Slap Cheek 2022

 

Slap Cheek

Slap cheek is one of those illnesses that seems to come around a couple of times a year. Dr. Ted mentioned that he has been seeing a lot of it this week, so it is worth knowing about it. This virus is also known as Fifth disease. It got that name back in the 1880s. At the time, childhood diseases that caused rashes were assigned a number. This was number 5 out of 6. Others on that list included measles and scarlet fever. It is also known as Erythema Infectiosum or Parvovirus B19. I just call it Slap Cheek. Just like Hand Foot Mouth (another of those viruses that make parents question why they signed up for this), Slap Cheek is a contagious rite of passage. Most people get it while they are still children and thus have immunity as adults. The majority of cases happen in kids between 4-14 years of age. It spreads through respiratory secretions, but can also be carried through infected blood. Unless you had a memorable case of it, most people don't actually know whether they have had it or not. You can check with the grandma or grandpa, but I bet they don’t remember either. The symptoms may have been mild enough that no one paid much attention. This illness can be quite variable. Some kids don't seem too impaired while others are miserable. The mild cases can present with a child who has a red chapped cheek for a day or so, and that's it!  The common denominator (hence the name) is one or both cheeks usually appear very red and irritated. Red cheeks aren't definitive. Some kids look flushed when they have a fever no matter what. This diagnosis often has some guessing involved. For most patients, the red cheeks are followed by a lacy, mottled rash that works its way up and down the body. This rash tends to cover the arms and legs more than the trunk. Of course there are exceptions; some kids don't read the textbooks and present in their own unique way. People with more moderate cases often have high fevers. Kids tend to be pretty fussy. These fevers can come and go over a period of several weeks.  In more severe cases it can cause painful or swollen joints (polyarhropathy syndrome). This is much more common in older kids or adults. In rare cases, it can also cause the body to temporarily stop making new red blood cells. This can lead to anemia. People with sickle cell disease, other types of long lasting anemia, or weakened immune systems are more at risk for these complications There is no real treatment for Slap Cheek. Western medicine doesn't have any magic wand for this. What you will likely get out of a visit to the doctor is assurance that there is nothing more serious going on. Four out of five of my patients with high fevers might have slap cheek, but that fifth might be the one with strep throat. In general, if you have a miserable kid with a fever that doesn’t respond to medication, it is usually worth having them checked out.  Frankly, the issue about slap cheek that is of the most concern, is that it can be dangerous to a fetus.  If a woman is infected in the early stages of pregnancy there is an increased chance of miscarriage. If you have a toddler with Slap Cheek, try to minimize exposure to anyone who is expecting. If you are pregnant and may have been exposed, take a deep breath and remember that most women had this as a child and are therefore not at risk. Just to be on the safe side, talk to your OB about getting a blood test to check your immunity. It is not reasonable to try to isolate yourself from your own child. The fact is, they were likely contagious before you had a diagnosis. The incubation period is thought to be about 4-21 days after the exposure. In other words, if you come into your doctor’s office and walk out with a red cheek, you didn't get it there; that would be way too soon. The kids are most contagious at the very beginning of the illness when the main symptom is probably simple fussiness. The cheeks might be red, but you reasonably figure that this could simply be caused by being a little warm. By the time the rash is in full throttle they are probably not very contagious anymore. Often patients have some congestion as part of the package. Treatment is symptomatic. Treat the fevers as needed with Tylenol/Ibuprofen and tepid baths. Make sure your child gets plenty of fluids and rest as needed. My best daycare, camp, and school guidelines are to keep a child home if they are fussy or have a fever. If you have a happy child with a red cheek, it seems unreasonable to expect you to stay home from work. Chances are, once one of the kids in daycare shows up with it, everyone has already been exposed.

