Friday, January 31, 2014

Pinworms (ugh)



Please visit the updated post from August 2016

Itchy butt at night? Uh oh. It might be pinworms.
All things considered, in the big scheme of things there are a lot of worse things that can happen, but you are certainly entitled to give a big groan if this is happening to you or one of your family members.
The Pinworm (Enterobius vermicularis if you want to impress folks the next time it comes up in conversation) is the most common worm infection in the USA.
The target age range is for the primary infection is children between the ages of 5 and 10.
These kids are usually the culprits bringing it home, but it is really easy for the pinworms to spread among family members if you live in close quarters and spend any snuggle time in the same bed.
Animals do NOT get pinworms, but they can carry them around on their fur and spread them that way.
The most common way for a person to get infected is by ingesting (or inhaling) the eggs.
The eggs can live out of the body for up to 3 weeks. If you happen to touch a surface that is contaminated and then put your fingers in your  mouth or handle food...tag you're it.


The eggs are way too small to be seen by the naked eye, but can be seen under a microscope.
It takes between one of two months after the exposure for the symptoms to appear.
The eggs mature into the worms.They are very small, white and threadlike. They live in the intestine and gradually make their way down the GI tract  until they are close to the anus.
The male worms die fairly quickly, but the female worms make their way out of the of the body and lay the eggs on the anus.
They tend to do this at night. One theory is that the body temperature is a little higher at night and this drives them out.
It is common for children with pinworms to wake at night. Children that are old enough to communicate may tell you that they are itchy or that their butt hurts.
Little girls might have itchy vaginas or vaginal discharge. Some kids just have mysterious tummy aches.

Diagnosis is done several way. Sometimes you can actually see little wiggling things in the poop
(You can just imagine the calls I get when that happens...), but it isn't usually quite so easy.
Some folks suggest putting a piece of scotch tape across the anus and looking in the morning to see if there is anything stuck on it. I prefer the actual look and see method.
I suggest that a parent to go check in the middle of the night. Make sure that they go to sleep with a very clean butt, perhaps take a good bath.  
Once your child has been asleep for several hours, take a flashlight and spread the butt cheeks far enough that you can actually visualize the anus.
Tell your child ahead of time that you are planning on doing a butt inspection, so that if they wake up they are not going to be startled.  
Pin worms will look like little white threads. They will likely be moving.

Once the diagnosis is made, most folks opt to treat.
The medications do not kill the eggs, just the worms, so they should be taken initially and then repeated in about two weeks.


There is an over the counter medication called Pin X. I have had patients have some success with this. It works about half of the time. 
(which is fine if you are in the right half)

We used to count on a prescription medication called Vermox/ Mebendazole as our standard treatment,but for some mysterious reason that is no longer manufactured and thus no longer available at most drugstores. 
Luckily the 450 Sutter pharmacy will compound it. (They are a terrific resource, they even deliver!)
Their cost for the 2 dose  treatment varies.(updated 1/21/2015)
Unfortunately the prices went up recently:
$89/ gummy
$98/ capsule
$60/ liquid (they would put it in a small amount, probably less than 1 teaspoon.
There is also a $10 delivery charge 

The other option is a prescription medication called Albendazole (albenza) which can also be quite pricy. This also only comes in a tablet so it is a bit challenging for younger kids  
  

The entire family should be treated if you want to really get rid of this as quickly as possible.

None of the medications are advised  for pregnant, breast feeding or children under two.

Natural remedies include eating a diet high in garlic and/or  enjoying some pumpkin seeds.
Worms love carbohydrates. Studies have shown that limiting sugar and white flour (which is a good idea anyway) may keep them from thriving.
Probiotics, which stimulate the healthy bacteria in the gut will also make the environment one where they can't flourish as well.
Vaseline around the anus at night will make it harder for the eggs to be laid.
Some folks suggest crushing up garlic and making a paste with the vaseline and putting that around the butt every night.

The fact is that if there was absolutely no further ingesting of the eggs, pin worms could resolve untreated after about 14 weeks  
(two life cycles), but the problem is most folks just keep on ingesting the eggs which gets them reinfected and so the cycle continues.

It is gross, I know, but the most common issue is fingers scratching an itchy butt and then making their way to the mouth.
We must do our best to eliminate the eggs and prevent the egg to mouth circuit.
Scrub under the fingernails and make sure that they are cut short.
Focus on frequent and effective good hand washing..
Do a nightly bath with particular attention to the butt.
Add some apple cider vinegar to the bath water.

