Friday, March 25, 2016

Hand/Foot/Mouth Update

We have been seeing a steady stream of Hand Foot Mouth this month. Many of the calls are related to figuring out when your kids can go back to school or daycare. I will address that issue at the end of this post.

Hand foot mouth is a very common illness that most kids get during childhood. It is easily spread through body secretions such as saliva, respiratory secretions and stool. The virus can be shed in the stool for several weeks! Although the virus most commonly associated with it is called coxsackievirus, there are other strains that sometimes circulate.

Most folks may only get it once, but I have seen some patients who don't seem to hold the immunity and have gotten it multiple times. As with most childhood illnesses, most of us got this out of the way when we were young. Adults who are unfortunate enough to come down with this tend to be quite miserable. Young infants are usually protected up to a point from maternal immunity (assuming mom has had it.) Of all the kids that we see with this, it is unusual for our youngest patients to be afflicted.

I actually like to call it Hand Foot Mouth and Butt, because in my experience, kids often get blisters on their butts as well as on the hands and feet. Some people have mild congestion, sore throat and fever as part of the package. Sometimes the rashes are a little more wide spread.

It is a very variable illness, meaning that one child will not look very sick and another can feel wretched. The lucky ones might simply have a mystery blister on the hand and that is the extent of it! Most of the time the worst symptoms resolve in a week or so. Every time a wave of this virus sweeps through it has some nuances.

Last fall when it was going around it seemed like it was a rougher strain. Many of the kids had mouth involvement and some of the blisters on the hands seemed to last a bit longer. Sometimes we will have waves of kids losing their fingernails; other times more of the parents seem vulnerable

There is no treatment for this virus. You simply support your child through it and of course call the doctor if something is causing you alarm.

Your goal is to keep your little one hydrated and comfortable. I have found that the kids with more mouth involvement are the most miserable. In extreme cases the mouth sores are so awful that they don't want to eat or drink and can face a risk of dehydration.

Controlling the pain is the best way to get them drinking. Even if they have no fever, it is appropriate to dose them up with Tylenol or Ibuprofen (Motrin/Advil). Tylenol comes in a suppository form if they are resistant to taking medicine by mouth.   

Offer cool creamy and soft foods (hooray if you have breast milk). Avoid anything acidic or sharp, like orange juice or tortilla chips. Smoothies and popsicles are great choices, but avoid citrus flavors.

I like an over the counter medication called Glyoxide that can be applied by Q-tip to affected areas (if your child lets you anywhere near them!)

For older kids with mouth sores try this:
1/2 teaspoon of Benedryl mixed with
1/2 teaspoon of Maalox
Squirt this mixture around the mouth every 4-6 hours.
Many kids get quite a bit of relief from this.

If you are worried about hydration it is worth having your child seen. A dehydrated child will have very low energy, decreased urine output and not a lot of tears or drool. They seem dry and droopy. As with any case of dehydration, if the oral route is failing, they may need some IV fluids. This is usually done in the emergency room.

If your child is running around, has normal activity level, and reasonably wet diapers, then they are "managing" and I wouldn't be too concerned.

The exposure period for this illness is usually from three days to a week. In other words, if your child was exposed on a Monday, they may start to show symptoms as early as Thursday but if a week goes by without anything happening you are probably out of the woods.

On the other hand, If you child has the illness, they are contagious as long as they still have blisters or a fever and perhaps can shed the virus for a week or two afterwards or longer.

If your child is happy and eating and has no fever but has a few blisters I would try to keep them away from a newborn or someone with a compromised immune system, but it seems excessive to expect you to keep your kids out of daycare if that is the only symptom. My general rule is that if they have a fever and are miserable, keep them home, otherwise let them go about their business.

Things to keep in mind:

  • They are likely contagious before you know they are sick and may have already spread it
  • They got it from somewhere. It is more than likely that someone at daycare already had it and started the spread
  • If you are a careful reader, as I mentioned, they can shed the virus in their stool for weeks!

Unless a school is going to absolutely quarantine every child for a month until they are all clear (which isn’t likely), as much as we would like to keep our daycare and schools virus free I don’t think it is possible, so instead I choose to move forward with as much common sense as possible. Here is my simple rule. Keep your fussy, febrile kids at home. (If you are not up on your Latin, febrile means having a fever)

Siblings are usually going to catch each others stuff. Hopefully the youngest babies won't succumb. Good hand washing is key to avoiding this.

