Friday, February 28, 2014

Measles on the rise?

Since it has been in the news recently and is hitting close to home with the exposure on BART,  Measles seemed like a worthy topic this week. 

Measles, also known as Rubeola is a very contagious respiratory virus. Infected people present with  high fever, cough, congestion and red eyes. After several days they will also develop a significant rash all over the body. These patients are clearly ill.. 
People are contagious as early as 2-4 days prior to showing any signs of the virus and may remain contagious until the rash is gone.

Complications are frequent.They range from ear infections to pneumonia, encephalitis and/ or seizures. 1-2 out of every 1000 cases are fatal. This is a serious illness. Unlike something like chicken pox, where some folks want to catch it so that they develop immunity. You really don't want your child to get the measles.
90% of unvaccinated people who come into close contact with an infected person will come down with the illness.

The routine Measles vaccine is combined with Mumps and Rubella and is referred to as the MMR
They used to sell the individual components but they haven't had them available separately for many years.
The first MMR  shot is routinely given to patients between 12-15 months and again between 4-6 years.
The vaccine is thought to be 95% effective. The second dose is given just to catch the occasional person who didn't get effective immunity from one dose and bumps the effectiveness up to 99%

Why do we wait so long before giving the protection to our babies?

Assuming that mom has been fully vaccinated (or less likely has had the actual measles) babies are born with passive immunity to the disease. This immunity starts to wane as they get older and is considered mostly gone by the time  they are between 12 and 15 months. If a child is vaccinated when they still have the maternal protection, the vaccine does not seem to be as effective.
Because of this, in our office we generally give the MMR at 15 months.
If you are traveling to a high risk area or there has been a clear exposure, the vaccine can be given as early as 6 months, but that shot won't count towards lasting protection and your child will still need to get 2 shots after the age of a year.

The Vaccination discussion is not an easy one.
I get it that as a parent, you are trying to do the very best that thing that you can do for your child. There is nothing trivial about this.
Unfortunately it can feel very difficult to find solid, balanced information about vaccines.
There is a lot of confusing and misleading information out there, especially on the internet. There are so many strong opinions.
My general rule of thumb is to discount the opinion of anyone who is rabidly one sided on either side of any discussion.

Facts do show that there has been significant decrease of a number of deadly illnesses since the advent of routine childhood vaccinations.
This is more than someone throwing statistics at me.
When I was just starting out as a nurse, fatal cases of Meningitis, and epiglottitis were common. I have seen first hand what a change there has been since the HIB vaccine became available.
Before routine use of the measles vaccine, there were about 500,000 cases of measles in the United States each year and about 500 deaths. Measles also led to about 48,000 people being hospitalized and another 1,000 people being left with chronic disability from measles encephalitis.

For my part, I choose to fully vaccinate my own children. It seemed to me to be the most sensible choice both for their health as well as the greater good in the goal of eliminating these diseases.

Certainly I have seen my share of patients having a miserable several days after shots.
It is absurd to pretend that that can't happen.
Luckily in all the years that I have been working in this office I have not had any patient have a serious, long lasting adverse consequence from any shot.

Of all the vaccinations out there, the MMR has had the worst of the reputations.
Study after study has shown that there is no link between between the MMR and autism., but there are still some folks reluctant to give their children the vaccination.

The MMR is a live vaccine and it is true that in some rare cases the reaction can be a little rough.
Interestingly, most kids are just fine the day of the immunization.
Typically the reaction comes along between a 7-21 days after the shot. This reaction may include high fever and rash. This is not thought to be contagious. It usually lasts only a day or so.
If your child is allergic to eggs, we are extra cautious when giving the vaccine. Some folks with a significant reaction to eggs may opt to get it at the allergist's office.
I have NEVER had any patient have an allergic reaction from the MMR or a serious post vaccination reaction other than about 20% who seem to get the fever the following week.

