Friday, August 28, 2015


 Kids can be so mean sometimes. I am not sure if it is harder to watch your child be bullied or to be the bully. In my case, for a period of time when our daughter Lauren was four, she was getting routinely picked on by another little girl at preschool. To compound things, this girl was in my carpool. I would drive the kids to school three days a week. Carpool parents - be aware of this astonishing fact. You are invisible. You are privy to all sorts of interactions and conversations that might leave you either horrified or amused as you drive the car full of kids hither and thither.  In this case I had to watch Emily torture Lauren every single day, impervious to the fact that I was in the car. (As you can imagine it was pretty infuriating.)

This is what I would hear, with mild daily variations:

Emily:  "Your shirt is ugly"
Lauren (clearly upset): "what? why?"

Emily: "I have a special thing I brought for show and tell and I am going to let everyone else in the car have a peek except you"
Lauren: "But I want to see it too!"

Emily: "You can't come to my birthday party"
Lauren (even more upset): "Why?"  

After a few weeks of this I realized that I needed to stage an intervention.

I drew two faces. One was  smiley face with pretty eyelashes. The other was a grumpy frowny face. I then said to Lauren " Which one would you like to be?"  I was dealing with a four year old girl, this wasn't rocket science. As predicted she pointed to the smiling image. I touched the grumpy drawing and said  " Emily seems to want to turn your smiley face into a grumpy face. I wonder if you could keep the smile face on even when someone is being mean. Let's try!"

We got out the trusted barbie dolls and did some role playing. We spent a dramatic session as Barbie cheerfully let all sorts of slights and insults roll of her very shapely back.  We created an assortment of interesting scenarios. Barbie never lost her cool.
I wasn't quite ready to paint Emily as a complete bully. I liked her parents and she wasn't mean 100% of the time. I tried to give her an out. As we put the Barbie's away I said, "I wonder why Emily says mean things sometimes. Maybe she is feeling grumpy herself because she is a little tired."

The very next day in the car we I was interested to see if all of our practice would make a difference. It didn't take long to find out.

Emily: "your shirt is ugly"
Lauren (with a big fake smile plastered on her face that I could see through the rear view mirror): "Luckily, you don't need to wear it. I think your shirt is pretty."

Emily: "you can't see my sharing"
Lauren: "I am sure it is very interesting"

Emily. "You can't come to my party"
Lauren: "I hope you have a fun time"

From the driver's seat I watched Emily become more and more confused and upset that her power seemed to be slipping. I refrained from giving an audible whoop and driving into the bushes.

And then...

Lauren (in a sickeningly sweet voice): "Are you a bit tired Emily?"
Emily (grumpy): "NO, I'm NOT tired"
Lauren (knowingly): "I think you must be a little tired"

No one watching could have accused her of doing anything wrong but she had discovered a way to gently torture Emily a bit, and she was running with it.

A few weeks later I was at a school event and I bumped into Emily's dad who drove the carpool the other two days. He said to me, "something is going on in the car that I don't understand". "Oh? What would that be?" asked innocent mom. "Lauren keeps asking Emily if she is tired and Emily starts getting very upset".  Hmmmmm.

As you can see, finding one on one time and playing through things can be quite effective. If you can, it is also  helpful is to identify the "nice kids" in the class. Ask your child who they might like to play with, reach out to that family and try to arrange some play dates outside of school time. If your child can have some solid allies in the social group, it makes it much easier to stand up to, or deal with someone else who is unkind. Keep in mind that it is a rare friend that is completely reliable. They all have days where  they "might be tired".  

Was Emily actually a bully? Perhaps she was looking for attention or actually just needed a nap.Often young children are really simply trying to figure things out. Nevertheless, If your child is routinely on the either end of hurt feelings, it is worth some attention.

Looking for other ways to empower your child? Check out This is a fabulous organization that came out of Santa Cruz.  They now have groups and classes all over the place. They have an entire section devoted to dealing with bullying with all sorts of really excellent resources:

If all of your efforts at home don't seem to be taking care of the issue, talk to your school to see if they have any anti bully programs in place. There is a inspiring program , that got its start in San Francisco. Talk to your school about looking into it. Keep in mind that most of the time you won't actually witness the bullying. Pay attention to your child's mood and behavior. If you notice any dramatic changes make sure you find opportunities for your child to communicate about what may be going on. Sitting with them in a quiet room before bedtime is a great time to do a daily debriefing about the day. In our family that was a ritual.

