Staphylococcus aureus, is a bacterial strain that has become quite famous – rightly or wrongly depending on the context. In this post, I will share a pediatric infectious diseases specialist’s perspective on the fact and fiction surrounding this germ.

What is MRSA?

MRSA is a particular subtype of Staph aureus bacteria. Staph aureus is everywhere and many people are “colonized” with Staph aureus. In other words, the bacteria live happily on our skin with all the other bacteria, minding their own business. Sometimes, if a person is colonized with Staph aureus, and there is a break in the skin from a cut or other injury, the Staph aureus can cause an infection. This can happen even if a person is not colonized with Staph aureus, because the bacteria are everywhere – in the environment on surfaces, on other people, etc. On people, Staph aureus like to live in the nose and other warm moist places like the armpits and groin area. MRSA is just like regular Staph aureus in where it lives and how it spreads – the major difference between the two is that the antibiotic choices for treating an infection caused by MRSA are more limited because MRSA is resistant to more antibiotics.

Isn’t MRSA rare?

No. In the Philadelphia area where I trained, at least half of skin infections tested are caused by MRSA. In other words, a child having a MRSA skin infection is not a unique event for a community. MRSA is more prevalent than most people realize. In addition to colonization, which you would never know from just looking at someone, many people have minor skin infections for which they never see their doctors because the infection comes and goes on its own with no treatment, or maybe with a little antibiotic ointment. Because samples from these infections are not tested for bacteria, we will never know what caused them and many could be caused by MRSA.

Rarely, a child can have a severe illness as a result of MRSA. This does happen, and appears to be happening more frequently now compared with 10 or 20 years ago, but far more common are simple skin infections caused by MRSA, and the vast majority of these do not progress to serious illnesses.

My grandmother was in a nursing home and died of MRSA. Now my child’s friend had a skin infection caused by MRSA – is this the same thing?

No. MRSA infections that people acquire in hospitals are different from community-associated (CA-MRSA) in a few ways. First, people in hospitals are there because they are ill, often with conditions that make it difficult to fight infections, like being elderly or getting cancer treatment. Second, people in hospitals often have devices that allow entry of bacteria into their bodies more easily, like IV lines or breathing tubes. Third, the strains of MRSA found in hospitals often have different characteristics from those found in the community. In hospitals, MRSA tend to be resistant to more antibiotics and have different properties that make the bacteria more harmful. Also, MRSA infections people get in hospitals are usually not the simple skin infections that children in the community get. Most children who get MRSA skin infections, even recurrent ones, don’t seem to go on to develop other more invasive infections caused by MRSA.

My child was diagnosed with a MRSA skin infection. Will it happen again?

Maybe. If you’ve been told your child has MRSA, don’t panic! In many cases, a single infection caused by MRSA is a one-time occurrence. Some children have recurrent infections with MRSA, but this is far more likely to be an annoyance and inconvenience rather than a serious illness. Recurrent MRSA infections can occur for a period of time, and then not happen again. Some of the time, changes in hygiene practices can stop the cycle of recurrent infection. If your child has recurrent infections, ask your doctor for more information about strategies to try. One important thing to keep in mind is that having MRSA, and even having recurrent MRSA infections, does not mean something is wrong with your child or her immune system – it is just bad luck.

Does someone have MRSA forever?

Maybe, but probably not. As I mentioned above, a significant proportion of the population is colonized with MRSA. The bacteria that colonize our bodies change over time due to a variety of factors, like age, antibiotic use, and environmental exposures. A person could be colonized with MRSA for a period of time, and then never again or not again for years.

Should the school be closed and decontaminated if there is a child with a MRSA infection?

No. Schools should be cleaned as they normally are to reduce bacteria and viruses on surfaces. MRSA and other Staph aureus predominantly live on people, in the nose and other moist body areas, so unless people are decontaminated (not advised!) MRSA can’t be eliminated.

Should kids with MRSA be excluded from school?

Absolutely not. For every one child with a diagnosed MRSA infection there are many more who are colonized with the bacteria, so it does not make sense to exclude a child on the basis of a diagnosis. A child with a MRSA skin infection is not a danger to other children or adults. As with any skin infection, open wounds should be covered. MRSA, while it can in some cases be more harmful than regular Staph aureus, is not any more contagious than regular Staph aureus. A much better strategy than exclusion is to teach children to wash their hands well and to avoid nose-picking, as these interventions will protect them against hundreds of diseases.

Can my child play with his friend who has MRSA?

