Friday, June 30, 2017

Swimming 2017/An advice nurse's guide

While significant hazards from swimming are rare when safety precautions are in place, there are quite a few issues that the advice nurses deal with on a regular basis.

A common question from families going on vacation is when is it safe for a baby to go into the hotel pool. In general I don’t recommend optional travel until your baby is several months old and has had their first set of vaccines (two sets is better). I am assuming that you are sensible enough that you aren’t planning on taking your one month old on a tropical vacation. If your baby isn’t brand new, then generally my answer about getting into the pool is “sure!”, but there are several factors to consider.

For young babies, a little splashing is okay, but I wouldn’t let them submerge their heads until they are old enough to keep their mouth closed. There are claims that very young infants are natural swimmers and don’t take in a lot of water; I prefer not to test that out. A big gulp of chemical filled water is yucky.

Is the pool outdoors? We all need to be careful with sun but baby’s thin skin is especially vulnerable. Babies need to have a big floppy hat and perhaps sunglasses and sunscreen. Just this week one of our fair young babies got a rotten sunburn on his face  (and it wasn't even particularly sunny out).

Be aware that the reflection from the  water can add to the risk of burning and remember that sunscreen does need to be reapplied even more often if the kids are getting wet. Get in the habit of paying a moment of attention to everyone’s skin at least every 15 minutes. If they are getting pink, it is time to get out of the sun. Don’t wait until they are bright red. While it is true that my fairest patients are the most at risk for a sunburn, all skin pigments should be protected. Shade is best! There are some cute little umbrella baby floats that offer quite a bit of shady protection if you are in a pool.

The next factor is the water temperature. Young babies don’t regulate their body temperatures very well, so make sure that any pool water is nice and warm and that the outside temp isn’t too chilly for them. Most hot tubs and Jacuzzis are too hot for young kids. For any of my older patients and families who enjoy the hot tub, be on the lookout for any pimply rashes that shows up within the next several days. These are often bacterial and may need to be treated.

Anytime you are hanging out at a pool please wear flip flops when wandering around poolside or in the locker room. Fungal infections and athlete's foot happen! A spray bottle with some diluted vinegar solution to spritz on the feet, followed by making sure that the feet are very dry before putting shoes and socks on, are good preventive measures.

Little girls that spend a lot of time wearing a wet bathing suit can also get irritations. It is a good practice to get the kids out of the wet suits as soon as possible. Do a good rinse off as soon as you can and then apply a nice moisturizer to avoid exacerbating dry skin.

We also get a bunch of calls about swimming and ears. If your child has had a recent ear infection they are fine to swim as long as the tympanic membrane is intact. If your child has had ear tubes or a recent ruptured eardrum, they should NOT be submerging their ears in the water (or the bathtub for that matter) without having protective ear plugs.  Sound Speech and Hearingmakes custom ones with sparkly color options that may help with compliance.

If your child has been doing a lot of water play, they may be prone to otitis externa (better known as swimmer's ear.) As opposed to an inner ear infection that requires an otoscope to make a diagnosis, an outer infection is often visible to the naked eye. The ear looks red and sore and may have some drainage. If that is happening, it is worth an office visit so that we can see what’s happening and prescribe some antibiotic ear drops if warranted. Keeping the ear canal as dry as possible may help prevent this condition. There is a simple proactive measure that can be cheaply and easily made by mixing equal parts of rubbing alcohol and white vinegar (50:50 mixture). This solution will increase the rate of evaporation of water in the ear canal and has antibacterial properties. Using this solution to rinse the ear before and after water exposure can help protect against infection.

If you are planning on swimming in open water (lake, river etc) make sure you check ahead of time to make sure there are no advisories. There are some local lakes and rivers that occasionally have some toxic algae bloom that I would not have wanted any of my patients to get near.

I mentioned that drinking pool water is yucky, but I am going to double down on the yuck factor in some lakes and rivers. These are the kids that end up with Giardia. A good rinse after swimming and making sure no water is ingested in very important.

Most of my local families know to be very wary of our local Ocean Beach, but if you are traveling to a place with a warmer and more inviting ocean, never turn your back on the water and beware of currents and strong waves.

Okay, don’t let the “Debbie Downer Advice nurse” spoil your fun. Go have fun swimming!

