This blog hit a milestone/ Half a million views!

 The majority of people reading my posts are the result of being on my email list. I used to send them via Constant Contact. Now I am happily on Substack.

I haven’t ever tried to calculate the actual number of emails opened and read. The one constant is that after I send the email, the posts get placed in my blog. This I can track and my little blog hit 500,000!

It motivated me to take a little trip down memory lane.

I can pinpoint when it started. Back in 2009 when I was working at Noe Valley Pediatrics there was an H1N1 flu epidemic. It feels like a lifetime ago. A vaccine was created fairly quickly, but there was a short supply. While many people are willing to wait in line for their own health care, trust me, that gets thrown on the window when it comes to their children.

The office phones were ringing off the hook and people tried to navigate getting their kids the shot as quickly as possible. There was no way to keep up with the demand for information. Continuous busy signals added to everyone’s stress.

The mother of one of our young patients suggested that I start a blog as a way to communicate any updates. I knew nothing about blogging, but it sounded reasonable. My blogging career was born.

Through the blog I was able to let people know quickly when we got the flu vaccine shipments and how we were managing the allocation.

Several months later, things had settled down from that scary flu season, but I now had a platform and I had thoughts on how to use it. I had come to recognize that many of my patients had the same questions (over and over and over). To minimize the need for frequent repetition, I started writing posts that addressed some of the more common issues.

The blog became an easy resource. At work if one of my callers had a question about a fever, a rash, strep throat etc, I would email a link to the related post and have them call me if they had any follow up questions. It was a great system.

I changed the name to Nurse Judy’s Approach. I got in the habit of sending out a weekly post on Friday mornings. I would often pick new topics based on what was going around. My patients also put in requests for things they wanted me to cover.

I confess to mixed feelings when I had my first moment of internet fame for my head lice post.

I loved writing and it felt so nice getting feedback about how my posts helped people get the information that they needed without freaking them out.

I also loved how much I learned along the way.

It’s time for some gratitude.

Thanks to my loyal readers who have stuck with me from the beginning, even as my subject matter has expanded and your children have grown. Welcome to all the newer readers who somehow found me.

Thanks to all of you who have shared the posts with others!

Thanks to the many doctors, specialists and experts in their fields who generously shared their wisdom with me when I would do a deep dive into a topic.

Thanks to Dr. Ted for encouraging me to keep the habit going. Collaborating with him while we update the old posts and create new ones is so much fun. No one can go down rabbit holes quite like the pair of us.

Yes we are hard at work for the enormous sleep post that I promised….It is coming.

Thanks especially to my husband Sandy who decided that my grammar was horrible enough that it shouldn’t be allowed out in public; he started editing for me several years ago. (While my attitude was always that if someone really got annoyed by an errant comma, they could get their information someplace else; BTW, he found six errors in the draft of this post!)

Thanks Rebecca for getting me over the hump

And later that day…..

Thanks for reading!!!

July 4th Safety Tips

 Here are some tips that can help you all have a safe & healthy holiday weekend.

Posting it a day early. It might be more useful for planning purposes.

Fireworks

Not surprising that these are on the top of the list.

Please be very careful of fireworks. If you are skipping the organized shows and planning on setting them off yourself, make sure your kids don't have any access to the fireworks or matches ahead of time. Do an inventory and know exactly what you have on hand. Keep the kids at a safe distance during the actual fireworks. Have a bucket of water or a hose nearby.

The danger isn’t only personal injury. If you are living in an area where the fire danger is elevated, please don’t be a dumbass.

Fireworks are LOUD

Loud music and fireworks can be damaging to your child's sensitive ears. Consider getting some ear protection if you are going to be someplace that can put hearing at risk:

How loud is too loud?

Dogs and cats hate the 4th of July

Try to keep your pets indoors with windows closed. There are items such as the Thundershirt or medications that you can give them if you know your animal has a tough time with the booms of fireworks. There are also some noise canceling headphones for pets, newly on the market.

I know this first hand, my poor grand-dog, Bowie, who is an enormous fierce looking shepherd/husky mix, is absolutely terrified of fireworks. We were in Golden Gate park last year and some (^%$#) set off a firework just yards away. Poor Bowie, all 75 pounds of him, jumped into his daddy’s arms and needed to be carried to the car. ( Luckily Adam is a strong guy)

Also, pay attention. Stressed out animals need to be observed especially closely with any interactions with your children and babies.

Make sure that your animals are microchipped or have current tags on, in case they get out.

Going out in a crowd

Since some of the holiday festivities may involve large crowds, I have some recommendations for dealing with situations where you might find yourself in a throng of people. Dress your child in bright clothes that stand out from the pack. Take a photo of them before you set out, so if heaven forbid you get separated, you have a current picture to pass around that shows exactly what they are wearing. Another sensible and creative idea is to write your phone number on your child's wrist and cover it with liquid band-aid to make sure it doesn't wash off. Make sure all phones are fully charged.

Have a solid plan with your older children. What should they do if they lose sight of you? Where should you meet up? This is a good time for the : ‘What would you do if’ game

Protect from the sun and stay hydrated

If you are in San Francisco chances are you probably don't have to worry about the heat. When my kids were growing up, our July 4th fireworks watching usually included warm blankets, hot chocolate and lots of thick fog. I remember one year when Lauren was 3 or 4 and we were driving to a vantage point, she saw a traffic light through the fog. "Is that a firework? It's beautiful!" Ah, our San Francisco babies.