There is no such thing as a silly question

 

There is no such thing as a silly question

Let me tell you a story...  I was a nurse with several years of experience under my belt when I moved to San Francisco. I was promptly hired at UCSF, which was, and remains in my experience, an excellent hospital. UC, because of its reputation, is a center where patients with many of the more exotic and hard to treat conditions are sent for care. On one of my first days on the job I was getting the “change of shift” report from a nurse; I don’t remember much about her and don’t know that I ever interacted with her again. She was passing along information about a patient who would be under my care for the upcoming shift. This little guy had an unusual illness with a long complicated name, no doubt named after the folks who discovered it. For the purposes of this post, and since I have long forgotten what it was, I will call it Hughie, Dewie and Louis disease. Here is the thing - this wasn’t something that I once knew and had forgotten. I had never, ever heard of it. Not even a glimmer of an idea. “ So, Your patient X has HDL disease...These are his orders” “Hold on a moment, What is HDL? I am not familiar with it.” There was a pause and maybe a sneer “You haven’t ever heard of HDL?” I imagine that this was my opportunity to get a bit shame-faced and say, "Oh! HDL, of course" and continue to get the report, but I don’t work that way. One of the things I respect the most in a person is to be comfortable with what they don’t know.  This was long before the days where I could pull out a phone and simply google it. This was now a game of poker. Some of you may not know, but Nurse Judy plays poker in Vegas. “I have never, ever heard of it. Can you please tell me a bit about it so that I can take better care of the patient?" She doubled down, I think she had come too far to save face and was hoping I would cave first. “How long have you been a nurse? Where have you worked before this”? I decided that engaging further was a waste of time, so I posed the question to the other doctors and nurses who were in the room. “Is there anyone here who can tell me a bit about HDL?” There was a resident sitting there who was happy to tell me all about this very rare condition. EVERYONE in the break room was hanging onto his every word. Hmmm. Fortunately that was an isolated incident at UC, but I carried the lesson along with me. Being comfortable enough to acknowledge what we don’t know, and learning how to find the information we seek, are important skills. As parents this is an important message to pass along to our children. In the world of the internet, finding information is no longer the challenge that it used to be. The real issue these days is sorting through everything that is out there. You may need to sift through quite a bit of hogwash to find accurate information. If I am talking to a parent and they are confused about a dose, a diagnosis or anything, the LAST thing I want is for someone to be embarrassed that they aren’t “getting it” and give up before they have a clear answer to their question. It is the rare person who actually knows everything (and they are likely insufferable and socially awkward!) Knowing what you don’t know and asking for guidance is just as important now as it was when I was a young nurse. As a paying consumer of healthcare, it is your absolute right to make sure you understand everything you need to before leaving a medical appointment, and in fact, your child's health may depend on it!

Tips for giving medicine/A useful list of considerations when giving any medication

 

