Friday, January 29, 2016

Zika Virus

Please see updated post on 2/2017 with current Zika updates

This week we received a health advisory from the public health department regarding the Zika virus. There are 3 categories of announcements from the health department:

  • A health update  provides us with updated information regarding a situation; these are unlikely to require immediate action
  • A health advisory may or may not require immediate action
  • A health alert conveys the highest level of importance and does require immediate action

You may have heard about it on the news, in between stories about snow storms and absurd politics. As expected the questions are coming in:

-   Is there concern about breastfeeding mothers and Zika?
-   Are there any particular concerns for children getting the virus?
-   The CDC site says the virus leaves the blood after a week. Are there concerns for possible future pregnancies?

Here are some Zika factoids:

Zika virus was first identified in 1947 in a rhesus monkey in Uganda's Zika forest (which gave the disease its name.) For decades Zika was a virus that turned up in monkeys and occasionally in humans in Africa and southeast Asia. Its symptoms were mild and the number of confirmed human cases was low.

This virus is on the rise. Until now, almost no one on this side of the world had been infected. Few of us have immune defenses against the virus, so it is spreading rapidly. Millions of people in tropical regions of the Americas may have recently gotten it.

Zika virus is spread to people through mosquito bites. The most common symptoms of this disease are fever, rash, joint pain, and conjunctivitis (red eyes). The illness is usually mild with symptoms lasting from several days to a week. Severe disease requiring hospitalization is uncommon. Only about 1 in 5 people infected with Zika virus even become symptomatic.

The nasty type of  mosquito responsible for Zika,  also spreads dengue virus, yellow fever virus and Chikungunya. Mosquitoes that spread Zika virus bite mostly during the daytime. My general  warning to be especially careful to avoid mosquitoes during dusk and dawn doesn’t offer any protection in this case.

Just as with malaria, people are the source for spreading the virus. A female mosquito bites an infected person and then can carry the virus to the next person she bites, so when people travel, they can bring the virus with them. They are thought to be infectious the first week only. The virus can take hold if enough people become infected for it to become endemic, meaning it's in a region permanently.  Mosquito bites and mother to unborn baby aren't the only ways this virus is transmitted. The new CDC report notes documented cases of infection from sexual transmission, blood transfusion and laboratory exposure. To date there are no confirmed cases of mothers passing the virus to the baby through breast milk. Either way, the benefits of breastfeeding way outweigh the risk and exposure would not be a reason to stop nursing. People infected with Zika virus don't infect one another through casual contact.

There is no vaccine or specific antiviral treatment available for Zika virus disease. Treatment is generally supportive and can include rest, fluids, and use of acetaminophen for fever and/or discomfort. Because of similar geographic distribution and symptoms, patients with suspected Zika virus infections also should be evaluated and managed for possible dengue or Chikungunya virus infection.  People infected with any of these illnesses should be protected from further mosquito exposure during the first few days of illness to prevent other mosquitoes from becoming infected and reduce the risk of local transmission.

Zika has a few especially  frightening aspects. There seems to be an alarming rise in Guillain-Barre syndrome that is probably related. This is a nerve disorder that causes muscle weakness. Most people recover in a few weeks, but severe cases can require life support to help with the breathing. Anyone of any age can get Guillain-Barre, although it is pretty rare. It is thought to be triggered from an infection. The scientists are actively studying this possible link.

There is also a probable connection between birth defects and pregnant women infected by the Zika Virus. In Brazil, where most of the reported cases seem to be, there have been many babies born with microcephaly (small heads) and the associated significant health issues. The most dangerous time is thought to be during the first trimester – when some women do not even  realize they are pregnant. Experts do not know how the virus enters the placenta and damages the growing brain of the fetus. Some countries are so concerned about this that they are suggesting that no one get pregnant until they have a better handle on controlling the spread (good luck with that!)

