Friday, June 26, 2015

Travel Tips updated

It's that time of the year again when many of my patients and families are  traveling.
Therefore, it is time to dust off, tweak and rerun the travel post. Fully half of the calls I took this week were from folks who were calling from a trip. After listening to the list of symptoms and concerns, I would be all set to say "Gee, it sound like you need to be seen for that" and the caller would answer "but I am in Delaware/ Minnesota/ Timbuktu"


"When is my baby old enough to fly?" is a question that we hear all the time. There are  many different factors to consider, so there is no one simple answer. Adopted babies might fly within the first few days on their way to their new home. Other folks make the valid choice to fly earlier than we are really comfortable with in order to see an aging relative or deal with a family crisis.

In ordinary circumstances, I would prefer to have the babies wait until they are over 2 to 3 months of age and have had their first set of immunizations (keep in mind that the first shot does NOT give full protection against some serious illnesses, but it is a start.) The size of the baby as well as the time of year are also factors. If there is some kind of crazy flu epidemic, I would think long and hard before taking a young baby on a plane. A few months ago we had that crazy measles outbreak. Last fall we has the Enterovirus D68. Right now, (June 2015) unless you are heading to South Korea, things seem reasonably quiet (knocking on wood as I type this.) Regardless of how old your child is, if you are planning a trip here are some tips and things to keep in mind.

Before you leave
I get calls from all over planet from parents who are dealing with a sick child during their trip.
Prior to the trip, check with your insurance company to see what the best method is for having out of state or international doctor visits covered. Some plans are much easier to deal with than others. Whether the visit is covered or paid for out of pocket, you also need to figure out what your actual options are. Is there an urgent care facility near by? Do you have a friend or relative with a pediatrician who is willing to see patients who are not in their practice? Does your insurance only cover an emergency room visit?

Hopefully you won't need to use this info, but if you are dealing with a sick child away from home it is nice to have a "Plan B" in place. If your child has a history of wheezing, it is wise to bring the meds along even if they haven't needed them in a while.

Surviving the flight
A few years ago I sat next to a mom with a very young baby. She was so worried about the possibility of getting evil looks from the other passengers that she had actually brought ear plugs to hand out to the people sitting around her. What she didn't have was anything to soothe her baby. Please always make sure that you have Tylenol or Motrin with you on the plane (not packed away in your suitcase). It is okay to bring small bottles through security. They need to be smaller than 3.5 ounces.I don't tend to give it ahead of time, but I am quick to medicate during the first sign of fussiness.

I often get questions about the use of Benadryl. This is an option for a child who is over 8 months with a long flight ahead. It helps dry up any congestion and makes 90% of kids who take it deliciously sleepy. Aha, but what about the other 10% you might ask? It turns those little darlings into hyperactive, wild hooligans. You do not want to find out on the plane that you are the parent of the 10%. There is no such thing as infant Benadryl, We use the children's liquid generic name diphenhydramine.

Many labels will warn not to give to children under 4. We routinely ignore that. You may want to give a test dose a few days prior to the trip to make sure it is a viable option for you.
I want parents to have the tools with them to deal with an unhappy child. Don't give any medication unless it is necessary. While I would usually err on the side of less medication, Benadryl and Tylenol/Motrin can be given at the same time.

Many babies and children can have trouble with their ears . For the younger ones, try to nurse or have them feeding during takeoff and landing. Sucking on a pacifier may be helpful as well. Have a lollipop or chewing gum for older kids. Ayr saline gel is a nice thing to have along. A dab at the base of the nostrils can moisturize the dry air and make the breathing easier (use it for yourselves as well.)

If you have a child with a history of ear trouble, have some of the little gel heat packs in your bag. You can activate them as needed and the warmth feels great to a sore ear.

Take WAY more diapers with you than you think you need for the trip. I was on another flight not too long ago when we sat on the tarmac for three hours. There was an unfortunate family behind me who had planned on a short little trip and was out of diapers long before we took off. It wasn't pretty. Plan accordingly.

Many folks automatically bring a change of clothes for their baby. It is also worth bringing an extra outfit for yourself. If you have a long flight ahead of you with a child on your lap, it may come in handy (I learned that one the hard way and sat for several hours covered with poop.)

Changing your baby on the plane can be a challenge. It is helpful to have little changing packs, with a diaper and some wipes, in individual zip lock bags. This will prevent you from having to take the entire bulky diaper bag with you into the tiny bathroom.

Bring some disinfectant wipes along and give the tray table and any surfaces a nice wipe down before you use them.

