously. Approximately 20% of patients require hospital admission because of unrelenting pain, inability to retain enteral fluids, proximal UTI, or inability to pass the stone.

The usually quoted recurrence rate for urinary calculi is 50% within 5 years and 70% or higher within 10 years, although a large, prospective study published in 1999 suggested that the recurrence rate may be somewhat lower at 25% to 30% over a 7.5-year period. Recurrence rates after an initial episode of ureterolithiasis have also been reported to be 14%, 35%, and 52% at 1, 5, and 10 years, respectively.

Risk Factors of Developing Kidney StonesCertain factors can increase a child’s risk of developing kidney stones.

History of kidney stones: Children who have had a kidney stone in the past have the highest risk of developing a stone in the future. Preventive measures can decrease the risk of developing a stone in the future.

Inadequate intake of fluids: The amount of fluid intake directly affects the amount of urine the body makes. Drinking small amount of fluids means that the kidneys make a small amount of urine, which increases the concentration of stone-forming substances in the urine. Drinking enough fluids can reduce the risk of recurrent stones.

Ketogenic diet: Diets that include a very small amount of carbohydrates, called ketogenic diets, can increase the risk of developing kidney stones. Ketogenic diets are sometimes used to treat seizure disorders.

Cystic fibrosis: Children with cystic fibrosis are at higher risk of developing kidney stones.

Abnormalities in urinary tract: Having congenital abnormalities in the kidneys, ureters, or bladder can increase the risk of developing a kidney stone.

Medications: Certain medicines increase the risk of forming crystals in the urine. Some of them include furosemide, acetazolamide, and allopurinol.

Inherited disorders: Several uncommon inherited disorders can increase a child’s risk of developing kidney stones. Testing for these disorders might be recommended.

“A stone’s throw away”

Meaning: A relatively short distance.

Example: “John saw Mary across

the street, just a stone’s throw away.”

“Carved in stone”

Meaning: Firmly established; set in concrete.

Example: “Our business plan isn’t carved in

stone—we can still make adjustment if we

need to.”

“Leave no stone unturned”

Meaning: To search in all possible places.

Example: “Don’t worry. We’ll nd your

stolen car. We’ll leave no stone unturned.”


Usage of Stone in Language


Metabolic Risk Factors in Children with Kidney Stone DiseaseThe evaluation of metabolic risk factors in children with renal stone disease is the basis of medical treatment aimed at preventing recurrent stone events and the growth of preexisting calculi.

In this retrospective study, the authors evaluated the metabolic risk factors and clinical and family histories of 90 children with kidney stone disease, who had been referred to the institution and subjected to clinical tests using a standardized protocol. The mean age of the pediatric patients was 10.7 years, and the male:female ratio was 1.14:1.0.

Biochemical abnormalities were found in 84.4% of all cases. A single urine metabolic risk factor was present in 52.2% (n = 47) of the patients, and multiple risk factors were present in the remaining 31.1% (n = 28). Idiopathic hypercalciuria (alone or in combination) and hypocitraturia (alone or in combination) were the most frequent risk factors identified in 40% and 37.8% of these patients, respectively. Renal colic or unspecified abdominal pain were the most frequent forms of presentation (76.9%), with 97.5% of stones located in the upper urinary tract.

In most patients, stone disease was confirmed by renal ultrasonography (77%). A positive family history in first-degree and second-degree relatives was found in 46.2% and 32.5% of the cases, respectively.

The authors conclude that specific urine metabolic risk factors are found in most children with kidney stones and that hypocitraturia is as frequent as hypercalciuria. Very often there is a positive family history of renal stone disease in first- and second-degree relatives.

– Spivacow FR, et al. Pediatr Nephrol. 2008;23(7):1129-1133.



Himalaya




Figure 2

Placebo group Cystone group

Calcium

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Figure 1

Placebo group

Cystone group

Calcium-6

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Beneficial Role of Cystone in Pediatric Urolithiasis This study was aimed to evaluate the efficacy and safety of Cystone in children with urolithiasis below 12 years of age, with special reference to urinary excretion of calculogenesis inhibitors. Eighty-seven children were included in this study. All patients received the same dosage of Cystone or placebo for a period of 4 months. Symptomatic relief was reported by 70.6% patients. The disappearance of stones was noted in 11 patients, as confirmed by x-ray KUB and ultrasound examination.

