Friday, April 24, 2015

Swimming/ an advice nurse's guide

Swimming  Updated 5/2016
We get a wide variety of calls related to swimming with your kids. The earliest one may be from the family who is going on vacation and wants to know if it is safe  for the baby to go into the hotel pool. In general I don’t recommend optional travel until your baby is several months old and has had their first set of vaccines (two sets is better). I am assuming that you are sensible enough that you aren’t planning on taking your one month old on a tropical vacation. If your baby isn’t brand new, then generally my answer about getting into the pool is “sure!”, but there are several factors to consider.

Is the pool outdoors? We all need to be careful with sun but baby’s thin skin is especially vulnerable. Babies need to have a big floppy hat and perhaps sunglasses and sunscreen. Just this week one of our fair young babies got a rotten sunburn on his face  (and it wasn't even particularly sunny out). Recent studies are finding that regardless of the labels, many sunscreen products do not give as much protection as they claim. Sprays especially don’t seem to protect as long.

Be aware that the reflection from the  water can add to the risk of burning and remember that sunscreen does need to be reapplied even more often if the kids are getting wet. Get in the habit of  paying a moment of attention to everyone’s skin at least every 15 minutes. If they are getting pink, it is time to get out of the sun. Don’t wait until they are bright red. While it is true that my fairest patients are the most at risk for a sunburn, all skin pigments should be protected. Shade is best! There are some cute little umbrella baby floats that offer quite a bit of shady protection if you are in a pool.

The next factor is the water temperature. Young babies don’t regulate their body temperatures very well, so make sure that any pool water is nice and warm and that the outside temp isn’t too chilly for them. Most hot tubs and Jacuzzis are too hot for young kids. For any of my older patients and families who do enjoy the hot tub, be on the lookout for any pimply rashes that show up within the next several days. These are often bacterial and may need to be treated.

For young babies, a little splashing is okay, but I wouldn’t let them submerge their heads until they are old enough to keep their mouth closed. There are claims that very young infants are natural swimmers and don’t take in a lot of water; I prefer not to test that out. A big gulp of chemical filled water is yucky.

If you are staying anywhere with a pool, make certain that your child has absolutely no access to the pool area when there is no adult present.

Many folks like the idea of swim lessons for their children as part of their normal routine, not just reserved for vacations. We don’t usually recommend formal lessons until your child is at least 6 months old. For the most part, swimming lessons for kids under 3 years are all about getting your child comfortable in the water. As a bonus, water play is a healthy form of exercise for the entire family and may improve motor skills.

Some studies claim that  participation in formal swimming lessons is associated with a huge reduction in the risk of drowning. That is a big deal because drowning is in fact the leading cause of unintentional injury and death among children aged 1–4 years in this country.  Even if your child seems like they are a good little swimmer, it is important that parents not have a false sense of security. Regardless of the situation, kids need to be watched like hawks whenever they are around water.

A person who is drowning may not thrash about and call attention to the fact that they are having trouble. They can slip silently under the water without being noticed until it is too late. Even if your child has proven themselves to be solid swimmers, you need to stay actively focused and engaged while they are in the water.

We had a scare with one of our families last summer. Several adults and children were enjoying a day at a friend's pool in the East Bay. They got out of the pool to have some lunch. Some of the oldest kids started to bicker. While the adults turned their attention to the squabble, a one year old got back into the pool unnoticed and submerged. Thank goodness another of the adults looked up, noticed and was able to get her out and perform CPR. The little girl is perfectly fine, but this was terrifying for everyone.

If you are exposed to any media, then there is a good chance that you have heard of Secondary Drowning.  Nurse Kenlee, who worked for many years in the ER, explains:

If someone had a near drowning in a pool, they are at risk of  flash pulmonary edema from chlorine irritation to the lungs. They may seem fine initially, but then present with cough and pinkish sputum. This usually shows up within 12 hours of the event.
Aspiration pneumonia from inhaling too much water into the lungs will have a slower onset and would present with cough, high fever and lethargy.

The bottom line is that caregivers need to closely monitor any child who has come out of the water coughing and sputtering. Especially keep an eye out for any further difficulties in breathing, extreme tiredness, or marked changes in behavior, all of which are signs that a swimmer may have inhaled a dangerous amount of fluid. If there is any concern, an emergency room or immediate medical intervention is needed. It is important to know what to look for, but to reiterate, in over 30 years with a practice full of swimmers, I am not aware of any of our patients having this issue.

