Friday, October 26, 2018

Acute Flaccid Myelitis

Acute Flaccid Myelitis

There are three categories of urgency levels when we get notices from the public health department:

  • Health Alert conveys the highest level of importance and warrants immediate action or attention.

  • Health Advisory provides important information for a specific incident or situation, this may not require immediate action

  • Health update provides updated information regarding an incident or situation. This is unlikely to require immediate action

This week we got a Health Advisory from the California Department of Public Health regarding the national increase in reports of suspected Acute Flaccid Myelitis cases. The Media has been all over this and it is scary indeed. It is hard not to get nervous. Of course I have had some calls about it.

It is NOT my intent to fan the flames and make folks panic, I just want to give you some basic knowledge and share what is currently known about it.
Acute Flaccid Myelitis (AFM) is a very rare neurological condition that is characterized by sudden onset of weakness in one or more limbs. An MRI will show distinct abnormalities of the spinal cord gray matter.
Nationally, from January 1 through October 16, 2018 the Center for Disease Control and Prevention (CDC) has reported 62 confirmed cases in patients from 22 US states. They are investigating other possible cases at this time, so the numbers will likely change.
More than 90% of the cases occur in patients who are under the age of 18 years old. Some lucky folks have recovered quickly and completely while others continue to experience paralysis and weakness.
There were similar episodes making the rounds a few years ago that were associated with Enterovirus D68 .

This time around patients have been tested for that strain of enterovirus. It has not been consistently detected in every patient with AFM, so there isn't a clear connection, but many experts still think that D68 is the most likely cause and that the virus has mutated to make it harder to detect. Other thoughts are that it could be connected with a mosquito borne illness. The investigations continue.

AFM is NOT thought to be contagious from person to person.
While I don’t want folks losing sleep over this, (our odds of winning the current giant lottery are on par with having to deal with this)
seek immediate medical attention if you see any of these symptoms:

  • Difficulty moving the eye or drooping eyelid
  • Facial droop or weakness
  • Difficulty swallowing or slurred speech
  • Sudden arm or leg weakness
If we are suspicious of AFM, further testing and likely an ER visit would be the next steps.

Friday, October 19, 2018

Halloween safety and activity guide 2018

Halloween can be such a fun holiday, but as you can imagine, as advice nurses we tend to hear about some of the misfortunes that can along as part of the festivities.

Carving a pumpkin can be a very fun tradition. Please make sure that your child's level of participation is consistent with their age and ability. Watch out for the sharp implements and make sure you assign your younger child to the safer tasks (young kids can draw on the pumpkin rather than carving.)

Clean up the mess. Pumpkin flesh is slippery and can cause falls and injuries when dropped on the floor. Layer newspaper or old cloths under your carving work space and clean up spills right away so no one slips or trips. Skip the candles, which may cause fires. A burning candle in a pumpkin may become a blazing fire if left unattended. Instead, use a glow stick (available in many colors) or flame-less candle to safely illuminate your jack-o'-lantern.

Choosing a costume
Children are more than twice as likely to be hit by a car on Halloween than on any other day of the year!

Decorate costumes and bags with reflective tape or stickers and, if possible, choose light colors. Have kids use glow sticks or flashlights to help them see and be seen by drivers. Is your dog going along with the trick or treaters? Have them wear a glow in the dark collar!

When selecting a costume make sure it is the right size to prevent trips and falls. Be sure to wear flame-resistant costumes. Remind your child that they need to pay very close attention to their surroundings and avoid walking near any candles or flames, especially if they have loose flowy costumes. If a sword, cane, or stick is a part of the costume, make sure it is not sharp or too long. A child may be easily hurt by these accessories if he or she stumbles or trips.

Make sure that no part of the costume is covering their ears solidly enough that their hearing might be impacted. Since masks can sometimes obstruct a child's vision, try non-toxic face paint and makeup as another option. Face paints have been in the news lately. Some of them have some toxic ingredients like lead. Be familiar with the ingredients before you apply anything to your child’s skin. Always test the makeup in a small area first. Always completely remove it before bedtime to prevent possible skin and eye irritation.

