Friday, November 27, 2015

The Power of story telling

My mom could go into a room full of chaos. “Once upon a time..” she would start in a steady calm voice.

It wouldn’t be long before everyone in the room was hanging on her every word; whatever they had been in a snit about a moment ago was forgotten.
She would then take her audience on a magical journey with a story that she often made up as she went. If it were a classic tale, you could count on her to take dramatic liberties. I don’t believe she told any story quite the same way twice. In her kindergarten classroom she would have her students shut their eyes as she told her tales.
"Use your imagination", she would tell them. "I am thinking of a big black dog, he has 2 floppy ears. He also has 2 tails and 3 eyes!"

One distinct recollection of a time when mom’s storytelling saved the day comes to mind. My younger daughter Alana had several friends spending the night. In one of my bigger lapses in good “mommy judgement” I had rented a movie that I thought they would all enjoy. It turned out to be fairly dark and scary (always pre-screen, don’t rely on faulty memory of what may or may not be appropriate.) One of the girls started to cry and some of the other girls started to get sad and upset. A few of them wanted to stop the movie, but of course most of the others wanted to keep watching. The situation seemed like it could go downhill quickly. Fortunately my mom was visiting. She took control, turned off the movie and started to tell stories. These weren’t toddlers; they must have been about ten. They sat raptly listening to story after story. The evening was saved.

Books are wonderful too, but in truth, they also are not quite the same as a story. A story is yours to tweak as you please. Stories are powerful mediums for working through issues. Folks who have asked me for parenting advice over the years know that using stories is a favorite tool. For as long as I can remember I have been counseling parents to create a fictional child with a similar name. Talk about what that parallel child has been going through. This tends to be a very non threatening way to talk about all sorts of issues. Once upon a time there was a little girl who had an “owie” ear. The doctor had given her some medicine to make it better, but when she tried the medicine it tasted yucky.”....

Once upon a time there was a little boy who didn’t like to stay in bed……

Once upon a time there was a little girl who didn’t want to go to school...

Once upon a time there was a little boy who liked to put pieces of cheese in his nose….

These stories are great ways to launch into a dialogue about all sorts of positive and/or negative ways that the protagonist can deal with  a variety of situations. This is an excellent problem solving technique.

When I was working on this post, I mentioned the storytelling theme to one of the wise mamas in my life. She immediately referred to these as “Annie Stories”. It turns out that back in 1988 this was quite the thing, and there was a book about how to use this method:

I use storytelling at work on a regular basis. Many of our savvy parents who know that they have a “shot phobic” patient on their hands, will make sure that they schedule the visit when Josie and I are both there. Josie is my amazing medical assistant who has been my ‘right hand’ at the office for many years.
I can’t even count how many times I have been called into an exam room where a crying, or cowering child is terrified of a “dreaded shot”.... I start my story:

“Once upon a time there was a patient who was so big. He played football for his high school. He was bigger than me, he was probably bigger than the grown up in your house, he was really big...and he was really scared of getting shots." At this point 90% of the kids are now still and listening to me talk. Yes,  they might be huddled on their parents lap, or on the floor under the chair. They are probably not making eye contact, but I have their attention.

“He wasn’t afraid of getting bumped around on the football field but he hated shots. He was so scared of them that he would try to hide. He tried to hide inside the garbage can, but he wouldn't fit..”   Now 99% are listening and some are almost laughing.

From here I am able to start a dialogue with them about why we are giving the shot. “It is magic protection so that if certain germs get inside of your body, you won’t get sick.” We talk about the fact that we wish there was a less yucky way to get the protection and that it is really normal for lots of people to be scared of shots. We talk about the fact that being brave is trying hard to hold still and it is still really okay to cry and yell if they need to. As soon as they are ready, Josie (the best shot giver in the country) has already gotten it done.

It all starts by engaging them with a story.

Not everything has to have a purpose. Sometimes stories are just for fun

If I happen to be taking a  walk outside and see something unusual such as  a pair of shoes sitting by themselves on a street corner, I can’t help to think to myself. Here is a story. How did those shoes get there? Take turns telling the same story. Families can have a wonderful time creating a collaborative tale.
Another wise Mama tells me that she used to have her kids give her three things that they wanted the story to include; perhaps a special name or a certain feeling.

Our kids these days are both blessed and cursed with the enormous choices of digital wonders. I am not opposed to limited use of regulated tech time, but it should not be in place of plain old imagination.

Recent studies show that books and stories started young have a real impact on brain development:

This Black Friday, as people run around to shop for all kinds of new technological marvels, don’t forget to “power down” and be thankful for the magic moments that you capture as you snuggle with your kids and simply tell a story. "Once upon a time......