You can't count on airlines giving you any reasonable snacks, so it is important to bring along enough provisions in case of delays.

Download some activities or shows ahead of time for your laptop or tablet. While I am dreading the day when cell phone use is okay in flight, technology has certainly made it much easier to keep your child entertained during the journey. Don't forget about the old fashioned low tech options!

If you are visiting family, print out a bunch of photos of the people you are going to see. You can use these for all sorts of art projects on the plane. Make a paper doll family! This can help your kids recognize folks that they don't see too much of. Wikki sticks are also a great activity to bring along. They are lightweight and not too messy. Reusable stickers will stick on the window.

Once you get to where you are going, make sure the place is adequately child proofed (this is also a discussion that it is worth having with your hosts before you get there). I had one situation just last year, where a 3 year old opened a drawer and got into grandma and grandpa's medications.

Is there a pet where you are going? Make sure that any dogs are safe with children.

If you are staying in a vacation home, do a quick safety check. Do they have working smoke detectors? A fire extinguisher?

Time zones are tricky. My best suggestion is eat when you are hungry, sleep when you are tired and just do your best. Staying hydrated and getting fresh air are essential. Sunshine is a bonus. 
The link above has wonderful information for dealing with jet lag. Even the best sleepers may have a period of needing a sleep training tune up when you get home.

You can have lots of fun while you are away and it is wonderful to see family. But, in my opinion, if you are traveling with children under the age of seven, don't call it a vacation. It's not. It is a TRIP (we used to call our visits to the various grandparents the "bad bed tour.")

A little preparation goes a long way and remember that some of the more challenging moments make for the best stories!

Here is one of mine..

Many years ago when my daughter Lauren was two, I got creative as I was planning for an upcoming flight as a solo parent. I had seen a craft in a magazine (long before pinterest existed) where a necklace had been made of cereal and I thought that that seemed like a fabulous thing for an airplane trip. Unfortunately, not all ideas turn out to be good ones. Lauren and I strung some Cheerios onto elastic and she proudly wore her new necklace onto the plane. Soon after take-off Lauren decided to eat some of the Cheerios. I noticed with some dismay that as she bit off a Cheerio, some would go into her mouth while other parts would shoot off like little spitty projectiles. They were landing (unnoticed by anyone but me) on just about everyone within three rows of us. As soon as I realized what was happening, I tried to see if there was a way for her to nibble them off without making a mess. When that didn't work, I tried to take the necklace off to make it easier or to have her stop eating them at all. But as mentioned, she was two. My choices were clear... tantrum on the plane or unsuspecting fellow passengers having little pieces of spitty Cheerios in their hair.

I opted for peace (besides, ignorance is bliss, right?)

Have safe travels and make great memories

Friday, June 19, 2015

Chickenpox/Shingles exposure guide

The Varivax (chickenpox vaccine) came out in 1995. Frankly our office was a little slow to adopt it. We did an about face one season when we had hordes of chickenpox patients who were absolutely miserable, and there didn't seem to be a sensible answer as to why we shouldn't simply give the shot to prevent it. The answer that "we had them and survived" seemed a little weak. While it is true that most chicken pox sufferers simply have a very unhappy week, complications do occur. Even the moderate cases can have painful lesions in the genitals and mouth. Some folks get them in the eyes and need round the clock eye drops. Some of the lesions end up leaving scars. At the very least you have a sleepless, itchy week and will need to take time off of work.

All of that being said, some parents opt out and this is not one of the vaccinations that will elicit a strong armed argument from us. For those still on the fence, keep in mind that children generally have an easier time with this virus than adults. It isn't quite as simple to catch as it used to be because there is so much less of it going around. If your unvaccinated child doesn't come down with it, consider getting them the vaccine before they are all grown up and out of the house.  

There are also some studies that indicate that future occurrence of shingles may be less likely in a patient who had the Varivax than someone who had the actual chicken pox. In all honesty that question probably won't be answered for another 40 years or so, when the first wave of kids who got the vaccine become middle aged. In our office we used to see the occasional young patient with shingles and so far since starting the Varivax program we have seen little or no shingles cases in vaccinated kids. I realize that this small sample is statistically useless but one can hope.

Similar to the MMR, infants have some maternal protection that starts to wane when they are about 7 months. The protection is probably gone by a year. The first dose of the shot is usually given between 12-15 months. Unlike the MMR, Varivax is not recommended before the age of a year even if traveling or your child has been exposed. A booster is given between 4-6 years. For children age 13 years or older who are getting the Varivax for the first time, the minimum interval between doses is 4 weeks.

