Friday, August 29, 2014

Hepatitis B/Your first vaccination opportunity

Deciding whether or not to vaccinate your child is a decision that some parents struggle with.

It can be hard to find a balanced discussion. The internet is full of one sided rhetoric (both pro vaccine and the anti vaccine factions are guilty of this). Can vaccinations have some side effects? Absolutely. Do they always work? Of course not. That being said, I personally believe that vaccinations save lives and that the benefits overwhelmingly outweigh the concerns.

Our office puts an enormous amount of thought into the vaccination schedule that we follow.
We don't just blindly follow the rules. In past years there were times that we were doing our schedule a little differently than other offices as we tried to minimize the amount of shots during one visit.
When the Pentacel combination vaccine was introduced, our schedule finally shifted around and now we follow the standard immunization recommendations. It appears that Dr. Sears seems comfortable with this vaccine schedule as well; so many of the parents who were trying to spread things around no longer feel the need to do so.

The first immunization that is given to many babies is the Hepatitis B vaccine. There are different forms of Hepatitis. The B strain is mostly contracted through blood exposure or sexual activity.
Hepatitis B is no joke. It is 100 times more contagious than HIV. It can lead to liver cancer and death. In Britain where babies currently do not routinely get the Hep B at birth, the cases of Hepatitis B have doubled in the last decade. The Hepatitis B vaccine was approved in 1981 and has over 30 years of proven safety. It was actually the first cancer preventing vaccine.

In this country, most hospitals will automatically give this within a day or so of birth unless you tell them otherwise. If mom is Hepatitis B positive (It is important to know your Hepatitis B status, check with your OB if you don't) it is essential for the baby to get the protection as soon as possible.
If mom is not a Hepatitis B carrier, then I am perfectly comfortable if you decide to hold off from getting it before you leave the hospital.  The official recommendation is to get that first one over with in the hospital and there is no down side, but if you are feeling overwhelmed with things and want a bit more time before jumping into the immunization program, I have no issues with my patients delaying that hospital dose, but don't delay too long. I would suggest getting started with it at the one month visit if you put off that immediate new-born dose.

Is your young child high risk? Probably not. But before you decide to waive the protection altogether please consider this. Hepatitis B can survive outside of the body for at least several hours.
I know of more than one case in this city where an unsuspecting child found a syringe in a playground. Living in an urban environment means it is not zero risk for exposure. Currently most day-cares and schools require the series before admission so most likely (unless you sign a vaccine waiver) your child will get need to get the Hep B series within the first few years of life.  It is much easier on your child to get this shot added to the rounds of shots that we give that first year of life. A few extra  shots makes no difference to them. Once they are over 18 months they are much more aware of every poke and trust me, you will be glad that you got these over with. Certainly all children should get the Hepatitis B series before they are teenagers, even if you sign a waiver to delay it when they are young. This vaccination is a three part series.

The Hepatitis vaccine seems to be quite safe and I usually do not see any obvious vaccine reaction to it. For more information, the CDC Hepatitis B vaccine information sheet can be viewed at the following link:

Friday, August 22, 2014

2014/15 Flu season/ vaccine info

Flu Vaccine 2014/2015 information

All about this season's flu vaccine

It is recommended that all children over the age of 6 months get the flu protection.
If you have an infant under 6 months of age, please consider getting the flu shot for yourselves and any of the baby's close contacts.
All children under the age of nine, who are getting the flu vaccine for the very first time should receive two doses of the vaccine in order to be considered fully protected. The two doses need to be separated by at least four weeks. If they did get one shot last season they only need one this season.
Children under the age of three get a half dose.  
Children over the age of two have the option of getting the shot or the nasal flu mist. This is a live vaccine.
The current studies are suggesting that the mist might be the most effective treatment for children between 2-8.
Most two year old toddlers do NOT like having something squirted in their nose, sometimes you are better off with the shot.
From what I could see, both methods seems about equally effective last season.

Every year the disease trackers do the best they can to predict which strains of the virus will circulate and try to match the flu vaccine to the anticipated strain. Some years have better matches than others.Last years match seemed pretty good.
Usually the vaccine differs from year to year, but this season the formulation is the same one that was used last year.
Our office will be supplied with the quadrivalent vaccine that covers H1N1, one other A strain and 2 B strains. The B strains are expected to cause the most severe cases in younger patients this season.
Some of the available vaccine out there this year from other places will be Trivalent.That covers only only 1 of the B strains.
Do try to get the quadrivalent if you have an option.

