Hand Foot Mouth

 

Hand Foot Mouth Virus

This has been a steady presence, but Katelyn Jetelina, the local epidemiologist who I follow on substack, mentioned this week that she is seeing a spike.

The name strikes terror in parents who aren't familiar with it and hear about it for the first time. Hand foot mouth? Like Hoof and Mouth? Say what?

Take a deep breath. I think of it as a rite of passage.

As with most childhood illnesses, most of us got this out of the way when we were young. The most common age to get it is 9 months to 7 years, with the largest cluster being 2-3 year olds. You actually want your child to get a mild case and get it over with.

If they don’t, then they are vulnerable when they get older, Adults who are unfortunate enough to come down with this tend to be quite miserable. If you know any grown up who got it from their kids they will emphatically tell you that it sucks.

Young infants are usually protected up to a point from maternal immunity (assuming mom has had it.) We rarely see very young kids get a severe case. Most folks may only get it once, but there are several strains that can cause it; some unfortunate people can get it multiple times.

I actually like to refer to it as ‘Hand Foot Mouth and Butt’, because in my experience, kids often get blisters in the diaper area as well as on their hands and feet. Some people have mild congestion, sore throat and fever as part of the package. Sometimes the rashes are a little more widespread. When I did this post a few years ago, Dr. Ted was seeing rashes that were all the way up the arms and legs.

Every time it comes around it seems to have a bit of a different nuance. One year with an especially nasty strain, a bunch of my little patients lost fingernails. Other years it seems to impact more of the parents.

It is a very variable illness, meaning that one child will not look very sick and another can feel wretched. The lucky ones might simply have a mystery blister on the hand and that is the extent of it! I have seen some kids just refuse to eat; it wasn’t until parents got a peek in the mouth that they figured out what was going on. Most of the time the worst symptoms resolve in a week or so.

Treatment is all about managing symptoms. Your goal is to keep your little one hydrated and comfortable. I have found that the kids with a lot of mouth involvement are the most miserable. In extreme cases the mouth sores are so awful that they don't want to eat or drink and can face a risk of dehydration.

Keeping them comfortable is the best way to get them to be willing to drink. Even if they have no fever, if they are in pain, it is appropriate to dose them up with Tylenol or Ibuprofen (Motrin/Advil). Tylenol comes in a suppository form if they are resistant to taking medicine by mouth. Here is a blog post which can help you choose one over the other. It includes a dosage chart.

To treat mouth lesions, I like an over the counter medication called Glyoxide that can be applied by Q-tip to affected areas (if your child lets you anywhere near them!)

For older kids with mouth sores try this:

1/2 teaspoon of Benadryl mixed with

1/2 teaspoon of Maalox

Squirt this mixture around the mouth every 4-6 hours. The goal is to apply it to the sores, but don’t worry if they end up swallowing a bit of it.

Many kids get good relief from this two ingredient concoction, but if this version isn’t helping, your doctor might prescribe something called magic mouthwash that adds lidocaine to the mix.

As far as eating goes, offer cool creamy and soft foods. Avoid anything acidic or sharp. Tortilla chips? Ouch!

Smoothies and popsicles are great choices, but avoid citrus flavors.

Cold nectars are often a hit.

Breast milk is a winner if you have some. If your child is reluctant to nurse, breastmilk can be made into a popsicle!

Popsicles in general are often a good way to get the fluids in. If you can’t get them to take some sips (or licks), this might be the time to negotiate with a sticker chart, or even some extra screen time.

If you are concerned that you are losing the hydration battle, it is worth having your child evaluated. A dehydrated child will have very low energy, decreased urine output and not a lot of tears or drool. They seem dry and droopy. They may need some IV fluids. This is usually done in the emergency room, but if it is during regular office hours, it always makes sense to start with an evaluation by your primary doctor.

Treating the lesions

Most kids aren’t terribly bothered by the blisters, but make sure their nails are filed just in case they are scratching at them. If they are complaining bitterly, even with a dose of pain reliever, look closely at the offending lesions to make sure they don’t look like they are getting infected. To be honest, they usually look red and a little yucky, but expanding redness or warmth around the site would be a reason to get checked.

Some kids feel comforted by an application of cream, or ointment. Emily’s skin soothers or calendula work well, but if you have a favorite, go ahead and try it to see if they get relief. Oatmeal baths might also feel good.