Because most of our patients get immunized, actual cases of chickenpox are getting more and more unusual, but they still are occurring. At our office, we ask that If someone suspects that their child might have chickenpox they alert us ahead of time. One of the nurses will go out and see if it is okay for them to come in. We do our best to try to avoid exposing our other patients. Most of the time it is a false alert. We go out, take a look at the rash and end up bringing them directly into an exam room.

Therefore last week when I went out to check someone, I was surprised to see what looked like a classic case of chickenpox.  Luckily it was a nice sunny day because that family was not welcomed in. That particular patient was NOT vaccinated. It turns out that there is a small spike in cases out there right now.

We get many calls  about the incubation and contagion period of chickenpox and shingles. Here is the scoop.

Kids are contagious a day or two before they get any lesions. They may have a low grade fever and be cranky. It is very likely that they are out and about in school, daycare or activities during this period spreading this virus to anyone who is not immune. It is what it is. No reasonable person expects you to keep your child home every time they are cranky. They remain contagious until all of the lesions have crusted over. That usually takes about a week.

So there you were in the park, playing with patient X. You get a call on day 2 from patient X's parent that they have come down with chickenpox. If they were having close interaction with each other, it is likely that your child was indeed exposed. The chickenpox virus is very contagious. It is airborne and can live on some surfaces. If your child is vaccinated or already had the illness, you likely don't need to worry too much. The vaccine is about 85% effective. The other 15% of folks tend to get much lighter cases. If your child in not immune you are now on alert.

From the first moment of exposure, the incubation period is usually 2 weeks but can range from 10-21 days. If 3 weeks go by with no sign of anything you are likely in the clear. Just because your child has been exposed is not a reason for you to keep them home from school or daycare and for you to miss work. They may or may not catch it.
Do be on the lookout for any signs that your child might be succumbing. The words "I want to go take a nap now" may be a red flag. If they get a fever you may want to issue a warning to any friends or caregivers as you wait to see if vesicles appear. If your child does come down with it they are now patient X and were likely contagious a day or so before the first sign of a rash.

After you recover from chickenpox, the virus can enter your nervous system and lie dormant for years. Eventually, it may reactivate and travel along nerve pathways to your skin - producing shingles. It is most common in folks when they are older adults. It may be stress related. One easy diagnostic trick is that the blistery rash will usually not cross the midline of the body.

Shingles can be spread only if someone comes into direct contact with the lesion. A healthy person who has immunity to chickenpox is generally not considered to be at risk. Someone with a compromised immune system or someone who has never had the chickenpox needs to be a little more cautious. If infected, they would catch chickenpox, not shingles, from the infected person. Over the years we have had a couple of patients who came down with cases of chickenpox that we traced back to a shingles exposure, but again, that is most unusual. It is NOT airborne. If the shingles patient keeps the lesions covered you can still go visit grandma.

Friday, June 12, 2015


Headaches are very common in children and adolescents. In one study, 56% of boys and 74% of girls between the ages of 12 and 17 reported having had a headache within the past month. By age 15, 5% of all children and adolescents have had migraines and 15% have had tension headaches. Does your child tend to head off to a quiet, dark room when there is too much going on? It could be migraines.
While headaches are more common in children once they reach 9 or 10, some children as young as 2-3 can articulate that their head hurts.

Migraines, tension and cluster are called primary headaches because they are neurological disorders not caused by an underlying medical condition. There is no specific medical test for migraines, so diagnosis is usually based on symptoms. Some of the classic symptoms include:

*A moderate to severe throbbing pain for 24-72 hours. Often this is on one side of the head. (for those of you who enjoy knowing its etymology,  the word migraine comes from the Greek hemicranios, meaning half a head.)
*nausea (they may or may not actually vomit)
*Sensitivity to light, noise or odor

Roughly 15-20% of migraine sufferers experience visual disturbances about 15 minutes before the headache sets in. This is known as an aura.

The drawing up at the bottom was drawn by one of my favorite people, Rachel, when she was seven years old  in an attempt to describe to her doctor what an aura felt like.

Migraines don't always manifest as headaches. Some children also have abdominal migraines. If your child is having frequent tummy aches and or complaints about nausea, ask them if they have any visual symptoms.

Migraines have a big genetic component. There is often a strong family history. A pediatric neurologist at UCSF says, "If you're having trouble finding the family history, the paternal grandmother is often the link.  Because migraine genes are expressed more often in women than in men, dad might pass on the genes to a child without knowing it."
There are also current studies to see if there is a connection between colic in a baby and migraines later on.  

