Friday, January 30, 2015

Ear infections/ to treat or not to treat


Ear infections are among the most frequent reasons for a visit to the pediatricians office. It feels like I am long overdue for addressing this issue in a blog post.

As opposed to an otitis externa (also known as swimmer's ear) where the outside of the ear is red and sore, an otitis media (a middle ear infection) is not visible from the outside. One of the biggest challenges is knowing if your child has an ear infection or not. 

Technology is changing, but at present, unless you actually have an instrument at home you will likely need to bring your child in for an exam if you are suspicious.
At the end of this post is some information about CellScope, an app that gives you the ability to check out your child's ears at home.

If they are old enough, they may simply tell you that their ear hurts. Keep in mind that some kids complain about fluid in the ear or pressure; it isn't always an infection.
 If they are still young and non-verbal, they may be extra fussy (especially when going to sleep) feverish or tugging at their ear. Many kids wake up more than usual at night. Most of the time kids are congested. Sometimes vomiting can be associated with ear infections.
Some kids seem like their balance is off. Others seem like they are having trouble hearing (I know, all of our kids can seem deaf when we are telling them something they don't care to hear.)

Other kids don't let you know at all. We have had patients in the office for a well child exam and have been caught by surprise when a routine ear check revealed a raging infection.  I have also seen ear infections go from 'zero to sixty' in no time flat. A child with a perfectly normal ear exam one day can have a horrible ear infection the next.
Most of the time, an infection in the middle ear (the space behind the eardrum) accompanies a common cold, the flu, or other types of respiratory infections. This is because the middle ear is connected to the upper respiratory tract by a tiny channel known as the eustachian tube. Germs that are growing in the nose or sinus cavities can climb up the eustachian tube and enter the middle ear. Children's eustachian tubes are smaller and more level than those of an adult. This means it is harder for them to drain well and easier to get blocked up with even mild swelling. Because of these drainage issues, when kids are congested, they also may have fluid in their ear (serous otitis). This is why I am more suspicious about a possible ear infection in a child who has a cold. What may start out as a virus can turn into something bacterial. That fluid is the perfect medium for bacteria to grow. I compare it to a stagnant pond just waiting for the mosquitoes to breed.

Kids with chronic serous otitis who get one infection after another will usually end up at the ENT doc who may put some tubes in the ear to help them drain. Melissa Wilson, Doctor of Audiology at Sound Speech and Hearing, adds that tubes are also put in to address the hearing loss that often accompanies middle ear fluid. Fluid build-up often causes a hearing loss on the order of 30-40 decibels. Average speech is about 60 decibels. So having fluid is like listening with your fingers plugging up your ears. Everything your child hears is muffled and over time, this can impact their speech and language development, and for the school-aged children this can cause issues with listening in the classroom and academics.

By the way, when kids have goopy eyes, many times they also have an otitis, which is why we may bring them in to check out the eyes and the ears rather than just giving eye drops over the phone.
Just because your child is tugging at their ear does not mean they have an infection. Some kids do it as a habit when they are tired. Others do it when they are teething (especially upper teeth.)  It can be a clue though that is worth paying attention to, especially if it accompanies any other symptoms. I realized after the fact that I had ignored my daughter Lauren's first ear infection for more than a week when she was fairly young. Looking back at videos you can see the poor kid simply grabbing at her ear constantly. This was long, long ago prior to my Noe Valley Pediatrics job. I was working at UCSF with complicated surgical cases and thoughts of an ear infection didn't even cross my mind.

If your child is diagnosed with an ear infection, chances are we will give you a prescription for antibiotics. If your child is miserable and feverish, it makes sense to treat it. If the eardrum is bulging and looks like the membrane may rupture, the doctor will advise you that you should absolutely go ahead with the medication regardless of how your child is acting.
On the other hand, If it is not a severe infection and your child seems consolable, we may suggest that it is perfectly fine to watch and see for a few days. Many ear infections can indeed clear up on their own and of course we all would like to avoid the use of antibiotics if we can.
Some of our parents come in eager to treat even if it is mild and others want to avoid antibiotics at all costs. It is hard finding the balance. We are happy to work with folks who want to do the watching and waiting, but sometimes it does involve multiple trips into the office while we can an eye on things. My main agenda, aside from making the kids more comfortable, is preventing an eardrum from rupturing. This does happen and we can't always stop it, but it is worth trying. If you have an eardrum that ruptures frequently it can cause scarring and this can lead to hearing loss.