Kids should be trained to keep their mouths closed when jumping into the water
and to enter very cold water slowly. This should help avoid aspirating large amounts of water. There is a big difference between water in the lungs and water in the belly. If your child swallows a lot of water they may end up with a tummy ache but it is rarely dangerous.

Anytime you are hanging out at a pool please wear flip flops when wandering around poolside or in the locker room. Fungal infections and athlete's foot do happen. A spray bottle with some diluted vinegar solution to spritz on the feet and then making sure that the feet are very dry before putting shoes and socks on, are good preventive measures.
Little girls that spend a lot of time wearing a wet bathing suit can also get irritations. It is a good practice to get the kids out of the wet suits as soon as possible. Do a good rinse off as soon as you can and then apply a nice moisturizer to avoid exacerbating dry skin.

We also get a bunch of calls about swimming and ears. If your child has had a recent ear infection they are fine to swim as long as the tympanic membrane is intact. If your child has had ear tubes or a recent ruptured eardrum, they should NOT be submerging their ears in the water (or the bathtub for that matter) without having protective ear plugs.  Sound Speech and Hearing makes custom ones with sparkly color options that may help with compliance.

If your child has been doing a lot of water play, they may be prone to otitis externa (better known as swimmer's ear.) As opposed to an inner ear infection that requires an otoscope to make a diagnosis, an outer infection is often visible to the naked eye. The ear looks red and sore and may have some drainage. If that is happening, it is worth an office visit so that we can see what’s happening and prescribe some antibiotic ear drops if warranted. Keeping the ear canal as dry as possible may help prevent this condition. There is a simple proactive measure that can be cheaply and easily made by mixing equal parts of rubbing alcohol and white vinegar (50:50 mixture). This solution will increase the rate of evaporation of water in the ear canal and has antibacterial properties. Using this solution to rinse the ear before and after water exposure can help protect against infection.

If you are planning on swimming in open water (lake, river etc) make sure you check ahead of time to make sure there are no advisories. Last year the Russian River had some toxic algae bloom that I would not have wanted any of my patients to get near.

I mentioned that drinking pool water is yucky, but I am going to double down on the yuck factor in some lakes and rivers. These are the kids that end up with Giardia. A good rinse after swimming and making sure no water is ingested in very important.

Most of my local families know to be very wary of our local Ocean Beach, but if you are traveling to a place with a warmer and more inviting ocean, never turn your back on the water and beware of currents and strong waves.

Okay, don’t let the “Debbie Downer Advice nurse” spoil your fun. Go have fun swimming!

If you are looking for swim lessons, there are plenty of great options here in SF. Here are some of the more popular options

La Petite Baleen Swim School . They have several different sites. The one in SF is in the Presidio at 933 Mason St.  866-896-3603

3200 California St
San Francisco, CA 94118 Phone number (415) 292-1200

Mission Bay 1675 Owens St
Phone number (415) 514-4545

There is an indoor and outdoor pool here with all sorts of options for just swimming with your baby or doing classes.

there are several branches in SF that offer swim classes:
The May/June sessions are likely full already, but if you plan ahead you may be able to join some July classes
Stonestown  415-242-7100
Presidio 415-447-9622
Embarcadero 415-957-9622

The city pools also have some classes available but they also fill up fast. Register at to sign up for swim lessons ( and other great classes)
This website will also give info about the city pool hours if you are interested in just having some pool time with your kids and skipping the expensive lessons
You may want to go by yourself first to scope out the water temperature.

My kids grew up going to the Janet Pomeroy Center. This is out by the zoo at 207 Skyline Blvd. It used to be called the Recreation Center for the Handicapped. The lovely thing about it is that the pool is very warm. They have several slots every week where you can go and play in the pool with your child. It is reasonably priced, but you need to call to enroll in advance, They don’t have any drop in sessions. The phone number is 415-665-4241

Do you have a pool that should make the list? Please share the info and I will add it to the post.

If your child is enrolled in swimming classes and they have a mild cold or cough, they can probably still go swimming if they are feeling up to it. If they are vomiting or have diarrhea, do everyone a favor and keep them out of the pool!

Thursday, April 16, 2015

Tick bites/ prevention and action plan updated 2015

Tick Bites/Prevention ( updated)

Dealing with Tick bites

Ah, the twisted thinking of an advice nurse. For most folks, spring brings to mind warmer weather, longer days, lovely flowers etc. Me? I think,"Here comes tick season"

Indeed the calls are already coming in and I have spoken to a half dozen patients about tick bites just this week.

It makes sense. With the nicer weather more of my patients are out there taking walks, hiking and enjoying the beautiful area that we live in.

