Thursday, August 25, 2016

Pinworms/updated treatment options

Itchy butt at night? Uh oh. It might be pinworms.

All things considered, in the big scheme of things there are a lot of worse things that can happen, but you are certainly entitled to give a big groan if this is happening to you or one of your family members.

The Pinworm (Enterobius vermicularis if you want to impress folks the next time it comes up in conversation) is the most common worm infection in the USA. The target age range is for the primary infection is children between the ages of 5 and 10.

These kids are usually the culprits bringing it home, but it is really easy for the pinworms to spread among family members if you live in close quarters and spend any snuggle time in the same bed. Animals do NOT get pinworms, but they can carry them around on their fur and spread them that way.

The most common way for a person to get infected is by ingesting (or inhaling) the eggs.
The eggs can live out of the body for up to 3 weeks. If you happen to touch a surface that is contaminated and then put your fingers in your  mouth or handle food...tag you're it.

The eggs are way too small to be seen by the naked eye, but can be seen under a microscope. It takes between one of two months after the exposure for the symptoms to appear. The eggs mature into the worms. They are very small, white and threadlike. They live in the intestine and gradually make their way down the GI tract until they are close to the anus.

The male worms die fairly quickly, but the female worms make their way out of the of the body and lay the eggs on the anus. They tend to do this at night. One theory is that the body temperature is a little higher at night and this drives them out. It is common for children with pinworms to wake at night. Children that are old enough to communicate may tell you that they are itchy or that their butt hurts. Little girls might have itchy vaginas or vaginal discharge. Some kids just have mysterious tummy aches.

Diagnosis is done several ways. Sometimes you can actually see little wiggling things in the poop. You can just imagine the calls I get when that happens. It isn't usually quite so easy.

Some folks suggest putting a piece of scotch tape across the anus and looking in the morning to see if there is anything stuck on it. I prefer the actual look and see method.
I suggest that a parent to go check in the middle of the night. Make sure that they go to sleep with a very clean butt, perhaps take a good bath. Once your child has been asleep for several hours, take a flashlight and spread the butt cheeks far enough that you can actually visualize the anus. Tell your child ahead of time that you are planning on doing a butt inspection, so that if they wake up they are not going to be startled.   Pinworms will look like little white threads. They will likely be moving.

Once the diagnosis is made, most folks opt to treat. The medications do not kill the eggs, just the worms, so they should be taken initially and then repeated in one to two weeks.

There is an over the counter medication called Pin X. I have had patients have some success with this. It works about half of the time (which is fine if you are in the right half.)

We used to count on a prescription medication called Mebendazole under the trade name Vermox as our standard treatment, but for some mysterious reason Vermox  was taken off the market. We have worked with compounding pharmacists to take the generic Mebendazole and turn it into a form appropriate for any age. My current compounder is the marvelous Eddie Lau at Feel Good Compounders 650-898-8221
www.feelgoodcompounders.com (he can make all sorts of yucky tasting medicine easier to swallow.) Their cost for the 2 dose pinworm treatment is as follows (updated 8/2016) :

$75/ gummy form (may not be available same day)
$65/ capsule
$65/ liquid

They will do free shipping, but that might take a day or so and most parents don’t want to wait. There is  a $15-20 delivery charge to get the medication the same day.
THIS IS A PRESCRIPTION OPTION! Our office will need to be contacted in order to get this medication. Compounding does take some time. Showing up at the store with no prior prescription will not give you instant gratification.

The other option is a prescription medication called Albendazole (albenza) which can also be quite pricey. This also only comes in a tablet so it is a bit challenging for younger kids. This one is still over $400 but at least gives the 2 dose course.

Mebendazole is just coming back on the market this year with a new name EMVERM, but it is VERY VERY expensive. According to Walgreen's, each dose is over $400!

ScriptDash is a fairly new pharmacy option (worth knowing about)  that competes with normal pharmacies and offers same day delivery for the same price. They accept all insurance companies. They will beat the Walgreen’s price on the Emverm and automatically apply a manufacturer's coupon, but in this instance, as long as it is available, compounding is the clear winner.

The entire family should be treated if you want to really get rid of this as quickly as possible.

None of the medications are ideal for pregnant, breastfeeding or children under two, but there have been no adverse reactions reported.