Tips for giving Medication

Parents have to pick their battles. Sometimes things aren’t so important. Does your child insist on getting the favorite but dirty shirt out of the hamper and wearing it for another day? Not such a big deal. I am a big believer of the “Don’t sweat the small stuff” way of thinking. I am also a fan of discussion and compromise when appropriate.  But once in a while, you need to establish that you are the ultimate decision maker, especially when there are health and/or safety considerations. Most of the time, the ‘medication battle’ is one that you need to win. Let's assume that your child has a condition that needs to be treated. If this is the case, have a firm but loving attitude. (Think Mary Poppins and her spoonful of sugar.) Make it clear that you mean business. Your child will be getting the medicine, one way or another. This is not a choice. For young infants, take advantage of their natural sucking reflex. There are some useful products available to help administer meds: Frida Baby Dr Brown If they are resisting, use the following technique. Hold them at roughly a 45 degree angle. If they are flat they are more likely to aspirate. If they are sitting up too high they can spit. Getting the right angle makes a big difference. Wrap them in a blanket (think straight jacket!) This will keep them from being able to use their arms to knock the medicine away. A syringe is much more effective than a spoon and is better for measuring. Make sure the numbers haven’t worn away. Dr Hurd suggests asking the pharmacy or your doctor's office for a fresh one at the first sign of any wear. Squirt a small amount into the side of the cheek. Keep the chin elevated. Give a tiny bit at a time and wait for a swallow. The key to this method is not giving too much at one squirt. For a 5 ml dose of something I would break it up into 10 squirts of .5 each time. Here is a rather amusing TikToks of Dr Ted and I demonstrating the technique Accept the fact that your child may be crying and screaming throughout the process. It usually gets easier. Allow yourself ample time for this. If you are rushed, you will be more stressed and apt to get aggravated. This method can be used with any age as needed. The only kids that can beat this system are the ones that learn how to vomit. Okay, what are your options if you have a vomiter on your hands? If your child needs antibiotics, sometimes they can get an injection. ( As tempting as it might be, please do NOT use getting a shot as a threat) If you are trying to get in a dose of fever reducers, suppository form might be your best option. If you have an especially challenging kid on your hands, see if there is a compounding pharmacy near you. A good compounder can make medications in different flavors such as grape, strawberry, marshmallow etc. Other meds can be made as liquids, suppositories or topical gels. My compounder of choice is Eddie Lau over at Feel Good Compounders. The phone is 650-898-8221 or info@feelgoodcompounders.com Be aware that compounds need an in-state prescription even for over the counter medications. Ideally you don’t need to use force. For kids who are old enough to reason, give them some choices: What would they like to drink after the medicine?  Should we have the pharmacy add a flavor? Would they like to try holding a lollipop and taking a lick after each squirt? If they cooperate and do their best to get the medicine down, make sure to give them lots of positive feedback! Don’t wait until your child is sick to teach them about cooperation with medicine. Try doing some role playing ahead of time. I have several approaches. Make it a game with some role playing. Have one cooperative stuffed animal and one stuffed animal (or doll) who is not going to take that medicine without a fight. The cooperative doll says things like, “ I know this tastes a little yucky, but it is really important and it will help make me feel better". You then respond, "I am really proud of you for being so cooperative." For the challenging doll, wrap the arms in a blanket the way you may have to with your child. say, "I am sorry that this is so hard, but it is very important for you to take this medicine." You might also let them pretend to be a parent who has to give the medicine to the uncooperative doll. Don't make it easy. Role reversal can give both sides some insight. If you don’t have the energy to put on a show, you can simply tell a story.  “Once upon a time there was a little boy named Gus who had an ear infection. He needed to take medicine, but it tasted yucky and it made him scared to try. His mommy gave him some fizzy juice and every time he took a bit of the medicine he quickly took a sip of the juice. He was so proud when he took it all, and soon his ear started to feel all better!" Incentive or rewards You can always have a standard sticker chart. Or if you are feeling more creative, another reward method is to make it possible to earn 10 pennies per dose. This will appeal to all the future business people. Put the money on the table. It is theirs to lose. Remove a penny for every 30 seconds that passes without cooperation. Kids hate seeing something concrete being taken away. If your child is old enough, this is a great math opportunity. A 10 day, twice daily course of antibiotics can be worth 2 dollars (adjust the reward however you choose.) Role playing, rewards and giving some choices will only go so far. When it is medicine time make it clear that any discussion will last no more than 5 minutes. Set a timer. When time is up, they can either cooperate or be wrapped up and given the medication in the method I describe above. When the kids realize you mean business they often stop the vigorous fighting after a few doses. If they think they can change your mind, they will continue to struggle. Here is an assortment of other tips, tricks and considerations. Not all medical records communicate as well as I would like. If your child is on any medications, take all of the meds with you (in the original containers) to your doctor's visits. If you can’t take the actual medication, at the very least take a photo. This is especially helpful in an urgent care situation when they don’t know your child or their medical history. Make sure you understand any medications that your child is taking: Dosage Storage Interactions with food or other medications Should it be taken on empty stomach or not Any special issues with sun exposure? Do NOT hesitate to ask your pharmacist, advice nurse or doctor if you have any areas that need clarification. If the dosage or quantity seems odd to you, ASK!!! I have seen medication errors avoided because the parents were savvy enough to express concern. Check your child’s body and skin before you give the first dose of a new medication. This way there will be a clear timeline if a rash shows up. Don’t try to sneak medicine into a larger volume of food or drink. Your kids will know it is there. If they do end up taking only part of it, you will have no real idea how much of it they got.  Your kids are not necessarily putting on a show. Some medications are really bitter. The generic ones are often the biggest culprits.  Make sure to do a thorough teeth brushing after taking a liquid medication. Many of them are syrupy and full of sugar in order to increase compliance. If your kid constantly fights taking liquid medications, consider trying to teach them how to swallow pills. You would be surprised how some really young kids can have success. Start with tic tacs or other small pieces of candy. See if they can swallow one. If they fail, oh well. They have a piece of candy in their mouth. If they can’t swallow it with water, try putting it on a spoon tucked into some yogurt or jelly and see if it goes down. Remember you are doing this with your child’s involvement. No sneaking things. Don’t lose their trust over something like this. You are on the same team, trying to help them feel better. Once they manage to get the tic tac down, ask your doctor what pill forms are available. Some children take a daily medication or vitamin pill and quite like them. Dr. Hurd cuts the gummy vitamins in quarters. Her kids have a positive association with taking something daily and there is no fussing involved. The problem can be when they like them too much! I remember a 9 year old patient who had a mysterious ongoing stomach ache. After some questioning, it turns out that he was helping himself to a handful of gummy vitamins daily. It is important to have all medication and vitamins stored safely in a childproof container. When I was a kid, my mom had our chewable vitamins tucked on a high shelf in our pantry. I have clear memories of my sister Marjie and I climbing on a stool to get them down and have “vitamin parties” . I firmly place all blame on my older sister here. She was usually the one with all the grand ideas. Fortunately we limited ourselves and didn’t have any consequences that I am aware of. Remind your children that medicine and vitamins are NOT candy and can only be given by a grownup. (I imagine that my mom did that….) Realize that that might be useless and take a moment to evaluate how ‘childproof’ your situation actually is, in case you have a little Marjie. If there is ever an overdose concern, call the Poison Control center. Poison Control number for California is 1-800-222-1222 Measurement guide Measuring Spoon Metric (1 mL = 1 cc) 1/4 teaspoon = 1.25 mL 1/2 teaspoon = 2.5 mL 3/4 teaspoon = 3.75 mL 1 teaspoon = 5 mL 1 ½ teaspoons = 7.5 mL 2 teaspoons = 10 mL 1 tablespoon = 15 mL 1 ounce = 30 mL Special shout out to Dr Sophia Hurd for doing a read through and adding some extra pearls.

