Wednesday, April 27, 2016

After hours/Urgent care options

Ideally I would recommend that everyone has a primary doctor for their children. Having a provider who knows your child when they are well can help affect decisions and treatment plans when they are dealing with an illness. Continuity is a real plus.
However, Murphy's Law generally seems to make certain that fever spikes  or the vomiting starts right at 5:01 pm when average doctor's office turn their phones off. While it is true that the Noe Valley Pediatrics advice nurses have the quirky but endearing habit of checking emails at all sorts of odd times when the office is closed, you can NOT count on reaching us and getting a response. Emails should never ever ever (can you tell I really mean it?) be the avenue you choose if you have an urgent matter.

One of the things that all people should make sure they are familiar with is their options for medical care after hours. Waiting until you or your child is ill is not the best time to start exploring your options. Do it now.  Does your insurance plan have a preferred option that won’t cost as much? Are there after hours advice nurses available? Where is the closest emergency room? Is it staffed with pediatricians? If you are traveling, plan ahead and figure out local options for care before the trip.

Here in the San Francisco Bay Area we have been lucky to have very good options for after hours care.

The original after hours care is the Pediatric Evening Referral Clinic run by the Physicians Choice Medical Group.

They used to be right near the CPMC California Campus ER. When they moved to the new location they also affiliated with UCSF.

The PERC clinic currently has two locations:

  • In San Francisco 3490 California Street, Suite 200    415-387-9293 
  • In Oakland  5700 Telegraph Ave #100 in Oakland     510-486-8344   

Patients are seen by  appointment:

Monday through Friday 6:00 pm - 9:30 pm,
Saturday, Sunday and holidays 8:30 am -9:30 pm

Weeknight pediatricians are made up of participating private pediatricians, including several of our doctors. Weekend doctors are fully trained and board certified pediatricians.

On weekdays the phone lines turn on at 5 pm. There is an advice nurse triage team that is available through the night, even after the clinic is closed.

As of April 2016, our patients have new after hours options that is closer for many of our patients living on the south side of town:

The Pediatrics After Hours Care at St Luke’s Hospital is affiliated with Sutter/ CPMC and is located at 1580 Valencia Street, 7th Floor #701

It is now open 7 days a week.
Monday-Friday 5:00pm-10:00pm
Saturday-Sunday 8:30am-10:00pm
Phone: 866-961-8588

This service does not currently have an advice nurse team, but the person answering the phone can help do some basic triage and help direct you to an emergency room if that is a better option. This new clinic has some other advantages besides the convenient location. They start the scheduling process as early as 2 pm, which may make it easier to make a plan if we are already solidly booked up here in our office and can’t get you in that day. They also offer weekend weight and bilirubin checks for our newborns. As a bonus, there is a special waiting area so that the healthy newborns aren’t exposed to the other sick kids.

When things are going as they should, both of the above after hours options send a report to your primary doctor's office. In our office, the nurse team reviews the reports and follows up to see how you are doing to maintain a sense of continuity.

If you are not in San Francisco, is a good option at 210 Baldwin Ave in San Mateo. Telephone 650-579-6581

This is a pediatric Urgent care facility and no appointment needed.

The Palo Alto Medical Foundation has several pediatric urgent care options:

They have a choice of appointment or drop in. The website gives info about the various locations and current wait times.

In Marin
Greenbrae Pediatric After hours clinic

1260 S Eliseo Drive Floor 2
Green brae CA
6:30 pm-9:30 pm Monday through Friday
9:00 am-9:00 pm Weekends and Holidays

There are plenty of general urgent care places popping up all over the place as well. Keep in mind, that with most urgent cares, there is no such thing as an appointment and folks just show up and get seen in the order that they come in. There is risk for a much longer wait. They are also not usually staffed with pediatricians. For a teen, this is usually not much of an issue, but for my younger kids, I would try to stick with one of the pediatric after hours clinics. If you do end up at another urgent care, please ask them to send over a report so that we stay in the loop.

Emergency Rooms
In a true emergency of course call 911. If it is less urgent, but you are certain that you child needs immediate medical attention we are lucky to have excellent options here in SF.