Last season the flu wasn't much of an issue. Most of the folks who got the shot ended up with decent protection. Plenty of people did get  the flu and had a miserable week, but no one in our practice had any severe complications.

We had ample supply of the vaccine last season, Towards the end of the season there were fatalities from flu that made the news (as there are many years) This caused a panic and a run on the vaccine. Many other offices did run out.
I anticipate that we again will have plenty of vaccine available for our patients but there are no absolute guarantees.
Getting your child vaccinated early in the season is your best bet. As soon as they turn 6 months old we can get them started.
Because we already have experience with this particular flu vaccine, I do not expect any problematic reactions to the shot or mist.
Some of our patients did seem to have low grade fevers for a day or two, but for the most part the vaccine was tolerated very well.
All of the Flu vaccine in our office is preservative free.

I will be blogging the reactions and the vaccine availability, and any details of when the flu starts to make it's rounds and what the symptoms look like on the weekly Noe Valley Pediatrics update blog.
We just got our first shipment of the baby doses.

Click below for the 2014 Flu information statement from the CDC

Friday, August 15, 2014

West Nile Virus

Please see the updated post on this topic 10/2015

I hate mosquitoes. Yes I am aware that they are part of the vast food chain but that doesn't stop my loathing. For the record, it is a mutual dislike and for some reason I rarely get bitten. The rest of my family, my daughter Lauren in particular, is one of their favorite treats, and they feast on her when given the opportunity. Even though I don't end up getting bitten, having a whining mosquito in the bedroom at night is a form of torture. What makes it worse is knowing that the bites are not just annoying, but they can be downright dangerous.

Of all the mosquito-borne illnesses, the West Nile virus is the one that has been in the local news recently. This is a mosquito borne illness that is thought to have originated in Africa (hence the name.) It has spread throughout the world and it was first detected in this country in 1999.  Unfortunately we now have it in most states, including California.

Mosquitoes get this virus from feeding on infected birds and then transmit it to humans. Humans are referred to as "dead end hosts"; they get the virus from being bitten by the infected insect but then can not spread it to each other. It is possible that it can be transmitted from blood transfusions, pregnancy or breast feeding but there are no known cases of infants who have gotten seriously ill from these transmissions.

The good news is that most of the time it is actually not such a big deal. Children under 5 seem to be at  relatively low risk and folks over 50 seem to get hit the hardest. It can be found year round but seems to peak in late summer/early fall. 80% of folks who get it have no idea that they are infected and feel perfectly fine. 20% of folks may have fever, joint pain, muscle weakness, stiff neck, diarrhea, vomiting, swollen glands, photo-phobia and/or a rash on the trunk. Not everyone will have every symptom. Most people showing these mild to moderate symptoms will recover completely, although there are reports that some of these folks can remain fatigued and achy for several weeks.
1% of infected people can get more serious neurological complications including encephalitis and meningitis. It can be fatal for those with serious cases. People with troubled immune systems are at the greatest risk. California has had 2 deaths from it so far this year.

The incubation period is usually between 2-14 days after the bite from an infected mosquito (most commonly 2-6 days.) There is, alas, no treatment beyond supportive care. It is thought that most people who have fought off the illness do end up with some level of immunity.

Any severe headache-fever-stiff neck combination always needs to be evaluated right away.  If West Nile virus is suspected there are blood tests that can help with the diagnosis.

Since there is no vaccination at this point, and no treatment, the key is prevention.

* Make sure that you have intact screens on all windows
* Get rid of any standing water that is around your house; do a double check to make sure there are no pots, bird baths...etc. that are places where mosquitoes can breed.
* Avoid being out and about during dusk and dawn when most of the biting happens.
* Try to wear (keep your child covered with) long pants/ long sleeves etc. Light colored clothing is recommended.
*If you are going into a heavy mosquito area use bug spray on exposed skin and clothing. The EPA has five registered insect repellants. Of those, there are three products that are more easily available.
  - DEET is one of the more popular options. It is considered safe for infants over the age of 2 months.
  - Oil of Eucalyptus is considered one of the least toxic options but interestingly, the age recommendation for it is for 3 years and older.
  - Picaridin is a newer option. It is odorless and is approved for children 2 years and older. It is great as a mosquito repellent but it is not thought to be as effective against ticks as Deet if you are going into the deep woods.