For those of you escaping the city…..

Get in the habit of doing a skin sun exposure check at least every 30 minutes (more frequently for fairer kids) to see if it is time to reapply the sunscreen. Be very wary about applying any of the aerosol sunscreens around a heat source (like a grill.) These are flammable and there are horror stories out there about terrible burns that have occurred.

Sunscreen post

Safe Grilling/food safety

Let's move our discussion over to grills. I was watching the news and a story came on about the hazards of metal bristles coming loose from utensils that are used to clean your grill. These metal strands may get lodged into pieces of food. People have been reporting mouth injuries and worse. Happily, that is one call that I have never gotten, but it seemed like a caution worth sharing. Check your utensil brushes to make sure there is nothing loose. While you are at it, check the grill surfaces to make sure there are no pieces of any foreign objects that can get stuck in the food.

Make sure your child can't get anywhere near any type of grill. The danger begins from the moment you light it and are waiting for it to be ready, until long after the cooking is done and you are certain it is completely cool.

If you are cooking meat, make sure that it is thoroughly and safely cooked. Food borne illnesses don't just love under-cooked meat; other foods can transfer the bacteria also. Pay attention to any picnic foods that will be out of refrigeration for several hours:

Outdoor woes

If your picnic/meal is outside and you will be spending time in grassy, wooded places, make sure you do a head to toe check for ticks once back inside:

Ticks are rampant right now. Finding them early before they have been attached for a couple of hours will vastly decrease any concern about disease transmission.

Tick Post

If you are doing any hiking, or have a dog who is tromping around in the bushes, then pay attention to the possibility of Poison Oak

No, it is not okay to keep your child in bubble wrap; that isn't my intent. Go forth and have a festive, fun and safe holiday. Happy 4th of July!

Adenovirus /Make sure you have a healthcare proxy if you are leaving your kids with caregivers

 

Adenovirus

Make sure you have a healthcare proxy if you are leaving your kids with caregivers

Oh poor sweet Coby,

This one's for you.

Coby is 15 ½ months old.

Last weekend his parents had flown off for a well earned quick getaway. He and his brother Elliot were staying with the other set of grandparents.

Murphy’s Law was on the case. On Saturday Coby developed a fever and was absolutely miserable.

‘Bobbie’ and ‘Zayde’ called me to check in. The fever was still up an hour after the Tylenol, and I could hear him pitifully wailing in the background. He is generally a mild mannered little fellow.

I suggested that it was worth taking him to urgent care. I thought it was a good idea to rule out an ear infection. Also, Dr Ted had been seeing a lot of Influenza type B (odd for June) so I told them to get that checked as well.

Important note…make sure that anytime parents leave kids with anyone, the caregivers have an official permission to be able to get the children medical care in case of a situation like this!

Ah second kids…While there was a healthcare proxy, signed and sealed for his big brother, but no one had thought to update it to include Coby.

We all hated to put a damper on their weekend, but it was time to call Lauren and Adam, let them know what was going on and get that paperwork taken care of just in case it was needed.

At urgent care Coby’s ears got the ‘all clear’. The rapid test for flu was negative. He was obviously sick with something, so they sent off a complete respiratory panel. The following morning we had our answer. Poor guy had a nasty case of Adenovirus.

Here is the post that I had done a couple of years ago.

At the end, I will give you all the details of what Coby’s particular course looked like. (it was no fun)

Adenovirus

Is this a new virus? Nope!

What’s new is the ability to easily do a respiratory panel to identify the actual virus. What I used to refer to as a ‘viral package’ or the ‘creeping crud’ now has a specific diagnosis.

So, what is adenovirus?

Adenovirus is a family of viruses that has more than 60 types. The correct pronunciation stresses the second syllable. (I was saying it wrong for years)

It is quite common. You've probably been exposed to it at some point in your life. In fact, by the age of 10- years, most kids have had at least one adenovirus infection.

It can happen year round but tends to be more common in the Winter and Spring. It is very contagious. Symptoms are variable and range from a mild cold to severe illness. Most people don’t bother to test a little sniffle, so it is hard to have accurate data on how common it actually is.

The more annoying and serious presentations include:

• Runny nose and congestion

• Pinkeye

• fever

• Cough

• Headache

• Sore throat

• Muscle aches

• Pneumonia

• Ear aches

• Vomiting

• Diarrhea

This is indeed the ‘viral package’ with a little bit of everything. The wave that was going around when I first did this post, as reported by Dr. Ted, was a “pharyngo-conjunctival fever,” aka sore throat, pink eye, and fever. Most cases last from 3 to 7 days, but the more severe cases can last for weeks. We once had a colleague whose child had a fever for 3 weeks with adenovirus.

Like other nasty viruses, there can be secondary infections.

People with weakened immune systems, or existing respiratory or cardiac disease, are at higher risk of developing severe illness from an adenovirus infection.

Exposure and spread

The onset of respiratory symptoms is usually between two and fourteen days after exposure. When it is gut related (vomiting and diarrhea) it moves a little more quickly and you will see signs within 3-10 days.

