Friday, February 24, 2017

Colds/coughs/congestion 2017 (symptomatic treatment/when do you need to be seen?)

This post was updated 10/2018


We are in the midst of full blown cough and cold season.  It is important to have some guidelines to help you figure out when a trip to the doctor's office is indicated. Many times, there is nothing to do but wait it out, so I am including  some tips to help you and your child get through the illness as comfortably as possible.

Colds and coughs are a common issue for all of us with or without kids. Studies say that most children will have an average of EIGHT colds within the first 18 months of life. Most of the time the congestion is caused by a viral syndrome. Allergies and teething* can also be culprits causing you to be congested.

*Most medical literature disputes whether or not teething is connected to any symptoms, but I have been at my job for many years, and I see what I see

All that mucous is the perfect breeding ground for bacteria, which is why something that starts as a virus can turn into an ear infection, sinus infection, or lower respiratory infection fairly quickly. Be warned,  we can see a patient one day with clear lungs and no ear issues, and the very next day they can seem a lot worse and have a raging infection.
Right now we have lots of families suffering with some nasty colds and coughs. The coughs have been lasting for several weeks.

When to come in  
If you are dealing with a congested family member, here are the questions to consider:

*Do they seem to be having any labored breathing?  Babies with labored breathing will look like their little tummies are going in and out more than usual. Respiration will be more rapid (I am more concerned with the lungs than a stuffy nose.) Noisy breathing alone is not a very good indicator as it may be caused by upper airway issues that we aren't too worried about.

*How is their mood?

*Do they have a fever?

*How is the appetite? If your baby is nursing well, that is very reassuring

*Are they sleeping well at night?

* What color is the mucous?

*How long has this been going on?

If you have any labored breathing, wheezing, a child who is much grumpier or fussier than usual, and/or a fever that is hard to control or has lasted more than 3 days, an office visit is needed.  I am also interested in mucous that is getting thicker and greener. Green mucous does not automatically signal a problem. It is just one more clue. 

It is okay to play the wait and see game if we have a reasonably consolable child with clear mucous who is eating and sleeping  well, whose breathing isn't alarming and who has no significant fever,  
Of course if the symptoms show no signs of improvement, please check in with your doctor's office. Many colds and coughs can last between 1 and 2 weeks. Some coughs can really hang on.

If you find that you are having a hard time assessing the respirations, try sticking your ear up to their lungs and see if you can hear anything. If you can hear nice clear air noises, that is great. If you hear whistles or squeaky noises, that may mean the congestion has spread down to the lungs. Using your ear as a stethoscope doesn’t always work; more than half the time you won't be able to hear anything, but once in awhile parents are able to get some important clues from the "ear to chest" evaluation.
If your child is old enough to cooperate, have them take a great big deep breath, in and out.
If they are wheezy or have any inflammation in their lungs, that deep breath will often trigger a bit of a coughing fit. If that happens, it is probably worth an office visit.
It is not a bad idea to get an idea of what “normal” looks like. If you are lucky enough to be reading this when your child is healthy, lift up their shirt and watch them breathe for a minute or two. How fast are their  normal breaths?

Any baby less than 2 months old is probably worth a visit to the office with their first cold, unless they are eating really well and seem completely happy. It is certainly at least worth a call to the nurse.

Sometimes a big mucous plug may be momentarily blocking an airway, causing a minute of distress that clears with a big cough. If coughing and steam are able to clear things up, it is more likely that it is upper airway congestion.

Management tips
The best way to manage congestion at home is to make sure your little patient is getting plenty of fluids (this will help to keep the mucous thinner.) Breast milk is perfect if you are lucky enough to have it.

With some older kids, cow's milk may not be the best choice because it can increase the amount of mucous (it doesn't impact everyone the same way.) I have plenty of patients who love their milk and taking it away for a couple of days is not a reasonable option. Sometimes thinning it will a bit of extra water is a good compromise.

Steam is great. Hang out in the bathroom when anyone takes a shower. Running a humidifier or vaporizer at night is a good idea. Turn it off during the day and give the room a chance to dry out so that you don't grow mold. Make sure you change the water daily. As long as you follow those rules, I don't have a preference between warm or cool mist.