Friday, November 20, 2015

Food safety/storage guidelines

Thanksgiving is a holiday associated with lots of yummy leftovers so it's usually my signal to update my food safety post. If you ever watch the news you know that food contamination issues can happen all year round. This post will give you some safe guidelines for foods that you buy and cook. If you do a lot of eating out, restaurants are supposed to have their cleanliness rating publicly displayed. Check the bottom of the article for some great links on food storage guidelines; everything from egg safety and turkey leftovers to breast milk storage.

It is certainly not a sterile world. As soon as they are able, your baby will start putting anything that they can reach into their mouths. You can't even begin to imagine the phone calls we get about the more disgusting items that some of our little patients have managed to get their hands..and mouths on. Just this week we talked to parents of various kids who had possibly had a nibble or taste of the following things:
essential oils
particles from an exploded cold/hot pack
kitty litter

So yes, the world is full of germs, and while I don't generally get too concerned about a little dirt here or a big sloppy dog kiss there, food borne bacteria can be nasty and we need to minimize any exposure.

Infants and young children are particularly vulnerable to food borne illness because their immune systems are not developed enough to fight off infections. This is especially important for infants under 6 months of age.  Extra care should be taken when handling and preparing their food and formula. Here are some basic food safety guidelines:

  • Wash hands for at least 20 seconds before food preparation. Soap is best. Hand sanitizer will do. Re-wash as needed after handling food that might carry germs (poultry, meat, raw eggs.)

  • Make sure kitchen towels and sponges are changed and cleaned frequently (sponges can go through the dishwasher.)

  • Keep your refrigerator temperature at 40 degrees or colder and your freezer below 0 degrees. (One way to make sure that the freezer has continued to have safe temps is to keep a baggie filled with ice cubes in the freezer. If they remain cubes, you are in good shape; if they melt and refreeze as a block of ice that means that at some point your freezer was not cold enough.) Label things in your freezer and rotate so that you are using up older stuff first.

  • Check the dates of baby food jars and make sure the lid pops when you open them.

  • Don't  put baby food back in the refrigerator if your child doesn't finish it and you used the "used" spoon to take the food directly from the jar. Your best bet - simply don't feed your baby directly from the jar. Instead, put a small serving of food on a clean dish. Add more as needed with a clean spoon. Remember that once saliva has come into contact with the food it is no longer sterile and some bacteria can grow quickly.

  • Don't leave open containers of liquid or pureed baby food out at room temperature for more than two hours. Bacteria thrive in temperatures between 40-140 degrees

  • Don't store opened baby food in the refrigerator for more than three days. If you are not sure that the food is still safe, remember this saying: "If in doubt, throw it out." (See links below for guidelines on how long food stays safe.)

  • Make sure that foods are properly cooked. A food thermometer is the best tool for this.
        Chicken ( white meat/ dark meat)...170/180
        Eggs....not runny

For all of you "older kids" who will be baking this holiday season, watch out for the batter. (I am a notorious offender), but even one lick from raw food containing a contaminated egg can get you ill.

Myth: Freezing food kills harmful bacteria that can cause food poisoning.
Fact: bacteria can survive freezing temperatures. When food is thawed, bacteria can still be present and can begin to multiply. Cooking food to the proper internal temperature is the best way to make sure any bacteria is killed.

Myth: vegetarians don't need to worry about food poisoning.
Fact: Fruits and vegetables are an important part of a healthy diet, but like other foods they may carry a  risk of food borne illness. Always rinse produce well under running tap water. Never eat the pre-washed 'ready to eat' greens if they are past their freshness date or if they appear slimy.

Myth:  Plastic or glass cutting boards don't hold harmful bacteria on their surfaces like wooden cutting boards do.
Fact:  Any type of cutting board can hold harmful bacteria on its surface.  Regardless of the type of cutting board you use, it should be washed and sanitized after each use. Solid plastic, tempered glass, sealed granite, and hardwood cutting boards are dishwasher safe. However, wood laminates don't hold up well in the dishwasher.  Once cutting boards of any type become excessively worn or develop hard-to-clean grooves, they should be discarded.

Myth:  Locally-grown, organic foods will never give you  food poisoning.
Fact: Any food, whether organic or conventional, could become unsafe with illness-causing food borne bacteria at any point during the chain from the farm to the table. Consumers in their homes can take action to keep their families safe. That is why it is important to reduce your risk of food borne illness by practicing the four steps: Clean, Separate, Cook, and Chill.