People are most contagious right before they get sick or within the first couple of days of the illness. Even people with very mild cases can spread it.

The most common ways that it spreads are

• Close contact (shaking hands)

• fecal/oral transmission

• contaminated surfaces

• airborne transmission from one infected person to another.

• Occasionally it can be spread through water and public pools

Testing

More often than not the diagnosis is the ‘best guess’ based on the symptoms. Those red eyes are often a big clue. If the patient is pretty sick or has a persistent illness, then your doctor may opt to do a respiratory panel to get a more definitive answer. A stool sample might also give a diagnosis. Blood work is not usually done, unless your provider wants to rule out something else, but it might show an elevated white blood cell count.

Note about nasal swabs in pediatrics.

Kids' noses are a breeding ground of all sorts of stuff. It is quite common to have an assortment of various bacteria show up. Pediatricians are skilled at knowing what needs attention. Adult doctors might tend to ‘over-treat’

Treatment

Most of the time treatment is based on the symptoms and there are no special medications (or magic wands). Antibiotics will not be helpful.

Symptomatic treatment includes, fluids, rest, fever medications as needed and a humidifier at night. Soothing eye drops are helpful for the pinkeye and Manuka honey feels great for the throats (only for folks older than a year.)

Saline mist inhalers are a game changer, especially if you can get your little one to cooperate. A little mist followed by snot suckers can be very helpful for clearing the nasal passages.

People who are immunocompromised and get a severe version may need to be hospitalized for supportive care. Those folks may have access to antiviral medications.

Prevention

Good hand washing and wiping down surfaces are important ways to protect yourself from this.

Try hard not to touch your face with unwashed hands.

Boost your immune system

Try to get enough sleep. Vitamin D and ZInc are associated with a healthy immune system. I also like sambucol/elderberry at the first sign of illness.

So, what did Coby’s course look like?

This is absolutely the sickest he had ever been. He had Covid when he was 5 months old, and it isn’t even close.

With this virus, the fever lasted for a full 6 days. The baseline was 101-102 even with meds. The highest that they measured was 103.7. The method of measuring was a forehead thermometer.

Motrin clearly had a bigger impact than the Tylenol, but he was most comfortable when he had both in his system. Bless his heart, there were a few moments, on full medication when he did a little dancing. That kept Grandma from being too worried.

His poops were mushy and very stinky.

His nose ran like a faucet, with thick yellow/green snot.

His breathing sounded noisy, but his lungs were mostly clear. There was no labored breathing (he wasn’t out of breath), but when the fever was high, his respiratory rate was elevated. Read here for more on what labored breathing looks like.

His appetite was pathetic, but he was drinking and fortunately still had some ‘Baboo’ available (Coby’s term for breastmilk). He did accept some sips of smoothies.

His cry was a bit hoarse, so he may have had a sore throat.

He was clingy and lethargic. Days were full of one contact nap after another. With all the congestion, this was the easiest way for him to breathe, since he was in a more upright position. Nights were awful.

He might have had some mildly pink eyes the week before, but that was the one classic symptom that really didn’t come into play.

Lauren called to check in with the regular pediatrician first thing Monday morning, just to keep them in the loop.

On Tuesday, day four of high fever, Coby went in to get checked. The doctor confirmed that this looked exactly like “classic adenovirus.”

She was told not to fret about the poor appetite as long as he was staying hydrated.

This link about tummy bugs has a good review of how to assess hydration status

She was also warned that this could linger for 10 days.

At that point it was all about symptomatic treatment. (and of course to check in if things seemed to be getting worse).

Happily on Day 6, the fever was gone, the poops returned to normal and the appetite came back. Kids are resilient!

Extra thoughts.

Sometimes after hours urgent care that doesn't specialize in pediatrics may be quick to prescribe medication that isn’t strictly necessary. To the doctor’s credit, this is often because that is what some parents seem to be looking for.

I know that it isn’t always an option, but seeing an actual pediatrician is preferable. Especially for kids younger than 3.

Link ER vs Urgent care

In Coby’s case they sent him out with both a course of antibiotics and a course of steroids. Neither was necessary or appropriate.

When the diagnosis came through the following day, we were all glad that the decision had been made by the family (and the wisdom of Dr Ted) to hold off.

Update:

Eight days after Coby first showed any symptoms, EJ succumbed. Enough time had passed that we thought we were in the clear. Suddenly he complained of feeling cold. “Ruh Roh”. This was soon followed by 102 fever and a headache. We are assuming, based on the timing, that it’s also adenovirus. As noted above the exposure for this can be 14 days.

Interestingly, one other of Elliot’s early symptom was pain with peeing. Specifically he reported that his pee felt hot, thick and stingy. Bet you didn’t know that a virus could start in your urinary tract! Sure enough, some strains of adenovirus are well known to cause “urethritis.” We did a home urine test to rule out a urinary tract infection. Fortunately, that particular complaint lasted only for one day. Ongoing pee issues would have required an ‘in office’ urine test.

The fever has lingered as a low-grade temp for 4 days, so far. There hasn’t been any congestion. Not all viruses present the same way in different people.

Now the countdown continues. I for one had been sharing spoons and closely snuggling with him for days.

