Your child has covid/ when do you need medical intervention?

 I was actually going to take this week off, but I know of multiple families who have had their kids test positive for Covid this week. This post is for all of you families who are actively dealing with a sick kid or who have been exposed.

When to worry!!!!

One of the hardest things for parents to learn is the very important basics of ‘When to Worry’ about an illness. Everything feels like it has higher stakes in this pandemic world that we are currently living in. Whether your child has Covid (any variant), Influenza, Rsv, Roseola, and/or any nasty virus du jour, there are certain things that I want you to pay attention to. Respiratory distress If your child is struggling to breathe they need to be seen, it doesn’t matter if they have a fever or not. When someone is working harder to breathe you may see the tummy going in and out more than usual. The breathing is more rapid. They may be making grunting or wheezy noises. The nostrils might be flaring. You also might see something called retractions, which is when the skin below the throat and around the ribs looks like it is sucking in.  Someone with breathing issues may look pale. For people of color, you can assess this by checking mucus membranes, nails or the palms. For a mild to moderate cough, see if sitting in a steamy bathroom brings some quick relief. If not, they need medical intervention. Warning sign: A baby having a hard time feeding and taking breaks for air Reassuring:  Feeding well What to do in advance: If you pay attention to what the baseline is, it will be easier for you to recognize trouble. If possible, before they are ill, get a sense of what your baby’s normal breathing looks like.  Actually look at their breathing, what does it look like when they are well? When they are calm, count their respirations. Fever If there is a fever higher than 101.5 give medication and wait an hour. You can also do cool compresses and lukewarm baths. Make sure they are not over bundled. If the fever has not budged, check in with your doctor or urgent care. These days if the fever is higher than 103, most practices will send you directly to the emergency room. What to do in advance? Have a thermometer that you trust. Before there is an illness, take everyone’s temp for several days at the same time of day to establish a baseline. Fever blog post Inconsolable If your child is crying inconsolably I am going to tell you the same thing I would tell the parent of a newborn. Is the diaper too tight? Do they possibly have a hair wrapped around a finger or toe? (that is more common than you might think), did they get an insect bite? Do a full body check to see if you can figure out the cause of the fussiness. If there is obvious source, even if there is no elevated temp, go ahead and give a dose of Tylenol or Motrin. Make sure you know the proper dose. Many times, fussiness can be caused by something as simple as severe gas pains. If you sense that this might be a possibliity, add a dose of simethicone to the mix. It certainly is not going to hurt and can possibly make a big difference. January looks like it might be a tricky month with so much illness making the rounds. Rather than feeling overwhelmed, try to focus on things that are actually in your control. What to do in advance? Get anyone who is eligible fully vaccinated. Have a stash of reliable masks. Make sure you are stocked with food and medications including pedialyte Make some soup and freeze it in reasonable portions Take steps to boost your immune system

Travel Tips part two/Managing the flight

 Most parents have travel stories that stay with us, kind of like a battle scar. Here is one of mine.

Many years ago when my daughter Lauren was two, I got creative as I was planning for an upcoming flight as a solo parent. I had seen a craft in a magazine (long before Pinterest existed) where a necklace had been made of cereal and I thought that this seemed like a fabulous thing for an airplane trip. Unfortunately, not all ideas turn out to be good ones. Lauren and I strung some Cheerios onto elastic and she proudly wore her new necklace onto the plane. Soon after take-off Lauren decided to eat some of the Cheerios. I noticed with some dismay that as she bit off a Cheerio, some would go into her mouth while other parts would shoot off like little spitty projectiles. They were landing (unnoticed by anyone but me) on just about everyone within three rows of us. As soon as I realized what was happening, I tried to see if there was a way for her to nibble them off without making a mess. When that didn't work, I tried to take the necklace off to make it easier or to have her stop eating them at all. But as mentioned, she was two. My choices were clear - tantrum on the plane or unsuspecting fellow passengers having little pieces of spitty Cheerios in their hair. I opted for peace (besides, ignorance is bliss, right?)

Of course, now, in the days of Covid, those mini projectiles would have been viewed to be almost as dangerous as nuclear material. Fortunately, things were a bit more innocent then. A spitty Cheerio was just yucky, not infectious

My post this week is full of tips for managing your trip. Cheerios necklaces, understandably, didn’t make the cut. Hopefully the collection of tips that I did include are much more useful than the cheerio debacle!

