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   https://www.cdc.gov/acute-flaccid-myelitis/infographic.html   If we are suspicious of AFM, further testing and likely an ER visit would be the next steps.

Time out variations/behaviors that 'cross the line'

To recap last week’s post: behaviors can be sorted into three categories: Good stuff that we want to encourage Annoying stuff that we want to discourage Actions (usually bad stuff) that require immediate attention or intervention Last week I wrote about catching kids being good and ignoring the irritating behaviors. (Attention/Parenting Pearls) Several parents sent me requests to address category 3 sooner than later. Parents and caregivers need to be prepared to deal swiftly with the more challenging behaviors. I am referring to the actions that cross the line. This would include anything that is safety related. It is beneficial for parents to think about these types of things before they happen. Maybe you will be lucky and won’t ever need to be the parent of the biter, but it never hurts to be prepared. This is a good “what would I do if?” activity for parents. Let us begin by replacing the concept of punishment with consequence: If you act a certain way________________the consequence will be__________ Load your arsenal with your sensible consequences ahead of time. Being consistent is essential. All the folks who parent your child need to be on the same page I like to use sports analogies and in this case let's consider hockey. When a player gets out of line, they are moved to the penalty box for a designated amount of time. When the time is up, they are allowed to return to the ice and all is forgiven. The player essentially just had a time out. The goal of a time out should be removing the person from a situation that got out of hand. A timeout is not a time for discussion; that comes later. Here is what makes the time out that I recommend a little different. This ‘chill out session’ can actually happen right on your lap. Find a name for this ‘time out’ period that works for you. Maybe ‘breathing space’. Maybe ‘reset time’. You are a safe place, but stop short of making your cozy lap the goal. This isn’t the time to sing and give a back massage. Some quiet counting and some nice deep breaths are all they should get. This could happen anywhere where you can sit down and hold your child close. You actually likely have a timer in your pocket. Most cell phones have an hourglass app that you can download for free. This period doesn’t need to be long. Some experts suggest that it be a minute per age, but I have a suggestion. Ask your child how long the session should be (this is very effective for some kids and absolutely ludicrous for others.) “You hit your sister. How long do you think we need to reset, 1 minute 2 minutes or 3 minutes?" We can’t anticipate everything of course, but here are some common behaviors that merit a reaction. Being physically rough This gets an immediate version of the ‘time out’ that you have chosen. (We get calls about biting quite a lot. I frankly don’t know which is worse, being the parent of the biter or the child that got bitten. Both are difficult. Separate the kids immediately. If you have the luxury of 2 adults, one can tend to the victim and the other can sit with the offender. Human bites can get easily infected, so if there is broken skin, they should get checked by a doctor.) We had a situation once in which Lauren came running and crying. "Alana bit me". "Alana, Why did you bite your sister?" "I forgot not to" was the response. Sometimes we laugh even though it is probably not the correct thing to do. Once they have been ‘reset’ they need to earn the privilege of close contact with the other person. They can go back to playing nearby but not in touching distance. “When I trust that no one will get hurt, you can play closer” If they act out physically to you and you are in a circumstance that allows for it, walk away. Don’t let your child abuse you. Use your own ‘walking away power’. Go out of the room and close the door for a moment. Make sure you are out of their line of sight.That is generally not the response they are looking for. Later, find a moment when everyone is calm and talk about what happened. Talking points: You weren’t gentle. What feelings were happening? Mad/ sad/ bored? It is fine if they don’t choose to pick one. What are some other choices that might have been better? Using words/using walking away power/ asking a grown up for help... Running off This is a safety issue. I don’t like to see kids on leashes, but we all understand the frustration that must have lead to that decision. Know the rules ahead of time. For instance, we hold hands when we cross the street. A child who is at risk of running off without listening, has lost the privilege of walking without being held on to. Perhaps they need to be strapped into a stroller until you are in a safe area. This is a behavior that you need to work on in more controlled situations. Find some parks with gates, so it isn’t