Halloween can be such a fun holiday, but as you can imagine, as advice nurses we tend to hear about some of the misfortunes that can along as part of the festivities.
Carving a pumpkin can be a very fun tradition. Please make sure that your child's level of participation is consistent with their age and ability.
Choosing a costume
Want to hear a terrifying statistic? Children are more than twice as likely to be hit by a car on Halloween than on any other day of the year.
Trick or treat rules
Expecting trick-or-treaters or party guests?
Now what do we do with all this candy!!!
Make a plan about how much candy they can eat at one time. It is okay to be a little more liberal than usual for a day or two, but come to an agreement about a reasonable candy intake over the next few weeks. Some dentists and orthodontists have buy back programs, where they will give your child a reward for turning in their candy. Click the link for a partial list:
You may need to be extra vigilant with teeth brushing this season.
Remember that candy freezes (and some of it is actually better that way; frozen snickers bars, yum!) My daughter Lauren was about 6 when she caught on that mom and dad were pilfering through her trick or trick bag and stealing all the good stuff. After that she guarded her stash more carefully.
Bonus tip from Cleo's mom:
"Once Cleo was out of the stroller and walking, we put glow stick bracelets and necklaces on her so we could see her more easily when out and about in crowded spaces in the dark (we do this at things like the Dia de Los Muertos parade, too.) Cliff's sells them in a big 100-stick bulk container. Not terribly eco, but gives a little extra "eyes on" help when navigating the crowds."
Post Halloween tip:
My little patient Franny, bent a glow stick in order to activate it and it broke.
Some squirted in her mouth. While, you do want to avoid un necessary contact with the insides of a glowstick, they are non toxic
- Head lice/ Sklice co-pay coupon
- Should you give tylenol before the shots? / vaccine reaction discussion
- HAND FOOT MOUTH (and butt) VIRUS
- Skin fold irritations
- The Poop series: Chapter #1 Baby poop
- Strep Throat
- Nurse Judy' Blog
- Tips for giving medication
- What to expect from the 2016/17 flu vaccine
- Pinworms (ugh)
Friday, October 30, 2015
Posted by Nurse Judy at 10:00 AM
Friday, October 23, 2015
Anaphylaxis is a very severe allergic reaction that can occur within moments of exposure to an allergen. It can be triggered by an allergy to a particular food (peanuts or shellfish are among the most common), biting or stinging insects (like bees), medication (like antibiotics), latex (the type of rubber many balloons are made from) or a variety of other allergic triggers. Allergic reactions occur when the body mistakenly identifies something as harmful and over reacts. With anaphylaxis, this reaction can be life threatening. Symptoms usually start within seconds or minutes of the exposure, but there are exceptions. Rarely, a reaction can be delayed by several hours. This would make it much harder to figure out the culprit.
In an anaphylactic reaction there may be different parts of the body involved:
Mouth: itching or swollen lips or tongue
Lungs: cough, wheezing, shortness of breath
Heart: weak pulse, dizziness, fainting
Skin: hives, itching, redness, swelling
Face: flushed, swollen (eyes and ears common)
Throat: itching, tight feeling, swelling
GI system: vomiting, diarrhea, cramps, nausea
The first time that someone has a severe allergic reaction is very frightening. Unfortunately subsequent reactions can be even more severe. It is essential to recognize symptoms that need immediate attention.
Several years ago, a patient in our practice had been given yogurt for the first time. The child’s face began to swell and she started to have labored breathing. Mom’s first instinct was to call me, I redirected her to call 911 immediately. If it feels like an emergency situation, 911 trumps the advice nurse. Of course, we do want to be kept in the loop and help with any follow up. This child turned out to be severely allergic to milk. Interestingly she had no trouble with breast milk. It is very important that folks figure out what the trigger is so that the you can try to avoid future reactions, although there are cases that remain a mystery.
Avoid and educate
Knowing that your child is at risk for anaphylaxis is very unnerving to say the least. It is very important to educate your child (age appropriate) and all teachers and caregivers about how critical it is to keep your child from being exposed to the allergen.