If your child has eczema, you might see that it flares up a bit with viral syndromes (because you weren’t having enough fun with simple lesions.) Being aggressive with moisturizers is always a good thing.

The exposure period for this illness is usually from three days to a week. In other words, if your child was exposed on a Monday, they may start to show symptoms as early as Thursday but if a week goes by without anything happening you are probably out of the woods.

On the other hand, If your child has the illness, they are contagious as long as they still have blisters or a fever and perhaps can shed the virus for a week or two afterwards or longer.

So, when can they go back to school?

If your child is happy and eating and has no fever but has a few blisters I would try to keep them away from a newborn or someone with a compromised immune system. My general rule is that if they have a fever and are miserable, keep them home, otherwise let them go about their business. It seems excessive to expect you to keep your kids out of daycare if they are fever free, eating well and acting normally.

Here is the hard truth:

They are likely contagious before you know they are sick and may have already spread it. They got it from somewhere; it is more than likely that someone at daycare already had it and started the spread.

While patients are most contagious at the beginning, they can shed the virus in their stool for weeks! Unless a school is going to absolutely quarantine every child for a month until they are all clear (which isn’t likely), as much as we would like to keep our daycare and schools virus free, I don’t think it is possible, so instead I choose to move forward with as much common sense as possible.

Here is my simple rule. Keep your fussy, febrile kids at home. (If you are not up on your Latin, febrile means having a fever.) These guidelines are supported by the AAP.

Siblings are usually going to catch each other's stuff. Hopefully the youngest babies won't succumb. Good hand washing is key to avoiding this. Be especially scrupulous hand washers, especially after changing diapers.

Almost all of the spread for this is from contaminated surfaces or hands, so make sure the shared toys are cleaned frequently.

If your child gets this (I should say when, not if) don't freak out. Time will fix it.

As always, if you look at your sick child and you are WORRIED (not just feeling sorry for them) go ahead and get them checked. Otherwise, you can handle this at home. Give them something cool and creamy along with a big hug. If your child is running around, has normal activity level, and reasonably wet diapers, then they are "managing" and I wouldn't be too concerned.

Dr. Ted’s tidbits

You may have heard this referred to as Coxsackievirus because that is the most common strain. This virus is a member of a family of viruses called enteroviruses. These single strand RNA viruses typically occur in the gastrointestinal tract, sometimes spreading to the central nervous system or other parts of the body. It is easily spread through saliva, respiratory secretions and stool. It can be shed in the stool for several weeks! Most doctors don’t bother to test for it because it is so easily recognized.

The photo below is of one of my patients with a worse than average rash.

Bizarre Airplane seat mates

 I was having a conversation with a friend about her unpleasant recent flying experience. We started talking about our ‘hall of fame’ bizarre seat mates and I am pretty sure I was the winner.

I have been on hundreds and hundreds of flights throughout my life. The vast majority of the time, I have completely forgotten any people sitting next to me by the time I have left the vicinity of the airport.

There are several glaring exceptions.

There was one flight where two women in my row spent the flight loudly whispering to each other in Russian, pausing and then staring pointedly at me. Rinse and repeat for the entire flight. When we landed I admittedly rushed to the nearest mirror to try to see what on earth they were looking at.

There was the chiropractic kinesiologist who spent five hours explaining what it was that he did and who then got out his activator tool and started treating my popping ears during the descent.

And then there was the man who read out loud (emphasize the word loud) from the sky mall catalog. Every other sentence was accompanied by a large, wet belch. I speculated that perhaps he had a deep fear of flying, was on some type of medication and had convinced himself that as long as he kept reading, we wouldn’t crash. I guess it worked?! The woman in the window seat and I exchanged frequent glances. She looked trapped and was leaning as far to the side as she possibly could. It was a long two hours.

But the winner of the gold medal was on a flight from Pittsburgh to Denver. I noticed a person at the gate area and sent up a little prayer to whoever “Please not next to me”.

It was hard not to notice him. He was a very tall and buff fellow. His head was shaved except for a large spiky mohawk. He looked fierce.

The plane was a small one with only 2 seats on each side. When I boarded it was clear that no helpful spirits had heeded my request, because there he was, not just in my row, but in my seat.