actually dangerous if they don’t listen. When you are practicing this, it is probably useful if you have an extra adult on hand, especially if you have more than one child with you. Find an opportunity to play a freeze game, or red light, green light, so that they can learn to stop at your command. Give lots of positive attention when it is merited. Going to an off limit area. (Think wires, hot stove, climbing inappropriately..) Do some reasonable child proofing in advance to make sure your home is as safe as possible. Blocking access to every wire isn’t usually possible so training a child that there are some places that are off limits is important. Be consistent and move the child away immediately. It might take a dozen times. If they are willfully defiant, I don’t believe in 3 strikes. That implies that they have 2 chances to ignore you. Be clear; “The next time you touch the wire we will need to ‘reset’. Throwing things That’s an easy one. Take it away. If they throw something that isn’t sanctioned, they lose it. When everyone is calm, you can decide when they have another chance. Perhaps have something soft and safe that you can offer in its place. “I see a little boy who wants to throw something. Someone could get hurt or something might get damaged. Lets see if you can play with this instead.” Here is a real life example of a child crossing a line and how it was dealt with: In my parenting class I tell the story of one of my daughter's friend Anya. She is one of my extra kids. For several years, Anya was working as a nanny. Any family would have felt like they won the lottery to have her helping them raise their kids. Anya took “firm but loving” to heart. One day, she was at a class with her little 2 year old charge. This was a little dance class at a multi purpose community room. In a corner by the stage there was a pile of martial art equipment. Anya was clear. “Don’t go near that pile”. Her little toddler was feeling a bit defiant that day and went right over like a dare and tried to touch one of the off limit objects. Anya calmly picked her up, removed her from the danger zone and back to the dancing group. The little toddler went right back over. This repeated several more times. Finally Anya picked her up and this time they left the room completely. Little B was at this point kicking and screaming. “When you are calm we can go back to the dance class, but if you go near that pile we will leave again.” This process took up most of the class time, but I think that for the last several minutes they were able to rejoin the class and finished up happily dancing. B had learned a lesson. (When Anya told me about this, she also mentioned that some of the parents observing all of this commented that it seemed a bit hard on B that she carried her out of the room. Really? I would give her an A+) Have you ever gotten towed? It’s horrible, but what is worst is that once you have paid the $$$ to collect your car, you find a ticket on the windshield. You are going to be careful in the future that it never happens again. The Timeouts are the initial tow. Some behaviors now have also earned the ‘ticket.' Try to find a consequence that makes sense. For kids over 3, using tech time as a commodity works well. They start with a daily allotment with opportunities to increase it within reason. Poor behavior docks some of the time away. Maybe a special outing gets cancelled. “You are not listening when I tell you to stop running. I don’t feel safe going to the park.” DO NOT make the consequence so big that you are not going to stick to it. No TV or play-dates for a month is just silly. I can't help hearing, "No soup for you!" (That is a Seinfeld reference for any of you too young to know what I am referring to) Do not let one parent undermine the other. Talk in advance as a team, or wait to pass judgement and come down with the sentence as soon as you are able to come to an agreement. Here are some parenting tools to use before or after an incident: Look for the triggers. Prevention is preferable to having to deal with something. If you see something about to happen, take some prophylactic step. Are kids starting to bicker? Perhaps it is time to give a snack, distract and/or separate. Tell stories about another child who crossed a line with their behavior.What were some of the consequences? Get out the stuffed animals and do a little playing. Your child is the parent and you are the misbehaving critter. Walking away power is a great choice if anyone is in a situation that is making them feel unsafe. If they are with a friend who gets mad and hits, getting up and leaving is a better choice than hitting back. Taking deep breaths is often a good way to slow down. Share the wisdom with your child that everybody makes mistakes and we can all learn from them. This post has the most relevance for parents with younger kids. For my patient readers who have older kids and still took the time to read this through, I haven’t forgotten about you. I will do a post dealing with teen consequences sometime soon.

