Friday, May 26, 2017

Measles on the rise? 2017

Topic of the Week: Measles 2017

Measles on the rise!
Summer often means travel. I have been getting lots of calls from families who have trips planned. The question is often whether or not their baby needs to get an early MMR. At this point, it depends on where you are going, but the answer may be yes.
From January 1 to April 22, 2017, 61 people from 10 states (California, Florida, Michigan, Minnesota, Nebraska, New Jersey, New York, Pennsylvania, Utah, and Washington) were reported to have measles. Minnesota in particular has an outbreak that the officials are keeping a close eye on.
There are also increasing numbers throughout Europe.
A measles outbreak is a bit like fire. There are embers out there. It is NOT a wildfire yet. Don't panic! A few hundred cases is a few hundred too many, but that does NOT mean there is a child with measles standing on every street corner. The next couple of weeks will be very telling. It is possible that the numbers of infected patients will spread dramatically. It is also possible that the infected individuals have been identified and quarantined and everyone can all breath a little easier.
Here are some facts about measles:
Measles, also known as Rubeola, is a very contagious respiratory virus. Infected people present with high fever, cough, congestion and red eyes. After several days they will also develop a significant rash all over the body. If you have a happy child, who is fever free who has a rash, that isn’t measles. Patients with measles are clearly very ill.
One of the reasons that it spreads so easily is that people are contagious as early as 2-4 days prior to showing any signs of the virus and may remain contagious until the rash is gone, or 4 days after the symptoms are all clear. This virus is so virulent that ninety percent of unvaccinated people will catch this virus once they are exposed.  What is even more alarming is that it can remain on surfaces or even in the air 2 hours after someone has sneezed or coughed! If someone travels on a plane while they are contagious, we can see a faster spread that will be even harder to contain.
Complications are frequent. They range from ear infections to pneumonia, encephalitis and/or seizures. 1-2 out of every 1,000 cases are fatal. This is a serious illness. You really don't want your child to get the measles.The routine measles vaccine is combined with mumps and rubella and is referred to as the MMR. The individual components have not been available separately for many years. The first MMR shot is routinely given to patients between 12-15 months and again between 4-6 years. For the second dose we have the option of combining it with the chickenpox vaccine called Varivax. That combo vaccine is called Proquad or MMRV. The MMR vaccine is thought to be 95% effective. The second dose is given just to catch the occasional person who didn't get effective immunity from one dose and bumps the effectiveness up to 99%. It can be given earlier than 4 years, but we aren't too concerned about the timing of the second dose as long as our patients have gotten the first one.  
Why do we wait so long before giving the first MMR protection to our babies? Assuming that mom has been fully vaccinated (or less likely has had the actual measles) infants are born with passive immunity to the disease. This immunity starts to wane as they get older and is considered mostly gone by the time the babies are between 12 and 15 months. If a child is vaccinated when they still have the maternal protection, the vaccine does not seem to be as effective. In our office we follow the standard recommendation and generally give the MMR at either the 12 or 15 month visit. The MMR is a live vaccine and it is true that in some rare cases the reaction can be a little rough. Interestingly, most kids are just fine the day of the immunization. Typically the reaction comes along between a 7-21 days after the shot. This reaction may include high fever and rash. This is not thought to be contagious. It usually lasts only a day or so. If your child is allergic to eggs, we are extra cautious when giving the vaccine. Some folks with a significant reaction to eggs may opt to get it at the allergist's office. I have NEVER had any patient have an allergic reaction from the MMR or a serious post vaccination reaction other than about 20% who seem to get the fever the following week. 
If you are traveling to a high risk area or there has been a clear exposure, the vaccine can be given as early as 6 months, but that shot won't count towards lasting protection and your child will still need to get a 2 shot series after the first birthday.
Your insurance company also might refuse payment if the shot is given outside of the routine schedule. If that happens, be aware that getting an early, extra dose may be an out of pocket expense
It takes about 10-14 days to get any significant protection from the first MMR. For instance, getting an MMR for a 7 month old to protect them from a travel situation the same week is not going to do much of anything.
Before routine use of the measles vaccine, there were about 500,000 cases of measles in the United States each year and about 500 deaths. Measles also led to about 48,000 people being hospitalized and another 1,000 people being left with chronic disability from measles encephalitis. Study after study has shown that there is no link between the MMR and autism,, but there are still some folks reluctant to give their children the vaccination.
Since July 2016 when  SB277 was signed into law, it is now a requirement for all children attending schools in California to have the measles vaccine unless they have a medical contraindication. 
Several years ago when I was working on my very first measles post, one of my adult friends said to me, "We all got measles and survived, what is the big deal?"  My response was, "It is true enough that the vast majority of folks who get measles will recover intact and have lifelong immunity. However, one to two kids out of 1,000 will die; many more than that will be permanently harmed. That is too many when we are talking about something that can be prevented. That 1 child out of 1,000 matters."