“Excuse me, but I have the aisle”

He grudgingly moved over to his assigned seat by the window. He was radiating hostility.

I got myself settled. Before take off, I pulled out a pack of gum from my purse and offered him a piece.

Suddenly, we were best friends…the magic of a piece of gum. I might have been better off keeping all the gum to myself.

He started talking.

He had been visiting his daughter who lived with the mom. He chatted about how hard it was to not live closer. He was happy to tell story after story of this little 5 year old, who he clearly loved. He mentioned that he had a form of PTSD and if he was startled out of a deep sleep he would get violent, so his daughter had learned to gently stroke his head and whisper into his ear when she needed to wake him up.

There was no sign of his slowing down. At some point, I got out my book, which is normally a social signal that it was time to stop chatting.

Nope, he paid no attention.

“ Can I show you some pictures of my daughter?”

“Sure”

He got out his phone and scrolled through quite a number of cute ones.

“And these are my two dogs”

Yep…lovely dogs. Always happy to look at dogs.

“And…oops”

The oops was that the next series of photos were no longer featuring dogs..

Flagrant dick picks. Ugh and awkward.

“Sorry, I guess I forgot these were on here”

(um, yeah, sure you did)

Pause

“You can go ahead and read now”

Between his incessant talking along with the show and tell of photos on his phone, there was only an hour left in the flight. I opened my book.

I hadn’t been reading long before I noticed that he had started snoring. Then to my horror his head started nodding down into my direction. The mohawk was now leaning on the top of my head.

“No, no, ick”….but the spirits above were still ignoring me.

My seat mate snuggled down, using my shoulder as a comfy pillow.

His earlier words were repeating in my head…PTSD, violent if startled awake.

I was NOT going to gently rub his head. I was stuck. He slept on my through the bumpy landing and didn’t wake up until we pulled into the gate.

I survived and got a story about it, but give me a peek-a boo-playing toddler anytime..

It took a couple of years before I started offering gum again.

I need to add that not all seat mates are the ones you quickly forget or can’t wait to get away from. I have interacted with many lovely and quirky individuals. ‘Nurse Judy’ is easily activated and I have ended up giving parental advice on more than one flight.

One of my favorite pair of seat mates was actually on a flight that I was on, going to Pittsburgh for my grandmother’s funeral. I was terribly sad but they had me laughing and relaxing long before we even took off. These guys were a hoot. They had brought along a gourmet picnic. They asked if I wanted to share. At first I declined until it became impossible not to join in the festivities. This including covering all three of our tray table with a gingham checked tablecloth. (obviously this was back in the day of bringing whatever you wanted onto the plane with you). It was just what I needed. I felt like I was part of a fairy tale.

As great as that was, it is still not quite the best. On what was clearly the most impactful flight of my life, I met my husband Sandy. The 50th anniversary of that flight is just a month from now.

Do you have you own story?

Creating a Healthy Bedtime Ritual/Make a Bedtime Book

 

No family's sleep routine is exactly the same.

When I was growing up my mom was early to bed and early to rise. She loved getting up at dawn and having the quiet house to herself while the rest of us slept.

My dad was a night owl and was delighted if I stayed up with him to keep him company. I remember doing some odd projects together including translating physics from Russian to English or building a ‘heath kit’ color TV. Sometimes it was just watching the late news. I typically called it a night long before he did.

So when Sandy and I had kids, creating a firm bedtime was not at the top of my list. It was right up there for Sandy though; he was (and still is) a data hound. He had read how important sleep was. He was the one who did most of the sleep training when the kids were young and he was certainly the enforcer when it came to bedtime.

One evening, the kids may have been 3 and 6, Sandy was out of town on business. It turned out that several of my good friends were also playing single mom that week. We gathered at one of their homes with all the kids and ordered in Chinese food. The kids were running around and the moms were chatting. I wasn’t keeping close track of the time, but it was late and the kids were starting to get cranky.

“Hey girls, don’t get whiney, This was a special treat and I let you stay up”

“No, we are tired! It is past our bedtime. Daddy would have made sure we were home and in bed!”

Uh…way to throw me under the bus, I was NOT expecting this response.

But even when they don’t tell you as clearly as mine told me, kids do thrive from routine. Have you ever noticed how some kids go down for a nap like clockwork at daycare but fight it at home? If the schedule is wishy-washy, kids will push to see what kind of power they can exert. That’s their job!