Managing the Trip

"When is my baby old enough to fly?"  When I was working as the advice nurse at NVP, this was a very common question. There is no simple answer without considering a multitude of factors. Parents might make the valid choice to fly earlier than they might otherwise do in order to see an aging relative or deal with a family crisis. Consider this, adopted babies might fly within the first few days on their way to their new home. It isn’t always black and white. In ordinary circumstances, I would prefer to have the babies wait until they are at least 2 to 3 months of age and have had their first set of immunizations (keep in mind that the first shot does NOT give full protection against some serious illnesses, but it is a start.) The size of the baby as well as the time of year are also factors.  Even before covid I was always paying attention to what illnesses are circulating. During an active influenza season, I would think long and hard before taking a young baby on a plane. It isn't unusual for there to be some type of health alert circulating, so keeping current on the news is important. It is always worth keeping an eye on the CDC travel guidance https://wwwnc.cdc.gov/travel Regardless of how old your child is, if you are planning a trip here are some tips and things to keep in mind. One of my wise readers suggests that if you are traveling out of the country it is worthwhile to register your journey with the state department https://step.state.gov/step/ . Great idea! COVID If your child is at an age to get vaccinated for COVID, do it ASAP, it takes time for the immunity to take hold. Regardless of vaccine status, getting them used to wearing a mask is important. Do some work on this ahead of time. As soon as they are old enough to cooperate, do some mask wearing around the house for longer and longer stretches at a time. Find a reward or sticker incentive that might help. Poke around on the internet. There are some cute videos that help encourage mask wearing. Do some play with the teddy bears wearing masks. People often ask for my recommendation on the best masks. The answer is whichever one they are willing to keep on! It might take some trial and error to find a mask that works for your child. Of course a good fit and adequate filtration are what make any mask effective. Moms, Eliezah, says that her two-year-old has done well with Rafi Nova, Andy & Evan, and Cat & Jack brands that taper and have metal at the nose. Mom and author, Alexandra shared that her daughter Emma has been wearing the Evolve Together KN94s and with the ear loops tied they fit great. If you have a mask that you love, please let me know. Airlines are actually doing a pretty good job at trying not to be vectors for the virus, but it is a good idea to wipe down the areas around your seat as soon as you board the plane. Try to do as much snacking before the flight to avoid eating on the plane, but that being said, do not stress about it if you little one wants to munch on something. Staying sane during the journey is an important consideration. Managing the flight. Keep in mind that a car seat is the safest place for your child. It is worth checking with your carrier to review their guidelines. I remember a trip I took years ago. I was sitting next to a mom with a very young baby. She was so worried about the possibility of getting evil looks from the other passengers that she had actually brought ear plugs to hand out to the people sitting around her. What she didn't have was anything to soothe her baby in case of discomfort. Please always make sure that you have Tylenol or Motrin with you on the plane (not packed away in your suitcase). It is okay to bring small bottles of the medication through security. They need to be smaller than 3.5 ounces. I don't tend to give it ahead of time, but I am quick to medicate during the first sign of fussiness.   Does your child suffer from Motion sickness? Click to review my post on that topic.   I often get questions about the use of Benadryl. This is an option for a child who is over 8 months with a long flight ahead. It helps dry up any congestion and makes 90% of kids who take it deliciously sleepy. Aha, but what about the other 10% you might ask? It turns those little darlings into hyperactive, wild hooligans. You do not want to find out on the plane that you are the parent of the 10%. Look for children's liquid (generic name is diphenhydramine). There is no such thing as ‘infant’ Benadryl; Labels will not usually have directions for children under 4. Instead you are faced with that largely unhelpful “check with your Doctor” Here is a Hack. Benadryl dose is the same volume as the Tylenol dose. In my years of practicing, I have found that most pediatricians I have worked with feel comfortable prescribing it to younger kids, but I always suggest checking with yours own pediatrician for their opinion. Once