Humidifier blog post

Keeping the head elevated makes a huge difference. Some of the younger babies will do best napping in their car seats, bouncy seat or swing. Make certain that they are in a safe place. For night time, try a crib wedge or place a towel underneath the mattress to raise it up a bit. Some parents place a book underneath two of the crib legs to get it on a mild slant

You can put saline drops or breast milk into the nose (and then suck it out with a Nose Frida or snot sucker). This is the most natural way to clear the nose. Your baby will no doubt hate this, but if you can manage to do it about ten minutes before a feeding, it may clear the nose up enough to make eating much easier. Do not torture your baby with the nasal irrigation if they are managing just fine.

Some of my parents really like  the Oogiebear nose and ear cleaners. These are safe, soft little plastic scoops that allow you to remove stubborn little boogies.

For patients over 6 months of age, ask your doctor about Windbreaker or Pipecleaner. These are Chinese herbs that we use to dry up congestion. Many of our families swear by these. They are sold at the Chinese medicine works on 25th and Noe. For convenience our office tries to also keep it them stock.
Consider acupuncture!
One of our neighborhood acupuncturists gets some good results from her treatments for your basic coughs and colds. Her treatment of children often does not use any needles.

Still in the realm of Chinese medicine, there is a new product on the market.
Dr. Loo, a local physician, has created a patch to treat the symptoms of congestion.
These are safe for any age!
Her website is a work in progress but you can learn all about the products by clicking below.
It is possible that we will have some of the patches available for purchase.

For older kids and adults, don't minimize the value of chicken soup! There was a fun study done a few years ago that found that soup drunk out of a mug was actually statistically better than soup out of a bowl.

So, what about the over the counter cough medications?
I have been an advice nurse here at Noe Valley pediatrics for a shockingly long time (1988.) For many many years the nurses and docs were pretty quick to prescribe over the counter cough and cold remedies to our patients over 6 months.
The rules and recommendations kept changing. First they moved the age to 2 and over, the next thing I knew the age was 6 and over.
In my experience, those meds were useful and harmless. It was nice to have an option for the younger patients to help them get over the hump of a nasty cold, but the powers that be are pretty firm that the labels remain for older kids only.

There are some homeopathic remedies out there that are considered completely safe. Chestal and Zarbees are are two of the brands I have had parents give good reports about.
Make sure that you don’t give anything honey based to a child under one year of age. The Zarbees does have an infant formula.
Boiron came out with something new this year called ColdCalm. This is a homeopathic remedy that comes in a little dropper that can be given to patients as young as 6 months of age.

Here in our office our docs may recommend a dose of Zyrtec or Benadryl at night to help dry the kids up and get them a good night's sleep. Before I would do that, I would want them checked out to make sure the lungs and ears are clear.

For night coughs, without taking anything orally, you might try a bit of  Vicks Vaporub on the feet!  Trust me, I scoffed at that as much as anyone, until I asked my patients to test it out and was shocked at how much it seems to help.

For parents and big kids I really like Sambucol and zinc lozenges. They mayy be placebos, but in my case I say " bring it on" because they seem to work. Remember that I work in the germ factory and (knock wood) I manage to avoid many of the things I tend to be exposed to. The second I feel that little tickle in my throat or any tell tale signs of an illness I take a zinc cold therapy lozenge (Walgreen's generic taste better and are cheaper) and a Sambucol lozenge twice a day.

Another very good thing to do for folks who are old enough is to use a Neti Pot or sinus irrigation. Make sure to use distilled water.
NeilMed has quite a few excellent products to help clear out the nose. For nursing moms, this is my absolute favorite remedy. If you have a deviated septum, this may not work well for you.

Good hand washing is of course essential.

Related posts
When is your child Contagious?

Friday, February 17, 2017

What's new with Zika?

