Friday, April 27, 2018

Warts and Molluscum

We get calls about warts on a fairly regular basis. Warts are usually caused by a virus. These tricky little skin growths have evolved over time so that they have the ability to invade the body without triggering the immune system.

Dr. Grogan, a terrific local podiatrist tells his patients to imagine that their body is a castle that has guards, but somehow the wart has sneaked through the defense system and is already at the castle walls.

Plan A for getting rid of them is to gently remind the body that there is a wart and we want it gone. Make the body pay attention to this unwelcome guest by causing a bit of irritation to the area. Think of this process as an “Intruder Alert” signal to the body.

Warts have an easier time getting onto skin that is not intact. If your child has eczema or is a nail biter, they are more prone to warts. A person whose immune system has been going through a tough time, one illness after another, may also be a bit more prone to getting warts.

A wart is on the bottom of the foot is referred to as a Plantar wart. Because there is so much pressure from walking on it, those warts tend to be deeper and probably will do better with help from the specialists. Dr Grogan's office uses something call cantharidin (fun fact, this is a substance secreted by blister beetles.) It may take 4 or 5 applications; most kids tolerate the treatments pretty well.

For warts on other parts of the body, Dr. Cheung my ‘go to” dermatologist, prefers the 40% salicylic acid patches (Mediplast.) These are used for any age. Cut the patch to the size of the wart and cover the area with duct tape.
Do the application after a shower or bath. Even if you skip a daily bath,the patch should be changed every 24 hours or so. When you remove the patch, it is quite normal for part of the wart to peel off. You can also use an emery board to gently debride the area in between patch changes.

Go ahead and make an appointment for the dermatologist to take a look at things and evaluate treatment options, but it is fully possible that if you make an appointment a month in advance, the home treatment will take care of it and then you can just cancel the appointment (of course give a 48 hour warning.)
Dr Schwanke is also happy to see a wart here in the office to help with a treatment plan.

If you do end up at the dermatologist, they will base the treatment on the age of the patient. For older kids, Dr. Cheung finds that freezing them off with cryotherapy is the most effective treatment. Most warts require multiple visits, spaced about a month or two apart.

If you are seeing clusters of warts, another possibility is a fairly common wart related skin disease called Molluscum (muh-luhs-kum) contagiosum (kən-tā-jē-ō-səm). Just like common warts, this is caused by a virus and can easily spread from person to person.

People can get molluscum by sharing towels and clothing. Wrestlers and gymnasts may get it from touching infected mats. Skin-to-skin contact also spreads the virus. Often the only sign of molluscum is pink or flesh-colored bumps on the skin. These bumps can appear anywhere on the skin.(usually not on the palms of the hands or the soles of the feet.) Most people get about 10 to 20 bumps on their skin. If a person has a weakened immune system, they may have way more than that.

Bumps on the skin can be the only sign that a person has molluscum contagiosum. These bumps often appear about 7 weeks after being exposed to the virus that causes molluscum. Sometimes, the bumps do not appear for many months. When the bumps appear on the skin, they often:

  • Begin as small, firm, dome-shaped growths.
  • Have a surface that feels smooth, waxy, or pearly.
  • Are flesh-colored or pink.
  • Have a dimple in the center. The dimple may be filled with a thick, white substance that is cheesy or waxy.
  • Are painless, but some bumps itch.
  • Turn red as the person’s immune system fights the virus.
  • Appear on other areas of the body after a person scratches or picks the bumps. Scratching or picking can spread the virus.
This condition usually goes away by itself within a year, but I would probably give the same advice as I do for warts; go ahead and make that non-urgent dermatology appointment. If it isn’t clearing up on it’s own within a month or two, it is worth seeing what treatment options are available to you. Unfortunately folks can get this more than once. Having a prior case does not seem to give immunity.There are lots of internet 'cures' for this including coating the body with silver....., but they are likely a waste of time and money.

Warts are viral - shoes, socks and anyplace where bare feet have been in contact with should get sprayed or wiped down with Lysol. It is best not to share baths with siblings if they have warts or molluscum. Swimming in a pool is fine because of the chemicals.

