Friday, July 21, 2017

Back to School: from Vaccine requirements to Adjustment tips

Back to School: from Vaccine requirements to Adjustment tips

When I was young, Summers were sacred and school started after Labor day. I am not sure when that shifted, but it seems that these days many of our patients start school in mid August. I am putting this post out now to hopefully avoid the panicked parents who call, needing an immediate check up, sports form, or updated vaccination record prior to school entry. In our office our checkups are already very booked up, so if you haven’t done so already it is probably too late to get in under the wire, but call NOW for any chance of getting in sooner. Below  is the standard school form if you lost yours:

School Form for SFUSD
This is the most updated one that I was able to find online.
There is no charge for forms filled out at the time of an exam.
All other forms have a $10 fee and a one week turn around time
(We try to get to them sooner but there are no promises.) Rush forms  will be done within 48 business hours. There is an additional fee for this.

Take a deep breath. Most schools will accept a promise of a scheduled check up as long as they have an immunization form that is complete. We are happy to work with our families to at least get you scheduled for some of those shots that are needed even if there isn't a check up appointment with the doctor available before school actually starts.

As most of you are aware, In June of last year, California Governor Jerry Brown signed Senate Bill (SB) 277 into law. This law went into effect July 2016. For the school year beginning August/September 2016, all children going into kindergarten, seventh grade or transferring to a new school for the first time had to be fully vaccinated or have a medical exemption. Personal or religious exemptions are no longer accepted.
There is a conditional entry for children who are not fully up to date, but they must have at least one of  all of the required vaccines.

The schools will be checking in to make sure that the series are completed in a timely manner. School districts already have their own systems for tracking and following up with kindergartners who are not fully immunized. Whatever systems the districts are already using will remain in place. Check out this valuable link for a complete list of what is required: Shots for School

For our younger patients, most licensed day care facilities also have a fairly strict vaccination policy. Those requirements are also listed in the above link. That website also has a feature where you can check out your school or daycare to see how well they have been doing in their vaccination efforts.

7th grade  is also the perfect opportunity to vaccinate with the other ACIP (the Advisory Committee on Immunization Practices) recommended vaccines for 11-12 year olds, including HPV and MCV4 (meningococcal).  Students entering the 7th grade  will need to show proof of a Tdap (Tetanus, Diptheria and Pertussis) booster. They also must show proof of two doses of the MMR vaccines.

Vaccinations are only one of the requirements for school entry.
Kindergartners must have a complete physical examination within 6 months prior to entering school. We try to avoid doing the well child exams prior to March for this very reason.

We routinely check their vision, hearing and urine as well as reviewing general health and development. In my opinion, these annual visits with your primary doctor  are just as important as getting the shots.

California law also requires that by May 31st each year, students in their first year of public school must submit proof of an oral health assessment performed by a licensed dental health professional.

I haven’t come across anyone being denied entrance if they haven’t been to the dentist, but it is good idea to be current with the Dentist regardless of the laws:

Routine testing for tuberculosis is not required for SF public schools. Rather than testing every child with a skin or blood test, the San Francisco Department of Public Health strongly supports a medical provider's risk assessment for TB as the universal screening requirement for school entry.  Only children identified as having one or more risk factors for TB infection will need to be tested. The most common risk factors are

  • Contact with a family member with history of or confirmed case of TB
  • Foreign born family or adopted  from country with a high-prevalence of TB
  • travel to high risk country
  • HIV contact
  • family member who has been in jail during past 5 years
  • frequent exposure to homeless, users of street drugs or residents of nursing homes
  • Clinical evidence of TB: Cough lasting  longer than 3 weeks, coughing up blood, night sweats, fever, weight loss.
If you do get your child tested you have 2 options. The PPD is a test applied to the inner arm that needs to be checked 48 to 72 hours after it is placed. There is also a blood test available calledQuantiferon. It is a little more accurate than the skin test, so if you have a real concern, that is something I would consider.

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

Okay, aside from the forms and the shots, first day of school, especially if it is a new place is an emotional time. Some kids are excited while others are stressed.

This is a great time to read some books or tell stories about school. If your child has some separation issues, consider giving them a hankie that smells like you that they can put in a pocket. Maybe get a set of best friends necklaces for you and your child to wear and you can look forward to matching them up at the end of the day.
It is a bonus if you know a nice friend who will be in your child’s class. Play-dates together before school starts can help smooth the transition. If you don’t know anyone, some schools will host a back to school event or offer up a roster. Don’t be afraid to cold call one of the new families and introduce yourself.

Try to carve out some extra time during the bedtime routine where you can have your kids tell you all about their day. Don't fall into this common trap:

"How was your day?"

Ask specific questions such as:
Tell me about the kids in your class.
Tell me about the teachers
Share something interesting that you learned today.

Alana loved going into the minutiae of her day so much that she never stopped (you should be so lucky!) This 27 year old calls her daddy daily as she commutes home, and tells Sandy all about her day.