Secondary headaches result from another medical condition. These conditions can range from a relatively harmless illness like sinusitis or the flu to more serious conditions. Strep throat is often accompanied by a headache. Simple cold/allergies are also common culprits. As miserable as these headaches are, most parents and practitioners are less concerned if there is an obvious cause like a virus.

Mystery headaches are somewhat more alarming. A red flag that you should contact a doctor about a headache would be one:

*    that wakes the patient out of a deep sleep
*    appears suddenly and is more severe and different from past headaches
*    comes along with weakness or numbness or tingling
*    makes it difficult to think or remember things
*    follows  a recent head injury (within 2 weeks)

Headaches that are associated with vomiting are also worth checking out (if the entire family has the flu and is having similar symptoms, I am much less concerned.)

If there is a headache that is coming more than once a week or with any kind of frequency that has you alarmed,  it is worth getting checked out. It is always worth starting with  your primary doctor, but they may want to do a referral to a headache specialist.

The first step is for the  neurologist to make sure that there isn't something serious going on. Once the scary stuff has been ruled out, they can be an essential part of your team helping to manage chronic headaches moving forward. Headache specialists can help you identify the triggers and explore many non-medical options. The folks at UCSF are on the cutting edge of managing migraines. They are exploring things like CoQ10 and Riboflavin rather than jumping to medication options (you need to see them to discuss dosages.) In fact they are currently looking for teens for a study seeing if melatonin might play an important role in treatment. If you have a teen 12-17 who might be interested in taking part in this check out this link:

The patient will need to only go in for one visit. The rest of the data will be gathered remotely. The participants will also be given a Fitbit that they get to keep!

If your child is having headaches, start keeping a journal to see if you can identify the causes. The information that will be most useful to the doctor is the frequency of the headaches and the tracking of the treatment. What did you try? Did it help?

As you think of other things to add to the journal look at this list of some common triggers and see if any obvious one come to mind:

*Irregular sleep habits
*Skipping breakfast
*Not getting regular exercise
*Change in weather
*Foods with additives/nitrates
*Red wine (hey this info is for you grown ups too)
*Hormone fluctuations
*Recent stress
*Lighting changes e.g., bright fluorescent
*screaming baby? 

My daughter Lauren had very frequent headaches. Our cousin Avi lovingly nagged and nagged her to see if a gluten free diet would help. He was relentless. She finally gave in and agreed to give it a shot. To her delight (and horror) it made a huge difference. She has been gluten free (and headache free) for years. When she gets an accidental exposure to gluten the headaches come roaring back. There is no ignoring the connection.

I get migraines when I drink a certain type of red wines. A glass of Syrah will trigger a headache that knocks me flat. Every step ricochets from my feet up through my head. Not fun. My learning curve on this was almost comical. I couldn't imagine that I was really reacting to only one type of wine and it took about 3 or 4 miserable experiences until I stopped all experiments and simply don't drink any Syrah.

If you or your child are suffering from headaches be a sleuth!

There was a recent study that showed in some cases regular exercise was just as effective as medication in preventing and reducing headaches.  

Some people have also had success with alternative therapies such as gentle chiropractics and or acupuncture.  

I will close with some last words of wisdom from the wonderful Dr Gelfand

*    Get regular sleep
*    Stay well hydrated with non caffeinated beverages
*    DON'T skip breakfast
*    Get regular exercise.
*    Chocolate is innocent!! It is no longer on the list of frequent triggers,  

I was very fortunate that Dr Amy Gelfand allowed me to "pick her brain" so to speak about this important topic. Dr. Gelfand is a child neurologist at the UCSF Headache Center. She specializes in diagnosing and treating children who suffer from a variety of headache disorders, as well as children with childhood periodic syndromes such as abdominal migraine that are felt to be precursors to migraine headache later in life.

September 2015 check out this blog from Dr Gelfand

Friday, June 5, 2015

Fever facts

I am taking a break from my sleep series because we have seen an unusual amount of fevers circulating for early June, It is time to brush off and update my fever post.
Fevers tend to get parents very worried, but those who attended my illness class know that they are only one factor to consider when evaluating a sick child. I am always more interested in your child's overall mood and behavior than I am in any specific number on a thermometer. Kids get fevers. An adult with a high fever is more of a concern.

There are many methods out there for measuring a body temperature. I personally don't feel the need to invest in any expensive thermometers. I am generally quite satisfied with a digital underarm reading. The important thing is that however you take it, your thermometer seems accurate. Test it on yourself or other family members and take your child's temp when they are healthy to make sure you trust it. I  don't have a favorite brand.