Attention/Parenting Pearl

Attention Let me start by making a claim that most people, at least subconsciously, appreciate attention. I am not talking about public speaking or being on stage. I am referring to something more basic, like validation or acknowledgment. If you are an attentive reader, some of these concepts will be familiar to you from previous posts.  Think about it; certain tasks are simply drudgery. Cooking dinner for an apathetic family who doesn’t appreciate the effort is not fun at all, but if you were met with a resounding YUM and Thank You (and they actually eat it and ask for seconds) it makes the whole experience more enjoyable Perhaps even laundry would be fun if someone routinely pointed out how white your whites are (full disclosure, I can turn anything pink and shrink it in the process.) I remember a young patient who was in for a cough. He slipped sideways on the exam table after a little coughing fit and got a little startled. He was on the verge of bursting into tears. I reacted with a big “look at that! You coughed so hard that it made you fall over!” He grinned at me, sat up..coughed again and purposefully fell over again. I laughed and we had established a pattern. I don’t know how long we could have kept that up, but I was going to tire of it long before he did. Cough Cough/ Fall over/Look how funny you are……. I stopped reacting. He did it several more times and when he realized I was no longer paying attention to it, he simply stopped. Attention is a powerful tool. Can you think of some patterns that you have established? The one with my little coughing friend caught on in a moment. Some of the patterns in your life have been ingrained for quite a while and it might take a bit more effort to rewrite the script. This drive for attention doesn’t fade with age. For most kids (and some adults) attention equals attention, and we often don’t differentiate between positive or negative. Some kids will do their best to elicit a reaction, even if that reaction is yelling. Assuming you are willing to accept the premise that we can use attention as a means to encourage good behavior and discourage what my kids daycare provider used to call the ‘inconvenient’ behavior, the next step is to consider how to do this. Let's divide behaviors into 3 categories. Behaviors we like and want to see more of Behaviors we don’t like and we want to see less of Dangerous behaviors that need to be dealt with immediately Encourage positive behavior Catch them being good! By no means am I suggesting that every little good deed needs to be showered with praise. Find a balance and use some common sense. The Nurtured Heart is a well studied approach currently being used by many mental health professionals and therapists. Showing your child plenty of positive energy and attention can promote what they refer to as the ‘inner wealth,’ which is essential for children to build successful relationships. You are not going to spoil them by giving them attention. https://childrenssuccessfoundation.com/about-nurtured-heart-approach/ Okay, if you have one of those days where the good behavior is nowhere to be found, then catch them trying to be good. A good effort is the first step. Take picky eaters and meal times. Give positive attention when you have a child who is sitting nicely at the table: I like that you tried something new (even if it is just a bite and they don’t even swallow it) Look at how Max is safely eating. He is chewing and swallowing instead of shoving food in his mouth. That makes me happy. Wow, You are eating nice growing food. Let me feel your muscles. When they are doing something that you like to see, let them know that you notice. Having them hear you telling someone else that you are proud of something they did counts. It is worth noting that giving attention to another child in the room can be pretty effective. “Look at how Oliver tries new things.” Wait a moment and you might get “Hey look, I am trying it also.” (You can’t count on that; Nurse Heidi says that her younger one would simply give a “good for him, I couldn’t care less") Keep in mind that you are not simply doing the “good girl” or "good boy" stuff. You are paying attention to the action. Try to discourage annoying behavior Nagging or raising your voice in response to an irritating behavior is giving the attention that they crave. The more often we energize these negatives by paying attention to them, the more kids will keep trying to push your buttons. They have figured out how to get a rise out of you and will likely continue to do so as long as it works. Contemplate some situations where you get caught in a nagging cycle. We may be able to affirmatively impact behaviors by being very intentional about what situations we validate or energize. Our goal should be that our kids are getting get more attention for the good behaviors than they do for the annoying ones. It is hard not to energize these things, but try. We want to make every effort not to fuel the challenging behaviors by giving them too much response. So many kids have realized that they can make parents nuts by NOT eating. Put food on the plate. (Small amounts are better and not as wasteful) If they don’t eat much, don’t fuss. If you like you can make a statement “ I see a little girl who is not eating.” If they toss food or throw a plate, pick it up and simply say, "throwing food means you are finished with this meal". If you think they are actually hungry, you can offer another chance in 10 minutes. Be consistent. It might be 15 