This year (2014) there have already been 15 reported cases of measles.
Most of those were travel related and most of the patients were unvaccinated.
Prior to this, The last large outbreak of measles in the U.S. occurred during 1989-1991, with 17,000 cases of measles and 70 deaths in California.  In 2013-2014, a large measles outbreak in the Philippines has resulted in over 1700 cases and 21 deaths. With so much traveling these days and higher numbers refusing to vaccinate, it is not surprising that we are seeing more cases here. 

Over the years, I have had many calls from parents worried about measles. I was able to reassure them that active cases of measles were very rare in California.  In fact, truth be told, I have not seen even ONE case of measles among my Noe Valley Pediatrics patients in all of the 26 years that I have been there.
I certainly hope that I never do.Unfortunately with more and more people opting out of vaccinations it doesn't feel like a very safe bet anymore.

Friday, February 21, 2014


I have been getting a lot of calls lately from concerned parents who have gotten a notice from school or daycare that their child has been exposed to impetigo.

Our world is full of bacteria. There are beneficial ones and dangerous ones.
We are constantly surrounded by potentially harmful bacteria that seem to have the "if you don't bother me, I won't bother you attitude". Many folks, without being aware of it, are carriers and routinely  have bacteria such as staph on their skin.
Our skin is our all important protective barrier. Bacteria that is not causing any trouble as long as it remains on the outside of the body can wreak havoc if it makes it's way in. When there is a break in the skin from a cut, bite, or an itchy rash that has been scratched, the bacteria can take advantage of that, enter the body and cause an infection.
Impetigo is one of the most common skin infections out there.
It is usually caused by either Staph or Strep. By far, most of the time Staph is the culprit
There are two types of impetigo.
Bullous impetigo is less common and usually shows up in much younger children. This is characterized by large pus filled blisters.
More common is the non-bullous impetigo, this will have crusty, rashy areas that may have a honey colored glaze. Most of the time you will see these lesions around the mouth and the nose.
This also often affects the diaper area, but  can show up anywhere, more often on exposed parts of the body.
These spots and rashy areas can spread. They don't seem terribly painful and most of the time your child might seem quite well. The spots simply may flare up on and off  but usually don't  clear up completely without treatment.  
(super red/open rashy areas around the butt might be strep. We can do a test for that in the office) 

Young children and school age children are the most common victims of Impetigo, likely because they tend to come into more 'close contact' situations with others.
It is easily spread from direct touching with an infected person,or from coming into contact with contaminated surfaces like toys.
The incubation period is 1-3 days.

If you are dealing with  a very small area, the standard treatment  is an antibiotic ointment. With a really mild infection over-the- counter Neosporin may take care of it. If you don't notice an obvious improvement within 48 hours you may need to be seen or talk to your doctor about getting a prescription ointment called Mupirocin (Bactroban is the trade name).
Some cases are severe enough to warrant a course of oral antibiotics. In our office we will almost always want an office visit to help make that determination.
If a family member has been diagnosed, wash any sheets, towels, toys etc
To prevent getting this in the first place, good hand washing is key.
Do your best to keep skin safe and intact. Dry, itchy skin is more at risk because of the tendency to scratch. Eczema seems to easily  get infected areas. Keeping the skin well moisturized can help. Calendula cream is thought by some to have a natural antibacterial property.
Keep nails short to avoid damaging scratching.

To prevent infection, any mild cut or open lesion should be kept covered  with an antibiotic ointment applied 2 or 3 times per day.  
If your child has a case of impetigo or has been exposed you may also want to put a thin film of Neosporin or Mupirocin  under the fingernails and inside the each nostril twice a day to prevent spreading. Dr Schwanke is a big advocate of getting the ointment inside of the nose since that is often the source of the bacteria.

Another thing to consider is a bleach bath. "What?" you say.
I know, the first time I learned about this I was fairly dubious, but it is currently a strong recommendation from many dermatologists.
Adding ¼ cup of basic bleach to a standard tub can be useful for preventing and treating a multitude of skin afflictions. This will kill any staph or bacteria that is hanging out on the skin. It turns out that it is usually not at all irritating and has very few adverse effects.

