Friday, September 22, 2017

A rash of rashes/when do you need to worry? 2017


A rash of rashes/when do you need to worry?

If you sneak a peek at the Noe nurses' email these past couple of weeks, most of the subject lines include the words, rash, spots, blotches or bites.

You can't imagine the scope of the emails we get. Some come along with photos of random body parts, not all of them easily identifiable. Rashes can be spotty, blotchy, hivey, oozy. They can be caused by allergies, bug bites, scabies, bed bugs, poison oak, contact dermatitis, virus, bacteria or fungus. They can be on only one body part or cover most of the patient. They can be part of a chronic condition that comes and goes, or something acute.

Once in awhile I can look at a photo of a rash and have a good guess what I am looking at, but more often things aren't completely clear cut. The most important thing really comes down to one very important and basic question: "Do we need to be worried about this rash or not?"

To simplify things, I divide rashes into one of two categories - Am I curious or concerned?

Rashes that I am curious about

If your child  is acting fine but has a random rash, ask yourself the following questions:

-Are there any new medications? (especially antibiotics. Even if it is the end of a course, this is important information.)

-Was there a recent illness/fever? If you had a mystery fever and then a rash comes out once the fever is gone, I am NOT as concerned about it. There are quite a few viral syndromes that wave goodbye with a rash

-Are there any new foods?

-Have they been enjoying lots of citrus or berries lately?

-Are there any new soaps, detergents, bubble baths?

-Have you used a new sunscreen or lotion of any sort?

-Do you have pets? (Think fleas)

-Has there been an exposure to a new animal? (think allergies)

-Has your child been in a hot tub?

-Is the weather very warm? (my San Francisco babies don’t like the heat)

-Has your child been laying in the grass or sand?

-Has there been any recent travel?

-Any recent hiking? (think poison oak)

-Has your child done recent a art project with a new substance?

-Have you checked the mattress and area around the bed to see if there are any spiders or insects hanging around? (shudder)

If your detective work has given a promising clue, make the common sense adjustments and see if you see any improvement.

Regardless of what is causing a rash, there are  several basic staples that are worth keeping on hand. The first three on the list  are used for basic skin care and can be somewhat preventive.

  • Cetaphil cleanser (no water needed, apply and wipe off)
  • Aquaphor
  • You all know that I love adding a splash of apple cider vinegar to the tub for all sorts of rashes
  • Over the counter hydrocortisone cream/ointment for itchy areas
  • Over the counter Neosporin or prescription Mupiricin for any open areas
  • Over the counter anti-fungal cream/ointment for any possible yeast rashes.
  • oatmeal bath (don't clog your drain with real oatmeal, there are special products used for this)
  • Zyrtec or Benedryl
  • Bleach! Believe it or not, many dermatologists will suggest a diluted bleach bath for helping clear up eczema or bacterial infections.

Of course feel free to call the advice nurse to help you troubleshoot. If you are a patient at  Noe Valley pediatrics we would likely try to schedule a convenient appointment slot for you to come in and have us take a look if a rash is persistent and your best attempts at clearing it with a variety of OTC creams isn't helping.  If the docs are baffled, the next step may be the dermatologist.


Rashes that I am worried about

Any purple rash needs to be evaluated. These rashes don't lighten up when you press on them. If you have a child who has a purple rash and also has a fever and looks ill, they need to get to an emergency room immediately to rule out meningitis. A stiff neck, vomiting and headache would make me even more concerned. These kids look SICK.

Any rash that comes along with a fever at the same time is probably worth being seen. Strep throat can do this. We have still not ever seen an actual case of measles in the office, but that also would present with a rash and fever at the same time. The patient will look sick.

Other viral syndromes that may have the rash and fever at the same time are Slap Cheek and Hand Foot Mouth. We don't have anything other than suggestions for symptomatic relief for those. You simply will need to ride them out.

If the rash is oozy and crusty it might be bacterial. Impetigo is fairly common.

If your child has had it in the past and you already have Mupiricin, you can try to treat a small area. If it isn't clearly taking care of things, an appointment is warranted. Sometimes oral antibiotics are indicated.

If a rash seems to have fluid filled centers, it could be chicken pox!

If the rash seems very painful or itchy certainly try Zyrtec or Benedryl, but if your child is uncomfortable let's get them seen to see if we can help. Some itchy rashes like poison oak may need oral steroids.

Hives are scary because most people associate them with a severe allergic reaction. What most people don't realize is that most of the time hives are not always a big deal. They are a signal that the body is reacting to something, but often it can be viral. I have had patients with mystery hives that have cycled on and off for several weeks before finally fading. If your child has hives along with any facial swelling or difficulty breathing, they need immediate attention. If they have a history of severe allergy to something, you should have an epi-pen or AuviQ on hand and follow that up with an emergency room visit for some close monitoring.