In patients with “upper tract stones,” there was a statistically significant difference in the 24-hour urinary excretion of phosphorus, calcium, and magnesium in pretreatment and posttreatment levels between the drug and placebo groups (Figure 1). In patients with “lower tract stones,” a difference in the 24-hour urinary excretion of calcium, phosphorus, citric acid, and magnesium was noted between the drug and placebo groups (Figure 2). Therefore, this study indicates that Cystone appears to have a favorable effect on inhibition of calculogenesis and prevent recurrence in pediatric urolithiasis.

– Bhatnagar V, et al. Med Update. 2004;11(11):47-54.

Difficult CaseAn 11-year-old girl, who has had nephrotic syndrome since the age of 20 months presents in relapse for the twelfth time. She has always been steroid responsive and had highly selective proteinuria with a normal serum complement. A renal biopsy at the age of 2 years was consistent with minimal change disease. Her last relapse was 9 months ago and she was off steroids for 3 months. The patient had a history of proteinuria and edema 5 days prior to this admission, but for the previous 24 hours, she experienced severe abdominal pain, vomiting, and dizziness on standing up.

ExaminationHeight—10th centile; weight—75th centile; apyrexial; edema of ankles and face; pulse—92/min, sinus arrhythmia; and blood pressure—85/60 mm Hg. Heart sounds were normal; chest clear; abdomen not distended, diffusely tender, and bowel sounds present.

Following admission, the patient continued to vomit copiously for more than 10 times a day. She continued to drink fluids and passed 300 mL urine per day with significant proteinuria. She felt faint and her abdominal pain improved. Three days later, she again complained of pain in her legs. She lost 1.2 kg of weight and had minimal edema. Her peripheries were cool, with loss of fine touch sensation and movement. Calf and thigh muscles were tender bilaterally. Peripheral pulses were decreased, femorals were weak, and popliteal and dorsalis pedis pulses could not be felt. Heart sounds were normal and her chest was clear. Her abdomen was little distended and tender.

Answers1) Hypovolemia, arterial thrombosis, peritonitis2) Coagulation screen, Doppler of leg pulses, aortogram, creatinine, and blood

culture3) Insert CVP line, intravascular volume replacement followed by rehydration,

steroids, anticoagulants, and penicillin.

DiscussionAbdominal pain in nephrotic syndrome frequently heralds the onset of major complications like hypovolemia or peritonitis. Peritonitis is unlikely because of the prolonged history, lack of fever when off steroids, and lack of increasing abdominal signs. Hypovolemia is very likely, often presenting with abdominal pain and vomiting, compounded with postural hypotension. Cool peripheries are almost conclusive. Fluid balance in an already hypovolemic patient should be very carefully watched. Salt-free albumin (1 g/kg), and if necessary, plasma infusion are good for volume replacement which can be judged on CVP. Then, rehydration should be started according to biochemistry.

The child also has ischemia of lower limbs. Initially, it can be thought of as poor perfusion, but a hypercoagulability state has frequently been described in nephrotic syndrome. Reports of arterial thrombosis and femoral vein thrombosis after venipuncture have been reported. In view of this, a clotting screen and Doppler soundings of the pulses after volume replacement should be done. Further treatment consists of penicillin as prophylaxis against pneumococcal infection after a blood culture. Relapses should be treated with steroids.

InvestigationsHb—12.6 g%; WBC—7.6 × 109 L; platelets—179 × 109 L

24-hour urine, 6.5 g of protein per 24 hours

Serum sodium—133 meq/L, potassium—5.1 meq/L, bicarbonate—16 meq/L, urea—55 meq/L, serum albumin—5 g/L

Questions1. What is the most likely cause of thrombocytopenia?2. What investigation would be most helpful to prove this?3. What could be the line of treatment to be adopted?