Yes! As discussed above, a MRSA diagnosis does not say anything about a person’s overall health or make them more likely to transmit disease. Also, your child could very well be colonized with MRSA too and you wouldn’t know it. The best way to prevent the spread of MRSA is to encourage routine hand washing and to discourage nose-picking. Also, avoid sharing towels and sharing sports equipment that rubs against the skin, such as soccer shin guards and football pads. Remember, your child is much more likely to catch a cold or stomach virus from a friend than they are to catch a MRSA infection.

Amanda Paschke, MD, MSCE

©2013 Two Peds in a Pod®

How can you tell if your child’s scrape is infected if his skin is already bright red?

I heaved a sigh of relief. My children greeted my husband and me at the door. The children had just baby-sat themselves. I thought everyone was unscathed until I saw one of my children covered in bandages. Cuts and scrapes? Apparently, although I had admonished them not to ride anything with wheels and not to climb on anything above the ground, the child with the bandages had tripped over her own feet during a benign game of four square.

“Did you wash the scrapes?” I asked.

“Yes,” the kids said, proudly nodding. They knew the first line of defense against a wound infection is to wash out cuts and scrapes. But as it turns out, they had only dabbed the cuts with wet paper towels. Aghast, I propelled the injured child off to the bathroom and hosed down the cuts. Too many times I have seen a minor scrape turn into a major skin infection.

When a wound is not thoroughly cleansed, the bacteria which normally live on intact skin (Staphylococcus or Streptococcus) find an opportunity to enter the body through the wound and cause infections. Even a mosquito bite can turn into a raging, puss-filled mess if scratched often and not cleansed enough. These days, some children carry on their skin a type of Staphylococcus called MRSA (Methicillin Resistant Staphylococcus Aureus). Since this germ can be tough to treat when it causes an infection, a thorough cleansing is more important than ever.

While infection is rarely introduced from the actual object that cuts the child, exceptions include cuts caused by animal or human bites (the human mouth is particularly filthy) and cuts caused by old, dirty or rusty metal. Tetanus lives in non-oxygenated places such as soil. So for deep or very dirty wounds, make sure your child’s tetanus vaccine is up to date.

Despite what many believe, wiping the surface of a cut with a wipe is not adequate to cleanse a wound. “Irrigate, irrigate, irrigate,” a wise Emergency Department physician explained to me when I was a resident in training. “I have never had someone return with a wound infection,” she said proudly. In the emergency room, saline is usually used. At home, soap and running water are effective. Stay away from hydrogen peroxide and rubbing alcohol because they can irritate rather than help the skin.

After washing your child’s cuts and scrapes, you can use bandages to help prevent further exposure to germs and to avoid irritation from clothes or from your child’s scratching, probing fingers. Infections, if they occur, can set in 2-3 days after your child gets her wound. Remove the bandage daily and check the wound for signs of infection such as pus, increased redness, warmth and pain. Wash the wound again, and then replace the bandage. You could also apply topical antibiotic such as Bacitracin to further help prevent wound infection.

So, even if your child just took a shower, wash him again if he scrapes himself. The sooner you irrigate even the tiniest of wounds, the better.

An ounce of prevention is worth a pound of antibiotics.

Naline Lai, MD and Julie Kardos, MD
© 2018 Two Peds in a Pod®

It’s 6 a.m., you are running late for work and your kid is “kinda” sick. Can you send him to daycare?

Dr. Kardos and Dr. Lai and a little friend talk about “Too Sick for School? The Latest Guidelines for Staying Home” at DVAEYC’s annual conference for early childhood educators

Yesterday we reviewed with an audience of early childhood education teachers the latest medical guidelines* for excluding children from early childhood education centers. Here are some of the updates we shared with the teachers attending the annual DVAEYC conference held at University of Pennsylvania:

When should a child go home from daycare? Remember the overriding goals for exclusion:

To expedite the child’s recovery

To prevent undue burden on teachers

To protect other children and teachers from disease

Following are the guidelines that most surprised our audience, as well as other highlights from our talk.  

Pink eye (conjunctivitis)– most kids can remain in school

• “Pink eye” is like a “cold in the eye” and can be caused by virus, bacteria, or allergies.
• Just as kids with runny noses can still attend school, so too can kids with runny eyes.
• A child with pink eye does not need to be on antibiotic eye drops in order to attend school. The presence or absence of treatment does not factor into letting a child attend school.
• Any child with pink eye who suffers eye pain, inability to open an eye, or has so much discharge that she is uncomfortable, needs to go home.
• If there is an outbreak (two or more kids in a room), the center’s health care consultant or the department of health can give ideas on how to help prevent further spread
• Good hand washing technique prevents the spread of the contagious forms of pink eye (viral or bacterial).