you have the green light, you may want to give a test dose a few days prior to the trip to make sure it is a viable option for you. My goal is for parents to have the tools with them to deal with an unhappy child. Don't give any medication unless it is necessary. While I would usually err on the side of less medication, Benadryl and Tylenol/Motrin can be given at the same time. Ear issues Many babies and children may have trouble with their ears. For the younger ones, try to nurse or have them feeding during takeoff and landing. Sucking on a pacifier may be helpful as well. Have a lollipop or chewing gum for older kids. Ayr saline gel is a nice thing to have along. A dab at the base of the nostrils can moisturize the dry air and make breathing easier (use it for yourselves as well.)  If you have a child with a history of ear trouble, have some of the little gel heat packs in your bag. You can activate them as needed and the warmth feels great to a sore ear. You might also try bringing a baggy of cotton balls soaked in garlic oil. You can ask the flight attendant to pop them in the microwave for 5 seconds to warm them up (feel them to make sure they aren’t too hot). Make sure that baggy stays sealed or everything you brought with you will smell of garlic. For adults and older kids, you can equalize the pressure by holding the nose and gently blowing until the ears pop. Gently please.You don’t want to cause more trouble by forceful blowing. Supplies Take WAY more diapers with you than you think you need for the trip. I was on another flight once when we sat on the tarmac for three hours. There was an unfortunate family behind me who had planned on a short little trip and was out of diapers long before we even took off. It wasn't pretty. Plan accordingly. Many folks automatically bring a change of clothes for their baby. It is also worth bringing an extra outfit for yourself. If you have a long flight ahead of you with a child on your lap, it may come in handy (I learned that one the hard way and sat for several hours covered with poop.) Changing your baby on the plane can be a challenge. It is helpful to create little changing packs in advance. Pack up several individual gallon ziplock bags with a diaper, wipes and whatever else you use with a change. This will prevent you from having to take the entire bulky diaper bag with you into the tiny bathroom. You can't count on airlines giving you any reasonable snacks, so it is important to bring along enough provisions in case of delays. It is okay to give things that feel a little like a treat, but be warned, having your kids amped up on sugar during a flight is NOT what you are going for. Activities Download some activities or shows ahead of time for your laptop or tablet. None of us want to overdo screen time, but if you have managed to keep it special, a long flight is the perfect time to make use of this tool. Don't forget about the old fashioned low tech options! If you are visiting family, actually print out a bunch of photos of the people you are going to see (what a concept). You can use these for all sorts of art projects on the plane. Make a paper doll family by gluing the faces onto popsicle sticks. Besides keeping them busy for a stretch, this activity also can help your kids recognize folks that they don't see too much of. Wikki sticks are also a great activity to bring along. They are lightweight and not too messy. Reusable stickers will stick on the window. Don't bring anything that will make you sad if you lose it in between the seats. Which brings me to the next point. Protect the Lovey, blanket or stuffed animals that come on the trip! Deciding which security items come along on your travels is a big decision. If your child has a favorite blanket that they snuggle with, losing something on the plane or even in the hotel sheets can be a nightmare. Jet Lag Time zones are tricky. Staying hydrated and getting fresh air are essential. Sunshine is a bonus. My best suggestion is eat when you are hungry, sleep when you are tired and just do your best. Just know that even the best sleepers may have a period of needing a sleep training tune up when you get home. http://www.reflexandmore.com/en/articles-heb/25-english/articles/21-jetlag The link above has wonderful information for dealing with jet lag.  Melatonin https://nursejudynvp.blogspot.com/2019/06/melatoninis-it-useful-is-it-safe.html As long as it is really just a few doses, I would have no worries about putting this in your toolbox. You can have lots of fun while you are away and it is wonderful to see family. But, in my opinion, if you are traveling with children under the age of seven, don't call it a vacation. It's not. It is a TRIP (we used to call our visits to the various grandparents the "bad bed tour.")  A little preparation goes a long way and remember that some of the more challenging moments make for the best stories!