Beyond making sure that your children feel safe, secure and comfortable, your job is to make sure that the rules are clear and the enforcement is consistent. Kids will ultimately follow them and thrive.

Have a set bedtime and try hard to stick to it.

Block out a reasonable amount of time for the process. It might vary from child to child but count on at least 30 minutes. Be present for this. Ideally this means keeping laptops and phones out of the room. Blink and your child will have outgrown these magic moments. Savor the sweetness.

The goal is for bedtime to be the time for deep connection rather than a battle. Sandy brought his guitar in and had a repertoire of oldies that he would sing. Make your own memories.

When you are establishing a firm, new routine, talking about it for the first time during the actual bedtime when your little one is tired is NOT the time to learn about new rules. This will work best if they are part of the team.

Have a conversation about this earlier in the day. Let them help create a routine that feels comfortable. Let them help negotiate how many songs/books etc. Discuss some rewards that they can earn for going right to sleep and not trying delay tactics

Some kids might do well with a simple sticker chart. They can earn stickers for easy bedtimes and a certain amount of stickers can turn into specific rewards.

Rewards can range from a special outing, to a few more minutes of screen time the following day. Find something that resonates with you.

Consequences for not cooperating need to make sense. These can simply be not earning that special outing, or cutting the allotment of screen time.

Problem Solve some common issues before they happen.

I am thirsty: okay to have a sippy cup or water bottle near the bed.

I want an extra yogurt pouch: Be clear on a reasonable window for getting a last minute snack. My grandson Elliot has learned to respect the “last call”. Once the teeth are brushed there is no more eating. “Tomorrow we will make sure to have a snack before you brush your teeth.” I know it breaks your heart to hear the “but I’m hungry”. Try not to cave.

I only want to wear my spider-man pajamas and they are dirty: Do your best to make sure you have options before you are in the midst of the bedtime chaos. If that favorite pair pjs or sheets aren’t going to be usable for another night, pop those in the laundry in the morning before you forget.

I am afraid there is a monster under my bed: “This house is safe. There are no monsters. If you like we can put a nightlight in here”. (Do not search for monsters. This would indicate that the possibility of a monster in the closet exists.)

I have to poop: This is a tough one, I would take them to the potty but do NOT engage or talk to them. Make it very businesslike.

Other considerations

• Avoid sugary foods, rough-housing and screen time in the period before bed.

• If possible make sure kids are exposed to natural daylight during the day.

• Start dimming lights and lowering the noise and energy level about 45 minutes before the actual bedtime. This is very impactful!

• A cooler room is more conducive to good sleep.

• Keep the bed for sleeping and napping. Do not use it for ‘time outs’ or playing.

• I have no issues with using a white or brown noise machine

• Model good behavior (sorry daddy, you were not such a good example in this one instance.)

• Try to keep the schedule the same every night. Weekends shouldn’t be different from school days.

• Illness or travel can completely derail a schedule. Do the best you can and just roll with it until you are home or everyone is feeling better.

• If you or your child are having consistent issues falling asleep, it is worth checking iron and Vitamin D levels. Low levels can be associated with insomnia.

If you are feeling more ambitious and have the bandwidth, another way to have a really clear routine is to make a Bedtime Book with your kids.

Children love ritual and will enjoy reading their special book night after night. You will tire of it long before they do. Here is a step by step guide to making your own. Many children love helping you make the book by posing for the appropriate pictures. Of course this means you actually have to print some, rather than having them live exclusively on your phone.

Make your Bedtime book:

Get a binder. Bonus if it has an insert on the front so you can slide in a photo; this should not be too hard to find.

Put the pages into clear page protectors for a waterproof book that you can tweak over time by adding or subtracting pages. You may want to update it yearly with current photos and rituals.

Call it what you want; MY BEDTIME BOOK or add your child's name and age.

Start the book with photos of important people and introduce them.

Here is (parent) and if there are two of you, here is (parent),

Here is (sibling)

Here is (pet)

This is Me (or us if there is more than one child sharing the book)

For young kids, I would keep it to your immediate family members and pets, but you can be as inclusive as you want but keep in mind that unless you want to be reading for hours, this is not the time for the entire family tree

Next add a picture of your house with street sign and address:

This is where my family lives (great way for kids to learn their address)

Picture of bed.