As mentioned earlier. The eggs can live on a surface outside of the body for up to 3 weeks.
They do better in moist environments.
High heat will kill them

They can be easily dispersed into the air.
Pay attention to this when changing the sheets. Avoid shaking the sheets out into the air as much as possible.

Wash all sheets, towels, pajamas and underwear in HOT water.
You want to vacuum or mop, NOT sweep.

Scrub the bathroom and any surfaces.

Remind yourself that there are worse things. but this is indeed the proverbial pain in the butt.



Friday, January 24, 2014

Head injuries

I can safely say that not a week goes by at work when I don't get the call.
The mom or dad is in tears as they recount in horror that their baby just fell.
Sometimes they left the baby on an unprotected surface for a moment, not imagining that the infant could manage to roll off.  That thud is an awful sound.
Sometimes they are right there watching it happen, but can't move fast enough to catch them.
Once in a while a baby is accidentally dropped. (watch out for wet, squirmy babies right out of the tub)
Sometimes a parent falls when holding the baby and they both get injured.

There are so many scenarios.

My husband came pretty close to dropping Lauren, our first born when she was very young. He just barely caught her by grabbing the bottom of the sleep sack that she was wearing. He had nightmares about that one for awhile.

I actually remember in my own case, what I describe as the definition of absolute ambivalence.
My four year old  Alana had a friend over and they were playing upstairs. I heard the unmistakable sound of someone tumbling down the steps.
As I ran to the scene I recall thinking, Who do I want that to be? My child or the friend?.
It turned out that it was my kid. They had been playing dress-up and she was wearing a pair of high heels (Satan's shoes). She stood up with a giggle and brushed herself off, but it took me a moment before I could take a breath and then we made a new rule about dress up shoes and steps.

The fact is that most of the time that kids are indeed fine following a mild to moderate fall.
I think that younger children are like cats. Instead of tensing up when they fall, they remain relaxed until they make contact and for that reason they avoid getting more injured.

Of course it isn't just babies who fall. Children and adults have accidents and sports injuries all the time.   

If your baby just fell or you are the first responder at any kind of accident, take a deep breath. You need to remain calm. You can have a glass of wine later.  

If there is a loss of conscience or any possible neck injury, CALL 911.

Most of the time your child will be crying after a moment or two of stunned silence.
Do a quick head to toe assessment.
Any obvious bleeding, bruising, sprains or fractures need to be tended to.
Check the mouth and make sure there are no loose teeth.

If your child will let you, get a cold pack on any bruises. If you are out of the house, a cold can from a vending machine can work.
If you are home, a bag of frozen peas makes a nice ice pack.
For toddlers and preschoolers...playing doctor before anything happens and letting them know that after a bump we put on the cold pack, may help them be more cooperative after an injury.

I also have had good results with the use of Arnica.
Arnica is a homeopathic treatment that comes as a topical ointment or little pellets that are taken by mouth. Many parents swear that it significantly decreases bruises.(roll  your eyes if you must, but I have seen it work.) 
It is worth having some around. 

Be aware that head wound can create a huge amount of blood if there is even a tiny little break in the skin.
If the skin remains intact, all of that blood can collect into an enormous goose egg.
These can look fairly alarming and can turn all sorts of lovely colors, but they do resolve.
Bruises and bumps by themselves are not typically a concern.

But, now comes the scary part... 
We are much more focused on any bleeding that might be happening beneath the skull.
If there is bleeding under the skull,  there is little room for any swelling. This could cause potential pressure on the brain.
Typically we would be alerted to the fact that this is happening by your child's behavior.
We want to pay attention to any vomiting, sleepiness, fussiness or dizziness.

I actually give the kids "one free vomit". Often they have cried hard enough that they might spit up a little. Let's not worry about that first emesis. If they vomit a second time, they need to be seen.
Do note that Murphy's Law pays close attention to these scenarios and your child could be coming down with a tummy bug that has no relation to the fall.

You may have heard the adage that following a head injury you should not let someone fall asleep. This comes from the fear that someone with a significant head trauma could go into a coma and if not monitored would simply not wake up.

