Friday, August 25, 2017

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


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

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

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

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

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

Every year the disease trackers do the best they can to predict which strains of the virus will circulate and try to match the flu vaccine to the anticipated strain. Although there have been some seasons recently where it was unchanged, typically the vaccine changes from year to year. This year's vaccine is not the same as last seasons. Some years have better matches than others. Let's keep our fingers crossed that this year has the magic combination. Our office will again be supplied with the quadrivalent vaccine that covers two A strains and two B strains. All of the flu vaccine in our office is preservative free. For any of you interested, the strains in the quadrivalent vaccine for the 2017/18 season are:
A/Michigan/45/2015 (H1N1) pdm-09-like virus,
A/Hong Kong/4801/2014 (H3N2)-like virus
B/Brisbane/60/2008-like virus
B/Phuket/3073/2013-like virus.

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

Since we never really know when the flu season will start with a vengeance, getting your child vaccinated early in the season is your best bet. The manufacturers claim that the protection is supposed to last through the entire season. My personal sense is that it does seems to loose it's oomph after 7 months or so. As soon as a baby turns 6 months old we can get them started with their first dose. Because we don’t have experience with this particular flu vaccine, I don’t have a sense of what kinds of reactions to expect. We don’t generally see any major reactions but every year it is different. Last year some of our patients had low grade fevers for a day or two, but for the most part the vaccine was tolerated very well. A day or two of fever is still better than a full-blown case of the flu. 

If your child has a sensitivity to egg, it is okay to give the shot, but we want to be cautious. I would recommend that you keep the patient hanging around the office for at least half an hour or so to make sure they aren’t having any issues. Please advise the nursing staff if you have any concerns. I have been giving flu shots for almost 30 years and in that time I have only seen ONE patient with an allergic reaction to the vaccine (and that patient has no history of egg intolerance, so you just never know.) This patient left the office and started complaining about an itchy feeling throat. Mom brought him right back in and he got a dose of epinephrine. I am sharing that as a reminder that it is important to keep a close eye on your child for at least 30 minutes after the shot. If they seem to be having any breathing issues or exceptional fussiness they should get checked out immediately (an emergency room is the best choice.)

In past years there have been delays and shortages with the supply, but so far everything seems like it will be smooth this season. We have already received our first shipment of the vaccines. For Noe Valley Pediatrics patients we will be having flu shot clinics starting September 12th. The clinics will be Tuesday,Wednesday and Thursday from 10:00 until 11:30 am and then from 2:00-4:00 pm. Call the same day to get on the list. Please understand we can only manage a set number of patients on any given day. Flu shot appointments are for shots only. If you have a reason to see the doctor, it is important to have an appointment on the main schedule. I tell parents that “we can add a shot to any doctor appointment, but we can’t add a doctor to a shot appointment.” We will be holding several evening flu shot clinics throughout the season.The next evening clinics will be October 18th and November 1st. Both of these are Wednesday evenings from 5:00 pm until 7:00 pm Families are welcome to the evening clinics.

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

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

I will update vaccine supply and any info about the clinic dates in my weekly emails and also on our Facebook page. I will also let you know what type of reactions I am seeing, and what the actual flu looks like when it starts knocking on the door this season.

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

Friday, August 18, 2017

What should you have in your first aid/emergency kit?

What should you have in your first aid/emergency kit?

A new mom recently asked me if she needed to purchase a first aid kit to have in the house in preparation for the new baby. There are indeed lots of commercially available kits out there, but it is pretty simple and less expensive to put together your own.

Last week my post was all about being mentally prepared for a variety of situations. This seemed like a logical follow up.
Having some items on hand is wise. Take time to make sure these things are organized and easily accessible so that you don’t waste time scurrying around if you need something quickly.

The following link is to my December post about having an appropriately stocked  medicine cabinet.

That post gives you a hefty list for things you should keep available at home.
Here are a few additions

Every family with a young child should have a nasal aspirator: The hospital will send you home with a bulb aspirator, but many people find those awkward.
I really advise that every new parent have a NoseFrida:

or NeilMed Naspira:

If the baby has a stuffy nose, or has secretions blocking their nasal passages, these snot suckers are a simple way to clear them. Have you ever had milk come out of your nose when you are laughing, sneezing or coughing? That can happen to your baby as well. An aspirator near by can make things less chaotic.