Travel Tips part one:safety

 

After almost 2 years of quarantine, so many of us have been missing our family and friends who live far away; lots of people are ready to accept some risks and do some traveling. This seems like an appropriate time to update and rerun my travel safety post. Next week I will give some management tips for the actual flight or trip. Both posts will include Covid considerations. My dad was a physicist who looked at the world from a unique perspective. How do things work? What is broken, what can I fix, but even more importantly what might go wrong and how can I prevent it? When he was teaching me to drive I remember him pointing to a boy with a ball on the sidewalk. “What could happen”? The ball could drop, fall into the street and the boy might rush into the street to follow it. Anticipating what could go wrong was the first step to prevention. My regular readers have heard me say that we can’t keep our children wrapped in bubble wrap. There are adventures to be had and loved ones to see. On the other hand, it is important to be aware of potential hazards. Knowledge is power and some accidents and harmful situations can be prevented. Others can be handled with less stress if you are properly forewarned. Health If you are traveling internationally, do you or your family need any travel vaccinations beyond the standard immunizations? Make sure you get these done at least a month before the trip if possible. The recommendations will vary based on where you are going and the age of your child. Make sure you have a copy of your immunization records with you on your travels. The CDC's Travel website is a great resource. This includes a list of COVID hotspots. No matter how much you miss people, I would be hesitant about traveling to a place that is running out of hospital beds. Covid precautions. If your child is at an age to get vaccinated for COVID, do it ASAP, it takes time for the immunity to take hold. As soon as they are old enough to cooperate, do some mask wearing around the house for longer and longer stretches at a time. It might take some trial and error to find one that works for you. People often ask for my recommendation on the best masks. The answer is whichever one they are willing to keep on! Of course a good fit and adequate filtration are what make any mask effective. One of my Oath Moms, Eliezah, says that her two-year-old has done well with Rafi Nova, Andy & Evan, and Cat & Jack brands that taper and have metal at the nose. Mom and author, Alexandra shared that her daughter Emma has been wearing the Evolve Together KN94s and with the ear loops tied they fit great. If you have a mask that you love, please let me know. Wipe down the areas around your seat as soon as you board the plane. Try to do as much snacking before the flight to avoid eating on the plane, but that being said, do not stress about it if you little one wants to munch on something. Staying sane during the journey is an important consideration. Getting care out of town If your child gets ill during the trip, it is important to know where to get care. I suggest doing some homework before you leave. This includes checking with your insurance if that is applicable, to see what will be the most cost effective choices. What local urgent care options are available where you are going? Do you have friends or family with a local pediatrician who will see travelers?  If your child has a history of wheezing, even if it hasn’t been an issue recently, take any inhalers with you on. Actually, bring them on the plane!  If they have ever had an anaphylactic reaction, make sure you have your epipen. That comes on the plane with you as well, along with your Tylenol  https://nursejudynvp.blogspot.com/2018/08/anaphylaxisepipen-options.html Be aware that your doctor's office can NOT call in prescriptions to another country! (Including Canada!) Gun safety? It might be awkward, but do it anyway - Ask your hosts if they own a gun. This might even be your own parents or siblings. Many people own guns and don’t give it a second thought if they are not used to having children in the house. It is essential to make sure that any guns are locked away, separate from ammunition. (This has nothing to do with the second amendment.) https://nursejudynvp.blogspot.com/2019/01/gun-safety.html Make sure that medications are child proofed. Grandma and Grandpa might have medications in areas that are easily accessible if they aren’t used to having young kids visiting. I had one little patient who got a dose of oxycontin right out of a nightstand drawer. Thank goodness she was okay. Is there a pet? Is the animal comfortable with kids? If animals are even the least bit growly, make sure they are kept in a different room. Some pets get stressed from having little ones around. I have dealt with more dog bite cases than I can count https://nursejudynvp.blogspot.com/2019/08/kids-and-pets.html Staying in a cabin/ Air B&B Make sure there is a carbon monoxide detector or bring your own. This is more important in the winter if there are wood burning stoves or space heaters https://nursejudynvp.blogspot.com/2017/11/carbon-monoxide-2017.html Most places have a smoke detector. Do a little test to make sure it has working batteries. Fire extinguishers are useless if you don’t know where it is and how to use it. Bed bugs...ugh Check the mattress before you unpack to make certain there are no bedbugs. The best way to do this is lift the sheets and make sure you don't see any red spots. Bed bugs are large enough to spot. https://www.bedbugreports.com/ In some cities like NY they are rampant. This is not a souvenir that you want to bring home. Crib safety Make sure your child's crib is up to current safety standards. If you are traveling internationally, be aware that cribs may not have the same safety standards that we have here in the US. General Holiday safety tips Are you staying somewhere with a Christmas tree? https://nursejudynvp.blogspot.com/2019/12/holiday-safety-checklist-2019.html Food safety This is often associated with international travel, but food can be contaminated anywhere. If there is vomiting, diarrhea and fever, this is likely bacterial and you should be seen. Making sure that you have clean water is essential. Make sure to avoid ice unless you are in a resort area that assures the safety of the water. It is worth asking the place where you are staying if the water is filtered. Street food, raw fruits and veggies, raw or under-cooked meats and fish, can all lead to trouble. Ask about poisonous plants https://nursejudynvp.blogspot.com/2019/04/keep-your-kids-safe-from-toxic-plants.html Swimming and Water safety If you are going anywhere with water nearby, appoint a water guardian. https://nursejudynvp.blogspot.com/2018/07/drowning-prevention-appoint-water.html Make sure there are alarms and fences around any pools, but there is no substitute for watching the kids like a hawk. Crowds Until we know more about new Covid variants that are making the news, I personally would suggest skipping any large crowds. But if a large crowd is part of your plans, take a photo of your child before the outing so you know exactly what they were wearing in case you get separated. Consider bright, recognizable colors. Write your cell number on their arm and cover it with liquid bandaid so that it doesn’t wash off. Make certain that your child knows the safety plan and where you should meet up if you get separated.  Hiking? Do a head-to-toe tick check every day. Winter isn't typically tick season, but with climate change, I never say never. The weather forecast is calling for much warmer than normal temperatures for most of the east coast this month, so if you are traveling on the east coast you might actually be able to enjoy some outdoor time. Altitude If you are above a certain elevation, it takes some folks a bit of time to adjust. You have to pay extra attention to sun and hydration.. https://nursejudynvp.blogspot.com/2018/03/dealing-with-altitude-2018.html I know I know, after reading all of this you are ready to curl up in a ball and call off the trip. That is not my intent. Do a little planning. When you call Grandma and or Grandpa with this very long and annoying checklist, just blame me. I can take it.

Covid Vaccines for kids 5-11

 