Fingers crossed that the other adults (myself included) in his life don’t get it!

Happy Birthday to my Father/Daddy/Grandpa/brilliant physicist/musician/Quirky/Sweet/Missed

 My dad would have turned 98 on June 21st. His birthday was always right around Father's Day; some years they fell on the same day. We lost him back in 2007. Time plays tricks and it feels impossible that it was so long ago.

When I wrote the first edition of this post, I put the call out to the family for their input. There were some classic stories like the time dad tried to calculate the width of a canyon based on how long it took for a sound to echo. In the same vein no one in the family can help but to think of dad during a thunderstorm. We all find ourselves calculating how far the lightning strike is by counting the seconds between the boom and the flash.

Dad strongly preferred back roads to the highways. We never stopped teasing him about one trip from Pittsburgh to New York, where we went miles out of our way because he was following the moon, rather than looking at a map, and had grossly miscalculated.

The lock for my high school locker was Kr Cr Ar -- If anyone needs help figuring out the code that would be 36 Krypton 24 Chromium 18 Argon. My dad had us remember combinations based on the periodic table. Yep, he was a nerdy scientist.

This had its pros and its cons. The first time my poor husband Sandy visited my house (at the vulnerable age of 18) my dad handed him a Scientific American magazine and asked about alternative approaches for addressing the problem posed in the article. Deer in the headlights would probably be an accurate description of Sandy at that moment. My mom rescued him “Robert, leave him alone.”

One of his passions was music. He was one of the rare people with perfect pitch. One night, I was sitting next to him at a large group dinner. There was the sharp clink of a fork hitting a wine glass. I heard him quietly ask,“Hmm what note was that?” He tuned out the rest of the conversation for a moment and then proclaimed “B Flat.”

I couldn’t help myself. I ran to the piano to see if he was right. We clinked the glass again. It was indeed B flat.

He played his violin until his last days. Certain pieces of music bring him right to me. We had a couple of Beethoven’s Violin and Piano Sonatas that were ‘ours.’

He came from a large family. His maternal grandfather, Michael Weiss had 14 children, so he had cousins everywhere. Family was tremendously important to him and he made the effort to stay in touch with people. He also created a system in which all the members on that branch had an identifying number. I was 2-4-2 — My grandmother was the second eldest, Dad was the 4th and I was the second. The extended cousins still use that at family events. The ‘Weiss’ number system lives on (my grandson is 24211).

He loved animals. When we were growing up he unhesitatingly welcomed the parade of stray cats that my sister Marjie brought into the family. To round things out, we also had an assortment of fish, gerbils and birds.

One of my all time favorite ‘dad stories’ was when one of the finches suddenly died. Dad had a cousin who taught veterinary medicine at Cornell. (Family number 14-2). Cornell happened to be where Sandy was in school. I got up there to see him as often as I could. Dad thought it would be interesting for me to bring the dead bird with me on my next trip so that cousin Richard could do an autopsy and ascertain the cause of death. He put the bird in the freezer to wait until my next visit.

I did NOT think this was a good idea and after a back and forth, strongly declined to take the frozen bird. Here is the thing, No one is quite sure how long the bird remained tucked away in the freezer.

He was curious about everything (why did the bird die?) and brilliant until Alzheimer’s dimmed his mind. If anyone had a question, before the days of google, the obvious choice was to “ask Grandpa.”

He also figured out a Back Scratching hack with a handy grid system. ABCD going down/12345 going across. If you had an itch you could easily instruct the ‘scratcher’ where to go. B3 is usually right in between the shoulder blades.

(I-3 was off limits)

Dad was game to do anything. We were always on the go to fairs, concerts, bowling, sporting events (Go Steelers, Pirates and Penguins) or even just to go watch a bridge being built. My mom was delighted to have quiet evenings with the rest of us out of the house.

When we weren’t actually going anyplace, we had a stash of board games including chess, Mastermind and Racko that he was always willing to play.

I don’t remember him saying no.

He was recycling and composting long before it was fashionable. His optimism that anything could be fixed or repurposed was overshadowed by his full schedule. Tools and willingness lost out to the fact that there were only so many hours in the day. This meant that his workbench in the basement became a veritable cornucopia of broken toys and unfinished projects, where it remained virtually untouched until we cleared out the house. That was a project that took us several years.

My dad didn’t tell a lot of jokes, but he was the universal recipient and appreciated any humor that was directed his way with a broad grin and a big laugh.

One of the traits that I got from him in spades and am most grateful for was his problem solving ability. Like my father, my default is to go right into problem solving mode. The truth is, sometimes people just need to kvetch, vent and have someone simply listen.

Learning that not everyone wants to have someone “fix” them is something that I continue to work on. This would have been a foreign concept to my father. If he saw something that could use some correction or fine tuning, he would dive right in. In some cases this might have been total strangers. A man limping? Let's evaluate the physics of his gait. An off-key singer? (his favorite) He invented a method to teach anyone to sing.

His kids and grandchildren coined the verb “to Grandpa someone,” which translated as constructive criticism, or instruction that was more than likely unasked for. He was pretty sure that anyone could learn anything, and he was ready and eager to teach.