When there is a ruptured eardrum, one common scenario is for a child to be quite miserable and suddenly they are much happier. They also have lots of yellow/orange stuff draining out of the ear. The good news is that the pain of the pressure in there is gone, but the tympanic membrane is an important protective barrier from the outside and it is no longer intact. Therefore, if your child does have a ruptured membrane, they do need to be seen and treated even though they are no longer quite as miserable. If there is more than one rupture it is worthwhile getting the hearing tested to make sure there is no lingering hearing loss after the eardrum heals.

If you do opt to treat, make sure that you finish the entire course of medication. I suggest doing probiotics to protect the gut. Do not give them exactly in conjunction with the antibiotics, rather try to space them in between doses. Also please don't forget to brush those teeth. Liquid antibiotics tend to be sticky and sweetened in order to make them more palatable.

It may take  the medication at least a couple of days or before you note a significant improvement. If your child is still super fussy or feverish after a full three days, let's take another look in there to make sure the meds are working. Some kids who are having a really difficult time may end up getting an antibiotic injection. These hurt a bit, but they are usually quite effective.

With or without the use of antibiotics there are several things you can do for comfort. Tylenol and/ or Ibuprofen are useful. There are some prescription ear drops that can numb the ear, but they have some contra indications, so we don't often prescribe those here.

Warmth usually feels good. Try a warm wet washcloth against the ear. You also can put some rice in a sock and heat that up in a microwave. Some folks swear by a warm hair dryer held about a foot away from the ear. Believe it or not though, my favorite remedy is garlic oil.*

Check the ear to make sure there is no reason to suspect a rupture. I don't like to add any drops if I have any suspicion that the eardrum may not be intact.  If there is no odor or drainage (a little wax doesn't count) garlic oil may be  a good option. Saute some cloves of garlic into some olive oil. Let the oil cool until it is warm/not hot. Take a cosmetic square (these are the round or square cotton pads that often come in a stack. I like them better than cotton balls for this.)  Dip one half of the pad into the oil, roll it up like a scroll and stick it in the ear. Do this as often as your child will allow.If it is the middle of the night and your child is screaming, you can try any of these.

*Anecdote: My daughter Alana had her tonsils out a few years ago when she was in her early twenties. She started communicating on message boards with random folk from all over the world who were going through the same ordeal. These strangers bonded over their misery and swapped suggestions for comfort measures. At day three, many of them got earaches. I never paid much attention to this in the past, but with such a wide body of folks communicating, it seems clear that this was a common part of the post tonsillectomy list of woes. I made some garlic oil for Alana and when she put it in her ear she felt almost instant relief. She shared it with the hundreds of new best friends and many of them tried it and thanked her for the suggestion. So there you have it. Garlic oil gives relief.

If you are concerned about hearing loss, either from frequent infections or chronic fluid, Sound Hearing and Speech in Potrero Hillis a great option for getting checked out: (415) 580-7604 Sound Speech and Hearing Clinic  

If you are intrigued by new technology and are interested in the ability to check your child's ears from home, check out cell scope! 
 www.cellscope.com
http://bit.ly/1vc2dLI   click here for the otoHOME site. use the promo code NURSEJUDY for a 20% discount

Friday, January 23, 2015

Does your kids still have the cooties?

 
There is so much stuff going around right now that it may be useful to update this post from last winter.

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, daycare or school. There is not always a simple answer. On one hand, of course we want to be 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. Perhaps they don't eat quite as much. It is also usually a big "Ruh Roh" when your normally active child tells you that they think they will go take a nap now. 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. Frankly, more than likely they got exposed there in the first place. 
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. Seriously, 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 their 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 producing 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.

Unfortunately this week I have spoken to many parents who are ill. Of course careful hand washing is essential, but quarantining yourself from your child is not usually realistic unless you have a way above average support system. If you are a breast feeding mom we are usually going to have you to continue to nurse. Do make sure you are taking care to drink extra fluids and rest as much as possible.

Spring will be here before we know it! 

Friday, January 16, 2015

Measles outbreak 2015

Measles on the rise?

I first blogged about measles back in February 2014 when we had a small outbreak here in the Bay Area. Remember the cases on Bart? Since it has been in the news recently with 17 new cases in Disneyland in late December, measles seemed like a topic worth revisiting. At last check this current outbreak has spread to 4 states with 26 people diagnosed. 