Some studies claim that  participation in formal swimming lessons is associated with a huge reduction in the risk of drowning. Many folks like the idea of swim lessons for their children as part of their normal routine, not just reserved for vacations. We don’t usually recommend formal lessons until your child is at least 6 months old. For the most part, swimming lessons for kids under 3 years are all about getting your child comfortable in the water. As a bonus, water play is a healthy form of exercise for the entire family and may improve motor skills.

If you are looking for swim lessons, here are some of the great options here in SF. Here are some of the more popular options

La Petite Baleen Swim School . They have several different sites. The one in SF is in the Presidio at 933 Mason St.  866-896-3603

3200 California St
San Francisco, CA 94118 Phone number (415) 292-1200

Mission Bay 1675 Owens St
Phone number (415) 514-4545

There is an indoor and outdoor pool here with all sorts of options for just swimming with your baby or doing classes.

there are several branches in SF that offer swim classes. The May/June sessions are likely full already, but if you plan ahead you may be able to join some July classes.

Stonestown  415-242-7100
Presidio 415-447-9622
Embarcadero 415-957-9622

The city pools also have some classes available but they also fill up fast. Register at to sign up for swim lessons ( and other great classes). This website will also give info about the city pool hours if you are interested in just having some pool time with your kids and skipping the expensive lessons. You may want to go by yourself first to scope out the water temperature.

My kids grew up going to the Janet Pomeroy Center. This is out by the zoo at 207 Skyline Blvd. It used to be called the Recreation Center for the Handicapped. The lovely thing about it is that the pool is very warm. They have several slots every week where you can go and play in the pool with your child. It is reasonably priced, but you need to call to enroll in advance, They don’t have any drop in sessions. The phone number is 415-665-4241

Do you have a pool that should make the list? Please share the info and I will add it to the post.

If your child is enrolled in swimming classes and they have a mild cold or cough, they can probably still go swimming if they are feeling up to it. If they are vomiting or have diarrhea, do everyone a favor and keep them out of the pool!

Saturday, June 24, 2017

Water safety/Secondary and Dry Drowning

When frightening stories make the news, I know that I can anticipate some calls about whatever the issue is. There were some recent stories in the media about secondary drowning. Several parents have reached out and asked me to address the topic in a blog post. Next week I will continue the swimming theme. I had it all rolled into one but it was way too long. You would be surprised how many different body parts we get calls about that are swimming related. You can read all about those next week.

Let’s get the scary stuff out of the way first. Drowning is the second most common cause of death in children in the United States. Prevention is key. A person who is drowning may not thrash about and call attention to the fact that they are having trouble. They can slip silently under the water without being noticed until it is too late. Even if your child has proven themselves to be solid swimmers, you need to stay actively focused and engaged on watching them like a hawk while they are in the water.
If you are staying anywhere with a pool, make certain that your child has absolutely no access to the pool area when there is no adult present. If you do have pool access, there are lots of pool alarms and safety monitors on the market. Hotels or apartments with fountains need to be treated with caution as well.

We had a scare with one of our families a few summers ago. Several adults and children were enjoying a day at a friend's pool in the East Bay. They got out of the pool to have some lunch. Some of the oldest kids started to bicker. While the adults turned their attention to the squabble, a one year old got back into the pool unnoticed and submerged. Thank goodness another of the adults looked up, noticed and was able to get her out and perform CPR. The little girl is perfectly fine, but this was terrifying for everyone. Dr. Karen Makely, one of the wonderful urgent care physicians over at St. Lukes, says that sometimes having a lot of adults around lends a false sense of security. Consider having each adult take turns being on a shift as the designated lifeguard.

Drowning is horrible, but the recent stories that scared the bejesus out of my families were about delayed drowning. You may have heard of dry drowning as well. They are not the same thing.
The primary difference between dry drowning and secondary (or delayed) drowning is the presence or absence of water in the victim’s lungs.

Dry drowning is something that can be brought on in several different ways. The first theory is that a sudden rush of water into the throat causes the airway to go into spasm. During this event, although no water enters the lungs, no air enters either, so the victim dies of asphyxiation. Another explanation is that  the shock of a swimmer’s suddenly entering extremely cold water causes the heart to stop.

Distinct from “Dry Drowning” is secondary or delayed drowning. This is also very rare, but  is something that parents need to know about. Symptoms usually develop within 6-24 after an incident. If someone had a near drowning or accidentally swallowed a lot of water, they are at risk for pulmonary edema from the fluid imbalance to the lungs. They may seem fine initially but then present with cough and increased labored breathing. This usually shows up within 24 hours of the event.

