Putting up with chickenpox - includes related article on quarantine policies

While in rare instances, chickenpox can be virulent, disease-ameliorating therapies do exist. The point to remember is that chickenpox is largely a benign childhood illness.

You get the news--your child has been exposed to chickenpox, one of the most highly contagious diseases. Very likely, your child will become one of the 3.5 million Americans to come down with the illness this year.(1)

You may greet this prospect with relief ("She's bound to get it sooner or later") or resignation ("May as well get it over with") or dread ("We won't be able to go anywhere for days") or anticipation ("An illness with spots--how curiously medieval"). You can also meet the onset of illness with information and know-how.

The Spotty Facts

About the virus. Most common in late winter and early spring, chickenpox is caused by Herpesvirus varicellae, a cousin to Herpesvirus hominis, which causes mouth and genital herpes infections. Like its relative, the varicella virus produces malaise, fever, and often itchy, blistery skin lesions. After the illness resolves, the virus lies dormant within nerve tissue along the spine, in some cases reactivating in the form of herpes zoster, better known as shingles.(2)

Who is susceptible? Anyone who has not had the disease. Once you have had it, your immunity is lifelong. Although 90 percent of all cases occur in children under the age of 10, chickenpox can come on at any age, even before birth.(3)

How do you get chickenpox? The disease is spread through airborne transmission, particularly in the early stages of illness, when the virus resides in the nose and throat. The virus is also spread through direct contact with infected skin lesions.

When is it contagious? A person with chickenpox is infectious from 24 to 48 hours prior to the onset of rash until the lesions crust over. Once exposed, a person will develop the illness within 10 to 20 days; the average incubation period lasts 14 days.(4)

What to expect. The illness most often begins with nonspecific miseries such as fever, headache, mild sore throat, malaise, and poor appetite. The rash follows, beginning as small pink spots that quickly progress to bumps, then fragile and often itchy blisters, and finally crusts, which typically fall off five days after they appear. The rash, although usually densest on the trunk, can appear anywhere, including the mouth, genitals, and conjunctiva of the eyes. The spots come out in crops over a period of about three days. Some children develop only one crop of a few lesions, while others break out in five crops of as many as 500 lesions. Fever often coincides with the rash, both of which peak at about day three. Temperatures can vary from normal to slightly elevated with sparse rashes, and can climb to 105[degrees]F with more severe eruptions.(5)

Caring for Your Sick Child

As soon as the spots appear, reassure your child that they are not serious. The crusty scabs will fall off on their own, often leaving shallow, pink depressions that are likely to fade within 6 to 12 months. Unless the scabs are picked or become infected with bacteria, scars are rare. To reduce the risk of scarring and infection, keep your child's nails short and implore your child not to scratch or pick at the pox.

Diet. Your child's appetite may flag, particularly if there are sores in his mouth. Encourage fluids (water, herb teas, fruit and vegetable juices) and soft foods. Also offer plenty of raw garlic, which has both immune-enhancing and antiviral properties.(6)

Vitamin and mineral therapy. Internal doses of vitamin A, beta-carotene, the B vitamins, vitamin C, and zinc all promote immune function and tissue healing. Vitamin E, an antioxidant, increases the efficiency of vitamin A and helps prevent scarring. Caution: Fat-soluble vitamins, including vitamins A and E, can cause toxicity if taken in high doses for prolonged periods of time.

Fever control. Because a moderately elevated body temperature has beneficial effects, you need not treat a fever unless it causes discomfort. If your feverish child is under three months old, however, or if the mercury pushes 104[degrees]F, call your doctor.

Should you decide to bring down a fever, do not give your child aspirin, as it has been associated with Reye's syndrome. You may give acetaminophen, checking first with your doctor if your child is less than four months old. Herbs such as elder flower and yarrow can help bring down fevers by inducing perspiration. Catnip and chamomile are also fever reducing as well as calming.

Comfort measures and skin care. Keep your child cool. Overdressing her, piling on the blankets, and giving her hot baths can lead to increased itchiness and more spots.(7)

Also avoid salves and ointments, for they can keep the skin from "breathing" and cause the scabs to come off prematurely. Lotions, including calamine, are fine, as long as they are not applied around the eyes.

Herbs that can be applied topically to relieve skin irritation and promote healing include calendula, comfrey, chickweed, yarrow, and plantain. Burdock leaves, which have traditionally been used as a poultice to ease the itching and burning of poison oak, may also help.

