MCA Training Made Easy

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1 MCA Training Made Easy MODULE 5 Children s Health Learning objectives After reading this module you will: Offer advice on infant formula milks available in your pharmacy Be aware of the infectious diseases that can afflict children and recognise the danger signs of serious health problems Know what to recommend to reduce pain and fever in a child and when to refer Recommend and advise parents on cold, flu and cough treatments Be aware of the signs and symptoms of more serious coughs Recommend treatments for colic, diarrhoea, vomiting and constipation and know when to refer Understand what causes worms and how to treat and prevent them Be able to offer advice on eczema, nappy rash and cradle cap treatments Know how to manage head lice appropriately in your area Be able to recognise and treat conjunctivitis 1 Most infant formula are cow s milk-based but these are not suitable for babies that are lactose intolerant. Instead soya milk should be recommended The Track and Train Medicines Counter Assistant Course is accredited by the General Pharmaceutical Council as providing the essential knowledge required to work in a pharmacy as a Medicines Counter Assistant. ALWAYS REMEMBER WWHAM! When recommending a suitable medicine for a customer, always remember the WWHAM questions to help you get the right information for your decision: Who is the medicine for? What are the symptoms? How long have the symptoms been present? Has any Action been taken so far? Are any other Medicines being taken? PART 1: INFANT FEEDING Managing children s health begins a lot earlier than you might imagine. In fact, it begins during pregnancy when everything the mother does has an impact on her child. See Module 4 Women s Health for more information. Once mum has had a baby, however, the reality of looking after a little one can be very different to what they were expecting. After all, no-one really tells you how hard it can be to get a baby into a good feeding and sleeping routine, or how much you can worry over the slightest sniffle! What advice can I give on infant feeding? Indeed, you might be asked to offer advice on the many different infant formula milks your pharmacy stocks. While breastfeeding is always best as it gives the baby the best start in life, infant formula are there for mums who are unable, or don t want to, breastfeed or for those who want the flexibility to do both. With a number of different products available, it can be confusing for a first-time mum to know what s the right infant formula for their child. These products are designed to mimic breastmilk so contain additional ingredients, such as long-chain polyunsaturated acids (LCPs) for brain development, probiotics to help digestion and nucleotides to aid the immune system. For babies under six months, cow s milk formula is the most commonly used types. TYPE Cow s milk, whey-based Cow s milk, casein-based Soya-based USED FOR: Most babies (standard formula) Hungry babies Lactose intolerant These are usually whey-based, making them similar to breast milk. Another cow s milk type is the casein-based formula which takes longer for babies to digest and are suitable for hungry babies. If the baby is unable to take cow s milk formula, usually because they are lactose intolerant, then suggest a soya formula instead. If your pharmacy is part of a milk tokens scheme then you may find that you are able to supply certain formula milks to customers for free. At six months, babies begin weaning onto solid foods and they can also be switched onto a follow-on milk formula, although this is not necessary. These contain more iron and other vitamins and minerals, but they are not available as part of the milk tokens scheme. Once baby is a year old, then they can take full-fat regular milk. PART 2: SERIOUS INFECTIONS It can be hard for a new mum to feel confident in handling her baby s health issues, in particular how to tell the difference between a minor ailment and a serious problem that needs urgent investigation, and perhaps a trip to the hospital accident and emergency (A&E) department. Always check with the pharmacist about referral to A&E,

2 Time Out Make a table of all the infant formula milks you stock in the pharmacy. List whether each formula is whey, casein or soya based, what age it can be used from, what additional ingredients it contains and whether it is available on the milk token scheme. calling an ambulance or referral to a children s ward. See the box on When to Refer to Hospital for the key symptoms you need to be aware of. What do I need to know about childhood infections? Another area of confusion is whether their child has one of the common childhood infections, such as chickenpox, measles and mumps. These days, children are immunised against most of these in the first year of life, with the exception of chickenpox. You might be asked advice about the effects of the MMR vaccine (that s the measles, mumps and rubella vaccine) as there has been widespread publicity suggesting it causes autism in children. Refer any mums to the pharmacist for advice, but Government advice is that there is no link between the MMR vaccine and autism. They can also be referred to their health visitor or the Department of Health website for further information. Additional useful contacts are the Meningitis helpline ( ) and NHS direct ( ). For most childhood infections, see the table for information on the symptoms and how to treat. COMMON CHILDHOOD INFECTIONS AND HOW TO TREAT Is it serious? Symptoms Contagious period Recommend Chickenpox (varicellazoster virus) No only in pregnant women Feeling unwell Slight fever Spots on the chest and back. Spots are very itchy, blister and spread to rest of body within a day or so, before scabbing over From day before spots appear until all spots have scabbed over Analgesics to reduce temperature, antihistamines and calamine lotion to reduce itch Wear loose clothes and have cool baths Avoid pregnant women as can cause miscarriage Refer to doctor as serious complications can develop (such as meningitis and pneumonia) Recommend analgesics to reduce fever and ease pain, place a wet towel over radiator to ease cough, close curtains if child dislikes light, give child lots to drink and keep away from