Melanie Cole, MS (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. Welcome to Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole. And today, we're talking about diagnosing and treating vaginal discharge and infections for adolescents and children, really helping parents and children identify vaginal discharge and infections that should be treated.

Joining me is Dr. Aimee Morrison. She's an assistant attending obstetrician and gynecologist at New York-Presbyterian Hospital Weill Cornell Medical Center, an Assistant Professor of Clinical Obstetrics and Gynecology at Weill Cornell Medical College - Cornell University, and fellowship-trained in Pediatric and Adolescent Gynecology. Dr. Morrison, thank you so much for joining us today. This is something not everybody wants to talk about. They don't always want to hear about it or talk about it, but it's something that, as I can remember, even being a child, it always happens to women throughout our life course. So, what are the most common types of vaginal discharge and infections that you see in children and adolescents?

Dr. Aimee Morrison: Yes, thank you for having me. And I agree, this is something that is very, very common and I see very commonly in my practice. I think it's always a great question of what's normal and what's not normal. And that really depends on the age of the child. So, specifically, when girls are very young, before they've started their periods, the vast majority of the time, infections and discharges are what we call non-specific. So, there's no particular bug or anything that we can identify causing it. It's usually just due to hygiene measures, meaning that as girls are starting to potty train, as they're starting to learn how to take care of themselves, to wipe properly, sometimes some things get messed up and some bacteria can get introduced that's not supposed to be there. So for example, if girls are wiping back to front, that can cause some bacteria to get into the vagina that wouldn't ordinarily be there. Or, as girls go to school, they get daycare bugs, they're wiping their nose, then they're going to wipe their vagina during toilet training, some bacteria can get transferred. So, we call those non-specific, because there's nothing that really can be done for it, except just watching, doing vulvar hygiene measures, and keeping the area clean.

I think one common misperception is that yeast infections can happen. So, these girls, again, these are young girls prior to puberty. They can have a lot of itching down there. That's usually the most common symptom of an infection. And so, itching, we think yeast. The prepubertal vagina is actually not the right environment for yeast. So, yeast is very, very rare.

That changes once girls hit puberty, then yeast infections become a lot more common. But in these girls, I would say normal discharge is the most common reason that I see them. So, normal discharge is happening throughout the menstrual cycle. It can be anywhere from clear and thin to white or yellow and thicker. All discharge within that range is what I consider normal. Things that are not normal are any discharge that's itching, that's usually a sign of a yeast infection, things like BV, that's a bacterial overgrowth that can often have a strange odor. And then, of course, as girls become older and start doing more adult activities, then we start to think about things like sexually transmitted infections as well.

Melanie Cole, MS: Wow. So, you've given us what's normal and what's not. That was such a comprehensive answer, Dr. Morrison. So, we always think of color if it's in our sinuses or something we've coughed up. We always think color is the indicator. Is that the case with vaginal discharge as well?

Dr. Aimee Morrison: Color can be a very helpful indicator. I will say in young girls who are not going through puberty yet, there really shouldn't be discharge of any color down there. That area is inactive, there really shouldn't be discharge. So, I would say any discharge in a young girl prior to puberty should warrant further evaluation. And girls who are going through puberty, color can be helpful. So clear, white, yellow is all normal. Things that are not normal in terms of color are things that are green, things that are bloody, anything that looks like pus or has a foul smell, and older girls should be evaluated.

Melanie Cole, MS: So, are there other symptoms? You mentioned itching, and if we've got discharge, and it's whatever color it is, and I mean, there's, as you said, so many things that could cause it. What about symptoms? Would we feel anything else if it was a yeast infection, if it was an infection of some sort, a bladder infection, anything that might cause us to look and go, "Whoa, what is that?" Stomach aches? Is there anything else that goes with it?