When given the choice I will generally opt for one of the true pediatric emergency rooms. You are not competing for care with the elderly heart attack and stroke victims that may be populating the waiting room and getting ranked higher on the triage scale. You will also be assured of seeing a pediatrician and having appropriate pediatric equipment. If an admission is needed, my preference would be either CPMC California campus or UCSF Mission Bay, so there also won’t be any transport needed if you are already at one of those ERs. I think it is worth the extra ten minute drive across town and may save you time in the long run.

The UCSF Pediatric ER in Mission Bay is located at 1975 Fourth Street:

This emergency room has scored very high in a nationwide ranking for getting patients seen in a timely manner.

CPMC pediatric emergency room is located at 3700 California Street/ at Cherry:

 Home visits
Some of my patients have used and had a doc do a house call within a few hours. They were very pleased with the entire system.

Saturday, April 23, 2016

Nurse Jen blogs about Probiotics

My 11 year old daughter recently laughed at the number of supplements I now set before her at mealtimes: Vitamin D (like many Americans, she is low) Magnesium (she has trouble sleeping) and Omega-3s (she hates “anything from the sea”) just to name a few! So I hesitated adding probiotics to the list because I’m concerned at what I am teaching her as she heads into puberty. Are supplements important building blocks for your body? Or does it not really matter what you eat because there is a pill for everything? The world of probiotics is overwhelming and confusing, it’s been a hot health topic in recent years and it’s still evolving. I’ve attempted to synthesize some of the research below, I hope it helps you make your own educated decision about probiotics and their role in your family’s health.

For recommended brands jump down to the end of the article.

What is going on in my gut?
An estimated 100 trillion microorganisms representing more than 500 different species inhabit every normal, healthy bowel. These microorganisms (or microflora) generally don’t make us sick; most are actually helpful. Gut-dwelling bacteria do a lot to help us - they keep pathogens (harmful microorganisms) in check, aid digestion and nutrient absorption, and contribute to our immune function.

So it makes sense that we’d start supplementing! Data from a 2012 National Health Interview Survey (NHIS) show that about 4 million (1.6 percent) U.S. adults had used probiotics or prebiotics in the past 30 days. Among adults, probiotics or prebiotics were the third most commonly used dietary supplement other than vitamins and minerals, and the use of probiotics quadrupled between 2007 and 2012. The 2012 NHIS also showed that 300,000 children age 4 to 17 (0.5 percent) had used probiotics or prebiotics in the 30 days before the survey.

Breast milk is naturally full of both probiotics and prebiotics. So it’s not surprising that companies started adding both to infant formula. This introduction is designed to mimic breast milk and promote both a balance of bacteria in baby's intestines as well as offset the growth of "unfriendly" organisms that could cause infections and inflammation.

What are pre and probiotics?
The word ‘probiotic’ means ‘for life.’ It refers to an oral supplement or a food product that contains enough microorganisms to alter the microflora of the host - your digestive tract. The microorganisms we’re talking about are typically Lactobacillus and Bifidobacterium. Their innate biological features essentially allow them to dominate and overcome potentially pathogenic microorganisms in your digestive tract.

A ‘prebiotic’ is a  nondigestible food ingredient that benefits your body by selectively stimulating the growth and activity of probiotic bacteria. Although indigestible by humans, prebiotics in the digestive system enhance the growth of certain probiotic bacteria in the colon, especially Bifidobacteria species. Think of prebiotics as food allowing probiotics to thrive.

Possible Health Benefits of Probiotics
The best case for probiotic therapy has been in the treatment of diarrhea. Research has shown that Lactobacillus and Bifidobacterium are promising in preventing and/or effectively treating disorders such as acute infectious diarrhea, traveler’s diarrhea, and antibiotic-associated diarrhea as well upper respiratory infections. Other possible health benefits are being studied as well, including whether probiotics can lower your child's risk of food-related allergies and asthma, treat eczema, prevent urinary tract infections and dental caries and even improve the symptoms of infant colic. Proposed future studies include the treatment of rheumatoid arthritis, irritable bowel syndrome, diabetes and cancer prevention.