There are loads of other the counter suggestions out there. Most are harmless but probably ineffective. Keep in mind that the goal is to irritate the wart enough that the body’s immune system is stimulated to come in and help get the job done. I will equate the natural remedies such as tea tree oil to using a watering can to fight a fire. The OTC wart patches are your fire extinguishers. The dermatologists and podiatrists have the fully equipped fire trucks!

Any lesion, wart or otherwise, on the body that isn’t gone within a month or two is worth an evaluation by a specialist. Dr. Cheung cautions that although it is very rare, some warts can turn into skin cancers, so get them checked out. Early intervention can make all the difference.

Friday, April 20, 2018

Temper Tantrums 2018

It is the rare parent who hasn't had to deal with the occasional tantrum. Here are a few tips for managing them.

If you have called me to talk about behavior, it is a good bet that you have already heard this analogy, but here goes: When you are a parent, imagine that you are the coach of a football team. Keep in mind that most of the coaching takes place before and after the games. Your team may win big or they might completely screw up. During the game you are mostly just a spectator. Leading up to the game you strive to prepare your players the best you can. After the game you can be the Monday morning quarterback and identify ways to improve.

I have found it very helpful for parents if they can recognize the difference between "game time" and "coaching opportunities." If we follow my theory, transition times, mealtimes, getting out of the house in the mornings and bedtimes are considered game time. You can't do any effective coaching or teaching during these moments. Hopefully you have created a "game plan" so that generally things go smoothly. When you encounter a situation that sets off a tantrum, do your best to just get through it as calmly and creatively as you can. If you notice that you are stuck in a rut and you can identify routine behavioral issues, you need to work on creating a new plan.

Here's an example of a "game time" situation. Many years ago I was a solo parent on a flight, returning home from grandparent visit/family visit. My sister Marjie had bestowed each of my daughters with a "my little pony" gift to entertain themselves on the flight. Alana the two year old had chosen the pink one, and Lauren the five year old was happy with the blue one. Mid way through the long flight, Alana wanted to make a trade. Lauren wasn't interested and quite within her rights, she soundly refused. Alana was usually a fairly mild mannered child, but I could see the tantrum brewing and she was about to cause a serious disruption. I did a quick negotiation with Lauren: "Hand over the blue pony now, and when we get home they are both yours." Lauren took only a second or two to recognize the value of this and gave Alana the blue pony. Crisis averted. This wasn't the moment to teach about sharing, or fairness. This was game time. Get off that plane intact. If we had been at home I may have handled it quite differently. It is absurd to think that you will handle a tantrum in the middle of a crowded public area the same way you would in your home. Home field advantage???

Watch for clues and do your best to ward off an impending tantrum if the warning signs are clear, but once your child has already entered the meltdown zone, it is time to change tactics. There is a popular parenting book that counsels parents to get down on the child's level and loudly evoke their inner caveman by chanting "You are mad, you are mad, you are mad mad mad!" When that book first came out, I would routinely hear parents out in our waiting room making more of a racket than the fussing kids. I must confess, that when I still hear the occasional parent grunting "you are mad" I roll my eyes a little bit, but the premise is actually a solid one. When your kid is having a tantrum, acknowledging that you are trying to understand what is going on in the first step."You seem mad, sad, frustrated etc" are often exactly what your child needs to hear.

If you told me that you have a headache and I responded by discussing the weather, it would not be very satisfying. Distraction is all well and good, but not until they get it that you are trying to understand what has them so upset. Validating a feeling is not the same thing as giving in to an unreasonable request. Try to hold them close, get them on your lap and wrap your arms around them so that they can't thrash around. Make shushing noises. Keep it simple. This is not the time for lots of words. Those come later.

If your child has frequent tantrums, see if you can figure out what is setting them off. Look for patterns. Many parents realize that kids get more fragile when they are getting hungry. Try having little snacks on hand and pay attention to any cues that might be leading up to a melt down. Are they tired? If tantrums are routine, you need to examine your child's nap/sleep schedule. Make sure that they have adequate Iron and Vitamin D intake; both of those can impact mood and sleep. Are they frustrated by something? In a calm moment, if your child is old enough, help them work on their problem solving skills.