One case comes to mind, of a school aged patient who was at Costco with some friends. The child was allergic to nuts. The friends parents allowed him to taste something from one of the samples. They had done a cursory check of the ingredients and thought it was safe. It turned out the the knife used to cut the samples had also been used to cut something with nuts, and the child ended up in the ER. Some kids are so sensitive that cross contamination (in this case, the knife) can cause a full reaction.
Talk to your child about the fact that just about everyone has a little something special going on, and it their case they need to be careful about whatever their trigger is. Check out this book, available on Amazon. It is a bit dated but still sweet and relevant, Perhaps pick one up for the class and make sure the teacher reads it out loud:
There is a new law, SB 1266 effective January 1, 2015, that mandates all schools keep an epinephrine auto-injector on hand and that someone on site be trained in its use. Check with your child’s school to make sure that they are complying.
Make certain that any babysitters or friends caring for your child know what allergens are potential hazards so that they can be certain to avoid them They should also have an injector handy just in case.
If you go to a restaurant, ask to speak to the chef so that you know the restaurant understands the importance of avoiding the ingredient in question. In serious cases, you might want to call ahead to make sure they are willing and able to accommodate you.
Just this week we had a patient with an anaphylactic reaction. To complicate things, this little 9 month old was already teething and fussy. She also is prone to eczema, so rashes are not unusual. The family had a recent checkup and had come home ready to increase solids and calories to fatten up their slender child. Dinner that evening was some Chinese take out. Our little patient was offered bits of foods from the various containers. They didn’t offer any foods that struck the parents as obviously new, but one of the containers was a shrimp dish. Although the baby didn’t actually eat any shrimp, she started to get very fussy and swiping at her face and ears. After several moments of excessive fussing from no overt cause, mom and dad opted to give her a bath and start the bedtime process.
When they removed her clothing they saw that she was covered with hives. At that point they wisely opted to go to the ER. It had been about 20 minutes since the food. The baby was fairly inconsolable and her face and ears were swelling. Luckily she did not appear to be having labored breathing (that would be a reason for a 911 call.) Once in the ER she vomited. She was given Epinephrine and kept overnight for observation. She was singing and happy the next morning with no seeming ill effects. The current plan is for to avoid any mystery foods and follow up with an allergist within a few weeks. The family will have an epipen or Auvi-Q on hand just in case.
Epipen and Auvi-Q are predosed epinephrine injections. They come in 2 strengths. The junior (.15mg) is for anyone under 66 pounds. Anyone over 66 pounds gets the full adult strength (.30 mg.)
Epinephrine is the only first line treatment for an anaphylactic reaction. It relaxes the muscles in the lungs to improve breathing. To quote my go to allergist Dr. Fast, “Epinephrine is what saves lives. It is never wrong to give epinephrine.”
In the case of a severe allergic reaction, give the immediate dose of epinephrine but then head over to the ER for some observation. It is possible for the symptoms to rebound. This is called a biphasic reaction. Hours after a patient seems stable, the symptoms can flare up again. Since it is always better safe than sorry, keeping a close eye on the patient is essential for the next 24 hours.
Epipens may be what most people are familiar with. The Auvi-Q is the new kid on the block. This little gizmo actually talks you through the injection. It also tells you that you need to get over to the ER for some follow up. This is great if a caregiver is giving it who is not as familiar with the procedure. Another plus for the Auvi-Q is that is it smaller and flatter, so it is easier to tuck into a purse.
Regardless of the brand, the autoinjector should be administered into the upper outer thigh. It can be given through thin clothing. New studies suggest that holding for 5 seconds is adequate. The leg should be restrained and the injector should be held against the thigh and then compressed, rather than jabbing it. The new recommendation comes in response to some rare lacerations from an epi pen needle given to an unrestrained leg.
Both the Auvi-Q and epipen have trainers available. Please ask your nurse or doctor's office to give you a demo and make sure you are comfortable using it.
The downside to both brands is that they are fairly temperature sensitive and should not be left in a hot car (keep in mind that they shouldn’t be left in the car anyway; they should be with you at all times!) They are also expensive if you don’t have good insurance. If you have a high deductible and you are close to meeting it towards the end of the year, this is an excellent time to get a refill.