Until more research is done, probiotics should not be given to children who are seriously or chronically ill until the safety of administration has been established.

Acute Infectious Diarrhea
Research has indicated that there is a modest benefit of giving probiotics in preventing acute gastrointestinal tract infections (the typical ‘tummy bug’) in healthy infants and children. There seems to be stronger evidence to support the use of probiotics, specifically Lactobacillus GG (LGG - the most effective probiotic reported to date ) early in the course to treat diarrhea, reducing the number of diarrheal stools and the duration of the diarrhea by approximately 1 day. Probiotics are most helpful for otherwise healthy infants and young children with watery diarrhea related to viral but not bacterial infections. LGG is thought to be particularly effective in rotavirus diarrhea.

With diarrhea, the main risk to health is dehydration and so our management aims to improve and maintain hydration. However, rehydration fluids like Pedialyte and coconut water don’t reduce the stool volume or shorten the episode of diarrhea. Research has shown that probiotics do. The rationale for using probiotics in infectious diarrhea is that they act against pathogens by competing for available nutrients and binding sites, making the gut contents acid, producing a variety of chemicals, and increasing immune responses. As "friendly" bacteria, probiotics improve health and are not harmful in themselves.

Overall, probiotics reduced the duration of diarrhea by around 25 hours, the risk of diarrhea lasting four or more days by 59% and resulted in about one fewer diarrheal stool on day 2 after the intervention. I’d say it’s worth trying the next time my kids get diarrhea.

Traveler’s Diarrhea
The NVP nurses often get calls from concerned parents in advance of travel to places like Mexico and India. Parents want to know how to best prepare for taking their little ones to countries where visitors are likely to pick up a GI illness. Beginning probiotics about a week before you leave is a great idea, says Ashley Hathaway, Certified Nutritional Therapist and Certified GAPS Practitioner with a special emphasis on gastrointestinal health. “Boosting immune function will help prepare your body to fight off those unfamiliar micro-organisms found in food and water. The probiotics will add an extra layer of protection to populate the gut with more beneficial bacteria.” She advises everyone in the family begin a high quality, refrigerated probiotic supplement a week ahead of departure, as well as packing one you can bring along with you on your trip.

Antibiotic-Associated Diarrhea
Research of probiotic use in the prevention of antibiotic-associated diarrhea in children also indicates a beneficial effect. In most of these studies, probiotics were started when antibiotic therapy was prescribed for an ear infection. Treatment with probiotics compared with placebo reduced the risk of developing antibiotic-associated diarrhea from 28.5% to 11.9%. Approximately 1 in 7 cases of antibiotic-associated diarrhea was prevented by the use of a probiotic. Children in these studies received either a probiotic supplemented formula or a separate probiotic as preventive treatment. Thus, probiotics can be used to reduce the incidence of antibiotic-associated diarrhea. Again, if my kids ever need antibiotics, I will supplement them with probiotics (preferably on an empty stomach at a different time I give the antibiotic for maximum effect.)

There have been no published research trials of children that have investigated the effect of probiotics for treatment of antibiotic-associated diarrhea.

Upper respiratory tract infections (URTI)
Upper respiratory tract infections (URTIs) include the common cold and inflammation of the trachea and larynx, with symptoms including fever, cough, pain and headaches. Most acute URTIs are caused by viral infections and usually resolve after three to seven days.

Probiotics were found to be better than placebo in reducing the number of participants experiencing episodes of acute URTI by about 47% and the duration of an episode of acute URTI by about 1.89 days. Probiotics may even slightly reduce antibiotic use and cold-related school absence. However, their effects in preventing URTIs are still poorly understood. Side effects of probiotics were minor and gastrointestinal symptoms were the most common. With these numbers though, I’m inclined to try probiotics for colds as well.

Dosage and Diet
So how do we dose when we’re talking about billions of bacteria? It’s vague, so the best guidance we have is to follow the dosage on the package and use baby formula for babies, children formula for kids, and adult formula for adults. For babies under 3 months, talk to your doctor before giving probiotics. Although I plan to use probiotic supplements during an illness and in advance of travel, when it comes to daily maintenance, I am personally inclined to forgo probiotic supplements and make adjustments to our family’s diet.

