Friday, January 26, 2018

They stuck What...Where?

They stuck What...Where?

While it might make an amusing anecdote well after the fact (and it keeps the advice nurse job from being far from boring) it can be quite the ordeal when you find out that your child has stuck some little object into an orifice.

By far and away the hole that gets the most inappropriate things passing through is the mouth; That got it’s own post several weeks ago. This week I am going to focus on all of those other interesting places that need to be explored. I refer to noses, ears, butts, if there is a hole...things get stuck in there.

One of my favorite stories is told by a friend who had a child that smelled fairly horrible. No amount of baths could mask a mysterious foul odor. The child was taken to the doctor who asked the magic question.

"Honey, do you ever stick anything in your nose?"
The child shrugged and then answered matter of factly, "just cheese..."

We get the calls on a fairly regular basis that a child has stuck something somewhere. Most of the time, it is the nose. It seems that it is just so hard to resist.

A year or so ago I had a call about a little fellow who had stuck a bright yellow lego piece in his nose. Mom was trying to figure out how big it was, it was really wedged in there. Her helpful child went over to the lego catalogue and was able to point out the exact piece that he had stuck up there.

Nurse Jen recounted the time that her daughter Isa stuck something in her nose in order to find out if the nose was connected to the throat. While a little proud of this attempt at an early science experiment, Jen recalls that a straight jacket was needed in the ER to get it removed. Isa was absolutely right - the nose is connected to the throat, but there are all sorts of sinus cavities where something could get waylaid.

Gianna Frazee, a wonderful local pediatrician, shared with me the story of a memorable five year old patient who felt the need to stick her tongue inside a Barbie doll head. The tongue swelled up and got stuck.
You may want to tell your children stories about other little children who have done these things and then had to go to the doctor and it was yucky getting it fixed. Perhaps a little teaching and mild scare tactics in advance might be preventative but the urge is strong. In my immediate family we told the tale of my niece Lena who stuck a raisin in her nose, and perhaps the power of the tale kept my own kids and the other nieces and nephews "raisin free."

If prevention hasn't done the trick and there is something stuck up the nose you have several options. If your child is old enough, have them try to gently blow it out. If that doesn't work, or your child is too young to have mastered the concept of nose blowing, you can try to suck it out. Whereas I did once have a mom who successfully sucked a pea out of her toddlers nose with her mouth, (good for her but...ugh), I would suggest trying the suction with a Nose Frida.

If that doesn't work, I have another method for you. Assuming the something is in the right nostril, push the left nostril closed with your finger and do a firm rescue breath into the mouth. If it doesn't blow the object out, reposition and try again. This works more than 50% of the time. I have seen all sorts of interesting things go into noses....peas, beads, little wads of paper, raisins, a starburst candy. Kids are creative!

It is fully possible that whatever it was was sucked up was subsequently swallowed, but never the less, if it went up in the nose and you weren't able to get it out, someone needs to look in there. As Dr. Kaplan says, "if it is an object, say for instance the #3 key from a toy telephone, it needs to be removed." If it is a small organic thing like a piece of rice, she doesn't get worried if it isn't retrieved as long as it doesn't seem to be causing any issues.

If you aren't quite sure if they stuck something in there or not, kids are often not the best historians when it comes to finding out the truth. If you ask them if they put something in their nose and they think that answering yes will either get mommy or daddy mad, or land them at the doctors the answer may well be an emphatic "Me? Something in my nose? I don't remember!"

Keep that in mind, as a constant running nose, foul odor, or signs of irritation in or around the nose could be signs that a foreign object is the source of the trouble.

The docs in our office are willing to try to get something out, but we might not be your best choice. If there is a way to get onto the schedule of an ENT that is usually the better option, They have better tools for getting the job done right the first time.

We also have our share of patients who stick things in ears. One of the more memorable for me was the little boy whose brothers had convinced him to do a wee experiment and see how many unpopped popcorn kernels could fit in his ears. Of course this was 4:30 on a Friday...right? As he came into the office I could hear him crying "I don't want them to have to cut off my ears." Those same brothers of course were behind that as well. Ah siblings. Although we may be able to remove something simple from the ear,that little fellow also ended up at the ENT.