other people for at least 7 days after the rash has appeared Check with pharmacist and refer IMMEDIATELY to hospital A&E Measles Can be serious if there are complications Starts with cold, cough, watery eyes and fever Blotchy, red/brown rash appears after 3rd or 4th day. Spots start behind the ears and are slightly raised, but not itchy Spots spread to the face, neck and rest of body. Child becomes very unwell (tired, irritable, aches and pains, poor appetite) with dry cough and high fever for around a week Earliest signs appear in the first 8 hours of infection: Severe pains in the leg, cold hands or feet Temperature with pale, dusky or blue-coloured skin around the lips. From hours after infection: In babies - High pitched, moaning cry Difficult to wake Refusing to feed Pale and blotchy skin, red or purple spots on the body From a few days before until 4 days after rash appears Meningitis Serious potentially fatal if not treated in time. Any suspected meningitis sufferers must be referred to the hospital immediately Varies between different types of meningitis always act quickly 2 Cont

3 MODULE 5 Children s Health Is it serious? Symptoms Contagious period Recommend that don t disappear when glass pressed against them (Glass Test) In older children - Fails the Glass Test Stiffness in the neck Drowsiness or confusion Severe headache Dislike of bright light Mumps No Starts with feeling unwell Slight fever Possible pain around the ear, swelling starts in glands under the jaw by the ear and moves to face, usually just one side first, with swelling lasting for about a week Sore throat, pain when chewing or swallowing, dry mouth Headache, loss of appetite Starts with a cold and slight temperature Swollen glands in the neck and behind the ears Rash of pale pink, flat spots appears 1-2 days later on the face General red rash spreads to the rest of the body Usually sufferer won t feel unwell Starts with cough and cold Cough gets worse until after 2 weeks when coughing bouts begin which make it hard to breath Cough often worse at night Whooping noise, choking and vomiting From a few days before until swelling goes down Can be managed by parents with pain relievers to ease swollen glands Recommend lots to drink, but avoid fruit juices as can hurt the throat Refer to doctor if other symptoms alongside Child usually doesn t feel unwell, so just give lots of fluids Rubella (German measles) No except in pregnant women From a week before rash appears and for 4-5 days after rash appears Avoid pregnant women and anyone trying to get pregnant as can damage the baby in first 4 months of pregnancy Whooping cough Yes From first signs until about 2 weeks after cold signs appear Refer to GP any cough that is getting worse and those with longer coughing bouts 3

4 4 Remember aspirin cannot be recommended for children under 16 years of age. Instead paracetamol or ibuprofen can be used, but don t advise using together WHEN TO REFER TO THE PHARMACIST FOR IMMEDIATE REFERRAL TO HOSPITAL A&E IMMEDIATELY (Call 999) If baby turns blue or pale and is floppy A high temperature, especially if there is also a rash Difficulty breathing, breathing fast or grunting breathing Very drowsy and hard to wake Child doesn t seem to know or recognise parents A temperature, but the skin on the hands and feet feel cold and clammy A purple-red rash on the body PART 3: PAIN AND FEVER Pain and fever are probably the main problems new mums are worried about. While fever is easy to spot, pain is not as babies can t say what s wrong and children often can t explain where it hurts. Understanding pain Headache: Headache is more common than we may expect in children. Around 10% suffer from migraines, with the same amount again affected by tension headaches. The symptoms will be the same as for adults, although children with migraine often complain of stomach pains as well (see Module 2: Pain for more information on headaches). Teething: Some babies are born with some milk teeth, but in general they start to poke through and cause trouble from around 6-9 months of age until about three years. As well as the pain, babies will also have many other symptoms that suggest they are cutting a tooth. This includes swollen gums, red/inflamed cheeks, lots of dribbling, fever, nappy rash, being irritable, changes in appetite/sleep and chewing on everything they can get their hands on. Between the ages of 6-12 years old teething kicks in again as adult teeth start to come through. Earache: Also known as otitis media, earache is a build up of fluid in the middle ear. It can be caused by a viral or bacterial infection or just mucus building up after a child has had a cold. It s quite common; about 1 in 5 children under the age of 4 years have at least one ear infection a year. It can be hard for parents to pinpoint earache as babies can t say they are in pain, but tugging at the ear, fever, being irritable and lethargy are key signs of earache. If the ear infection gets worse there maybe some discharge. Glue ear happens when the ear infection keeps coming back. Sprains, strains and fractures: It s unlikely that any child will get through their childhood without several sprains and strains, and in some cases at least one fracture! For sprains and strains the symptoms they ll complain about include pain, swelling, redness and possible bruising. It can be difficult to tell if there is any fracture but the bone may be at an odd angle and the child is unable to move the affected part properly. Immunisations: Pain at the site of the injection and fever are common in babies and children after they have had their vaccinations. See table for immunisation schedule. CHILDHOOD IMMUNISATION SCHEDULE AGE 2 months 3 months 4 months 12 months 13 months Three years and four months or soon after Girls years old VACCINATION Polio, diphtheria, whooping cough, tetanus, haemophilus B influenzae (Hib, can cause meningitis), pneumococcal (protects against pneumococcal infection that can cause a type of meningitis) Polio, diphtheria, whooping cough, tetanus, Hib, meningococcal type C Polio, diphtheria, whooping cough, tetanus, Hib, meningococcal C, pneumococcal Hib, meningococcal C MMR (measles, mumps and rubella), pneumococcal MMR, polio, diphtheria, whooping cough, tetanus Human Papilloma Virus (HPV) Booster of polio, diphtheria and tetanus The Department of Health issues a booklet in which all immunisations can be recorded. Further information on vaccines can be found on: Managing pain All pain, including earache, can be treated with oral pain relievers, such as paracetamol and ibuprofen (see Module 2 Pain). Although earache should be referred to the doctor, guidelines now recommend it is treated first with pain relievers (paracetamol is the recommended first choice) - antibiotics are only used if the earache doesn t clear up in a couple of days or gets worse. Don t recommend aspirin. It MUST NOT be given to anyone under the age of 16 years because it can cause Reye s syndrome a serious condition affecting the brain. Paracetamol (e.g. Calpol, Disprol) is the only pain reliever that can be recommended for babies who are having their first vaccinations; it