Some excellent resources for food safety tips can be found at:  (this site keeps track of any food recalls)   (great site for seeing how long food will last)   (this site has loads of kid friendly activities) (Kellymom is a worthy site for all sorts of breastfeeding info)

Enjoy your Thanksgiving!

Friday, November 13, 2015

RSV (update)

November is often considered the start of RSV season. Sure enough we have already seen it in the office and confirmed our suspicions with our in-office test.

Here is the RSV post, updated for the 2015/16 season.

What is severe RSV disease?
Respiratory syncytial (sin-SI-shul) virus, or RSV, is a common, seasonal, and easily spread virus. In fact, nearly all children will get their first RSV infection by age 2.
Like most viruses it ranges in its severity from case to case.

Severe RSV disease is the number one reason babies under 12 months old have to be admitted to hospitals in the US. You know the wretched colds that knock you flat and stand out in your memory? These are the colds that come with runny noses, sniffling and sneezing, harsh cough and fever. That illness might well be RSV. I actually can almost diagnose it over the phone when I hear the patients coughing. The cough sounds like it hurts.

There is a test that we can do in the office (a swab to the nose) to see if it is RSV or not, but unless your child is looking really sick we might not bother. It doesn't necessarily change the approach. We often do nebulizer treatments for our wheezers, but with RSV they don't always help all that much.

Time usually fixes this and all that we can offer is often the same symptomatic treatment and supportive care that we would do for any bad cold and cough. Treat the fever as needed   

To clear the nose, squirt some saline or breast milk in each nostril and then suck it back out with either a  Nose Frida/ aspirator or the Neil Med Naspira I think those are much easier to use than the standard bulb aspirators.
I also just learned about a brand new product. The Oogie bear is a safe little scoop that can safely get into the nostril and removed the more stubborn boogies.

If your child is having trouble eating because of all the congestion, try doing some clearing about ten minutes before a feeding.
It is also helpful to keep their heads elevated. They may need to spend the night in a safe infant seat or you can try to raise the mattress a bit. For older kids, add an extra pillow. Let them sit in a steamy bathroom, and use a humidifier at night. Increase fluids during the day.

RSV can cause ear infections and pneumonia. Severe RSV disease symptoms include:
  • Coughing or wheezing that does not stop
  • Fast or troubled breathing
  • A bluish color around the mouth or fingernails
  • Spread-out nostrils and/or a caved-in chest when trying to breathe
  • Gasping for breath

If your child is having trouble breathing, or significant trouble feeding, they may need to be hospitalized for a night or two for fluids, oxygen and observation. I would say that we have several kids routinely hospitalized for this every year (not just young babies.) There is no other real treatment for RSV other that close observation, but for certain high risk patients, there is a medication that is given monthly that significantly protects them. This medication is called Synagis.

If your child was premature, or has cardiac or pulmonary issues they may qualify. Talk to your doctor's office ASAP to find out if your child fits into the guidelines. Alas the guidelines are quite restrictive. Much to the dismay of most sensible practitioners, they became even tougher last year. We used to be able to get it for preemies who were born before 35 weeks. The new rules moved that to 30 weeks. So far I don’t have any candidates this season. I hope it stays that way. In California the official RSV season starts on November 1st. (I don't think that RSV knows that it has a season, but that is when the insurance companies will start shipping the medication.)

Since most of our children can not get protected with Synagis, please take precautions to prevent the spread of this nasty virus, especially for the youngest most vulnerable babies.

Wash your hands before touching your child. Make sure others wash up, too. Clean toys, crib rails, and any other surfaces your baby might touch. Try to keep your baby away from crowds. Avoid anyone with a cold or fever. Don't let anyone smoke near your baby. Tobacco smoke exposure can increase the risk of severe RSV disease.

Sadly it takes multiple exposures before you develop immunity. Most folks get RSV about 8 times until they finally seem to be not as vulnerable! It spikes again in older folks when the immunity tends to wane and it can sweep through retirement communities, so be cautious for the older adults in your life as well.

If your child is unfortunate enough to get a nasty case of RSV during the season it takes a long time for the lungs to calm down. In my experience it is not uncommon for these kids to have a tough winter. Every new cold seems to retrigger the wheeze. This does NOT necessarily mean they have asthma. For repeat wheezers, if the nebulized medications bring relief it might be worth owning a machine. We rent them out of the office for $5/ day, but you can purchase them for less than $100 from Walgreen's. Having a nebulizer safely tucked away in the bottom of the closet may save you from a night time or weekend trip to the emergency room.