Fermenting foods to enhance their taste and nutritional value is an ancient and widespread practice. Although the term probiotics is relatively recent, as are science-based investigations, the use of probiotic containing fermented foods in many cultures of the world predates the advent of refrigeration. The applied notion of improving health by supplementing the natural microflora of the human intestines with additional bacteria taken by mouth actually goes back to the late nineteenth century.

Foods such as raw fermented pickles, raw sauerkraut, kimchee, kombucha, milk or coconut kefir, homemade yogurt, fermented relish and raw milk cheese will all add healthy, potentially pathogen fighting bacteria to the gut in place of supplements. When it comes to kid foods, why not add some of these fermented and cultured foods to our kids’ plates? Nutritionist Ashley Hathaway, owner of SF Nutritional Therapy, recently added a spoonful of beet sauerkraut to my kids’ scrambled eggs and guess what… of my kids ate it and liked it! Try some of her recipes (link below) and see what your kids think.

Overall, probiotics appear to be here to stay as part of the physician's armamentarium for the prevention and treatment of disease; but more evidence-based research is required.

Recommended brands
Aim to give probiotics first thing in the morning before eating breakfast and away from hot liquids such as tea or coffee. This will enhance their absorption. Refrigerated probiotics are generally a higher quality than those found on the shelf. Common brands such as Culturelle Kids, Florajen 4 Kids and Gerber Soothe colic drops are fine but also include unnecessary additives like maltodextrin (Culturelle and Florajen) and sunflower oil and triglyderide oil (Gerber.)   Ashley says “Probiotics do not need added ingredients to be effective. Often a sugar source (maltodextrin for example) or a water soluble fiber source (inulin) will be added to provide ‘food’ for the bacteria - otherwise known as a prebiotic. Although these added ingredients may help the bacteria survive in the digestive tract, they aren’t required for the probiotic to be effective, and some can be undesirable for other aspects of health.”

Maltodextrin seems to be a common additive to probiotic supplements so I asked Ashley to explain why we might want to avoid it. She says “Maltodextrin is an artificial sugar used as an inexpensive food additive. It has a high glycemic index, which means it can spike blood sugar. Some recent studies found that maltodextrin promoted the growth of unhealthy bacteria within the GI tract, which seems quite counterintuitive to taking a probiotic!  In addition, it can have similar side effects and health risks as most food additives. These side effects include allergic reactions, unexplained weight gain, bloating and flatulence.” She strongly recommends seeking out supplements that do not include maltodextrin.

Below are links to some top rated brands for kids, starting with some of Ashley’s favorites:




Top rated brands:

For those with dairy sensitivities, there are dairy-free brands such as Florajen 4 Kids, Rainbow Light Probiolicious, Floratummies, and Kyo-Dophilus.

PS from Nurse Judy.

More and more, I am starting to include probiotics on my list of suggestions for a myriad of issues. I have found them to be very helpful, especially for my patients with acute tummy bugs. I have also been offering up some Gerber Soothe for young colicky babies. I had some free samples to hand out and I am getting good reports.

If you have a probiotic that has been working for you, feel free to stick with it. There are lots of good brands out there. If you have a young baby who is getting one of the probiotics in powder form, you can mix it with a bit of breast milk, apply that to your nipple and have the baby nurse it off.

Friday, April 15, 2016

Fostering a good sibling relationship

Imagine your partner says to you, "Honey, I really love you. You are one of the most important people in my life. Please don't be concerned that a younger, very cute person will be spending a lot of time with me. They will possibly be sleeping with me in my bed for a while. There may be some sucking on my breast."


The oldest child was the center of the world for a time. Moving over to make room for a new member of the family isn't always easy.

Some big brothers and sisters are actually eagerly expecting the baby's arrival. Others are too young to really understand what is going on. Regardless, there is a big adjustment to be made. Many parents report that the older siblings are quite sweet to the baby, but act out horribly to the parents. Once in a while, but less often they will also act out towards the baby. Nurse Jen remembers the time that her oldest daughter dropped a medicine ball on her new sister. Others have no malice but don't have a sense of how to be gentle.