Any painful rash that is only on one side of the body and doesn't cross the midline could be shingles. It is rare for children to get this, but it can happen.

So to recap, if you are WORRIED, make sure that you are seen appropriately sooner than later. If you are simply curious, it is time to play detective.

Friday, September 15, 2017

Organizing your crap....I mean treasures 2017




I spent last week in Pittsburgh, Pennsylvania at my childhood home going through stuff. I am certainly blessed that I am part of an awesome team and not dealing with this all by myself. My sisters, daughters and nieces were all there with me. Mom was a kindergarten teacher and as such she had kept piles of worksheets and odd stuff that could come in handy for a future craft project. She always claimed that she wasn't the pack rat in the family but I am not sure there is too much credibility to that statement. My dad absolutely didn’t believe in tossing things, so there is a workbench full of all sorts of unfinished projects. He came by it honestly. When folks were going through his mother's things, they came across a little baggy clearly labeled "String that is too short to use." The house was ( is...it very much still is) filled with generations of letters and photos, newspaper clippings and the occasional treasure. There are shelves of dusty old books dating back to as early as 1892. Of the pictures we found, some are labeled so that we know who they are. What a gift that is!

I was so grateful for those faint markings on the back of a photograph to show me that I was looking at a picture of my Great Great grandmother...wow. This is the takeaway message for you. If you have old photos, make sure that they are labeled. Sit down with the older generation and have them identify whoever they can. Do it now. Don't wait.

I toy with the idea of writing a book one day about this process. Perhaps the title would be “75 toothbrushes of Darlington Road”, because we found at least that many. After a fairly exhausting week, I had no energy to create a brand new post. It seemed timely to rerun an old post I had written about organizing stuff. Efforts taken now can prevent your kids from having to do what I am doing someday in the future.
Here is the old post:

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, September 8, 2017

Fevers 2017


Last week in the SF Bay Area the heat was unprecedented. .For the first time in my 31 years of living here, I went to a night game at AT&T park wearing shorts and a sleeveless shirt (orange of course) I didn’t even bother to bring a sweatshirt. Seasoned Bay Area people know that normal equipment for the ball park for a summer night includes sweatshirts and a blanket.
One the Friday before the 3 days weekend, the phones exploded with calls about very high fevers. I am not sure if some were heat related or there was a new virus making the rounds.

Fevers tend to get parents very worried, but those who attended my illness class know that they are only one of the factors that you need 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 usually more miserable and needs to be evaluated sooner to figure out what is going on.

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. A Popsicle or 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 awhile 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 3 months 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 20 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
https://nursejudynvp.blogspot.com/2014/12/tylenol-vs-advil-dosage-charts.html

Last week in the SF Bay Area the heat was unprecedented. .For the first time in my 31 years of living here, I went to a night game at AT&T park wearing shorts and a sleeveless shirt (orange of course) I didn’t even bother to bring a sweatshirt. Seasoned Bay Area people know that normal equipment for the ball park for a summer night includes sweatshirts and a blanket.
One the Friday before the 3 days weekend, the phones exploded with calls about very high fevers. I am not sure if some were heat related or there was a new virus making the rounds.

Fevers tend to get parents very worried, but those who attended my illness class know that they are only one of the factors that you need 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 usually more miserable and needs to be evaluated sooner to figure out what is going on.

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. A Popsicle or 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 awhile 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 3 months 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 20 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, September 1, 2017

Dealing with Bullies 2017


There has never been a more important time to teach our children about tolerance and kindness. Bullies can start their habits when they are really young. I am updating this post from several years ago.

Kids can be so mean sometimes. I am not sure if it is harder to watch your child be bullied or to be the bully. In my case, for a period of time when our daughter Lauren was four, she was getting routinely picked on by another little girl at preschool. To compound things, this girl was in my carpool. I would drive the kids to school three days a week. Carpool parents - be aware of this astonishing fact. You are invisible. You are privy to all sorts of interactions and conversations that might leave you either horrified or amused as you drive the car full of kids hither and thither. In this case I had to watch Emily torture Lauren every single day, impervious to the fact that I was in the car. (As you can imagine it was pretty infuriating.)

This is what I would hear, with mild daily variations:

Emily: "Your shirt is ugly"
Lauren (clearly upset): "what? why?"

Emily: "I have a special thing I brought for show and tell and I am going to let everyone else in the car have a peek except you"
Lauren: "But I want to see it too!"

Emily: "You can't come to my birthday party"
Lauren (even more upset): "Why?" 

After a few weeks of this I realized that I needed to stage an intervention.