Okay how does all of this impact you? If you have not been traveling lately and have no plans to travel this should have little or no impact on you. If you have recently returned from a trip to any of the Zika hot spots AND have any illness symptoms, make sure that you share that info with your doctor or nurse. If you are pregnant and may have been exposed, contact your OB as soon as possible. Testing must be coordinated with the local health department and would only be done for someone who has been in one of the impacted areas and is showing symptoms.
If you have an upcoming trip planned, keep in mind that until there are firm answers, the CDC has issued a travel advisory to pregnant women to avoid traveling to any countries where the Zika virus is rampant. If travel is not optional, strict mosquito avoidance is essential. Keep body parts covered, use DEET or other mosquito repellents according to the labels. Stay indoors with screen protection as much as possible.

The good news is while it's not certain, scientists believe once an individual has been infected with the virus, they are immune and won't become infected again.There is currently not concern for future pregnancies.

For up to date information on which countries are impacted, check the CDC website:

Friday, January 22, 2016

Cradle cap/Nurse Kenlee's tips

Cradle cap is one of those things  that we get calls about on a regular basis. I was amazed to find that Nurse Judy had not yet tackled the issue in one her blogs.  I asked if I could give it a shot and she agreed, so here we go!
Cradle cap, also known as infantile or neonatal seborrhoeic dermatitis, crusta lactea, milk crust, or honeycomb disease is a yellowish, patchy, greasy, scaly and crusty skin rash that occurs on the scalp of recently born babies. The cause is unknown but most doctors believe it is hormonal and is related to an abnormal amount of oil in the hair follicles. It is common to see cradle cap on the scalp but can occur anywhere there is hair growth, such as eyebrows, eyelids and armpits. It usually occurs within the 1st few months of life and can continue until around 1 year old or until they get their hair.
 Pediatric dermatologist, Dr. Sorrell of Lucile Packard at Stanford advised to use plain mineral oil (found in constipation aisle) daily to area. Use a soft toothbrush or baby brush to gently brush away the scaly skin. If this does not work, try using a mild topical hydrocortisone cream 1% twice daily. Also, use a liberal amount of Vaseline to scalp to lock cream in. Yes, your child’s head and hair will look greasy but it will improve the cradle cap. If scalp is still resistant, talk to your doctor about adding an antifungal cream, stronger steroid or getting a dermatology referral.
Natural approaches that many people have luck with include massaging pure natural oil into the scalp such as coconut oil or olive oil and letting it soak for about 15 minutes per day prior to washing head. After shampoo, gently brush scalp with a soft bristle brush or cloth to remove loose, dead skin. Also, a baking soda rub overnight was reported to help a few patients. On occasion, for stubborn cases, Dr. Kaplan may suggest an OTC dandruff shampoo such as Selsun Blue or Head and Shoulders.
Of course if at any point the dryness spreads beyond the scalp, the scalp becomes inflamed, painful or starts to bleed; you should notify us right away. Bottom line from Nurse Judy, if you child seems bothered from the condition in any way, check in with your doctor.
While working in the emergency room, cradle cap was not a common complaint but I did see it from time to time and knew that it was normal, harmless and no treatment was really required. Then along came my daughter who stayed bald until right before her 1 year photo shoot. As her hair grew, her head started to get flaky.  I initially thought I must have let my poor baby’s head get sunburn and it was peeling. After crying with mommy guilt to Dr. Hurd, she assured me, it was cradle cap and I started my home remedy of coconut oil massages. However, no one ever warned me that as the skin peeled off so would clumps of her new beautiful hair!
I swore that she must have had alopecia but she is now a 21 month old beauty with a full head of wonderful blonde hair.

Friday, January 15, 2016

Dealing with Altitude

Please see the updated post March 2018

This is the time of year when we get a lot of calls from folks wanting to take a road trip up to the mountains and asking about whether or not altitude is a problem for the baby. Keep in mind that many babies are born in places quite a bit above sea level and live their lives in high altitude year round.

Some folks in general are more sensitive to altitude issues than others, but there is no real difference between adults and children.Most people can tolerate altitudes below 2500 meters/8200 feet with only mild discomfort. If your child has significant heart or lung issues if is worth checking in with your specialist prior to travel. For the majority of my patients, Tahoe is generally okay for any age.