April Tuesday

 

Today is April Fools Day. It brings to mind a story that always makes me smile. When Lauren was in first grade her class worked on creating calendars. She painstakingly entered family birthdays, holidays and special events that were important to her. She proudly showed us all of her work and we looked through the decorated months. April proved to be the most interesting. On April 2nd of course, she noted my birthday, but on April 1st, (which fell on a Thursday that year) she had carefully written in April Tuesday. Huh? “Lauren, this is a beautiful calendar, what is April Tuesday?” “ You know, April Tuesday, when we play tricks.” Oh! April Fools day! All this time, she had heard April Tuesday!  “April Tuesday” what a clever brain you have, I can understand how April Fools Day sounds like April Tuesday! And sometimes it is on a Tuesday!" For the record, in my family, April first has been April Tuesday ever since.  Another classic from Lauren came to our attention when we were on a family car trip. We were doing some singing when we realized that the lyrics to the classic song Puff the magic Dragon had gone through some changes. ‘Noble kings and princes would bow whene'er they came’ had become “ noble dooble princes would bow wherever he came” In the very next verse, ‘A dragon lives forever, but not so little boys’ was turned into ‘ a dragon lives in butter’ It was hard not to chuckle. Lots of families have stories of things that their kids hear and pronounce in novel ways. Here is the tricky part. Parents need to tread carefully. There is a big difference between laughing ‘at’ someone and laughing ‘with’ someone. Some kids love telling jokes, putting on a show and eliciting a giggle from their audience. Other kids are more sensitive and could get their feelings hurt if you end up laughing at the odd things they come up with. Know your kid, If they are able to have a good time with it, have a good laugh together. If not, write it down. Someday I assure you that they will love looking back at some of their own personal Mondegreens. If you haven’t heard that term before, a Mondegreen is a term that writer Sylvia Wright came up with in a 1954 essay in which she tells about how she misunderstood a line from The Bonnie Earl O’Murray. The correct line was “laid him on the green’ She heard this as ‘Lady Mondegreen’. This one little error became the term for these butchered lyrics. If you google it, there are quite a few lists of common misunderstood words to songs. If you are in need of a laugh, some are quite amusing. (My all time favorite is from the Beatles Lucy in the Sky with Diamonds. Instead of the real words, “The girl with kaleidoscope eyes”, people have heard “The girl with colitis goes by.”) Before I end this post, I want to make one more note about April Fools Day. I would love it if parents had a conversation with their kids about tricks in general. In an effort to teach our kids to be kind, there is a simple question - will a certain trick make someone laugh or cry? If the answer is not clear, maybe that trick is not such a good idea.