Friday, October 13, 2017

Fires/smoke and air quality alerts

The Bay Area Air Quality Management District ( has issued a Health Advisory and Spare the Air Alert this week. Very unhealthy air quality from the wildfires in the North Bay is causing unprecedented levels of air pollution throughout the Bay Area. Due to active wildfires and changing wind patterns, air quality could be impacted for many days to come. Outside of the active fire areas, air quality will be variable and unpredictable. Air quality may improve at times or get worse, very quickly.

For those of you who are reading this and are not in the Bay Area, go outside and take a deep breath of fresh air. Now take another one and savor it. We tend to take so much for granted, Including breathable air, until we are faced with situations like this.

Sunday evening in the middle of the night I woke up and thought I smelled smoke. I crept down to my kitchen to make sure that I hadn’t left on an appliance. There was nothing obvious. I poked my sleeping husband, “do you smell something?” He grunted “mmmph” which I took as a NO, so l went back to sleep. It turns out that many of the people I know had done some vestige of the middle-of-the- night sniffing around. Some had gone outside to make sure there was nothing burning in the immediate vicinity. When I turned on the news on Monday morning we had an answer. The news about the fire up in the north bay was devastating. So many homes, schools, and businesses are gone, including the home of one of my very best friends, where I was lucky enough to spend countless weekends in their little patch of heaven. It is heartbreaking.

An acquaintance of mine who is a reporter reached out and I got my 30 seconds of fame later that morning

Understandably the phones and emails have been nonstop for parents worried about the impact of the smoke.

It is not surprising that many people are experiencing some degree of irritation from the smoke. For those of you who are not local, we are talking about serious smoke. Here in SF we are almost 70 miles away from the actual flames but we are still impacted. There is ash on the cars. Have you ever been to a bonfire or campfire? You know how your clothes reek of smoke? That is how the air smells. The beautiful panoramic views that we get from our hilltops are clouded by a gray haze. Scratchy throat, stingy eyes, irritated sinuses, headaches are prevalent.

The most basic suggestion is common sense. Pay attention to local air quality reports. The link will give you information about how the air is improving or worsening:

Stay indoors and keep your indoor air as clean as possible. Keep windows and doors closed. Luckily it isn’t too hot this week, but if it gets warmer, run an air conditioner if you have one, ( most folks in SF don’t actually own one.) If you do have one, keep the fresh-air intake closed and the filter clean to prevent outdoor smoke from getting inside.

Do not add to indoor pollution. Don’t use anything that burns, such as candles or incense. Don’t vacuum unless you have a really good filtered machine. Normal vacuums stir up particles that are already inside your home. Don’t smoke tobacco or other products; the air is already polluted enough!!

Avoid any strenuous activity outside. It is fine to get to where you need to go. I just wouldn’t do any extra outdoor playing until things improve. I don’t think the bounce house birthday party in the park is a good idea this weekend.

Use an air filter
If you have a HEPA filter, use it. My patients reported that the local stores were completely out of the machines today. I would suggest that you take advantage of online shopping. It is probably not a bad investment even if the air is improved by the time you get it.
I am by no means an expert on Hepa filters and there is a lot of information online. I feel like consumers reports is a pretty good guide, so I am including that:

Keep in mind that the ionic filters that create ozone are not recommended and will not remove the particles that we are concerned about.

Do not rely on dust masks for protection. The only masks that will be at all protective are labeled N95 o N100. They don’t seal well on a young child, so your best bet is staying indoors.

In San Francisco with our blessed fog that comes and clears things out on a regular basis, we are accustomed to better than average air quality. It is important to keep in mind that there are populations around the world where the norm is very unhealthy air all of the time. For most healthy folks, a week or so of terrible air won’t have a lasting impact.

If you have a child with sensitive lungs absolutely keep an eye on them. Wheezing, shortness of breath, chest pain and/ or rapid heartbeat would be reason to get seen by the physician. If your child has a prescription for inhaled steroids, it might be a good idea to get those out and start using them at the first sign of any issues. Remember that if an inhaler hasn’t been used in over 2 weeks, it may need to be primed.

At this time, there has been no medical directive issued to leave the area . It is hard to say how long the fires and bad air will be an issue, and more information may be forthcoming from the Air Quality District in the next few days. There seems to be no good answer at this point as to when to go and how far folks would need to travel to be safe as there are wildfires all over southern California as well. Do what you feel is best for you and your family.