Once the pox have crusted over, says Dr. Ellen Dale, a Golden, Colorado, naturopath, you may apply tea tree oil, which by virtue of its disinfectant properties, helps prevent infection and hence scarring. After the scabs have fallen off, you may use vitamin E.(8)

General hygiene. During the peak of the rash, wash the bedsheets once a day, and dress your child in clean, preferably cotton pajamas. Keep your child's nails short and hands clean. Also offer frequent baths--every three or four hours, if possible--patting your child dry with a fresh towel. Bathing may be tapered to once or twice a day after the scabs have formed. Here are a few time-honored ingredients for chickenpox baths:

* Oatmeal. You can pour about a cup of oatmeal directly into the bathwater. To avoid messy clean-ups, try colloidal oatmeal (such as Aveeno). Alternatively, you can bind raw or partially cooked oatmeal in a washcloth--or, as Denver pediatrician Mary Kohn, MD, suggests, inside a clean sweatsock--and proceed to gently rub your child's skin with it.(9) The motion of the rough texture against the skin satisfies the urge to scratch without damaging the lesions.

* Baking soda. To relieve itching, add one-quarter to one-half cup under running water.

* Yarrow. An extract or a strong infusion of this herb has anti-inflammatory and antiseptic effects.

* Chamomile. This herb, in extract or infusion form, helps promote healing, decrease inflammation, disinfect the pox, and calm the nerves.

Herbal remedies. Lomatium, osha (ligusticum), and echinacea are antiviral and immune boosting. Marshmallow root and red clover are even gentler, yet effective immune supporters. Red clover is also good for the skin. You can add any of these herbal extracts to mild teas or juices. Should your child refuse these drinks, you can rub the extracts on the soles of his feet. If you are a nursing mother, you can take the herbs internally, wait 15 to 30 minutes, then breastfeed your ailing infant.

Homeopathic remedies. Dana Ullman, director of Homeopathic Educational Services in Berkeley, California, recommends Rhus tox for restless children with "intense itching, especially at night and from scratching" and Aconitum for the "initial states of chickenpox, when there is fever, restlessness, and increased thirst." Belladonna may help when the illness is accompanied by "severe headache, flushed face, hot skin, and drowsiness with inability to sleep." Apis is the remedy of choice for "itching and stinging chickenpox that is worse with heat ... and better with cold."(10)

Potential Complications

Although complications of chickenpox are uncommon, you should know about them and call your doctor if symptoms develop. The most serious conditions are these:

* Secondary bacterial infection. Chickenpox lesions can become infected with bacteria such as staph or strep. If such infections are not treated, the bacteria may pass into the bloodstream and cause pneumonia, arthritis, or bone infections. Should the normally clear fluid of a blister become yellowish, or a crust change from dry to weepy, your child may need topical or oral antibiotics.

* Chickenpox pneumonia. This illness occurs most often in adults, particularly pregnant women. Recovery is usually prompt. Symptoms include a bad cough, chest pain, rapid or difficult breathing, blue-tinged lips, and the coughing up of blood.

* Encephalitis (brain inflammation). This condition occurs in less than 1 out of 1,000 cases of chickenpox.(11) Signs are fever, repeated vomiting, headache, stiff neck, confusion, incoordination, and extreme lethargy.

Certain populations are at risk for developing complications of chickenpox. Teenagers and adults tend to have severe cases. Immunosuppressed individuals--including children who have leukemia or are on corticosteroids or chemotherapy--can become seriously, even fatally, ill. If your child has a chronic disease and has been exposed to chickenpox, check with your doctor.

Chickenpox during pregnancy also carries risks, for both mother and fetus. Fortunately, chickenpox and pregnancy, both common occurrences, rarely occur together. Estimates of incidence in the United States range from 1.3 to 7 cases per 10,000 pregnancies.(12)

In a study of 44 pregnant women who contracted the illness, 9.3 percent developed pneumonia, 9.3 percent went into premature labor, and 2.4 percent died.(13) In about 24 percent of cases, chickenpox during pregnancy leads to fetal infection.(14)

Fetal outcomes depend on when the mother comes down with chickenpox. Infection during the first 20 weeks of pregnancy can cause congenital varicella syndrome, characterized by intrauterine growth retardation, scarring, poor limb development, eye problems, and such central nervous system disorders as retardation and seizures. According to a 1990 medical journal, "Congenital varicella syndrome is extremely rare, with only 40 cases reported since the 1940s."(15)

After the first 20 weeks of gestation, infants are most at risk if the mother comes down with chickenpox between four days before and two days after childbirth--a timespan during which the mother's protective antibodies may not be available to the baby About 20 percent of infants exposed during this critical period will contract chickenpox.(16) Whereas their prognosis was at one time gloomy, a 1990 study of 240 infants born to women with perinatal chickenpox failed to find a single death.(17)

If a mother contracts chickenpox three or more days after childbirth, the infection will be transmitted via the respiratory tract, rather than the bloodstream. And her infant will likely experience less serious symptoms.