Event: 8th Annual Pediatric Clinical Trials ConferenceDate: May 2 to 4, 2012Venue: Philadelphia, Pennsylvania, United States

Event: Pediatrics ReviewDate: July 7 to 14, 2012Venue: Civitavecchia, Italy

Event: Issues of Obstetrics, Gynecology and PerinatologyDate: May 17 to 18, 2012Venue: Yalta, Ukraine

Upcoming EventsEvent: The 2nd Global Congress for Consensus in Pediatrics & Child HealthDate: May 17 to 20, 2012Venue: Moscow, Russian Federation

Event: Royal College of Paediatrics and Child Health (RCPCH) 2012 Annual ConferenceDate: May 22 to 24, 2012Venue: Glasgow, United Kingdom

Event: 46th Annual Meeting of the Association for European Paediatric and Congenital CardiologyDate: May 23 to 26, 2012Venue: Istanbul, Turkey

Laughter—The Best Medicine


A father and his son went fishing one day. Sitting in the boat for a couple of hours gave them not much to do, so the son started thinking about the world around him and asked his father some questions.

“How does this boat float?”

The father thought for a moment, then replied, “Don’t rightly know, son.”

The boy returned to his contemplation, and soon came up with another one, “How do fish breathe underwater?”

Once again the father replied, “Don’t rightly know, son.”

A little later the boy asked, “Why is the sky blue?”

Again, the father replied, “Don’t rightly know, son.”

Worried he was going to annoy his father, he said, “Dad, do you mind me asking you all these questions?”

The father immediately assured him, “Of course not, son. If you don’t ask questions, you’ll never learn anything!”

• • •

Gary was traveling down a quiet country road when he noticed a large group of people standing around outside a house. He stopped and asked a farmer why such a large crowd was gathered.

The farmer replied, “Billy Bob’s mule kicked his mother-in-law and she died.”

“I see,” Gary said. “Well, she must have had a lot of friends.”

“Naw,” the farmer said, “we all just want to buy his mule.”

• • •

A man was sitting reading his paper when his wife hit him round the head with a frying pan.

“What was that for?” the man asked.

The wife replied, “That was for the piece of paper with the name Jenny on it that I found in your pants pocket.”

The man said, “When I was at the races last week, Jenny was the name of the horse I bet on.”

The wife apologized and went on with the housework.

After 3 days, the man was watching TV when his wife bashes him on the head with an even bigger frying pan, knocking him unconscious.

Upon re-gaining consciousness, the man asked why she had hit him again.

She replied “Your horse called up.”

• • •

One friend asked another friend, “What will you advise your children about marriage?”

The friend replied, “I will never marry in my life and I will give the same advice to my children also.”

• • •

They were easy, but I had trouble with the answers.

How were the exam questions?


Nappy RashIntroductionDiaper rash, a skin problem that develops in the area beneath an infant’s diaper, is commonly observed in children by 3 years of age, especially in infants aged between 9 and 12 months.

Nappy rash is soreness of skin in the area covered by the diaper and is most commonly due to prolonged exposure of the skin to feces and urine. Babies with sensitive skin, those with a tendency of dryness and eczema, are more vulnerable to nappy rash. Once bowel and bladder control has been achieved, the chances of experiencing nappy rash are reduced, as the exposure of skin to feces and urine is minimized.

Infection: The warmth and moisture within a heavy diaper form a milieu conducive to growth of bacteria, but more commonly yeast like Candida. Babies on antibiotics for long, or whose nursing mothers are on antibiotics for long can have Candida dermatitis in the diaper area. Newborns with oral thrush can sometimes develop Candida infection in the perianal area too. Some infants/children can develop bacterial infection over the rash, with purulent discharge, resembling impetigo.

All diaper rashes do not appear similar. It may begin as a beefy red area around the anal opening, and may spread to the groin involving the thigh folds, scrotal skin, or labia. If a mild rash is left untreated or is exposed repeatedly to feces (which is acidic), small scattered erythematous papules; raised and swollen patches of erythematous skin; small patches of skin excoriation; and rarely, bullous eruptions could be observed.

TreatmentTreatment includes local application of barrier creams and zinc oxide. Antifungal topical applications would be useful for Candida dermatitis. For bacterial infection like impetigo, topical and sometimes systemic antibiotics would be required. Rarely, when the rash is severe enough to cause skin excoriation or bullous eruptions, a mild steroid application might be required for the anti-inflammatory effect.