My dad had a remarkably even temperament. It is possible that he never once raised his voice to me. I would like to think that this was mutual, but every time he tried to teach me the error of my bowling technique, I would lose control of my temper (I should have listened, I am a terrible bowler.)

It was no fun being mad at him. He would simply get sad and say something along the lines of “I am going into the backyard to eat worms.”

He was a family man who loved his wife, children and grandchildren with all his heart and we knew it. He started with girls only, three daughters, followed by five granddaughters. The switch flipped. The next two grandchildren were boys, followed by five great grandsons, who he never got to meet but would have been so proud of. One is a budding chess enthusiast who gets exasperated with his mom for making bad moves — she wishes she could travel back in time with him so he could play against his great-grandpa!

To all the parents out there, my memories of my dad center around the gift of time. This was the most valuable thing my father could and did give to me. Spending time with your kids is something you will never regret. If you are not getting enough, make this post a spark to have your see what you can shift around to get more quality time.

Here is a simple activity that my dad loved. Find an “inclined plane” (otherwise known as any board or piece of cardboard that you can lean on a slant.)

Roll things down

Watch your kid laugh

Here is a bonus story about my dad, for people who like the inexplicable

Thanks to 2-4-1, 2-4-2-2 and 2-4-1-1 for your help!!

Strep Throat

 Strep throat is a bacterial infection most commonly caused by the Group A streptococcus bacteria. There are other strains of strep bacteria (Group D, Group G, to name a few), which can cause sore throats, but typically heal on their own without treatment and do not lead to serious concerns.

While you can catch this illness no matter how old you are, classic strep throat is most common in school-aged kids. Due to the growth of receptors on tonsil tissue, kids between 5 and 15, seem to have a much greater affinity for the strep bacteria than at any other age.

It is quite unusual for babies under 2 years of age to have it (they don’t generally have the receptors for strep on their tonsils), but there are always exceptions.

Symptoms

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

• Sore throat

• Fever

• Body aches

• Headache

• Stomach ache

• Nausea

• Dizziness

• Smelly breath

• A red sandpapery rash all over the body that starts in the armpits

• In kids under 5, the primary symptom might be more congestion than sore throat

• NOTE: Typically the strep throat 'package' does not come along with a lot of congestion. If an older child has lots of coughing, clear mucus and sore throat, it is more likely viral.

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

Get out your little flashlight and do some checking. If you are lucky enough maybe they will actually open their mouth; most of the time the throat will look quite red. You may see red or white patches in the throat or on the palate (the back part of the roof of the mouth).

The tongue might also have red and white patches. This is referred to as strawberry tongue for obvious reasons. Feel around the neck and see if the glands or lymph nodes feel swollen. Sniff the breath. Often parents call and say that it smells like their kids swallowed a 'swamp creature'. The breath smells gross.

Symptoms are not always straightforward

Be aware that children under 6 often say that their "mouth" or “neck” hurts, but they are talking about their throat.

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

Complaining of tummy and headache with sore throat should significantly increase your suspicion for strep throat, especially in the absence of cough and congestion.

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

Contagiousness

Strep throat is quite contagious, but it is not uncommon for some family members to have it, while others escape. Remember the difference in tonsil tissue by age? Because of this, some parents might not automatically get strep throat infections from their kids. (The minute someone in your family gets that sore throat we would suggest sucking on a zinc lozenge and some Sambucol; maybe you will get lucky).

Some patients also seem way more susceptible to strep than others. Nurse Judy used to get it all the time until she had her tonsils out. That is not an uncommon story.

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

How to avoid strep:

Strep throat, is very contagious in school-aged children, but the transmission may be minimized with good practices. Since it lives on surfaces, good old fashioned hand hygiene is very effective at decreasing spread.

• Wash hands well with soap and water

• Wipe down surfaces, especially in the bathroom, kitchen, doorknobs, and cell phones.

• Don’t apologize for wearing a mask in a crowd

• Avoid swapping spit, sharing drinks, etc

• Replace toothbrushes for household contacts with strep

Testing for strep:

Many doctor’s offices will test with a rapid NAAT test that is very reliable (it’s like PCR). With this technology, most offices are no longer sending swabs out for culture (the 24 hour result), although that would be recommended if testing within 2 weeks of another positive test.

If your child hates the swab there are 2 things you can do to help.

1. First is to have them lift their legs when they are saying AAAAH. The brain gets confused by this and forgets to gag.

2. Another tip that we learned from a 3 year old patient is to growl like a lion. The growling is the perfect way to open up the throat and the mouth for that swab to sneak in.

Most in-office testing is specific for Group A strep. There are different strains of the strep bacteria that can cause various infections. If the in-office test is negative, and you’ve had chronic (more than a week) symptoms, it is sometimes possible to test for other forms of strep bacteria by asking for a special test to be sent out to a lab called an “upper respiratory culture.” Ask your provider about this.

A note on strep “carriers”:

Some folks are carriers. This means that they have a small amount of the bacteria living in their body all of the time and it doesn't make them ill. Those folks may be chronically positive on testing, even when they feel well. This gets confusing, because they might separately catch a virus, go to the office, get tested for strep, turn out positive, but the strep bacteria wasn’t causing their symptoms.

Unless you know you’re a carrier, it’s usually worth it to simply treat a positive result.

Are antibiotics necessary?