Make sure that your child doesn't have any latex sensitivity before you do too heavy of an exposure. Many masks are made of latex. We actually had a patient who had an allergic reaction to the hair tinsel. You may want to do a test run of the costume and make up a couple of days ahead of time to rule out any allergies.

Trick or treat rules
Children under the age of 12 should not be alone at night without adult supervision. If kids are mature enough to be out without supervision, remind them to stick to familiar areas that are well lit and trick-or-treat in groups. Never go into a strangers house without supervision.

Popular trick-or-treating hours are 5:30 p.m. to 9:30 p.m. so be especially alert for kids during that time if you are out driving.

A good meal prior to parties and trick-or-treating may discourage youngsters from filling up on Halloween treats.

Bring plenty of water along when you go trick or treating. Just trust me on this one.

Make sure that your children know that after trick or treating, the grown up needs to pick through trick or treat bag and toss anything that looks suspicious. There is a warning out in Colorado this year about "pot laced" treats. That could happen here just as easily. Anything that looks like it has been tampered with should get tossed. Some candies are real choking hazards. If you have a younger child in the house, make sure they don't have access to the stash.

If you have a child with nut allergies (I am sure this is NOT your favorite holiday) make sure that they turn over ALL the candy so that you can separate out anything that might cause trouble. My favorite allergist adds another piece of advice. Most of the time nuts may be just one of the ingredients, but as a general rule, kids who are allergic to nuts should also be able to identify the nuts that they are allergic to. If it is peanuts, make sure they know what an actual peanut looks like.

Expecting trick-or-treaters or party guests?
Consider purchasing non-food treats for those who visit your home, such as coloring books, stickers or tattoos. Provide healthier treats for trick-or-treaters such as low-calorie treats and drinks.(Okay, fine...maybe you don't want to be "that" house, but I had to put it on the list.) Be sure walking areas and stairs are well-lit and free of obstacles that could result in falls. Keep candle-lit jack o'lanterns and luminaries away from doorsteps, walkways, landings, and curtains. Place them on sturdy tables, keep them out of the reach of pets and small children, and never leave them unattended.

Now what do we do with all this candy???
Make a plan about how much candy they can eat at one time. It is okay to be a little more liberal than usual for a day or two, but come to an agreement about a reasonable candy intake over the next few weeks. Some dentists and orthodontists have buy back programs, where they will give your child a reward for turning in their candy. Check with your dentist to see if they participate.

Bibi, one of our mom's, doesn't bother with the dentist and has instituted her own buyback program. Her kids can exchange candy for new lego pieces.

You may need to be extra vigilant with teeth brushing this season.

Remember that candy freezes (and some of it is actually better that way; frozen snickers bars, yum!)

My daughter Lauren was about 6 when she caught on that mom and dad were pilfering through her trick or trick bag and stealing all the good stuff. After that she guarded her stash more carefully.

Here are some tips that some wise mamas have added to this post over the years:

"Once Cleo was out of the stroller and walking, we put glow stick bracelets and necklaces on her so we could see her more easily when out and about in crowded spaces in the dark (we do this at things like the Dia de Los Muertos parade, too.) Cliff's sells them in a big 100-stick bulk container. Not terribly eco, but gives a little extra "eyes on" help when navigating the crowds."

My little patient Franny, bent a glow stick in order to activate it and it broke. Some squirted in her mouth. While you do want to avoid unnecessary contact with the insides of a Glow sticks, they are non toxic

Here are some local Halloween activities for the 2018 season.

bayareakidfun Halloween events

Friday, October 12, 2018

Strep throat 2018

Strep throat is a bacterial infection caused by the Group A streptococcus germ.

This illness is most common in people between 5-15 years of age but people of any age can get it. For some reason is is quite unusual for babies under 2 years of age to have it, but there are always exceptions.