Problem solving activities work very well after a situation has happened. Talk about what went wrong. See if they can help plan a better way to deal with it the next time.

Step one is always identifying the problem. Break it down to a small but manageable issue. Rather than the diffuse "fighting with sister" get down to a very specific issue, such as "sister won't the share yellow crayon."

Step Two is talking about some choices one might have in that situation. Some are good choices, others not so much. They all make it to the list. Adding a silly one is just fine and makes this feel more like a game. Choices could include:

  • Using a different color;
  • Using words and asking sister nicely to share (may need to wait a minute for her to finish coloring her own yellow parts.)
  • Asking a grown up for help;
  • Start screaming;
  • Grabbing the crayon;
  • Draw a frowning face on your hand with a black crayon;
  • Use your "walking away power" and take some deep breaths.

Hopefully with some gentle guidance they can identify the more positive choices on the list.

Problem solving exercises are very empowering for your child. The age range for when kids are able to take part in these is fairly variable, but they will all get there.

For kids over 3, see if they can recognize their own warning signs before losing control. This is a tool that will serve them so well for their entire life. Perhaps create a song together that they can sing when they are approaching tantrum stage. Mr. Rogers has a song about dealing with mad feelings:

Any time that you see your child get calm without losing control give them loads of positive feedback.

Kids can also get a lot out of a well told story. Create two little children that you can tell tales about. They are the same age as yours, with very similar family circumstances. One tends to make good choices and the other also gets into trouble often. Allow your child to chime in and talk about why these other children had a tantrum and what they ended up doing about it. Kids do much better talking about these very relatable characters than they do about their own actions. Once they come up with a plan for the made up child, you can bring it back around; "Maybe you could try that also."

Even the best kids have occasional meltdowns. Do NOT let your kids beat up on you. This might be the time for you to calmly use your own,”walking away power” if you are able to do so safely. This is a good message and a good consequence. Later on you can talk about how you are choosing not to stay in a situation where you might get hurt. Typically, kids are looking for some attention. You leaving the room is rarely the action they were going for.

All tantrums can be turned into learning experiences for you and your child. Stay calm and be consistent.

Friday, April 13, 2018

Constipation 2018/Because the poop has to come out!

Constipation - The poop, the whole poop, and nothing but the poop

One day your kids will be completely out of diapers. Believe it or not, the day will come when they no longer want you to wipe their butt after a poop (that age tends to vary greatly from child to child.) The years pass and while at some point you tend to lose track of your child's bowel movements, it is the rare parent that gets a completely free pass. If you are a patient of Noe Valley Pediatrics, I am betting that at some point before your child goes off to college, you are going to have a conversation with the advice nurse team about your child's BMs.

It is quite common for kids to occasionally complain about tummy aches. In my experience, a full 90% of these are constipation related. Of course we never want to ignore other possibilities. Abdominal pain could be all sorts of other things that need attention. Tummy aches that come from constipation tend to be very sharp, but also intermittent. Sometimes the pain can radiate to other parts of the body.

If we have a patient with a complaint of a tummy ache, we are going to want to know the frequency and consistency of the stools. Here is the tricky part. If your kid is really backed up (and it is unbelievable how much poop they can have inside of them) sometimes the solid poop can't get through. What they will pass is some very runny substance that is getting around the solid mass of impacted stool. Because of this, your first thought might be that your child has diarrhea. Sorry kids, but the parents now need to know way more than you might be comfortable sharing. When was the most recent poop? Was it normal size? Smaller than usual? How often are they pooping? Are they sitting for a long time trying to get it to come out? Are the stools coming out in little hard pieces? If your older child is feeling a little bit shy about it, consider having them take a picture. There is something called the Bristol Stool chart that can help with the description.

Having a regular poop routine is helpful (particularly for boys who stand to pee). They should get into the habit of sitting on the toilet for 5 minutes at least 2 times per day, even if they don't think they have to go to the bathroom. Ideally this will be done after meals. Sitting on the toilet should be limited to 5 minutes and there should be no straining! (Maybe take the Harry Potter book out of the bathroom.) After 5 minutes, just get the kids up - if they have the urge again, then they can sit back down. Many children don't like to poop at school or camp. (Hey some adults have strongly prefer the privacy of their home bathroom as well.) If they happen to get off schedule and the urge hits them at an inconvenient time, they will often hold it until the urge passes. Some kids become very adept at this and can hold onto a remarkable amount of stool. They may pass a tiny little hard pellet every day or so. If you ask them if they pooped, the answer will be "yes".