A pregnant woman may also develop shingles--a reactivation of the chickenpox virus, appearing as a band of painful pox along the course of a nerve, typically on the torso. In this case, the virus tends not to be released into the bloodstream. The fetus, apt to be spared contact with the virus, is further protected by maternal antibodies.(18) In other words, while a mother with shingles may feel terrible, her baby is usually safe.

What should you do if you are exposed to chickenpox during pregnancy? If you have already had the disease, do not worry--your fetus will be protected by your antibodies. If you think you have not had chickenpox, ask your healthcare practitioner for a blood test to determine your immunity. (Note: 80 percent of adults who do not remember having had chickenpox are found to be immune to the disease.(19)) If you are immune, no worries; if you are not, your healthcare practitioner may want to give you a shot of varicella-zoster immune globulin (VZIG).

What about newborns whose siblings have chickenpox? Most doctors see no problem as long as the infants are healthy and the mothers are immune to chickenpox, indicating that their antibodies were passed on to their babies in utero. If a mother lacks immunity, however, doctors often recommend that both mother and baby get a shot of VZIG before engaging in intimate contact with a sick family member.

What about chickenpox in older infants? Chris Nyquist, MD, at the Denver Children's Hospital Department of Infectious Diseases, recommends a doctor visit for any infant under two months of age who develops chickenpox.(20) When an infected infant is older and otherwise healthy, most pediatricians are less concerned.

Anyone at high risk of developing complications from chickenpox can take advantage of modern medical treatment. The antiviral drug acyclovir, when given intravenously, has prevented complications in immunocompromised children and has shown "modest clinical benefit" in otherwise healthy adults.(21) Doctors often recommend acyclovir for seriously ill pregnant women and for newborns who contract a severe case of chickenpox at birth. So far, this drug has not been associated with adverse reactions in the fetus.(22) Whether or not it can prevent the congenital varicella syndrome remains unknown.(23)

Recently, oral acyclovir has been used to shorten the duration and severity of chickenpox in children who are not at risk for complications. Although reportedly free of serious side effects, this treatment only modestly reduces suffering and neither alters the rate at which the virus is transmitted to others nor reduces the rate of complications. Proponents point to the benefits of mitigating the economic burden of chickenpox, $380 million annually of which is attributable to parental loss of income from work. Treating all children with acyclovir to shorten the course of illness, however, would add about $128 million to the annual cost of chickenpox.(24) It would also potentially increase the pool of viruses resistant to acyclovir(25) and possibly stimulate reactivation of the herpes virus (in the form of shingles) later in life.

Varicella-zoster immune globulin (VZIG), given as an injection, loads an exposed susceptible person with chickenpox antibodies. Populations often recommended for VZIG therapy include immune-compromised individuals, nonimmune pregnant women, and newborns exposed to chickenpox between four days before and two days after birth. If given within 72 to 96 hours of exposure, VZIG can attenuate, and sometimes prevent, the disease, although its ability to protect the fetus has not been well established.(26)

A varicella vaccine (VARIVAX), which has been in the testing and development stage for years, has not yet been approved for general use. Whether or not it should be remains controversial [see "Vaccines and Natural Health" in this issue].

While in rare instances, chickenpox can be virulent, disease-ameliorating therapies do exist. The point to remember is that chickenpox is largely a benign childhood illness. Most children sail through it without so much as a scar.

Quarantine Policies

Many school policies still adhere to the 1986 American Academy of Pediatrics (AAP) recommendation that children with chickenpox stay home from school for seven days after the onset of rash or until all pox have crusted over--at which point the illness is no longer contagious. Other school policies are more relaxed.

In 1988, after researchers challenged the AAP's stance on school exclusion by proving that substantial viral transmission occurs before the rash appears, the AAP modified its quarantine policy, stating that children may return to school on the sixth day after the rash appears, and sooner if the disease is mild with few pox.(1) Subsequent research has shown that viral transmission decreases after the rash appears.(2)

Some experts suggest that an early return to school might increase "herd immunity" and thererby decrease the likelihood that exposed students will get the disease during adulthood, when complications are more likely. Others disagree, saying that such a policy would create a risk for immunosuppressed people and nonimmune pregnant women.(3)

In making the quarantine decision, or in determining whether or not to isolate your child from someone with chickenpox, keep all these points in mind. And remember that people with chickenpox are contagious before they know they have the disease.