Friday, May 19, 2017

Ticks 2017/Expecting a nasty tick season this year

 Please see updated post 4/2019

Topic of the Week:Ticks

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

Indeed the calls are already coming in and I have spoken to a half dozen patients about tick bites just this week. It makes sense. With the nicer weather more of my patients are out there taking walks, hiking, and enjoying the beautiful area that we live in. The extra rain this season is contributing to one of the largest tick seasons that we have seen in many years. Ticks can be an issue all year long, but the nymphs are born in the spring. These tiny little ticks are the ones most likely to transmit diseases. Of the many varieties of ticks out there, the ones responsible for the majority of  disease transmission are the deer ticks. If you want to impress folks at your next cocktail party, our local deer tick is officially identified as the ixodes pacificus.
Although only a small percentage of tick bites are harmful, the diseases can have a major health impact, so we need to pay attention. There are multiple types of bacteria responsible for tick borne illnesses.  Ticks here in California are known to transmit several different diseases, including Lyme. There are many conflicting reports, but recent studies coming out the past couple of  years suggest that the rates for tick borne diseases are  higher in California than previously thought.
The key is prevention.
Spray the clothing with the bug repellent Permethrin. This is okay for anyone over 2 months of age. Use Deet on exposed skin, avoiding hands, eyes, and mouth.
If you are looking for more natural remedies, try some of these essential oils: 
Lavender - This smells sweet to us but bugs tend to hate it. It can repel mosquitoes, flies and other insects.
PennyRoyal - this is a member of the mint family and it is toxic to insects
Lemongrass - this essential oil comes from tropical lemongrass and has a citrusy scent. It is a natural flea and tick repellent that can be sprayed directly on the skin.
Eucalyptus - use this alone or along with citronella oil to keep bugs away. According to the Journal of Medical Entomology, eucalyptus extract can reduce tick bites.
Lemon - Some lemon essential oil can work against fleas and other bugs. Slightly dilute it and spray it on your clothing and and skin.
Sorry to say that none of the above are going to work as well as the DEET.
If you are going to be walking or hiking in densely wooded areas try to stay in the middle of the path. Avoid wood piles and logs. Light colored long sleeves and long pants are recommended.But let's face it, on a hot day we are not going to have our bodies covered completely, so here is the deal....
Everyone needs to get a naked head-to-toe body check after a walk in the woods. If you are camping, do a full body check daily. Ticks can hide in out of the way places on your body. Don't forget to check the scalp. If you are dealing with thick darker hair, you can rub your fingertips along the scalp and feel for any bumps. Check in between the fingers,toes and behind the ears. Check armpits and belly buttons as well. You really need to be very thorough. Many of the ticks are very tiny and hard to see. Be familiar with little moles and freckles so you can recognize a new spot which might be a little tick.
If you are returning to your home after a hike, use a lint roller to do a quick pass over your clothes. You may be shocked at what you collect from that. Then carefully take off all clothing (try not to shake things out) and put everything in a hot dryer for 60 minutes to kill any wandering ticks. Don’t forget to check the car seat!