Caregivers of young swimmers should try to head off some of these issues by training their kids to keep their mouths closed when jumping into water and to enter very cold water slowly.  This should help avoid aspirating large amounts of water. There is a big difference between water in the lungs and water in the belly. If your child swallows a lot of water they may end up with a tummy ache but it is rarely dangerous. The recent tragic news story about a child who died in Texas with this diagnosis is a bit of a puzzle. He had days of vomiting and diarrhea. Every physician that I spoke to says that it is respiratory, NOT tummy symptoms, that they would be on the lookout for. There is likely more to that story than is getting reported. It is the outliers that make the news.

Here is the takeaway message. It is important to closely monitor any child who has come out of the water coughing and sputtering. Especially keep an eye out for any further difficulties in breathing, extreme tiredness, or marked changes in behavior, all of which are signs that a swimmer may have inhaled a dangerous amount of fluid. If there is any concern, an emergency room or immediate medical intervention is needed. The first 24 hours are probably the most critical period. It is important to know what to look for, but to reiterate, in over 30 years with a practice full of swimmers, I am not aware of any of our patients having any serious complications from a mouthful of water. 

I spoke to Dr. Tamariz from the CPMC ER. He reiterates how extremely rare this is, but stresses that if any CPR or resuscitation was needed, a follow up emergency room visit is essential regardless of how well they may appear. For the majority of swimmers that accidentally get a mouthful of water, observation at home is fine unless they are showing the obvious symptoms that are listed above. If you are concerned, go the the emergency room. They will check the oxygen level, listen to the lungs, and keep an eye on things until everyone feels comfortable. If clinically indicated they might do an x-ray but it is not automatic.

I am going to close with a little tidbit of common sense. Labored respirations should ALWAYS prompt you to seek medical attention, even if there is no concern about recent swimming.

Next week I will continue the swimming theme, sharing all the possible swimming related call that the advice nurse team receives!

Friday, June 16, 2017

And now a word from Mr. Nurse Judy - Father's Day 2017

Happy Father's Day to all who are celebrating this weekend. 

Warning: Last year when Sandy wrote his first Father's Day Post for my blog, I got reports of parents sniffling all over Bart. Welcome to "Mr. Nurse Judy's" annual post.
XOXO  Nurse Judy

I want to thank you all for the kind comments I received after last year’s post about my wonderful relationship with my children, a relationship that continues to get better, even now as I close in on the end of my 6th decade of life, and my daughters near the end of their 3rd decade. It is a role that is paramount to me, and I refuse to let time and distance interfere with my efforts to continually improve it. So far, I think I’ve been pretty successful, and the rewards are immeasurable. Certainly it’s a lot easier when they are young, living in your home, and “need” you to be involved in their lives. But the foundation you create early for how you want that relationship to be makes it a lot easier to enable it to grow, flourish and blossom at any stage of life, even now as they establish their own lives, careers, and relationships. For those of you who didn’t have the chance to reads last year’s post, you can find it here:

I want to make clear that I have no special training or educational background in this area. What follows are simply my own philosophies about fatherhood; you may disagree with some or all of them. But this is what has worked for me and I cannot really imagine a father with a better relationship with his adult kids than I have!

So first an update on my relationship with my daughters.  At this time last year, Lauren and I were weeks away from traveling to Tanzania for the challenge of a lifetime. AND WE DID IT!!! We summitted Kilimanjaro on the morning of July 19th, an absolutely grueling climb that took me to the very limits of physical, intellectual, and emotional endurance. In fact, I couldn’t have done it without Lauren’s support, and I was quick to make sure she knew that. We spent two weeks together in very close quarters, most of that time unwashed, extremely sleep deprived, and cold. Summit temperature was 24 below zero! The only cross words that were exchanged were over a misplaced towel (I both misplaced it and spouted those cross words!) I never want to face an ordeal like that again!! At least not until April 2018 when we climb to the base camp on Mt. Everest! See – the relationship just keeps giving!

