The stuck WHAT in their mouth? Coby swallows a penny

 Last week my 28 month old grandson Coby swallowed a penny.

Lauren heard something in his mouth that didn’t sound normal.

“What’s in your mouth?”

“A coin!”

“What?! Open your mouth!”

“I swallowed it.”

“Did you really!?!?”

“Yes”

“What kind of coin was it?”

“The gold one.”

As I told him over the phone the next day, when you are smart enough to inform your mommy, “I swallowed the gold one,” you should also be savvy enough NOT to put things in your mouth that don’t belong.

When it happened, Lauren knew to refer to my old blog post, but as a nod to Coby I figured this is one worth updating and refreshing.

They put WHAT in their mouth?

Kids like to explore. Many times this involves sticking things where they don’t belong. Being fairly oral critters, most of the time the object they are handling gets placed in the mouth. When this happens there are two passages where something might go down.

If it goes into the esophagus, that is the beginning of the digestive tract. It hopefully will make its way down into the stomach, through the intestines and then get pooped out.

If something was swallowed, here are some things to consider:

Is it stuck?

How does the child look? Are they able to take a sip of water? Can they swallow just fine? Is their breathing relatively normal?

If something has gotten stuck in the esophagus they will look uncomfortable. There will be frequent coughing and throat clearing going on. You will know that something is amiss. This will necessitate a visit to the ER.

(In Coby’s case, he was able to easily drink water and eat an applesauce pouch, which was very reassuring)

Is it poisonous?

If you have any doubt about that, call the poison control center

1-800-222-1222 . For more info about dealing with poison, here is my blog post.

Is it potentially germ laden?

The answer is most likely yes, but that doesn’t mean you need to freak out.

When I was still working in the pediatrician’s office, I would get calls all the time about kids eating things that are pretty disgusting. More often than not, there were no actual consequences.

Young infants are the most vulnerable to germs, but the good news is that they don’t usually have the hand/mouth coordination to actually get anything into their mouth.

Once they have mastered that milestone, they are old enough that a normal healthy gut has good bacteria that can be somewhat protective.

If whatever it is that they ingested is going to cause trouble, symptoms will usually show up with tummy aches, vomiting and loose stools within a day or so. Persistent tummy upset will usually warrant an evaluation.

Is it a battery or magnet?

Any battery can be trouble, but button batteries can be a tremendous hazard because they can be easily swallowed and they seem to be everywhere these days.

Several years ago I got a call from a mom of 15 month old twins. There they were, sitting on the floor with mom’s pedometer right in between them. It was open and the battery was gone. Because of the uncertainty involved, we did have to send them to get x-rays. Indeed there it was, that little battery, sitting in the stomach of one of the kids.

In this case it passed safely, but if a battery gets stuck anywhere on the way it can cause a dangerous amount of damage.

As an important safety measure, pay attention to where any button batteries are in all of your little gadgets and make sure that your kids have no access to them. Keep a strict inventory and perhaps stick a piece of duct tape across any battery compartments.

Other objects that you need to be wary of are magnets. I am not talking about the little letters that you may have on your fridge. The ones that cause concern are the industrial strength magnets that you may find in some “grown up” toys like buckyballs or jewelry.

If more than one of those get swallowed it can wreak havoc on the intestines and be deadly. Keep them away from your kids!

Water/Agua beads

I am glad that these weren’t around when my kids were little. Coby is such a little goat, that Lauren has wisely not let them anywhere in her house.

These are little sensory beads that can grow to almost 100 times their original size when wet. They claim to be non-toxic, but they can be very dangerous if swallowed. These beads are associated with thousands of ER visits every year. If the beads are ingested they can continue to grow inside the body. This can cause severe discomfort, vomiting, intestinal blockage and life-threatening injuries.

As an aside, they are probably helping put many plumbers’ kids through college. Your pipes will thank you for not letting these into your home.

Is it sharp?

If the something that they have swallowed has a point or sharp edge, keep an extra close eye on your child. Feel the tummy to see if it is nice and soft. Look for blood in spit up or drool. Keep an eye on the stools.

If your child seems to have a rigid painful belly or has any dark, tarry poop or bright red blood they will need to be seen right away.

You may as well laugh

Some of the stories of what kids ingest are worth a giggle once everyone gets the all clear. One episode that I remember was a 3 year old patient who managed to swallow one of her Grandma’s one carat diamond stud earrings. It did pass through and was retrieved with no harm at all to the swallower. However, Grandma didn’t want it back; it was reunited with the mate and is in a safe deposit box waiting until the little girl is 18.