Your local municipalities should be able to provide you with information regarding air quality, safety precautions, evacuation and recommendations for local facilities that have filtered air.

A friend of mine who lives in Santa Barbara and has been through this a number of times, posted a very good list that is worth sharing:

Home Evacuation Checklist – How to Prepare for Evacuation:

Inside the House
  • Shut all windows and doors, leaving them unlocked.
  • Remove flammable window shades, curtains and close metal shutters.
  • Remove lightweight curtains.
  • Move flammable furniture to the center of the room, away from windows and doors.
  • Shut off gas at the meter; turn off pilot lights.
  • Leave your lights on so firefighters can see your house under smoky conditions.
  • Shut off the air conditioning

  • Gather up flammable items from the exterior of the house and bring them inside (patio furniture, children’s toys, door mats, trash cans, etc.) or place them in your pool.
  • Turn off propane tanks.
  • Move propane BBQ appliances away from structures.
  • Connect garden hoses to outside water valves or spigots for use by firefighters. Fill water buckets and place them around the house.
  • Don’t leave sprinklers on or water running, they can affect critical water pressure.
  • Leave exterior lights on so your home is visible to firefighters in the smoke or darkness of night.
  • Put your Emergency Supply Kit in your vehicle.
  • Back your car into the driveway with vehicle loaded and all doors and windows closed. Carry your car keys with you.
  • Have a ladder available and place it at the corner of the house for firefighters to quickly access your roof.
  • Seal attic and ground vents with pre-cut plywood or commercial seals.
  • Patrol your property and monitor the fire situation. Don’t wait for an evacuation order if you feel threatened.
  • Check on neighbors and make sure they are preparing to leave.

I also want to share some wisdom from Heather, a local mom who started a group called

As many of you know well, we have neighbors in need. 22 fires, many out of control, continue to rage in our backyard counties. In San Francisco, many miles away from the wildfires, we wake up daily to a visible, dense layer of smog and keep our stir-crazy kids and pets inside so they won’t breathe in what has become pretty horrible air quality. In the towns directly affected by this horrific and overnight destruction, hundreds of people have lost everything they have with thousands more forced to evacuate their homes, waiting in the wings to see what happens next. Some have lost or missing family members including precious animals. I cannot imagine what the air quality is closer to the destruction and active fire zone, nor how long it will take for kids to even be able to go back to school, much less what it will take to rebuild homes and businesses after the damage is done.

Because many of you, like me, feel lost in how to help, I have asked my friends directly affected by this tragedy what we can do from afar. There are many resources available out there; here are a few I found to be noteworthy:

1.   Donate to a credible monetary fund in the area who is directly helping victims in Napa. This is a good and relatively easy one to do remotely; the fund will use the money however it is best needed on a day by day basis:

2.   Help feed and nourish Santa Rosa and the Sonoma County community by providing healthy and nutritious meals to those in need; SAGmonkey is run by a friend and long-time resident of Sonoma County who is generously giving his time and energies to help to rebuild our community.

Your donations will go directly to the purchase of food and supplies to prepare and distribute fully cooked meals over the course of the next three months. By utilizing the resources of the Redwood Empire Food Bank and other local food pantries we will prepare and distribute meals for those in need. We want to make a difference in the lives of our neighbors and friends by providing this service. We have a commercial mobile kitchen trailer that is fully licensed by the State of California and the County of Sonoma.

3.   Consider volunteering to staff a shelter, donating food and other needed items, and helping pets:

Donation drop off points listed here for SF and East Bay residents to avoid tying up roads:

4.   If you know anyone who can host people or animals in need,the travel site HipCamp is connecting evacuees who cannot return to their homes with people who have available space to host them at ranches and rural properties, bed and breakfasts, and even RVs. Anyone who wants to be added to the list can contact HipCamp

5.   ADOPT-A-FAMILY! We were lucky enough to be able to take in dear friends who had to evacuate their home this week. We’re trying to turn a tragedy into a “Fun sleepover” for kids, dogs and adults. Since our friends who live in an affected area know many people affected directly, they recommend this as something folks really need right now. This is a difficult task if you don’t know anyone there but worth the ask as you check in with friends, colleagues and local businesses etc. who may have been affected.
Hoping the wind and weather helps us all see some relief soon…
In love and light,

Friday, October 6, 2017

Lead exposure and prevention 2017

Unfortunately in our current world, many of us live in environments where our kids not completely safe from getting some lead exposure. Lead does not break down or fade away with time. It remains in the environment and we are stuck dealing with bad habits past and current.