Make sure you are prepared and own infant nail clippers or scissors. Some babies are born with very long nails and can end up really scratching themselves if you don’t clip or file them :

I asked Dr Katherine Morioka of City Optometry what folks should have on hand in case of an eye injury. She suggests that a first aid kit should include artificial tears, an eye wash kit, gauze and first aid tape.

Away from home:
CAR: Every car that you drive should have its own emergency kit in the trunk.
Some of the items I am going to add are NOT typically found on general lists.

Have a change of clothes, extra diapers, clean socks, extra layers (for every family member.) In San Francisco, the fog can come in quickly; don’t end up looking like a shivering tourist and resort to having to buy another Alcatraz sweatshirt.

A baggy with basic first aid supplies:

  • Gauze pads/ a roll of coban self adhesive wrap/ Neopsorin/ antiseptic wipes (a clean pair of socks can serve double duty in case you don't have gauze.)

  • A tweezer for removing a splinter or tick (shudder)

  • Scissors

  • Instant cold pack/ hot pack

  • Tylenol or Motrin

  • Zyrtec or Benadryl

  • Anrica (for bumps and bruises)

  • Flashlight/ Batteries

Have some durable snacks, pouches or bars and some water. If you are on a road trip double down on this and make sure you have provisions in case you get stuck.

  • An index card with important phone numbers including poison control.

Okay, here are some things that are not on the general lists:

  • Keep a pair of  heavy duty gloves on hand.

  • Have some cash. Small bills are the best. If there is an emergency and there is no electricity for credit card or ATM transactions, having cash is invaluable. We learned this tip from an uncle who was impacted by Hurricane Andrew in Florida in 1992. There was no power for days. Family members needed to wire him money and he was not even an Nigerian prince offering us millions!

  • Have a deck of cards or activity for your kids if you get stuck someplace. A fresh coloring book with crayons or something novel to keep them calm and entertained can help keeps everyone’s sanity.

  • Barf bags (every time you fly, take the unused one from your seat) These are better kept in the glove compartment than the trunk.

  • Have some empty gallon zip lock bags

  • Portable potty: You can make your own. All you need is  an inflatable ring. Find a cheap inner tube or inflatable potty from Amazon. Tuck around a tall kitchen garbage bag, When they are finished going, the poop or pee is in the bag with very little clean up needed. When your child is just starting the toilet training journey, these can be really handy.

  • Make sure you have baby wipes/ paper towels/ fabreeze or air freshener

  • Disposable blue absorbent underpads (take the one from your office visit if your baby didn't pee on it!) You will find a lot of uses for these!

  • Have some empty gallon zip lock bags

Get in the habit of checking this stash thoroughly, several times a year. Perhaps do it with the clock change when you check your smoke detector batteries. Check expiration dates, diaper sizes, battery life, phone number accuracy,... etc.

Diaper bag:
As long as you are close to the car, you don’t need to carry too much with you.
Keep a small baggie with some gauze/ antiseptic wipes/ small packet of neosporin. If you more than 30 minutes from the car, have tylenol/ibuprofen, and benedryl/zyrtec with you. If there are medications in your diaper bag, pay attention that young children don’t have easy access to them.

Friday, August 11, 2017

Problem solving skills 2017

Some of our patients are heading off to school within the next couple of weeks. It is a big adjustment for everyone. When you are no longer with your child 24/7 you want to make sure that they are prepared to deal with unexpected situations.

Today's topic is a about an important activity that you can do with your child that teaches them to be "problem solvers".  Adults need to learn to be problem solvers also. Some people are much better at this than others. For instance, if you got in a fender bender, what would you do? Many folks would just freeze and panic. What should you do?

  • Assess for injury; call 911 if needed
  • If you are on a highway, wait for assistance. Getting out of the car is often dangerous!
  • Do you have an AAA membership? Know where the card is.
  • Know where your insurance info is kept (make sure you have a copy accessible)
  • Take a photo of any damage
  • Take a photo of the other driver's insurance card and driver's license...etc.
  • Always have a charger in your car for your cell phone so that a low battery is never an issue.

Having a plan in advance could help you stay calm.

But I do want to add one more benign tidbit here. What if you lost your cell phone or it ran out of batteries and you don't happen to have a charger? Do you know important phone numbers, or do you count on speed dial? Having a list of important numbers in an accessible place is a good idea for everyone.