Every year might be different. Some kids who didn’t even look back to say goodbye one year, might pitch a fit in another. Lauren had no trouble saying goodbye to mom and dad her first several years at school until she was in third grade and Alana was in Kindergarten. The Kindergartners day ended earlier than the rest of the school and somehow Lauren found that intolerable. If she caught glimpse of me picking up Alana, she got weepy. I remember having to sneak through the school grounds making sure that there was no way Lauren would see me until it was time for her to go home as well.

It has been several weeks since I have sent out a post that mentioned poop. so I will add one more tip. Please make sure that your kids don't get constipated.  This is pretty common during the back to school season. There are several reasons for this. Some kids tend not to drink as much. Others are simply having too much fun or don't want to get up to leave a classroom. Most kids (and some adults) simply have a strong preference for pooping at home  Some mornings are rushed and there isn't time for a relaxed pooping routine. Keep your antenna up. There are lots of kids that just won't poop at school. Don't let them get backed up.

Prepare for the onslaught of germ season. Good hand-washing habits can help.

Friday, July 14, 2017

How loud is too loud? Protecting your baby's hearing.

With the recent July 4th holiday, a few folks were asking me if the noise from the fireworks could cause hearing damage. Any noise can cause problems if it is loud, close and prolonged.

Mammals are born with lots of very tiny and delicate hair cells in their inner ears. These cells help to amplify sound. Your baby's ears are more sensitive than those of an adult. Not only do they have thinner skulls, but they also have a full complement of these little hair cells, so sounds will have full amplification. Exposure to loud noises over our lifetime damages these cells. As we get older the higher frequencies tend to be the first sounds that we lose the ability to hear.

Your baby's hearing actually starts to develop between 24-28 weeks of gestational age. It is thought that the noises they hear are slightly muffled (imagine what it feels like when you are under an inch or so of water). They can certainly hear well enough that they seem to recognize the voices of those who have been talking to them while they were in utero. I am certain that both of my babies knew my voice immediately.

So yes, we need to make sure that we protect our baby's hearing, but the fact is that all of us need to pay attention to loud noises that can lead to hearing loss.

To give you an idea of how loud various sounds are, take a look at the following list:

Whisper                                         30 decibels
Normal conversation                     60
Telephone dial tone                       80
Traffic noises from inside a car     85
Bart train                                       90 (range from 73-99)
Power mower                               107
Stereo headset                             110
Emergency vehicle siren              110-120
Sand blasting or rock concert      125 
Gun shot                                      140

There are a number of free apps for your smartphone that can act as sound meters. One that my nieces told me about is called Sound Meter  

I played around with it the other day in the office when there was a screaming child in every exam room. That meter went right up!

The longer the exposure to loud noises, the more damage that can be done. OSHA has guidelines set for safe exposure on the job.

85     decibels for 8 hours
88     decibels for 4 hours
91     decibels for 2 hours
94     decibels for 1 hour
97     decibels for 30 minutes
100   decibels for 15 minutes
103   decibels for 7.5 minutes
For those of you who recognize a pattern, good for you! For every 3 decibels over 85, the safe exposure time gets cut in half.

Okay, so what do we do with the above information?  

  • Make sensible choices.
  • Make sure that all earbud or headphones that your kids use are turned down to a reasonable level.
  • Avoid environments where your child will be subjected toPROLONGED long noises (That BART platform is probably not going to cause any trouble unless you spend a lot of time down there.)
  • If you know in advance that you will be in a super noisy place, consider some of the new baby friendly volume limiting headphones...see below for some choices

I have actually had parents call me to ask if it is okay to take their baby to a rock concert. My "NO" possibly reached 100 decibels.

Even though most babies in this country are given a hearing test before they leave the hospital,  it is a good idea to have your child's hearing tested on a regular basis once they are over the age of 3 or 4 (sooner if you have concern.) 

When hearing is assessed, there are two different factors that are measured, the frequency and the loudness. The loudness of the sound is measured in decibels. The frequency is measured on the Hertz scale. The lower tones are the lowest numbers. People with the sharpest hearing may be able to hear frequencies ranging from sounds with tones as low as 20 hertz and as high as 20,000 Hertz. A sound higher that 20,000 is known as ultrasonic. Some animals, dogs for instance, can hear much higher frequencies than humans. Human speech tends to fall between 1000-5000. A patient passes our basic office test if they  can hear a range of frequencies from 500-4000 at the level of 25 decibels.

Any in-office hearing test has the risk of being inaccurate, especially for patients under the age of 4. I have had a patient who flagrantly failed the test, but when I told them I have a secret question, stand behind them, and whisper, "would you like a sticker?" They usually answered, "yes please."

If you are concerned about your kids' hearing (and remember there is a great big difference between hearing and listening), play a whispering game with them and see how they do.
If we all agree that your child is actually having trouble hearing, the next step will be a visit to an audiologist for a much more accurate exam and/or a visit to the ENT specialist.