Granted, in the rare, worst case scenarios this is indeed true, but I have Never had that happen to any of our patients (and remember this is a very frequent call)

If your child calms down and seems to be acting okay, I do let them take their normal nap.
Face it, without a nap, your little one will be cranky and falling asleep and may  be near impossible to assess. Don't let them take a 'super nap' .
Wake them up after two hours.
Depending on how far and hard they fell, I would check on them every couple of hours during the night. You can set your clock to make sure you get up to do this.
With an infant you can offer them a dream feed. They don't need to be fully roused.
With an older child, let them know you will be asking them for a "magic word" during the night and when you come to them they simply need to say whatever predetermined word or phrase such as "I love you" and then then can go back to sleep. You are simply establishing consciousness, you often don't need to wake them completely up.
Keep in mind that if your child is in a deep sleep stage, a gentle whisper might not be enough to wake them up.
For older kids,  if they know ahead of time that you will be coming in, they are easier to wake up.


Pupil changes would be of immense concern but would happen only with a serious injury and would NOT be the only symptom.
Some folks, as their baseline, have pupils that are not exactly the same size. They were born this way but no one noticed.
I would suggest checking your child's eyes before they fall so that you don't get freaked out if they seem off to you after a fall if you are noticed that for the first time.  

After a solid knock to the head you are not out of the woods the next day.
Any dizziness or headaches that occur within a week or two following the head trauma need to be paid attention to.

If your child has a concussion, it is critically important to avoid another head bonk within the next couple of weeks. There is a something called Secondary Impact Syndrome that can occur when this happens . In this case one plus one does NOT equal two.

Please exercise common sense precautions to avoid being the person who has to call about a fall, but do remember that most of the time it is harder on the traumatized parent than it is for the patient. Accidents happen to even the most vigilant care giver.

If you call, we will want to know:
*How far do you think they fell?
*What kind of surface did they fall onto?
*What was the immediate reaction?
*How long did it take until they stopped crying?

A basic Neurological exam might include the following
(of course some of these are age dependent)

*can they answer simple questions?
*Is there any complaint of blurry vision
*Do the pupils react to light at the same speed (generally if a penlight is shined into the eyes, the pupil will get smaller)
*Can they touch their finger to their nose? Do this with each hand.
*Is there any clear drainage from the nose or ears? (Murphy's Law again...what Toddler doesn't have a runny nose?)

If they are assessed and there is concern, the next step is generally imaging (CT Scan). This is a valuable option when it is genuinely needed, but if you child looks good, I would hesitate to put your child through the stress, expense and radiation. 

Stay safe!

Friday, January 17, 2014

What would you do if???

I have been doing these little weekly emails for just about a year now.
Some posts are clearly more relevant to parents with young children. Some are much more applicable to older children. Some are more global and your child's age doesn't matter so much.

Today's topic is a about an important activity that you can do with your child that teaches them to be "problem solvers".

Although at first glance it may seem targeted to parents with older children, in fact everyone could learn from it. Adults need to learn to be problem solvers also. Some are much better at this than others. (You know who you are)

For instance, if you got in a fender bender, what would you do?
Many folks would just freeze and panic.
Having a plan in advance could help you stay calm

Your plan could include the following.
*Assess for injury..call 911 if needed
*Know where your insurance info is
*Take a photo of any damage
*Take a photo of the other driver's insurance card and drivers license
etc
*Always have a charger in your car for your cell phone so that a low battery is never an issue.


Years ago, the concept that everyone would carry around an individual cell phone seemed as futuristic as the communicators on Star Trek. Now, of course It is hard to imagine how we got along without them. It was, however, the lack of the cell phone that prompted me to create a game that became a favorite in our family.

It must have been 1994 and I was on my way to pick up Alana from preschool. She was about 4 years old at the time. It was one of those days. I was uncharacteristically running late. Then, I got stuck in terrible traffic. To compound things, I took some random turns to try to work around the congestion and ended up utterly lost. (Remember that this was also before Google maps or GPS)  My stomach was in a knot and I wondered what my younger daughter would do when mommy was late picking her up.

It turned out that she was calmly waiting for me in the office, but that was the day that the "what would you do if" game was created.

It went something like this:
I would ask a question such as,"What should you do if mommy is late picking you up? What are some of the choices? Which is the best one?

Getting a teacher or trusted grown up to wait with her or take her to the office was clearly the right answer and I praised her for figuring that out on her own.

Alana loved this game.
We created all sorts of situations
" What if we were at a store and you couldn't find me?
Alana.." I would go to the check out and ask them to page you"
We never made it too simple...
Mommy :"What if they refused?"
Alana :"I would demand to talk to the manager"

Our scenarios covered any number of little emergencies including earth quakes, fires, and getting lost or separated. 