I just learned another fact that knocked my socks off. A recent study claims that at least 30% of our tubes of various ointments are contaminated with bacteria. It doesn't take much thought to figure out how that would happen. We touch the tube tip with our unwashed fingers, or we touch the tube to the surface of our skin.
Do me a favor, from now on, try to keep any new tube sterile. Squeeze the dose of ointment or cream onto an applicator (you can use a spoon) and avoid having any direct contact with the tip or rim.

Okay, to sum it up.
If you are one of the families who got the Impetigo warning....
Hopefully your school setting has done it's job and has thoroughly cleaned toys, surfaces etc.
Aside from that, checking your child to make sure they have no spots anywhere is the only action plan that I would advise.
If they have any questionable spots, treat as discussed.

As I mentioned in my recent post about contagiousness, A notice about impetigo exposure would not be a reason to keep them home from school.
Chances are, unless you have been out of day care for an extended period,  they have already been exposed.

Friday, February 14, 2014

Pet Safety

Please see updated post May 2016
I personally think that most families are enriched by having a pet.
Of course, as an advice nurse I have a bit of an unusual take on things. I do get plenty of animal related calls.
A little knowledge and planning can help keep the relationship between your pet and your child happy and safe. 

For those of you who already have pets living with you, I understand that animals are essential and much loved members of the family. In some cases they may actually feel like your first child,  but  here are a few things to consider:

Many cats are quite happy to welcome a baby to the family, but cats are cats. Once your child has the ability to chase after them, the cat will usually establish dominance once or twice with a good swipe.  Kids (and new puppies) learn pretty quickly what the rules are.
Do watch out for cat scratches, they can get infected fairly easily. It is essential to clean them well and apply an antibiotic ointment. (Don't use peroxide, current thinking says to avoid it because it causes  tissue irritation). If there is any increasing redness or red streaking appearing around the scratch site, that might be a sign that it is infected and it should  be evaluated.

If your crawling child starts getting little spots, consider that they might be flea bites. Fleas are rampant here in San Francisco year round. When not on your pet, fleas tend to hang out in the carpets and while they might not bother you, your child is spending more time on the rug and presents a tasty treat.

Please do your best to keep your kitties out of your baby's crib or bed. I know I sound like an old grandmother, but it is  a safety hazard for a cat to snuggle around an infant's face.

Meow mix has never hurt anyone, but you want to make sure that the cat food is not left out where your toddler can get into it.

Now, getting a little more disgusting, make sure the litter box is somewhere where the child has no access. You don't want to be the parent who calls me horrified that their baby just had a snack of cat poop.

Make sure you closely supervise any interactions with your dog and your new baby to make sure the dog is not exhibiting any behaviors that you need to worry about.
If the dog is at all growly, as heart wrenching  as it may be, they might need to be placed in a home with no kids.
Most dogs are perfectly wonderful with the children but even with the most loving dogs please make sure that your baby or toddler is not allowed near them at meal time. Let your doggy have a baby free zone where they can eat in peace.
By far most of the bites that I get called about are food related.

Just recently we had a toddler get bitten by the family dog. One of those "treat balls" was unearthed under the sofa where it had been hiding for months. The dog got very territorial when the toddler tried to get it and the baby took the brunt of it.
Bites by a family dog are the rare exception. By far most of the animal bites that I get called about happen outside of the home. 
If you are visiting a friend or relatives house and they have a pet. Ask them explicitly if the animal has any history at all of aggressive behavior with children. Some folks have a blind spot where their beloved pets are concerned and lose their common sense. If there is any doubt please ask that the pet be kept away from your child.

If you are walking down the street, teach your child that before you pet any strange animal you ask the owner for permission.  Some animals tied up outside a store may be stressed and don't feel comfortable being approached.

Once you have the all clear to say hello, demonstrate the safest and best way to meet an new animal.
Show  them how to hold out their hand first and let the animal give them a sniff.
For younger kids, consider teaching them the one finger petting technique have them make a fist except for the pointer finger. This way they can pet the animal with that one finger without grabbing hunks of fur.