5 MODULE 5 Children s Health can be used from 3 months, or from 2 months for vaccinations. Ibuprofen (e.g. Nurofen for Children) can be used for children from the age of 3 months check the label as this is not true for all ibuprofen manufacturers. There is no evidence that one pain reliever is better than the other, although ibuprofen s effects can last up to 2 hours longer than paracetamol. Remember that ibuprofen can cause problems in children with asthma and so must not be recommended for these children - always refer customers with asthma to the pharmacist. Advise customers giving paracetamol to children to take care and check the dosing. Remind them not to give any other paracetamol-containing products because of the risk of overdose. You can also recommend teething powders and topical anaesthetics, containing ingredients such as lidocaine (e.g. Anbesol, Calgel, Dentinox, Bonjela teething gel). The age from which these can be used varies; some can be recommended from birth, others from 2-3 months of age. Always check the label. Don t confuse Bonjela teething gel with adult Bonjela gel, which must not be used in children under 16 years of age. This is because it contains choline salicylate, which has a possible link to Reye s syndrome. It s important to be aware that hospitals sometimes use ibuprofen and paracetamol together and also GPs often recommend this for babies and children; refer any customers enquiring about this to the pharmacist. If a fracture is suspected or the sprain is in the back or neck, refer to the pharmacist, otherwise recommend the RICE technique. This means the child must follow the RICE protocol: Rest the damaged part apply Ice packs or cold compresses to the area Compress the area (e.g. with an elastic bandage) and Elevate the injured part of the body Pain can also be eased with a pain reliever. Understanding fever Fever is, unsurprisingly, a raised temperature of over 37.8 C (100 F) if measured with a thermometer in the mouth. If measured under the arm, the child has a fever when the thermometer is higher than 37.2 C (99 F). Fever is a sign that there is an infection or illness in the body fever is triggered when the body detects bacteria or viruses. What are febrile convulsions? These are fits/seizures that sometimes happen in children with high fever, over 39 C (102.2 F). They usually happen between the ages of 3 months and 3 years and are due to the baby s brain not being able to cope with the stress of a high temperature. They are frightening for parents, but they re not as serious as they look and they only last for a minute or two. Around two-thirds of children don t have any further convulsions. Managing fever Temperature can be monitored using a thermometer. This can be taken orally (accurate, though can be difficult to get an infant or child to keep in their mouth long enough), under the arm (least accurate) or rectally (most accurate, though most parents are reluctant to use this). Although mercury thermometers used to be the gold-standard, these have been largely replaced by the use of digital thermometers which are accurate and relatively inexpensive. Recommend paracetamol or ibuprofen for fever and check this with the pharmacist. See Managing Pain section for further advice. TOP TIPS Your extra help in pain and fever You can also provide some additional help for parents trying to treat their children s pain and fever see Module 2 Pain for more information on headache, other types of pain and fever management tips. For teething recommend: Give the baby a teething ring Chill a carrot/piece of apple and allow child to chew on it to soothe the gums, but only under supervision as there is the potential for the child to choke Apply a barrier skin around the mouth and neck to protect against dribbling For fever: Give lots to drink; for babies, this should be in the form of boiled, cooled water Sponge with tepid water not cold water Remove clothing and bedding Remember: do NOT give aspirin to children under 16 years old Time Out Consider the advice you would give to a mother about measuring the temperature of her child, Think about thermometers and the advice you would give on using them. Analgesics are the first line treatment for earache, with paracetamol the recommended choice. However, always refer children with earache to the pharmacist for advice 5

6 6 Time Out Consider the cold and flu products you stock for children. Make a note of what age they can be used from and what dosage is suitable for children of different ages. Colds are more common in children than adults, because their immune systems are not well developed. Always check the age of the child that is suffering from a cough or cold as the age from which many ingredients can be used from varies widely PART 4: COLDS, FLU AND COUGHS Understanding colds and flu To some parents it seems as though their child has a permanent runny nose. It s certainly true that kids, because their immune system is not fully developed, get more colds than adults. And with over 200 different cold viruses on the loose, not to mention the different strains of flu virus, it s easy to see why runny noses are something parents tackle regularly. Symptoms of a cold include sneezing, blocked and/or runny nose, sore throat, cough, tiredness and mild fever. Flu symptoms include sudden high temperature, sweating/chills, aching joints, dry cough, extreme tiredness, loss of appetite and feeling sick. For more detail on colds and flu see