Not all that long ago, Dr. Jessica saw a little blue bead in an ear during a routine exam which she was able to safely remove, while a little silver pellet from an ear of a different patient was referred out. 

Parents shouldn’t be sticking things in their kids' ears either. Q-tips are the biggest offender. Between 1990 and 2010 there were more than 260,000 children treated in the emergency room for ear injuries related to cotton tipped applicators.

Yes, we have had the occasional thing stuck in the butt (in fact it was a tube of mascara most recently;) those are fairly rare thank goodness.

It would be nice to think that there is a magic age when folks grow out of this. Nurse Kenlee currently works in an adult ER. She says that the stories she could tell are probably not suitable for sharing!

Friday, January 19, 2018

Old letters and Photos

Old letters and photos
I was just back in Pittsburgh, Pennsylvania with my sisters, Marjie and Amy, sorting through boxes of stuff in the house that I grew up in. Pittsburgh in January is cold and snowy, perfect weather for hunkering down and staying inside. I equate this undertaking to taking a teaspoon full of liquid out of a 50 gallon aquarium. It is hard to see progress; there is so much to do. We have opted to take our time and gather together every few months so that we can celebrate the memories and poke through things together. It is a luxury that we are able to do that. As a bonus, my younger daughter Alana flew in from Michigan to join us for the weekend.

I grew up in a house that was filled to the brim with books on every subject. (We will start dealing with the books at the next visit.) There were plenty of costumes and odd clothes with which to play dress-up. At one point there was even a hoop skirt; I have no idea where that came from. Having a mom who was a kindergarten teacher made it a given that we had plenty of odd things on hand for variety of arts and crafts activities.

The last visit was geared toward ridding the house of the obvious junk:

This visit we focused on the shoe boxes jam packed with letters, papers and pictures.

My family, going back to great grandparents, were faithful correspondents and it seems that they didn’t believe in throwing away letters. This is now truly the proverbial mixed blessing. Even though it is a daunting task, there is something magical about holding an old letter. We lose something in this digital age.

In regards to the photos, my father loved to take pictures of everything. Some are in envelopes, many are duplicates, some are in albums ( my mom’s efforts), but the majority are loose in boxes. The unflattering, out of focus photos got the same treatment as the good ones. They are all waiting to be sorted, all gazillion of them.

My grandmother’s photos and letters are there as well. Some of the photos date back to the 1800s! I took the opportunity to reach out to some cousins that might be interested in checking out old family treasures and we had a fabulous gathering of people who had driven hundreds of miles to get together and help us identify the people in some of the older photos

Here is a copy of the Facebook post that I added during the trip:

I got a gift from the universe today. We have been going through an amazing stash of family letters and photos this week. Reading the love letters from my grandfather Asher to my grandmother Flora was one of the highlights. We realized that somehow or other, none of us knew the story of how they met. How could that be? The loss of my mom last year was staggering. We couldn't just turn to her and ask her for the story. I then remembered that 30 years ago or so, my grandmother had been interviewed by the National Council of Jewish women as part of an Oral History project.

I googled, Flora Isaacs Oral History and there it is, two hours of my grandmother talking, divided into 4 parts. This is something to savor. We listened to the first side last night. This evening Amy and I listened to part 2 and sure enough we got to hear Grandma tell us the tale of how she and Grandpa met.

We had all sorts of lovely serendipity. My sister found an old pair of rhinestone folding opera glasses tucked out of the way in a small box in the attic. She brought them down for us all to see. Later that day, as I sorted through piles of letters, I happened to take the time to read one from my grandmother to my mom: “Mrs. So and So brought you a gift. They are wonderful little opera glasses that fold up; make sure you write a thank you note.”

Okay lovely readers, here is your takeaway assignment. Figure out who are the people in your photos. Even if they are digital, make sure that you manage to accurately label them. If you have old photos, get your parents, grandparents, aunts, uncles... etc. to look through them with you, and tell you who the people are. This information is lost otherwise.