I drew two faces. One was smiley face with pretty eyelashes. The other was a grumpy frowny face. I then said to Lauren " Which one would you like to be?" I was dealing with a four year old girl, this wasn't rocket science. As predicted she pointed to the smiling image. I touched the grumpy drawing and said " Emily seems to want to turn your smiley face into a grumpy face. I wonder if you could keep the smile face on even when someone is being mean. Let's try!"

We got out the trusted barbie dolls and did some role playing. We spent a dramatic session as Barbie cheerfully let all sorts of slights and insults roll of her very shapely back. We created an assortment of interesting scenarios. Barbie never lost her cool.

I wasn't quite ready to paint Emily as a complete bully. I liked her parents and she wasn't mean 100% of the time. I tried to give her an out. As we put the Barbie's away I said, "I wonder why Emily says mean things sometimes. Maybe she is feeling grumpy herself because she is a little tired."

The very next day in the car we I was interested to see if all of our practice would make a difference. It didn't take long to find out.

Emily: "your shirt is ugly"
Lauren (with a big fake smile plastered on her face that I could see through the rear view mirror): "Luckily, you don't need to wear it. I think your shirt is pretty."

Emily: "you can't see my sharing"
Lauren: "I am sure it is very interesting"

Emily. "You can't come to my party"
Lauren: "I hope you have a fun time"

From the driver's seat I watched Emily become more and more confused and upset that her power seemed to be slipping. I refrained from giving an audible whoop and driving into the bushes.

And then...

Lauren (in a sickeningly sweet voice): "Are you a bit tired Emily?"
Emily (grumpy): "NO, I'm NOT tired"
Lauren (knowingly): "I think you must be a little tired"

No one watching could have accused her of doing anything wrong but she had discovered a way to gently torture Emily a bit, and she was running with it.

A few weeks later I was at a school event and I bumped into Emily's dad who drove the carpool the other two days. He said to me, "something is going on in the car that I don't understand". "Oh? What would that be?" asked innocent mom. "Lauren keeps asking Emily if she is tired and Emily starts getting very upset". Hmmmmm.

As you can see, finding one on one time and playing through things can be quite effective. If you can, it is also helpful is to identify the "nice kids" in the class. Ask your child who they might like to play with, reach out to that family and try to arrange some play dates outside of school time. If your child can have some solid allies in the social group, it makes it much easier to stand up to, or deal with someone else who is unkind. Keep in mind that it is a rare friend that is completely reliable. They all have days where they "might be tired". 

Was Emily actually a bully? Perhaps she was looking for attention or actually just needed a nap. Often young children are really simply trying to figure things out. Nevertheless, if your child is routinely on the either end of hurt feelings, it is worth some attention.

Looking for other ways to empower your child? Check outKidpowerThis is a fabulous organization that came out of Santa Cruz. They now have groups and classes all over the place. They have an entire section devoted to dealing with bullying with all sorts of really excellent resources: Kidpower - Bullying

If all of your efforts at home don't seem to be taking care of the issue, talk to your school to see if they have any anti bully programs in place. There is a inspiring program No Bully , that got its start in San Francisco. Talk to your school about looking into it. Keep in mind that most of the time you won't actually witness the bullying. Pay attention to your child's mood and behavior. If you notice any dramatic changes make sure you find opportunities for your child to communicate about what may be going on. Sitting with them in a quiet room before bedtime is a great time to do a daily debriefing about the day. In our family that was a ritual.

Let's turn the tables. If you hear that your child is the bully, or you get to see them in action, make sure that you carve out some one on one time to work on some skills. Some kids seem to be bullies because they simply want attention and don't know a better way of making and keeping friends.Talk to them about kindness. Talk about choices. Find one particular situation that you know about and work on that. "You pushed your sister and made her cry. What was going on? Were you mad, sad, frustrated? What were some other choices that you could have made? What should be the consequence if it happens again? What should be a nice treat/ reward if you make a better choice the next time you are in that situation?"

If you find that you are having issues on either side of this spectrum that are beyond your scope, the next step may be having a meeting with your child's teacher.

Your child may not be directly involved in any bullying but it is the rare child who doesn't see occasional evidence of meanness happening around them. This group of observers are often the kids who can make a real difference. Not only do we want our children to be kind, we also want them to figure out the best way to be brave without putting themselves in danger. Sometimes it takes a certain amount of bravery to play with a child who is a target to the bullies. At the very least talk about reporting any bullying to a grown up or teacher.

These days with all the social media, a good bit of bullying can happen over cyberspace. Make sure that kids know that you reserve the right to monitor their online accounts. Until they are ready to pay for their own cell phone plans, it is what it is.