Mild symptoms can still have an impact. Folks may have headaches, tire easily and be a bit short of breath. Dr. Kaplan adds that tummies can get upset because the gas in your gut expands. Make sure your bring gas-X or simethicone along to help deal with this.

It is essential to make sure that you and your kids stay hydrated. Breastfeeding moms should take extra care that they are drinking enough.

Sunburn can happen easily in the high altitude. This is even more of an issue when there is snow or water to reflect the sun. Make sure you have appropriate sun protection for skin and eyes.

In the winter time, the air tends to be drier. The need to use heat in your accommodations can exacerbate that. It is worth bringing along your humidifier. (If you are flying, consider purchasing an inexpensive one when you get there.)

The biggest difference between adults and young children is that the adults can communicate what they are feeling. Babies can’t. If your baby appears pale, fussy or has labored breathing, get them to a travel clinic to be assessed. Make sure they have the oxygen level checked. On the other hand, young babies aren’t generally hiking around or doing anything strenuous so in some cases, they may have an easier time.

If you are traveling to a place that is higher than 8,200 feet, see if you can get there in stages so that your body has a little bit of time to acclimate. Know ahead of time what medical services are available should any family members run into trouble. Dr. Kaplan has had some patients, traveling to Colorado high country, who needed supplemental oxygen.

I personally am an altitude wimp. I like my oxygen and have trouble if I am anywhere over 5,000 feet. I will NOT be accompanying my husband and oldest daughter this coming July when they climb Mt. Kilimanjaro...20,000 feet.


Friday, January 8, 2016

Cleaning up made simple

A few months ago I had a phone chat with one of the moms in my practice about some behavior issues. Her daughter was 2 1/2. At home there was an unpleasant amount of parental nagging and child tantrums.

Mom was astonished recently when she spend a few hours at her daughter’s daycare. She watched in awe as the kids all immediately followed the request to clean up the toys.
After lunch, this little group sat nicely, eating their healthy meal and then got up to  clear their plates. What completely knocked this mom over was watching all of the kids line up to compost whatever food scraps there were.  Composting, Really?!? As she told me, this was a completely different child than the one she had living with her. This is a really clear example of how important rules and consistency are.
It is, in fact, not at all uncommon for kids to behave beautifully  in some situations and completely act out in others.

If rules are clear and simple, most kids will follow them.  As long as rules are in the child’s best interest and reasonable, kids thrive in a consistent environment. Kids need to understand the rules. If there are rewards/incentives what are they? What are the consequences for not following through. Once the kids are old enough, have them be involved in negotiating the new “official guidelines.”  What do they think would be a reasonable consequence. Are there certain incentives that they would like to work towards?

How can you implement this at home? Think small. Not everything has to be regimented but let’s address one common area of conflict, such as cleaning up toys, and make it simple.

Easier said than done, but try to have an organized system so that putting toys away is straightforward. Know where they came from so that they can be returned to where they belong. If you can’t do that, you possibly have too many toys and you should take some of them out of circulation.

Large toy boxes/trunks are okay for really large items, but they tend to become a dumping ground. You are better off investing in shelves with different bins. Low shelves are for toys that kids can have easy access to. Have a designated high shelf area for setting aside toys that need adult involvement.

Take a photo of the toy that lives in the bin and glue the image on. This can be a family project. (Great rainy day activity!) Maybe the picture can include your child holding the toy. There can be a box for little cars, a box for dolls, a box for crayons...etc.

Perhaps have a rule about only 2 or 3 boxes being down at a time until your child shows you that they can manage cleaning up more of a variety. Sorting can be a game. Give a transition time:

“Ten minutes until clean up."
“Five minutes until clean up."

Some kids may do well with a timer.

Everyone needs to understand what the new clean up rules are:

  • When playtime is over, it is time to do the full clean up
  • Put on some music or have a clean up song.
  • Children have a set amount of minutes to put the toys away.