What's new with Zika
Last year Zika was all over the news. Some viruses make a big splash in the headlines, but then fade away. Unfortunately Zika is still something that we need to pay attention to.
Here are some facts about Zika:
Zika virus was first identified in 1947 in a rhesus monkey in Uganda's Zika forest (which gave the disease its name.) For decades Zika was a virus that turned up in monkeys and occasionally in humans in Africa and southeast Asia. Its symptoms were mild and the number of confirmed human cases was low.
This virus is still on the rise. Until a few years ago almost no one on this side of the world had been infected. Few of us have immune defenses against the virus, so it is spreading rapidly. Millions of people in tropical regions of the Americas may have been infected within the past couple of years
The world is shrinking, and mosquitoes don’t pay too much attention to borders. This year Zika has made it’s way to our country, There are now pockets of reported cases in Florida and Texas.
It is constantly evolving. Some areas where it was very prevalent are perhaps seeing a decrease.  Other countries like Mexico are seeing more cases.
For up to date information on which countries are impacted, check the CDC website:
The Zika virus is spread to people through mosquito bites. The most common symptoms of this disease are fever, rash, joint pain, and conjunctivitis (red eyes). The illness is usually mild with symptoms lasting from several days to a week. Severe disease requiring hospitalization is uncommon. Only about 1 in 5 people infected with Zika virus even become symptomatic.
The nasty type of  mosquito responsible for Zika also spreads dengue virus, yellow fever virus and Chikungunya. Mosquitoes that spread Zika virus bite mostly during the daytime. Just as with malaria, people are the source for spreading the virus. This is how it works: a female mosquito bites an infected person and then can carry the virus to the next person she bites, so when people travel, they can bring the virus with them. An infected person is thought to be infectious the first week only. The virus can take hold if enough people become infected for it to become endemic, meaning it's in a region permanently. Mosquito bites and mother-to-unborn baby aren't the only ways this virus is transmitted. The CDC now confirms documented cases of infection from sexual transmission and blood transfusion. Although the Zika virus can be found in breast milk, to date there are no confirmed cases of mothers passing the virus to the baby through nursing. Either way, the benefits of breastfeeding way outweigh the risk and exposure would not be a reason to stop nursing. People infected with Zika virus don't infect one another through casual contact. 
Men who have been in a Zika hot spot should be careful to use birth control for 6 months after any possible exposure. Women should avoid pregnancy for 2 months after any possible exposure.
There is no vaccine or specific antiviral treatment available for Zika virus disease. Treatment is generally supportive and can include rest, fluids, and use of acetaminophen (not ibuprofen) for fever and/or discomfort. 
Because of similar geographic distribution and symptoms, patients with suspected Zika virus infections also should be evaluated and managed for possible dengue or Chikungunya virus infection. People infected with any of these illnesses should be protected from further mosquito exposure during the first few days of illness to prevent other mosquitoes from becoming infected and reduce the risk of local transmission.
Zika has a few especially  frightening aspects. Approximately 1 in 4,000 cases are having the complication of Guillain-Barre syndrome. Guillain-Barre is a nerve disorder that causes muscle weakness. Most people recover in a few weeks, but severe cases can require life support to help with the breathing. Anyone of any age can get Guillain-Barre, although it is pretty rare. It is thought to be triggered from an infection. 
Even more widespread  is the documented connection between birth defects and pregnant women infected by the Zika Virus. In Brazil, where most of the reported cases seem to be, there have been many babies born with microcephaly (small heads) and the associated significant health issues. The most dangerous time is thought to be during the first trimester – when some women do not even realize they are pregnant.  Unfortunately there are new studies showing that a young baby’s developing brain can be impacted even if they did not get infected in utero. Infants under 18 months may be at risk for developmental delays if they contract this virus.
Okay how does all of this impact you? If you have not been traveling lately and have no plans to travel, Zika is not something that you need to fret about here in the Bay Area. If you have recently returned from a trip to any of the Zika hot spots AND have any illness symptoms, make sure that you share that info with your doctor or nurse. If you are pregnant and may have been exposed, contact your OB as soon as possible. Testing used to be coordinated with the local health department but It is now available at commercial labs. Testing should only be done for someone who has been in one of the impacted areas and is showing symptoms. The the tests are far from perfect.
Testing for Zika is not recommended for any non pregnant patients.
If you have an upcoming trip planned, keep in mind that until there are firm answers, the CDC has issued a travel advisory to pregnant women to avoid traveling to any countries where the Zika virus is rampant. If travel is not optional, strict mosquito avoidance is essential. 

