Tips and Tricks in Adoption and Pediatrics

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Bleach Baths

Sounds horrible, right? Actually, dilute bleach baths have a role in a few pediatric conditions, so I thought I'd share instructions here.

For children with recurrent, sympomatic infections with staph bacteria, particulary MRSA, we use bleach baths, in conjuction with nasal treatment with Bactroban, to decrease MRSA colonization, and reduce infection risk. Here's a handy guide from the Infectious Disease specialists at Seattle Children's. As always, you'll need to check with your provider first, and the Bactroban is by prescription.

In moderate-severe eczema, especially with frequent bacterial infections or colonization (suspected when eczema patches are unusually red, cracked, painful, oozy/crusted), new evidence suggested that regular soaks in dilute bleach baths may decrease the bacterial burden on the skin, and associated inflammation. Check with your provider first, but here's how, from an excellent review article in Pediatrics by Krakowski et al.:

Explain to patients that their skin may benefit from "swimming in pool water." Then, give them these instructions for making a pool right in their very own bathroom.     

  • Add lukewarm water to fill the tub completely (about 40 gallons of water).
  • Depending on the size of the tub/amount of water used, add 1/4 to 1/2 cup of common bleach solution to the bath water. Any sodium hypochlorite 6% solution will do (for example, Chlorox liquid bleach); the goal is to make a modified Dakin's solution with a final concentration of about 0.005%.
  • Stir the mixture to ensure that the bleach is completely diluted in the bath water.
  • Have patients soak in the chlorinated water for 5 to 10 minutes.
  • Thoroughly rinse skin clear with lukewarm, fresh water at the end of the bleach bath to prevent dryness and irritation.
  • As soon as the bath is over, pat the patient dry. Do not rub dry, as this is the same as scratching.
  • Immediately apply any prescribed medications/emollients.
  • Repeat bleach baths 2–3 times a week or as prescribed by the physician.
The following restrictions apply:    
  • Do not use undiluted bleach directly on the skin. Even diluted bleach baths can potentially cause dryness and/or irritation.
  • Do not use bleach baths if there are many breaks or open areas in the skin (for fear of intense stinging and burning).
  • Do not use bleach baths in patients with a known contact allergy to chlorine.

Ink Test for Scabies

Here's a simple test that you or your doctor can do when you're asking the "is it scabies" question. First, look carefully for fresh itchy bumps or thin grayish squiggly lines (burrows) in the skin, especially at hands, inner wrists, fingerwebs, elbows, armpits, ankles, feet, diaper area, belt-line, and abdomen. Infants and young children can get scabies on the face, scalp, and neck, unlike older folks. Magnifying glass and bright light can help.

Take a dark washable wide-tip marker, and rub around the suspicious bumps or burrows. Then take an alcohol wipe or alcohol-soaked gauze and wipe away the ink. If there's a scabies burrow under the skin, the ink often remains, showing you a dark irregular line. Occasionally a tiny dark dot is visible at the end of the burrow - that's the mite.

At the doctor's office, we might use mineral oil and a scalpel to scrape the burrow and a fresh bump or two onto a microscope slide, to look for the mite, or its eggs and feces. But the ink test can be done at home, if you're curious that way. In children recently adopted from institutional care, we do have a pretty low theshold to treat for scabies for intensely itchy skin rashes.