From January 1, 2014 through November 2014 the World Health Organization reports that in the Philippines there were 55,388 suspected cases of measles, 19,041 confirmed cases and 107 deaths from the illness. As of November 29 2014,  25 US travelers who returned from the Philippines have become sick with measles. Most of these cases were among people who are unvaccinated. The World Health Organization and the Philippines Department of Health are working to control the outbreak.

During the same time period in this country the CDC reported 610 cases. This does NOT include the ones in Disneyland. In 2013 we had less than 200 reported cases country wide. Another report found that in 2002 the percentage of kindergarten children who were vaccinated for measles was 95%. That percentage has dropped to 92%. Houston, we have a problem!

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 or 4 days after the symptoms are all clear. This virus is so virulent that ninety percent of unvaccinated people will catch this virus once they are exposed.  What is even more alarming is that it can remain on surfaces or even in the air 2 hours after someone has sneezed or coughed!

Complications are frequent. They range from ear infections to pneumonia, encephalitis and/or seizures. 1-2 out of every 1,000 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.

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. For the second dose we have the option of combining it with the chickpox vaccine called Varivax. That combo vaccine is called Proquad or MMRV. The MMR 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%. It can be given earlier than 4, but we aren't too concerned about the timing of the second dose as long as our patients have gotten the first one. 


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

Assuming that mom has been fully vaccinated (or less likely has had the actual measles) infants 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 the babies 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. In our office we follow the standard recommendation and generally give the MMR at either the 12 or 15 month visit. 


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 a 2 shot series 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 data 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 chose 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 the MMR and autism,

 http://www.immunize.org/catg.d/p4026.pdf, 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.

As noted earlier, we are seeing the largest spike in cases in many years. 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 27 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.

 Here is another good article about how fast measles can spread

http://www.medicinenet.com/script/main/art.asp?articlekey=186409 

Friday, January 9, 2015

Febrile Seizures


Last month a nanny rushed frantically into the office holding a 9 month old who had suddenly started thrashing, his eyes had rolled up and he didn't appear to even recognize her. He then vomited (all over the poor nanny, but bless her, she didn't even seem to notice that at the time.) By the time they arrived in our office our little patient seemed okay, but very subdued. This was the first time this child had had something called a febrile seizure. If you don't know about them, they can be terrifying. Parents who had no idea what was happening during a first seizure tell me it was the most horrifying moment of their lives. Even if you know about them, they aren't fun but trust me, it takes a huge edge off of the situation. We are seeing lots of high fevers this month so it is important that all parents know about these.

The word febrile is one of those Latin words that has made it's way into routine medical lingo. It simply means having a fever. Someone who is afebrile is fever free.
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General statistics show that 4-5% of all children will have febrile seizures. We do have our share of patients in this practice who get them, but our actual percentage seems a bit lower than that. They can tend to run in a family. The symptoms may range from smaller tremors to large jerky movements. The eyes may roll back. It is common for kids to seem quite drowsy and "out of it" for a period of time right afterwards.

Most of the time the first episode happens between 6 months and 3 years. Most kids completely outgrown them by the time they are five. These seizures are NOT associated with epilepsy. The seizures themselves appear to be harmless but care needs to be taken to make sure the child doesn't sustain an injury or choke while they are seizing.

Febrile seizures usually come on when a fever is in the process of shooting up rapidly. It is rare to have them associated with a temperature under 102. If you see your child having a seizure your only job is to keep them safe. If your child is laying down, turn them on their side. Don't stick anything in their mouths. Make sure their airway remains open. Febrile seizures usually last less than 2 minutes. If you are able to stay calm enough, take a look at a clock, watch or phone to get a sense of the time. If a seizure is lasting longer than a minute (especially if it is the first time) it is perfectly appropriate to call 911. If the seizure is short and your child seems stable you don't need an ambulance, but you do need to get them some medical attention right away. One of the things we want to figure out is the source of the fever. It may be viral, but we will want to have the usual suspects ruled out (ears, throat, lungs, urine.)

With all the fevers we are seeing this season, please note that It is very common for kids who are in the process of spiking a fever to look quite pale and seem a bit trembly, that is NOT usually a seizure.