Notes

(1.) Dale Moore and Richard Hopkins, "Assessment of a School Exclusion Policy during a Chickenpox Outbreak," Am J Epid 133, no. 11 (1 June 1991): 1161-1166. (2.) Phillip A. Brunnel, MD, "Chickenpox: Examining Our Options," NEJM 325, no. 22 (28 (Nov 1991): 1578. (3.) Stephen T. Green, MD, et al., "Public Health Policy on Varicella Infection," JAMA 263, no. 11 (16 March 1990): 1495.

A WONDERFUL CHILDHOOD ILLNESS

You wake sandwiched awkwardly between us and limp to the bathroom, lisping somehow your foot has filled up with air you said, can't wake on air. Sitting on the stool, idly poking, you find the first pock that explains your fever and call me in, matter of factly say, look there's a volcano on my leg. Rising to pull up your bottoms, you turn a little sigh, looking down and behind, oh no, you say, I have the spreads everything's come all unlumped in there. And all around the day you say things about arms like cactus in the desert and caterpillars making cocoons of your eyes. I rock and read, bring juice and sing, and wonder, sit staring at you, remember how you hung upside-down inside me, think the weight of your head a heavy glass ball where glitter still falls thick in water, drifts slowly to snow scene and sparkles the magic of unsettled words. You are grateful and floating for expression, croak, I love you so much I could crack. I feel it, too, you kiss you, that egg in my chest ripening.

Notes

(1.) Henry H. Balfour, Jr., MD, et al., "Acyclovir Treatment of Varicella in Otherwise Healthy Children," J Peds 116 (April 1990): 633. (2.) Odette Batik, MD, and Nancy Stevens, MD, "Varicella in Pregnancy," J Fam Med 28 (March 1989): 319. (3.) Waldo Nelson, MD, ed., Textbook of Pediatrics (Philadelphia: W B. Saunders, 1979), p. 873. (4.) Saul Krugman, MD, and Samuel Katz, MD, Infectious Diseases of Children (St. Louis, MO: C. V. Mosby, 1981), p. 487. (5.) Ibid., pp. 488-490. (6.) James F. Balch, MD, and Phyllis A. Balch, CNC, Prescription for Nutritional Healing (Garden City Park, NY: Avery, 1990), p. 42. (7.) Brit Med J (21 Dec 1991): 1614; abstracted in Pediatrics for Parents (March 1992). (8.) Ellen Dale, ND, in a telephone interview (30 Oct 1992). (9.) Mary Kohn, MD, in a telephone interview (29 Oct 1992). (10.) Dana Ullman, MPH, Homeopathic Medicine for Children and Infants (New York: Jeremy P. Tarcher/Perigee Books, 1992), pp. 58-59. (11.) See Note 4, p. 496. (12.) See Note 2, p. 320. (13.) Charles Prober, MD, et al., "Consensus: Varicella-Zoster Infections in Pregnancy and the Perinatal Period," Ped Infect Dis J 9, no. 12 (Dec 1990): 866. (14.) Ibid. (15.) Ibid. (16.) Ibid., p. 867. (17.) Phillip A. Brunell, MD, "Varicella in the Womb and Beyond," Ped Infect Dis J 9, no. 10 (Oct 1990): 770-772. (18.) See Note 13, p. 868. (19.) See Note 2, p. 320. (20.) Chris Nyquist, MD, in a telephone interview (29 Oct 1992). (21.) See Note 1, pp. 633-634. (22.) A spokesperson for the Drug Consultation Center in Denver, CO, in a telephone interview (30 Oct 1992). (23.) See Note 13, p. 869. (24.) Phillip A. Brunell, MD, "Chickenpox: Examining Our Options," NEJM 325, no. 22 (28 Nov 1991): 1577. (25.) Mark Perkins, MD, and Phillip Brunell, MD, letters to the editor, NEJM 326, no. 18 (30 April 1992): 1224-1225. (26.) See Note 2, p. 320.

Linda B. White, MD, a physician with internship training in pediatrics, has turned to full-time parenting and writing. A freelance writer and novelist, she is the author of The Grandparent Book (Gateway Books, 1990). Linda lives in Golden, Colorado, with her husband Barney, a water lawyer and skier, and their two children, Alex (8) and Darcy (6), both of whom have weathered chickenpox.

COPYRIGHT 1994 Mothering Magazine
COPYRIGHT 2004 Gale Group