Module 6 Winter Health. Managing colds and flu New advice is that cold and flu remedies containing decongestants and antihistamines should not be used in children under 6 years of age. This is because there is no evidence that that they work for children in this age group, but they can cause unpleasant side effects such as allergic reactions, effects on sleep and hallucinations. For parents looking for advice on treating colds and flu for a child under 6, recommend paracetamol or ibuprofen painkillers to help reduce fever, soothe sore throats and ease discomfort. From 3 months, parents can try volatile oils such as in topical rubs and inhalations (e.g. Olbas Childrens, Karvol, Snufflebabe). Saline nasal drops can be used from birth onwards and can help to loosen a stuffy nose. Children aged over 6 years can use oral or topical decongestants, although you can recommend paracetamol or ibuprofen painkillers as for children under 6. Oral decongestants e.g. pseudoephedrine are sometimes combined with other medicines such as paracetamol. Always check the label of any cold and flu product before recommending them for children. For extra help in managing colds and flu see Module 6 Winter Health. Cold and flu: WHEN TO REFER TO THE PHARMACIST Cold or flu lasts longer than 10 days (this could be hayfever, year-round allergy or malaria) There is earache or discharge from the ear Severe pain in the face or forehead Shortness of breath or wheezing A high temperature above 39 C (102.2 F) Child with flu symptoms who has been in a malaria area in the past three months Understanding coughs If children are eating, breathing and feeding normally then a cough is usually not much to worry about. There are two types of cough: chesty and dry/tickly. Chesty coughs, also called a productive cough, cause extra mucus and phlegm to be produced. A dry cough starts with a tickly, irritated throat followed by a dry, barking cough with no phlegm being brought up. See Module 6 Winter Health for more information. In children it is important to recognise the symptoms of croup (see below), whooping cough and asthma as they need referral. Managing coughs Always check the label of cough remedies before recommending them. Certain cough mixtures should not be used in children under six years of age, for the same reasons that cold and flu remedies are restricted in this age group. Simple cough mixtures, such as paediatric simple linctus, glycerol syrup (e.g. Tixylix Baby Syrup) and dilute acetic acid (e.g. Meltus Baby Cough Linctus) can be used by children under 6 to soothe the throat and ease the cough. Always check the label of any cough products before recommending them some cannot be used in very young children, and doses vary depending on age. Children aged 6 years and over can use mixtures that contain ingredients that specifically tackle chesty or dry/tickly coughs. For chesty coughs, expectorants such as guaifenesin, ipecacuanha and ammonium chloride, help bring up phlegm (e.g. Benylin Children s Chesty coughs, Calcough Six Plus Syrup, Tixylix Chesty Cough). For dry coughs recommend a cough suppressant, such as pholcodine (e.g. Tixylix Dry Cough Linctus). This can cause drowsiness and constipation. Some cough remedies contain additional ingredients, such as decongestants and antihistamines that may also cause drowsiness but these may help children with problems sleeping (e.g. Benylin Children s Night Coughs). It is a good exercise to look at the labels and patient information leaflets of these products to familiarise yourself with them, and remember that some cough and cold mixtures are not suitable for children under 6 years of age.

7 MODULE 5 Children s Health Understanding croup Croup is caused mainly by viral infections that cause the main airways to the lungs (the larynx and voicebox) to become narrowed. It affects children aged 6 months to 6 years, but is most common when children are around 2 years old. It starts like a cold with a blocked nose and mild fever. A very dry, barking cough develops, with a rasping sound when the child breathes in (called stridor) this is often worse at night. There can also be shortness of breath and hoarseness. Occasionally it can be more serious, see when to refer box. Managing croup Refer the parent to the pharmacist, who may refer them to their GP. In mild cases, parents may be advised by their GP to keep the child in a humid atmosphere to ease breathing. This could be in a bathroom with a hot bath running (doors and windows closed), using a vaporiser or having a damp towel over a radiator. that breaks down lactose is reduced, so lactose is not digested properly, causing colic symptoms. Managing colic It can be managed in several ways: Switching to a lactose-free infant formula milk (under doctor guidance) Adding lactase drops (e.g. Colief) to infant formula feeds or expressed breastmilk (under doctor guidance) Using activated dimeticone (also known as simeticone) products although there is no real evidence that these are effective. They work by bringing together small bubbles of wind, making it easier for baby to pass one large amount. Some should be given before feeds (e.g. Infacol), some with or after feeds (e.g. Dentinox Infant Colic Drops) Sodium bicarbonate is present in gripe mixtures and, again, helps babies to pass wind. These are usually given with or after feeds up to a maximum of six times daily Colic can be eased by switching to a lactose-free infant formula or adding lactase drops to feeds. Coughs: WHEN TO REFER TO THE PHARMACIST There is also wheezing, breathlessness, chest pain, fever Cough gets worse and coughing bouts longer, and there may be a whooping noise (whooping cough) Cough lasts longer than two weeks Productive cough with yellow-green, rust-coloured or blood-stained phlegm The child has unexplained weight loss There is a regular night-time cough or cough after running around (may be asthma) If a dry barking cough with rasping sound when breathing in, especially if there is also restlessness and lots of saliva, drawing in of the chest wall below the ribs, fast breathing, blue tinge to the lips (could be serious croup needs referral to hospital) PART 5: GASTROINTESTINAL PROBLEMS Understanding colic Colic occurs in babies under 3-4 months of age. It is not serious, but it can be very distressing for