Knowledge is power. It is worth getting your child tested. In our office we usually suggest a blood test at either the 9 month, 12 month or 15 month exam depending on the circumstances (if there are obvious hazards we test on the earlier side.) I suggest coupling the lead test with a routine CBC (complete blood count) that also tests the iron level.

Once in awhile things can get sidetracked at some of the the well child exams. There are so many things to talk about and sometime the kids are kicking up a bit of a ruckus towards the end of the visit. If the doctor doesn't bring up the subject of getting a blood test, feel free to remind them. You should find out which laboratories are preferred by your specific insurance plan. Although they are not always in network, the hospital labs facilities are often more adept and drawing blood from our younger patients.

When we get the lead results, the best news is <2 or undetectable. In past years the public health department lead prevention program would get involved if the level was over 10 but as of 2016 the standards have changed. Now, NO measurable level is considered okay. If there is some lead showing up, they want to figure out where it is coming from and keep that level from getting higher. If your child in San Francisco has any elevated lead level the city will send out a public health nurse to help you explore your environment and see if they can figure out the source. The lab is legally required to report all positive tests for environmental and communicable issues.

For reference a level over 45 is an urgent situation that needs treatment.

This link gives a full description of what the different levels signify:

Young children are much more likely to be exposed to lead hazards by touching lead-contaminated surfaces and then putting their hands in their mouths. In addition, children's bodies absorb more lead than adult bodies do because they are still growing; but lead is a problem for all of us. Pregnant women need to be especially careful because any exposure can harm their unborn babies.

Lead in the water is always a concern. The following links are terrific resources:

According to the very helpful Childhood Lead Prevention Program here in SF, new brass fixtures can actually be more of a problem than the old pipes. Even if the new fixtures claim to be lead free, it is possible for some lead to get into the water. Only use cold water for cooking, drinking or making baby formula because hot water is more likely to contain higher lead levels. If you haven't used a faucet in the last six hours, flush it out for one to two minutes before drinking or cooking with it. The longer water has been sitting in the pipes, the more lead it can absorb. You can use the initial water for watering plants.

If you want to go the extra mile and get your water tested, in San Francisco, it is free for anyone on the WIC program. Contact the lead program for a voucher. For everyone else it is $25/tap. Click the link for directions :

There are also some products for testing water available from Amazon, but as is the case with most things, they have mixed reviews.

If you are not lucky enough to live in a place with safe water, consider getting a filter that is tested to remove contaminants. Boiling water will NOT remove lead. Make sure that if your child is getting only filtered water that they are getting necessary fluoride.

Pipes and water are only one of the many ways in which kids can get exposed. Most of the lead gets into your child from the hand to mouth route. They either chew on something directly, or put hands that have been in contact with lead dust into their mouths.

Common Sources can include:

  • paint chips.

  • keys (don't let your child chew on them)

  • Brightly painted pottery or toys

Beware of things imported from different countries The brighter the color, the more apt they are to have lead. It's hard to be absolutely sure if a toy has lead in it or not. Start by to see if a specific toy has been recalled.

Be wary of cheaper toys -- like those from vending machines or street fairs -- and especially plastic jewelry. If you notice that your child is putting a toy in her mouth frequently and you're not absolutely sure it's lead-free, take it away. To lower the risks of poisoning, make sure that your child is playing with age-appropriate toys that he's not at risk of swallowing.

  • Antique furniture varnish

  • Varnish on bathtubs

  • Some lipstick brands

  • Some candies imported from other countries

  • some computer cables (of course chewing on cables is not a good idea no matter what)

  • Dirt and sand that get tracked in from outdoors

  • urban gardening (increases contact with possibly contaminated soil)

  • Ayurvedic medicine

  • Imported beads or necklaces

  • Potentially eating a lot of bone broth. I wasn’t able to find any definitive studies, but it makes sense that lead is stored in the bones, and if the animals were exposed to lead in the soil, the broth from the bones could be an issue\

  • Pre 1997 imported vinyl blinds

Prevention is the best defense!