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

It is impossible to have real statistics about this. Most folks don't jump into the doctor's office every time they have a sore throat. There are likely millions of untreated cases of strep out there at any given time and of course most of them will have no issues in the future.

It’s worth noting that in Europe, not all cases of strep are treated right away with antibiotics. They reserve treatment for those with significant or prolonged symptoms. However, in the US, we feel better safe than sorry. If we know you have a case of strep throat, we will strongly advise that you do a course of antibiotics to avoid the above complications. This has resulted in slightly lower rates of rheumatic fever in the US.

Current medication protocol

There are two most common oral antibiotics, and a shot is available for children that are unable to tolerate oral antibiotics.

• Amoxicillin: great taste, and can be given once a day every day for 10 days (much easier than two or three times a day like it used to be). Some doctors will still choose to do twice daily dosing.

• Penicillin: vile tasting liquid, so not recommended for little kids. In its pill form, it needs to be given 2-3 times per day, but has a more “narrow spectrum” aka can preserve the gut microbiome better than amoxicillin, ideally resulting in less side effects. Be aware, the urine might smell funky during treatment.

• Penicillin injection: one and done, but it’s large and painful. Best for kids that absolutely cannot tolerate medicine or are vomiting.

• For people who are allergic to penicillin or amoxicillin: azithromycin can be given daily for 5 days, but please note that it’s at a higher dose than what is used for ear infections or pneumonia.

• Once your kids can swallow pills it can be a game changer. For tips on giving meds check out Nurse Judy’s blog post

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

Some studies conclude that if you do end up on antibiotics, taking probiotics can help keep a healthy gut.

Symptomatic treatments until the antibiotics kick in

• Tylenol or Motrin (we are treating pain, not necessarily fever)

• Lozenges

• Tea with honey (no honey for kids until one year old)

• Gargling with salt water

• Popsicles

• Cold fruit nectar

• Humidifier at night (if the air is dry)

• Check out Manuka honey if you can find it. It has proven antimicrobial properties and 1-2 tsp per day is safe (although it can’t replace antibiotics).

Severe (and uncommon) complications

There are some exceedingly rare complications of strep throat that should not occupy your mind but are nonetheless good to know about in case some of their unique symptoms appear after strep:

• Abscesses: shortly after or during infection, pus can collect in the spaces behind the mouth and throat in the neck. This is serious and often requires an emergency room visit. These children will have extremely high fever, a “hot potato” voice (very muffled), and an inability to close their mouth or turn their head. They are often drooling excessively.

• Rheumatic fever: a serious fever that develops 2-4 weeks after strep throat infection. It has an autoimmune cause, and can be associated with joint pains, involuntary movements, and heart valve problems. Treating the initial strep infection with antibiotics will reduce the risk of this by about 70-90%.

• Post-streptococcal glomerulonephritis (say that five times fast): an extremely rare condition in the US, it’s characterized by decreased urination about 2-3 weeks after infection. The urine that comes out is very dark, possibly bloody. There may be puffiness in the face and arms as well as headaches. This is not typically associated with a fever.

• PANDAS (Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci, say that ten times fast): an even more extremely rare disorder, this is an autoimmune condition characterized by the extremely abrupt exacerbation or onset of OCD disorder or tic disorder symptoms. The timing can be weeks to months after strep infection, and treatment remains poorly understood. Time seems to improve symptoms, but pediatric rheumatologists and infectious disease doctors can use steroids or naproxen.

Strep throat is very common and severe complications are very unusual, so while it is not our intent to scare people, but knowing what to look out for can save lives.

If you are one of the families dealing with strep throat, don’t forget to change your toothbrush 3-4 days after starting the antibiotics so that you don't get re-infected!

Nurse Judy’s Substack is free. I have no current plans to add a payment option. But feel free to pass these along and share.

Say Yes when it's an option/ A pillow, a new suitcase and Happy Father's Day

 Last week, we were in Boulder for the wedding of one of Alana’s oldest and dearest friends. Alana flew in on Wednesday. After her first night there, she reached out to Sandy asking if he could bring her one of our good pillows since the hotel pillows were not to her liking (she fully admits that she is high maintenance when it comes to bedding.)

Sandy tends to say yes and this was no exception. So, when we flew in on Friday he brought a larger suitcase in order to fit the pillow. Obviously this meant that he had to now check a bag rather than carrying one on for free.

I brought my little suitcase through to the gate. It was a full flight, so when they asked for volunteers, I didn’t think twice about checking mine. I knew that we would be waiting around for Sandy's anyway.

When my suitcase arrived on the carousel we immediately saw that it had a large crack in it. I brought it to the counter and the customer service person recognized that it was too damaged for further use. She walked us to the end of the terminal where behind a locked door, there was a huge room filled with brand new suitcases. This was not a lost and found. We got to choose any one we wanted that was of a similar size.

So thanks to Alana not liking her pillow, I now have a new suitcase that is much nicer than the one that got broken.

It does make me wonder how often United destroys luggage.

It also reminded me of an old post that Sandy had written for my blog many years ago.

It was all about saying yes instead of no. Thirty four years later, in Alana’s case he is still the dad who says yes.

With Father’s Day next weekend it felt like a fine time to rerun it.