Ticks can be an issue all year long, but the nymphs are born in the spring. These tiny little ticks are the ones most likely to transmit diseases.


Of the many varieties of ticks out there, the ones responsible for the majority of  disease transmission are the deer ticks. If you want to impress folks at your next cocktail party, our local deer tick is officially identified as the ixodes pacificus

Although only a small percentage of tick bites are harmful, the diseases can have a major health impact, so we need to pay attention. There are many conflicting reports, but recent studies coming out this year suggest that the rates for tick borne diseases are a bit higher in California than previously thought. Ticks that have been caught and examined are testing positive for two separate bacterial illnesses. We are most familiar with Lyme (Borrelia Burgdorferi)  but they are finding that here in the San Francisco Bay Area just as many, if not more ticks, are infected with Borrelia Miyamotoi.  This second illness is a close cousin to Lyme. It has the similar flu like symptoms including headaches, nausea and muscle pain. It does not have the rash that is associated with Lyme. They are both treated with the same antibiotics.

The key is prevention.

If you are going to be walking or hiking in densely wooded areas try to stay in the middle of the path. Avoid wood piles and logs. Light colored long sleeves and long pants are recommended. Spray the clothing with the bug repellent Permethrin. This is okay for anyone over 2 months of age. Use Deet on exposed skin, avoiding hands, eyes, and mouth.

But let's face it, on a hot day we are not going to have our bodies covered completely, so here is the deal....

Everyone needs to get a naked head-to-toe body check after a walk in the woods. If you are camping, do a full body check daily. Ticks can hide in out of the way places on your body. Don't forget to check the scalp. If you are dealing with thick darker hair, you can rub your fingertips along the scalp and feel for any bumps. Check in between the fingers and toes, check armpits and belly buttons.You really need to be very thorough. Many of the ticks are very tiny and hard to see. Be familiar with little moles and freckles so you can recognize a new spot which might be a little tick.

If you are returning to your home after a hike, take all clothing and put everything in a hot dryer for 60 minutes to kill any wandering ticks. Don’t forget to check the car seat!

It is very important to remove the tick as quickly as possible. If a tick is removed within 4 hours of the bite, the chances of any disease transmission are SIGNIFICANTLY decreased. For Lyme disease, the tick generally needs to be attached for more than 24 hours to be a concern.

If you do find a tick, please stay calm. I can still remember vividly, years ago, a mom carrying her toddler into the office screaming (the mom, not the kid) "HELP ME GET THIS THING OUT OF MY BABY!" Hey, Arachnophobia is appropriate in this case, because ticks are indeed arachnids (the spider family), but put on a brave face for your child.


The best way to remove a tick is with tweezers or a special tick removing tool. Grasp the tick as close to the skin as you can and firmly pull up and away. Do not twist. The Public Health department councils that you should not try any of the folk remedies such as Vaseline, burning match etc. If you own a dog or go hiking frequently, do yourself a favor and get one of the tick removing tools. You can get them pretty cheaply from any sporting good or pet store. Amazon has a ton of different brands. I do not have a favorite.

Once the tick is out, clean the area with an antiseptic soap, apply a dab of Neosporin and then keep watch on the area to make sure there is no infection.

Okay, We got a tick bite. We removed it, but now what???   

*watch the site for sign of local infection

* observe for 30 days, If there is any odd rash, flu like illness, aches, or fever it is important to notify your doctor. We will want to know the date of the bite, and if possible the region where the tick came from. Any recent travels are important data.


Unfortunately the blood tests for tick borne diseases such as Lyme are initially not all that helpful. To start off with, you can get both false positive and false negative results (making it pretty useless.)  It turns out that once you have symptoms several weeks after the bite, the tests for Lyme are apt to be more accurate, but that isn't all that useful right after the tick encounter when we are trying to decide whether or not to treat. There are no current tests widely available out there yet for the newer B.Miyamotoi

Rather than testing the patient, I would focus on the tick. If you do a lot of hiking, keep a little baggy in a pocket of a backpack or diaper bag so that you have a place to stick any ticks that you remove.  

The Sonoma County Health Department will identify the tick for free to see if it is the type you need to be worried about. They will also take it a step further and test it for Lyme disease. They charge a  fee of $29 (such a deal.) They don't test the ticks for other illnesses. They do the testing every Thursday and get you the report by Friday. They say that about 1-3% of the ticks test positive.


Read the instructions on their website for how to send the tick

As many of you have heard me say time and time again, ask a question and get multiple opinions and answers. Kerry Padgett at the California Department of Public Health in Richmond California has been identifying ticks for our patients for many years. The folks over there don’t test the tick. A tick testing positive doesn’t necessarily mean that it was on long enough to transmit a disease. A tick testing negative for Lyme may be infected with the Lyme like illness that we can’t test for yet.