Let's turn the tables. If you hear that your child is the bully, or you get to see them in action, make sure that you carve out some one on one time to work on some skills. Some kids seem to be bullies because they simply want attention and don't know a better way of making and keeping friends.Talk to them  about kindness. Talk about choices. Find one particular situation that you know about and work on that. "You pushed your sister and made her cry. What was going on? Were you mad, sad, frustrated? What were some other choices that you could have made? What should be the consequence if it happens again? What should be a nice treat/ reward if you make a better choice the next time you are in that situation?"

If you find that you are having issues on either side of this spectrum that are beyond your scope, the next step may be having a meeting with your child's teacher.

Your child may not be directly involved in any bullying but it is the rare child who doesn't see occasional evidence of meanness happening around them. This group of observers  are often the kids who can make a real difference. Not only do we want our children to be kind, we also want them to figure out the best way to be brave  without putting themselves in danger.  Sometimes it takes a certain amount of bravery to play with a child who is a target to the bullies. At the very least talk about reporting any bullying to a grown up or teacher.

Little actions can make a big difference to someone.

Friday, August 21, 2015

Flu Vaccine 2015/16

Everything you need to know about the Flu Vaccine for the upcoming 2015/16 season:

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 have ever had more than two previous doses of any flu vaccine, they only need one this year.

Children under the age of three get half of the adult dose.

Children over the age of two have the option of getting the shot or the nasal flu mist. This is a live version of the flu vaccine. Last year, studies suggested that the mist might be the more effective treatment for children between 2-9. That changed this year and there is no preference or thought that one method might be more effective than the other.
(Keep in mind that most two year olds do NOT like having something squirted in their nose; sometimes you are better off with the shot.)
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 year, based on what I saw in our office, they seemed to match the B strain fairly well, but missed with the A. Getting the shot was still absolutely the right choice. While some of my vaccinated patients did end up with mild to moderate cases of type A, no one who was vaccinated ended up with the circulating B strain. The folks who tested positive for the B strain were a pretty miserable group.

Usually the vaccine differs from year to year. Last season was unusual in that  the formulation was unchanged. This year the vaccine does have some new components.
Our office will again be supplied with the quadrivalent vaccine that covers two A strains and two B strains. All of the Flu vaccine in our office is preservative free. For any of you interested, the strains  in the quadrivalent vaccine are:

A/California/7/2009 (H1N1)pdm09-like virus;

A/Switzerland/9715293/2013 (H3N2)-like virus;

B/Phuket/3073/2013-like virus. (Our wonderful vaccine rep was a little reluctant to read this one out loud)

B/Brisbane/60/2008-like virus

We don’t carry the trivalent in our office. The trivalent covers only only 1 of the B strains.
Try to get the quadrivalent if you have an option. You never know if that extra B strain is going to be an important player or not.
Last season the flu wasn't too much of an issue for our patients. Plenty of people did get the flu and had a miserable week, but no one in our practice had any severe complications.

Since we never really know when the flu season will start with a vengeance, 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 with their first dose. Because we don’t have experience with this particular flu vaccine, I don’t have a sense of what kinds of reactions to expect. We don’t generally see any major reactions to the shot or mist, but every year it is different. Last year 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. If your child has a sensitivity to egg, it is okay to give the shot, but we want to be cautious. I would recommend that you keep the patient hanging around the office for at least half an hour or so to make sure they aren’t having any issues. Please advice the nursing staff if you have any concerns.
I have been giving flu shots for almost 30 years and in that time I have only seen ONE patient with an allergic reaction to the vaccine (and that patient has no history of egg intolerance, so you just never know.) This patient left the office and started complaining about an itchy feeling throat. Mom brought him right back in and he got a dose of epinephrine. I am sharing that as a reminder that it is important to keep a close eye on your child for at least 30 minutes after the shot. If they seem to be having any breathing issues or exceptional fussiness they should get checked out immediately.

Last season, after frustrating delays early in the season obtaining the flu shots, we did ultimately end up with adequate supplies. I anticipate that we again will have plenty of vaccine available for our patients but there are never absolute guarantees. It currently looks like we will be getting some early shipments of the flu shots in mid August/September. I am hearing that the mist might be delayed until mid October. Once mid October comes around we will try to schedule a few Saturday morning flu vaccine clinics for the Noe Valley Pediatrics patients and families.
I will update vaccine supply and any info about the clinic dates in my weekly emails and also on our Facebook page. I will also let you know what type of reactions I am seeing, and what the actual flu looks like when it starts knocking on the door this season.