Once your child has had one or more febrile seizure, we are going to treat all future fevers with a little more care. Fevers are the bodies way of fighting an infection. As long as a fever is lower than the 101 range and the child seems happy I tend to leave the low grade temps alone and not treat. This is not the case with my seizure prone patients. Those little ones should have a plan in place to treat all fevers as soon as they are detected. This may include alternating Acetaminophen and Ibuprofen to make sure the protection doesn't wear off.

Check out the previous post on Dosages.







Friday, January 2, 2015

Document your milestones/Keep a journal




Welcome to January, the month when people often find themselves making all sorts of resolutions for how to live better.

I have a suggestion for one that is easy to keep. This will be useful and has the potential to bring plenty of smiles in the years ahead.

Start keeping a journal!

Sure, we all take a lot of photos and movies these days, but there is nothing like the written word.

If you haven’t done it from the first it is never too late to begin. Start keeping track of milestones and illnesses. Having things written down can be a valuable resource. I am not advocating keeping a list of every bowel movement (yes there are parents who do that; you know who you are) but knowing how often your child has had strep throat, an ear infection or any significant illness can be quite handy. Especially if you have more than one child, it is often easy to get things mixed up. I have more that one parent who has said,  “I know one of my kids gets a rash on Amoxicillin, I am just not sure which one.”

Keeping  record of milestones and illnesses alone makes keeping a journal worth the effort, but immortalizing memories and anecdotes is what makes it fun and even more valuable.

My 27 year old daughter Lauren has been on 259 flights. Two of the flights were skydiving expeditions and another flight had her at the controls flying a private plane. (This mom knows how to feel somewhat proud and somewhat horrified at the same moment.) If you give me a moment I can also retrieve all sorts of odd facts, like the first movie she ever saw in the theatre and when she lost her first tooth.

I actually started keeping track of things when I first found out I was pregnant. Clearly you don’t need to write things daily, but keeping track of milestones and fun things that kids come up with can create a wonderful database of stuff that you are sure to refer to and enjoy as your children grow. Mine unfortunately does have some huge gaps when I never got to it; just do the best you can.

What started out as my personal musings written in a notebook, morphed into a family journal when I transferred it to a word document. If you like you can create a shared document that both parents can add to. Google drive would be perfect. (Make sure you backup any important documents!) In our journal (both kids share the same one) daddy’s voice was written in italics.

My husband had the wonderful habit of documenting conversations.
The following was from when Alana was seven and daddy was picking her up from school.

Alana:   I'm doing a picture in reds and pinks.
Sandy:   Why?
Alana:   Because Van Gogh had a red period.
Sandy:   You're learning about Van Gogh?
Alana:   Yeah. And then I'm going to do a painting in different shades of
blue.
Sandy:   Why
Alana:   Because Van Gogh also had a blue period.
Sandy:   Well that's terrific.
Alana:   And Miss Price is going to bring a real artist to class so he
can teach us.
Sandy:   Well that will be very exciting.
Alana:    But it won't be Van Gogh because he's dead!

In our case I am delighted that we were able to track early milestones like first words and motor skills. Over the years random facts like teachers names, the revolving door of boyfriends and life events have all been documented.

One of my favorite posts recounts about the time that 5 year old Lauren and I took a family ceramics class at the local Randall museum. At the start of the first class, the instructor had everyone get a feel for the clay. We stretched and pulled in into all sorts of shapes. As we played he asked ”Who knows where clay comes from?” Lauren was never shy. Without missing a beat, she called out the answer in a loud, authoritative voice. “Cows! Clay comes from cows!” There was a moment of stunned silence as all the grown ups at the table did our very best not to break out in laughter. “Hmmm”, said the teacher, handling it very nicely. “Great guess, but it actually comes from the earth”
Cows?? I remember that being one of the hardest giggles I ever had to stifle. Laughing in the face of my five year old was not something I wanted to do. Kids do come up with some wonderful stuff.

Another one that became part of family lore was the time that 3 year old Alana bit her sister. Mommy:  “Alana, why did you bite your sister?! You know you shouldn’t bite!”
Alana: “I forgot not to.”  That “I forgot not to” line still comes up every once in a while.

When does it stop?? My kids say never. They especially insist that I keep up with their flight tallies! (We count every take off. Alana is up to 180)

You might be dealing with any of the more challenging aspects of parenting like sleep deprivation, the “terrible twos” or teens that are giving you a run for your money. Warning, time zips by. Blink and they are out of the nest. Carpe Diem! The online journal is a great way to capture moments forever.