A nutritious diet is VERY important. Iron, calcium and vitamin C compete with lead for absorption. Healthy eating should be considered a first line of defense.

Consider having a 'shoes off' policy to avoid tracking lead dust inside. This is especially important if someone in the household has routine lead exposure during their job; make sure they clean off well before having close contact with other family members.

Make sure your kids get in the habit of frequent hand washing, especially before meals and snacks

Do the best you can to make sure there are no obvious lead sources inside your home. Any home built prior to 1979 is at greater risk. If you have an older house with any peeling paint, make sure that cribs and high chairs are moved away from walls.

There are some home testing kits that check paint for lead, but they are often misused. The easiest paint to test is that on wood or varnish. In order to get an accurate result, you need to scratch the surface and mix the test liquid with more powdery paint. I don't have a favorite brand.

If you have any concerns about your home, regardless of whether or not your child has been tested for lead, call the SF lead program to arrange a public health nurse visit or speak with the Public Health nurse.

Friday, September 29, 2017

Head Lice 2017/updated treatment and referral options

Head Lice 2017/updated treatment and referral options

I hope you don’t need to be reading this post except for a bit of  Schadenfreude

Lice is a chronic problem that our patients deal with throughout the year. My original post about lice back in 2013 actually went viral. I learned to accept that my moments of fame are generally poop or vermin related. Lice have become more resistant and the treatment and services available have changed over the years, so it time to update the post.

Learning that your child has head lice can be incredibly aggravating. Trust me I know. You might be suspicious because your child is scratching their head or you may have gotten a call from school that your child was exposed. It is rare to actually see the live lice crawling around, although I was once measuring a child's height and as they stood tall against the wall there was actually a halo of lice scurrying all over her head...ugh. Not everyone gets itchy, Your child might be crawling with them and never give a clue.

Once a person gets head lice, the mature or adult head lice can lay up to 10 eggs or nits each day. These nits hatch in about 7 to 12 days. Baby lice or nymphs are about the size of a pinhead when they hatch, and quickly mature into adult lice in about 9 to 12 days. Lice don't like light and they move very quickly, therefore the diagnosis is often made by finding the nits. One site claims that the average speed of a louse is 3.75 inches per minute. This is equivalent to 18.75 feet in one hour, and approximately 450 feet per day. This is over the length of one football field! The nits are small white, opaque or tan specks that adhere tightly to the hair shaft. If you flick something on a hair and it floats away, it may just be dandruff. The nits are usually close to the scalp. If they are further up the hair shaft, likely they have been around awhile undetected and got farther away from the head as the hair grows.

Check your child's head in a methodical manner, paying special attention to the areas behind the ears, the nape of the neck and the crown. Make sure you are in a well lit area. Remember that if one person in the family is infested, you should check everyone. I have had moms speculate that people with a Y chromosome don’t do too well at this task. If you don't have someone reliable to check your head, you may actually be able to feel a nit on your own hair; Run your fingers through your hair from scalp to the ends. A nit will feel like a tiny little knot. If you feel something, yank it out and take a look. A nit doesn't encircle the entire hair, but looks like a tiny sesame seed stuck on one side.

When my children were in elementary school we all got it. That was when I became an expert and spent weeks doing head checks on their entire school. My eyes aren’t as good as they used to be, but I can still consider myself a better than average ‘nitpicker’. Is that a good thing? I am not sure.

I thought I was done dealing with lice on a personal level, but when my daughter Alana was a SENIOR at Lowell, she and many of the peer helpers ended up with head lice. The culprit was an old couch in their break room that was infested. The reason that I share this is so that you know I have been there. I understand why some parents start insisting that they want to pour strong pesticides on their little darlings’ heads. Stop. Take a breath. There are other options.

If you have found some bug or nits, it is time to treat. You have several methods to consider.

Nurse Judy Original Method
My old post had a several step protocol for using the over the counter medication. It still may be the most cost effective way to treat and I have parents successfully get rid of lice if they do all of the steps. Poison, Suffocate, Sizzle.