Natural remedies include eating a diet high in garlic and/or believe it or not, enjoying some pumpkin seeds. Worms love carbohydrates. Studies have shown that limiting sugar and white flour (which is a good idea anyway) may keep them from thriving.
Probiotics, which stimulate the healthy bacteria in the gut will also make the environment one where they can't flourish as well. Vaseline around the anus at night will make it harder for the eggs to be laid. Some folks suggest crushing up garlic and making a paste with the Vaseline and putting that around the butt every night.

The fact is that if there were absolutely no further ingesting of the eggs, pinworms could resolve untreated after about 14 weeks (two life cycles), but the problem is most folks just keep on ingesting the eggs which gets them reinfected and so the cycle continues.

It is gross, I know, but the most common issue is fingers scratching an itchy butt and then making their way to the mouth. We must do our best to eliminate the eggs and prevent the egg to mouth circuit. Scrub under the fingernails and make sure that they are cut short. Focus on frequent and effective good hand washing. Do a nightly bath with particular attention to the butt. Add some apple cider vinegar to the bath water.

As mentioned earlier, the eggs can live on a surface outside of the body for up to 3 weeks. They do better in moist environments. High heat will kill them. They can be easily dispersed into the air. Pay attention to this when changing the sheets. Avoid shaking the sheets out into the air as much as possible. Wash all sheets, towels, pajamas and underwear in HOT water. You want to vacuum or mop, NOT sweep. Scrub the bathroom and any surfaces. Put toothbrushes through the dishwasher.

Remind yourself that there are worse things. but this is indeed the proverbial pain in the butt.

Friday, August 19, 2016

What to expect from the 2016/17 flu vaccine

Here is everything that you need to know about the Flu Vaccine for the upcoming 2016/2017 season:

Some flu seasons can be deadly and very frightening. See the info-graphic below.
It is recommended that all children over the age of 6 months get the flu protection. If you have an infant under 6 months of age, please consider getting the flu shot for yourselves.

All children under the age of nine, who are getting the flu vaccine for the very first time should receive two doses of the vaccine in order to be considered fully protected. The two doses need to be separated by at least four weeks. If they have ever had more than two previous doses of any flu vaccine, they only need one this year.

Children under the age of three get half of the adult dose. The nasal flu mist is not available this year. Studies indicated that it wasn’t effective last year. Truthfully I didn't see any evidence that it was any better or worse than the shot, but so it goes. Every year the disease trackers do the best they can to predict which strains of the virus will circulate and try to match the flu vaccine to the anticipated strain. Usually the vaccine differs from year to year, although there have been some seasons recently where it was unchanged.

Some years have better matches than others. On March 4, 2016, the Vaccine and Related Biological Products Advisory Committee (VRBPAC) voted overwhelmingly to recommend the influenza strains proposed by the World Health Organization (WHO) for the northern hemisphere Flu vaccine for the 2016/­2017 season. The selection resulted in 2 of the strains being changed in the trivalent vaccines and 1 strain for the quadrivalent.

Our office will again be supplied with the quadrivalent vaccine that covers two A strains and two B strains. All of the Flu vaccine in our office is preservative free. For any of you interested, the strains in the quadrivalent vaccine for the 2016/17 season are:

● A/California/7/2009(H1N1)pdm09­like virus;
● A/Hong Kong/4801/2014(H3N2)­like virus;
● B/Brisbane/60/2008­like virus.
● B/Phuket/3073/2013­like virus. (only in the quadrivalent)

We don’t carry the trivalent in our office. The trivalent covers only only 1 of the B strains.
You never know if that extra B strain is going to be an important player or not so try to get the quadrivalent if you have an option.

Last season the flu was fairly late. We didn’t start to see it in earnest until mid February.
Plenty of people did get the flu and had a miserable week, but no one in our practice had any severe complications. The folks who had the flu shot did not seem to be quite as ill, but there were some vaccine failures (myself included!)

Since we never really know when the flu season will start with a vengeance, getting your child vaccinated early in the season is your best bet. As soon as they turn 6 months old we can get them started with their first dose. Because we don’t have experience with this particular flu vaccine, I don’t have a sense of what kinds of reactions to expect. We don’t generally see any major reactions but every year it is different. Last year some of our patients did seem to have low grade fevers for a day or two, but for the most part the vaccine was tolerated very well. If your child has a sensitivity to egg, it is okay to give the shot, but we want to be cautious. I would recommend that you keep the patient hanging around the office for at least half an hour or so to make sure they aren’t having any issues. Please advise the nursing staff if you have any concerns.