parents as babies will cry for three or more hours per day, usually every evening. Babies will often also pull their legs up against their chest. Often colic is suggested when no other cause can be found for baby s regular crying. The cause of colic is not known, but it is thought to be due to a temporary intolerance to cow s milk or lactose. In colicky babies, the enzyme TOP TIPS Your extra help in colic Although colic is unpleasant for parents and babies there are techniques that can help: Sit baby upright when feeding Always burp baby after feeding Use fast flow teats as these stop babies sucking too hard and taking in excess air Warming the stomach can help, such as lying face down on a warm hot water bottle or having a warm bath Keep baby moving, such as taking for a drive or in the pram, or distracted ( white noise from a vacuum cleaner helps!). Understanding constipation This is when the stools, or faeces, are not passed as often as normal or are hard (often like pellets). Constipation is common in babies, but it is important to recognise when bowel habits are different to normal for example, formula babies usually only have a bowel movement every few days. Constipation can be caused by different things: a change in eating habits (it often happens when babies are getting weaned around 4-6 months), if they are dehydrated, if bottle feeds have not been diluted properly or even if they are taken out of their routine or put in a different environment. Managing constipation Use natural methods to get the bowel moving Constipation is best treated using natural methods, such as increasing fibre and fluid intake. Diarrhoea should always be treated with oral rehydration salts and loperamide avoided in children under 12 years 7

8 8 To replace the fluids lost during sickness and vomiting, recommend an oral rehydration solution Mebendazole is the drug of choice for treating worms but it can only be used in those over two years. Always treat the whole family if one member has worms as it is highly contagious such as increasing the amount of fibre (for example, pureed fruit and vegetables for babies) or liquid they are drinking (a small amount of orange juice in water can help). There are also laxative options: lactulose (e.g. Duphalac can be used in those under 1 year), docusate sodium (e.g. Docusol Paediatric Solution, can be used from 6 months), and senna (e.g. Senokot Syrup from 6 years). However, these should not be recommended as standard, natural options should always be tried first. Understanding diarrhoea The stools are loose, watery and occur more frequently than normal. There may also be wind and stomach pains. Diarrhoea can be caused by an infection, like traveller s diarrhoea (see Module 3 Summer Health), or if there is an intolerance to food. Parents may find that they notice more diarrhoea when they are weaning babies at around 4-6 months and when babies start teething and crawling as they often put dirty toys in their mouths. Managing diarrhoea Children with diarrhoea, especially babies, can become dehydrated very quickly. It is essential that sufferers replace all the fluid they have lost, through drinking boiled, cooled water. During diarrhoea, essential salts and minerals are also lost and you should always recommend an oral rehydration solution - the only treatment that can be given to children under 5 years (e.g. Dioralyte, Electrolade). These are also said to shorten the duration of diarrhoea. If customers are having trouble getting their children to take them, recommend adding some squash to make them easier to take. Rehydration salts are made up by emptying the contents of the sachet into water. For children, one sachet should be given after each loose bowel motion. For infants, doctors may advise that all feeds (except breastfeeding) is stopped and rehydration sachets given instead. All infants with diarrhoea or vomiting must be referred to the pharmacist as they are at greater risk of dehydration than older children and adults, and more prone to resulting complications. Advice on replacing lost fluids is the most important issue in managing diarrhoea. Adsorbent-containing products (e.g. kaolin) that can be used in children are available (e.g. Junior KAO-C for 1 year plus); and morphine-containing products (e.g. Diocalm can be given children aged 6-12 years). Loperamide should not be recommended for children under 12 years. Always read the labels on products for details on doses. TOP TIPS Your extra help in diarrhoea You can also provide some additional help for parents trying to treat their children s diarrhoea: Keep them eating, ideally carbohydrates, such as pasta, bread and crackers It may be best to avoid dairy products for 24 hours Make sure they drink lots, ideally fresh water or boiled, cooled water if fresh water is not available. Diarrhoea: WHEN TO REFER TO THE PHARMACIST If the symptoms persist for more than hours If there are other symptoms such as fever, vomiting, lack of interest in food and lots of loose watery nappies All infants as they are more prone to dehydration Understanding vomiting Vomiting is different from possetting, which is the small amount of milk that babies bring back up after a feed. Vomiting is the contents of the stomach coming back up out of the mouth with a lot of force! Usually it is caused by bacterial or viral infections or intolerance to foods; although some children will vomit if they are upset or have a migraine. Managing vomiting Usually vomiting is short-lived, but there is the danger that children can become dehydrated through loss of fluid. In which case recommend an oral rehydration salt to maintain fluid levels. Vomiting: WHEN TO REFER TO THE PHARMACIST Prolonged or repeated vomiting If it is stained with green or yellow bile or blood If there is repeated forceful vomiting in new born babies If there are other symptoms, such as fever, rash, diarrhoea, headache, drowsiness or dehydration (sunken eyes and fontanelle, no wet nappies for several hours, dry mouth) All infants as they are more prone to dehydration Understanding worms Threadworms are a parasite that live in the intestines and are very contagious. They are