  • Make sure that you have intact screens on all windows
  • Get rid of any standing water that is around where you are staying; do a double check to make sure there are no pots, bird baths...etc. that are places where mosquitoes can breed. The larvae are dependent on water for breeding. 
  • The type of mosquitoes that carry Zika don't care what time of day it is. While may mosquitoes prefer biting at dusk and dawn, there is always risk with these nasties.
  • Try to wear (keep your child covered with) long pants/ long sleeves etc. Light colored clothing is recommended.
  • If you are going into a heavy mosquito area use bug spray on exposed skin and clothing. The EPA has five registered insect repellents. Of those, there are three products that are more easily available.
 - DEET is one of the more popular options. It is considered safe for infants over the age of 2 months.
 - Oil of Eucalyptus is considered one of the least toxic options but interestingly, the age recommendation for it is for 3 years and older.
 - Picaridin is a newer option. It is odorless and is approved for children 2 years and older. It is great as a mosquito repellent but it is not thought to be as effective against ticks as DEET if you are going into the deep woods.


As with any new  product, do a little test patch on the skin to make sure there is no sensitivity before you widely spritz it. They all come in different concentrations. You will need to read the labels to see how often you need to reapply. Avoid contact with eyes.

Mosquitoes don’t like fans! The nasty insects are lightweight enough that a good breeze may make it hard for them to zoom in on their target.
The good news is while it's not certain, scientists believe once an individual has been infected with the virus, they are immune and won't become infected again.There is currently no concern for future pregnancies.

Friday, February 10, 2017

Iron (updated post 2017)

Is your child getting enough iron?

Babies are actually born with maternal iron stores that start to diminish sometime between 4-7 months.
If your baby is breastfed and nursing is working well for you, breast milk is of course the perfect food and the iron in it is very well absorbed.
If your baby is on formula it is important that you use one that is iron fortified.
Once the baby is six months or so, I would suggest starting solids and making sure that the baby is getting adequate iron. By the time a baby is 7 months old, breast milk alone is no longer adequate for your child’s complete nutrition needs
Daily iron requirements are as follows:
7-12 months: 11 mg
1-3 years: 7 mg
4-8 years:10 mg

9-13 years: 8 mg
14-18 years: 15mg
19-50 years: 8 mg
51+ years: 8mg

9-13 years: 8 mg
14-18 years: 11 mg
19-50 years: 8 mg
51+ years:8 mg
Iron is essential for energy, growth and brain activity. I actually learned several years ago that there is a strong connection between insomnia and anemia! If your child is having trouble sleeping, one of the first things I would explore is the diet.
Anemic kids (and adults) can also have headaches, restless leg syndrome, low energy, and trouble focusing. They may have cold hands and feet, and look pale. Children who have low iron levels also tend to put non food items in their mouths more than other kids. If you have a child who loves to chew on ice, that can also be a signal that they are anemic.
If you have concerns about anemia at any age, give your doctor a call and they can see if it makes sense to order a CBC (complete blood count.)
In our office, most of the doctors will give you a lab slip to get your iron level checked around the 1 year exam. (I suggest getting a lead level done at the same time.)
Depending on your child’s diet and how old your house is (lead risk), we would recommend getting the screening done at either the 9 month, 12 month or 15 month exam.)
There are two components in the CBC (complete blood count) that give us most of our information about your child's iron level. The hemoglobin is part of the red blood cell that carries oxygen. Your body needs iron in order to have a normal hemoglobin level. The normal hemoglobin level ranges between 11-16
The hematocrit is a measure of what percentage of the blood is the red blood cells. The normal range for a child 6 months to 2 years is 33-40%.
These ranges can vary from lab to lab and I have seen lots of goofy lab results over the years that have terrified parents needlessly. If we ever get an extreme result of any sort the first action should be to repeat it..
Iron rich foods can be divided into two groups: heme versus non-heme.
Heme iron is much more easily absorbed. Animal sources like meat, poultry,eggs and fish contain heme iron.
The dark meat chicken and turkey are higher in iron than the white meat.
The egg yolk is a better source than the egg white.
Non-heme iron can be found in dried fruits, beans, tofu, enriched cereal and dark green leafy veggies.
Fortified baby cereals are an easy way to help get your iron requirements for the beginning eaters.
Cooking in cast iron pans is actually a great way to get some extra iron into the diet.
Iron is a fairly tricky mineral when it comes to absorption. Some foods may actually be high in iron but are also high is something called phytic acid which block absorption.
Iron loves vitamin C but doesn't absorb well with milk. Because of this, kids who drink more than 24 ounces of milk once they have hit the one year mark have a higher incidence of anemia.
For you anemic adults out there I hate to pass along that coffee and tea also are a problem when it comes to helping the iron do it's job.
Hopefully you can offer enough food choices that you can get adequate iron from your diet.
If you have a very fussy eater and the lab shows that the iron level is low, you may need a supplement. Unfortunately, iron supplements can cause constipation and the drops can cause some tooth discoloration (so brush those teeth.)
Some of the supplements that come in a yummy chew-able or gummy form are easy to take, but MUST be kept in a childproof area. Too much iron (if your little one gets a hold of them) can be very toxic.
One of my favorite brands is Floradix.  Read the label, but for most toddlers the dose is 1 teaspoon/ day.
Floradix contains honey as one of the ingredients, so this is NOT an option for a baby under one year.