Click the link for some Auvi-Q co pay assistance auvi-q.com
If you own an epipen or Au Vi Q, check the expiration dates. They don't usually have a shelf life of over a year or so because the rubber diaphragms can get dry and cracked.. If it is an emergency and the only one you have is expired, still give it...but you are are reading this go check right now and make sure yours is current.
Children with reactive airway disease and/or eczema are more at risk for allergic reactions, but they can happen to anyone. While it is essential to be vigilant, rest assured that most allergic reactions are mild to moderate and not life threatening. Benedryl liquid is an OTC antihistamine is something that every household should have on hand to help deal with mild reactions.
As a precaution, I recommend that all first time foods be tried when there is time to observe for a little while to make sure there is no reaction. Giving something brand new and then putting a baby straight to bed is not a good plan. This is especially important with high risk foods like nuts, milk, eggs, shellfish, and any medication.
While of course not everyone needs to carry around epinephrine, but it is so important to be able to recognize the symptoms and act quickly if you are concerned about the possibility of an anaphylactic reaction.
AS OF 10/27/2015 there is a recall on the AU VI Q due to some dosing issues.
Posted by Nurse Judy at 8:44 AM
Friday, October 16, 2015
Parents have you gotten your Hepatitis A vaccine?
Hepatitis A is an inflammatory disease of the liver that is caused by a virus. Some people consider the Hep A shot a travel vaccine because it is the most common vaccine-preventable illness that folks get infected with when traveling. We think that everyone over a year old should get it even if you aren't going anywhere. Hepatitis A is certainly more common in countries with lower standards of sanitation, but this virus doesn’t care about borders. There are plenty of cases right here in this country.
Transmission occurs through direct person-to-person contact (fecal-oral transmission); contaminated water, ice, or shellfish harvested from sewage-contaminated water. You can also get it from contaminated raw, inadequately cooked, frozen fruits, vegetables, or other foods. Hepatitis A is quite hardy and can live outside the body for quite a while. It can survive being frozen. This is a nasty virus. Hand washing is important and can stop you from spreading it, but won't protect you from catching it. It makes no sense not to get the vaccine if eligible.
Poor hand washing and then handling food is a common mode of transmission, but so is changing a diaper. Thus diaper age children, infected with the virus, are a large reservoir for spreading it. People are most infectious 1–2 weeks before the onset of clinical signs and symptoms, and can shed the virus in the stool for months and months. Dr. Schwanke had read somewhere that in some cases poop can remain contagious for up to a year!
The incubation period averages 28 days (range 15–50 days). Infection can be asymptomatic or range in severity from a mild illness lasting 1–2 weeks to a severely disabling disease lasting several months. Most common symptoms include the abrupt onset of fever, malaise, poor appetite, nausea, and abdominal discomfort, followed within a few days by jaundice. Urine may be very dark colored and stool is often clay colored or freakishly light. The likelihood of having symptoms with a Hep-A infection is related to the age of the infected person. Fortunately, although it is rarely fatal, adults with this can become quite SICK!
Here is one of the most important facts worth emphasizing: In children aged <6 years, most (70%) infections are asymptomatic. In the young children who are actually acting ill, jaundice is not a common symptom, so it might be awhile until someone figures out that they are dealing with a form of Hepatitis. Most of the time,young children don’t usually exhibit many symptoms at all, or appear too ill, but they pass the virus along to their caregivers who get walloped. We have seen it sweep through a daycare, with many of the caregivers and parents catching it.
The vaccine first became available in Europe back in 1993 and started getting phased in to our vaccine schedule in 1996. Interestingly, although it is recommended, it is not one of the vaccines that are required for school entry. It can be given as soon as a child reaches their first birthday and should be followed by a booster six to twelve months later. Protection against hepatitis A begins approximately two to four weeks after the initial vaccination. Protection is proven to last at least 15 years and is estimated to last at least 25 years if the full course is administered. There is currently no follow up booster suggested, but if the immunity looks like it is waning, I imagine that will get revisited. The vaccine comes only in preservative free form (no thimerosal concerns). I rarely see any side effects at all. Once in awhile a baby post vaccine might be extra fussy, but that is rare and not necessarily shot related.