Below are some suggestions that may help ease the transition.

Do some gentle preparation by including books about new babies among your reading choices. Please keep reading other favorites that have nothing to do with a new baby as well.

Once the baby has arrived give your older child  plenty of opportunity to talk about what if feels like to have a baby in the house. Validate that it is very normal for the big sister/brothers to sometimes feel mad, sad or aggravated (kids might feel guilty about the way they are feeling.) Many children need to be told that the new brother or sister is here to stay as a part of the family. Sending the baby back in not an option.

Have the new baby come along bearing a gift for the big sibling. I am not sure what the age cut off for getting away with this is. Lauren was a remarkably clever almost 3 year old when Alana came along. Never the less, when we gave her a little present from her baby sister, she accepted it without question. She was delighted and was quite pleased with the very thoughtful baby.

Some big siblings feel very important if you let them be "helpers". Find some safe baby related tasks for them to assist you with.

The most  important tip of all is to make sure that you carve out one on one time with the older child. Often they are craving mom right now. If mommy is breast feeding, make sure that in between feedings she hands the baby off to the other parent or support system for burping, diaper changes, etc. and make a fuss about having "special big boy/girl time." Nurse Jen says that lots of people gave her this advice but she didn't realize that having a sleeping baby in a sling doesn't count. She wanted me to make sure to add that if you are holding the baby, it doesn't count as the "one on one" time.

As your kids get older, the oldest child will always feel a bit entitled to some solo time.

If you can manage it, take just one child with you on routine errands and turn them into adventures. Perhaps you can have only one child at a time allowed to "help" with a meal. Even a walk around the block or some special time at bedtime makes a difference. Try to make sure that each parent gets special time with each kid.

Once the second child comes along you will feel like simple math no longer adds up. One plus one must surely equal five. You will manage to find the balance, but those first few months are challenging to say the least.

With the first child you had the luxury of focusing on schedules and nap time as if they were set in stone. Unless you are remarkably lucky or hire someone, a true schedule doesn't really exist with this second child. Naps? Maybe while you are driving from here to there. (Somehow these second and third children muddle through.)

Do your remember how careful you were with the first one? You avoided crowds and made sure that no one came around if they weren't completely healthy. The new baby will simply be developing that immune system a bit earlier. There is almost no avoiding it, unless you never go out and you quarantine your older child to an unreasonable degree. Second kids get exposed to things quite a bit sooner. (They survive.)

I do like to make the big siblings the deputies of the Hand Washing Patrol. Have Purell around (you can also get the kind that is alcohol free;) Call it magic soap. Tell your deputy that they are in charge of making sure that anyone who is going to touch the baby cleans their hands first. This may help make sure that they don't feel like they are constantly being nagged at.

One more important thing to keep in mind is that all of your kids will reach their milestones on their own timeline. It doesn't pay to compare them to each other or to the other kids in the play group. My baby Alana, for the record, doesn't mind when I use her as an example. She is graduating with a Masters from the University of Michigan in just a few weeks. She is a super star all around, but goodness was she slow starting out.

Talking: Lauren was singing Rogers and Hammerstein musicals at a remarkably young age. She not only knew the lyrics, but she sang them in tune. (I have video proof of this.) Alana barely had ten articulate words before she was two. Lauren would translate for her and act surprised that we didn't know that  "gbabpgpsmp" meant, "I want popcorn please."

Walking: Lauren took her first steps at a year. Alana waited until she was about 16 months and then carried a chair across the room within a day of mastering walking.

Toilet training: Lauren was an early 15 months. Alana had no interest until she was 3. I thought we were going to have to buy depends.

They will all get there.

Siblings will have days when they are best friends and days when they torture each other. My older sister and I were fast friends until 4:00 pm like clockwork every day when she started to pull my hair while saying "Jeep Jeep". My husband was tortured by his older sister until his early teens! My daughters interspersed periods of intense closeness with periods of mild bickering.