Friday, November 6, 2015

Parapertussis/Whooping cough's milder cousin

What is parapertussis? It is annoying for sure, but it isn't quite as scary as it sounds.

Bordetella is a bacterium best known for whooping cough in humans (B.pertussis) and kennel cough in dogs (B.bronchiseptica). B. parapertussis is a lesser known member of the family. It is estimated that 1%-35% of known Bordetella infections are caused by B. parapertussis. Because only a small percentage of patients actually ever get tested, these are tough statistics to get accurate. To compound the challenge of data gathering, parapertussis is not one of the diseases that mandates reporting it to the public health department, so it really is tough to have a real sense of numbers.

The nastier cousin, B.Pertussis is making the rounds. Because it is currently active at some local San Francisco schools and daycares, several of our coughing  patients have asked to be tested. A number of those results came back negative for pertussis (fortunately), but  positive for parapertussis. The PCR test done to rule out pertussis tests for both. (It is actually possible for folks to have both illnesses at the same time, how unfair is that?!)  Parapertussis has some distinct differences. It is very similar to regular pertussis but not nearly as severe or long lasting. One main difference is that parapertussis does not produce the pertussis toxin which is responsible for some of  the more severe symptoms.

With parapertussis, patients can still have the prolonged cough, (with characteristic coughing fits) and vomiting but we are talking about 3 weeks instead of 3 months. This is a fairly variable illness; up to 40% of patients with it can be almost symptom free.
Just as with Pertussis, we are more concerned about infants younger than 6 months, or someone with an underlying health condition or compromised immune system.

This month our patients who tested positive were all fully vaccinated, and that makes sense. While the whooping cough vaccine gives about 80-90 % protection against pertussis to folks who get it, it does NOT protect against parapertussis.

Just like pertussis (and the common cold), parapertussis  is transmitted from coming in contact with respiratory secretions.

The incubation period is also similar to that of pertussis. This is measured from the time someone was exposed until they come down with the illness. Most commonly it is 7-10 days, but it can be as short as 5 days and you can’t really count yourself as out of the woods until at least 21 days have past since the exposure and no symptoms have presented.

A patient is infectious (they can spread the illness and make someone else sick) from a day or so before showing the first symptom until up to about 3 weeks after the beginning of the illness. If treated, a person is still considered  contagious until they have finished a 5 day treatment.

There are not really any official guidelines for managing the illness. Basic symptomatic treatment measures such as steam, fluids and rest will help get you through. Certainly if the patient is less that 6 months old, or in close contact with a young baby or someone high risk, they should get treatment as soon as possible. The standard treatment is five days of Azithromycin. Remember that patients are considered contagious until they have completed the course.

For the older, lower risk patients, should we treat? The limited studies that are out there suggest that treatment that is initiated within the first 6 days of the onset of the symptoms may possibly help get the patient better faster. Another benefit of early treatment is that it can minimize the spread.

Prophylactic treatment, to prevent the disease in someone who was exposed but isn’t sick yet, is worth considering for high risk contacts, if started within 2-3 weeks of the exposure. Most experts agree that starting prophylaxis more then 3 weeks after the exposure is probably of no benefit.

But in most cases, it isn’t that simple. We don’t tend to bother seeing patients unless they have a cough that is really troublesome or lingering; we couldn’t possibly bring everyone in the minute they start to cough. The other issue of course is that nobody wants to overuse antibiotics. With pertussis and parapertussis, the illness often starts for a week or so with a mild cold before the coughing begins.By the time we recognize that we are dealing with parapertussis, the reasonable window for treating may already be passed.

I do have my antenna up for any illness that has coughing spasms. Many of these patients seem fairly well, until a coughing fit hits. Often there will be vomiting from coughing so hard. There may or may not be a characteristic whoop.

Here is the question many of you are asking: Can they go to school? Officially parapertussis is considered a mild but irritating illness. It is not a reason to keep them home. Keep in mind that people are contagious a bit before they have flagrant symptoms, so we have to exercise a bit of common sense here. Someone who was at school on Monday and starts coughing on Tuesday has already exposed all of the classmates. They also likely picked it up from a fellow student. Keeping them home if they feel fine and have no fever makes no sense. If you have a child who is miserable, feverish, poor appetite, poor sleeping, with labored breathing, that child should not be at school. Likely they need to be seen by the doctor!

Even though school and normal activities are fine, please be cautious about letting your coughing child be around any vulnerable newborns. I recognize that siblings present a uniquely complex issue. It is usually not reasonable or even possible to try to quarantine them for weeks.
Check out the links below for help with symptomatic treatment