This game came in handy more than once. The shining example that comes to mind happened after years of playing this game. Alana and I were walking the dog on the beach one day. I had donated blood earlier that morning and didn't realize how foolish I was for doing anything strenuous. I got very light headed and ended up down on the sand trying hard not to completely pass out.
Alana was ten at the time and she went right into problem solving mode. We did have cell phones at this point, She got the dog on the leash, Patted some water on my forehead and calmly called daddy. I could vaguely hear her talking. "Mommy fainted...I think she is okay"
  
The game was such a success that my sister taught it to her kids. Hers had an interesting spin because they lived in Alaska,
"What would you do if you saw a bear?
"What would you do if a Moose wanders into the yard?

There were actually times when these things happened, and my nephews were able to act calmly and appropriately!

Topics can range from handling a bully to getting separated on Muni. Being prepared for unexpected situations can be invaluable.

If your child finds themselves without you and in need of assistance, finding a grown up wearing a uniform is often a valid option for some of the difficult situations.
Finding a parent who has a child with them  and asking them for help, might be another safe option. 

This game is meant to empower. It is wonderful for some kids, but could be terrifying for others. You need to assess your child's temperament before playing.
Either way, identify a problem or situation. Start with simple, less scary ones. Discuss all the possible solutions and then agree what the best plan should be for any given situation.

Stressful situations happen.
Teaching your child to take a deep breath and use their problem solving skills is one of those things you can do now that can have lasting implications for them when they grow up. 
Even teaching a very young child to dial 911 in an emergency can be life saving! 

You have to figure out if this will be empowering for your child as it was for Alana.

Preparation is power. 



Sunday, January 12, 2014

Skin fold irritations


We love pudgy babies....there is something about all of those chins and chubby thighs.....but as your baby gets rounder and rounder, they develop all sorts of little creases. It is common for the skin in these area to get irritated. This issue doesn't only affect babies of course.
Many folks have enough skin and sagging parts that this can remain an issue throughout the lifespan.

The medical term (which I don't think I ever actually use) is intertrigo.
Intertrigo is inflammation of the skin. It tends to occur in warm, moist areas of the body where two skin surfaces rub or press against each other. Such areas are called "skin folds."
These problems areas can occur all over the body. Common areas are the upper thigh/ groin area, the armpits and behind the ears.I think that the calls that I get the most about are the neck and chin. (think drool)

Prevent Prevent Prevent:

Babies and children don't need to bathe every day, but they do need a bit of daily hygiene. It is important to be paying attention to all skin folds on a daily basis.
If you ignore them, you may be caught by surprise by how red and stinky they can get.
Do a routine naked check. This includes separating all areas where the skin makes contact with itself and making sure that there isn't trouble brewing in those creases. 

My favorite tools for both prevention and treatment are cetaphil cleanser, aquaphor, apple cider vinegar and a simple piece of tissue.

When you do give your baby or child a bath, apple cider vinegar in the bath (¼ -½ cup per tub) does seem to help prevent a good number of rashes.

When you are bathing your child make sure you get into all of those folds. When you are toweling them off, make sure those creases get completely dry. Just like I use a tissue when changing a diaper, you can do the same thing with the skin folds. Gently smooth open the fold and tap with the tissue. The tissue will likely stick to the area because of the moistness. Tap until the kleenex no longer sticks and the area doesn't feel at all tacky.  That super dry area is way less likely to be irritated.

If it is not bath time, you can clean these areas with the Cetaphil cleanser.
This cleanser does not require water. You can just apply it and wipe it off
(There are several Cetaphil products, make sure you get the right one, for this we don't want to use the foaming wash). After cleaning the area, apply Aquaphor. You can do this several times a day as needed.

When you baby is teething and drooling up a storm, the creases in the neck can be quite challenging. If you already have irritation in the folds that you are struggling with, it might be yeast. Yeast thrives in warm, dark, moist areas.

If the area has any odor, I would go ahead and use a topical antifungal cream. Lotrimin is fine.
Start by cleaning with the Cetaphil. Then do a layer of the Lotrimin. Follow up with a top protective layer of Aquaphor.

If the area is very raw, you can also add a dab of Neosporin (generic triple antibiotic ointment is fine) several times a day. Just like the anti-fungal cream, this is applied after the Cetaphil and followed by Aquaphor..it is okay to use it in conjunction with Lotrimin.

If you are not seeing improvement after a few days of treatment, call your doctor to have a look.