If you find a tick, it is very important to remove the tick as quickly as possible. If a tick is removed within 4 hours of the bite, the chances of any disease transmission are SIGNIFICANTLYdecreased. For Lyme disease, the tick generally needs to be attached for more than 24 hours to be a concern. 
If you find a tick, please stay calm. I can still remember vividly, years ago, a mom carrying her toddler into the office screaming (the mom, not the kid) "HELP ME GET THIS THING OUT OF MY BABY!"  Hey, arachnophobia is appropriate in this case, because ticks are indeed arachnids (the spider family), but put on a brave face for your child.
The best way to remove a tick is with tweezers or a special tick removing tool. Grasp the tick as close to the skin as you can and firmly pull up and away. Do not twist. The Public Health department councils that you should not try any of the folk remedies such as Vaseline, burning match, etc., but Dr. Kaplan claims success by applying peppermint oil. This should cause the tick to back out.  If you own a dog or go hiking frequently, do yourself a favor and get one of the tick removing tools. You can get them pretty cheaply from any sporting good or pet store. Amazon has a ton of different brands.
My extra daughter Rachel just used the tick tornado to get a tick off her little one and was really pleased at how easy it was:
Once the tick is out, clean the area with an antiseptic soap, apply a dab of Neosporin and then keep watch on the area to make sure there is no infection.
Okay, We got a tick bite. We removed it, but now what???   
  • watch the site for sign of local infection
  • observe for 30 days. If there is any odd rash, flu like illness, aches, or fever it is important to notify your doctor. We will want to know the date of the bite, and if possible the region where the tick came from. Any recent travels could provide important data.
Unfortunately the blood tests for tick borne diseases such as Lyme are initially not all that helpful. To start off with, you can get both false positive and false negative results (making it pretty useless.)  It turns out that once you have symptoms several weeks after the bite, the tests for Lyme are apt to be more accurate, but that isn't all that useful right after the tick encounter when we are trying to decide whether or not to treat.
Rather than testing the patient, I would focus on the tick. If you do a lot of hiking, keep a little baggy in a pocket of a backpack or diaper bag so that you have a place to stick any ticks that you remove.  
The Sonoma County Health Department will identify the tick for free to see if it is the type you need to be worried about. They will also take it a step further and test it for Lyme disease. They charge a  fee of $31 (such a deal.) They don't test the ticks for other illnesses. They do the testing every Thursday and they will have the results by Friday. They say that about 1-3% of the ticks test positive.
Read the instructions on their website for how to send the tick.
As many of you have heard me say time and time again, ask a question and get multiple opinions and answers. Kerry Padgett at the California Department of Public Health in Richmond, California has been identifying ticks for our patients for many years. The folks over there don’t test the tick. A tick testing positive doesn’t necessarily mean that it was on long enough to transmit a disease. A tick testing negative for Lyme may be infected with the Lyme like illness that we can’t test for yet.
They are happy to tell you if it is a tick that you need to be on alert for. You can send the tick to:
Kerry A. Padgett, Ph.D.
Supervising Public Health Biologist
California Department of Public Health
Division of Communicable Disease Control
Vector Borne Disease Section
850 Marina Bay Parkway
Richmond, CA 94804