Make sure the shared toys are cleaned frequently. If your child gets this (I should say when, not if) don't freak out. Time will fix it. Think about it as a rite of passage.

Give them something cool and creamy along with a big hug. As always, if you look at them and you are WORRIED (not just feeling sorry for them) call for an evaluation.

The beautiful little lady below is Nurse Kenlee's daughter Gillian. Kenlee assures you that all those lesions completely cleared up.
 

Friday, March 18, 2016

Organizing your crap...I mean treasures

The first thing that people tend to notice when they go into my garage is Brownie the large ugly (...sorry Lauren) paper mache gorilla who has been taking up residence on a high shelf in there for almost 25 years. “Brownie” was created by Lauren’s first grade class. It was part of an enormous class project that ended up on display at a local mall many years ago. When the school year ended there was a drawing to see which lucky student won the right to keep Brownie for ever and ever.

Lauren was the lucky winner. She was beyond delighted. We were horrified. For years, when we would do the occasional garage clean up, she was still not ready to part with him. Now he is simply a large barnacle. He has taken root and we barely notice him unless someone asks the usual "What on earth?..." He is part of the garage.  The garage is full of many other objects that we likely don’t remember we have and don’t really need. Brownie is just the shining example. At least we can manage to fit our cars in (which probably makes ours better than many). To be fair, if my husband was left to his own devices, the garage would be immaculate.

It is always a delicate balance figuring out what to keep and what to toss when you have a budding, prolific artist in your life. You want to value their creativity but there is only so much room on the fridge. Sadly more and more refrigerators are no longer even magnetic!  On a side note, please make sure that your child is given the opportunity to create with real paper. Electronic programs can be amazing with what they can do, but they should not be a substitute for for crayons or water painting. Ceramic, or 3-D artwork is even more of a challenge for storage or display, especially when many folks in SF have limited room.

One of the things I did when my girls were fairly young was to start organizing early, and it is something I am grateful  for. Having a simple plan in advance can be very helpful. If you have room, get a display board for the special pieces, but just like a museum, art gets rotated.

When it is time to make room for new art, what happens to the old stuff?
The choices are recycle (a much kinder word than throwing out,) save, or give as a gift. If something is getting recycled, get it out of sight quickly. You don’t want your kid to find their art crumbled in the trash. For the things worth saving, each child should have one expandable file folder per year for things that are flat. My kids had one folder for each grade, as they got older the things that were saved morphed from art to school papers and projects that were keepers. For Lauren, my actress, that was where we kept programs and newspaper clippings.

The files have limited space. Have your kids be part of the committee that decides what gets saved. At the end of the year we always had a lot of fun going down memory lane by looking through the folders. At that time we were able to do some further culling; not everything needed to be kept.

Another option is to take photos of the art which can be kept in an album or stored digitally. These days art can easily be turned into calendars, mugs, birthday cards  or anything really!

Thinking about giving away some of the special pieces that you don’t need to keep? That is what extended family is for!  Warning, there is always the danger that it will land back in your lap 20 years later. When my husband's parents passed away, there it was, a pile of art done by our kids that had been proudly displayed in their home for years. That art now belongs to us again, and it is keeping Brownie company in the garage.

Friday, March 11, 2016

Lead Exposure (update)

Young children are much more likely to be exposed to lead hazards by touching lead-contaminated surfaces and then putting their hands in their mouths.  In addition, children's bodies absorb more lead than adult bodies do because they are still growing; but lead is a problem for all of us. Pregnant women need to be especially careful because any exposure can harm the unborn babies.

Recent media coverage of water quality issues in Flint, Michigan has brought concerns about lead contamination to many people’s consciousness.

The SF public Utility commission issued this statement on 2/1/2016:

The primary cause of the water quality concerns in Flint appears to have been a failure to maintain corrosion control – a basic principle of water delivery (after disinfection/treatment). In San Francisco, we have been a model utility in lead abatement for decades. All lead pipes and service lines were removed from the San Francisco retail service area over 2 decades ago. The San Francisco Water Department replaced more than 7000 lead service lines in the 1980s.
We discontinued the use of lead joints in our distribution system. We began lead monitoring in 1992 (in adherence with the Lead & Copper Rule, one of the US EPA’s National Primary Drinking Water Regulations.) Sometimes minor fittings or joints with some lead materials are discovered in older parts of our system; when discovered they are replaced. Our excellent corrosion control practices eliminate any exposure to these minor lead surfaces. San Francisco’s corrosion control practices are optimized to minimize the potential for lead contamination.