Picture of a special blanket.

This is the safe comfy place where I sleep.

These are my special stuffed animals.

If your child has two homes you can take a picture of each room and make 2 copies of the book so there is one at each house. It is nice to have a ritual that is consistent in both places.

Take pictures of your nighttime rituals such as:

I get into Pajamas

Picture of a toothy smile - Before I go to sleep I brush my teeth. It is important to have clean and healthy teeth.

We get into bed and the lights get a little darker (picture of snuggling).

You can add some open-ended pages that allow the story to vary each night. Options include things like:

Pick several from this list:

We have read our (number that you have agreed on) stories/books

We have sung our (number that you have agreed on) songs

Let's talk about something I did today that I am proud of

Let's talk about something I did today that was kind

Let's talk about something I learned today

What was the silliest thing that happened today

Let's talk about something special that we can look forward to tomorrow

We send special goodnight "thought kisses" to people that we love

Finally, end with pages appropriate to winding down the good night process:

Getting good sleep is important. My body does a lot of growing when I am asleep.

My family is very proud of me when I stay in bed all night. If I get up too much they might get grumpy (photo of silly grumpy faces)

Now it is time to say good night and to turn off the light; maybe I will get a special massage (optional but what a nice way to end the day)

Good night!! See you tomorrow!!

Reading

Snuggles

Good Night kisses

This blog hit a milestone/ Half a million views!

 The majority of people reading my posts are the result of being on my email list. I used to send them via Constant Contact. Now I am happily on Substack.

I haven’t ever tried to calculate the actual number of emails opened and read. The one constant is that after I send the email, the posts get placed in my blog. This I can track and my little blog hit 500,000!

It motivated me to take a little trip down memory lane.

I can pinpoint when it started. Back in 2009 when I was working at Noe Valley Pediatrics there was an H1N1 flu epidemic. It feels like a lifetime ago. A vaccine was created fairly quickly, but there was a short supply. While many people are willing to wait in line for their own health care, trust me, that gets thrown on the window when it comes to their children.

The office phones were ringing off the hook and people tried to navigate getting their kids the shot as quickly as possible. There was no way to keep up with the demand for information. Continuous busy signals added to everyone’s stress.

The mother of one of our young patients suggested that I start a blog as a way to communicate any updates. I knew nothing about blogging, but it sounded reasonable. My blogging career was born.

Through the blog I was able to let people know quickly when we got the flu vaccine shipments and how we were managing the allocation.

Several months later, things had settled down from that scary flu season, but I now had a platform and I had thoughts on how to use it. I had come to recognize that many of my patients had the same questions (over and over and over). To minimize the need for frequent repetition, I started writing posts that addressed some of the more common issues.

The blog became an easy resource. At work if one of my callers had a question about a fever, a rash, strep throat etc, I would email a link to the related post and have them call me if they had any follow up questions. It was a great system.

I changed the name to Nurse Judy’s Approach. I got in the habit of sending out a weekly post on Friday mornings. I would often pick new topics based on what was going around. My patients also put in requests for things they wanted me to cover.

I confess to mixed feelings when I had my first moment of internet fame for my head lice post.

I loved writing and it felt so nice getting feedback about how my posts helped people get the information that they needed without freaking them out.

I also loved how much I learned along the way.

It’s time for some gratitude.

Thanks to my loyal readers who have stuck with me from the beginning, even as my subject matter has expanded and your children have grown. Welcome to all the newer readers who somehow found me.

Thanks to all of you who have shared the posts with others!

Thanks to the many doctors, specialists and experts in their fields who generously shared their wisdom with me when I would do a deep dive into a topic.

Thanks to Dr. Ted for encouraging me to keep the habit going. Collaborating with him while we update the old posts and create new ones is so much fun. No one can go down rabbit holes quite like the pair of us.

Yes we are hard at work for the enormous sleep post that I promised….It is coming.

Thanks especially to my husband Sandy who decided that my grammar was horrible enough that it shouldn’t be allowed out in public; he started editing for me several years ago. (While my attitude was always that if someone really got annoyed by an errant comma, they could get their information someplace else; BTW, he found six errors in the draft of this post!)

Thanks Rebecca for getting me over the hump

And later that day…..

Thanks for reading!!!