Someone with strep throat will usually present with one or more of these symptoms:

  • Sore throat
  • fever
  • body aches
  • headache
  • stomach ache
  • nausea
  • a red sand papery rash all over the body

Strep with the rash may be referred to as Scarlet fever...sounds scary right?? Indeed it used to be. Now that we have antibiotics to treat it with Scarlet Fever is not much more alarming than simple strep.

Get out your little flashlight and do some checking. If you are lucky enough maybe they will actually open their mouth; most of the time the throat will look quite red. You may see red or white patches in the throat or on the palate (the back part of the roof of the mouth.)
The tongue might have red and white patches. This is referred to as strawberry tongue for obvious reasons. Feel around the neck and see if the glands feel swollen. Sniff the breath. Often parents call me and say that is smells like their kids swallowed a 'swamp creature'. The breath smells yucky.

Not everyone has all the symptoms.

Be aware that children under 5 often say that their "mouth" or “neck” hurts, but they are talking about their throat.

Some folks don't even complain about a sore throat and some cases don't present with an elevated temperature.

This week in the office we have had many patients without a sore throat who are testing positive. The chief complaints have been tummy ache and head ache.

It is quite contagious, but it is not uncommon for some family members to have it, while others escape. I would say that in my experience the odds are about 50/50. (The minute someone in your family gets that sore throat I would suggest sucking on a zinc lozenge and some sambucol; maybe you will get lucky.)

The incubation period ranges from 1-5 days but most of the time folks show the first symptoms about 2-3 days after exposure. You can catch it from being in close contact with someone else who has it. If you treat with antibiotics (which is recommended) you are not contagious once you have completed 24 hours of the medication. If you don't treat, you remain contagious and can spread the illness for about 3 weeks.

Given enough time, strep can resolve by itself but the antibiotics absolutely shorten the severity and duration of the illness as well as significantly decrease the risk of complications. Untreated strep throat can lead to complications later on, such as rheumatic fever and heart valve problems.

It is impossible to have real statistics about this. Most folks don't jump into the doctor's office every time they have a sore throat. There are likely millions of untreated cases of strep out there at any given time and of course most of them will have no issues in the future. However, better safe than sorry. If we know you have a case of strep throat, we will strongly advise that you do a course of antibiotics.

Typically the strep throat 'package' does not come along with a lot of congestion. If I am hearing about someone with lots of coughing, clear mucus and sore throat, it is more likely viral.
On the other hand, a sore throat with fever and not a lot of congestion gets my antenna up. I am not kidding when I mention stinky breath. A lot of the parents that I talk to can tell strep from the smell and they are almost always right!

Nausea and tummy aches are quite frequent with strep, but add some diarrhea to the mix and I am no longer as suspicious. Nausea plus loose stools is usually more of a tummy bug of sorts.

We test for strep in the office with a rapid strep test that we find fairly reliable. If the test is negative, but the symptoms are very suspicious for strep, we will send a culture to the lab to double check the result.
If your child hates the swab there are 2 things you can do to help.
First is to have them lift their legs when they are saying AAAAH. The brain gets confused by this and forgets to gag.
Another tip that I learned from 3 year old Amelia is to growl like a lion. The growling is the perfect way to open up the throat and the mouth for that swab to sneak in.

Our test is specific for Group A strep. There are different strains of the strep bacteria that can cause various infections.
If the in office test is negative, the lab test may still come back positive with another strain. 

Some folks are carriers. This means that they have a small amount of the bacteria living in their body all of the time and it doesn't make them ill. Those folks may show a very faint positive on the quick test. Some patients also seem way more susceptible to strep than others. I used to get it all the time until I had my tonsils out. That is not an uncommon story. 

If you do end up being treated, it is important that you finish your course of antibiotics. If you are not seeing an improvement within 72 hours of starting the medication, make sure you check in with your doctor. It is rare, but strep can lead to serious complications including abscesses on the tonsils, ear infections as well as kidney problems.

Change your toothbrush 24 hours after starting the antibiotics so that you don't get reinfected!