The public health department team shared the link below for all sorts of tick related info:
Public health department tick info

Here is the bottom line. Regardless of whether or not you get the tick tested....
Watch the person who has been bitten very carefully for the next 4-5 weeks. If there are any suspicious symptoms within the month following a tick bite you absolutely want to speak to your doctor about doing a course of antibiotics. Reactions that are a cause for concern would be a bulls eye rash around the tick bite site and/or any type of flu symptoms. Some of the less frequent tick borne illnesses might have a more diffuse rash. Not everyone gets all symptoms.
We don't want to treat every tick bite with antibiotics for obvious reasons. As with everything, we need to strive for balance. We can't keep our kids in a box. Go out there and enjoy the hike, but then do that thorough body check and you should be fine. If you are a pet owner and you treat your pet with one of the flea and tick treatments, keep in mind that those ticks may leave the pet and go find someplace else to hang out!

Friday, May 12, 2017

Mother's Day Musings

Maternal -  How would you define that word? For me it evokes, unconditional love, guidance, nurturing.
For those of you in that middle generation, savor these years. You have your mom and your kids. If you are lucky, maybe there are some grandparents in the mix. Being the magic middle of the sandwich might present some challenges, but please TREASURE these years.
For the daughters and sons looking for the perfect gift, give the gift of time.
Go on a special outing, take lots of photos. The memories are more valuable than jewelry. Okay go ahead and throw in some chocolate covered strawberries, but you get the idea.
Actually forget the strawberries; give mom a nap!  Or a candle lit bubble bath (remove the bath toys!)
Make it a Mother’s Day tradition to tell your kids stories about your mothers, grandmothers, and great grandmothers. Did they have some favorite pieces of wisdom? Share them! Did they have some favorite songs? Sing them! 
On the other side of that coin, and not to put a dark cloud on the day for folks who are fully celebrating, but for many people Mother’s Day is one of those made up Hallmark Holidays that can range from being moderately uncomfortable to downright painful.
For me, it has been looming for weeks now like an impending shadow. This will be my first motherless Mother's Day. I am very aware and grateful I still get to revel in the wonderful relationship that I have with my daughters (and many of their friends), but but but but……..
Every time I turn on the TV or the radio, there it is, Mother’s Day, Mother’s Day, Mother’s Day. What are you going to buy your mother this year?  Where will you take your mother?  Show your mother how much you love her. Newspapers, magazines, Muni signs; Richard, my brother-in-law, calls it a capitalist plot.  It got me thinking. There must be so many of us out there. People who never had a mom, people who have lost a mom. Moms who lost a child, women who couldn’t have children, women who made the choice not to have kids but feel a twinge every once in awhile.
There are also so many wonderful families with no mommy but two amazing daddies.  How about immigrant families who are forced to be separated? The list goes on and on. Ouch!
What would my mom do? She would reach out and touch people who needed some love this week.
Let’s go back up to the word maternal at the beginning of this post. In my mind that word has very little to do with gender or biology. Who are the maternal figures in your life?. Reach out and give them a little acknowledgment (or a chocolate covered strawberry!)

Friday, May 5, 2017

Toilet training tidbits/Poop series Chapter three

Poop Chapter 3/ Toilet Training tidbits
Toilet training is one of those hot button topics that seems to have lots of very differing opinions. The most basic thing to pay attention to is how unique each of our children is.
My kids were no exception to this.
My first daughter Lauren was fast at everything she did. She was singing show tunes at 18 months. She was interested in the potty and was mostly trained well before she was 2.
But sure enough, she went through a period of horrible constipation. Watch out for those early kids. I see this happen ALL the time!
Alana took her time with all of the milestones. Having my older kid do everything so quickly made it feel even slower. She was slow to walk, slow to talk and not in the least bit interested in getting rid of the diaper.
Be careful how you ask the questions!
Me: " Hey Lani, don't you want to be a big girl? Do you want to wear these wonderful big girl undies?"
Alana: " Nope. I like being a baby. I like my diapers."
Hmmm, for some reason, that wasn't the response that I was expecting and I didn't have a follow up.
Just when I was figuring that this 'big for her age' almost 3 year old would need to start wearing "depends" all of a sudden she was magically ready. She asked for underwear and barely had an accident after that. As with everything, Alana waited until she was good 'n ready before doing anything and then simply mastered it.
(her first poop in the potty was 5/31/93 How can I possible know this???? Check out the "keep a journal post!" )
All the kids will get there sooner or later. If you wait until they seem ready, they can be trained within a week. If you start too soon, expect several months of aggravation. Watch your child's cues.
For all kids I suggest getting a selection of the children's books and videos about potties training. Let them get familiar with the concept that some day, big kids pee and poop in the potty or toilet.
Dr. Schwanke’s favorite is an old book called Toilet Learning, by Allison Mack. He likes that the sensible title helps parents recognize that it is learning, not training. He points out that this book might be especially good for boys. It is still available on Amazon.
Dr. Anne has had many of her parent’s report back that they have liked the Oh Crap potty training guide (also available on Amazon).
Regardless of which ones you choose, books can be a fun part of the learning process. There are lots of cute ones out there.