Fever – by itself, is not an automatic exclusion

• For practical purposes, a fever (no matter how it is taken) in a child who is over 8 weeks old is a temperature of 101 degrees F. Therefore, 99 degrees F is NOT a fever, even if that number is higher than the child’s baseline temperature.
• If a child with a fever acts well and does not require extra attention from teachers, then that child is medically safe to stay in school. Sending him home is unlikely to protect others. Kids are contagious the day before a fever starts, so febrile kids most likely already exposed their class to the fever-proking illness the day before the fever came.
• If the fever causes the child to become dehydrated or makes the child too sleepy or miserable to participate in class, then that child should go home.
• Any baby  two months of age or younger with a fever of 100.4 or higher needs immediate medical attention, even if he is not acting sick.
• If a child has not received the recommended immunizations for his age, then he needs to be excluded for fever until it is known that he does NOT have a vaccine preventable illness.
• If a child goes home with a fever, he does not need medical clearance to return to school.
• Read more details about fever and “fever phobia” here.

Head lice, while icky and make our heads itch just to think about them, carry no actual disease.

• The child with live lice should go home at regular dismissal time, receive treatment that night, and be allowed back in school the next day.
• By the time you see lice on a child’s head, they have been there for likely at least a month. So sending him home early from school only punishes the child, causes the parent to miss work needlessly, and does nothing to prevent spread.
• Lice survive off of heads for 1-2 days at most (they need blood meals, and die without them), so a weekend without people in school kills any lice left behind in the classroom by Monday morning.
• Lice do not jump or fly and thus need close head-to-head contact to spread, hence the reasons behind why your child’s center spaces matts at nap time  a certain amount distance apart, and do not allow kids to share personal objects such as combs.

The mouth ulcers and foot rash of Hand Foot Mouth

Hand-foot-mouth disease- not an automatic exclusion

• This common virus, spread by saliva, causes a blister-like rash that can appear on hands, feet, in the mouth and in the diaper area, sometimes in all of these locations. Hand washing limits spread, and kids can attend school with this rash.
• The child who refuses to drink because of painful mouth lesions should go home so the parent can help improve hydration. In addition the child who refuses to participate in activities  should stay home. You can read more about this virus here.

Poison ivy rash is not contagious to other people. The rash of poison ivy is an allergic reaction/irritation from wherever the oil of a poison plant touched the skin. The ONLY way to “catch” poison ivy is from the poison ivy plant itself. But if the itch from poison ivy makes a child too miserable to participate in class activities, she may need to go  home. Read more about poison ivy here.

Vomiting more than twice, associated with other symptoms (such as fever, hives, dehydration or pain),  or with vomit which is  green-yellow or bloody are all  reasons a child should leave school. Recent history of head injury  warrants exclusion and immediate attention since vomiting can be a sign of bleeding in the head.  See our post about vomiting.

Diarrhea, meaning an increase in stool frequency, or very loose consistency of stools, is a reason to go home if the diarrhea

• cannot be contained in a diaper,
• causes potty accidents in the toilet trained child
• contains blood, is bloody or black
• results in more than two stools above baseline for that child—too many diaper changes compromises the teacher’s ability to attend to other children.
• is with other symptoms such as fever, acting very ill or jaundiced (yellow skin/eyes)
• Read more about poop issues here.

Molluscum contagiosum is a benign “only skin deep” illness similar to warts—direct vigorous contact or sharing of towels or bath water can spread the virus among kids but the rash itself is harmless and not a reason to stay home from school. Read our prior post for More on this little rash with the big name.

MRSA is a skin infection that looks red and pus filled and is typically painful for the child. Treatment involves draining the infection and/or taking oral antibiotics. If the infected area is small and can be covered completely, a child may stay in school.

Measles This illness causes high fever, cough, runny nose, runny eyes, and cough and a total body rash. Your local Department of Public Health will provide recommendations about how long to exclude a child with measles as well other precautions a school should take. So they are safe, unvaccinated children will have to be excluded for period of time as well.

Also note, at times, the department of public health will exclude even children who are acting well from school for outbreak management of a variety of infectious diseases.

Surprised? As you can see, there are few medical reasons to keep your child home from daycare for an extended period of time. As Dr. Lai often says to the big kids, “If there is nothing wrong with your brain, you can go to school and learn.” Bottom line-  no matter the reason, if you realize at six in the morning that your child will not be able to learn and function at baseline, keep him home and seek the advice of your child’s pediatrician.