Dr. Aimee Morrison: Absolutely. So in addition to itching, a funny color, a funny odor, anything that's not getting better with treatment should warrant further evaluation. Anything that's causing pain. So, particularly pain in the pelvis, we think about an infection that's gone from the vagina, now potentially up into the uterus or the ovaries. That's more common with sexually transmitted infections, so things like chlamydia, gonorrhea, trichomonas. That's highly unlikely with things like yeast or BV. But again, anything that is pain, that's not getting better with Tylenol, not getting better with treatment, should warrant further evaluation.

Melanie Cole, MS: So, what kind of treatments are available? I remember the days of Monistat and, you know, you had to get a prescription, but now for yeast anyway, you don't need a prescription, correct? Tell us what do you do for these kinds of Issues that women come up with from childhood all the way through.

Dr. Aimee Morrison: So, Monistat is still available over the counter. Monistat is an antifungal, so that is used to treat yeast infections. There's also a great prescription option called Diflucan. That's a one-time pill. That generally clears up yeast very, very quickly. If there's another sort of infection that's going on, so BV or bacterial vaginosis, any other identified bug or infection, it can usually be treated with antibiotics.

That being said, like I mentioned earlier, for younger girls, there's usually not something that we can put our finger on that's exactly causing the symptoms. So in that case, what I typically recommend is what we call vulvar hygiene measures. So, things we can do is to keep the area as clean and dry as possible. So, that usually involves, although it doesn't sound that revolutionary, things like plain warm water baths. So, I call those boring baths. No soaps, no bubbles, no glitter bombs, nothing fun and exciting. Just plain warm water baths for about 15 minutes a day. That's the best way to clean that area down there, kind of flush out any bacteria, any kind of irritants that may be causing symptoms.

Other things that are very helpful are the use of barrier ointments. So, those are things like Aquaphor, Vaseline, just to provide a barrier between the skin that's very, very sensitive down there and the outside environment. So if it's something like tight-fitting clothing, sweat, scented soaps, things like that that are causing irritation of the skin, those barrier ointments can be very helpful.

Melanie Cole, MS: Now, you mentioned tight-fitting clothing and a lot of girls wear leggings, and if they're working out or walking and sometimes they're pretty tight, especially around that area. So, can those kinds of things-- really they cause that irritation, but you talked about putting something anti-chafing that's not exactly comfortable. Do you recommend not wearing those kinds of tight clothes?

Dr. Aimee Morrison: So, yes, those are very popular and they are very comfortable. Unfortunately, any sort of tight-fitting clothing can trap moisture down in the underwear area in the vulvar area. Anything that traps moisture is just a risk factor for yeast development. So, yeast love moist, warm environments. They love any kind of sugar. So, patients with diabetes in particular that are poorly controlled will be prone to yeast infections. So if someone is suffering from recurrent yeast infections, meaning they're happening three, four times a year, then I do recommend avoiding tight-fitting clothing. However, many times, yeast infections can happen in young girls and adolescents for no particular identifiable reason, and it doesn't happen again. So if it's a one-time thing where they get a yeast infection, they take a dose of Diflucan, then they can continue to wear whatever clothes they want, including leggings, tight-fitting clothing, if that's what they feel most comfortable in.

However, again, if it happens again a couple times per year, then we start to think about other things besides just treating them with medication. So, what things can we do to make the environment down there dry and clean as possible? So, that may mean they're wearing tight-fitting clothing. But after exercise, they change out of it very quickly, and they shower quickly after exercising instead of walking around in those sweaty, tight-fitting clothing. That may mean changing their pads more often. So even if a pad has not soaked through in four or five hours, there's still that moisture that's getting trapped there. So, more frequent pad changes can help. Avoiding scented pads. Scented pads can also cause irritation. So, trying just plain cotton unscented pads. So, there are non medical things that we can do as well to help decrease the frequency of infections if they keep happening.

Melanie Cole, MS: Another thing that came to mind was bathing suits, and sometimes we wear our bathing suits all day in and out of the water all day.