July 4th Safety Tips

 Here are some tips that can help you all have a safe & healthy holiday weekend.

Posting it a day early. It might be more useful for planning purposes.

Fireworks

Not surprising that these are on the top of the list.

Please be very careful of fireworks. If you are skipping the organized shows and planning on setting them off yourself, make sure your kids don't have any access to the fireworks or matches ahead of time. Do an inventory and know exactly what you have on hand. Keep the kids at a safe distance during the actual fireworks. Have a bucket of water or a hose nearby.

The danger isn’t only personal injury. If you are living in an area where the fire danger is elevated, please don’t be a dumbass.

Fireworks are LOUD

Loud music and fireworks can be damaging to your child's sensitive ears. Consider getting some ear protection if you are going to be someplace that can put hearing at risk:

How loud is too loud?

Dogs and cats hate the 4th of July

Try to keep your pets indoors with windows closed. There are items such as the Thundershirt or medications that you can give them if you know your animal has a tough time with the booms of fireworks. There are also some noise canceling headphones for pets, newly on the market.

I know this first hand, my poor grand-dog, Bowie, who is an enormous fierce looking shepherd/husky mix, is absolutely terrified of fireworks. We were in Golden Gate park last year and some (^%$#) set off a firework just yards away. Poor Bowie, all 75 pounds of him, jumped into his daddy’s arms and needed to be carried to the car. ( Luckily Adam is a strong guy)

Also, pay attention. Stressed out animals need to be observed especially closely with any interactions with your children and babies.

Make sure that your animals are microchipped or have current tags on, in case they get out.

Going out in a crowd

Since some of the holiday festivities may involve large crowds, I have some recommendations for dealing with situations where you might find yourself in a throng of people. Dress your child in bright clothes that stand out from the pack. Take a photo of them before you set out, so if heaven forbid you get separated, you have a current picture to pass around that shows exactly what they are wearing. Another sensible and creative idea is to write your phone number on your child's wrist and cover it with liquid band-aid to make sure it doesn't wash off. Make sure all phones are fully charged.

Have a solid plan with your older children. What should they do if they lose sight of you? Where should you meet up? This is a good time for the : ‘What would you do if’ game

Protect from the sun and stay hydrated

If you are in San Francisco chances are you probably don't have to worry about the heat. When my kids were growing up, our July 4th fireworks watching usually included warm blankets, hot chocolate and lots of thick fog. I remember one year when Lauren was 3 or 4 and we were driving to a vantage point, she saw a traffic light through the fog. "Is that a firework? It's beautiful!" Ah, our San Francisco babies.

For those of you escaping the city…..

Get in the habit of doing a skin sun exposure check at least every 30 minutes (more frequently for fairer kids) to see if it is time to reapply the sunscreen. Be very wary about applying any of the aerosol sunscreens around a heat source (like a grill.) These are flammable and there are horror stories out there about terrible burns that have occurred.

Sunscreen post

Safe Grilling/food safety

Let's move our discussion over to grills. I was watching the news and a story came on about the hazards of metal bristles coming loose from utensils that are used to clean your grill. These metal strands may get lodged into pieces of food. People have been reporting mouth injuries and worse. Happily, that is one call that I have never gotten, but it seemed like a caution worth sharing. Check your utensil brushes to make sure there is nothing loose. While you are at it, check the grill surfaces to make sure there are no pieces of any foreign objects that can get stuck in the food.

Make sure your child can't get anywhere near any type of grill. The danger begins from the moment you light it and are waiting for it to be ready, until long after the cooking is done and you are certain it is completely cool.

If you are cooking meat, make sure that it is thoroughly and safely cooked. Food borne illnesses don't just love under-cooked meat; other foods can transfer the bacteria also. Pay attention to any picnic foods that will be out of refrigeration for several hours:

Outdoor woes

If your picnic/meal is outside and you will be spending time in grassy, wooded places, make sure you do a head to toe check for ticks once back inside:

Ticks are rampant right now. Finding them early before they have been attached for a couple of hours will vastly decrease any concern about disease transmission.

Tick Post

If you are doing any hiking, or have a dog who is tromping around in the bushes, then pay attention to the possibility of Poison Oak

No, it is not okay to keep your child in bubble wrap; that isn't my intent. Go forth and have a festive, fun and safe holiday. Happy 4th of July!