According to the very  helpful Karen at the Childhood Lead Prevention Program here in SF, new brass fixtures can actually be more of a problem than the old pipes. Even if the new fixtures claim to be lead free, it is possible for some lead to get into the water. It is important to  run the water for a moment to eliminate any water that had been stored in the pipes.

If you want to go the extra mile and get your water tested, in San Francisco, it is free for anyone on the WIC program. Contact the lead program for a voucher. For everyone else it is $25/tap. Click the link for directions :


There are also some products for testing water available from Amazon, but they have mixed reviews.

If you are not lucky enough to live in a place with safe water, consider getting a filter that is tested to remove lead. Boiling water will NOT remove lead.
Make sure that if your child is getting only filtered water that they are getting necessary flouride.

Pipes and water are only one of the many places where kids can possibly get exposed. Most of the lead gets into your child from the hand to mouth route. They either chew on something directly, or put hands that have been in contact with lead dust into their mouths.

Other Common Sources can include:

*paint chips. (House built before 1978 are most at risk)

pipes 
Only use cold water for cooking, drinking or making baby formula because hot water is more likely to contain higher lead levels. If you haven't used a faucet in the last six hours, flush it out for one to two minutes before drinking or cooking with it. The longer water has been sitting in the pipes, the more lead it can absorb. Use the initial water for watering plants or ......

*keys (don't let your child chew on them)

*Brightly painted pottery or toys 
Beware of things imported from different countries The brighter the color, the more apt they are to have lead. It's hard to be absolutely sure if a toy has lead in it or not. Start by checking www.recalls.gov to see if a specific toy has been recalled.

Be wary of cheaper toys -- like those from vending machines or street fairs -- and especially plastic jewelry. If you notice that your child is putting a toy in her mouth frequently and you're not absolutely sure it's lead-free, take it away. To lower the risks of poisoning, make sure that your child is playing with age-appropriate toys that he's not at risk of swallowing.

*Antique furniture varnish

*Varnish on bathtubs

*Some lipstick brands

*Some candies imported from other countries

*some computer cables (of course chewing on cables is not a good idea no matter what)

*Dirt and sand that get tracked in from outdoors

*urban gardening (increases contact with possibly contaminated soil)

*Ayurvedic medicine



*Pre 1997 imported vinyl blinds

Unfortunately in our current world, many of us live in environments where our kids are in fact getting some lead exposure. Lead does not break down or fade away with time. It remains in the environment and we are stuck dealing with bad habits from the past.

It is worth getting your child tested. In our office we usually suggest a blood test at either the 9 month, 12 month or 15 month exam depending on the circumstances (if there are obvious hazards we test on the earlier side.) I suggest coupling the lead test with a routine CBC (complete blood count) that also tests the iron level.
It is easy for everyone to get sidetracked at some of the the well child exams. There are so many things to talk about and sometime the kids are kicking up a bit of a ruckus towards the end of the visit. If the doctor doesn't bring up the subject off getting a blood test, feel free to remind them. 

When we get the lead results, the best news is <2 or undetectable. In past years the public health department's lead prevention program would get involved if the level was over 10 but as of 2016 the standards have changed. Now, NO measurable level is considered okay. If there is some lead showing up, we want to figure out where it is coming from and keep that level from getting higher. If your child in San Francisco has any elevated lead level the city will send out a public health nurse to help you explore your environment and see if they can figure out the source.

For reference a level over 45 is an urgent situation that needs treatment.

This link gives a full description of what the different levels signify:
Prevention is the best defense!

A nutritious diet is VERY important. Iron, calcium and Vitamin C compete with lead for absorption. Healthy eating should be considered a first line of defense.

Consider having a 'shoes off' policy to avoid tracking lead dust inside. This is especially important if someone in the household has routine lead exposure during their job; make sure they clean off well before having close contact with other family members.