Dr. Aimee Morrison: Yes, that is another thing that can predispose to just irritation, infections. In some ways, going to the pool is great. Chlorine can kill a lot of bacteria. So, some people actually feel better after they go to the swimming pool. But just like you mentioned, sitting around all day in a wet bathing suit can predispose to that moist environment, where bacteria, yeast like to grow. So as much as I tell patients to change out of sweaty clothing as soon as possible, I tell patients to change out of wet bathing suits as soon as possible and to shower off after.

Melanie Cole, MS: Dr. Morrison, this is really a very important informational episode that we're discussing here today, this topic. And it's not always easy, as I said at the beginning. Before we wrap up, as you were giving us advice on personal hygiene and good vaginal health, back in my day we had douches, and I think they're still around. Do you advise not using those? And things like baby powder, because sometimes the discharge can smell, or we think that we smell it and we're not sure if everybody else does.

Dr. Aimee Morrison: So, vaginal douches still do exist. They may go under different brands like Summer's Eve, vaginal cleansing soaps and things like that. I do not recommend those. So, those can alter the vaginal environment such that the good bacteria gets destroyed and allows overgrowth of the bad bacteria, or the bacteria that can smell, or the yeast.

This always sounds a little bit funny, but I like to think of the vagina as a self-cleaning oven. So, I tell patients they do not have to do anything to clean down there, but plain warm water. The body is very smart. The body knows how to regulate and clean the vagina. Having some bacteria down there is normal and is healthy. So, I do not advise patients that they should put anything else besides plain warm water down there, in there, or around that area.

In terms of a smell, you're right. There is always somewhat of an odor down there, particularly after sweating, in various points of the menstrual cycle, the odor can change. That is all normal. What is not normal is if somebody can smell it through your clothes. So if you are smelling it as you're taking off your clothes and doing laundry, all normal. If you're ever worried about it, you can ask someone who's close to you, so a parent, a best friend, a sister. If they notice any sort of smell when you're still wearing your clothing. If that's the case, that's abnormal. And that's when we start to think, is there something else going on like BV?

Melanie Cole, MS: I'm going to play this show for my daughter because she told me, she's like, "You're not supposed to wash down there with soap." And I mean, I've kind of done that all my life. And she's like, "No, it's a self-cleaning oven." She said the same thing.

Dr. Aimee Morrison: She did? That's great.

Melanie Cole, MS: I'm so glad that you said that. She's going to chalk one up to her being correct. Now, as we wrap up, Dr. Morrison. What role can parents play? My daughter and I talk about these kinds of things. And as you said, someone you can trust can help you if you think it smells or if you're not sure what it looks like, but what role do you want us to play in supporting our children and adolescents and involving them while respecting patients' privacy in the exam room, give us your best advice here in your summary.

Dr. Aimee Morrison: So, my best advice to parents is to provide reassurance and normalcy around the changes that are happening down there. So, rather than saying, "Oh, this discharge is funny smelling, it's weird," or "Things shouldn't look like that," or "Things shouldn't be that way," the majority of the time, things like including discharge are normal, and they happen throughout puberty.

So, I think the worst thing that people could do is to make their kids feel ashamed about body changes, ashamed about discharge, ashamed about odor. Just kind of normalize that this is part of growing up. Bodies change, including breasts, including the vaginal area. But if the patient is ever worried about it, rather than passing judgment, I think it's always helpful to see your local pediatrician or your friendly gynecologist just to provide that extra reassurance if patients are still worried about it.

Melanie Cole, MS: Thank you, Dr. Morrison. What a great episode this was. Parents, share this show with your adolescent children, with your daughters, because this is information that we all need to hear. It's information that people whisper about behind closed doors, but it's really important that we get to know our body and our body does things. So, we have to know what those things are and what they look like and when it's really important to seek help from friendly gynecologist or our pediatrician. Thank you again, Dr. Morrison, for joining us. And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Kids Health Cast. We'd like to invite our audience to download, subscribe, rate, and review Kids Health Cast on Apple Podcasts, Spotify, iHeart, and Pandora. And for more health tips, go to weillcornell.org and search podcasts. And don't forget to check out Back to Health. There's so many great podcasts there as well. I'm Melanie Cole. Thanks so much for listening today.

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