If you see a lot of nits, you should start by loosening them up with either plain white vinegar or an “egg releaser” product such asClearlice. Both of these work well but might neutralize the active ingredient in the Nix and should be used first and rinsed out thoroughly.

Next step is to wash the hair with a strong stripping shampoo such as Prell. This is a classic old shampoo that should be at a local, larger drugstore. You can certainly get it online. Experts say that this helps the Nix be much more effective because it strips the hair of any oil and makes it hard for the lice to hide. The next step is a 30 minute application of Nix. Ignore the package that tells you to leave it on for 10 minutes. This application is still way less toxic than the more concentrated version that is used to treat scabies and is left on the entire body for 24 hours.

One of the moms in my practice shares the tip that combing out the hair while it still has the conditioner in it stops the bugs from being able to move as you are combing it out. She found it much easier than working on the dry hair. (Thanks Alice.)
Alice's family also loved using this

 to view the comb out, especially if they just have the eggs.Seeing the eggs helped convince her kids that the combing out was indeed necessary.

There are resistant bugs out there, so Nix alone will not be enough. The media gave these guys the moniker Super Lice a few years ago. The stuff of nightmares. There is a new UltraNix on the market that claims to be more effective

You have killed the weaker ones with the Nix, but to get the stronger bugs, you need to follow up a day or two later with cetaphil or oil. Olive oil or coconut oil are probably the best oil choices, but it really doesn’t matter. What we are doing is suffocating any survivors. Slather the hair with the goop of your choice, put on a shower cap and leave it on for several hours. Some studies say that it takes 6 hours to do the job. Do NOT put your child to sleep wearing a plastic shower cap on their head. This should be done during waking hours. The Prell shampoo will come in handy once again to help you rinse out so that the hair doesn’t feel too oily.

The final step for kids who are old enough is to sizzle any survivors with a hair straightening flat iron. When you comb out, It is important to use a good metal flea comb. Having a good one makes a big difference. Do a daily thorough combing to make sure you aren't finding new nits.

Prescription route

If you have good insurance, there is a prescription medication called Sklice

Sklice is a lice treatment that has been on the market for several years. The key factor is that the super lice are NOT resistant to Sklice yet. Sklice is fairly non-toxic. It is the only FDA approved drug that contains Ivermectin. Ivermectin has been used as an oral medication to treat river blindness in millions of patients. To treat lice, it is applied topically and left on for ten minutes. It is approved down to 6 months of age. The cost will vary depending on your insurance plan. As of March 2016 you can go to for a $10 copay coupon. This website will give you all the directions that you need along with other useful lice info. With the copay assistance, your out of pocket price may not be more than $40.
Sklice directions claim that you don't need to do any nit combing after the treatment. One tube/one ten minute treatment. Even folks with lots of hair just need to use the one tube. I have asked the Noe Valley Walgreen's to keep it in stock.


If you opt to hand off the responsibility and hassle and money is no object, there are companies that will do the treatment and the nit removal for you.
Hair Fairies has been taking care of head lice for nearly two decades. There are eight locations nationwide. We are lucky enough to have several in the Bay Area. Our closest location is probably the salon on Fillmore street here in the city:415-292-5900.

Folks who have used them have nothing but good things to report. The fee is based on the time it takes to pick all the nits. The cost can add up, but many parents are so happy to have someone else do this for them, that they feel it is a worthwhile expense.
Maria Botham, the president and CEO says:

"We’ve dedicated ourselves to understanding head lice and getting rid of them. We use that expert knowledge to develop safe, mild, clinically proven head lice removal products and techniques — and, ultimately, to bring confidence and peace of mind to families like yours. Each situation, each child and family is special, so we treat you that way. Our skilled technicians are professional and personable, our salons reassuring and fun. And, simply put, our products work! We use them in our salons every day. That’s why families, healthcare professionals, schools and camps around the country trust Hair Fairies to get rid of head lice. It’s a responsibility we take seriously. So many parents tell us they’ve spent hundreds of dollars and countless hours trying over-the-counter products that claim to get rid of head lice but don’t. All while their child is miserable. Hair Fairies is the better choice — economically and emotionally. If your family encounters head lice, take a deep breath. Stay calm. Hair Fairies is by your side."
Tell them that Nurse Judy sent you for a free head check. If head lice or nits are found, the NURSE JUDY promo will get you 20% off your first treatment. For the record, I receive nothing in return for my recommendation of this or any other product that appears in my blog.