Don’t save the crappy photos. Having a smaller collection of good pictures is much more valuable.

Get the stories! Do you know how YOUR grandparents met?

Friday, January 12, 2018

Building and Protecting your immune system

Topic of the Week:
Building and Protecting your immune system
Please see updated post 1/2020

This is the season to focus on boosting your immune system. I have had multiple requests to address this topic in a post.
One of the blessings of working at Noe Valley pediatrics is that although we are a western medicine, science based practice, the advice nurse team is allowed to stray off the rigid telephone triage guidelines that most advice nurses must adhere to. My patients over the years have been on the receiving end of advice from me that includes some more natural or holistic suggestions.

This post in particular strays way off the basic western medicine path and includes a combination of conventional wisdom, with some anecdotal remedies shared with me by healers from a variety of modalities. Some of the things that I suggest can be found as my husband laughingly describes it, down the “placebo aisle” of the local drugstore, but as we are in the full throes of a variety of illnesses, many of my patients are ready to try anything.

My kids grew up with my husband's grandma’s recipe fondly referred to as Muggala Guggala, (see below for recipe*) I imagine many families have their own health rituals. As long as you are not ignoring a condition that warrants medication such as asthma inhalers or antibiotics, there is little harm in exploring some natural options. Who knows, you might find something that helps.

Good Hand Washing is the cornerstone to staying well.

If you were out and about in a crowd of sniffling,coughing people make sure you scrub up and change your clothes as soon as you get home.

Getting enough sleep is essential. If kids seem tired, you might need to start the bedtime routine a bit earlier. If you are interested in really finding out more about the actual quality of your child’s sleep, Knit Health is an interesting, reasonable option.

For older kids and adults make sure you limit the screen time for at least an hour before going to bed. Most experts suggest longer than that, but I accept that it often isn’t that realistic. (For the record, binge watching Game of Thrones right before bed is NOT a good idea.)

Make sure you and your kids are getting enough Vitamin D. Many folks have vitamin D levels that are significantly below where they should be and would benefit from a daily supplement .

Make sure you are getting enough Iron. Magnesium, iron and vitamin D are all connected to sleep as well as to a healthy immune system. (Magnesium also helps with pooping.)

I don’t love to binge on most vitamins, but a multi that has A and C is especially important during the cold and cough season. Check out Ester C. This is an exclusive form of vitamin C that is designed to give round the clock immune support. Sandra Roddy Adams, my chiropractor, gives this a big thumbs up.

Zinc is an important cold fighter and some studies show that it can decrease the duration of a cold by 50%.
Zicam lozenges are what I like. I actually think that the generic orange flavor tastes the best. These work better if you catch it early! With any zinc product it might be best to take with something in your stomach to avoid nausea. Kids need to be old enough to safely take a lozenge or chews

I asked my cousin Sam, who is a retired family practice physician if he had any favorite supplements. Echinacea,
ginger,garlic,myrhh, cayenne, vitamin C, vitamin B6 and bioflavanoids all made his list. For the grown ups out there, he recommended a Source Naturals Wellness Formula that has a lot of the good stuff in one capsule.

More and more studies are finding that having a healthy gut is essential to the immune system. My friend Sari is a craniosacral therapist in Arizona. When I reached out to pick her brain about this post she concurred with me that more and more studies are finding that having a healthy gut is essential to the immune system.

Probiotics are good for any age

Oil of oregano is thought to be a great immune booster. I would recommend this for grown ups or kids over 6 who are very cooperative, It has a very strong taste and causes some oregano burps but can work pretty well

Omega 3 are mostly found from eating fish, but most people probably don’t get as much as they should. This supplement makes it to most of the lists as a worthy supplement.