Click below for the 2015 Flu Vaccine information statements from the CDC (mist)

Friday, August 14, 2015

Constipation/The poop, the whole poop, nothing but the poop

Please see the updated post April 2018

One day your kids will be completely out of diapers. Believe it or not,  the day will come when they no longer want you to wipe their butt after a poop (that age tends to vary greatly from child to child.) The years pass and at some point you tend to lose track of your child's bowel movements completely. That being said, it is the rare parent that gets a completely free pass. If you are a patient of Noe Valley Pediatrics, I am betting that at some point before your child goes off to college, you are going to have a conversation with me about your child's BMs.

It is quite common for kids to occasionally complain about tummy aches. In my experience, a full 90% of these are constipation related. Of course we never want to ignore other possibilities. Abdominal pain could be all sorts of other things that need attention. Tummy aches that come from constipation tend to be very sharp, but also intermittent. Sometimes the pain can radiate to other parts of the body.

If I have a patient with a complaint of a tummy ache, I am going to want to know the frequency and consistency of the stools. Here is the tricky part. If your kid is really backed up (and it is unbelievable how much poop they can have inside of them) sometimes the solid poop can't get through. What they will pass is some very runny substance that is getting around the solid mass of impacted stool. Because of this, your first thought might be that your child has diarrhea. Sorry kids, but the parents now need to know way more than you might be comfortable sharing. When was the most recent poop? Was it normal size? Smaller than usual? How often are they pooping? Are they sitting for a long time trying to get it to come out? Are the stools coming out in little hard pieces?

I have a theory that many children don't like to poop at school or camp. If they happen to get off schedule and the urge hits them at an inconvenient time, they will often hold it until the urge passes. Some kids become very adept at this and can hold onto a remarkable amount of stool. They may pass a tiny little hard pellet every day or so. If you ask them if they pooped, the answer will be "yes".

I like to do a little 'Nurse Judy poop math' (this can't possibly surprise any of my followers.) Figure out how large your child's average size stool might be. Let’s say it is the size of a hot dog. Assume your child doesn't have a BM for 3 days. For the next 6 days after that, they pass only 1/2 of a hot dog size poop. Within 9 days, just a bit over a week, they now have poop in there the size of 6 hot dogs. No wonder they are having a tummy ache!

It is time to sit and talk to your child about a very important rule. There are many choices that we will face in our lives with very few incontrovertible truths, but this is one of them: THE POOP HAS TO COME OUT! Have your younger kid play with some play dough and a toilet paper tube. Only a certain amount can fit through before something rips. Not pooping is not an option. These kids need to be cleared out. All the prune juice into the world is not going to be able to blast through an impacted mass of stool.

Massage and a warm bath are step one. Some kids actually maybe able to pass some stool while in the tub because they are relaxed. I know it sounds gross, but if you are ever in this situation, you will be happy to see them poop anyway that you can make it happen. Some people find that adding a few teaspoonfuls of either baking soda or epsom salts to the warm bath water will can also help.

If they still haven’t pooped, it is time to try some glycerin into the butt. You have several options. A glycerin suppository is a hard stick of glycerin, usually found at most drugstores in the baby aisle. You can break off a piece, lube it up with some KY jelly, Vaseline or Aquaphor and just stick it in there. Hold the butt cheeks together so that your child doesn’t push it right back out. Another option (which I prefer) is a liquid glycerin called Pedialax. The directions on the box advises that  these are for use in kids over 2, but I have no concern about using them on infants. With these, you end up inserting the lubricated tip of the applicator into the butt, squeeze in the small amount of liquid glycerin and then remove the applicator. They usually work some magic within 30 minutes. Once you get some of the hard stool out, we can start to focus on making some adjustments to the diet.

Alas, the favorite foods are often the starchy breads, cheese and pasta that do nothing but block them up even more. The BRAT diet (bananas/rice/applesauce/
toast) is what we use to firm up stools if a child has diarrhea. When dealing with constipation issues we will want to avoid those until they are having softer stools. Some kids seem to have a much easier time if you eliminate milk. Try that for a week and see if it helps (if you do this, make sure they are getting enough calcium.)

Fruits and veggies are great. Smoothies might be useful if they won't eat them raw.
Make sure they are drinking plenty of healthy fluids. Sometimes simply the addition of extra water or prune juice are all that is needed to get you back on track. Pineapple, peeled grapes, figs and raw crunchy red peppers can be especially helpful additions to the diet. See if you can somehow hide some molasses and flaxseed oil in some oatmeal or baked goods. Kids will often eat something if they had a hand in baking it. Do a daily dose of probiotics. These help keep a good balance of healthy bacteria in the gut which is good for digestion.