I lived in New York back in the early eighties. It was a different city back then. At one point there were a rash of home break-ins and burglaries. A friend of mine who was an actress obsessed quite a bit about this. She went as far as rehearsing made up scenes for any given situation to avoid being frozen by fear. Go figure, one day someone did break into her apartment. She went right into her pre-rehearsed mode. Figuring that acting a bit cuckoo would get any 'bad guy' off balance, she immediately broke into the character that she had prepared. In a loud, shrill British accent she yelled, “Welcome!!! Would you like to stay for tea?" She did the Mad Hatter proud. She went on with a list of options. "Would you like herbal or black? I have delicious honey from local bees!" As expected, the intruder was completely caught off guard. He mumbled something, turned and ran. Brilliant. Not that I am recommending that particular course of action, but having a plan in advance is always a good thing.

Years ago, the concept that everyone would carry around an individual cell phone seemed as futuristic as the communicators on Star Trek. Now, of course it is hard to imagine how we got along without them. It was, however, the lack of the cell phone that prompted me to create a game that became a favorite in our family.
It must have been 1994 and I was on my way to pick up Alana from preschool. She was about 4 years old at the time. It was one of ‘those days’. I was uncharacteristically running late. Then I got stuck in terrible traffic. To compound things, I took some random turns to try to work around the congestion and ended up utterly lost. (Remember that this was also before Google maps or GPS.)  My stomach was in a knot and I wondered what my younger daughter would do when mommy was late picking her up. It turned out that she was calmly waiting for me in the office, but that was the day that the "what would you do if" game was created. It was all about building on the concept of planning in advance for an assortment of situations. It went something like this:

I would ask a question such as, "What should you do if mommy is late picking you up? What are some of the choices? Which is the best one?"
Getting a teacher or trusted grown up to wait with her or take her to the office was clearly the right answer and I praised her for figuring that out on her own. Alana loved this game. We created all sorts of situations:

" What if we were at a store and you couldn't find me?
Alana: " I would go to the check out and ask them to page you."

We never made it too simple...

Mommy :"What if they refused?"
Alana :"I would demand to talk to the manager"

Our scenarios covered any number of little emergencies including earthquakes, fires, and getting lost or separated. The better you are at problem solving, the easier it gets to improvise.

This game came in handy more than once. The shining example that comes to mind happened after years of playing this game. Alana and I were walking the dog on the beach one day. I had donated blood earlier that morning and didn't realize how foolish I was for doing anything strenuous. I got very light headed and ended up down on the sand trying hard not to completely pass out. Alana was ten at the time and she went right into problem solving mode. We did have cell phones at this point. She got the dog on the leash, patted some water on my forehead and calmly called daddy. I could vaguely hear her talking. "Mommy fainted...I think she is okay."

The game was such a success that my sister taught it to her kids. Hers had an interesting spin because they lived in Alaska at the time:

"What would you do if you saw a bear?"
"What would you do if a moose wanders into the yard?"
There were actually times when these things happened, and my nephews were able to act calmly and appropriately!

Topics can range from handling a bully to getting separated on Muni. Being prepared for unexpected situations can be invaluable.
If your child finds themselves without you and in need of assistance, finding a grown up wearing a uniform is often a valid option for some of the difficult situations. Finding a parent who has a child with them and asking them for help, might be another safe option.

This game is meant to empower. It is wonderful for some kids, but could be terrifying for others. You need to assess your child's temperament before playing. Either way, identify a problem or situation. Start with simple, less scary ones. Discuss all the possible solutions and then agree what the best plan should be for any given situation.

Stressful situations happen. Teaching your child to take a deep breath and use their problem solving skills is one of those things you can do now that can have lasting implications for them when they grow up. Even teaching a very young child to dial 911 in an emergency can be life saving!

You have to figure out if this will be empowering for your child as it was for Alana. My daughter Lauren never liked to play it. In fact, I remember one day when Lauren and I were taking a walk, I tripped on something, stumbled and fell. I was perfectly fine, but Lauren's reaction was to start screaming. As she says, "mommies aren't allowed to fall". Every kid is different. As your child grows, the situations that you might want to bring up will increase in scope.
Preparation is power.

It saddens me we have to be prepared for things other than losing track of our kids on Muni, but that is the world we live in.
Have a family plan in place in case of emergency.  If someone other than one of the regular people is going to pick up your child, have a family “safe word” so that they know they were sent by you.