Lice Clinics of America – South San Francisco is a science-based lice removal company. This is a new service that was not included in the last post. They are the exclusive provider of the revolutionary AirAllĂ©TM device, an FDA-cleared medical device that kills head lice and lice eggs using just heated air; this allows us to offer a single (~1 hour) treatment to get rid of 99.2% head lice and lice eggs. Their clinic is committed to treating every patient in a caring, clean and professional manner. Their core values lie in client centered, quality service. The results are guaranteed!
They are located at 1001 Sneath Lane, Suite 107, San Bruno, CA 94030. The clinic is open seven days per week by appointment only! 650-746-8788The total cost is $185 per treatment. Some PPO insurances will cover part of the cost. If everyone in the family is treated they will give a 30 day guarantee. Tell them Nurse Judy sent you and get a 10% discount.
If you don’t want to leave home, There are a few companies that do home visits.

Go on line or call 415-574-8198. Sharon, the owner, founded the company in 2008. They use all natural and organic products. They service many of the local schools and preschools in the Bay Area. There is a $10 travel fee and a $35 cost for head checks. If lice are found, that $35 is applied to the treatment. Each treatment is $100/ person. They recommend two treatments. There is a 30 day guarantee.
Both Hair Fairies and Bug-A-Lugz will furnish you with a form to bring to your doctor for a signature. Some insurance may reimburse for these services. I learned of this company from one of my patients who had a good experience with him. He comes out to your house and charges by the hour, 125/hr plus a small travel fee. He works all over the Bay Area. He managed to go through all three family members in just over an hour, much cheaper than Sklice for all.

Their website is a wealth of good information.
These folks do house calls day and night

Clean up:
Sadly, getting rid of the bugs is probably the easiest step. It is essential to make sure you eliminate any lurking lice in your house (and car) that are waiting to crawl right back into your treated hair.
Wash sheets and pillow cases for the first two days after treatment. Wash towels, recently worn clothing and any hats or hoods that have been in contact with the lice. (Sometimes a trip to a Laundromat that has the big dryers and lots of machines can help you take care of the clean up more efficiently.) Items that can not be washed should be dry cleaned, put in a hot dryer for at least 30 minutes or placed in a ziplock bag in the freezer for 24 hours. Sealing items in an airtight bag for several weeks is also a common recommendation, but may not be reliable. Combs and brushes should be cleaned by soaking in hot water (about 130*F) for 10 minutes. All rooms and furniture, including car seat should be vacuumed. I have never been a fan of the pesticide sprays, but I am intrigued by the non toxic versions that are now on the market.
Hair Fairies has an all natural lice repellent spray that folks swear by for spritzing around all the areas that could have infested. This can help with all of your non-washables such as hats, carpets, couches and car seats. Maria the owner says that some folks even take the spray with them on airplanes (great idea!)
Lice do not jump or fly. Since they travel by crawling, it is important that your children learn not to share brushes, hats, hair bows or headphones. Crowded coat racks are a good way to catch them.
(As are old nasty couches in a Peer Helper break room.) Teach them to hang their coats separately. If your child is in a class or daycare with a lice outbreak, talk about eliminating any dress up or costume boxes.

Are you at an event with a photo booth that has all of those creative hats to try on for the picture? Tag, you’re it.

If your child has long hair, pull it back into ponytail or braids to minimize the risk. Although it is unproven, some people say that washing the hair on a routine basis with tea tree oil shampoo or vinegar rinses may act as a prevention.

Both Hair Fairies and Bug-A-Lugz have special shampoos that they sell as part of the practice that can be used preventatively.
Remember that lice do not care about family income, education, lifestyle or cleanliness. 10 million Americans are infested each year.

Pets do not transmit or carry human lice.
As icky as lice are, it is important to keep one’s sense of humor. There are worse things out there, really. Years ago I had come across an article equating the “stages” of dealing with lice to the Elizabeth Kubler Ross stages of grieving. Thanks to the wonders of the internet I was able to dig it out of cyberspace:

And here is another post that a mom shared. This woman does a weekly parenting blog.

If this post made you itchy just reading it, trust me, I have been scratching my head all week.