If you can avoid it, try not to be the judge and jury. See if you can let them work out mild skirmishes.
Observational statements can be fairly effective. " I see two girls who are having a hard time sharing."

Teach your children the very important tool called 'Walking away power'. If they are having trouble with a sibling, leaving the room is a better choice than whacking them.

Fast forward 20 years:
My family was on a cruise, savoring time together. We were in Cozumel. My husband Sandy was off on a real dive, while the girls and I went Snuba diving. Snuba is a combination of Scuba and snorkeling. With Snuba you breathe through a 30 foot tube that is connected to an oxygen source the floats along the surface. My daughters were swimming along the ocean floor. I was about 10 yards above them watching them animatedly communicate with each other through hand gestures and some signing. I remember proudly thinking...look at my daughters. They are both intelligent, funny, kind and lovely. See how well they can communicate in that secret language that siblings share. I love them so much. I am so glad they have each other and that they have gotten so close as they have gotten older. Our time was up and the guide gestured to all of us that it was time to go up to the surface. They removed the mouth pieces and.......the fight continued:

"You were getting tangled in my hose"
"You were kicking too hard and making too many bubbles"  and so on.
A mom can dream......

This post has been updated from one that I ran several years ago. I think that we could possibly get through a snuba excursion in peace, although Lauren has since gotten her actual Scuba licence. The sisters are incredibly close and relish time together (which is all too rare.) I still marvel over how different they are. Lauren and her dad will be climbing Mt. Kilimanjaro this summer. Alana and I will find ourselves a nice spa or cafe somewhere..

Friday, April 8, 2016

Tick Bites:Prevention and Action Plan (update)

Ah, the twisted thinking of an advice nurse. For most folks, spring brings to mind warmer weather, longer days, lovely flowers etc. Me? I think,"Here comes tick season."  Nurse Lainey found one on her own ear just this week. She considered getting rid of her dogs immediately, but they are too cute, so they get to stay.

Indeed the calls are already coming in and I have spoken to a half dozen patients about tick bites just this week. It makes sense. With the nicer weather more of my patients are out there taking walks, hiking and enjoying the beautiful area that we live in. I think the extra rain this season has contributed to some early tick sightings. Ticks can be an issue all year long, but the nymphs are born in the spring. These tiny little ticks are the ones most likely to transmit diseases. Of the many varieties of ticks out there, the ones responsible for the majority of  disease transmission are the deer ticks. If you want to impress folks at your next cocktail party, our local deer tick is officially identified as the ixodes pacificus.

Although only a small percentage of tick bites are harmful, the diseases can have a major health impact, so we need to pay attention. There are multiple types of bacteria responsible for tick borne illnesses. In fact, this year a new one was discovered in Minnesota, Wisconsin and North Dakota. Ticks here in California are known to transmit several different diseases, including Lyme. There are many conflicting reports, but recent studies coming out the past couple of  years suggest that the rates for tick borne diseases are  higher in California than previously thought.

Check out this little tick Guide:

The key is prevention.

If you are going to be walking or hiking in densely wooded areas try to stay in the middle of the path. Avoid wood piles and logs. Light colored long sleeves and long pants are recommended. Spray the clothing with the bug repellent Permethrin. This is okay for anyone over 2 months of age. Use Deet on exposed skin, avoiding hands, eyes, and mouth.

But let's face it, on a hot day we are not going to have our bodies covered completely, so here is the deal....

Everyone needs to get a naked head-to-toe body check after a walk in the woods. If you are camping, do a full body check daily. Ticks can hide in out of the way places on your body. Don't forget to check the scalp. If you are dealing with thick darker hair, you can rub your fingertips along the scalp and feel for any bumps. Check in between the fingers,toes and behind the ears. Check armpits and belly buttons as well. You really need to be very thorough. Many of the ticks are very tiny and hard to see. Be familiar with little moles and freckles so you can recognize a new spot which might be a little tick.

If you are returning to your home after a hike, take all clothing and put everything in a hot dryer for 60 minutes to kill any wandering ticks. Don’t forget to check the car seat!