Symptomatic treatments until the antibiotics kick in include

  • Tylenol or Motrin (we are treating pain, not necessarily fever)
  • Lozenges
  • Tea with honey (no honey for kids until one year old)
  • Check out Manuka honey if you can find it. Not all honey is created equal.
  • Gargling with salt water
  • Popsicle s
  • Cold fruit nectar
  • Having a humidifier running at night.

Friday, October 5, 2018

Colds/coughs/congestion 2018 (symptomatic treatment/when do you need to be seen?)

We are right at the beginning of the cough and cold season. It is useful to have some guidelines to help you figure out when a trip to the doctor's office is indicated. Many times, there is nothing to do but wait it out, so I am including some tips to help you and your child get through the illness as comfortably as possible.

Studies say that most children will have an average of EIGHT colds within the first 18 months of life. Even if we don't have young children, colds and coughs are a common issue for all of us. Most of the time the congestion is caused by a viral syndrome. Allergies and teething* can also be culprits causing you to be congested.

{*Most medical literature disputes whether or not teething is connected to any symptoms, but I still maintain that there surely feels like there is an x in the equation.}

All that mucus is the perfect breeding ground for bacteria, which is why something that starts as a virus can turn into an ear infection, sinus infection, or lower respiratory infection fairly quickly. Be warned, we can see a patient one day with clear lungs and no ear issues, and the very next day they can seem a lot worse and have a raging infection.

When to come in 
If you are dealing with a congested family member, here are the questions to consider:

Do they seem to be having any labored breathing? Babies with labored breathing will look like their little tummies are going in and out more than usual. Respiration will be more rapid (I am more concerned with the lungs than a stuffy nose.) Noisy breathing alone is not a very good indicator as it may be caused by upper airway issues that we aren't too worried about.

  • How is their mood?

  • Do they have a fever?

  • How is the appetite? If your baby is nursing well, that is very reassuring.

  • Are they sleeping well at night?

  • What color is the mucous?

  • How long has this been going on?

If you have any labored breathing, wheezing, a child who is much grumpier or fussier than usual, and/or a fever that is hard to control or has lasted more than 3 days, an office visit is needed. I am also interested in mucus that is getting thicker and greener. Green mucus does not automatically signal a problem. It is just one more clue.

It is okay to play the wait and see game if we have a reasonably consolable child with clear mucus who is eating and sleeping well, whose breathing isn't alarming and who has no significant fever.
Of course if the symptoms show no signs of improvement, please check in with your doctor's office. Many colds and coughs can last between 1 and 2 weeks. Some coughs can really hang on.

If you find that you are having a hard time assessing the respirations, try sticking your ear up to their lungs and see if you can hear anything. If you can hear nice clear air noises, that is great. If you hear whistles or squeaky noises, that may mean the congestion has spread down to the lungs. Using your ear as a stethoscope doesn’t always work; more than half the time you won't be able to hear anything, but once in awhile parents are able to get some important clues from the "ear to chest" evaluation. If your child is old enough to cooperate, have them take a great big deep breath, in and out.

If they are wheezy or have any inflammation in their lungs, that deep breath will often trigger a bit of a coughing fit. If that happens, it is probably worth an office visit.

It is not a bad idea to get an idea of what “normal” looks like. If you are lucky enough to be reading this when your child is healthy, lift up their shirt and watch them breathe for a minute or two. How fast are their normal breaths?

Any baby less than 2 months old is probably worth a visit to the office with their first cold, unless they are eating really well and seem completely happy. It is certainly at least worth a call to the nurse.

Sometimes a big mucus plug may be momentarily blocking an airway, causing a minute of distress that clears with a big cough. If coughing and steam are able to clear things up, it is more likely that it is upper airway congestion.

Management tips
The best way to manage congestion at home is to make sure your little patient is getting plenty of fluids (this will help to keep the mucus thinner.) Breast milk is perfect if you are lucky enough to have it.

With some older kids, cow's milk may not be the best choice because it can increase the amount of mucous (it doesn't impact everyone the same way.) I have plenty of patients who love their milk and taking it away for a couple of days is not a reasonable option. Sometimes thinning it will a bit of extra water is a good compromise.