Make sure your child is getting enough magnesium. Natural Calm (available at Whole Foods and  natural food stores) is source that many folks like.  An appropriate  dose can get even the most stubborn gut moving. There is no way to “overdo” magnesium by eating magnesium rich foods, but you don’t want to take too much in a supplement form.
Kids ages 4-8 can take 130mg/day; kids ages 9-13 can take 240mg/day. The Natural Calm adult dose is 175 mg/tsp (mixed in other liquids.) Big kids can easily take 1-11/2 tsp. Smaller kids a bit less. If they take too much it might cause cramping. Start with a small dose and see if it helps.

Here is an important new consideration to the discussion that is not found anywhere in my old constipation post.  Go on line and check out the Squatty Potty. Some of the reviews are quite amusing, but the overwhelming verdict is that many people are finding this a deal changer. In other cultures, people squat to poop and have no issues. Talk about your “third world problem”.  It turns out that our sitting position is not really helping our body with elimination. You might want to experiment with a little foot stool in front of the toilet or potty that gets your child in a better position. You can try it too!

If you have a young child, check out the book Itsy bitsy Yoga.  Some of the stretching positions might help move things along.

Acupuncture is another option
Check out

If massage, position and good diet don’t  seem to be doing the trick, talk to your doctor about getting your child on Miralax. Miralax is an over the counter fiber that is heavily used by pediatric GI specialists to deal with constipation. Miralax has recently had some articles about it that made some folks uncomfortable about it’s use. There are no studies about its safety for long term use and one of the biggest concern is the lack of testing in pediatrics.  While that is true, official studies aside, it has been used for years and years without any known contraindications The specialists don’t seem to have concern about the safety. Miralax doesn't get absorbed into the system. What it does is pull the fluids into the intestine to make sure the stools are softer. We have some patients who are on it for an extended period of time with no ill effects. That being said, I never want anybody on medication that they don't need.

If your child has been give a dosage for a course of Miralax, I am perfectly happy if you do a daily adjustment of the dose depending on that day's stool. If it feels like you are already achieving softer stool, it is okay to decrease the dose and perhaps skip a few days. The minute the poops become less frequent or more solid it will be time to bump back up the dose.

If you are pretty sure you child is not constipated and they have an abdominal pain that is more steady than intermittent, they need to be evaluated!

Friday, August 7, 2015

SFUSD immunization requirements 2015

When I was young, summers were sacred and school started after Labor day. I am not sure when that shifted, but it seems that these days many of our patients start school in mid August. This is the time of year for the panicked parent to call, needing an immediate check up (not going to happen), sports form, or updated vaccination record prior to school entry.

Take a deep breath. Most schools will accept a promise of a scheduled check up as long as they have an immunization form that is complete. We are happy to work with our families to at least get you scheduled for some of those shots that are needed even if there isn't a slot with the doctor available. I assure you, most schools don't look too closely at the forms; if one of the docs forgets to check a box, your child won't be kicked out of class.

Below  is the standard form if you lost yours:

California schools are required to check immunization records for students when they enter kindergarten, upon advancement or admission into7th grade, and for students transferring into a new school at any age.    

Here is a list of the shots that most San Francisco schools require:   
Before entering kindergarten:
DTaP (Diphtheria, Tetanus, Pertussis): 5 doses
A 4th dose after the age of 4  is acceptable.

Polio: 4 doses
If the 3rd was given after the age of 4, that is acceptable

Hepatitis B: 3 doses
Most 5 years olds faced with those extra Hepatitis B shots are going to give their parents the well deserved "stink eye" if you put this off and didn't complete the series before entering kindergarten (Hepatitis B/ do you need to do it right away?

MMR (measles, mumps and rubella): 2 doses  
If they got an early dose prior to the first birthday, that doesn't count as one of the doses

Varivax (chicken pox): 1 dose is required. 2 is preferred

7th graders require a Tdap (whooping cough) booster. They also must show proof of two doses of measles-containing vaccines (e.g., MMR) before starting school.

This is also the perfect opportunity to vaccinate with the other ACIP (the Advisory Committee on Immunization Practices) recommended vaccines for 11-12 year olds, including HPV and MCV4 (meningococcal).

Routine testing for tuberculosis is not required for SF public schools. Rather than testing every child with a skin or blood test, the San Francisco Department of Public Health strongly supports a medical provider's risk assessment for TB as the universal screening requirement for school entry.  Only children identified as having one or more risk factors for TB infection will need to be tested. Some of the private schools insist on TB testing regardless of the recommendation of the SF Public Health Department.  

In June of this year, Governor Jerry Brown signed Senate Bill (SB) 277 into law.
This law goes into effect July of 2016. For the school year beginning August/September 2016, all children going into kindergarten, seventh grade or entering a school for the first time will need to be fully vaccinated or have a medical exemption. Personal or religious exemptions will no longer be accepted.