Covid vaccines for kids

It is shocking and sad that the topic of vaccinations has become such a divisive issue. I remember my mom telling me about how every parent she knew couldn’t wait to get in line to get their kids protected from polio and measles as soon as the immunizations became available. They saw firsthand how destructive these diseases could be. Vaccines save lives. Unfortunately for everyone, there is so much misinformation making the rounds. Disinformation is meant to cause harm.  Misinformation is generally not malicious, it just isn’t based in fact. It ends up causing plenty of harm in its own way. Please keep in mind, reasonable people really are on the same page. We all want our children to be safe and healthy. We also would like this pandemic to be in our rear view mirror sooner than later. Regardless of your stance on this topic, there should be absolutely no shame in asking questions. I want you to feel comfortable with the decisions you make regarding vaccination. Here is the essential thing. Please find a source (not your aunt’s gardener who gets most of his info from his cousin’s facebook posts). Your pediatrician is often an excellent source. Doing your own ‘research’ if it is not based on reputable data, can take you down a costly and potentially harmful rabbit hole. I have been trying to gather as much data as I can on this topic and one of the wisest statements I have heard so far was from Dr. Eric Ball, during a webinar hosted by the CDPH His point was, the choice you have is simple. Would you rather have your child get immunized or have them get the covid virus? The data speaks for itself. The Virus Kids do get covid. They might not all get terribly ill, thank goodness, but at the time that I am writing this, children 0-17 represent 17% of all cases nationwide. 6.4 million have tested positive (that is likely vastly under reported). 60,000 have been hospitalized and 600 have died. If you look at the top ten causes of death for children 5-11 during the past year, Covid-19 comes in number 8. And 5,200 have been hospitalized with multi system inflammatory disease (MIS). https://www.cdc.gov/mis/mis-c.html We are still learning about long term complications in patients. The impacts from the virus are continuing to show up weeks to months after the infection. Of course not all of them are as serious as the MIS, but pediatricians are seeing kids with what they are referring to as long covid. For these unfortunate patients, insomnia, fatigue, muscle pain and persistent cold-like symptoms are common. Some of these are not showing up for months after the initial virus. Frankly I am more concerned about protecting kids from potential long covid, than I am worried about the initial infections. Kids also serve as a vector. Not only can they spread covid to family members who might not fare quite as well, but the more ‘vectors’ the virus has access to, the greater the possibility that it can mutate into an even more terrible form. Immunity from the illness is not as protective as the immunity you get from the vaccine. Think of it like this, when kids are getting the flu vaccine for the first time, they need to get a series of two shots. The first one is a start, but doesn’t protect. The second one is what teaches the body to recognize and protect. Having had the illness is like having had the first flu shot. The vaccine First of all, all science to date has shown that the vaccine is safe. Billions of doses have been given. Kids' immune systems are indeed amazing. They are able to respond to a smaller dose than adults. The trials showed that they only require ⅓ of the dose that the older folks were getting. The schedule is similar to that of the adult series with a 3 week interval in between the shots. Certainly many people have several days of side effects. These might include aches, fevers and even some swollen glands, but once those fade, there haven’t been reports of any long term issues. Poor Sandy felt like he was hit by a truck for 2 days. I rubbed arnica all over my arm and was mostly fine after 24 hours. In any case we both said,” bring it on! Hooray that our immune systems are working.” Some folks have a much easier time than others. Either way I would suggest carving out some down time the day after the shot just to be on the safe side. Check out Dr. Teds section below for the scientific explanation about those side effects. Having a day or two of feeling yucky is much better than having actual covid. Even mild cases of the virus can lead to long term issues that we are just learning how to manage. The vaccine is not actually new. It has been in the works for more than 20 years. I am going to address a few of the common concerns that you may have read about. Myocarditis Post vaccination there have been 2 out of 100,000 cases reported. Aha...but guess what, there have been a reported 150 out of 100,000 cases of people who got myocarditis from having actual covid. It is nice to know that up until now there were NO cases in the 5-11 year old age range https://www.cdc.gov/mmwr/volumes/70/wr/mm7035e5.htm Fertility This is a non issue. There has been absolutely no documented impact on fertility. Oh yes , except for the well publicized case of Nicki Minaj's cousin’s friend’s enlarged testicles. Micro chips I hope none of my readers actually buy into this kind of misinformation, but just in case here is a list of some myths that have been dispelled https://www.cdc.gov/coronavirus/2019-ncov/vaccines/facts.html It is safe for kids to get vaccinated even if they have already had covid. In the clinical trials, 9% of the children had previous covid infections. These kids actually ended up having milder side effects compared with those who had never been infected. Is the vaccine perfect? Of course not. There are plenty of breakthrough cases, but the numbers are clear that the hospitalizations and deaths are overwhelmingly higher for people who have not had both shots. Although the risk is not zero, the incidents of Long Covid appear to be significantly lower in people who have already had the series of at least two shots We don’t always love our options. If you are a parent then you are familiar with this. Your toddler might insist on wearing their favorite shirt that is in the laundry because the dog peed on it. “I am sorry”, you tell them. That is not one of your choices. We don’t have time to wash it. You can choose between shirt A and shirt B.. Sometimes our choices suck. But that is the world we are living in. Here they are again. I will add a third option: Get Covid  Get vaccinated Stay in a complete bubble Unfortunately opting to wait and watch to see how things are going is essentially akin to picking door number 1. If I had a child in the 5-11 range. I would be getting them the shot at the earliest possibility, especially with the holiday season right around the corner. Dr. Ted’s Science Those side effects can be celebrated. Side effects from shots are a hard thing to watch. All of a sudden, your child spends a day feeling sleepy, feverish, or in pain, and "you did this to them" is all you can sometimes think about. But I put a positive spin on this phenomenon. When the body’s immune system is active and learning, it creates antibodies, along with a number of other inflammatory signals. These signals are what cause us to feel symptoms. We see this mirrored in the COVID-19 research: people with asymptomatic disease are more likely to make little or no immunity to the virus, whereas antibody levels are much higher for those with significant symptoms. So the day or feverishness after a shot could bring a sigh of relief: the body is stating the message was received. This doesn’t mean you should worry if your child doesn’t have symptoms or behave differently the day after a shot, they might just have a different experience of those feelings. But those short-lived symptoms do not leave lasting damage, only lasting protection!