Local honey has antioxidants and is thought to be helpful for the immune system. Dr. Anne was the one who added this to the list. She actually adds honey to her coffee! I tried it and it isn’t bad. Hey, working in this office gives us a lot of exposure to everything that is going around. We will try anything!
Remember that infants under one year should NOT eat honey

Chinese Medicine - Dr Schwanke started using Chinese herbs in our office many years ago, but only carry a limited line that we use for ear infections and congestion. We are fortunate to have the creator of those formulas right in the neighborhood at the Chinese Medicine Works. It is important that any Chinese medicine comes from a reputable source. I like the gentle warriors brand because it is made locally

It might be worth exploring some herbs if you or your kids keep getting sick.

My amazing friend Anita is an acupuncturist in Colorado.
She encourages warming foods for her patients. These keep the internal temperature up. Viruses prefer the cold environment. She suggests that drinks be room temperature or warm/hot. Don’t add ice to drinks. Use warming spices and herbs such as garlic, cinnamon and cloves.
Soup is always good! Here is a bonus Acupressure point good for boosting the immune system: acupressure point stomach 36

Herbs and Homeopathy
Sambuccol is at the top of my list when it comes to my personal self care. This is an elderberry base, fairly widely available that has some scientific studies backing up it’s immune boosting properties. (Even Sandy doesn’t scoff at this one.) I start taking these the moment that I feel the scratchy throat feeling that makes me worried that I am starting to come down with something.The earlier you start this, the better it works. The bottle says for children over 2. The UK version gives the dosage for over 1.

These are homeopathic sprinkles that I refer to as fairy dust.
I don’t understand homeopathy, but many folks swear by these. I take a tube every time I fly. Sandy tried to figure out what’s in them and the only ingredient he recognized was duck liver.

This herb is on many folks list of remedies. The studies have been mixed as to whether or not it works. Make sure you are a label reader when getting this supplement

My friend Oran is a wonderful healer who lives in Israel. Both of my daughters had moments during their travels there when they showed up on her doorstep with various illnesses and she nursed them right back to health. She has the ‘No White’ rule when people are sick. No white sugar, No White Flour and No Dairy. All of those can contribute to inflammation.
She also shared something that I confess I had never heard of. She suggests cutting an onion in half and leaving it on a plate right near the head of the bed.

It is very important to avoid secondhand smoke. If you are someplace where the air is dry, or in SF you have turned the heat on, consider using a humidifier at night. Make sure you keep it clean and turn it off during the day. Running it 24/7 can create a mold situation.

It is fairly common for parents to call us, incredibly frustrated when their kids seem be sick all the time. It makes sense when you think about it. If they are depleted from illness number one, when illness number two comes around they are more vulnerable. Everyone is being exposed to so much this season. I have patients who actually have more than one illness at a time. RSV and Flu together seems to be a popular combination at the moment. Unfortunately most viral syndromes simply take time. Antibiotics are NOT useful for a virus.

If you are stuck in a cycle of catching one thing after another and the above suggestions haven’t helped, explore your options and see if you can keep your child out of daycare for a week or so. Sometimes that break makes a big difference.
Don’t forget to swap out the toothbrush or put it in the dishwasher.

* Muggala Guggala - 1 cup milk, 1 Tbsp of butter, 2 Tbsp honey - heated in a saucepan.

PS Mama Jaime chimed in to share that she has found that Thrive Market is a good place to get many of these supplements at a good price.

Friday, January 5, 2018

Tummy Bugs 101 (2018)

Topic of the Week:
Tummy bugs 101/dealing with diarrhea and vomiting

By far most of the tummy bugs that we see are caused by a virus. Time will generally take care of these. The typical symptoms are vomiting, loose stools and sometimes fever. Not everyone has every symptom. Vomiting without the loose stools could also indicate something else going on, like strep throat, a urinary tract infection, an ear infection or even appendicitis. When the diarrhea comes along, the good news is that it usually signals that we can narrow our attention to some type of tummy issue. The bad news of course is that when the patient is losing fluids from both ends, dehydration now becomes more of a concern. I also don’t want to minimize how miserable it is when you are in the full throes of an acute GI episode and don’t know whether to sit on the toilet or kneel at it.