If you are an avid reader of Nurse Judy’s blog, you may remember that when she was in grade school, Alana ended every night by telling one of us all about her day…in exquisite, and often lengthy, detail! The big, the little; the important and the minutiae. Well, more than 20 years later, I get to do that with her all over again. Every day. And I look forward to it and resent it when another friend has a need for Alana’s time! After obtaining her MSW last June, Alana is now a practicing therapist in a community mental health center in Michigan. She has about a 30-minute commute in each direction and on her car ride home, I get to keep her company!!!! And we talk all about our respective days. The time flies past and she is home before we both know it, but not without each of us learning a little bit more about something in each of our lives. What I have primarily learned is that her counseling clients are the luckiest people in the world because they have Alana as their therapist. I listen in wonder and respect as I get to share in the progress they make dealing with the issues that brought them to her in the first place. She is changing lives on a daily basis and I get to be the fly on the wall. I am overjoyed that she still wants to spend that time of her day with me. I frequently tell her that I am in awe of what she is doing and remind her that she has to take the time to sit back and reflect on that also, and not just move on to the next client…  which brings me to my first point of this year’s father’s day recommendations for building that relationship with your children:

Find reasons to be proud, and praise them whenever you can!  From the first time they can lift their head by themselves, to the first crawl, to standing up, and that first use of the potty, let them hear your voice filled with pride and encouragement. Let it become ingrained in them that you are their number 1 supporter, for both the little and big accomplishments in life.  As I mentioned last year, that’s why I took a day off of work to go see a very shy 2nd grade Alana (right now, all her friends are saying “who the heck are you talking about?”) get up on stage just to say one line in a play; it was a grand small accomplishment that deserved to be recognized. When younger, even though they can’t understand the words, they can hear and feel the sentiment in your voice, and for the rest of their lives, that sound will provide great sources of satisfaction and comfort, and it will provide a lifetime of encouragement for future exploration. Now, I am not one of those in favor of participation trophies and I am not saying that everything they do should get this level of exuberance. But be generous with the praise, especially in their formative years.  This brings me to my next recommendation:

Value the efforts too, not just the successes! There is an old saying that good judgement comes from experience; experience comes from bad judgement! It is a cycle that cannot be completed without falling down. So let them fall down, but don’t bemoan the failure; commend the attempt, and any part of the effort that will help them gain “good judgement” next time. It is quite easy for children to focus on your critical evaluation of whatever it is they are attempting, while underappreciating the praise you may simultaneously be conveying. For example, if you’re trying to teach them to throw a ball, don’t focus on the fact that the ball landed by their feet. Appreciate that there are things they may simply be incapable of at any given age. It’s up to you to understand that, not them, so focus on the things that they can do well (gripping the ball, placing the feet, shifting the weight…) and celebrate these building blocks that will one day end up in those ultimate tasks being that much easier, and enjoyable! Simply focusing on the failure of achieving the end result will certainly lead to frustration, and possibly anger and resentment.

It's ok to be wrong. In fact, it’s good! Admit it, and apologize!It is sad when I see a parent who either insists they are never wrong, or twists circumstances to make it seem that they were not wrong in a specific situation. It’s very easy to play that mental game with a child in an effort to demonstrate that you always know what’s best, or think you will be respected because you are always right. Satisfied that you out-strategized a child in this mental arena? Get over it; it’s not that hard. And it’s not that smart. I (and I think my daughters would agree,) created some of our most profoundly important relationship building moments by admitting I was wrong about something, and apologizing for it. Think about it – is there anything more empowering to your young child than having a person in a position of authority implicitly say to them “I not only heard you but I really listened to what you had to say. I thought about it with all my years of advanced experience, education, and knowledge, and I realized that you were right and I was wrong.” Trust, confidence, consideration, kindness, communication…. there are innumerable benefits to acknowledging your own fallibility to your child! And it tells them it’s ok to be fallible too! You don’t expect/need/want perfection, and they don’t have to live up to that standard. And it teaches them that being wrong is a part of life, not something to be defensive about, and can be dealt with responsibly and respectfully.