As with any new thing, do a little test patch on the skin to make sure there is no sensitivity before you widely spritz it. They all come in different concentrations. You will need to read the labels to see how often you need to reapply. Avoid contact with eyes. 

If you see any dead birds, give them a wide berth and report them to 1-877-968-2473 (WNV -BIRD) or online at That website also will give you the up to date numbers on how many West Nile virus cases there are  in California, county by county.

I was in western Massachusetts in early summer and there were simply swarms of mosquitoes and other nasty biting insects wherever we went. It made me realize how lucky we are here in San Francisco that it isn't as "buggy" as it seems to be elsewhere. If you are seeing mosquitoes around your house, San Francisco's Environmental Health Department will send an inspector  to investigate (415-252-3805.) They will check the area around your home (including sewers) to see if they can find  any breeding areas.

To be sure, we still do get patients covered in bug bites, but to date I have not seen any cases of diagnosed West Nile or mosquito borne illnesses among any of my patients. Some people seem to have much more of a reaction to bites than others; it does not appear that there is any correlation to the magnitude of the local reaction and exposure to the West Nile virus.

Thanks so much to Denise Bonilla, the Senior Public Health Biologist at the Vector-Borne Disease Section of the California Department of Public Health  for being such a great resource.

Here are some bonus facts about mosquitoes

*Both males and females make that awful whining noise, but only the females bite humans 
*Mosquitoes are especially attracted to people who drink beer *Mosquitoes love the smell of sweaty feet 

Friday, August 8, 2014

Infant Acne

Infant acne is a very common affliction and one that we get a LOT of calls about. Although the timing can vary, it typically shows up between 3 and 6 weeks of age and is usually gone in a couple of months. Your previously flawless infant is suddenly covered with pimples. This will include whiteheads, pinkish pimples and red, rough patches of skin. The rash can spread beyond just the face and move to areas all over the chest and the head. The situation seems to get aggravated and redder when the baby is warm. The cause of the infant acne is thought to be a combination of maternal hormones and baby sweat glands starting to work

Infant acne drives parents crazy, but usually doesn't bother the baby at all. Of course, not all rashes are infant acne. Little white pimples called milia are also quite common and may be present at birth. Some babies may be sensitive to detergents, soaps or something in a breast feeding mom's diet. As with any rash, if the baby seems bothered by it (they may be rubbing at their face as if they are itchy) if they seem unusually fussy ( probably unrelated, but.....) or the rash seems oozy or crusty, schedule an appointment to have the baby evaluated. Any distinct large pustule should be checked out to make sure it isn't Staph. 

Infant acne loves to show up when the grandparents are about to meet the baby for the first time or you are ready for a photo shoot (this is what Photoshop is made for. My generation wasn't so lucky!)
There is no standard treatment. Simply wash the areas with gentle soap and water. Some folks say that applying breast milk or Calendula cream  directly to the rashy area seems to help calm it down.

While the rash on your baby's face  is very likely infant acne, I understand if you feel the need to check in anyway by sending a photo or giving us a call. Trust me, I get it. In my own case, when my first born Lauren suddenly resembled a teenager with horrible acne, I broke down and made that very first call to the pediatrician.

Friday, August 1, 2014

Nurse Jen blogs about dental care

I have two daughters, 6 and 9. They brush their teeth regularly, don't overindulge on sugar, and floss once in awhile. They've always received glowing reviews from their dentist for their oral hygiene. I'm not against x-rays, but because of this positive feedback I opposed our pediatric dentist's gentle suggestion for annual x-rays. I remember Googling it in the waiting room and I found a 2012 study published in CANCER associating yearly or more frequent dental x-rays to an increased risk of developing meningioma, the most commonly diagnosed brain tumor. I made my best parenting decision and waited two years for more x-rays (they still went in for the recommended cleanings every six months.) Despite more glowing praise for the appearance of my kids' teeth on the outside, they both had cavities to fill!