Warning, Have some tissues handy. The first time I posted it, dozens of my patients told me that it made them cry.

____________________________________

In honor of Father’s Day, Nurse Judy has invited me to pen this week’s column and share some of my thoughts about why I have, and believe you can have, the absolutely greatest relationship with your kids through all stages of their lives. I believe that inherently, mothers are more nurturing, protective, overtly emotional, physical, and “maternal” in their instincts, beliefs and behaviors towards their children. But from the moment I first saw Lauren, a day that all who know me recognize as the most impactful day of my life, I knew I was going to give Nurse Judy a run for the money. I, like many of my generation, had an ok relationship with my parents. But it was not the one I wanted with my kids, and that became immediately obvious that day Lauren was born.

I have been called a lot of things over the years. I am frequently referred to as Mr. Nurse Judy. After years of taking our golden retriever to the park up the hill in the afternoon when the local elementary school let out, I became known to a few generations of kindergarteners and first graders as Java’s daddy. I was known as a business executive. But the grandest name I treasure is that of daddy (or father or papa bear or now Papa…) Why? Because after building a relationship with Lauren for 28 years, and with Alana for 25 years, I continue to have new and grand experiences with them, experiences that are direct descendants of the beliefs I had in raising them. And now I have a daughter who jumped at the opportunity to go on a daddy/daughter cross country road trip when she left for grad school, where we got to eat yellow (yes, there’s a story there) in Indiana, and simply cross a bridge into Kansas, make a U-turn, leave and say “we’re not in Kansas anymore.” And I have a daughter who is still my roller coaster buddy every August, and is accompanying me on what may be the stupidest thing I ever try – climbing Kilimanjaro. So how did I get here?

First of my early parenting philosophies was simply make time. I’m not talking about the “I’ll play with you when I get home and I’ll read you a bedtime book” type of time. I’m talking about the “take a morning off to hear your 2nd grader say one line in a play; use vacation days to chaperone school outings; play Barbie for hours on end; and supervise a cabin full of 5th grade boys on the school trip” kind of time. A typical dad probably spends more time away from their child than the mom. So take advantage of the time that you can have! As soon as my kids came home from the hospital, I never missed an opportunity to be with them. Each night, when an infant would wake up and cry, I went in. It was pickup and delivery to Judy to nurse them. Judy thinks I was doing this for her but she was just a benefactor. I picked them up, sang softly or told stories to them as I cleaned them up, and then brought them to our room. And then back to their cribs. Every night. We built up quite the relationship. Bath time? That was mine too. Nightly bedtime ritual? Well we both had one. But much of my daughters’ love for the great rock and roll of my youth comes from that time we spent every night. As they became toddlers, every weekend I took them to Miz Brown’s diner in Laurel Village. So Judy could get more sleep? Hmm, ok, but not really. It was completely selfish on my part. Want more time? Be the home that welcomes the gathering of the friends. While perhaps not directly involved in your child’s life at that moment, the benefits are extraordinary in what you get to witness, the welcoming environment you’re modeling for your kids, and the lifetime of relationships with your childrens’ friends, who consider you an extra dad. (2023 update - as a result of this, I have officiated three times at the wedding of one of my extra daughters!)

Next on my list of dad-parenting beliefs is “don’t look for a reason to say yes; assume that’s the answer, and instead force yourself to look for a reason to say no.” It’s simple but at least for me, it was initially uncomfortable and unnatural. But once I grew comfortable with this practice, it was an epiphany! Saying yes to as much as you can say yes to, is so much easier than saying no. And it has such wonderful benefits. Questioning, exploring, learning, experiencing…and you get to be a cool dad! Talking about going on a family camping trip when you’re asked if they can try camping in the house? Say yes, and set up the tent in the living room, light the fire, roast marshmallows, and sleep in sleeping bags. We can all think of valid reasons not to do this and I’m certain my instinctual reaction was “too much time; too much effort, and then I have to clean it all up and put it away.” But saying “no” wasn’t going to lead to the magnificent shared family memory we now have 20+ years later, and I certainly don’t remember anything about setting it all up or taking it down. “Dad, can I help?” Of course there are reasons to say no; it will certainly take more time. And you may have to watch your language. Unless it’s urgent, so what? Invite your 3-year-old to crawl under the car with you. Rub some dirt on their nose to make it official! And let them help! “Can I go someplace?”; “can someone sleep over?” Yes. And yes. Unless something is a threat to their health and well-being, be quick with the yes! Might some of these yeses have less than ideal implications to you and your free time? Probably, but that’s not what you’re going to remember! Only after saying yes can you then figure out if there is a “no” reason significant enough to change your mind. The more you say yes, the more they will ask you. As school children. As teenagers. And now as adults.

You will recognize my last pearl of wisdom as a modification of the Peter Pan syndrome. Let them be kids as long as possible! While it may be cliché, as we all know and live every day, once that’s gone, it’s gone forever, and I know that I, and maybe you, wish you could get it back! So don’t take it away from them. Don’t be in such a hurry to “help” them see things as you see them, through adult eyes and perceptions. They are emotionally, physically, and intellectually naïve – it's a wonderful time so don’t rush to take that away from them. In fact, for a truly wonderful relationship, force yourself to see the world as they do! That’s why I once found a pet/fish store open till midnight so I could go out and replace the fish that had died when Lauren was asleep (and yes, I brought the dead fish with me to try to get a match!) Of course she would have to learn to deal with the death of a beloved pet, and eventually beloved humans. But she didn’t have to learn about it that day, and it let her be a kid a little bit longer.