Kidpower outlines some concrete actions for dealing with this.


Little actions can make an enormous difference to someone.

Friday, August 25, 2017

Flu vaccine info 2017/18 includes Noe Valley Pediatrics flu shot info


2017/2018 FLU VACCINE INFO


Here is everything that you need to know about the Flu Vaccine for the upcoming 2017/2018 season:

Some flu seasons are worse than others. I can still remember in 2009 when the H1N1 swept through. Healthy people were dying. It was terrifying. We need to remember that the flu is one of the deadliest vaccine-preventable childhood diseases. Each year, influenza kills more children in the United States than meningococcal infection and whooping cough combined. Just two years ago in the 2015/16 season, 26,000 children were hospitalized with flu related symptoms. Between October and April, on average, 15 children died every month. Sixty percent of the children who died were otherwise healthy with no known underlying medical conditions. Eighty percent of the children who died from the flu were not vaccinated. Despite the severity of influenza in children, immunization rates are lower than those for other vaccine-preventable diseases.

Infants can’t get the shot until they are 6 months old. If you have a baby at home who is too young to get the shot, please make sure that all the household contacts are protected so that you don’t bring the virus home. It is recommended that all children over the age of 6 months get the flu protection. Children, especially those younger than 5 years, are at higher risk for serious flu-related complications. Folks of any age with chronic health problems like asthma, diabetes and disorders of the brain or nervous system also are at high risk of serious flu complications.

Children under the age of nine, who are getting the flu vaccine for the very first time, need to receive two doses of the vaccine in order to be considered fully protected. The first dose “primes” the immune system; the second dose provides immune protection.The two doses need to be separated by at least four weeks. Over the years I have seen patients who have had only their first shot come down with the flu. One will not fully protect them.

If your child has ever had more than two previous doses of any flu vaccine, they only need one this year. It takes about 2 weeks for the shot to take effect. Children under the age of three get half of the adult dose. The nasal flu mist is not available for the second year in a row.

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. Although there have been some seasons recently where it was unchanged, typically the vaccine changes from year to year. This year's vaccine is not the same as last seasons. Some years have better matches than others. Let's keep our fingers crossed that this year has the magic combination. 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 2017/18 season are:
 
A/Michigan/45/2015 (H1N1) pdm-09-like virus,
A/Hong Kong/4801/2014 (H3N2)-like virus
B/Brisbane/60/2008-like virus
B/Phuket/3073/2013-like virus.

There is a trivalent vaccine available in many pharmacies that doesn’t contain the B/Phuket. (I guess they said Phuket? Sorry I couldn’t resist)
You never know if that extra B strain is going to be an important player so get the quadrivalent if you have the option.
 
Last season the flu cases started showing up fairly late. We didn’t start to see it in earnest until late January. Plenty of people did get the flu and had a miserable week, but no one in our practice had any severe complications. There were some vaccine failures but the folks who had the flu shot did not seem to be nearly as ill as an unvaccinated person.

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. The manufacturers claim that the protection is supposed to last through the entire season. My personal sense is that it does seems to loose it's oomph after 7 months or so. As soon as a baby turns 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 had low grade fevers for a day or two, but for the most part the vaccine was tolerated very well. A day or two of fever is still better than a full-blown case of the flu. 

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 (an emergency room is the best choice.)

In past years there have been delays and shortages with the supply, but so far everything seems like it will be smooth this season. We have already received our first shipment of the vaccines. For Noe Valley Pediatrics patients we will be having flu shot clinics starting September 12th. The clinics will be Tuesday,Wednesday and Thursday from 10:00 until 11:30 am and then from2:00-4:00 pm. Call the same day to get on the list. Please understand we can only manage a set number of patients on any given day. Flu shot appointments are for shots only. If you have a reason to see the doctor, it is important to have an appointment on the main schedule. I tell parents that “we can add a shot to any doctor appointment, but we can’t add a doctor to a shot appointment.” We will be holding several evening flu shot clinics throughout the season. In September we will stay open late to give shots from 5pm until 7pm on September 13th and 27th. Families are welcome to the evening clinics.

When you come for a shot appointment, it is helpful if your child is wearing short sleeves or clothes that will allow us easy access. If your child is especially fearful of shots, let us know in advance and we can schedule a longer visit for them. We can offer ice packs or numbing cream by request. There is a $5 charge for the cream. Plan in advance. This needs to be applied 20-30 minutes before the injection.

We are happy to immunize parents as well, but this will be an out of pocket $40 charge. We will not be billing your insurance. We can give you a bill that you can submit on your own.

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 2017 Flu Vaccine information statements from the CDC.
This is the same statement that has been active since 2015. They did not feel that there were any significant changes to report.