This one requires little thought. You should make sure that Hepatitis A vaccine is included in your child’s immunization schedule. Our office routinely starts the series within the first 15 months. Parents, also please check your own health records and make sure that you are protected. Adults are often quite clueless about their own vaccination status!
Posted by Nurse Judy at 7:25 AM
Friday, October 9, 2015
I hate mosquitoes. Yes I am aware that they are part of nature's vast food chain but that doesn't stop my loathing. For the record, it is a mutual dislike and fortunately I rarely get bitten. The rest of my family, both of my daughters in particular, are tasty targets, who they feast on when given the opportunity. Some loose studies that were trying to make sense of why mosquitoes target some people more than others postulate that the favored blood type seems to be O, followed by B. A is the least favorite (I am A-). Even though I don't end up getting bitten, having a whining mosquito in the bedroom at night is a form of torture. What makes it worse is knowing that the bites are not just annoying, but they can be downright dangerous.
Of all the mosquito-borne illnesses, the West Nile virus is the one that has gotten the most media coverage lately. This is a mosquito borne illness that is thought to have originated in Africa (hence the name.) It has spread throughout the world and it was first detected in this country in 1999. Unfortunately we now have it in most states, including California.
In 2014 in California:
- There were 561 cases of the more serious form of West Nile neuro invasive disease
- There were 31 fatalities, which exceeded all previous years.
- The proportion of mosquitoes infected with WNV was the highest level ever detected in California
- The prevalence of WNV infection in tested dead birds, 60 percent, was the highest ever detected in California
In 2015 as of last Friday we have had 311 confirmed cases. Luckily, most of these folks survived.
Mosquitoes get this virus from feeding on infected birds and then transmit it to humans. Humans are referred to as "dead end hosts;" they get the virus from being bitten by the infected insect but then can not spread it to each other. It is possible that it can be transmitted from blood transfusions, pregnancy or breast feeding but there are no known cases of infants who have gotten seriously ill from these transmissions.
The good news is that most of the time it is actually not such a big deal. Children under 5 seem to be at relatively low risk for getting terribly ill and folks over 50 seem to get hit the hardest. It can be found year round but seems to peak in late summer/early fall. With a warm October expected we likely have another month before it starts to slow. 80% of folks who get WNV have no idea that they are infected and feel perfectly fine. There are probably thousands of cases that go under the radar since we would never consider testing if someone is only showing mild symptoms of a mystery illness. The unfortunate other 20% of infected folks may have fever, joint pain, muscle weakness, stiff neck, diarrhea, vomiting, swollen glands, photo-phobia and/or a rash on the trunk. Not everyone will have every symptom. Most people showing these mild to moderate symptoms will recover completely, although there are reports that some of these folks can remain fatigued and achy for several weeks. 1% of infected people can get more serious neurological complications including encephalitis and meningitis. It can be fatal for those with serious cases. People with troubled immune systems are at the greatest risk.
So far this year, 2015, there have been 311 reported cases in 28 counties. San Francisco hasn’t had any cases reported, but you don’t have to travel too far to be in a county that has. (Marin, Alameda and Santa Clara to name a few.) The incubation period is usually between 2-14 days after the bite from an infected mosquito (most commonly 2-6 days.) There is, alas, no treatment beyond supportive care. It is thought that most people who have fought off the illness do end up with some level of immunity.
Keep in mind that any severe headache-fever-stiff neck combination always needs to be evaluated right away. If West Nile virus is suspected there are blood tests that can help with the diagnosis.
Since there is no vaccination at this point, and no treatment, the key is prevention.
- Make sure that you have intact screens on all windows
- Get rid of any standing water that is around your house; do a double check to make sure there are no pots, bird baths...etc. that are places where mosquitoes can breed. The larvae are dependent on water for breeding.
- Avoid being out and about during dusk and dawn when most of the biting happens.
- Try to wear (keep your child covered with) long pants/ long sleeves etc. Light colored clothing is recommended.