There are also all sorts of potty seats. Some have steps and fit over the toilet. Others play music. Talk about all of the options that are out there. Which one would your child like to try?
Let them watch you do your business. Although, most kids start out by sitting down, little boys and dads...go play the "sink the cheerio game" (I don't really need to spell that one out, do I?)
Do everything in your power to keep the stools soft. If you don't pay attention, you can be heading for trouble. Check in with all the different care givers for a daily poop report so that you are all aware if your child skips a few days.
Toddlers are now physiologically able to hold their poop. If they hold it too long, it will be uncomfortable coming out; this will make them want to hold it even more.
Make sure they are getting plenty of fluids and fiber. Perhaps have them help you bake some muffins full of prunes, and molasses and all of those wonderful 'make you poop' ingredients. Kids tend to like to eat what they help bake. See if they will drink a smoothie that they helped make in the blender. It is worth your energy to make sure those stools don't get hard enough to hold. Be creative!
Many kids will easily make the transition to the potty between 2 and 3. Wave a new package of big kid superhero or princess undies around and they may be sold.
Watch out for reward backfires. With Lauren we were offering some little M&M for each poop in the toilet. She proudly squeezed out a pea size piece of poop, pointed to the ‘no longer clean’ potty and received her treat...."but wait Mom and Dad...look there's more!"
Some parents have success offering limited use of the ipad or phone for potty sitting. Sometimes a simple star chart is all you need.
Aside from show and tell and talking about it, I usually leave the more recalcitrant kids alone until they are 3-ish. If they are in a tolerant daycare, exposure to some little friends who have made the transition makes a difference.
Disposable diapers are very absorbent and make it very comfortable for kids to hang out with a dirty one.
When your child seems ready, some folks find that they can fast track the toilet training on a warm week when they can have the kids run around naked. Most kids are not inclined to just pee anywhere when the diaper is off.  If a deadline is forced on you, such as acceptance to a preschool that only accepts kids who are potty trained, drawing a firm line in the sand and just getting rid of the diapers is the fastest way to do this. Make sure that you carve out several days at home where you don't need to be anywhere. Ideally you are not forced into this before you are all ready.
You may opt to allow this to happen in stages. For some reason most kids are way more comfortable tackling the pee issue but are much more reluctant to poop out of the diapers. Go ahead and work on peeing in the potty first. If necessary, let them tell you when they need to poop and then put a diaper or pull-up on for that.
Kids get involved in playing and often don't pay much attention to their body's cues. Get in the habit of taking them to the potty every hour or so. The adults who are watching them need to be consistent.
Make sure that they are wearing outfits that they can pull up and down easily so that when they do remember on their own they are not hampered by difficult buttons.
For your older kids, consider having them go to the store with you when you buy the diapers. Use cash. Singles if you have them. Show them the money that you give to the store every time you buy some diapers.
Look at some toys and discuss that when they are ready, instead of a box of diapers, you can perhaps use some of the money to buy that toy instead, but only when they think they are ready. Obviously this tactic works better when the kids are old enough to understand the concept.
As far as consequences, older kids are also ready to deal with stinky poop. I think they need to help you with a bit of the clean up process. Talk about how nice it would be if the poop went right into the toilet.
I would give some nice positive attention for any attempt at sitting on the potty and giving it a real effort. Set a timer and have them sit on the potty or toilet for five minutes when they are working on a poop. Give them a little place for their feet so that the knees are bent a little.
Consider having a written poop agreement that spells out any rewards that have been discussed. 
Dr Anne adds that language is important.
“What can we do to keep your new undies dry”
Being out and about with a newly potty trained child is an adventure. You will quickly learn which friendly merchants have clean and accessible toilets that you can run in and use.
You will learn to watch out for the tell tale signals. The hand down at the crotch and the jiggling up and down usually mean you have a minute or less to find a bathroom. I used to have an inflatable potty in my trunk that came in handy on many occasions.
Do not shame or yell at a child who isn't quite ready. If your child is over 3 ½ and you don't feel that you are making progress, it might be time to talk to the pediatrician to see if we can help you move forward.
Night time is a whole different issue. I suggest working on the toilet training for during the day and using pull ups at night. Wait until your child is waking up dry or asking to get rid of the night time pull ups before you tackle this.
Below is a drawing that my 4 year old nephew Andy drew during the process.
For those of you who have trouble translating the message, the left side is pee and poop on the floor and the right side is the successful poop in the toilet.