Adenovirus /Make sure you have a healthcare proxy if you are leaving your kids with caregivers

 

Adenovirus

Make sure you have a healthcare proxy if you are leaving your kids with caregivers

Oh poor sweet Coby,

This one's for you.

Coby is 15 ½ months old.

Last weekend his parents had flown off for a well earned quick getaway. He and his brother Elliot were staying with the other set of grandparents.

Murphy’s Law was on the case. On Saturday Coby developed a fever and was absolutely miserable.

‘Bobbie’ and ‘Zayde’ called me to check in. The fever was still up an hour after the Tylenol, and I could hear him pitifully wailing in the background. He is generally a mild mannered little fellow.

I suggested that it was worth taking him to urgent care. I thought it was a good idea to rule out an ear infection. Also, Dr Ted had been seeing a lot of Influenza type B (odd for June) so I told them to get that checked as well.

Important note…make sure that anytime parents leave kids with anyone, the caregivers have an official permission to be able to get the children medical care in case of a situation like this!

Ah second kids…While there was a healthcare proxy, signed and sealed for his big brother, but no one had thought to update it to include Coby.

We all hated to put a damper on their weekend, but it was time to call Lauren and Adam, let them know what was going on and get that paperwork taken care of just in case it was needed.

At urgent care Coby’s ears got the ‘all clear’. The rapid test for flu was negative. He was obviously sick with something, so they sent off a complete respiratory panel. The following morning we had our answer. Poor guy had a nasty case of Adenovirus.

Here is the post that I had done a couple of years ago.

At the end, I will give you all the details of what Coby’s particular course looked like. (it was no fun)

Adenovirus

Is this a new virus? Nope!

What’s new is the ability to easily do a respiratory panel to identify the actual virus. What I used to refer to as a ‘viral package’ or the ‘creeping crud’ now has a specific diagnosis.

So, what is adenovirus?

Adenovirus is a family of viruses that has more than 60 types. The correct pronunciation stresses the second syllable. (I was saying it wrong for years)

It is quite common. You've probably been exposed to it at some point in your life. In fact, by the age of 10- years, most kids have had at least one adenovirus infection.

It can happen year round but tends to be more common in the Winter and Spring. It is very contagious. Symptoms are variable and range from a mild cold to severe illness. Most people don’t bother to test a little sniffle, so it is hard to have accurate data on how common it actually is.

The more annoying and serious presentations include:

• Runny nose and congestion

• Pinkeye

• fever

• Cough

• Headache

• Sore throat

• Muscle aches

• Pneumonia

• Ear aches

• Vomiting

• Diarrhea

This is indeed the ‘viral package’ with a little bit of everything. The wave that was going around when I first did this post, as reported by Dr. Ted, was a “pharyngo-conjunctival fever,” aka sore throat, pink eye, and fever. Most cases last from 3 to 7 days, but the more severe cases can last for weeks. We once had a colleague whose child had a fever for 3 weeks with adenovirus.

Like other nasty viruses, there can be secondary infections.

People with weakened immune systems, or existing respiratory or cardiac disease, are at higher risk of developing severe illness from an adenovirus infection.

Exposure and spread

The onset of respiratory symptoms is usually between two and fourteen days after exposure. When it is gut related (vomiting and diarrhea) it moves a little more quickly and you will see signs within 3-10 days.

People are most contagious right before they get sick or within the first couple of days of the illness. Even people with very mild cases can spread it.

The most common ways that it spreads are

• Close contact (shaking hands)

• fecal/oral transmission

• contaminated surfaces

• airborne transmission from one infected person to another.

• Occasionally it can be spread through water and public pools

Testing

More often than not the diagnosis is the ‘best guess’ based on the symptoms. Those red eyes are often a big clue. If the patient is pretty sick or has a persistent illness, then your doctor may opt to do a respiratory panel to get a more definitive answer. A stool sample might also give a diagnosis. Blood work is not usually done, unless your provider wants to rule out something else, but it might show an elevated white blood cell count.

Note about nasal swabs in pediatrics.

Kids' noses are a breeding ground of all sorts of stuff. It is quite common to have an assortment of various bacteria show up. Pediatricians are skilled at knowing what needs attention. Adult doctors might tend to ‘over-treat’

Treatment

Most of the time treatment is based on the symptoms and there are no special medications (or magic wands). Antibiotics will not be helpful.