- If you are going into a heavy mosquito area use bug spray on exposed skin and clothing. The EPA has five registered insect repellents. Of those, there are three products that are more easily available.
- DEET is one of the more popular options. It is considered safe for infants over the age of 2 months.
- Oil of Eucalyptus is considered one of the least toxic options but interestingly, the age recommendation for it is for 3 years and older.
- Picaridin is a newer option. It is odorless and is approved for children 2 years and older. It is great as a mosquito repellent but it is not thought to be as effective against ticks as DEET if you are going into the deep woods.
As with any new thing, do a little test patch on the skin to make sure there is no sensitivity before you widely spritz it. They all come in different concentrations. You will need to read the labels to see how often you need to reapply. Avoid contact with eyes.
Mosquitoes don’t like fans! The nasty insects are lightweight enough that a good breeze may make it hard for them to zoom in on their target.
If you do see any dead birds, give them a wide berth and report them to 1-877-968-2473 (WNV -BIRD) or online at westnile.ca.gov. That website also will give you the up to date numbers on how many West Nile virus cases there are in California, county by county. It is updated weekly.
I was in western Massachusetts last summer and there were simply swarms of mosquitoes and other nasty biting insects wherever we went. It made me realize how lucky we are here in San Francisco that it isn't as "buggy" as it seems to be elsewhere. If you are seeing mosquitoes around your house, San Francisco's Environmental Health Department will send an inspector to investigate (415-252-3805.) They will check the area around your home (including sewers) to see if they can find any breeding areas.
The helpful folks at the California Department of Public Health pointed out that even with the extended drought, the mosquito abatement districts are still seeing A LOT of mosquito activity due to more stagnant water.
To be sure, we still do get patients covered in bug bites, but to date I have not seen any cases of diagnosed West Nile or mosquito borne illnesses among any of my patients. Some people seem to have much more of a reaction to bites than others; it does not appear that there is any correlation to the magnitude of the local reaction and exposure to the West Nile virus. If your little one is getting bitten, check the bedroom carefully. Look at the mattress and all the corners of the room; bites could be from spiders, fleas or other culprits
- Both males and females make that awful whining noise, but only the females bite humans
- Mosquitoes are especially attracted to people who drink beer
- Mosquitoes love the smell of sweaty feet
- Mosquitoes can sense CO2 from up to 75 feet away.
- Mosquitoes only fly as fast as 1-1½ miles per hour.
Mosquitoes love pregnant women (regardless of their blood type) possibly because they emit a little extra CO2.
Posted by Nurse Judy at 9:53 AM
Friday, October 2, 2015
Please see the updated post September 2016 for info on a new product!
I think the most common calls I get are about fussy, gassy babies (although I sure do talk about poop a lot; perhaps it's a tie.) Often these colicky kids have wretched periods during the late afternoon and early evening when it seems to be especially hard to settle them (I refer to this as the witching hours.)
With most of my patients this usually seems to improve at least a little once you hit the 3 month mark (keep your fingers crossed.) If one of those gassy babies is yours and you are breastfeeding, the first thing I will ask about is your diet. I know that not everyone agrees that there is a connection, but in my case I swear to you that if I even looked at cabbage my kids cried for a week. The biggest culprits in my opinion are:
- caffeine (in tea and chocolate among other things)
- gassy foods (like cabbage, onions, broccoli)
- spicy foods
What I suggest you do is see if you can establish a connection between an extra fussy day and something that you recently ate. Yes, I have some moms that know perfectly well that coffee is a problem but drink it anyway because they can't face the day without it. As always, it is a balance. It is worth finding out if there is a connection between your diet and your baby's gassiness, but then make whatever choice works best for you.
The other thing that breastfeeding moms should pay attention to is hind-milk. The milk that the babies get as they empty a breast is helpful with digestion. Sometimes greenish stools (not necessarily something that I worry about) and increased gas issues are because they are switching breasts too soon and never getting to the hind-milk.