I like to do a little 'Nurse Judy poop math' (this can't possibly surprise any of my regular readers.) Figure out how large your child's average size stool might be. Let’s say it is the size of a hot dog. Assume your child doesn't have a BM for 3 days. For the next 6 days after that, they pass only 1/2 of a hot dog size poop. Within 9 days, just a bit over a week, they now have poop in there the size of 6 hot dogs. No wonder they are having a tummy ache!

It is time to sit and talk to your child about a very important rule.

There are many choices that we will face in our lives with very few incontrovertible truths, but this is one of them: THE POOP HAS TO COME OUT! Have your younger kid play with some play dough and a toilet paper tube. Only a certain amount can fit through before something rips. Not pooping is not an option. These kids need to be cleared out. All the prune juice into the world is not going to be able to blast through an impacted mass of stool.

Thanks to Dr Wild for telling me about the following video!

Parents can take a look and see if you think it might be a good teaching tool for your child.

Massage and a warm bath are a good starting point. Some kids actually maybe able to pass some stool while in the tub because they are relaxed. I know it sounds gross, but if you are ever in this situation with an utterly miserable child who is holding onto their poop as though it is a treasure, you will be happy to see them poop anyway that you can make it happen. Some people find that adding a few teaspoonfuls of either baking soda or epsom salts to the warm bath water will can also help.

If they still haven’t pooped, it is time to try some glycerin into the butt. You have several options. A glycerin suppository is a hard stick of glycerin, usually found at most drugstores in the baby aisle. You can break off a piece, lube it up with some KY jelly, Vaseline or Aquaphor and just stick it in there. Hold the butt cheeks together so that your child doesn’t push it right back out. Another option (which I prefer) is a liquid glycerin called Pedialax. The directions on the box advises that these are for use in kids over 2, but I have no concern about using them on infants. With these, you end up inserting the lubricated tip of the applicator into the butt, squeeze in the small amount of liquid glycerin and then remove the applicator. They usually work some magic within 30 minutes.

Chronic constipation is not a quick fix. The first step is obviously to get rid of the poop, but then the muscles need some time to be retrained.
Once you get some of the hard stool out, we can start to focus on making some adjustments to the diet. Alas, the favorite foods are often the starchy breads, cheese and pasta that do nothing but block them up even more. The BRAT diet (bananas/rice/applesauce/ toast) is what we use to firm up stools if a child has diarrhea. When dealing with constipation issues we will want to avoid those until they are having softer stools. Some kids seem to have a much easier time if you eliminate milk. Try that for a week and see if it helps (if you do this, make sure they are getting enough calcium.)

Fruits and veggies are great. Smoothies might be useful if they won't eat them raw. Make sure they are drinking plenty of healthy fluids. Sometimes simply the addition of extra water or prune juice are all that is needed to get you back on track. Pineapple, peeled grapes, figs and raw crunchy red peppers can be especially helpful additions to the diet. See if you can somehow hide some molasses and flaxseed oil in some oatmeal or baked goods. Kids will often eat something if they had a hand in baking it. Do a daily dose of probiotics. These help keep a good balance of healthy bacteria in the gut which is good for digestion.
Fiber is essential. The usual rule of thumb is that a child should be consuming their age + 5 in grams of fiber (For instance, a 10 year old needs 15 grams of fiber, a 15 year old needs 20 grams of fiber per day). This is up to a maximum of the adult dose of 25-30 grams per day. It is important to make sure that all this fiber is washed down with lots of water. Too much fiber and too little water will actually bulk up the stools and worsen constipation. If you are finding it a little tricky trying to get enough fiber into their diet, try offering FiberOne bars, fiber gummies, fiber powders (Metamucil, benefiber, citrucelle, etc) to get to their goals.