Do you have your earthquake/emergency kit ready? Does it include adequate diapers, medications, pet food? Where will everyone meet up if home is not a safe option? Find out from your school what kind of emergency plans they have in place. Teach your kids to get in the habit of looking for emergency exits, especially for your older kids who are at a concert, theater or a club.

I think that the "what would you do" exercise is actually something that you might want to do with a nanny or caretaker. Training to keep calm in any type of emergency situation is essential.

Friday, August 4, 2017

Food Heroes and Villains

Up until just recently coconut oil was considered heaven sent. It cured all sorts of things. When I saw the recent news putting it back on the list of terrible foods, I groaned out loud. I feel the need for a little rant. I hope you will bear with me!

Everyday we have different foods take turns getting a blast of media attention. We see lists of the world's healthiest foods and list of foods that should be avoided at all costs. Some things that are on the ‘wonder food’  list one day might be on the ‘avoid at all costs’ list the next. Take red wine for instance, one minute it is the best thing to help you avoid heart disease...oops but it might increase the risk of some cancers.

Of course some of these headlines are often followed by frantic calls to the advice nurse. When the organic rice was found to have measurable amounts of arsenic the phones practically exploded. In fact arsenic is pretty hard to completely avoid and is found in other foods as well.

The list goes on…..

  • Probiotics will save the world
  • Soy will cause your sons to grow breasts
  • Gluten should be completely avoided
  • Even my favorite kale and its fellow cruciferous veggies are now thought to be not as perfect as they were made out to be due to potential thyroid disrupting risks and high oxalate levels that could lead to kidney stones
  • Eggs have been moved to the good guy list. Sugar is more likely to be the cause of high cholesterol than eating eggs every  day.

You get the idea. Navigating through all of this info is so challenging when you are trying to feed your family a healthy diet.

The food pyramid has been turned upside down and there are so many fads that come and go. I asked Nurse Lainey and her internet savvy sister Katie to do a little poking around for me and within a short period of time they came up with an extensive list of dietary trends, including something that sounds particularly alarming called ‘souping’.

I am not about to sort through all of  the fads (the posts are often too long as it is.) Rather I am going to give you the message, "take a deep breath and do the best you can. Everything in moderation!"

If you are lucky and you have a child who will eat plenty of different foods, make a valiant effort to give variety and not to binge on any one thing.

Below is my take on some obvious current heroes and villains.

Organic and Non GMO: Hero
We probably can’t really count on any labels to be completely accurate anymore, but if you can  afford it, I prefer organic produce if it is available:

Sugar: Bad Guy! Try to minimize added sugar. You might be shocked by how much sugar is added to things. Be a good label reader. Agave, which used to be considered a healthier alternative is no longer on the “good guy” list.  If you are looking for a natural sweetener, current consensus would put honey at the top of the list for healthiest option. Remember that this is NOT a good choice for any baby under one year. No honey for them!

My preference would be that sugar and dessert not be used as a reward on a regular basis. If our body has had enough “growing food”, an occasional sweet treat is fine.

Gluten: Mixed. I get aggravated when folks dismiss this. More and more people can really not tolerate gluten, regardless of what testing shows.  Both of my kids ate plenty of bread their entire lives but developed fairly severe gluten reactions as young adults. I have had many patients do an elimination diet and find that they feel much better when they cut it out of their diets. Not everyone suffers the same symptoms. It makes no sense to get rid of gluten if you show no signs of being impacted by it. That being said, in general white flours, breads and pastas are pretty low on the nutrition scale. 
Rice/arsenic: just don’t overdo! There are in fact measurable levels of arsenic in rice. There is more found in the brown rice than white. Rinsing the rice well prior to cooking it might reduce some of the levels. I would not recommend more than a couple of servings of rice per week. We are fortunate that there are plenty of other options. Most other grains out there that don’t have this issue:

Trendy food Pouches: Read the labels!
Just because something is organic, doesn’t mean it is good for you. I know all the pouch foods are quite popular. The are convenient and the kids generally like them, but some are loaded with ingredients that you really don’t need.

They are also a nightmare for the landfill.

As with anything, find some balance.

Wise words from Nurse Lainey. If you want to do some creative eating for yourself, please keep in mind that your children have different nutritional needs. They are not just little adults!