It is very important to remove the tick as quickly as possible. If a tick is removed within 4 hours of the bite, the chances of any disease transmission are SIGNIFICANTLY decreased. For Lyme disease, the tick generally needs to be attached for more than 24 hours to be a concern.

If you do find a tick, please stay calm. I can still remember vividly, years ago, a mom carrying her toddler into the office screaming (the mom, not the kid) "HELP ME GET THIS THING OUT OF MY BABY!"  Hey, arachnophobia is appropriate in this case, because ticks are indeed arachnids (the spider family), but put on a brave face for your child.

The best way to remove a tick is with tweezers or a special tick removing tool. Grasp the tick as close to the skin as you can and firmly pull up and away. Do not twist. The Public Health department councils that you should not try any of the folk remedies such as Vaseline, burning match.. etc. If you own a dog or go hiking frequently, do yourself a favor and get one of the tick removing tools. You can get them pretty cheaply from any sporting good or pet store. Amazon has a ton of different brands. I do not have a favorite (or you can do what Nurse Lainey did, which is just give a loud #@%$ and yank it off.)

Once the tick is out, clean the area with an antiseptic soap, apply a dab of Neosporin and then keep watch on the area to make sure there is no infection.

Okay, We got a tick bite. We removed it, but now what???   

  • watch the site for sign of local infection

  • observe for 30 days, If there is any odd rash, flu like illness, aches, or fever it is important to notify your doctor. We will want to know the date of the bite, and if possible the region where the tick came from. Any recent travels could provide important data.

Unfortunately the blood tests for tick borne diseases such as Lyme are initially not all that helpful. To start off with, you can get both false positive and false negative results (making it pretty useless.)  It turns out that once you have symptoms several weeks after the bite, the tests for Lyme are apt to be more accurate, but that isn't all that useful right after the tick encounter when we are trying to decide whether or not to treat.

Rather than testing the patient, I would focus on the tick. If you do a lot of hiking, keep a little baggy in a pocket of a backpack or diaper bag so that you have a place to stick any ticks that you remove.  

The Sonoma County Health Department will identify the tick for free to see if it is the type you need to be worried about. They will also take it a step further and test it for Lyme disease. They charge a  fee of $31 (such a deal.) They don't test the ticks for other illnesses. They do the testing every Thursday and they will have the results by Friday. They say that about 1-3% of the ticks test positive.
Read the instructions on their website for how to send the tick

As many of you have heard me say time and time again, ask a question and get multiple opinions and answers. Kerry Padgett at the California Department of Public Health in Richmond California has been identifying ticks for our patients for many years. The folks over there don’t test the tick. A tick testing positive doesn’t necessarily mean that it was on long enough to transmit a disease. A tick testing negative for Lyme may be infected with the Lyme like illness that we can’t test for yet.

They are happy to tell you if it is a tick that you need to be on alert for. You can send the tick to:

Kerry A. Padgett, Ph.D.
Supervising Public Health Biologist
California Department of Public Health
Division of Communicable Disease Control
Vector Borne Disease Section
850 Marina Bay Parkway
Richmond, CA 94804

Kerry shared the link below for all sorts of tick related info including some activities for kids.

Here is the bottom line. Regardless of whether or not you get the tick tested....

Watch the person who has been bitten very carefully for the next 4-5 weeks. If there are any suspicious symptoms within the month following a tick bite you absolutely want to speak to your doctor about doing a course of antibiotics. Reactions that are a cause for concern would be a bulls eye rash around the tick bite site and/or any type of flu symptoms. Some of the less frequent tick borne illnesses might have a more diffuse rash. Not everyone gets all symptoms.

We don't want to treat every tick bite with antibiotics for obvious reasons. As with everything, we need to strive for balance. We can't keep our kids in a box. Go out there and enjoy the hike, but then do that thorough body check and you should be fine. If you are a pet owner and you treat your pet with one of the flea and tick treatments, keep in mind that those ticks may leave the pet and go find someplace else to hang out

Friday, April 1, 2016

2015/16 Flu season thus far...

No flu season is exactly the same. Some are much more challenging than others.