times of you taking the food away before they get that you mean business. If they will only eat that one favorite food, have it available with little comment. Remember the attention is given when they are willing to eat something else. Whining is another issue that can make us all a little nuts. This is the classic example of irritating but not dangerous.Take advantage of the rare miracle when they ask for something without the tone and pounce on it. “I love how you asked for that without whining!!!” How about interrupting when you are on the phone? See if you can catch them being patient. Have a “test” conversation that lasts 15 seconds (you don’t actually have to have a live person on the other end of the call.) Give your patient child a big high five for not interrupting. Work on making the “patience interval” longer and longer. “Hey I really like the way you waited until I was off the phone, that makes me happy.” For the interrupting child just hold up your hand; when you are off the phone you can calmly say, “ I am now off the phone, how can I help you". It is helpful for many kids to be clear about the rules before the phone call. You might want to have a family “team meeting” to problem solve a specific issue. Telephone interrupting is a easy one to work on. Clarify the expectation that they won’t interrupt. Have a “practice week” that will have rewards for patience and consequences for interrupting. The team can decide in advance what these would be. Tech time is a useful commodity. Start with the basic daily allotment. Rewards add a certain amount of time, and consequences lose time. Have a special word that they can use if they feel that what they have to say is so important that it can’t wait. (for the “I need to poop right now and I can’t unbutton my pants”, it might be worth getting off the call!) Defining the consequences for certain behaviors ahead of time is important so that if that behavior occurs, your child already knows what the possible responses may be. By doing this, you don’t have to “ignore” your child, but you also don’t have to energize the behavior. When the annoying behavior happens, sometimes it can be as simple as saying “we’ve talked about this before. Let’s calm down first, and then we can remember what our rules are so that we do better with this the next time.” A dangerous behavior would be one that could get someone injured. That requires an immediate intervention or time out. (I will tackle with that issue for a future post)

The stigma of mental illness

It is suicide prevention awareness week. That makes this an appropriate time to address the stigma of mental illness. I can’t cure it and I can’t fix society's shortcomings, but just perhaps I can touch the people who read my posts. Sometimes just getting the conversation started can make it less taboo and that is a reasonable first step. The elephant in the room is Mental Illness. Here is a startling statistic: According to the World Health Organization, one in four people will be affected by a mental health concern at some point in their life. Either you or someone close to you has dealt with or is currently dealing with this issue. You might not even be fully aware of it! There is often so much reluctance to be open about it. Parents call me dozens of times a day to talk about physical illness. Sure, if they are calling from work, they might talk in a hushed voice if we are discussing diarrhea or an itchy penis, but there is no shame involved. Okay, perhaps head lice and pinworms have a wee bit of shame (they shouldn’t) but there is generally no stigma associated with physical ailments. I hope you get where I am going with this. I also get the other calls. These parents are often so tentative as they reach out to share their concerns regarding depression, anxiety, or symptoms related to their child's mood or behavior. When I tell them how often I have these discussions about my teenage patients, most parents are a combination of surprised and somewhat relieved to need feel quite so alone. I am grateful that those who have known me for many years trust me enough to have the harder conversations. How is it that we have managed to suppress the acknowledgement about how common it is? Think about our bodies. We all deal with a variety of illnesses or discomfort. Many things are mild enough that they don’t impact our daily routine. A mild sniffle probably won’t keep you home from work or school. Some little acute illnesses come and go. Some illnesses are more chronic but can be managed with medication and treatment. Regardless of what is going on, we allow ourselves to talk about it. Mental illness has some similarities in that it has an extreme spectrum. It can be mild enough that folks can go about their daily life without letting on to the families and co-workers that they are struggling. Some could describe this as ‘managing’, but what an awful burden this places on the person who feels the need to struggle in silence. Some mental health issues are more chronic. Life is being impacted. These folks need treatment and/or medication. With the correct medication or therapy, many folks are functioning just fine. Find me someone who never gets anxious and depressed! You likely can’t. We all get a bit out of whack at times. If we are able to talk about it before it overwhelms, that has to have some merit. There are certain small actions that we can take in our families and circles of friends to try to rid ourselves of the stigma. Make sure you find the time for the conversations to happen. With