I have been giving flu shots for almost 30 years and in that time I have only seen ONE patient with an allergic reaction to the vaccine (and that patient has no history of egg intolerance, so you just never know.) This patient left the office and started complaining about an itchy feeling throat. Mom brought him right back in and he got a dose of epinephrine. I am sharing that as a reminder that it is important to keep a close eye on your child for at least 30 minutes after the shot. If they seem to be having any breathing issues or exceptional fussiness they should get checked out immediately.

For the last several seasons we had some frustrating delays early in the season obtaining the flu shots but we did ultimately end up with adequate supplies. It currently looks like we will be getting some early shipments of the flu shots in mid August/September. This is the first year in quite a while where the Flu mist will not be available. As soon as I heard the first hint of an issue, I was able to increase my order for the shots. I anticipate that we again will have plenty of vaccine available for our patients but there are never absolute guarantees.We might not be able to be as generous taking care of parents and nannies, but your kids will get their shots.

I will update vaccine supply and any info about the clinic dates in my weekly emails and also on our Facebook page. I will also let you know what type of reactions I am seeing, and what the actual flu looks like when it starts knocking on the door this season.
Click below for the 2016 Flu Vaccine information statements from the CDC

Friday, August 12, 2016

Fevers 2016

 Please see the updated post September 2017

We have seen an unusual amount of fevers circulating for mid August, It is time to brush off and update my fever post.
Fevers tend to get parents very worried, but those who attended my illness class know that they are only one factor to consider when evaluating a sick child. I am always more interested in your child's overall mood and behavior than I am in any specific number on a thermometer. Kids get fevers. An adult with a high fever is more of a concern.
There are many methods out there for measuring a body temperature. I personally don't feel the need to invest in any expensive thermometers. I am generally quite satisfied with a digital underarm reading. The important thing is that however you take it, your thermometer seems accurate. Test it on yourself or other family members and take your child's temp when they are healthy to make sure you trust it. I  don't have a favorite brand.
If you have one of the new ear or temporal scanning units feel free to keep using that. Sometimes their "high" readings seem a little higher than I believe to be accurate; don't ever let a number freak you out.
Temperatures can be measured in either Fahrenheit or Celsius
Here is a quick conversion chart that might come in handy.
98.6 F=37 C
99.5F=37.5C
100.0F=37.8C
100.4F=38C
101F=38.4C
102F=38.9C
103F=39.5C
104F=40C
105F=40.6
For this post, I will be referring to the temperatures on the Fahrenheit scale.
*****
For any child older than 3 months
 As long as your child is active and happy, I generally don't feel the need to "treat" a fever unless it is over 101.5 or so.
One of the most common questions that our advice nurse team gets is, "When do I need to worry about a fever?" As I mentioned, I am much more concerned about the lethargic, whimpering child who has a normal body temperature than I am the singing child with 104. But, here is the
Nurse Judy's rule about fevers:
If the fever is over 102 (it doesn't matter how you measure, just be consistent):
*Treat with proper dose of Acetaminophen or Ibuprofen
*Do a tepid bath or place cool compresses on the forehead, insides of elbows and neck
*Get them drinking. Little sips at a time are fine. Popsicle s and ice-chips are good for older kids
*re-check the temp in 45-60 minutes
If it is STILL over 102 and hasn't budged at all, that is a fever that I am concerned about.
It is time to get your child seen.
When children are in the process of spiking a fever, it is not uncommon for them to tremble and look shaky. When fevers are breaking it is common to have lots of sweating.
Children with fevers may have a higher respiration and pulse rate.
One of the more frightening aspects of a fever can be a febrile seizure.  About 4% of children will have these. Febrile seizures can be terrifying to watch, but they usually stop within 5 minutes. They cause no permanent harm. Trust me, if you have never heard of this, watching your child have a seizure has been reported as the scariest experience EVER.
Knowing that that they do happen once in a while and are generally harmless should help keep you from freaking out. If your child is having a seizure they may have large jerky motions and their eyes may roll back. Your job is to stay calm. Make sure their airway is open. It is perfectly reasonable to call 911.