Try not to help too much. When the time is up, make sure you give positive feedback. The toys are safe and ready for the next time they want to play with them. If they did NOT clean up, now it is your turn. Anything that you clean up is yours to do with as you please. You can put it high up where the kids don’t have access until they agree to do a better job cleaning up.

This process eliminates potential sources of nagging:
  • These are the clean up rules; they are clear and simple.
  • Cleaning up is easy. It takes a few minutes. It can even be fun!
  • kids remain in control of the toys that they put away.
  • Or mommy/daddy can clean up but the toys are gone for a while.

Many of our kids have so much stuff (mine were no exception) that you may wish to consider rotating toys. If you take something out of circulation for a while it might feel new and fresh when you bring it back. Doing a toy swap with friends is another good way to have an assortment of things to play with that feel new and exciting. Keep in mind that some kids are rougher than others. Don’t lend out anything that you care too much about. It may not come back in the same shape that it went out!

Start small, be clear and consistent, problem solve so that you don't end up in nagging cycles to kids who ignore you. Who knows, the next step might be composting!


Friday, January 1, 2016

slap cheek ( update)

Slap cheek is one of those illness that seem to come around a couple of times a year. It is not unusual to see it in late fall/ early winter. It is also known as Fifth disease or Erythema Infectiosum. (Fun fact - it got the name Fifth disease back in the 1880s when childhood diseases that caused rashes were referred to by a number. This was number 5 out of 6. Others on that list included measles and scarlet fever.) It is caused by  Parvovirus B19.

Just like Hand Foot Mouth, Slap Cheek is a fairly contagious rite of passage. It is mostly spread through respiratory secretions, but can also be carried through infected blood. Most people get it while they are still children (usually between 4-15) and thus have immunity as adults.

Unless we had a bad case of it most of us don't actually know whether we have had it. You can check with Grandma, but I bet she doesn't remember either. The symptoms may have been mild enough that no one paid much attention. This illness can be quite variable. Some kids don't seem too impaired while others are miserable. The really mild cases can present with a child who has a red chappy cheek for a day or so, and that's it!
The sicker kids can be achy (joint pain is common for those old enough to voice their complaints) and fussy with high fevers on and off for several weeks. The common denominator (hence the name) is one or both cheeks usually appear very red and chappy. For most patients, the red cheeks are followed by a lacy, mottled rash that works its way up and down the body.  It tends to cover the arms and legs more than the trunk. (Of course there are exceptions; some kids don't read the textbooks and present any which way that they like.) There may be several days in between symptoms.

Very rarely kids can get quite ill with this. In my many years here, I have NEVER had any patients who didn't get over it completely and without any lasting adverse effects, so relax, but remember Nurse Judy's rule; any fever that is lasting 4 or 5 days needs to be checked on.

The most important thing to note about slap cheek is that it can be dangerous to a fetus. If a woman is infected in the early stages of pregnancy there is an increased chance of miscarriage. Keep in mind, most women had this as a child and are therefore not at risk. But since most people also don't really know if they had it or not, It is best to avoid contact with pregnant women as much as possible if your child has been diagnosed with this. If you are pregnant and may have been exposed, talk to your OB about getting a blood test to check your immunity.

The incubation period is thought to be about 4-21 days after the exposure. (In other words if you come into our office and walk out with a red cheek, you didn't get it here; that would be way too soon.)

The kids are most contagious at the very beginning of the illness when the main symptom is probably simple fussiness. The cheeks might be red, but you reasonably figure that this could simply be caused by being a little warm. Frankly, by the time the rash is in full throttle they are probably not very contagious anymore.

Treatment is symptomatic. Treat the fevers as needed with Tylenol/ Ibuprofen and tepid baths. Make sure your child gets plenty of fluids and rest as needed.

My best daycare and school guidelines are to keep a child home if they are fussy or have a fever, but if you have a happy child with a red cheek, it seems unreasonable to expect you to stay home from work. Chances are, once one of the kids in daycare shows up with it, everyone has already been exposed.

This virus can cycle on and off for a few weeks before it is done with  you.