our children, let feelings be okay. ANY FEELINGS. If someone is crying or feeling sad, don’t diminish it with a simple “ it will be okay, or don’t cry” As a parent, I know what is is like to watch someone who we love have to deal with this. My daughter Alana suffered from some anxiety when she was in college. Until we figured out what was happening, she had a few difficult years. Alana was having a feeling of chronic “throat tightness.” This lead to the occasional feeling of breathlessness and she would wake her up gasping for air. Sleep deprivation followed. This created a spiral that understandably lead to anxiety. Fortunately we were able to make the connection that gluten was significantly involved in her symptoms. Alana is a bit unusual in her approach. She widely announced to the world that she was having anxiety issues. Her friends responded. Shockingly high numbers, she hadn’t realized, were in therapy or already on meds. They barraged her with suggestions of various tools that had helped them. Coloring books, tapping, meditation, hypnosis. Some things gave some moments of relief, but in her case the underlying physical cause needed to be dealt with first. A wise friend once said.”You are only as happy as your least happy child”. I find that to be all too true. In the midst of her anxiety waves, I would feel like I had a fist clenched inside my gut. My daughter is fortunate that she ultimately had something that she has some control over (although she points out that being super allergic to gluten sucks.) She is also a rare person that she never allowed herself to feel isolated or shamed. After college, Alana went on to work for several years as a counselor and trainer at the SF Suicide Prevention hotline, before getting her Masters in Social Work. After graduating, she worked for several years in a community mental health center with clients of all ages. She acknowledges that as a therapist now, her firsthand experience with anxiety gives her extremely valuable insight. Here are some tips that she shares: proactively do some psycho-education about emotions. You can do this using games like Uno, where each color represents a different emotion. When you play a red card, you can prompt your child to talk about a time that they felt angry, or explore different coping skills around how to deal with feeling mad. Blue can represent a time that they felt sad. Green, a time where they felt excited, etc… Often times parents are afraid to ask their kids directly if they are feeling suicidal, because they are afraid that it may trigger these thoughts. On the contrary, research demonstrates otherwise - that talking about depression and suicide openly helps individuals feel more supported and more open to explore alternative ways to cope. The internet is full of some really solid suggestions. https://www.powerfulmothering.com/30-games-activities-and-printables-to-teach-emotions-to-young-kids/ If you are concerned that you are seeing behaviors that are impacting daily life, please be open to therapy. My opinion? Everyone would probably benefit from therapy. Therapy equals tools...who doesn’t need tools? Sometimes you might need to try a few different providers before you find someone who feels like a good fit. Don't give up. A good therapist can help you identify an issue that might need further treatment. They might advise seeing a psychiatrist to get started on some medication. Medication is not always necessary but in some cases can help achieve the balance that is lacking. The American society for suicide prevention states: Although there is no single cause of suicide, one of the risks for suicide is social isolation, and there’s scientific evidence for reducing suicide risk by making sure we connect with one another. We can all play a role through the power of connection by having real conversations about mental health with people in everyday moments – whether it’s with those closest to us, or the coffee barista, parking lot attendant, or the grocery store clerk. It’s also about the connection we each have to the cause, whether you’re a teacher, a physician, a mother, a neighbor, a veteran, or a suicide loss survivor or attempt survivor. We don’t always know who is struggling, but we do know that one conversation could save a life. I love to take urban walks with my friends. One of my walking partners is my amazing friend DeeDee. Not only does she pick up litter from the sidewalk and stop to ask anyone who is holding a map to see if they need directions, but she always has her antenna up to see if there is someone out there in need of that one conversation or outreached hand. She was moved by the story of a man who survived a suicide attempt from jumping from the Golden Gate Bridge. Kevin Hines story This brave man is sharing his story widely in the hope that he can help others. He talks about the day he jumped. He had told himself that if someone had noticed him and said, “Hey, are you okay?” he likely wouldn’t have gone ahead with it, at least that day. Instead, although he was surrounded by many, he felt completely alone. Finally someone spoke to him. “Hey, can you take our photo?” He jumped. Ever since she heard that story, if DeeDee sees someone alone and looking sad, she stops and reaches out. “Are you okay?” SF Suicide Hotline 415-781-0500 If you would like to take a class in Youth Mental Health First Aid here is a link: https://www.mentalhealthfirstaid.org/.../course-types/youth/

Anaphylaxis/Epipen options

Anaphylaxis/Do you need to carry injectable epinephrine?