Once your child has had even one febrile seizure we tend to be more aggressive with fever control and will treat even a low grade fever. It is important to talk with your doctor about this so that you have a plan in place that you are comfortable with. Most kids grow out of the seizures by the time they are 5 years old.
If the fever is accompanied by a very fussy child, I want them seen so that we can figure out what is going on.
Even if your child is acting just fine, if a fever lasts for more than 3 days, I consider it time to have a look so that we can make sure there isn't an infection source (like ear infection, urinary tract infection, strep throat or pneumonia.) Any fever that comes along with a purplish rash could be an emergency (this is not the singing child. They would look alarmingly ill.)
During flu season, we sometimes do see a fever that lasts for five days or longer. If there is a classic virus going around that I am seeing a lot of, I will occasionally relax my "3 day rule". If the kids seems like they are 'managing' (drinking, peeing, easy breathing, consolable, fever responds to medications) I am okay watching them for another couple of days.
This particular illness that we are seeing does have 4-5 days of fairly high fevers.  A small group of these have ended up with respiratory infections that did need to be treated, so my 3 day rule is staying in effect.
Many viral syndromes "wave goodbye" with a rash. Roseola is a classic example.
If your infant is under 8 weeks of age we want to be notified of any fevers!
However, there are a few common causes:
*over bundling....
Seriously, sometimes the babies come in with 10 blankets wrapped around them. Please don't do that. The best rule of thumb is giving them one layer more than you are wearing. If your baby was indeed over bundled, get some of those layers off and re-check the temp in about 10 minutes to see if they have cooled down.
*dehydration..
..Sometimes if moms milk isn't in yet, babies can be simply dehydrated and need to get some fluids. This is the time that you need to squirt some milk or formula directly into your baby's mouth. You can use a syringe or a dropper. More often than not the elevated temperature will normalize fairly quickly from some fluids.
If there is no obvious cause for an elevated temperature, and it doesn't resolve within 30 minutes your baby needs to be evaluated. Giving a fever reducing medication to a newborn should only be done under strict guidance from your pediatrician.
Some fever facts:
*Fevers turn on the body immune system. They are one of our body's protective mechanisms
*Many fevers can actually help the body fight infection.
*Fevers that are associated with most viral syndromes and infections don't cause brain damage. Our normal brain's thermostat will not allow a fever to go over 105 or 106.
*Only body temperatures higher than 108°F (42.2°C) can cause brain damage. Fevers only go this high with high environmental temperatures (e.g., confined to a closed car.)
Click here for my blog post about dosages for Tylenol and Advil
Dosage chart 





Friday, August 5, 2016

They put WHAT in their mouth?


Kids like to explore. Many times this involves sticking things where they don't belong.
Being fairly oral critters, most of the time the object they are handling gets placed in the mouth. When this happens there are two passages that it might go down.

If it goes into the esophagus it hopefully will make it's way down into the stomach, through the intestines and then get pooped out.

If something was swallowed, here are things to consider:

Is it stuck?
How does the child look? Are they able to take a sip of water? Can they swallow just fine? Is their breathing relatively normal?

If something has gotten stuck in the esophagus they will look uncomfortable, There will  be frequent coughing and throat clearing going on. You will know that something is amiss. This will necessitate a visit to the ER.

Is it poisonous?

If you have any doubt about that, call the poison control center


Is it potentially germ laden?
We get calls about kids eating things that are pretty disgusting. Young infants are  the most vulnerable, but usually don’t have the dexterity to actually get something into their mouth without some help. Once they have mastered the hand/mouth coordination skill, they are old enough that a normal healthy gut has good bacteria that can be somewhat protective.  If whatever it is that they ingested is going to cause trouble, symptoms will usually show up with tummy aches, vomiting and loose stools within a day or so.  Persistent tummy upset will usually warrant a stool test to help us figure out what the culprit is.