For adults, ferrochel is reasonably priced, available online, and seems to be well tolerated.
Be aware that iron supplementation can cause very dark, almost black stools. This is harmless. As long as your child has a nice soft tummy and is comfortable, the black stools can be ignored.
Some common iron rich foods:
Chicken liver 3 oz                                          11.0mg
Lentils 1 cup cooked                                     2 ½ mg
Ground beef 3 oz                                          5 ½ mg
Tofu ¼ cup                                                     3 ½ mg
Beans ½ cup cooked                                     2 mg
Spinach ½ cup cooked                                   2 ½ mg
Potato with skin, white, baked ½ medium      2 ½ mg
Prune juice ½ cup                                           ½ mg
Broccoli ½ cup                                                 ½ mg
Enriched baby cereal ¾ cup                            4-18 mg
Tortilla 1 average                                             1 mg
Molasses 1 Tablespoon                                    0.9 mg
Raisins ½ cup                                                   1.6 mg
Other good iron rich options are nuts, and seaweed snacks. Become a good label reader!
When your little one eats their iron rich foods, give them positive reinforcement, feel their muscles, and tell them that all that healthy food is helping them grow big and strong.
Story time......
I have a family in the practice who called me about their little 2 year old being a poor sleeper. As I mentioned earlier in the post, insomnia can be connected to anemia, so one of my first questions was about the iron intake.
Both of the mamas are vegetarians. Over the years I have seen the remarkable phenomena of really young kids craving foods that they need and recoiling from things that they are allergic to. I myself am a vegetarian, but made sure to let my girls follow their own path.
I suggested that these parents hold their noses and offer some meat to their little guy to see if he was interested.
Several weeks later, they followed up with me. It turns out that this fellow loves his meat. He is a veritable vacuum cleaner, “Meat meat meat”.
They are feeding him what he wants. He is sleeping like a champ.

Sunday, February 5, 2017

Tips for giving medicine/ The old spoonful of sugar/2017

Parents have to pick their battles. Sometimes things really aren’t so important and we don’t have to necessarily get “our way”. I am a big fan of discussion and compromise when appropriate. Generally though, the medication battle has to be one where we come out on top.
The obvious assumption is that you have decided for a valid reason that your child has a condition that needs to be treated. If this is the case, have a firm but loving attitude.  (Think Mary Poppins and her spoonful of sugar.)
Make it clear that you mean business and whether or not they like it, they will be getting the medicine, one way or another.
If they cooperate give them lots of positive feedback.
If they are resisting use the following technique.
For your young child, hold them at a 45 degree angle,  If they are flat they can choke a bit, and if they are sitting up too high they can spit. Getting the right angle makes a big difference.
If they are using their hands to knock the medication away, wrap them in a blanket (think straight jacket!)
A syringe is much more effective than a spoon and is better for measuring.
Squirt a small amount in the side of a cheek.
Keep the chin elevated.
Give a tiny bit at a time and wait for a swallow in between.
Some of our tough customers are most likely crying and screaming throughout the process. It gets easier.
If you are giving a teaspoonful, that would be 5 ml in a syringe. Giving .5 ml per squirt would mean 10 squirts. This may take several minutes, but the dose will go in.
The only kids that can beat this system if you are doing it slowly enough are the ones that learn how to vomit.
Okay, what are your options if you have a vomiter on your hands?
If your child needs antibiotics, sometimes we can give an injection.
If you are simply trying to get in a dose of fever reducers, suppository form might be your best option. (Not so easily 'spit' out.)
For kids who are old enough to reason, let's give them some choices. What would they like to drink after the medicine? Should we have the pharmacy add a flavor?
Sometimes holding a lollipop and taking a lick after each squirt helps with a bitter taste.
A compounding pharmacy can do almost anything in flavored suspensions and can even do some medications in topical gels. This year my compounder of choice is Eddie Lau over at Feel Good Compounders. They can be reached at 650-898-8221 or
Eddie was telling me that they can do creative things like ibuprofen in a topical gel form or suppository for our most difficult medicine takers. I never realized that those were an option. Some of the generic antibiotics are truly vile. Your poor child is not putting on a show. Eddie told me that he has tried to mask the bitterness, but there is no real hiding it.