Anaphylaxis is a very severe allergic reaction that can occur within moments of exposure to an allergen. People can die from this if it isn't treated. It can be triggered by an allergy to a particular food (peanuts or shellfish are among the most common), biting or stinging insects (like bees), medication (like antibiotics), latex (the type of rubber many balloons are made from) or a variety of other allergic triggers. Allergic reactions occur when the body mistakenly identifies something as harmful and overreacts. With anaphylaxis, this reaction can be life threatening. Symptoms usually start within seconds or minutes of the exposure, but there are exceptions. Once in awhile, a reaction can be delayed by several hours. This of course makes it much harder to figure out the culprit. In an anaphylactic reaction there may be different parts of the body involved. Mouth: itching or swollen lips or tongue Lungs: cough, wheezing, shortness of breath Heart: weak pulse, dizziness, fainting Skin: hives, itching, redness, swelling Face: flushed, swollen (eyes and ears common) Throat: itching, tight feeling, swelling GI system: vomiting, diarrhea, cramps, nausea The first time that someone has a severe allergic reaction is very frightening. Unfortunately subsequent reactions can be even more severe. It is essential to recognize symptoms that need immediate attention. Several years ago, a patient in our practice had been given yogurt for the first time.The child’s face began to swell and she started to have labored breathing. Mom’s first instinct was to call me; I redirected her to call 911 immediately. If it feels like an emergency situation, 911 beats the advice nurse. Of course, we want to be kept in the loop and help with any follow up. This child turned out to be severely allergic to milk. Interestingly she had no trouble with breast-milk. It is very important that folks figure out what the trigger is so that the you can try to avoid future reactions, although there are cases that remain a mystery. Knowing that your child is at risk for anaphylaxis is very unnerving to say the least. It is very important to educate your child (age appropriate) and all teachers and caregivers about how critical it is to keep your child from being exposed to the allergen. One case comes to mind of a school aged patient who was at Costco with some friends. The child was allergic to nuts. The friends parents allowed him to taste something from one of the samples. They had done a cursory check of the ingredients and thought it was safe. It turned out the the knife used to cut the samples had also been used to cut something with nuts, and the child ended up in the ER. Some kids are so sensitive that cross contamination (in this case, the knife) can cause a full reaction. Here is another story of one of our patients with an anaphylactic reaction: This little 9 month old was already teething and fussy, which complicated things. She also is prone to eczema, so rashes are not unusual. The family had had a recent checkup and had come home motivated to increase solids and calories to fatten up their slender child. Dinner that evening was some Chinese take out. Our little patient was offered bits of foods from the various containers. They didn’t offer any foods that struck the parents as obviously new, but one of the containers was a shrimp dish. Although the baby didn’t actually eat any shrimp, she started to get very fussy and swiping at her face and ears. After several moments of excessive fussing from no overt cause, mom and dad opted to give her a bath and start the bedtime process. When they removed her clothing they saw that she was covered with hives. At that point they wisely opted to go into the ER. It had been about 20 minutes since the food. The baby was fairly inconsolable and her face and ears were swelling. Luckily she did not appear to be having labored breathing (that would be a reason for a 911 call.) Once in the ER she vomited. She was given epinephrine and kept overnight for observation. She was singing and happy the next morning with no seeming ill effects. The current plan is to avoid any mystery foods and follow up with an allergist within a few weeks. The family will have an epipen on hand just in case. As a caution, I recommend to try all first time foods when there is time to observe for a little while to make sure there is no reaction. Giving something brand new and then putting a baby straight to bed is not a good plan. This is especially important with high risk foods like nuts, milk, eggs, shellfish, and any medication. It is also a good idea for every household to own Zyrtec liquid (scroll down for dosage chart.) If your child is old enough,talk to them about the fact that just about everyone has a little something special going on, and it their case they need to be careful about whatever their trigger is. Check out this book, available on Amazon. Perhaps pick one up for the class and make sure the teacher reads it out loud. No Nuts for Me Make certain that any babysitters or friends caring for your child know what allergens are potential hazards so that they can be certain to avoid them They should also have an injector handy just in case. If you go to a restaurant, ask to speak to the chef so that you know the restaurant understands the importance of avoiding the ingredient in question. In serious cases, you might want to call ahead to make sure they are willing and able to accommodate you. If your child has any mystery reaction to something, it is worth having a visit with the doctor so that we can help pinpoint the cause. In some cases we will refer you to see an allergist. Mild allergic reactions can be treated with a dose of Zyrtec or Benadryl. Keep in mind that Benadryl might make some