Symptomatic treatment includes, fluids, rest, fever medications as needed and a humidifier at night. Soothing eye drops are helpful for the pinkeye and Manuka honey feels great for the throats (only for folks older than a year.)

Saline mist inhalers are a game changer, especially if you can get your little one to cooperate. A little mist followed by snot suckers can be very helpful for clearing the nasal passages.

People who are immunocompromised and get a severe version may need to be hospitalized for supportive care. Those folks may have access to antiviral medications.

Prevention

Good hand washing and wiping down surfaces are important ways to protect yourself from this.

Try hard not to touch your face with unwashed hands.

Boost your immune system

Try to get enough sleep. Vitamin D and ZInc are associated with a healthy immune system. I also like sambucol/elderberry at the first sign of illness.

So, what did Coby’s course look like?

This is absolutely the sickest he had ever been. He had Covid when he was 5 months old, and it isn’t even close.

With this virus, the fever lasted for a full 6 days. The baseline was 101-102 even with meds. The highest that they measured was 103.7. The method of measuring was a forehead thermometer.

Motrin clearly had a bigger impact than the Tylenol, but he was most comfortable when he had both in his system. Bless his heart, there were a few moments, on full medication when he did a little dancing. That kept Grandma from being too worried.

His poops were mushy and very stinky.

His nose ran like a faucet, with thick yellow/green snot.

His breathing sounded noisy, but his lungs were mostly clear. There was no labored breathing (he wasn’t out of breath), but when the fever was high, his respiratory rate was elevated. Read here for more on what labored breathing looks like.

His appetite was pathetic, but he was drinking and fortunately still had some ‘Baboo’ available (Coby’s term for breastmilk). He did accept some sips of smoothies.

His cry was a bit hoarse, so he may have had a sore throat.

He was clingy and lethargic. Days were full of one contact nap after another. With all the congestion, this was the easiest way for him to breathe, since he was in a more upright position. Nights were awful.

He might have had some mildly pink eyes the week before, but that was the one classic symptom that really didn’t come into play.

Lauren called to check in with the regular pediatrician first thing Monday morning, just to keep them in the loop.

On Tuesday, day four of high fever, Coby went in to get checked. The doctor confirmed that this looked exactly like “classic adenovirus.”

She was told not to fret about the poor appetite as long as he was staying hydrated.

This link about tummy bugs has a good review of how to assess hydration status

She was also warned that this could linger for 10 days.

At that point it was all about symptomatic treatment. (and of course to check in if things seemed to be getting worse).

Happily on Day 6, the fever was gone, the poops returned to normal and the appetite came back. Kids are resilient!

Extra thoughts.

Sometimes after hours urgent care that doesn't specialize in pediatrics may be quick to prescribe medication that isn’t strictly necessary. To the doctor’s credit, this is often because that is what some parents seem to be looking for.

I know that it isn’t always an option, but seeing an actual pediatrician is preferable. Especially for kids younger than 3.

Link ER vs Urgent care

In Coby’s case they sent him out with both a course of antibiotics and a course of steroids. Neither was necessary or appropriate.

When the diagnosis came through the following day, we were all glad that the decision had been made by the family (and the wisdom of Dr Ted) to hold off.

Update:

Eight days after Coby first showed any symptoms, EJ succumbed. Enough time had passed that we thought we were in the clear. Suddenly he complained of feeling cold. “Ruh Roh”. This was soon followed by 102 fever and a headache. We are assuming, based on the timing, that it’s also adenovirus. As noted above the exposure for this can be 14 days.

Interestingly, one other of Elliot’s early symptom was pain with peeing. Specifically he reported that his pee felt hot, thick and stingy. Bet you didn’t know that a virus could start in your urinary tract! Sure enough, some strains of adenovirus are well known to cause “urethritis.” We did a home urine test to rule out a urinary tract infection. Fortunately, that particular complaint lasted only for one day. Ongoing pee issues would have required an ‘in office’ urine test.

The fever has lingered as a low-grade temp for 4 days, so far. There hasn’t been any congestion. Not all viruses present the same way in different people.

Now the countdown continues. I for one had been sharing spoons and closely snuggling with him for days.

Fingers crossed that the other adults (myself included) in his life don’t get it!