Make sure your child is getting enough magnesium. Natural Calm (available at Whole Foods and natural food stores) is source that many folks like. An appropriate dose can get even the most stubborn gut moving. There is no way to “overdo” magnesium by eating magnesium rich foods, but you don’t want to take too much in a supplement form.
Kids ages 4-8 can take 130mg/day; kids ages 9-13 can take 240mg/day. The Natural Calm adult dose is 175 mg/tsp (mixed in other liquids.) Big kids can easily take 1 to 1-1/2 tsp. Smaller kids a bit less. If they take too much it might cause cramping. Start with a small dose and see if it helps. This also comes as a gummy!!!

Posture makes a difference! Go online and check out the Squatty Potty. Some of the reviews are quite amusing, but the overwhelming verdict is that many people are finding this a deal changer. In other cultures, people squat to poop and have no issues. Talk about your “third world problem”. It turns out that our sitting position is not really helping our body with elimination. You might want to experiment with a little footstool in front of the toilet or potty that gets your child in a better position. You can try it too!

If you have a young child, check out the book Itsy bitsy Yoga. Some of the stretching positions might help move things along.

Acupuncture is another option. Check

We have had some success sending folks for biofeedback. Alas this may or may not be covered by your insurance.

If massage, position and good diet don’t seem to be doing the trick, talk to your doctor about getting your child on Miralax. Miralax is an over the counter fiber that is heavily used by pediatric GI specialists to deal with constipation. Miralax has recently had some articles about it that made some folks uncomfortable about it’s use. There are no studies about its safety for long term use and one of the biggest concern is the lack of testing in pediatrics. While that is true, official studies aside, it has been used for years and years without any known contraindications The specialists don’t seem to have concern about the safety. Miralax doesn't get absorbed into the system. What it does is pull the fluids into the intestine to make sure the stools are softer. We have some patients who are on it for an extended period of time with no ill effects. That being said, I never want anybody on medication that they don't need.

If your child has been given a dosage for a course of Miralax, I am perfectly happy if you do a daily adjustment of the dose depending on that day's stool. If it feels like you are already achieving softer stool, it is okay to decrease the dose and perhaps skip a few days. The minute the poops become less frequent or more solid it will be time to bump back up the dose.

If you are pretty sure you child is not constipated and they have an abdominal pain that is more steady than intermittent, they need to be evaluated!

Thanks so much to the wonderful UCSF GI specialist, Dr. Wild, for helping me update this post!

Friday, April 6, 2018

Urgent Care Options 2018

Please see updated post 3/2019

Urgent care/emergency options 2018

Murphy's Law generally seems to make certain that the fever spikes or the vomiting starts right at 5:01 pm when the average doctor's office turns their phones off. It is important to be familiar with your after hours/urgent care options.
Some of the common calls that folks need help with after hours are dosage questions. Here is the link to a post with that info:

Waiting until you or your child is ill is not the best time to start learning about what choices exist in your area. Does your insurance plan have a preferred option that won’t cost as much? Are there after hours advice nurses available? Where is the closest emergency room? Is it staffed with pediatricians?
If you are traveling, plan ahead and figure out local options for care before the trip.
For Noe Valley Pediatrics patients who need help after hours, we ask you to start with the pediatric after hours clinic/triage nurse line:415-387-9293
If the nurse is NOT able to help, you will be directed to our answering service where the Noe Valley Pediatrics physician who is on call that night will be paged. The answering service number is415-753-4697

Here in the San Francisco Bay Area we are lucky to have very good options for after hours care.

In San Francisco 3490 California Street, Suite 200                         415-387-9293
In Berkeley 3000 Colby St Suite 301 (New Location 7/2017) 510-486-8344  
Patients are seen by appointment:
Monday through Friday 6:00 pm - 9:30 pm, (phones open at 5:00for appointments)
SaturdaySunday and holidays 8:30 am -9:30 pm (Phones open at7:30 am)

Weeknight pediatricians are made up of participating private pediatricians, including several of our doctors who work an occasional shift in the clinic there. Weekend doctors are fully trained and board certified pediatricians.
On weekdays the phone lines turn on at 5 pm. The advice nurse triage team is available through the night, even after the clinic is closed. The availability of the triage nurse makes this our number one choice.