Don’t try to explain why work is so busy, that you need to do it to pay the bills that benefit them, and thus you don’t have time to play Chutes and Ladders for the 5th time in the past 2 hours. Instead, see it through their filters – why would anyone want to deal with things that are drudgery and frustrating when you can have fun playing a grand game? They didn’t ask to be your child – you decided to make them your child. I hope that decision was made with an appreciation for the fact that this responsibility instantly became the single greatest responsibility you have ever undertaken. The consequences of that decision are literally life changing for all involved. If it’s not your greatest responsibility, then something’s awry and you will miss out on immeasurable joy.

In the summer of 1988, my family of 3 (Lauren was 1) was invited to a swimming party at the home of my then senior VP. He had 4 adult daughters. While everyone was subtly vying for his attention, I spent the greater part of the day with Lauren in the pool. Late in the afternoon, the VP’s wife found me and pulled me aside to tell me that her husband had spent much of the day watching us play in the pool. Why? As she explained, he had been the wonderful corporate soldier. Moved all around the country when he was asked to. Frequently traveling. Successfully moved up to senior VP of one of the world’s largest companies. And she told me that if he had to do it all again, he would rather have spent the time in the pool with his daughters, because now he was here, envying me and the relationship I was already building with my child. Over the course of my career, I was often asked to make those same sacrifices, but by then I had already learned my golden rule – I worked to live; not lived to work. And while I had a satisfying and rewarding career, I never reached for those corporate stars that were dangled in front of me. Because one day I was hoping that I would have the type of relationship with my children that allows me to eat yellow with one of them and climb a mountain with the other.

Now most of the time Papa is busy saying yes to the grandsons.

Once upon a time/ I made up a fairy tale

 

My grandsons Coby and Elliot were visiting this last weekend. I was doing some bedtime snuggles with Elliot. “Can you tickle my back while you tell me the story about the king and the 3 sons that go on a trip and one is nice and the others are in a rush” “A story about a king?” I asked “And one prince stops to help the bee” Oh for heaven's sake; now I remembered. A few months ago I found an old notebook of my mothers. It is full of pages and pages of handwritten shorthand and prompts for story ideas. Unfortunately her handwriting is challenging to say the least. (I can fully blame my terrible penmanship on her). It feels like a treasure waiting to be explored. While I hadn’t successfully deciphered any of her actual stories, it encouraged me to try to create my own cockamamie fairy tale and the last time I was visiting the kids in LA I had tried it out on Elliot. I had followed one of mom’s basic templates, Good deeds would generally be rewarded with some type of good karma. Her heroes generally had the superpowers of kindness and curiosity. Her villains were mostly self-important, selfish and grumpy. It was a fairly safe bet that goodness would triumph over evil. Elliot evidently remembered the story I had made up and wanted to hear it again. Once upon a time, there was a king. He gathered his three sons and told them that he wanted them to complete a quest. They needed to travel across the kingdom. He was going to pick who would be the next king. The first son started out in a rush, certain that he would be the fastest. The second one was close behind. To summarize, the two princes hurried along and wouldn’t stop to help the various creatures along the way who needed some assistance. I barely remembered the specifics but EJ was able to prod my memory. Elliot is four. I was surprised and a little impressed that he remembered it. The first critter that needed assistance was a bee that was stuck in some honey. He called for help, but the first two princes rudely rushed by without stopping. The third prince had been enjoying his journey. He was looking at the lovely countryside and listening to the birdsongs when he heard a call. “Can someone please help me? My wings are stuck in the honey!” The kind young prince immediately stopped. “ Let me see if I can get you unstuck, but please don’t sting me if I get close” “Oh, I certainly won’t sting you, I am grateful to you for trying.” The prince used a little dry leaf to get the bee unstuck and the happy bee flew away. The next encounter was with a squirrel who couldn’t remember where he had hidden his nuts. He was very hungry. The prince helped him dig around and found his stash of acorns. I couldn’t remember the third, but there was EJ recalling all the details. “It was a snake! He needed help shedding his old skin, it was stuck” “ Oh, of course, you have such a good memory!” So eventually the youngest prince arrived at the destination. His brothers and the king were waiting for him. The brothers started teasing him about how slow he was, when suddenly lots of bees, squirrels and snakes showed up to thank him for saving their friends. The bees brought lots of honey as a gift. Then the king told everyone that the winner wasn’t the one who got there the fastest, but the one who was the kindest… The snake offered to bite the mean princes, but the youngest prince told him not to. And of course, they all lived happily ever after. At this point Elliot said, “I love you Grandma and I will always stop to save you.” and he turned over and was fast asleep. Goofy fairy tale for the win. The fact that Elliot had held on to this silly story reminded me of how much kids are taking in. I love thinking that the gentle messages from the story somehow linger. Take your time enjoying the journey. Getting someplace the fastest isn’t necessarily the win. Be kind. For more about the power of storytelling, check out this old blog post.