Most of the time, like the earring, it is simply a matter of watching for whatever it was to pass through. I have seen all sorts of stuff get swallowed and pooped out without incident. I think I have seen enough change to put a kid through college. Most coins smaller than a quarter go through fairly easily.

Here is a fun fact. I am more concerned about a penny that is newer than 1982. Why? Because these newer pennies are more zinc than copper, and the Zinc can be more reactive with the stomach acid.

However, when a worried parent would call me to report a swallowed penny, asking them what year it was, was unlikely to be helpful.

Nurse Judy’s ‘corn in the poop’ tip

Okay, so they have swallowed something, what’s the next step?

Once it is clear that nothing is stuck, let’s encourage a quick passage! Increase the amount of fluids that your child drinks. Perhaps add prunes. If your child is old enough that they are beyond simple pureed food, consider giving some corn kernels (you won’t see that in any textbook). Have you figured it out yet? For those of you who need this spelled out, corn kernels are usually fairly recognizable after they have been pooped out. They can act as a marker. That bright yellow kernel of corn can help you track the transit time.

(Lauren gave Coby corn as directed, but then didn’t look too carefully to see if the penny passed. In all fairness, Coby was in the process of potty training himself, so some poops were in the potty, and one was messy enough that she ended up simply tossing the training underwear rather than having to deal with it.)

When do we need to start paying extra attention to this ‘oral’ behavior?

Once in a while just about every kid is going to do some exploration, but if your child is old enough to know better and seems inclined to continue to put non food items in their mouth, this might be a condition known as Pica. Pica is the persistent eating of substances such as dirt or paint that have no nutritional value. This is worth pointing out to your doctor. There might be a nutritional deficit or something else going on. Low iron levels or high lead levels could be part of the issue.

Choking

Up until now, we were discussing things that went into the esophagus.

If the object goes into the trachea it may block the airway and you have a choking situation on your hands, or it could get aspirated into the lungs. Neither is good.

Your child will clearly be having breathing difficulties if this has happened. It is important to note that if someone has a blocked airway, they can not speak or make sounds. They will likely have a color change and look pale or blue.

It is critically important that all parents and caregivers are trained to do a choking rescue. Of course with any emergency you should call 911

Prevention!

To avoid this happening on your watch, do your best to keep little items away from the young kids. Anything that can fit into a toilet paper tube is too small for an infant or young child to be handling. Food pieces should be soft or cut into long strips rather than round pieces.

Encourage safe eating: sitting instead of running around, chewing and swallowing rather than shoving in wads of food. Parents, please model good behavior!

So what about the new devices that can help if your child is choking? These are relatively new and get mixed reviews. Alas these are not geared to children less than 22 pounds, but might still be a nice piece of mind for older toddlers.

A final note on the penny.

I had seen countless patients who swallowed pennies without any complications, so I was not terribly concerned.

But then….Coby got a fairly significant rash.

There were a few Xs in the equation. He had just finished a course of Amoxicillin, which was the likeliest culprit. It also could have been viral. But just to make things interesting, there was also the remote possibility that it could have been a reaction to the zinc or copper.

Fortunately the rash resolved and we are assuming that the penny is somewhere in the plumbing system as opposed to being stuck somewhere.

And now Coby is eagerly retelling his version of this story: “mama heard something in my mouth… it was a coin…. I swallowed it!”

Me: Lauren, can I get a photo of Coby holding a penny, for my blog?

Lauren: You think I would trust him with a penny!?!?

This photo will have to do.

July 4th Safety Tips/ There may be things you haven't considered

 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 a couple of years ago 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!

Sandy's first Father's Day Post

 Ten years ago, Sandy wrote his first “Father’s Day” blog post . It ended up being one of my most popular posts. I am rerunning it this week. The words of wisdom don’t have an expiration date.

2016

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 (ed: which we successfully did in July 2016, followed by Everest Base Camp in 2018). 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 children’s 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 never remember saying no; you will always remember saying yes!

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; 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.

Sandy went on to write a sequel which is linked here

Happy Father’s Day to all who celebrate

XO

Alana gets engaged

 I am taking a break from health related topics.

There is so much icky stuff in the news these days, that I am delighted announce that my youngest daughter, Alana got engaged last week.