Most years we have an abundance of vaccine. Other years there is a shortage. Sometimes we end up with an adequate supply but it gets to us so late that we are challenged trying to get all of our patients immunized at the last minute. Every once in awhile the media focuses on Influenza fatalities and if there are vaccine supply issues that season it causes a bit of panic.

Sometimes the vaccine is a great match for the circulating strains. Other years it completely misses. The vaccine reaction varies as well. This makes sense because the formula usually changes every year as the experts try to predict which strains to include. Some years the patients seem uncomfortable and feverish for a day or so after flu shot; other years the reaction is very minimal.

The symptoms of the illness also change from year to year. I recall one season where every other patient was complaining of severe leg pain that lasted several days. Some years the high fever lasted for over a week. In those years, my antenna was way up for those first cases until we could see that this was a common trend.

The year that really stands out was 2009 when H1N1 was the big player. Because it was a strain that hadn’t been seen in most of our lifetimes, everyone was especially vulnerable. Many people, including young adults, were dying. It was terrifying. The H1N1 vaccine was quickly manufactured, but in small quantities. There was no way that the supply was going to take care of the demand. You can imagine that all the parents tried to do everything in their power to get a dose of the limited vaccine for their children. Our phones were insane.

One of the wise moms in our practice suggested that a blog would be the easiest way to communicate quickly with our patients. The blog that year was simply about the availability of the H1N1 vaccine and it morphed from that humble beginning into what it is now. That was how my first blog was born.

This 2015/16 season, the Influenza cases didn’t start showing up until fairly late, but then arrived with a blast. The illness swept through entire families. The brunt of it seemed to be late February through mid March. There are still a few cases showing up but at a trickle now. My heart went out to the poor sick moms and dads in the office who were trying to keep themselves upright while still trying to tend to their ailing kids. There were strains of both A and B circulating. The symptoms didn’t seem to differ all that much from strain to strain. The vaccine was somewhat protective. Reports claimed that it had over a 60% match. One of the most prevalent strains circulating was H1N1. The H1N1 has been included in the annual vaccine ever since it came back on the scene several years ago.
Most of our patients who tested positive this season  had not received the Influenza vaccine this year. We actually only had one official failure (someone with a positive test), but it was that patient's first flu shot season and they had only gotten their first one so far, so they were not fully protected.

One of the moms who got sick told me that she will never again skip getting the flu shot. That is wise, but even with the shot, some folks we talked to by phone, who certainly sounded like they had the flu, were in fact fully vaccinated. Were they quite as sick as the others? Perhaps not. They were still plenty miserable.

The reports also claimed that the rapid office tests had a significant number of false negatives this season. I believe that to be true. I didn't fully trust some of our negative results. Sending the swab along to the lab would give accurate report, but sometimes it isn’t worth the time and expense.

The symptoms that we saw with the flu this season were high fever (103-104), body aches, sore throat, headaches, cough and congestion. Appetites were diminished and energy was wiped out. Many folks also had stomach aches. Typically the course lasted 4-5 days of full fledged misery and then a few more days until the patients were getting back to feeling normal. We have not seen any serious secondary illnesses so far this year (knocking on wood as I type this.)

Some of our patients with an early diagnosis started on Tamiflu (an antiviral medication) and claimed that it helped quite a bit. I had one patient on it who got very agitated, so we opted to stop it. I am not sure if the Tamiflu was to blame or not, but the literature does say that it can happen.

We still have viable flu vaccine in the office, but at this point in the season I probably would no longer bother getting it unless this is your child’s first season and they have only gotten one so far. (The first year of getting flu shots for anyone under 9 is a 2 dose series. The doses need to be spaced at least 4 weeks apart.) In our office, there is no longer an option for flu mist this year; that ship has sailed.

As flu seasons go, there was nothing particularly notable this year. There were mild delays getting the flu mist, but since the flu didn’t show up until 2016, that was pretty irrelevant. With the Influenza, we just never know. Some seasons can really kick us in the butt.

And we get to start the process all over again in August when we get the new vaccine for the 2016/17 season!