Tolerance! I mentioned above that you should “appreciate that there are things they may simply be incapable of at any given age. It’s up to you to understand that, not them…”  You must acceptvery early on that you are incapable of thinking like a child, nor they as an adult. Kind of like the “Men are from Mars, Women are from Venus” paradigm, you and your children speak the same language, live in the same environment, are familiar with the same behavioral mannerisms, yet you have such different frames of reference, experiences, emotions, intellect…that at times it will seem to each of you that the other is speaking a foreign language. And you are!! It is so very easy at those times to get frustrated, and even worse, angry. But it is unrealistic for you to expect them to be able to think, analyze, and express themselves at the level you do. They don’t have your emotional and intellectual development and it is unfair to simply use your advanced capabilities as the measure of their intent. When you feel that coming on, take a break, remind yourself of this, and try your best to see things as they do. You most surely won’t completely succeed, but every little bit of empathy you can muster will bridge that gap just a little. It’s also never a bad idea to voice this self-realization; let them know that you are consciously aware that you are cross communicating and invite them to help think about how each of you can get your respective thoughts out. They’ll develop patience, compassion and problem solving skills!

Establish ground rules for how to disagree! My girls and I had a very useful rule – we weren’t allowed to go to sleep mad! The rest of the argument or disagreement could proceed along its natural course, but ultimately it had to end at this rule. It was really quite simple in its effectiveness since it forced (encouraged?) us to resolve our differences. There were times long after bedtime that one of them would either come out of their room to say “I’m still mad” or amusingly, would slip notes under our door detailing the issue (Alana was the talker; Lauren the writer!) This led to frequent comical exchanges of notes going back and forth under each other’s doors but it was such an easily understood rule that it almost always worked! The key though is to take it to heart! As my brother-in-law sometimes says “gravity, it’s not just a good idea, it’s the law,” my daughters and I made this a law, and if one of us was “violating” the law by claiming fatigue, or anger, or issue complexity, or…etc., the other party was free to demand that we follow the law, sometimes leading to late nights and missed bedtimes! But always successful resolutions of the issue. And guess what? Most of what I wrote above represents the philosophies that I tried to use to help make sure each day ended on a happy note.

Happy father’s day to all. See you next year when we get back from Everest!

Friday, June 9, 2017

Slap Cheek 2017

Slap cheek is one of those illnesses that seem to come around a couple of times a year. I have seen a number of patients with it this week, so it appears that it is starting to make the rounds.
This virus is also known as Fifth disease or Erythema Infectiosum. (Fun fact - it got the name Fifth disease back in the 1880s when childhood diseases that caused rashes were referred to by a number. This was number 5 out of 6. Others on that list included measles and scarlet fever.) This one is caused by Parvovirus B19.

Just like Hand Foot Mouth, Slap Cheek is a fairly contagious rite of passage. It is mostly spread through respiratory secretions, but can also be carried through infected blood. Most people get it while they are still children (usually between 4-15) and thus have immunity as adults.

Unless we had a bad case of it most of us don't actually know whether we have had it. You can check with Grandma, but I bet she doesn't remember either. The symptoms may have been mild enough that no one paid much attention. This illness can be quite variable. Some kids don't seem too impaired while others are miserable. The really mild cases can present with a child who has a red chappy cheek for a day or so, and that's it! The sicker kids can be achy (joint pain is common for those old enough to voice their complaints) and fussy with high fevers on and off for several weeks. The common denominator (hence the name) is one or both cheeks usually appear very red and chappy. For most patients, the red cheeks are followed by a lacy, mottled rash that works its way up and down the body.  It tends to cover the arms and legs more than the trunk. (Of course there are exceptions; some kids don't read the textbooks and present any which way that they like.) There may be several days in between symptoms. Some kids look flushed when they have a fever no matter what, so red cheeks aren't definitive. This diagnosis has some guessing involved.

Very rarely kids can get quite ill with this. In my many years here, I have NEVER had any patients who didn't get over it completely and without any lasting adverse effects, so relax, but remember Nurse Judy's rule; any fever that is lasting 4 or 5 days needs to be checked on.

I will reiterate one of my common statements. When your child is sick you have a choice. Are you mostly feeling sorry for your poor little one who is clearly feeling crumby or are you deeply concerned about them. If you are really worried, regardless of what we think is going on, it is absolutely worth having your child checked out. Four out of five of my patients with high fevers might have slap cheek, but that fifth might be the one with strep throat. 

The most important thing to note about slap cheek is that it can be dangerous to a fetus. If a woman is infected in the early stages of pregnancy there is an increased chance of miscarriage. Keep in mind, most women had this as a child and are therefore not at risk. But since most people also don't really know if they had it or not, It is best to avoid contact with pregnant women as much as possible if your child has been diagnosed with slap cheek. If you are pregnant and may have been exposed, talk to your OB about getting a blood test to check your immunity.