kids sleepy and it could muddle your assessment. For an anaphylactic reaction epinephrine is the only first line treatment. It relaxes the muscles in the lungs to improve breathing. To quote Dr. Fast, a local allergist, “Epinephrine is what saves lives. It is never wrong to give epinephrine." One of my mom readers shared her story with me after this post first went out. She recently spent five days in the hospital due to an allergic reaction. She had 4 of the 7 symptoms (including full body hives), but was NOT given epinephrine early because she wasn't having respiratory distress. It took several days to get the allergic reaction under control. Not only does epinephrine help with the respiratory distress, but it lessens the release of the chemicals that are causing the reaction in the first place. The world health organization  would agree with Dr Fast that using epi early is a "no Brainer" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666145/ Auto injector options Epipen Epipen comes in 2 strengths. The junior (0.15mg) is for anyone under 66 pounds. Anyone over 66 pounds gets the full adult strength (0.30 mg) .Epipens have been in the news due to high cost and recent shortages. If you have an epipen, check out the lot numbers, some of them have extended their expiration date  May 2019 update The avilailability of the epi pen junior has been very spotty.  Auvi Q is available directly from the website. Auvi Q Auvi Q is a competing product that I always preferred. I liked it because it is flat and easy to stick in a pocket. It also actually talks you through the steps. When you are in the midst of a patient having a reaction, that can be more helpful than you would imagine. It was recalled several years ago due to trouble with the needles. I was thrilled to find out that AuviQ is available again, and believe it or not...drum roll please…. It has a ZERO copay to anyone with commercial insurance or a household with income less than $100,00.00. Auvi Q comes in 3 strengths: 0.1 for infants from 16.5-33 pounds 0.15 children 33-66 pounds 0.30 for anyone over 66 pounds  You have several options.  You can go to the Auvi Q website and download the prescription. Have your doctor sign and fax it over to them and they will deliver it directly to your door: https://www.auvi-q.com The customer service phone number is on the website and I found them extremely helpful. Of you can now get the Auvi Q at your local walgreens. They signed an agreement just this week (July 2019)   Regardless of which one you use, the auto-injector should be administered into the upper outer thigh. It can be given through thin clothing. The leg should be restrained and the injector should be held against the thigh and then compressed, rather than jabbing it. In the case of a severe allergic reaction, give the immediate dose of epinephrine but then head over to the ER for some observation. It is possible for the symptoms to rebound. This is called a biphasic reaction. Hours after a patient seems stable, the symptoms can flare up again. Since it is always better safe than sorry, keeping a close eye on the patient is essential for the next 24 hours Children with reactive airway disease and/or eczema are more at risk for allergic reactions, but they can happen to anyone. No, of course not everyone needs to carry around epinephrine, but it is SO important to recognize the symptoms and act quickly if you are concerned about the possibility of an anaphylactic reaction. There is a law, SB 1266, effective January 1, 2015, that mandates all schools keep an epinephrine auto-injector on hand and that someone on site has been trained. Check with your child’s school to make sure that they are complying. Zyrtec Dosage Chart The dose of cetirizine depends on age as below: 6 - 12 months of age: 2.5 mg given once daily (maximum dose 5 mg daily) 12 - 24 months of age: 2.5 given once or twice daily (maximum dose 5 mg daily) 2 - 6 years of age: 2.5 - 5 mg given once daily (maximum dose 5 mg daily) Over 6 years of age: 5 - 10 mg given once daily (maximum dose 10 mg daily) Zyrtec comes in a 1mg/ml solution (so 2.5 mg = 2.5 ml). There is also a 10mg/ml oral drops preparation (so 5 mg is 1/2 ml). Make sure you check the strength of the solution.

Dealing with Motion Sickness/Something new on the horizon

It is not unusual for us to get calls from folks who have a child or family member that suffers from motion sickness. Females are more likely affected than males. People who suffer from migraines tend to be especially susceptible. While the majority of people who have the most issues with this are between 2-12, some younger babies seem to have trouble as well. We have some unfortunate moms who have babies that vomit every time they go out in the car. If you know in advance that motion sickness is an issue, here are a few natural remedies that you may want to try. If you are someone who deals with this a lot, you will have plenty of car rides ahead to do your experiments and see what works for you. Getting fresh air by having a window open is the first course of action. Do some distraction by playing a game that has your child looking out the window. Experts say to specifically look at the horizon. For those kids who are not super sensitive, you can play some 'I Spy' games. See if you can find interesting license plates or different colors or letters on signs. Don't sabotage your trip by bringing along trip activities that have your child focusing on things inside the car. Even the best passengers might be fine until they start reading or looking at a phone or map. Most kids do best when their tummies are not too full or too empty. Little crackers to snack on might be useful. There are wristbands that provide pressure to some acupressure points