Adverse Childhood Exposures

 

Adverse Childhood Exposures

One of the things I have enjoyed the most about doing my blog posts is the research and personal education involved. I have years of experience under my belt, and while there is a great deal that I know about a lot of things, I have no shame accepting that there is even more out there that I don’t know. I am eager to keep learning. Right before the pandemic began, I went to the 2020 UCSF Chancellor’s Health Policy Lecture. The speaker was the brilliant and inspirational Dr. Nadine Burke Harris. Dr. Burke Harris was a pediatrician in San Francisco’s Bayview-Hunters Point neighborhood. She is currently the very first surgeon general for the state of California. The topic of the lecture was Adverse Childhood Experiences, known as ACEs. This is a subject that she is clearly passionate about. The American Academy of Pediatrics is now asserting that ACEs are the single greatest unaddressed public health threat facing our nation today. That is quite the statement! This isn’t new groundbreaking information. In fact, the data has been there for over 30 years, which makes it even more frustrating that it was not on my radar. Why isn’t there more general awareness? The more I learned, the more intrigued I became. The findings are clear. Adverse Childhood Experiences (ACEs) experienced during childhood can have lifelong health implications. It makes so much sense!  Often western medicine focuses on treating symptoms. It is not surprising that out of 3 trillion dollars spent on healthcare only 5% of that money is spent on preventive medicine. I will borrow a metaphor from Dr. Burke Harris. If people are drinking from a well and many of them are getting sick, it is all too common for many doctors to treat the diarrhea rather than checking to see if the water is contaminated. Fortunately, there are doctors who make an effort to get to the root of problems. In 1985, Dr. Vincent Felitti was frustrated that patients in his San Diego obesity clinic, after initial success, were failing to keep the weight off. When he took a closer look, he was astonished to find that more than half of the clients who kept regaining their weight had some history of sexual abuse. He realized that it couldn’t be a coincidence. Ultimately, he linked up with another doctor, Robert Anda. Dr. Anda had been studying how depression and feelings of hopelessness affected coronary heart disease. They decided to collaborate on a much larger study and the findings were significant. The ACEs study looked at the following risk factors: Parents divorced or separated Physical abuse Physical neglect Emotional abuse Emotional neglect Sexual abuse Witnessed domestic violence Substance abuse in household Mental illness in household Family member in prison Since the original study, questions about other obvious stressors, such as loss of a parent, food scarcity, homelessness, disability, exposure to gun violence, and discrimination, have been added to the screening tools. However, the issues bullet-listed above were the ones that were tested and scored. They found that, as suspected, there was a link between childhood trauma and onset of chronic disease through the lifespan. What they weren’t expecting was how common of an issue this was. While it may come as no surprise that poverty is associated with higher scores, it turns out that very few of us got a free pass. This initial large study was done through Kaiser and the participants were mostly college educated, middle to upper class: 67% of people in the study had a score of at least 1 ACE 17.6% had a score of 4 or more ACEs This relates to so many of us. You may be one of the more fortunate with a low score, but unless you live a remarkably isolated life, someone you know is impacted. There is a dose response relationship between ACE scores and health outcomes. This simply boils down to the higher the risk, the more an effect there is likely to be. A person with an ACE score of: 3 or more is twice as likely to develop heart disease 4 or more is three times as likely to suffer from depression 4 or greater is 32 times more likely to have learning issue 6 or greater has a 20 year lower life expectancy! A high ACE score can be a predictor of high blood pressure, smoking, teen pregnancy, and suicide. The list goes on and on. This actually may be one of the biggest health discoveries we have ever seen! There seems to be a fairly strong relationship between cause and effect.  The connection between these childhood stressful experiences and subsequent issues like depression, substance abuse, suicide and other social issues seemed fairly obvious. The reason for the connection to physical ailments such as cancer, heart disease, and immunity issues was a bit more baffling to me until I heard Dr. Burke Harris speak. Then the clouds lifted and it made total sense. DUH. In her analogy, if you see a bear in the woods, you would have a full on “fight or flight” stress response. Your body is doing what it needs to escape. You also have an immune response to help you recover in case you are injured. This is just what your body needs to help you survive this emergency. But, if the bear comes home from the bar into your house every night, this frequent response is going to have serious implications. That frequent stress response is impacting the body and quite literally getting “under the skin”.  I did a blog post several years ago about how your stress level can add up silently before it overflows: https://nursejudynvp.blogspot.com/2016/10/managing-stress.html Of course, not all stress is the same. Positive stress stems from adverse experiences that are short-lived. We learn how to cope and adapt. For a child, examples might be the first day at school, falling off of a bike, or even having to share a toy when they would rather not. For some infants, it can be something as simple as exposure to a stranger. This type of stress might cause an increase in heart rate and changes in hormone levels. With the support of a caring adult, children can learn how to manage and overcome positive stress. This type of stress is considered normal adaptive stress and coping with it is an important part of the developmental process. Kids learn to ‘go with the flow’. They learn to get back on the bike and learn how to ride. They learn to get along with others. Babies learn that some people other than mommy or daddy are safe. Tolerable stress refers to more intense experiences that are hopefully short-lived. This could be an earthquake, death of a loved one, or family disruptions such as separation or divorce. The initial impact packs a wallop, and then eases somewhat. Here is the important thing to note. If the child has support from a caring adult, this stress remains tolerable. Kids can learn how to adapt thereby building resilience. Let me put this in a context that many can relate to. Think of your child as a bank account. Stress is a debit, nurturing is a deposit. The positive stress that I mentioned previously could be like using your credit card and paying it off in full every month. This actually gives you a good credit score. If you use the card for a much larger purchase, you may begin to have a negative balance if you don’t have enough to pay it off right away. This is tolerable if you are able to make regular payments. It becomes a real problem when you can’t keep up and are now accruing more and more interest. It is easy to slide deeper and deeper into debt. If you are filling up the “account” with positive nurturing behaviors, hopefully your child can “afford” the occasional larger expenses because you have helped them have a robust savings account filled with positive past experiences that can be used to inform current and future expenses. Without “funds in the account” constant stress is no longer tolerable and can become maladaptive and is referred to as toxic stress. This toxic stress can result in direct and measurable physical impact by altering healthy brain development and causing multi-system effects. It can lead to disruptions in the ways that the neurological, endocrine, and immune systems operate. This then can affect other systems throughout the body as well. MRIs show that actual changes are taking place in the brains of kids who experience early adversity. Science is telling us that ACEs are risk factors that have real implications for our children’s health - the mind may forget but the body remembers. You might not even recognize that there is an issue. Some research revealed that many children who develop emotional and behavioral problems don’t begin showing symptoms until the 4th grade. This post is simply an attempt to build awareness about an important issue. Every child should be screened for ACEs. There are easy ways to do this (think audit) and more and more ways to make changes and make real differences for people (think deposit).  Thank you to Dr Michelle Stephens for her valuable input on this post