My youngest Alana kept me on my toes.From the minute she could crawl, she was scampering across the park to say hello to anything with fur.

If you don't have a pet and are considering getting one:

I am a total animal lover and I think that having a pet  is a wonderful thing.
In our case our family was adopted by a stray Siamese cat when Lauren was still a baby. He lived a very long life and I am sure never regretted choosing us as his family.

We also wanted a dog.
My mother-in-law had plenty of strong opinions. Amongst them were some pearls of wisdom that resonated with me..
Her theory was:
*All children need a dog, teenagers especially so. There is nothing quite like the unconditional love of a dog to get you through tough times.
*The last thing an adolescent needs is to lose their dog during those tumultuous years.
*Barring an unforeseen tragedy, the lifespan of a dog is roughly predictable, so plan accordingly.

When she first mentioned this to me I was actually a little horrified. It felt so callous and calculating, but when I thought about it a little further and it made perfect sense.
We ended up getting our beautiful golden Java when my girls were 9 and 12. We were blessed to have her with us for 12 wonderful years. Our family was much richer for it.

Do know ahead of time that as much as you bargain with your child and make agreements about how the dog responsibility will be shared....just give up right from the start. The dog is yours. You will be the one remembering to feed them, doing all the walks in the rain and the poop scooping. Trust me.
Luckily the value of getting a family pet goes way beyond teaching your child responsibility.

Friday, February 7, 2014

When is your child contagious?

(In other words, can they go back to school or daycare?)

 Some of my most common questions revolve around when kids are contagious and when are they ready to go back to nanny-share, day care or school.
There is rarely a simple answer. On one hand, of course we want to be a responsible parents and not expose others to our sick child.   On the other hand we want to protect our own recovering child from going back too quickly where they may come down with something new. In order to logically best  make these decisions there are many issues that we need to consider.

Some parents have an easy time taking time off and others simply can't afford to. It is naive to think that these aren't real factors.

What makes this so tricky,  is that most viral syndromes can be spread a day or two before the kids show clear signs that they are ill. Many kids may be a little fussier than usual. They might take a longer lap. Perhaps they don't eat quite as much.Your antenna might be up that something is brewing, but are those reasons to miss work and keep your child at home??? Of course not!

The fact is, if you child comes home from school in the afternoon and is sick that evening, most likely everyone they were with earlier that day has already been exposed and I am going to take that into consideration when we try to come up with the most sensible plan on when they can return.

If you are in a small share care situation, it is essential to have a talk with the nanny and the other families involved to make sure you are all on the same page.
I would suggest that you create a "sibling" relationship. This simply means that you all accept that the kids are most likely going to get each others mild illnesses.
Frankly, if you plan on staying at home until your little toddler is free from a runny nose, you will be waiting a very long time before you leave the house.
Remember that some clear runny noses are not contagious. Teething as well as some allergies can be the cause.
As far as common colds go, the average child under 2 years of age has EIGHT colds a year.
While I would like to keep my youngest and most vulnerable patients free from viral syndromes and colds as long as possible, exposure to these common viruses is in fact developing the immune system. At some point they are going to have to deal with some mild illnesses. Think of it as a rite of passage.

Typically if I have a child with a fever over 101, a  new case of diarrhea, or a brand new green mucous y cough or cold it is worth keeping them home for at least a day to see what  is coming next.
If your child has an infection that is being treated with antibiotics, we generally consider them no longer contagious after they have been on the medication for at least 24 hours.
Bacterial conjunctivitis is also usually given the all clear after 24 hours of eye drops. (of course you need to finish the course) 

There is never any complete assurance that can be given that your little one is "not contagious".

Use your best common sense. When in doubt avoid contact with anyone who is vulnerable. This would include newborns, or someone with a compromised immune system.

If you are questioning whether or not to go on an upcoming play date, explain your situation to the other parents. They may be perfectly fine hanging out with you and your snotty nosed child, or perhaps they have an important event coming up and want to be more cautious. Let them decide. Full disclosure ahead of time is the best practice.