Make sure your kids get in the habit of frequent hand washing, especially before meals and snacks

Do the best you can to make sure there are no obvious lead sources inside your home. Any home built prior to 1979 is at greater risk. If you have an older house with any peeling paint, make sure that cribs and high chairs are moved away from walls.

There are some home testing kits that check paint for lead, but they are often misused. The easiest paint to test is that on wood or varnish. In order to get an accurate result, you need to scratch the surface and mix the test liquid with more powdery paint. I don't have a favorite brand. 

If you have any concerns about your home, regardless of whether or not your child has been tested for lead, call the SF lead program to arrange a public health nurse visit. The easiest way is to call 311 and ask for the lead prevention program.

Friday, March 4, 2016

Super Lice

I recently saw the headline about super lice and shuddered. As if regular lice weren’t bad enough! Things have changed in the past several years since I wrote my old head lice post. The bad news is that lice are even more resistant to the over the counter medications. On the positive side, there are some more resources available to help you out than there were several years ago.

Diagnosis: Learning that your child has head lice can be incredibly aggravating. Trust me I know. You might be suspicious because your child is scratching their head or you may have gotten a call from school that your child was exposed. It is rare to actually see the live lice crawling around, although I was once measuring a child's height and there was actually a halo of lice crawling all over her head...ugh. Not everyone gets itchy, Your child might be crawling with them and never give a clue.

Once a person gets head lice, the mature or adult head lice can lay up to 10 eggs or nits each day. These nits, or lice eggs, hatch in about 7 to 12 days. Baby lice or nymphs are about the size of a pinhead when they hatch, and quickly mature into adult lice in about 9 to 12 days. Lice don't like light and they move very quickly, therefore the diagnosis is often made by finding the nits.  One site claims that the average speed of a louse is 3.75 inches per minute. This is equivalent to 18.75 feet in one hour, and approximately 450 feet per day. This is over the length of one football field!
The nits are small white, opaque or tan specks that adhere tightly to the hair shaft. If you flick something and it floats away, it may just be dandruff. The nits are usually close to the scalp. If they are further up the hair shaft, likely they have been around awhile undetected.

Check your child's head in a methodical manner, paying special attention to the areas behind the ears, the nape of the neck and the crown. Make sure you are in a well lit area. Remember that if one person in the family is infested, you should check everyone. You may actually be able to feel a nit on your own hair; it will feel like a tiny little knot.
 
If you have found some bug or nits, it is time to treat. You have several options
 
My old post had a several step protocol for using the over the counter medication.  It started by using a strong stripping shampoo such as Prell followed by a 30 minute application of Nix. Due to resistant bugs even then, we followed up several days later with cetaphil, olive oil or mayonnaise left on for several hours to suffocate them. The final step for kids who were old enough was to sizzle any survivors with a hair straightening flat iron. Poison, Suffocate, Sizzle.

If you are really pinching pennies, that method is still probably marginally cheaper than getting a prescription but not all that much. Although I would occasionally get calls asking for a prescription to be phoned in, my suggestions, if followed to the letter, seemed to work well. For historical purposes here is the link to my old post:


I had reasonably good success, but the lice have only gotten more and more resistant. It feels like a waste of time to even bother with the Nix
If you do opt to tackle the treatment yourself, I think that your easiest option is Sklice. Sklice is a lice treatment that has been on the market for several years. The key factor is that the super lice are NOT resistant to Sklice yet. This treatment is available only with a prescription. Sklice is fairly non-toxic. It is the only FDA approved drug that contains Ivermectin.  Ivermectin has  been used as an oral medication to treat river blindness in millions of patients. To treat lice, it is applied topically and left on for ten minutes. It is approved down to 6 months of age. The cost will vary depending on your insurance plan. As of March 2016 you can go to www.sklice.com for a $10 copay coupon.
This website will give you all the directions that you need along with other useful lice info. With the copay assistance, your out of pocket price may not be more than $40.
 
Sklice directions claim that you don't need to do any nit combing after the treatment. One tube/one ten minute treatment. Even folks with lots of hair just need to use the one tube. I have asked the Noe Valley Walgreen's to keep it in stock. 450 Sutter Pharmacy also tries to always have it on hand and they deliver.
 
If you opt to hand off the responsibility and hassle and money is no object, there are companies that will do the treatment and the nit removal for you.
 