9 MODULE 5 Children s Health about half an inch long and look like threads of cotton, and are most common in children, who will complain of very itchy bottoms, especially at night. Threadworms are passed on through tiny eggs which are in dust, on food, in carpets, towels, bed linen, toys, through pets, soil where animals play and touching other infected children. The eggs get under fingernails and are easily swallowed and grow into worms in the bowels. The worms lay eggs around the bottom, causing the itching, and the worms can be seen in the stools. To confirm worms are present, ask parents to press a strip of clear sellotape against the child s anus first thing in the morning. The worms and eggs can be seen on the sellotape. Managing worms There are two choices for treatment and everyone in the family must be treated, with the exception of any pregnant women, who must be referred to the pharmacist: Mebendazole is the drug of choice (Ovex, available as a tablet or suspension). This is given as a single dose for children over 2 years, with a follow-up dose taken after 14 days if there is re-infection Piperazine (available in combination with senna as Pripsen), which is made into a drink with water or milk. This is taken as two doses two weeks apart and can be used in children as young as 3 months. It should not be given to children or adults who have epilepsy, kidney problems or who complain of stomach ache, colic or severe diarrhoea TOP TIPS Your extra help in worms You can also provide some additional help for parents trying to prevent worms in their children: Encourage good hygiene, such as washing hands after going to the toilet and disinfect the toilet area regularly Worm pets regularly and get children to wash their hands after stroking animals Keep children s nails short and make sure they wear pyjamas to bed Bath children or wash round their bottom every morning. the meantime, it can be very irritating for the child and distressing for parents to manage. Atopic eczema is the type that affects most children, with red, dry, itchy flaky skin on the face, body and outer limbs. This type of eczema is linked to things that cause allergies, such as house dust mites, cats and dogs, pollen and even foods, like cow s milk (particularly in babies). It s also linked to other allergic conditions, with around 50% of children with eczema also having hayfever or asthma. For more information see Module 7 Skin Problems. Managing eczema If possible, encourage parents to find out what triggers their child s eczema so that they can avoid these. This isn t always possible and they may also find that the skin flares up when their child is poorly. Emollients: Like adults, children s eczema should be treated first of all with a medical moisturiser, called an emollient. These come as creams, ointments, lotions, soap substitutes (for washing with instead of soap) and bath oils that help trap moisture in the skin to stop it becoming dry and cracked. When using emollient bath oils, parents should be warned to take care as babies may get slippery in the bath when handled and older children may slip in the bath. Parents should be advised to use emollients on the child all the time, even when the eczema has cleared up as this can prevent flare-ups. Steroid creams: Any customer who wants to buy a steroid cream for a child must be referred to the pharmacist. When skin flares up you would normally recommend a short course of topical steroid creams such as hydrocortisone. However, these cannot be used in children under 10 years, so you will need to refer these sufferers to the pharmacist. For those over 10 years remember that steroid creams can only be used for mild-to-moderate eczema, can t be used on the face, eyes, ano-genital area or on broken skin and should only be used for a maximum of one week. Anti-itching: You can offer something to help with itching, such as crotamiton cream (e.g. Eurax, this cannot be recommended for children under 3 years), or oral antihistamines (e.g. chlorphenamine in Piriton). Older antihistamines cause drowsiness which some parents may feel is a benefit if the child is having problems sleeping. For tips on managing eczema see Module 7 Skin Problems. Time Out This is a big task but worthwhile! Make a note of all the different emollients you stock in your pharmacy, divide them into those that are creams/ointments, lotions, soap substitutes and bath oils (ask your pharmacist for help as there may be some more emollients kept in the dispensary, such as aqueous cream). Make a list of how each of these should be used. Children with eczema are also likely to suffer from hayfever and asthma. PART 6: SKIN, SCALP AND EYE PROBLEMS Understanding eczema Eczema is a skin condition that affects around 1 in 5 children in the UK, starting between 2-12 months of age. Fortunately, most of them grow out of it by the time they are teenagers but, in Eczema: WHEN TO REFER TO THE PHARMACIST If the eczema gets worse If there are any signs of infection (weeping, blisters) If emollients have been used for 7 days and the eczema flare is not under control 9

10 10 Understanding nappy rash The most common cause of nappy rash is urine the chemicals in urine (in particular ammonia) cause an irritant contact dermatitis reaction (a type of eczema). It can also be caused by an excess of sebum - an oily substance produced by the sebaceous glands in the skin that helps prevent skin becoming dry - this condition is called seborrhoeic dermatitis (see later for more information), or by an infection of the skin, changes in the diet, diarrhoea or illnesses, and strong soaps and detergents. Nappy rash is unsurprisingly, mainly the area covered by a nappy. It is angry, red, itchy and sometimes blotchy or spotty. If it is caused by a fungal infection the skin will be inflamed with extra spots at the edges of the red area. Ask your pharmacist to show you a picture of this and of normal nappy rash to compare. Managing nappy rash Advise parents to use a barrier cream to protect the skin against urine. This includes zinc and castor oil ointment, petroleum jelly or any of the branded barrier creams that are available (e.g. Drapolene, Sudocrem). Some of these also have antibacterial ingredients, such as cetrimide and benzalkonium chloride, to help prevent a further infection. If there is a fungal infection, you can recommend an anti-fungal cream, such as clotrimazole (e.g. Canesten). This should be used for at least 2-4 weeks to