Her boyfriend Tim had asked her a very sensible question.

How surprised do you want to be?

Her answer -

Just surprised enough to know that I should have my nails down.

His response

When we are on our trip to the UK, make sure you have nice nails.

The trip was during the last weeks of May. Her nails were lovely. So she knew it was coming, but he still managed to surprise her.

They both love magic and enjoy going to see local magicians.

Tim made an arrangement with a local British street magician to be in a predetermined location. Friends of Alana and Tim were meeting up with them that day. Their job was to get the ring to the magician.

Coming out of the Tower of London, exactly as Tim had anticipated, Alana immediately spotted the magician and made a bee line in his direction.

Tim had some fun with it “We don’t have a lot of time because we are meeting up with our friends, so only one or two tricks”

When the ring appeared in one of the illusions and Tim got down on his knee, Alana was NOT expecting it.

Their friends were in hiding, video taping the entire interaction.

It was perfect.

Are there any New York Times Games folks out there?

I did my daily WORDLE on the day of their engagement.

The answer was AGREE

I thought that was the perfect word. After all, she said yes!

When I posted that in the family chat, my older daughter Lauren thought my excitement about the word was a bit of a stretch.

But, then I did the spelling bee

Even Lauren agreed that having the word engaged there was quite the fun coincidence.

These little oddities started before Alana was even born.

Several days before her birth, her gender was still unknown to us. (Not because we wanted to be surprised, she just wouldn’t show us the goods) We had just settled on the names.If she was a girl she would be Alana. A boy would have been Adam.

My mother in law was in town on ‘baby watch’ doing the Sunday crossword puzzle. She called me over in amazement with the following two answers in the puzzle:

103 Across: It’s a girl. 34 Down: Alana

(actual puzzle appears below)

The family refers to it as Alanaland

Here is another example

The day following the engagement, they went to see Kenneth Branagh performing in the Tempest, and check out who was sitting right behind them! No, this is not AI. Yes it really is King Charles. The headline in all the British papers the next day was “King Charles makes surprise visit to Royal Shakespeare Theater!”

Alanaland!

Congratulations to Alana and Tim may you have a lifetime of wonderful adventures together

Slapped Cheek Otherwise known as Fifth Disease/Parvo B19/Erythema Infectiosum

“Slapped cheek” is one of those illnesses that seems to come around a couple of times a year. This May, wastewater samples in Northern California have confirmed the presence of the virus; that tracks. Dr. Ted has been seeing a lot of it this week.

This virus is also known as fifth disease. It got that name back in the 1880s. At the time, childhood diseases that caused rashes were assigned a number. This was number 5 out of 6.

For those of you who like to collect trivial facts, the original numerical list includes:

• First Disease: Measles (Rubeola)

• Second Disease: Scarlet Fever

• Third Disease: Rubella (German Measles)

• Fourth Disease: Dukes’ Disease (Also known as Filatow-Dukes’ disease or Staphylococcal Scalded Skin Syndrome; rarely used today)

• Fifth Disease: Erythema Infectiosum (Parvovirus B19)

• Sixth Disease: Roseola Infantum (Exanthem subitum)

You might hear it occasionally referred to by its medical terms, but most people just call it slapped cheek.

Just like Hand Foot Mouth (another one of those viruses that sometimes makes parents question why they signed up for this parenting gig), slapped cheek is a contagious rite of passage.

Most people get it while they are still children and thus have immunity as adults. The majority of cases happen in kids between 4-14 years of age. While it can occur at any age, the infection is highly prevalent in this group because the virus spreads easily in close-contact settings like schools and daycares.

It spreads through respiratory secretions, but can also be carried through infected blood.

Unless you had a memorable case of it, many people don’t actually know whether they have had it or not. You can check with the grandma or grandpa, but I bet they don’t remember either. The symptoms may have been mild enough that no one paid much attention.

Common Symptoms

This illness can be quite variable. Some kids don’t seem too impaired while others clearly feel miserable. The mild cases can present with a child who has a red chapped cheek for a day or so, and that’s it! The common denominator (hence the name) is one or both cheeks usually appear very red and irritated.

Red cheeks aren’t definitive. Some kids look flushed when they have a fever no matter what. This diagnosis often has some guessing involved.

For some patients, the red cheeks are followed by a lacy, mottled rash that works its way up and down the body. This rash tends to cover the arms and legs more than the trunk. Of course there are exceptions; some kids don’t read the textbooks and present in their own unique way. People with more moderate cases often have high fevers. Kids tend to be pretty fussy.