They are happy to tell you if it is a tick that you need to be on alert for.
You can send the tick to:

Kerry A. Padgett, Ph.D.
Supervising Public Health Biologist
California Department of Public Health
Division of Communicable Disease Control
Vector Borne Disease Section
850 Marina Bay Parkway
Richmond, CA 94804

Kerry shared the link below for all sorts of tick related info including some activities for kids.

Here is the bottom line. Regardless of whether or not you get the tick tested....

Watch the person who has been bitten very carefully for the next 4-5 weeks. If there are any suspicious symptoms within the month following a tick bite you absolutely want to speak to your doctor about doing a course of antibiotics. Reactions that are a cause for concern would be a bull's eye rash around the tick bite site and/or any type of flu symptoms. Not everyone gets all symptoms.

We don't want to treat every tick bit with antibiotics for obvious reasons. As with everything, we need to strive for balance. We can't keep our kids in a box. Go out there and enjoy the hike, but then do that thorough body check and you should be fine. If you are a pet owner and you treat your pet with one of the flea and tick treatments, keep in mind that those ticks may leave the pet and go find someplace else to hang out.

This post is an updated version of one that was run last year.

Friday, April 10, 2015

Pertussis Update

Please see updated post January 2019

Pertussis has been a steady presence for the past couple of years but it has been back in the news this month with a spike in the numbers.

Commonly known as whooping cough, Pertussis is a very contagious respiratory illness caused by a type of bacteria called Bordetella pertussis. These bacteria attach to the cilia (tiny, hair-like extensions) that line part of the upper respiratory system. The bacteria release toxins, which damage the cilia and cause inflammation.

Worldwide, it is estimated that there are 16 million pertussis cases and about 195,000 pertussis deaths in children per year. Despite generally high coverage with childhood pertussis vaccines, pertussis is one of the leading causes of vaccine-preventable deaths worldwide. Most deaths occur in young infants who are either unvaccinated or haven't had at least 3 shots in the series.

Historically there is a cycle associated with whooping cough. It seems to peak every 3-5 years.
In 2010, here in California there were more than 9,100 reported cases and at least 10 deaths.
We may be at the beginning of the next cycle. The timing fits. Using California as an example, the state saw just shy of 2,000 cases in 2013, but it recorded more than 10,000 in 2014. The last time that numbers this high were seen in California was in the 1940s, before widespread whooping cough vaccination took place.There have already been 3 reported infant deaths here in California in 2015.

For the most up to date info from the public health department click the link 

This illness usually starts with a week or two of a runny nose and cough. There may or may not be a low grade fever. At week two, the cough gets much worse. The patient will often have coughing fits...and I mean FITS!! This is spasms of coughing for minutes at time that make even the hardiest person feel like they can't catch their breath.
They may or may not have a high pitched "Whooping" sound with the cough (hence the name). Some folks will vomit after these coughing fits
Sweating, gagging and choking episodes are common.
Some people cough so hard from this that they can break ribs.
This cough lasts and lasts...and then lasts some more.
In Chinese medicine this is referred to  as the "Hundred day cough" and they aren't kidding.
This is a miserable illness for anyone.
I have spoken to parents who had chosen not to vaccinate and had to deal with several months of this horrid illness. Every one of them says they rued the decision to pass on the protection.
For young infants Pertussis can be deadly.
Babies routinely get their first vaccination for this around 2 months of age.
The initial series is given at 2 4 and 6 months* There is a booster dose given at 12 months and again before kindergarten entry.
They don't seem to have adequate protection until they have received the 3rd shot at the 6 month visit.
Once they have had 3 doses they are roughly 75% protected. This goes up to ~90% after the 4th  dose.  (Doses 1 2 3 are the initial series. Doses 4 and 5 are referred to a boosters)

*In our office, the vaccine that we use is the Diphtheria/Tetanus/Pertussis combined with Hib and Polio in a shot called Pentacel.

Hib, Polio and DTaP are all available as separate vaccines.
The Pertussis component of the vaccine does not come separately.

Because babies are so vulnerable to this illness, A fairly new and current practice recommends giving all pregnant moms a TDAP  (Tetanus/Diphtheria/Pertussis) with every pregnancy. This should be done in the third trimester between 27-36 weeks. Please talk to your OB if you have questions about that.
It is also essential that all the family contacts have current vaccine protection. This means Dads, grandparents, caregivers and siblings or anyone who anticipates spending any time with your new baby. Studies claim that 75% of babies who get pertussis contract it directly from family members or caregivers.
If you had the shot OR the actual illness more than 5 years ago the immunity wanes. You should get another booster.