If your baby is under two months old and you suspect that they have a tummy bug, we will want to monitor them closely. Young babies can get dehydrated much more easily than a larger child.

If you are breastfeeding, smaller more frequent feeding will often be much easier for the baby to keep down. Of course it is not always easy to know what's up. Many babies spit up on a regular basis daily and normal baby poop is very liquidy. But, if you are worried, they are spitting up more than normal, and have increased fussiness I would suggest getting them evaluated. For a young infant, watery/clear stool would also get my antenna up. With a dehydrated infant, the fontanel (soft spot) may appear more sunken, and they will be significantly sleepier or fussier than usual. If they are nursing well, and peeing fine that is very reassuring.

With any age, the main focus for someone suffering from a tummy bug should be hydration. It is okay and even expected for the patient to have less of an appetite for food for a few days. Unless the person is extremely slender, we are not too worried with a bit of weight loss. Most folks will gain it right back up when this passes. Don’t stress about the food intake. Pushing food will likely just aggravate the situation if they aren’t ready. We just need to make sure that they are getting adequate fluids.

Start by giving clear fluids (breastmilk is fine you have it.) Because we lose lots of electrolytes when we vomit or have diarrhea, it is best to replace the fluids with something that replaces the electrolytes as well. Water is not your best choice.There are products on the market that are specially formulated for this purpose.

Pedialyte is the classic brand that has been around for many years.. There are Pedialyte popsicles that are terrific for older kids. They recently improved the flavor quite a bit, which has improved compliance. It still has a mild soapy taste so not everyone will take it. There is also product out there called Drip Drop that some folks feel tastes a little better. The exercise drinks like Gatorade are another option but have more sugar than the Pedialyte. Consider keeping a Pedialyte product on hand so that you are prepared if a tummy bug strikes. Pedialyte now comes in a little tube of powder that you mix yourself. I would have it as part of your travel emergency kit as well.
As of 2019, Pedialyte also has a fizzy version. It is clear colored so that you don't need to worry about artificial dyes.

I don’t have any hard and fast rules about fluid amounts. Electrolytes are the better choice, but you have to do the best you can if they simply refuse those. Try some diluted juice, coconut water, ginger ale, or colas that have lost some of the fizz . Whatever they are agreeing to drink, I typically wait at least ten minutes after they have thrown up before I offer anything.Think of a drip irrigation system. If all you can get in there is a dropper full, that’s okay! Get that fluid in, drop by drop, ice chip by ice chip. Do the best you can.

If they are thirsty, don’t let them guzzle. Stick with an ounce at a time. If you have a tiny tea set, or a fancy shot glass, those are fun ways to measure small amounts. You can have a star chart for the reluctant drinkers.

Please note, so that you don’t freak out, right before someone is going to vomit, it is normal for them to look quite miserable. Some kids get very pale and shaky. Some folks actually look greenish. Once they throw up, most of the time they feel a bit better and the color normalizes.

If your child has an elevated temperature as part of this illness, a tepid bath can help get the fever down. If the bath hasn’t done the trick, the fever is over 101, and your child is miserable it is worth giving some fever reducing medicine. Ibuprofen tends to be a bit harder on the stomach so I would choose acetaminophen (Tylenol) when I have an illness that includes tummy symptoms. Another advantage to the Tylenol is that it comes in suppository form, so it is more easily tolerated by a vomiting kid. Dosage chart

How to assess hydration

If your child is running around and has good energy, I am usually not too concerned. There is a big difference between subdued and lethargic. Some kids are well hydrated but still feel lousy and are quieter than usual. We can call them subdued. If you have a kid with big juicy tears and lots of drool, they are probably not terribly dehydrated. The body doesn’t waste the fluid.

On the other hand, a dehydrated child is lethargic. They do not want to play. The urine is more concentrated (darker and smellier) and way less frequent. Their mouth feels dry. Their breath might be stinky (of course if they have been vomiting that is probably a given.) Their skin may be dry. Normally if you pinch up a bit of skin on the wrist, it will immediately correct itself. If someone is dry, it may remain up in the pinch for a moment.