Franklin pharmacy (the old 450 Sutter pharmacy) is back in business at their new location at 1508 Franklin Street in San Francisco. Elaine, the compounder there has done some wonders turning antibiotics into either savory cheese crackers or sweet sandwich cookies.
Their phone is 415-775-3917. This creative option has worked well for some kids.
Don’t wait until your child is sick to teach them about cooperation with medicine. It might be a good idea to do some role playing ahead of time.
Have one cooperative stuffed animal and one stuffed animal (or doll) who throws a fit.
For the cooperative doll say things like, “ I know this tastes a little yucky, but it is really important and it will help make you feel better. I am really proud of you for being so cooperative."
 For the challenging doll, wrap the arms in a blanket the way you may have to with your child. say, "I am sorry that this is so hard, but it is very important for you to take this medicine."
You might also let them pretend to be a parent who has to give the medicine to the uncooperative doll. Don't make it easy. Role reversal can give both sides some insight.
When the time comes that you have to give a dose of medication,choices and rewards are fine, but make it clear that the discussion will last 5 minutes and no more (set a timer.) When the timer is up they will be given the medicine the same way a baby gets it, The window of opportunity for having any choices will be gone. When the kids realize you mean business they cave fairly quickly.
One reward method is to make it possible to earn 10 pennies per dose. Put the money on the table.
A penny is taken away for every 30 seconds that passes without cooperation. Kids hate seeing something concrete being taken away.
If your child is old enough, this is a great math opportunity. A 10 day course of antibiotics can be worth 2 dollars (adjust the reward however you choose.)
Never try to sneak medicine into a larger volume of food or drink. Your kids will know it is there. If they do end up taking only part of it, you will have no real idea how much of it they got.
I have actually had some pretty young kids who hate taking liquid medicine learn to swallow capsules or pills.
Start with tic tacs or other small pieces of candy. See if they can swallow one. If they fail, oh well. They have a piece of candy in their mouth. If they can’t swallow it with water, try putting it on a spoon tucked  into some yogurt or jelly and see if it goes down.
Remember you are doing this with your child’s involvement. No sneaking things. Don’t lose their trust over something like this. You are on the same team, trying to help them feel better.
If your child ends up taking syrupy medications at some point or another make sure you brush their teeth after each dose.
If they are taking antibiotics I strongly suggest that they also take probiotics to protect the body chemistry and prevent yeast. Ideally, don’t give a probiotic at the same time as the other medications, but stagger it throughout the day if possible.
Some children take a daily medication or vitamin pill and quite like them. This year we had a 9 year old boy who presented in the office with an ongoing stomach ache. After some questioning, it turns out that he was helping himself to a handful of gummy vitamins daily.
Telling your child that medicine and vitamins are not candy and can only be given by the grown up is a start, but it is also essential that all medications and supplements (including vitamins) be kept in a childproof area. If your child does take an overdose of any medication call the Poison Control Center to find out how concerned you need to be.
Poison Control number for California is 1-800-222-1222
If you are ever giving a medication and are not sure about proper dosing, never hesitate to call your doctor’s office/ advice nurse for clarification.