Thanks to the ladies at Sound Speech & Hearing  for sending information about the following options for hearing protection:

  • We recommend volume limiting headphones for little ears... Puro Sound makes excellent ones which were rated #1 by the NYT Wirecutter this past year. Link here: - kids wireless headphones These are also good for teens and adults who are into really loud headphones (like the popular Beats by Dre, which can hit 110 dB, and become unsafe quite quickly). You can use code SOUND (as in our clinic) for 10% off at anytime.
  • Best hearing protection for babies - earmuffs that have a stretchy headband. We recommend Em's 4 Bubs: ems-for-bubs-baby-earmuffs
  • Lots of options for toddlers and kiddos. We like Baby Banz and Em's 4 Kids. Teenagers exposed regularly to loud sound (example, playing in a band) can invest in custom hearing protection with special filters: tru-customs

They also shared this excellent link

This post is an update of one that I ran several years ago. That one was prompted by piece that the New York times ran about sound machines in babies' rooms.

That question still comes up once in a while. As long as the sound is on a low setting and not directly up against your baby's ear, you don't need to worry. Just be sensible.

Friday, July 7, 2017

Sippy cups/ time to find a better alternative!

One of my favorite aspects about doing these blog posts is that I am constantly learning.

I recently heard and read some opinions about the downside of sippy cups. A child who completely skips the sippy cup stage is the exception rather than the norm, so this seems like something worth looking into. I set aside some time to pick the brain of Jennifer Katz, who is a well known speech therapist here in the Bay Area.

Speech therapists are expects on the movements of all of the mouth and tongue muscles. My time with Jennifer was very informative. She explained to me that as babies grow, their swallow pattern should change and mature. The way in which an infant swallows involves a tongue thrust that is necessary for sucking and latching. As the babies grow, we would expect that they should be moving away from this pattern. With the more mature swallow, the tongue rises higher in the mouth and can do wave like motions that are needed for dealing with more textured foods. Drinking from a sippy cup prolongs that infant tongue thrust.

It isn’t just about eating. When the tongue doesn't elevate, it will tend to rest forward in the mouth and this can impact speech and language development.

In extreme cases, kids can end up with high narrow palates and lower, more forward jaws. Those kids can in turn end up being mouth breathers with an increase in drooling issues. This is the proverbial slippery slope.

Most of the time this doesn’t become an issue, but if we can avoid the possibility in the first place by offering alternative to the sippy cup, it seems like a good choice.

Jody Vaynshtok, one of my favorite speech therapists here in the Bay Area agrees that she is in the anti-sippy cup camp and encourages families to explore some of the wonderful alternatives. Any cup with a retractable straw or real straw can keep liquids in the cups and out of the messy zone.

Have your child practice drinking from a straw:


There are several pop-up straw cups that don’t leak. Once they learn how to use the straw, go ahead and cut the straws so that they are pretty short.This ensures that the tongue can still elevate.

Some cups come with valved toppers. Good2Grow spill-proof bottle toppers have a good shape. The character tops are pretty cute and might encourage some kids to drink more water.  Sports bottles work as well.

 Kid Basix Safe Sippy Cup is another good option that gets good marks from the speech therapists

I understand the convenience of the sippy cup. I would even say that if you are in a situation where a spill can’t be tolerated, then occasional use of a standard sippy cup is just fine.

And calm down all of you moms and dads who have kids that have come to rely on sippy cups! We can’t undo the past. Let’s just move forward with a better plan.
 sippy cups! We can’t undo the past. Let’s just move forward with a better plan.

Here is an addendum from Superstar pediatric dentist Dr Rothman.
Thanks for the sippy cup note. I am an anti sippy cup person for many reasons. Totally in agreement with my friend, Jennifer. Let me add that it also changes tooth and jaw development and causes tongue thrust swallowing patterns. In order for the maxilla to grow in length the nasal septum pulls it forward. There is no primary growth factor like cartilage growth for the maxilla to grow in width. It widens because the tongue solidly pushes on the lateral palatal shelves and expands the upper arch with bone eventually filling in to maintain stability and prevent relapse. because the tongue loses the proprioception of tongue on roof of mouth and is displaced anteriorly, this becomes becomes the habitual placement of the tongue during all swallowing. The roof of the mouth does not grow laterally and the plastic lip from the sippy cup displaces the upper teeth forward and the lower teeth back oftentimes leaving an open bite that may or may not self correct. Optimum time to stop is before 18 months. You can see the parallel with a pacifier. So many people in healthcare just say if it calms the baby then leave it be but it has the same long term effects on the teeth and roof of mouth. Studies have shown an increase in malocclusions and crossbites in children who remain on the pacifier and sippy cup for prolonged periods of time.

Here is another PS from Mama Sarah who says she loves the following cup for her kids