If you haven't found any magic cures from a diet elimination, it is perfectly fine to experiment with some different colic remedies. Simethicone is the ingredient found in most of the OTC gas drops that you can get at a drug store. Some of the name brands are Mylicon or Little Tummies. Simethicone drops are very safe and helpful in about 70% of my patients. They are certainly worth a try.
Homeopathic colic remedies come in a few products. I am most familiar with Coccyntal drops (made by the Boiron company) and colic tablets by Hylands. These seem to help about 60% of the time. I consider them fairly harmless if used properly. They too are worth having in your arsenal. Grippe Water is an herbal remedy that can be found in many health food stores or Whole Foods. I find this helps about half of the time. Stools might get a touch green with this (not to worry.)
Soothe probiotics drops: These claim to cut crying time by 50% after a week of use. They should be given daily.
Soothe probiotics drops: These claim to cut crying time by 50% after a week of use. They should be given daily.
Brew some chamomile tea, add a few grains of sugar and give a dropperful or two to your baby. This also helps about half of the time. Probiotics may be helpful with digestion in general. This is especially true for babies who were born via c-section.
Colief is a fairly new product specifically for babies who may have a lactose intolerance. Regardless of the directions on the box, it is fine to administer directly to the baby without mixing with breast milk. If you are going to give this a try, you need to make sure you give it with each feeding for a few days to see if it is helping. (You may have a couple of months of colic ahead of you; you will have plenty of time to try all of these.) Dr. Schwanke thinks that the reason any of the above remedies work is because they have sugar in them. I think there is probably more to it than that.
Don't forget about massage! Go on line and check out baby massage techniques on You-tube or take an infant massage class. Make gentle clockwise circles on the baby’s palm with your thumb. Bicycle their little legs. Get up and dance. Hold your baby over your shoulder with their knees tucked up in fetal position. Give firm pats on the back. Sway, bounce and sing. (I teach the "shuffle" at my baby boot camp class.) Warm (not too hot of course) baths are very soothing for some babies.
Ready to think outside the box? Advanced Allergy Solutions ( http://aasclinics.com ) has treated babies and had some good results for colic. This is completely noninvasive and I have had patients who claim improvement.
Craniosacral therapy has been helpful for some of our fussy babies. Two of my favorites are Sandra Roddy Adams 4150566-1900 and Laura Sheehan 415-681-1031
Amy Gelfand, a pediatric neurologist at UCSF, looks at the connection between colic and a family history of migraines. Interestingly, recent evidence suggests there may be a relationship between infant colic and migraines. Mothers with migraine are more likely to have a colicky infant, and colicky infants are more likely to grow up to have migraines as adolescents.
Given this connection between infant colic and migraine, the UCSF Pediatric Headache program is now starting a program for management of infant colic. Their goal is to use what they know about helping children with migraines to also help babies with colic.
Here is a snippet of info from Dr. Gelfand:
What will happen at my baby’s visit with the UCSF pediatric headache neurologist?
Your baby’s pediatrician has referred you to see a pediatric neurologist who specializes in managing migraine in children. At the visit, the neurologist will go over your baby’s health history and the details of your baby’s crying pattern. She or he will also review your family history of migraine. It may help to ask your family members about their headache history in advance of the visit as only about half of adult migraineurs in the U.S. have ever been diagnosed by a physician. The neurologist will also perform a neurologic examination of your baby.
If there is a family history of migraine, it is possible that migraine could be playing a role in your baby’s colic. Given the young age of infants with colic, our approach in the UCSF infant colic program focuses mainly on behavioral interventions to help manage crying. We also want to ensure you have adequate support, as taking care of an inconsolably crying infant can be tiring and stressful. We only recommend medications that are safe for babies, and we work closely with your pediatrician to ensure that medication choices—if they are needed—are safe for your baby.
There are lots of experts who are convinced that the worst of the colic cases slowly build up to the 6 week peak and then slowly subside. As mentioned earlier, by the time three months comes around, most of our families can see the light at the end of the tunnel. One study that I read years ago postulated that kids with lots of colic symptoms ended up with higher IQ's. Hold that thought....
As with everything, this stage will pass. Enjoy the calm moments.
Posted by Nurse Judy at 8:30 AM