What you need to know about Lead Exposure and Prevention

 

There is no safe thing as a safe blood lead level. Unfortunately in our current world, many of us live in environments where our kids are not completely in the clear from getting some lead exposure. Lead does not break down or fade away with time. It remains in the environment and we are stuck dealing with bad habits past and current. For the first time in 10 years the CDC has reduced the Blood lead reference value to 3.5 ug/dl. When I first started working at Noe Valley Pediatrics that reference number was 10. In 2012 it was lowered to 5. Now, for the first time in 10 years the CDC has reduced the blood lead reference value once again. Now it is 3.5 ug/dl. This means when your child gets a lead result, if it comes back any higher than 3.5 it will trigger some attention and hopefully resources to help you deal with it. Knowledge is power. It is absolutely worth getting your child tested. It is standard for pediatricians to order a blood test at either the 9 month, 12 month or 15 month exam depending on the circumstances. If there are obvious hazards they may order the test at the earlier visit. Since your baby is already going to get poked, I suggest asking them to couple the lead test with a routine CBC (complete blood count) that also measures the iron level. As you well know, things can get sidetracked during your little one's well child exam. There are so many things to talk about and sometimes the kids are kicking up a bit of a ruckus towards the end of the visit. If the doctor doesn't bring up the subject of getting a blood test, feel free to remind them. If they don’t do the testing in the office, you should find out which laboratories are preferred by your specific insurance plan. Although they are not always in network, the hospital labs facilities are often more adept and drawing blood from the younger patients. If there is any lead showing up, you want to figure out where it is coming from and make sure you keep that level from getting higher. In San Francisco, if your child has any elevated lead level, the city will send out a public health nurse to help you explore your environment and see if they can figure out the source. Be aware that when a lab finds an elevated level, it is legally required to report all positive tests to the health department. For reference, a level over 45 is an urgent situation that needs treatment. This link gives a full description of what the different levels signify Young children are much more likely to be exposed to lead hazards by touching lead-contaminated surfaces and then putting their hands in their mouths. In addition, children's bodies absorb more lead than adult bodies do because they are still growing; but lead is a problem for all of us. Pregnant women need to be especially careful because any exposure can harm their unborn babies. Lead poisoning affects learning and behavior, damages organs, causes dental cavities, decreases hearing and decreases intelligence. Lead Paint In 1979 lead based paint was banned from use in house paint. That is well and good, but the 2015 census claimed that 83% of houses in San Francisco were built before that law went into effect. It is possible that that statistic has changed with all the new neighborhoods popping up, but the fact is, the majority of our kids are growing up in older homes. If you do have an older house with any peeling paint, make sure that cribs and highchairs are moved away from walls. There are some home testing kits that check paint for lead, but they are often misused. The easiest way to test paint is to check the paint that is on wood or varnish. In order to get an accurate result, you need to scratch the surface and mix the test liquid with more powdery paint. It is okay to do a small test, but try not to disturb paint in old buildings yourself. This is one of those cases where it is best to hire a professional. A list of Lead certified professionals is available by calling 1-800-597-5323 or clicking on the link. Lead in the water Lead in the water can be a concern. It is worth finding out if your water sources are safe! This is especially critical If you have a baby getting formula that is mixed with tap water. Check your pipes right away. Don’t wait until your child gets a routine lead test to find out if there is an issue. According to the very helpful Childhood Lead Prevention Program here in SF, new brass fixtures can actually be as much of a problem as the old pipes because they can give someone a false sense of security. Even if the new fixtures claim to be lead free, it is still possible for some lead to get into the water from the pipes. Only use cold water for cooking, drinking or making baby formula because hot water is more likely to contain higher lead levels. If you haven't used a faucet in the last six hours, flush it out for one to two minutes before drinking or cooking with it. The longer water has been sitting in the pipes, the more lead it can absorb. You can use the initial water for watering