Steam is great. Hang out in the bathroom when anyone takes a shower. Running a humidifier or vaporizer at night is a good idea. Turn it off during the day and give the room a chance to dry out so that you don't grow mold. Make sure you change the water daily. As long as you follow those rules, I don't have a preference between warm or cool mist.

Keeping the head elevated makes a huge difference. Some of the younger babies will do best napping in their car seats, bouncy seat or swing. Make certain that they are in a safe place. For night time, try a crib wedge or place a towel underneath the mattress to raise it up a bit. Some parents place a book underneath two of the crib legs to get it on a mild slant

You can put saline drops or breast milk into the nose (and then suck it out with a Nose Frida or snot sucker). This is the most natural way to clear the nose. Your baby will no doubt hate this, but if you can manage to do it about ten minutes before a feeding, it may clear the nose up enough to make eating much easier. Do not torture your baby with the nasal irrigation if they are managing just fine.

Some of my parents really like the Oogiebear nose and ear cleaners. These are safe, soft little plastic scoops that allow you to remove stubborn little boogies.

For patients over 6 months of age, ask your doctor about Windbreaker or Pipecleaner. These are Chinese herbs that we use to dry up congestion. Many of our families swear by these. They are sold at the Chinese medicine works on 25th and Noe. For convenience our office tries to also keep it them stock.

Consider acupuncture! One of our neighborhood acupuncturists gets some good results from her treatments for your basic coughs and colds. Her treatment of children often does not use any needles. The Acupuncture Den

Still in the realm of Chinese medicine, there is a new product on the market. Dr. Loo, a local physician, has created a patch to treat the symptoms of congestion. These are safe for any age!
Her website is a work in progress but you can learn all about the products by clicking below. It is possible that we will have some of the patches available for purchase.

For older kids and adults, don't minimize the value of chicken soup! There was a fun study done a few years ago that found that soup drunk out of a mug was actually statistically better than soup out of a bowl.

So, what about the over the counter cough medications? I have been an advice nurse here at Noe Valley pediatrics for a shockingly long time (1988.) For many many years the nurses and docs were pretty quick to prescribe over the counter cough and cold remedies to our patients over 6 months. The rules and recommendations kept changing. First they moved the age to 2 and over, the next thing I knew the age was 6 and over. In my experience, those meds were useful and harmless. It was nice to have an option for the younger patients to help them get over the hump of a nasty cold, but the powers that be are pretty firm that the labels remain for older kids only.

There are some homeopathic remedies out there that are considered completely safe. Chestal and Zarbees are are two of the brands I have had parents give good reports about. Make sure that you don’t give anything honey based to a child under one year of age. The Zarbees does have an infant formula. Boiron came out with something new this year called ColdCalm. This is a homeopathic remedy that comes in a little dropper that can be given to patients as young as 6 months of age.

Here in our office our docs may recommend a dose of Zyrtec or Benadryl at night to help dry the kids up and get them a good night's sleep. Before I would do that, I would want them checked out to make sure the lungs and ears are clear.

For night coughs, without taking anything orally, you might try a bit of  Vicks Vaporub on the feet! Trust me, I scoffed at that as much as anyone, until I asked my patients to test it out and was shocked at how much it seems to help.

For parents and big kids I really like Sambucol and zinc lozenges. They may be placebos, but in my case I say " bring it on" because they seem to work. Remember that I work in the germ factory and (knock wood) I manage to avoid many of the things I tend to be exposed to. The second I feel that little tickle in my throat or any tell tale signs of an illness I take a zinc cold therapy lozenge Walgreen's generic taste better and are cheaper) and a Sambucol lozenge twice a day. Ester C is also a good supplement to add.

Another very good thing to do for folks who are old enough is to use a Neti Pot or sinus irrigation. Make sure to use distilled water.
NeilMed has quite a few excellent products to help clear out the nose. For nursing moms, this is my absolute favorite remedy. If you have a deviated septum, this may not work well for you.

Good hand washing is of course essential.

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