ManagementPrevention is based on keeping the perianal area dry and clean as much as possible. Changing diapers frequently helps avoid rashes. Rubbing the area vigorously with wipes can compromise the skin integrity. Talc is not recommended as the particles may be inhaled. Since talc could contain asbestos like fibers, it has been considered as a potential carcinogen. Corn starch powder may be a good alternative. Once a rash is developed, the skin in the affected area should be washed with water and a mild soap. Scrubbing should be avoided. Leaving the skin exposed for some time everyday helps it to heal faster. Exposing the rash to some source of heat also accelerates healing.

Causes of Nappy RashFeces and urine: When bacteria in the stool react with urine, ammonia is formed, which can develop a rash. When infants have diarrhea, the stools may be acidic and cause skin irritation.

Friction: When a baby’s sensitive skin comes in constant contact with a wet diaper, a reddish area is developed on the exposed skin.

Chemicals: Sometimes the fragrance within a disposable diaper (nowadays most of the diapers available in the market are odorless), or detergent used to wash a cloth diaper can cause skin irritation and lead to rash. Allergy to wipes can also cause rashes.

New foods: Introduction of new foods including semisolids can cause a change in the stool composition and render the skin susceptible to rashes. There is also a possibility of the baby’s skin being sensitive to something in the breastfeeding mother’s diet.

Editorial Team Editor in chief: Dr Pralhad S Patki • Managing Editor: Dr Jayashree B Keshav • Editorial Assistants: Shruthi VB, Rashmi Raj, Shahina KR • Layout Artists: Dayananda Rao S, Santosh G

Advisors: Suresh TL, Manohar Pai K, Dr Ranjan K Pejaver, Dr Archana Bilagi


A prospective, phase III clinical trial was conducted to evaluate the efficacy and safety of diaper rash cream in the management of infantile irritant diaper dermatitis (IIDD). A total of 15 infants suffering from IIDD and whose parents were willing to give informed written consent were included in the study. Before beginning the study, the “diaper rash cream” was applied in a test dose and observed for the development of any immediate hypersensitivity manifestations for a period of 30 minutes. If there were no immediate hypersensitivity manifestations, the parents were advised to apply the “diaper rash cream” once daily, after bath for a period of 2 weeks, on the skin covering the groin, lower stomach, upper thighs, and buttocks. All the infants were followed up on the 7th and 14th day of application, and at each follow-up visit, a detailed clinical examination was carried out.

There was a significant improvement in the clinical manifestations of IIDD in all the included infants within 3 days, and there was complete recovery from the clinical manifestations of IIDD after a week’s application in all the included infants. The positive benefits observed are due to the synergistic action of the active ingredients of the formulation —anti-inflammatory activities (Aloe vera, Vitex negundo, and Rubia cordifolia), antibacterial activities (Zinc calx, Aloe vera, Vitex negundo, and Rubia cordifolia), wound-healing activities (Aloe vera), and antioxidant activities (Vitex negundo, Prunus amygdalus, and Rubia cordifolia).

– Chatterjee S, et al. Antiseptic. 2005;102(5):251-255.

Diaper Rash Cream in the Management of Infantile Irritant Diaper Dermatitis

Beginning at the Bottom: Evidence-based Care of Diaper DermatitisHeimall LM, et al.

N Am J Matern Child Nurs. 2012;37(1):10-16.

Diaper dermatitis (DD), an acute inflammatory reaction of skin in the perineal area, is an extremely common pediatric condition. Nurses’ practice of preventing and treating DD is inconsistent and often not evidence-based. In addition, a 2008 Skin Injury Prevalence Study revealed that 24% of inpatients had DD.

The researchers developed a project to determine a consistent and evidence-based approach to DD prevention and treatment including the availability of products. A complete literature review was conducted in addition to benchmarking with other pediatric hospitals, consultation with topic experts, and evaluation of current nursing practice prior to revising the existing perineal skin care nursing standard. The evidence supports frequent diaper changes, use of super absorbent diapers, and protection of perineal skin with a product containing petrolatum and/or zinc oxide. As supported by the literature, the researchers revised the standard to include improvements in practice as well as product updates for prevention and treatment. Hospital-wide implementation of the revised standard included training “Skin Care Champions” to educate staff and support practice improvements. Ongoing education and monitoring by the Skin Care Champions is necessary to further improve the prevention and treatment of DD for the patients.



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