plants. This link has good information about our local water and testing. If you want to get your water tested, in San Francisco, it is free for anyone on the WIC program. Contact the lead program for a voucher. For everyone else it is $25/tap. There are also some products for testing water available from Amazon, but as is the case with most things, It is important to read reviews carefully. If you are not lucky enough to live in a place with safe water, consider getting a filter that is tested to remove contaminants. Boiling water will NOT remove lead. If your child is getting only filtered water, make sure that they are getting necessary fluoride. Other Common Sources of Lead: Paint and pipes and water are only a couple of the many ways in which kids can get exposed. Most of the lead gets into your child from the hand to mouth route. They either chew on something directly, or put hands that have been in contact with lead dust into their mouths. Keys - don't let your child chew on them Brightly painted pottery or toys. Beware of things imported from different countries The brighter the color, the more apt they are to have lead. It's hard to be absolutely sure if a toy has lead in it or not. Start by checking www.recalls.gov or www.cpsc.gov to see if a specific toy has been recalled. Be wary of cheaper toys -- like those from vending machines or street fairs -- and especially plastic jewelry. Make sure you are buying things directly from a trusted source. If you buy something online, it isn’t always clear where it is actually from.  If you notice that your child is putting a toy in their mouth frequently and you're not absolutely sure it's lead-free, get rid of it and find something safe to take its place. Of course it is always important to make sure that your child is playing with age-appropriate toys that they are not at risk of swallowing. Children arts and craft products - some products have been recalled due to the violation of paint standards. Look for the label Meets ASTM D-4236 to make sure they are safe Coatings, jewelry and decals on some imported children's clothing Antique furniture varnish Varnish on bathtubs Some lipstick brands Some candies imported from other countries some computer cables - of course chewing on cables is not a good idea no matter what Dirt and sand that get tracked in from outdoors Urban gardening increases contact with possibly contaminated soil. Always grow vegetables and fruit in raised beds with OMRI(organic material review institute) certified Lead Free soil available at the hardware stores.  Ayurvedic medicine Imported beads or necklace  Pre 1997 imported vinyl blinds Prevention is the best defense! A nutritious diet is VERY important and should be considered a first line of defense. Lead in the body is distributed to, and absorbed by, the brain, liver, kidneys and bones. A healthy, low-fat diet rich in iron, vitamin C and calcium reduces the body’s ability to absorb lead. Lead actually binds to these critical nutrients and is eliminated instead of being absorbed by the body’s organs and bones. Having regular meals and snacks can also be protective since lead can have more opportunity to absorb on an empty stomach. Iron Iron deficiency increases absorption of lead from the stomach and intestines. Good sources of iron are: · Iron-fortified cereals · Green leafy vegetables · Pureed meats · Lean red meats · Tuna, salmon, fish · Raisins, dates, and prunes · Dried beans and peas · Skinless poultry · Nuts or sunflower seeds Vitamin C Vitamin C and iron rich foods work together to reduce lead absorption. Good sources of vitamin C include: · Oranges and tangerines · Grapefruit · Limes and lemons · Strawberries · Cantaloupe · Kiwi · Potatoes and sweet potatoes · Tomatoes · Broccoli · Bell peppers Calcium Calcium reduces lead absorption and also helps to build strong bones and teeth. Foods that are good sources of calcium are: · Milk and milk products · Cheese and yogurt · Green leafy vegetables · Calcium-enriched orange juice · Tofu · Salmon · Peanuts If you notice that your child is not growing out of the "everything in the mouth" phase and is constantly putting non food items in the mouth, it is worth bringing this up to the doctor. This can be the sign of an elevated lead level. Consider having a 'shoes off' policy to avoid tracking lead dust inside. This is especially important if someone in the household has routine lead exposure during their job; make sure they clean off well before having close contact with other family members. Make sure your kids get in the habit of frequent hand washing, especially before meals and snacks If you have any concerns about your home, regardless of whether or not your child has been tested for lead, call the SF lead program to arrange a public health nurse visit or speak with the Public Health nurse. Call 311 or visit www.sfdph.org/dph/eh/cehp/lead Thank you to the very helpful folks at the Children's Environmental Health Promotion Program at the San Francisco Department of Public Health for their input on this post.