That’s a lot of symptoms to think about, but how does it look most of the time?

• About 20-30% of children may have no symptoms at all.

• Early on, around 50-60% develop mild cold-like symptoms such as congestion, runny nose, headache, sore throat, or low energy.

• Fever occurs in roughly 20-40% of cases and is usually low-grade, although some kids run higher fevers.

• The classic bright red slapped cheek rash develops in most symptomatic children and is followed by the lacy body rash in roughly 70-80% of cases. Mild itching can happen but is less common.

• Fussiness and fatigue are also common, especially in younger kids, though thankfully most children continue to drink fluids and bounce back fairly quickly.

On the whole, even though the title sounds alarming, most kids with Parvovirus B19 don’t usually look terribly sick (we see you readers who are waving your hands around; some kids are indeed truly wretched).

Rare symptoms

In rare severe cases it can cause very painful or swollen joints (polyarhropathy). This is much more common in older kids or adults. In even more rare cases, it can also cause the body to temporarily stop making new red blood cells. This can lead to anemia. If the patient seems suddenly paler than usual, or low energy, it is worth checking in with your doctor.

People with sickle cell disease, other types of long lasting anemia, or weakened immune systems are more at risk for these complications.

Rebound Symptoms

One confusing thing about slapped cheek is that it often comes in phases. Many kids start with a few days of mild fever, fussiness, congestion, or low energy that seems to improve. Then, about a week later the famous red cheeks or lacy rash show up. Some children even seem to get a second round of low-grade fevers or feel crummy again during this stage. Doctors call this a ‘biphasic’ illness, which is just a fancy way of saying it can feel like the illness comes in two waves. Thankfully, the second phase is usually milder and more about the rash than serious illness.

The good news is that this is not one of the viruses that you can get multiple times! Once you’ve been infected, your body is generally protected for life.

Treatment

There is no real treatment for slapped cheek beyond symptomatic care. Treat the fevers and/or fussiness as needed with Tylenol/Ibuprofen and tepid baths. Make sure your child gets plenty of fluids and rest.

Modern medicine doesn’t have any magic wand for this. However, just because you think your child might have slapped cheek, don’t exclude the possibility of an illness that would benefit from treatment. In general, if you have a miserable kid with a mystery fever that isn’t responding to standard medications, it is usually worth having them checked out. It might be something like strep throat.

In any event, even if the only thing you get out of a visit to the doctor is assurance that there is nothing more serious going on, sometimes that is worth it.

Pregnancy

Frankly, the issue about slapped cheek that is the biggest concern, is that it can be dangerous to a fetus.

If a woman is infected for the first time in the early stages of pregnancy there is an increased chance of miscarriage.

If you are pregnant and may have been exposed, take a deep breath and remember that most women (to the tune of 60-70%) had this as a child and are therefore not at risk.

If you have a child with slapped cheek, obviously, try to minimize exposure to anyone who is expecting. However, if you are the pregnant one, it is not reasonable to try to isolate yourself from your own child. The fact is, they were likely contagious before you had a diagnosis.

Just to be on the safe side, talk to your OB about getting a blood test to check your immunity.

Incubation and Reducing Spread

The incubation period is thought to be about 4-14 days after the exposure, with most symptoms starting after 6-11 days. In other words, if you come into your doctor’s office and walk out with a red cheek, you didn’t get it there; that would be way too soon.

The kids are most contagious at the very beginning of the illness when the main symptom is probably simple fussiness. You figure it is a simple cold or teething. By the time the rash is in full throttle and you’re pretty certain you’re dealing with slapped cheek, they are probably not very contagious anymore.

Our best daycare, camp, and school guidelines are to keep a child home if they are fussy or have a fever. If you have a happy child with a red cheek, it seems unreasonable to expect you to stay home from work. Chances are, once one of the kids in daycare shows up with it, everyone has already been exposed.

Case Study: Nurse Judy’s 27 month old grandson Coby.

Coby presented with a fever on Thursday evening.

Murphy’s Law had a good handle on this one, since daddy was out of town for the three day weekend, so mama Lauren had the 5 year old (who was a champion), a sick toddler, and a large dog to deal with as a single parent.

His fever went as high as 102.5. It responded to Tylenol and Motrin. When the medication was on board, he seemed pretty okay. When the meds wore off he was very ‘fragile and pitiful’.