Some anti-fungal powders can be useful in creases, but the challenge is applying them without your child inhaling harmful particles.
If you are someone who likes powders, sprinkle the powder into your hand away from the baby and gently apply to the trouble area without causing the powder to get airborne.

As with most things, an ounce of prevention is worth a pound of cure.(nothing wrong with an old adage as long as it is apt)  

Friday, January 3, 2014

Strep Throat


Strep throat is a bacterial infection caused by the Group A streptococcus germ.

This illness  is most common in people between 5-15 years of age.

Someone with strep throat will usually present with one or more of these symptoms:
*Sore throat
*fever
*body aches
*headache
*stomach ache
*nausea
*a red sandpapery rash all over the body 

As a parent you can check your kids out for the following:
*Throat will usually look quite red. You may see red or white patches in the throat or on the palate ( the back part of the roof of the mouth) 
*Tongue might have red and white patches ( Known as strawberry tongue)
*glands may feel swollen
*stinky breath


Not everyone has all the symptoms.
Some folks don't even complain about a sore throat!
Some folks don't get a fever!

Strep with the rash may be referred to as Scarlet fever...sounds scary right?? Indeed it used to be. Now that we have antibiotics to treat it with Scarlet fever is no more alarming than simple strep.


It is quite contagious, but it is not uncommon for some family members to have it, while others escape. I would say that in my experience the odds are about 50/50.
(The minute someone in your family gets that sore throat I would suggest sucking on a zinc lozenge and some sambucol..maybe you will get lucky)
The incubation period ranges from 1-5 days but most of the time folks show the first symptoms about 2-3 days after exposure.
You can catch it from being in close contact with someone else who has it.
If you treat with antibiotics (which is recommended) you are not contagious once you have completed 24 hours of the medication
If you don't treat, you remain contagious and can spread the illness for about 3 weeks.
It does resolve by itself but the antibiotics absolutely shorten the severity and duration of the illness as well as significantly decreasing the risk of complications. 

The reason I tend to be watching out for it when I hear about the symptoms is because untreated Strep throat can lead to complications later on, such as rheumatic fever and heart valve problems.
It is impossible to have real statistics about this.
I imagine that there are seriously millions of untreated cases of strep out there at any given time and of course most of them will have no issues in the future. 
Of course most folks don't jump into the doctors office every time they have a sore throat...and as I mentioned, it does resolve on its own.
That being said, If we know you have a case of strep throat, we will strongly advise that you do a course of antibiotics.

When parents call and we try to decide whether or not they should come in to get tested we try to consider all of the symptoms.
For some reason is is quite unusual for babies under 2 years of age to have it, but there are always exceptions.
Be aware that children under 5 often say that their "mouth" hurts, but they are talking about their throat.




Typically the strep throat 'package' does not come along with a lot of congestion.
If I am hearing about someone with lots of coughing, clear mucous and sore throat, it is more likely viral.
On the other hand, a sore throat with fever and not a lot of congestion gets my antenna up.
I am not kidding when I mention stinky breath. A lot of the moms that I talk to can tell strep from the smell and they are almost always right!

Nausea and tummy aches are quite frequent with strep, but add some diarrhea to the mix and I am no longer as suspicious. Nausea plus loose stools is usually more of a tummy bug of sorts.

We test for strep in the office with a 5 minute quick strep test that we find fairly reliable. If the test is negative, but the symptoms scream strep, we will send a culture to the lab to double check the result.

Our test is specific for Group A strep
 There are different strains of the strep bacteria that can cause various infections 
If the in office test is negative, the lab test come back positive with another strain.  

Some folks are carriers. This means that they have a small amount of the bacteria living in their body all of the time and it doesn't make them ill. Those folks may show a very faint positive on the quick test.
Some patients also seem way more susceptible to Strep than others. I used to get it all the time until I had my tonsils out. That is not an uncommon story.  

If you do end up being treated, It is important that you finish your course of antibiotics.
If you are not seeing an improvement within 72 hours of starting the medication, make sure you check in with your doctor.
It is rare, but strep can lead to complications including abscesses on the tonsils, ear infections as well  as kidney problems.

Change your toothbrush 24 hours after starting the antibiotics so that you don't get reinfected!

Symptomatic treatments until the antibiotics kick in include
*Tylenol or Motrin (we are treating pain, not necessarily fever)
*Lozenges
*Tea with honey (no honey for kids until one)
*Gargling with salt water
*Popsicle s
*Cold fruit nectar 
*Having a humidifier running at night.