clear any remaining fungus in the skin. If the rash is very severe refer to the GP TOP TIPS Your extra help in skin problems There are some tips you can offer to parents of children with skin problems to help prevent flare ups. For eczema: Try to determine what the triggers are e.g. certain food or pets Keep the skin moisturised between flare-ups, which means keep using the emollients Wear soft clothing, such as cotton, that doesn t irritate the skin Put mitts on children to stop them scratching their eczema, although it can be hard to keep them on For nappy rash: Change nappies as soon as they are dirty Wash skin with warm water and dry well Always apply a barrier cream before putting on a clean nappy Leave the nappy off as much as possible, although this can be messy! Understanding cradle cap Cradle cap is another form of eczema, called seborrhoeic dermatitis. It develops in areas where there are lots of oil-producing glands, called sebaceous glands. These are found in the scalp, eyebrows, eyelids and creases of the body, but in babies you will mainly see it on the scalp. Although it starts as a red, scaly rash, most parents won t notice it until thick, yellow scales develop. Although it doesn t look particularly nice it isn t itchy and doesn t cause many problems, except occasional loss of hair. It usually clears up by around the first birthday, but can go on until three years of age. Ask your pharmacist to show you a picture of cradle cap. Managing cradle cap In mild cases parents don t need to do anything, but you will often find that they want to. A traditional treatment is to apply gently warmed olive oil to the area to soften the scales, leave on overnight and remove the next day by rubbing the scalp with a towel and then combing out the scales. Mild shampoos that treat cradle cap are also available (e.g. Dentinox Cradle Cap Treatment Shampoo, Capasal Therapeutic Shampoo). If the cradle cap is severe, gets worse or spreads to other parts of the body, refer to the pharmacist. Understanding head lice Very few people get through their childhood without at least one bout of head lice, it s that common! The head louse is a tiny dark insect, smaller than the head of a match, that lives on the head and the hair where it lays tiny eggs close to the scalp. They pass by direct contact (they don t jump, but they do walk from one head to another) and through combs and brushes. Once one child in the family has head lice, expect everyone else to catch it too. The signs of head lice to watch out for are a rash on the scalp, lice droppings (like fine black pepper) on pillowcases, eggs and their empty white shells (called nits) in the hair behind the ears. Nits look like dandruff but if the white flakes can t be shaken off then its head lice. There may also be an itchy scalp. Parents can check for lice by using a fine toothcomb or special nit comb on really wet hair, ideally with a hair conditioner smoothed in. It s best to do it over a pale surface or towel so you can see the grey-brown lice when they drop. Managing head lice Everyone in the family should be checked for head lice once there has been an unwelcome visitor brought into the house and treated if necessary. There are two approaches to treatment: non-insecticide or insecticide.

11 MODULE 5 Children s Health HEAD LICE TREATMENTS Ingredient Type Usage NOTES: Dimeticone (e.g Hedrin) Non-insecticide.Coats and suffocates the lice, stopping them from functioning Applied to dry hair from roots to tip and left on for 8 hours or overnight before washing out; repeated 7 days later. Apply to dry hair, ensuring all scalp and hair is coated. Leave on for 10 minutes, then comb through using comb provided in pack to remove dead lice and eggs. Repeat process 7 days later Apply to dry hair and leave on for 12 hours, preferably overnight, then shampoo out. Repeat after 7 days Used on wet hair after shampooing and left for 10 minutes Lice less likely to develop resistance. Cyclometicone (e.g. Full Marks Solution) Non-insecticide. Coats and suffocates the lice, stopping them from functioning As above Malathion (e.g. Derbac-M Liquid Insecticide Permethrin (e.g. Lyclear Crème Rinse) Insecticide Most treatments require a second application 7 days later to kill any head lice that have hatched since the first treatment. As well as the above products, parents can be advised to use Wet Combing techniques to kill and prevent recurrence of head lice. Hair should be damp and coated with conditioner and a nit comb is used to comb through the hair repeatedly. It must be done every 4 days for at least 2 weeks for it to be successful and should be carried on until no lice are seen in three combing sessions in a row. Special Bug Busting kits are available that contain different combs to remove lice and nits. The trouble with insecticides is that lice can be resistant to these treatments. It used to be that there was local guidance on what was the first choice insecticide to use but now the advice is to try one and if that doesn t work, try a different one. The more recently introduced silicone based head lice treatments are thought to be at least as effective as insecticides and resistance to them doesn t develop. If a treatment appears not to work, it s worth checking if the customer did use the first one properly e.g. did they use a lotion and leave it on overnight? did they repeat it a TOP TIPS Your extra help in head lice There is no guaranteed way to prevent head lice but you can recommend the following: Regularly check hair and scalp to see if any head lice are present Tie back long hair Don t use insecticide treatments just in case because there is an outbreak of head lice at school only use if a child is definitely infected week later? did they check that no one else in the family is infected and may be passing lice on? Understanding conjunctivitis Conjunctivitis is an inflammation of the surface of the white of the eye and inside of the eyelids called the conjunctiva. This can be caused by an irritation, an allergy or a bacterial or viral infection and the eye will look red/pink and feel gritty and burning. If there is an infection there will also be a sticky discharge that can crust over and make it hard to open the eyes, especially first thing in the morning. Children are one of the key groups at risk of