If you have one of the new ear or temporal scanning units feel free to keep using that. Sometimes their "high" readings seem a little higher than I believe to be accurate; don't ever let a number freak you out.

Temperatures can be measured in either Fahrenheit or Celsius
Here is a quick conversion chart that might come in handy.

98.6 F=37 C

For this post, I will be referring to the temperatures on the Fahrenheit scale.

For any child older than 3 months
 As long as your child is active and happy, I generally don't feel the need to "treat" a fever unless it is over 101.5 or so. 

One of the most common questions that our advice nurse team gets is, "When do I need to worry about a fever?" As I mentioned, I am much more concerned about the lethargic, whimpering child who has a normal body temperature than I am the singing child with 104. But, here is the
Nurse Judy's rule about fevers:

If the fever is over 102 (it doesn't matter how you measure, just be consistent):

*Treat with proper dose of Acetaminophen or Ibuprofen

*Do a tepid bath or place cool compresses on the forehead, insides of elbows and neck

*Get them drinking. Little sips at a time are fine. Popsicle s and ice-chips are good for older kids

*re-check the temp in 45-60 minutes

If it is STILL over 102 and hasn't budged at all, that is a fever that I am concerned about.
It is time to get your child seen.

When children are in the process of spiking a fever, it is not uncommon for them to tremble and look shaky. When fevers are breaking it is common to have lots of sweating.
Children with fevers may have a higher respiration and pulse rate.

One of the more frightening aspects of a fever can be a febrile seizure.  About 4% of children will have these. Febrile seizures can be terrifying to watch, but they usually stop within 5 minutes. They cause no permanent harm. Trust me, if you have never heard of this, watching your child have a seizure has been reported as the scariest experience EVER.
Knowing that that they do happen once in a while and are generally harmless should help keep you from freaking out. If your child is having a seizure they may have large jerky motions and their eyes may roll back. Your job is to stay calm. Make sure their airway is open. It is perfectly reasonable to call 911.

Once your child has had even one febrile seizure we tend to be more aggressive with fever control and will treat even a low grade fever. It is important to talk with your doctor about this so that you have a plan in place that you are comfortable with. Most kids grow out of the seizures by the time they are 5 years old.

If the fever is accompanied by a very fussy child, I want them seen so that we can figure out what is going on.

Even if your child is acting just fine, if a fever lasts for more than 3 days, I consider it time to have a look so that we can make sure there isn't an infection source (like ear infection, urinary tract infection, strep throat or pneumonia.) Any fever that comes along with a purplish rash could be an emergency (this is not the singing child. They would look alarmingly ill.)

During flu season, we sometimes do see a fever that lasts for five days or longer. If there is a classic virus going around that I am seeing a lot of, I will occasionally relax my "3 day rule". If the kids seems like they are 'managing' (drinking, peeing, easy breathing, consolable, fever responds to medications) I am okay watching them for another couple of days.

This particular illness that we are seeing does have 4-5 days of fairly high fevers.  A small group of these have ended up with respiratory infections that did need to be treated, so my 3 day rule is staying in effect.

Many viral syndromes "wave goodbye" with a rash. Roseola is a classic example.

If your infant is under 8 weeks of age we want to be notified of any fevers!
However, there are a few common causes: 

*over bundling....
Seriously, sometimes the babies come in with 10 blankets wrapped around them. Please don't do that. The best rule of thumb is giving them one layer more than you are wearing. If your baby was indeed over bundled, get some of those layers off and re-check the temp in about 10 minutes to see if they have cooled down. 

..Sometimes if moms milk isn't in yet, babies can be simply dehydrated and need to get some fluids. This is the time that you need to squirt some milk or formula directly into your baby's mouth. You can use a syringe or a dropper. More often than not the elevated temperature will normalize fairly quickly from some fluids. 

If there is no obvious cause for an elevated temperature, and it doesn't resolve within 30 minutes your baby needs to be evaluated. Giving a fever reducing medication to a newborn should only be done under strict guidance from your pediatrician.

Some fever facts:

*Fevers turn on the body immune system. They are one of our body's protective mechanisms
*Many fevers can actually help the body fight infection.
*Fevers that are associated with most viral syndromes and infections don't cause brain damage. Our normal brain's thermostat will not allow a fever to go over 105 or 106.
*Only body temperatures higher than 108°F (42.2°C) can cause brain damage. Fevers only go this high with high environmental temperatures (e.g., confined to a closed car.)

Click here for my blog post about dosages for Tylenol and Advil