The incubation period is thought to be about 4-21 days after the exposure. (In other words if you come into our office and walk out with a red cheek, you didn't get it here; that would be way too soon.)

The kids are most contagious at the very beginning of the illness when the main symptom is probably simple fussiness. The cheeks might be red, but you reasonably figure that this could simply be caused by being a little warm. Frankly, by the time the rash is in full throttle they are probably not very contagious anymore. Often patients have some congestion as part of the package.

Treatment is symptomatic. Treat the fevers as needed with Tylenol/ Ibuprofen and tepid baths. Make sure your child gets plenty of fluids and rest as needed.

My best daycare, camp and school guidelines are to keep a child home if they are fussy or have a fever, but if you have a happy child with a red cheek, it seems unreasonable to expect you to stay home from work. Chances are, once one of the kids in daycare shows up with it, everyone has already been exposed.

This virus can cycle on and off for a few weeks before it is done with  you.

Sunday, June 4, 2017

Sunscreen 2017

In honor of Summer's imminent arrival, I am going to dust off, tweak, and rerun my sunscreen post. 
I still maintain that a little sun exposure here or there is not the end of the world; it feels great and gives a dose of vitamin D. That being said, no one should get too much unprotected exposure. Sunburns are not only painful, they can lead to skin cancer. The scientists are telling us that too much time in the sun, even if we don't burn, should be avoided. The most recent studies are even more alarming, demonstrating that the increase in melanoma cases being seen have an absolute connection to sun exposure.
Sun can do the most damage to our skin between the hours of 10am and 4pm. Reflection from water and/or snow can make any exposure more intense.
The link below will lead you to  a great little site that can tell you what the UV risk is on a particular day depending on where you are.
Your best bet for preventing sunburn is of course is to stay in the shade when possible and also wear a big floppy hat and loose protective clothing. Have a parasol or a shade umbrella over strollers and baby carriers. Pay attention to babies in backpacks; they might be getting more exposure than you are aware of. Umbrellas are not foolproof. You can also get sun exposure through glass. Pay attention to the car seat.
Eyes can get damaged from the sun. Do your best to get your child used to wearing sun glasses. The lighter the eye color, the more sensitive they are likely to be, but everyone should wear eye protection.
Don’t forget about lips! There are lots of chapsticks with SPF protection.
The fact is, even if you are very careful, if you are out enjoying life, it is very difficult to eliminate all sun exposure. If your child is under 6 months old and the choice is sunburn versus sun screen, choose the sunscreen every time!  If you are using a sunscreen for the first time, do a test patch on one small area on a thigh or wrist a few hours before sun exposure. If you slather your child with a new sunscreen, spend a day out  in the sun and then they break out in a rash, we would have to figure out if it is heat? sun? sunscreen? Doing a test patch first assures you that it is not the sunscreen that is causing the rash. For older kids, the use of a sunscreen should be routine. Nurse Jen had a great idea that works with her little girls. They apply a daily sunscreen to their face with makeup brushes. What used to be an ordeal has turned into something fun. Great habits now will avoid wrinkles and potentially serious skin problems later on.
Apply the sunscreen at least 15 minutes before going out. 30 minutes is better. Ideally put it on before the clothes go on to make sure you don’t miss a spot. For significant sun exposure, sunscreen needs to be reapplied at least every 2 hours, even if they claim to be waterproof.
Don’t forget the feet!
Quite a few studies  state that It is not worth getting any SPF that is over 50. These studies suggest that they don't offer a significant increase in protection, just more chemical exposure and a false sense of security. Get a lotion that protects against the UVA and UVB rays. The cost does not necessarily correlate with the better choices.
There are several reasons that the sprays are not your best option. It is easy to miss spots with the sprays and inhalation can cause problems. The biggest concern for me though is that they can be flammable. There are some nice mineral powders out there, but with those, it is also really important that you child doesn’t breath in the particles. Lotions and sticks don’t have those issues. Below is a list of some of the better sunscreen choices.
The Environmental Working Group has listed their best kid sunscreens:
While the FDA maintains that there is no data showing that there are safety concerns, the EWG suggested avoiding any products that have retinyl palmitate or oxybenzone.
With good options available, why take a chance.
We need to be a little more protective of our fairest kids. If your child is out with a nanny or friend, don't hesitate to remind them to be on the "sun protection patrol". Trust me, sunburns are just as painful for the grown up who lets it happen on their watch.