Julie Kardos, MD and Naline Lai, MD

©2017 Two Peds in a Pod®

*A straight-forward, comprehensive guide to the guidelines can be found in Managing Infectious Diseases in Child Care and Schools, 4th edition, Editors: Susan S. Aronson, MD, FAAP and Timothy R. Shope, MD, MPH, FAAP, published by the American Academy of Pediatrics.

Welcome, early-childhood education teachers! We are excited to talk to you at the Philadelphia Convention Center on Friday, May 6 at 3:30pm as part of the DVAEYC Conference (Delaware Valley Association for the Education of Young Children Conference) “Picture Every Child Confident and Secure.” We will be teaching about when to send children home from school for medical reasons. Topics include fever, head lice, and MRSA. We look forward to seeing you then!

Julie Kardos, MD and Naline Lai, MD
©2011 Two Peds in a Pod®

I spent all day doing laundry. All right, maybe it wasn’t all day but it sure felt like it. Cleaning up after a vomiting child can be tough in the winter time. Unfortunately, it’s too cold to rinse off any sour curds outside. As I scraped off the sheets into the kitchen sink, I wondered how long the germs could live. I turned to my Disease Prevention Manager, Clare Edelmayer  at Doylestown Hospital, PA to find the answer.

She says depending on the germ and the surface it lands on, a germ can live for hours to days and sometimes months.

Most bacteria and viruses die within hours if they are outside the body. Surprisingly, survival does not depend on how deadly the germ is. For example, HIV virus in blood will die as soon as the blood dries outside the body.  However, some strains of flu viruses can survive 24-48 hours on non-porous surfaces such as your kitchen counter or on the handle of a plastic spoon and 2-8  hours on porous surfaces such as your toddler’s sleeve or on paper tissues. 

Methicillin Resistant Staphylococcal Aureus (MRSA), a bacteria which can cause skin infections filled with pus, stays alive for several hours to several days on surfaces.  Hepatitis B virus, a cause of liver disease, can stay viable on surfaces for 2 weeks or more, and the bloody-diarrhea producing Clostridium Difficile can live on surfaces up to 5 months. 

In other words, most germs die within hours, but don’t count on germs dying before they have a chance to enter your unsuspecting child’s mouth or nose. A dilute bleach solution works well to clean surfaces outside the body and of course, have your children frequently wash their hands.

The next time one of my kids throws up this winter, I’m tempted just to bury the sheets under the snow out back and fetch them in the spring.

Naline Lai, MD with Julie Kardos, MD
©2011 Two Peds in a Pod®

I heaved a sigh of relief. My children and their friend greeted my husband and me at the door. The children had just baby-sat themselves. I thought everyone was unscathed until I saw one of my children covered in band aids. Apparently, although I had admonished them not to ride anything with wheels and not to climb on anything above the ground, the child with the band aids had tripped over her own feet during a benign game of four square.

“Did you wash the scrapes?” I asked.

“Yes,” the kids said, proudly nodding. They knew the first line of defense against infection is to wash out a wound. But as it turns out, they had only dabbed the cuts with wet paper towels. Aghast, I propelled the injured child off to the bathroom and hosed down the cuts. Too many times I have seen a minor scrape turn into a major skin infection.

When a wound is not thoroughly cleansed, the bacteria which normally live on skin (Staphylococcus or Streptococcus) find an opportunity to enter the body. Even a mosquito bite can turn into a raging puss filled mess if scratched often and not cleansed enough. These days, some children carry on their skin a type of Staphylococcus called MRSA (Methicillin resistant Staphylococcus aureus), since this germ can be tough to treat, a deep cleansing is more important than ever.
While infection is rarely introduced from whatever cuts the child, exceptions include cuts caused by animal or human bites (the human mouth is particularly filthy) or cuts caused by old, dirty or rusty metal.  Tetanus lives in non-oxygenated places such as soil. So for deep or very dirty wounds, make sure your child’s tetanus vaccine is up to date.

Despite what many believe, wiping the surface of a cut with a wipe is not adequate to cleanse a wound. “Irrigate, irrigate, irrigate,” a wise Emergency Department physician explained to me when I was a resident in training. “I have never had someone return with a wound infection,” she said proudly. In the emergency room, saline is usually used, but at home soap and running water are effective. Stay away from hydrogen peroxide because it can irritate rather than help the skin. Stay away from rubbing alcohol because it hurts and is not necessary if soap and water are used.

So, even if your child just took a shower, wash him again if he scrapes himself. The sooner you irrigate even the tiniest of wounds, the better.  An ounce of prevention is worth a pound of antibiotics.

Naline Lai, MD and Julie Kardos, MD

© 2010 Two Peds in a Pod®