The Pediatrics After Hours Care at St Luke’s Hospital is affiliated with Sutter/ CPMC and is located at 1580 Valencia Street, 7th Floor #701 This clinic has been open for about two years now.
It is now open 7 days a week.
Monday-Friday 5:00pm-10:00pm
Saturday-Sunday 8:30am-10:00pm
Phone: 866-961-8588

This service does not currently have an advice nurse team, but the person answering the phone can help do some basic triage when making the appointment and help redirect you to an emergency room if that seems necessary. This clinic has some advantages besides the convenient location. They start the scheduling process as early as 2 pm, which may make it easier to make a plan if we are already solidly booked here in our office and can’t get you in to see us that same day. They also offer weekend weight and bilirubin checks for our newborns. As a bonus, there is a special waiting area so that the healthy newborns aren’t exposed to the other sick kids.

The two options listed above are the only urgent care facilities with which our office has a close relationship.
When things are going as they should, both of the above after hours options send a report to the primary doctor's office. In our office, the nurse team reviews the reports and follows up to see how you are doing to maintain a sense of continuity. Most of the insurance plans that we are in network with are accepted, but not 100%. Do yourself a favor and know your best covered options before your child gets ill!! No one will be able to get you accurate coverage information outside of business hours, which is when you might be needing it.

I am listing the others below as a convenience.

If you are not in San Francisco, on the Peninsula you have several good options. is a pediatric urgent care facility. There is no appointment needed.
210 Baldwin Ave in San Mateo. Telephone 650-579-6581

The Palo Alto Medical Foundation has several pediatric urgent care options:
They have a choice of appointment or drop in. The website gives info about the various locations and current wait times.

In Marin
6:30 pm-9:30 pm Monday through Friday
9:00 am-9:00 pm Weekends and Holidays

There are plenty of general urgent care places popping up all over the place as well. Keep in mind that with most urgent cares, there is no such thing as an appointment and folks just show up and get seen in the order that they come in. There is risk for a much longer wait. They are also not usually staffed with pediatricians. For a teen, this is usually not much of an issue, but for my younger kids, I would try to stick with one of the pediatric after hours clinics. If you do end up at another urgent care, please ask them to send over a report so that we stay in the loop.
Emergency Rooms
In a true emergency of course call 911. If it is less urgent, but you are certain that you child needs immediate medical attention we are lucky to have excellent options here in SF.
When given the choice I will generally opt for one of the true pediatric emergency rooms. You are not competing for care with the elderly heart attack and stroke victims that may be populating the waiting room and getting ranked higher on the triage scale. You will also be assured of seeing a pediatrician and having appropriate pediatric equipment. If an admission is needed, my preference would be either CPMC California campus or UCSF Mission Bay, so there also won’t be any transport needed if you are already at one of those ERs. I think it is worth the extra ten minute drive across town and may save you time in the long run.
The UCSF Pediatric ER in Mission Bay is located at 1975 Fourth Street:
This emergency room has scored very high in a nationwide ranking for getting patients seen in a timely manner.

CPMC pediatric emergency room is located at 3700 California Street/ at Cherry:
This ER generally gets high marks from our patients.



While we strongly prefer to have our youngest patients be seen by a pediatrician, there are ‘those days’ when our office is completely booked up early. If there is something going on that is not worthy of an emergency room visit and you don’t want to wait until the pediatric urgent care offices open, here are some options.
With any urgent care, make sure they send a report to your primary doctor’s office. If you were not seen by a pediatrician, it is always a good idea to touch base with your own doctor the next day to review the diagnosis, treatment plan and follow up needs.

Care Practice
This place is not terribly far from our office on 14th and Guerrero.
They are a fee for service practice.
They will see all ages.
Visits are appointment only. They are currently open 4 days a week.
They do not have X-ray or Ultrasound capabilities

Golden Gate Urgent care

There are several locations. These folks do take some insurance They do see pediatrics for basic issues. They also do x rays.
You can drop in, but it makes sense to book an appointment online to minimize the wait time.

If you get labwork or Xrays done at an urgent care, please realize that you will need to follow up with them for the results.