People who have been exposed to Whooping cough will usually start showing symptoms 7-10 days after the exposure and are contagious by the time they give that first sneeze.
If someone is diagnosed, a course of antibiotics will help limit the spread and may minimize the symptoms. It won't make your cough go away, but the illness won't be quite as severe and you won't be contagious.

On a similar note, as I noted earlier the vaccine is not 100% effective, but folks who are vaccinated tend to get a much milder case than those who have no protection.

Testing for Pertussis is far from perfect. We usually send a culture obtained by a swab stuck up the nose. (as pleasant as it sounds)
The results may take more than a week, so the decision about whether or not to treat often needs to be made based on the clinical history and symptoms rather than a lab result.

If you have Pertussis, symptomatic treatment includes a cool mist humidifier and drinking plenty of fluids.
Smaller more frequent meals may help make vomiting less of an issue.
Smoke exposure will make things much worse.
Cough medicines don't seem to be of much use, alas.
For older kids, check out Honey Loquat syrup (whole foods carries it)

Friday, April 3, 2015

Helping your child maintain a healthy weight

In my solid foods class one of the things I talk about is how important it is for you to help your child establish a healthy relationship with food. It is never too early to start.  
Don't push food. When they indicate that they are "all done", don't coax them to take that last bite or fuss over a clean plate. In order not to waste food, only give them a small amount at a time. Add more on request. Of course give them as much as they want (unless they routinely eat until they barf!)

Offer a wide assortment of healthy meals and snacks. Pinterest is a fabulous resource for creative ways to make food interesting and appealing. Most young children will eat what they want/need. If you have concerns about health or adequate weight gain, it is reasonable to check in with your doctor's office and see where they are tracking on the growth chart. We like to see the height and the weight increasing at a reasonably parallel rate. If your child seems happy, healthy and is growing well, please trust them.

Give positive feedback for trying new foods. (Click here to review my past post on picky eaters) I generally suggest allowing a reasonable amount of sweets (the definition of what constitutes reasonable will vary from family to family.)  I have found that kids completely banned from sugar love it all the more when they have an opportunity to get a hold of anything sweet.

In our family we tried to stress "growing food first". Anything with some nutritional merit could fall into that category. Once your body had enough growing food, if there was room for something extra, that was fine. I would rather not to consistently set dessert aside as a reward.

In spite of our best efforts it is sadly typical in our society to have folks on either end of the healthy weight spectrum. On one end are the kids who are way too thin. While some completely healthy kids are genetically predisposed to be very thin, Anorexia and Bulimia are a real concern. It is real. It is rampant. In my youngest daughter's fairly small eighth grade class, several of the girls had severe cases that landed them in the hospital. It isn't limited to girls. If you have a child (teens and preteens are most at risk) who is losing weight and/or has any food aversions, it is easy to be in denial but please keep your antenna up and check in with your doctors office.

On the other end of the spectrum are kids who are heavier than they should be. As much as we recognize the importance of healthy eating and getting more exercise, putting these things into practice can be a challenge.
Keep in mind that it is not unusual for kids to have a bit of "pre-puberty pudginess" 

I generally don't like to focus on numbers. It also may feel like a veritable minefield opening up the weight discussion with your preteen or adolescent. I would make the focus on health for the entire family. Everyone would benefit from more exercise. The entire family will benefit from eating a healthy nutritious diet.

We are always on the lookout for local programs to support young children and families through this process. The ones that exist are expensive, have fairly long wait lists and require a significant time commitment. Therefore we were delighted when we found out about a new fabulous resource called Kurbo. This is an app that helps get the kids engaged in a healthy eating/exercise plan. I have been eagerly awaiting the moment when it was available on both Androids and I phones and now it is! The folks behind it started out with the Stanford weight loss program. They know what they are doing. The app is free, but to get the most out of this, you can sign up for some coaching. It is significantly less expensive than comparable programs.

The Kurbo folks wanted to share 2 recent fun articles on Kurbo kids & families. The first is about a family in Los Angeles whose young son was told by his doctor that he had to lose weight, and he has lost over 17 pounds on Kurbo.  The second is by the Editor of Parents Magazine who did Kurbo with his daughter.  The results: she lost weight, looks and feels better.  It is great seeing results experienced by these Kurbo Kids!

If you are interested in checking it out, We have a promo code that will give you some savings: NoeValley (no space, capital N, capital V).