that seem to give relief. You can find these on Amazon. There are several brands. A popular one is called sea-bands. They come in multiple sizes and colors. Otherwise simply massage the wrist and lower arm area. The magic spot is located on the inner arm about 1.5 inches above the crease of the wrist, between the two tendons there. Ginger seems to be very helpful. For older kids, there is a ginger gum specifically made for nausea (also available on Amazon). Find your favorite ginger cookie or candy. Trader Joe's has a wide assortment. Of course don't give anything to a young child that might be a choking hazard. Check out ginger lollipops (often marketed towards pregnant women.) Motion Eaze is a topical aromatherapy that some folks swear by. You just dab a drop behind the ears and it provides relief within a few moments. Don't do this one for the first time before you embark on a long car ride. The smell is fairly pungent and other folks in the car might have a hard time with it. If you prefer not to apply a scent directly, there are several essential oils that have been found to help with nausea. Peppermint, spearmint, ginger and lemon are all on the list. Consider letting your child chose the favorite scent. You can apply a few drops to a cotton ball and put it in a baggy. The kids can take sniffs whenever they feel the need. Hylands and Boiron both make a homeopathic motion sickness remedy. As with many homeopathic remedies they gets mixed reviews. Homeopathy does seem to be the ticket for some folks, and is unlikely to cause trouble as long as it is used as directed. It might be worth a try. My husband likes to cry "placebo" I say, "Bring it on, whatever works!" If you are going on a long car ride, plane ride or boat trip and you have struck out with the natural remedies there are some medication options. Benedryl is an antihistamine that often works quite well for motion sickness. It comes as a liquid. The bottle says for children over the age of 6, but in our office we do use it for younger kids. The dose usually agrees with the tylenol dose volume. Kids over 22 pounds would get 5 ml or one teaspoon. Always check with your own doctor's office to see what their policy is. Benedryl makes most kids sleepy, but don't count on that. It gets some kids hyper. You probably don't want to find that out on a cross country flight. Dramamine is another choice. It is an over the counter medication specific for motion sickness. Children 2-6 years of age can take ½-1 tab; children 6-12 years of age can take 1-2 tabs. These chewable tablets can be repeated every 6 hours, no more than 3 doses in a 24 hour period. Start with the smaller dose first to see if it works. Giving the dose 30-60 minutes before travel is recommended. For kids over 6, Bonine is another reasonable choice. This medication can be given at the first sign of nausea and is less sedating. For patients over the age of 12, if all else has failed some people use a scopolamine patch. This is a much stronger prescription medication that I would never use as a first line drug. Some of my motion sensitive older patients have found these valuable for cruises. Luckily, kids do tend to grow out of it...except for an unfortunate few. If you or your child have chronic motion sickness issues, it can be eye related. Cover one eye for several moments to see if the symptoms ease. If this works, you may have something called vertical heterophoria. It is worth having a consult with an eye doctor. My favorite eye expert in this is Dr. Vincent Penza Some people with chronic motion sickness have also gotten relief from chiropractic treatment. There is a new product on the horizon that got my attention. The media is abuzz about special glasses that have been reported to be real game changers for folks who have tried them. https://www.smithsonianmag.com/innovation/could-these-glasses-cure-your-motion-sickness-180969722/ Unfortunately, I haven’t been able to find out how to get them in this country quite yet. If you are interested, it seems that pre ordering a pair is possible if you have connections in Europe who are able to send them to you. In the meanwhile, if you or a family member suffers from this very annoying ailment, See if any of these other methods will help you out until those magical glasses become available If you are on a car ride, assuming the kids are old enough to comply, have them try very hard to give you as much warning as they can. Ideally they should try to get in the habit of warning the driver at the first twinge. The initial signs are usually paleness, yawning and restlessness. They may feel a little sweaty. This is quickly followed by the nausea and vomiting. With enough warning you might have time to pull over and get them out of the car for a couple of moments until the motion sickness eases. Being stoic is not a good plan; it usually backfires. In my car, I actually kept barf bags in the glove compartment. I used to collect unused ones from my airplane travels.They may come in handy. If you don't have an actual barf bag, have a container or plastic bag that you can whisk out at a moment's notice. Your trunk should be prepared: A change of clothes (don’t forget socks) A clean towel A plastic bag for putting the soiled clothes in Some wet wipes A lollipop to get the yucky taste away Febreze for cleaning off the seats (you will bless me) While kids are usually the ones most apt to barf in your car, motion sickness can afflict any of us at different times. I hope that some of these tips can help you out. I remember my days as a carpool driver. One of my little passengers had Emetophobia ( fear of vomiting) and would quite literally open the car door and leap out if anyone so much as made a gagging noise. It kept things interesting!