This prompted me to pay closer attention to my kids' teeth ....and do a little more research on the subject. Following are my findings, along with some advice from Dr. Claudia Masouredis (our respected pediatric dentist.)

Did you know your child can actually 'catch' cavity causing bacteria by sharing a spoon with you? If you (or any other care provider or friend of your child) is prone to cavities, protect your child and do not share utensils, toothbrushes or anything else that goes in the mouth.

Everyone in your family should take good care of their teeth. Set a good example and let your child see you brushing twice a day and flossing every day. Begin wiping away bacteria from your child's gums before their first tooth even erupts. When teeth are present, gently scrub them with a clean toothbrush (no toothpaste.) Kids as young as age 2 or 3 can begin to use toothpaste when brushing, under supervision. *Ask your dentist when they can start using toothpaste with fluoride (we want to make sure they are old enough not to swallow the toothpaste first.) SF water is fluoridated so they are getting beneficial levels of fluoride if they drink tap water.

The American Dental Association recommends that parents take their child to a dentist no later than his or her first birthday. This gives the dentist a chance to look for early problems with your child's teeth. Pediatric dentists specialize in treating children's dental health. You and your child's dentist should review important information about diet, bottles, tooth brushing and fluoride use. Visiting the dentist from a young age will help your child become comfortable with his or her dentist. It also establishes the good habit of regular dental check-ups. Children who were born prematurely or weighed very little at birth and/or who have ongoing special health care needs are at a higher risk of developing cavities. Enamel hypoplasia or a weaker enamel coating of the primary teeth has been correlated with pre-term infants. These children have a higher rate of dental decay from having this weaker enamel.

As your child's permanent teeth grow in, the dentist can help seal out decay by applying a thin wash of resin to the back teeth, where most chewing occurs. Known as a sealant, this protective coating keeps bacteria from settling in the hard-to-reach crevices of the molars. In addition, I learned that electric toothbrushes are far more effective and are worth the cost if they help prevent cavities. Most also have the added benefit of having built-in timers to encourage longer brushing!

When it is time for x-rays, ask your dentist if they use high speed or digital imaging, which has less radiation. As part of the ADA's recommendations to minimize radiation exposure, the ADA encourages the use of abdominal shielding (e.g., protective aprons) and thyroid collars on all patients. In addition, the ADA recommends that dentists use E or F speed film, the two fastest film speeds available, or a digital x -ray. (AADP)

Dental x-rays are valuable in helping dentists detect and treat oral health problems at an early stage. Many oral diseases can't be detected on the basis of a visual and physical examination alone, and dental x-rays are valuable in providing information about a patient's oral health such as early-stage cavities, gum diseases, infections or some types of tumors. In particular, when teeth are very close together it is impossible to determine if there is active decay on those surfaces of the teeth without an x-ray. How often dental xrays should be taken depends on the patient's oral health condition, age, risk for disease and any signs and symptoms of oral disease that the patient might be experiencing (AADP.) For example, a child with a history of past cavities and is between 0 to 6 years may require x-rays every 6 months depending on their oral hygiene and diet.

If they do end up getting cavities (despite your best efforts) the National Institutes of Health reminds us that new materials mean pediatric dentists have more filling and repair options than ever. Silver amalgam has become a less attractive dental restorative material for restoration of primary teeth. After many decades of scientific and nonscientific controversy, use of silver amalgam for primary teeth is waning, not because of its mercury content but because dentistry has come up with more suitable materials such as composite resin. Tooth-colored resins are also more attractive. Our pediatric dentist does not have any silver left in her office, I urge you to ask for the newer composite resin materials. A filling done with composite resin preserves more healthy tooth structure as only decayed areas need to be removed - metal requires a lock and key design which can result in the unnecessary removal of more tooth structure.

I learned from my lesson (several visits and hundreds of dollars later) and now my kids and I ALL floss almost
every night. As with most parenting decisions, you do your best and remain flexible.....and try not to beat yourself up over your missteps.  

Nurse Judy adds... 
*Check with your dentist for their toothpaste recommendations.Many will start your baby off from the start with a tiny amount of gentle paste that does contain fluoride 
Below is the link to my post from last year.