infective conjunctivitis, often because they rub their eyes when they have a cold transferring the cold virus straight to their eyes and causing conjunctivitis. They also transfer it to other children through touch. Managing conjunctivitis Conjunctivitis in children tends to resolve without treatment, in most cases. You need to explain that to avoid cross-infection between the eyes and other family members separate towels must be used and avoid touching the eyes (see Top Tips), although this will be hard to do with children! The antibiotic chloramphenicol can treat infective conjunctivitis and is available as drops which should be applied every 2 hours, or an ointment which can be applied 4 times a day (e.g. Optrex Infected Eyes). Whichever formulation is used, the treatment should be applied for 5 days. (For more information see Module 12 Eyes, Ears and Scalp). However, Royal Pharmaceutical Society guidelines state that chloramphenicol should not be used in children under 2 years of age, so instead recommend other eye remedies, containing propamidine (e.g. Brolene, Golden Eye). If the infection looks severe the pharmacist will refer 11

12 Time Out What treatment or action would you recommend for the following customers, and what additional measures would you advise? Which of these could you deal with yourself and which should you refer to your pharmacist? Newly developed spots on the chest of a 5-year old that are starting to spread to the back and face A 6-month old baby who has had a couple of bouts of diarrhoea and has red, rosy cheeks A 3-week old baby that is crying for four hours every evening A 3-year old who has fallen in the park and says his ankle is sore. He can put pressure on the ankle Dry cough in a 6-year old, that only seems to appear after she have been running around A child aged 4 years with one eye producing a sticky discharge A 10-year old who has had a flare-up of eczema in the crooks of his arms An 8-year old who still has head lice despite being treated with permethrin the patient to their GP. If the conjunctivitis is caused by an allergy then recommend sodium cromoglicate drops (e.g. Opticrom Allergy Eye Drops). Conjunctivitis: WHEN TO REFER TO THE PHARMACIST Pain or swelling around the eye If there is anything in the eye Vision is affected or there is pain when looking at lights Severe pain in the eye The eye discharge is green-yellow and returns quickly after being wiped away The child also feels unwell or has a rash on the face as well The eye is not moving normally or there has been an eye injury The eye doesn t improve after two days of treatment TOP TIPS Your extra help in conjunctivitis There are some tips you can offer to parents of children with conjunctivitis to prevent infection being passed on to the other eye or other members of the family: Take care to keep anything that the infected child has been using, such as flannels and towels, away from other members of the family Bathe the affected eye(s) with sterile salt water to help remove any crusts and soothe the eye. They should wipe from the inner corner of the eye to the outside, using a separate piece of cotton wool for each eye to prevent spreading the infection Wash the child s hands after they touch their eye if possible 12

13 AT A GLANCE: MEDICINES USED IN THIS MODULE Drug Main Actions Main Side Effects Benzalkonium Chloramphenicol (e.g. Optrex Infected Eye drops) Chlorphenamine (e.g. Piriton syrup) Clotrimazole cream (e.g. Canestan cream) Crotamiton (e.g. Eurax cream) Cyclometicone (e.g. Full marks Solution) Dimeticone (e.g Hedrin lotion) Docusate sodium (e.g. DulcoEase capsules) Glycerin Guaifenesin (e.g. Tixylix Chesty Cough) Hydrocortisone cream (e.g. Hc45 cream) Ibuprofen (e.g. Nurofen syrup) Kaolin (e.g. Junior KAO-C) Lactulose Lidocaine (e.g. Dentinox Teething Gel) Loperamide (e.g. Imodium capsules) Malathion (e.g. Derbac M Liquid) Mebendazole (e.g. Ovex tablets) Antibacterial agent Antibacterial Antihistamine Topical anti-fungal Antipruritic for itching Non-insecticide treatment for head lice Non-insecticide treatment for head lice Laxative Demulcent Expectorant Topical steroid NSAID which reduces pain, fever and (in prescription doses) inflammation Adsorbent Laxative Topical anaesthetic Anti motility drug Insecticide for headlice Treatment for threadworms Transient stinging Drowsiness headache, impaired co-ordination, difficulty in passing urine, dry mouth, blurred vision, and gastro-intestinal disturbances Local irritation, mild burning sensation and itching Occasionally irritation of the skin Skin irritation Skin irritation Abdominal cramp and diarrhoea None known Gastrointestinal discomfort has been reported Spread and worsening of untreated infection; thinning of the skin. Not for children under 10 years of age Gastro-intestinal discomfort, nausea, diarrhoea, and occasionally bleeding and ulceration. None known Flatulence, cramps, and abdominal discomfort Occasional hypersensitivity reactions Abdominal cramps, dizziness, drowsiness, and skin reactions. Cannot be used for children under 12. Skin irritation and hypersensitivity reactions Very rarely abdominal cramps Cont 13

14 AT A GLANCE: MEDICINES USED IN THIS MODULE Drug Main Actions Main Side Effects Morphine (e.g. Diocalm Dual) Oxymetazoline (e.g. Vicks Sinex Nasal Spray) Paracetamol (e.g. Calpol syrup) Permethrin (e.g. Lyclear Crème Rinse) Piperazine (Pripsen powder) Propamidine (Golden Eye drops) Senna (e.g. Senokot syrup) Simeticone (e.g. Infacol drops) Sodium cromoglicate eye drops (e.g. Opticrom Aqueous Eye Drops) Opiate anti motility drug for diarrhoea Nasal decongestant Analgesic for pain and fever Insecticide for headlice Treatment for threadworms Antibacterial Laxative Anti-foaming agent for colic Mast cell stabiliser treatment of allergic conjunctivitis Drowsiness Nasal irritation, headache, rapid heartbeat Rare, but includes rashes, blood disorders Itching, redness and stinging Nausea, vomiting, colic, diarrhoea, allergic reactions Occasionally burning or itching of the skin Abdominal cramp and diarrhoea None known Burning and stinging Complete your learning Well done on completing the module! Now visit to access: Weblinks to learn more and signpost your customers Forum to chat with other MCAs about your learning Online assessment to make sure you are on track