Is it a battery?
Any battery can be trouble, but button batteries can be a tremendous hazard because they can be easily swallowed and they seem to be everywhere these days. Several  years ago  I got a call from a mom of 15 month old twins. There they were, sitting on the floor with mom's pedometer right in between them. It was open and the battery was gone. Because of the uncertainty involved, we did have to send them to get x-rays.  Indeed there it was that little battery, sitting in the stomach of one of the kids. In this case it passed safely, but if a battery gets stuck anywhere on the way it can cause a dangerous amount of damage. Please know where all the button batteries are in all of your little gadgets and make sure that your kids have no access to them. Keep a strict inventory and perhaps stick a piece of duct tape across any battery compartments.

Other objects that you need to be wary of are magnets. I am not talking about the little letters that you may have on your fridge. The ones that cause concern are the industrial strength magnets that you may find in some "grown up"  toys  like buckyballs  or jewelry.
If more than one of those get swallowed it can wreak havoc on the intestines and be deadly. Keep them away from your kids!

Is it sharp?
If it is something that has a point or sharp edge, keep an extra close eye on your child. Make sure the tummy stays nice and soft. If your child seems to have a rigid painful belly, they will need to be seen right away. Keep an eye on the stools. Any dark, tarry poop or bright red blood would be a reason to get immediate help.
One of the sharpest things that we were keeping an eye out for some years ago was one of a Grandma's one carat diamond stud earrings. That passed through and was retrieved with no harm at all to the swallower (Grandma didn't want it back; it was reunited with the mate and is in a safe deposit box waiting until the little girl is 18.)

Most of the time, it is simply a matter of watching for the whatever it was to pass through. I have seen all sorts of stuff get swallowed and pooped out without incident. I think I have seen enough change to put a kid through college. Most coins smaller than a quarter go through fairly easily.

Let's encourage a quick passage! Increase the amounts of fluids that your child drinks. Perhaps add prunes. If your child is old enough that they are beyond simple pureed food, consider giving some corn kernels  (You won't see that in any textbook). Have you figured it out yet? For those of you who need this spelled out, corn kernels are usually fairly recognizable after they have been pooped out. They can act as a marker. Corn can help you track the transit time.

If your child is old enough to know better and seems inclined to continue to put non food items in their mouth, this might be a condition known as Pica. Pica is the persistent eating of substances such as dirt or paint that have no nutritional value. This is worth pointing out to your doctor. There might be a nutritional deficit or something else going on.

If the object  goes into the trachea it may block the airway and you have a choking situation on your hands or it could get aspirated into the lungs. Neither is good. Your child will clearly be having breathing difficulties if this has happened. They will likely have a color change is they are fully obstructed. If someone is obstructed, they can not speak or make sounds. Of course with any emergency you should call 911, but it is my hope that all parents and caregivers are trained to do a choking rescue.

To avoid this happening on your watch, it is SO important to keep little items away from the young kids. Anything that can fit into a toilet paper tube is too small for an infant or young child to be handling. Food pieces should be soft or cut into long strips rather than round pieces.
Encourage safe eating: sitting instead of running around, chewing and swallowing rather than shoving in wads of food. Parents, please model good behavior!

Dr Kaplan advises that a rule of thumb to keep in mind is that the size of your child's airway is about the same diameter of their pinky finger or ear canal. That is pretty small!
All parents should be able to do a choking rescue!





Kids like to explore. Many times this involves sticking things where they don't belong.
Being fairly oral critters, most of the time the object they are handling gets placed in the mouth. When this happens there are two passages that it might go down.

If it goes into the esophagus it hopefully will make it's way down into the stomach, through the intestines and then get pooped out.

If something was swallowed, here are things to consider:

Is it stuck?
How does the child look? Are they able to take a sip of water? Can they swallow just fine? Is their breathing relatively normal?

If something has gotten stuck in the esophagus they will look uncomfortable, There will  be frequent coughing and throat clearing going on. You will know that something is amiss. This will necessitate a visit to the ER.

Is it poisonous?

If you have any doubt about that, call the poison control center


Is it potentially germ laden?
We get calls about kids eating things that are pretty disgusting. Young infants are  the most vulnerable, but usually don’t have the dexterity to actually get something into their mouth without some help. Once they have mastered the hand/mouth coordination skill, they are old enough that a normal healthy gut has good bacteria that can be somewhat protective.  If whatever it is that they ingested is going to cause trouble, symptoms will usually show up with tummy aches, vomiting and loose stools within a day or so.  Persistent tummy upset will usually warrant a stool test to help us figure out what the culprit is.