If they are refusing fluids or can't keep down anything, you need to check in with your doctor’s office. If they are vomiting up bile (bright green) that is another signal that their tank is really on empty and they need a little help turning things around. These are the kids that sometimes get carried into our office draped over their parent’s shoulder.

If I am giving phone advice, and it sounds like a child is dehydrated,I am usually going to skip the office visit. If the child is lethargic and you have been attempting small amounts of fluids and failing, then a trip to the emergency room is appropriate. Once there your child may get some IV fluids which often perk them right up.

Most of the time the ER is not necessary. Frequent but tiny amounts of fluids is a remarkably effective approach. Generally the vomiting is the first thing to ease. If they remain nauseated, there is a magic pill called Zofran. This is an effective but strong medication. We don’t like to give it without an office visit, to make sure we are not ignoring an underlying cause that needs treatment.

Once your child has started keeping down fluids, it is okay to advance the diet if they are interested in food. More often than not, we expect the stools to continue to be looser than normal for a bit longer. Trust your kids to some extent. I find that most of the time they crave the foods that their bodies can handle. If you have an outlier asking for a hotdog, follow your instincts and say no.

Bland starchy foods are your best bet. I suggest a modified BRAT diet. Bananas, rice, applesauce, crackers, toast, potato, pasta, boiled chicken and watermelon are all okay.
I find that folks have a quicker time getting over this if they avoid dairy (some folks can stay on yogurt and tolerate that fine).

In my experience, getting started with probiotics right away is the key to getting over this quickly. We need to get the gut healthy again so that it can tolerate a normal diet and the good bacteria in the probiotics is critical to this.

There are plenty of good brands out there. One of my favorites is Florajen for kids which you can get from the Noe Valley or Diamond Heights Walgreen’s. It is kept in the back in the refrigerator, but there is no prescription needed. Baby Jarro Dophilus (Whole Foods or health food stores) is another brand that we have had success with. If you have a trusted brand on hand, it is fine to stick with that.

One of the most common calls to our advice nurse team is when a patient seemed like they were improving and have had a bit of a relapse. This is usually caused by advancing the diet a little too quickly (especially dairy.) You may need them dairy free for a week before things return to normal. Yes, this includes cheese....

If your child is keeping food down but has loose stools, I have had great success using the Similac expert care for Diarrhea (it used to be called Isomil DF) It is difficult to find this locally. Amazon might be your best bet. For older kids, I still use this soy based formula as the base for a smoothie:

   -   Similac DF or other Soy based formula
   -   Banana
   -   Frozen yogurt (if not tolerating dairy, find a non dairy alternative)

Mix the ingredients in a blender. This smoothie is usually easily accepted, well tolerated and helps form up the stool. Watch out that it doesn’t do too good of a job. We don’t want to let the poop get hard.

What if it isn’t a virus?
If you or your child has fever, chills, bloody diarrhea and vomiting, that could be food poisoning. The most common culprits are Salmonella, Shigella and Campylobacter. Sometimes the symptoms might not show up for a few days, making it hard to identify the source.

Even though many of those illnesses are self limiting, getting seen is a good idea. We may send a stool sample to the lab to check for a bacterial stool culture. There are special containers required for this. You can get those from the office or the lab. Mom or dad, it is your job to get the poop into the specimen container and to the lab (thank you for your understanding.)

If you or your child are just back from travel or camping and has awful gassy, incredibly stinky stools, we should make sure that you don’t have giardia or some other parasite. If that is a possibility, we would send another type of stool sample to the lab that requires a different set of specialized containers. This is called an O&P (ova and parasites.) As opposed to many of the other tummy issues, these do not usually resolve without help of some medication. If you have a pet with loose poops, that can be an important clue.

With any ongoing tummy issue it is important to get some routine weigh ins.

Many times tummy pain is from constipationGas pains tend to be sharp and intermittent. Any steady abdominal pain that is lasting more than several hours should be evaluated.

With anything poop related, often defense is your best offense. Wash your hands!!!