Hair Fairies has been taking care of head lice for nearly two decades. There are eight locations nationwide. We are lucky enough to have several in the Bay Area. Our closest location is probably the salon on Fillmore street here in the city:415-292-5900.
 
Folks who have used them have nothing but good things to report. The fee is based on the time it takes to pick all the nits. The cost can add up, but many parents are so happy to have someone else do this for them, that they feel it is a worthwhile expense.
 
Maria Botham, the president and CEO says:

"We’ve dedicated ourselves to understanding head lice and getting rid of them. We use that expert knowledge to develop safe, mild, clinically proven head lice removal products and techniques — and, ultimately, to bring confidence and peace of mind to families like yours. Each situation, each child and family is special, so we treat you that way. Our skilled technicians are professional and personable, our salons reassuring and fun. And, simply put, our products work! We use them in our salons every day. That’s why families, healthcare professionals, schools and camps around the country trust Hair Fairies to get rid of head lice. It’s a responsibility we take seriously. So many parents tell us they’ve spent hundreds of dollars and countless hours trying over-the-counter products that claim to get rid of head lice but don’t. All while their child is miserable. Hair Fairies is the better choice — economically and emotionally. If your family encounters head lice, take a deep breath. Stay calm. Hair Fairies is by your side."
 
Tell them that Nurse Judy sent you for a free head check.  If head lice or nits are found, the NURSE JUDY promo will get you 20% off your first treatment. For the record, I receive nothing in return for my recommendation of this or any other product that appears in my blog.
 
If you don’t want to leave home, Bug-A-Lugz is another great service.

 http://www.bugalugz.com or call 415-574-8198. Sharon, the owner, founded the company in 2008. They use all natural and organic products. They service many of the local schools and preschools in the Bay Area. There is a $10 travel fee and a $35 cost for head checks. If lice are found, that $35 is applied to the treatment. Each treatment is $100/ person. They recommend two treatments. There is a 30 day guarantee.
 
Both Hair Fairies and Bug-A-Lugz will furnish you with a form to bring to your doctor for a signature. Some insurance may reimburse for these services.
 
Clean up: Sadly, getting rid of the bugs is probably the easiest step. It is essential to make sure you eliminate any lurking lice in your house (and car) that are waiting to crawl right back into your treated hair.
 
Wash sheets and pillow cases for the first two days after treatment. Wash towels, recently worn clothing and any hats or hoods that have been in contact with the lice. (Sometimes a trip to a Laundromat that has the big dryers and lots of machines can help you take care of the clean up more efficiently.) Items that can not be washed should be dry cleaned, put in a hot dryer for at least 30 minutes or placed in a ziplock bag in the freezer for 24 hours. Sealing items in an airtight bag for several weeks is also a common recommendation, but may not be reliable. Combs and brushes should be cleaned by soaking in hot water (about 130*F) for 10 minutes. All rooms and furniture, including car seat should be vacuumed. I have never been a fan of the pesticide sprays, but I am intrigued by the non toxic versions that are now on the market.
 
Hair Fairies has an all natural lice repellent spray that folks swear by for spritzing around all the areas that could have infested. This can help with all of your non-washables such as hats, carpets, couches and car seats. Maria the owner says that some folks even take the spray with them on airplanes (great idea!)
 
Prevention: Lice do not jump or fly. Since they travel by crawling, it is important that your children learn not to share brushes, hats, hair bows or headphones. Crowded coat racks are a good way to catch them. Teach them to hang their coats separately. If your child is in a class or daycare with a lice outbreak, talk about eliminating any dress up boxes. If you child has long hair, pull it back into ponytail or braids to minimize the risk. Although it is unproven, some people say that washing the hair on a routine basis with tea tree oil shampoo or vinegar rinses may act as a prevention.

Both Hair Fairies and Bug-A-Lugz have special shampoos that they sell as part of the practice that can be used preventatively.
 
Remember that lice do not care about family income, education, lifestyle or cleanliness. 10 million Americans are infested each year.

Pets do not transmit or carry human lice.
 
*****
 
As icky as lice are, it is important to keep one’s sense of humor. There are worse things out there, really. Years ago I had come across an article equating the “stages” of dealing with lice to the Elizabeth Kubler Ross stages of grieving. Thanks to the wonders of the internet I was able to dig it out of cyberspace:

 
If this post made you itchy just reading it, trust me,  I have been scratching my head all week.