Is it a battery?
Any battery can be trouble, but button batteries can be a tremendous hazard because they can be easily swallowed and they seem to be everywhere these days. Several  years ago  I got a call from a mom of 15 month old twins. There they were, sitting on the floor with mom's pedometer right in between them. It was open and the battery was gone. Because of the uncertainty involved, we did have to send them to get x-rays.  Indeed there it was that little battery, sitting in the stomach of one of the kids. In this case it passed safely, but if a battery gets stuck anywhere on the way it can cause a dangerous amount of damage. Please know where all the button batteries are in all of your little gadgets and make sure that your kids have no access to them. Keep a strict inventory and perhaps stick a piece of duct tape across any battery compartments.

Other objects that you need to be wary of are magnets. I am not talking about the little letters that you may have on your fridge. The ones that cause concern are the industrial strength magnets that you may find in some "grown up"  toys  like buckyballs  or jewelry.
If more than one of those get swallowed it can wreak havoc on the intestines and be deadly. Keep them away from your kids!

Is it sharp?
If it is something that has a point or sharp edge, keep an extra close eye on your child. Make sure the tummy stays nice and soft. If your child seems to have a rigid painful belly, they will need to be seen right away. Keep an eye on the stools. Any dark, tarry poop or bright red blood would be a reason to get immediate help.
One of the sharpest things that we were keeping an eye out for some years ago was one of a Grandma's one carat diamond stud earrings. That passed through and was retrieved with no harm at all to the swallower (Grandma didn't want it back; it was reunited with the mate and is in a safe deposit box waiting until the little girl is 18.)

Most of the time, it is simply a matter of watching for the whatever it was to pass through. I have seen all sorts of stuff get swallowed and pooped out without incident. I think I have seen enough change to put a kid through college. Most coins smaller than a quarter go through fairly easily.

Let's encourage a quick passage! Increase the amounts of fluids that your child drinks. Perhaps add prunes. If your child is old enough that they are beyond simple pureed food, consider giving some corn kernels  (You won't see that in any textbook). Have you figured it out yet? For those of you who need this spelled out, corn kernels are usually fairly recognizable after they have been pooped out. They can act as a marker. Corn can help you track the transit time.

If your child is old enough to know better and seems inclined to continue to put non food items in their mouth, this might be a condition known as Pica. Pica is the persistent eating of substances such as dirt or paint that have no nutritional value. This is worth pointing out to your doctor. There might be a nutritional deficit or something else going on.

If the object  goes into the trachea it may block the airway and you have a choking situation on your hands or it could get aspirated into the lungs. Neither is good. Your child will clearly be having breathing difficulties if this has happened. They will likely have a color change is they are fully obstructed. If someone is obstructed, they can not speak or make sounds. Of course with any emergency you should call 911, but it is my hope that all parents and caregivers are trained to do a choking rescue.

To avoid this happening on your watch, it is SO important to keep little items away from the young kids. Anything that can fit into a toilet paper tube is too small for an infant or young child to be handling. Food pieces should be soft or cut into long strips rather than round pieces.
Encourage safe eating: sitting instead of running around, chewing and swallowing rather than shoving in wads of food. Parents, please model good behavior!

Dr Kaplan advises that a rule of thumb to keep in mind is that the size of your child's airway is about the same diameter of their pinky finger or ear canal. That is pretty small!
All parents should be able to do a choking rescue!



Monday, August 1, 2016

2016 school vaccination requirements


When I was young, Summers were sacred and school started after Labor day. I am not sure when that shifted, but it seems that these days many of our patients start school in mid August. This is the time of year for the panicked parent to call, needing an immediate check up (sorry folks, that is probably not going to happen), sports form, or updated vaccination record prior to school entry.
Below  is the standard form if you lost yours:


Take a deep breath. Most schools will accept a promise of a scheduled check up as long as they have an immunization form that is complete. We are happy to work with our families to at least get you scheduled for some of those shots that are needed even if there isn't an appointment with the doctor available.
As most of you are aware, In June of last year, California Governor Jerry Brown signed Senate Bill (SB) 277 into law.
This law went into effect July 2016. For the school year beginning August/September 2016, all children going into kindergarten, seventh grade or transferring to a new school for the first time will need to be fully vaccinated or have a medical exemption. Personal or religious exemptions will no longer be accepted. 
The law has also tightened up the age requirements.
California law now states that children must be five years old on or before September 1, 2016 to be legally eligible for Kindergarten and six years old on or before September 1, 2016 to be eligible for first grade.
Students who will turn five between September 2nd and December 2nd 2016 are eligible for a transitional Kindergarten program for the 2016-2017 school year. In October, the  children enrolled in the transitional kindergarten program this year will be required to apply for Kindergarten assignment for the 2017-18 school. The vaccine requirements for transitional Kindergarten and Kindergarten are the same.

Here is a list of the shots that San Francisco schools require:   
Before entering kindergarten:
DTaP (Diphtheria, Tetanus, Pertussis): 5 doses
If the 4th dose was given after the age of four, 4 doses is acceptable.
Polio: 4 doses
If the 3rd was given after the age of 4,  3 doses is acceptable
Hepatitis B: 3 doses
While I am completely sympathetic to the parents who don’t want to start the series when they are still in the hospital, I do suggest that you get started with these during the first year.

MMR(measles, mumps and rubella): 2 doses are required
If they got an early dose prior to the first birthday, that doesn't count as one of the doses
Varivax (chickenpox): 1 dose is required. 2 is preferred

Interestingly the Hepatitis A vaccine is not required by school.  We strongly recommend that everyone get that one taken care of as soon as the kids turn 1. 

There is a conditional entry for children who are not fully up to date, but they must have at least
1 MMR
1 Varivax
1 DTaP
1 Polio
1 Hep B.
The schools will be checking in to make sure that the series are completed in a timely manner.
School districts already have their own systems for tracking and following up with kindergartners who are not fully immunized. Whatever systems the districts are already using will remain in place.

Vaccinations are only one of the requirements for school entry.
Kindergartners must have a complete physical examination within 6 months prior to entering school.
We routinely check their vision, hearing and urine as well as reviewing general health and development. In my opinion, this is just as important as getting the shots.
California law also requires that by May 31st each year, students in their first year of public school must submit proof of an oral health assessment performed by a licensed dental health professional.

 Students entering the 7th grade  will need to show proof of a Tdap (Tetanus, Diptheria and Pertussis) booster. They also must show proof of two doses of the MMR vaccines.

7th grade  is also the perfect opportunity to vaccinate with the other ACIP (the Advisory Committee on Immunization Practices) recommended vaccines for 11-12 year olds, including HPV and MCV4 (meningococcal).

Check out this valuable link www.shotsforschool.org for a complete list of what is required
.For our younger patients, most licensed day care facilities also have a fairly strict vaccination policy. Those requirements are also listed in the above link. That website also has a feature where you can check out your school or day care to see how well they have been doing in their vaccination efforts.

Routine testing for tuberculosis is not required for SF public schools. Rather than testing every child with a skin or blood test, the San Francisco Department of Public Health strongly supports a medical provider's risk assessment for TB as the universal screening requirement for school entry.  Only children identified as having one or more risk factors for TB infection will need to be tested.
The most common risk factors are
*Contact with a family member with history of or confirmed case of TB
*Foreign born family or adopted  from country with a high-prevalence of TB
*travel to high risk county
*HIV contact
*family member who has been in jail during past 5 years
*frequent exposure to homeless, users of street drugs or residents of nursing homes
*Clinical evidence of TB: Cough lasting  longer than 3 weeks, coughing up blood, night sweats, fever, weight loss.
If you do get your child tested you have 2 options. The PPD is a test applied to the inner arm that needs to be checked 2-3 days after it is placed.
There is also a blood test available.

Some of the private schools insist on TB testing for all of their students, regardless of the recommendation of the SF Public Health Department.  I have gone to the mat with one of the local parochial schools and lost.

Back to school is an exciting time. Try to carve out some extra time during the bedtime routine where you can have your kids tell you all about their day.
Don't fall into this common trap.
"How was your day?"
"fine"
Ask specific questions such as:
Tell me about the kids in your class.
Tell me about the teachers
 Share something interesting that you learned today

It has been several weeks since I have sent out a post that  mentioned poop. so I will add one more tip.
Please make sure that your kids don't get constipated. Many children will not poop at school until they are really comfortable there. Some mornings are rushed and systems can get backed up. Keep your antenna up.