Night times were tough.

He had mild congestion, a cough and red cheeks. The cough started as a bark and morphed into a looser hack after a few days. His voice was pathetically hoarse, so croup was one of the diagnoses that we were considering.

Coby is very verbal for his age, and was able to tell his mom that something in his mouth was hurting him. She didn’t notice any sores.

(It is worth noting that kids under 5 with a sore throat will often complain that their ‘mouth’ hurts).

When the fever was lingering for 3 days, Lauren took him into urgent care and came out with the diagnosis “some virus.”....in other words, treat the symptoms and check back in if something changes or it doesn’t go away in a couple more days.

She was given an oral steroid to start if the croupy cough was causing any distress. She didn’t need to start it.

The red cheeks became more significant on Monday.

Checking in with other kids in day care confirmed a cascade of viral stuff, some kids had mild fevers, others with congestion.

So, was it slap cheek? Maybe.

Viral syndromes often remain a mystery.

The key is:

Are you worried about your kid, or do you mostly feel sorry for them? In Coby’s case it was the latter.

 

Dealing with Excessive Heat/How to recognize Heat Stroke/Tips for keeping cool

 

Temperatures are soaring.

Memorial day means the beginning of the summer season. It seems like a good time to update this post that we ran a couple of years ago. There are some important additions, especially for teen athletes.

As many of you can attest, the hot weather hasn’t waited for summer this year.

Not only is it hotter earlier than usual, but it is more extreme.

Even places that are used to hot weather are seeing heat waves that are sadly breaking all kinds of records.

We are anticipating that most of the country will likely be dealing with temperatures over 90 degrees, many over 100, as the norm.

The important number is actually the heat index. This is calculated based on the temperature and the humidity. Humidity does make things worse. If you are in a place with high humidity the sweat doesn’t evaporate as quickly and this keeps the body from releasing heat as fast as it may need to. If you want to calculate the heat index of where you are, you can use this link.

Even in San Francisco, where we often are blessed with our lovely fog, we have more hot days than I can ever remember.

Being overheated can have serious consequences, especially in young babies.

Symptoms of heat exhaustion might include:

• Fevers 100-104

• Clammy skin

• Muscle cramps

• Nausea

• Dizziness

• Lethargy

If not tended to, this can lead to heat stroke, which can be deadly! Signs of Heatstroke include:

• A temp at near or above 104 (fever reducing meds are not useful in this circumstance)

• Flushed skin

• Elevated heart rate

• Weakness

• Dizziness

• Loss of consciousness

Medical intervention is essential!

A quick word about intense exercise in the heat (pay attention, teen athletes):
Most kids are not going to develop anything this serious from a hot day at the playground, but older kids, teens, and adults can occasionally get into trouble when they push themselves really hard in extreme heat. This is especially true during sports practices, intense hikes, boot camps, or suddenly trying to “power through” after not being acclimated to the heat yet. It’s most commonly seen on the first or second day of practicing a new sport.

When muscles overheat and break down too quickly, it can lead to something called rhabdomyolysis (“rhabdo” for short). This can actually damage the kidneys. Warning signs can include severe muscle pain or cramping, unusual weakness, swelling, vomiting, dizziness, or urine that looks dark brown like cola.

You’ll know you’re at risk for this if you reach the point where it feels like “my muscles have physically stopped being able to do this” and you decide to power through nonetheless. If that’s the sensation, it’s important to listen to your body. The most severe rhabdo victims are the ones that try to “power through” on a hot day.

The best prevention is not trying to be a hero in triple-digit weather. Take lots of breaks, hydrate before you feel thirsty, replace electrolytes if you are sweating heavily, and avoid the hottest part of the day whenever possible. Coaches, parents, and athletes should all know that pushing your body in extreme heat is usually not the right answer.

If someone seems confused, collapses, has severe muscle pain, or develops dark urine after heavy activity in the heat, they need medical attention right away.

Hydration is an essential part of preventing heat related complications.

It is important to replenish the fluids as well as the electrolytes that you lose when you are hot and sweaty. Pedialyte or similar electrolyte drinks may be better than plain water. Breast milk is perfect (of course). Even if your baby seems to be nursing well, if it is very warm out, keep an eye on the number of wet diapers! You may need to sneak in some extra fluid.

Nursing moms need to remember that they are losing fluid every time they feed their babies. It is essential to replace that as well as adding extra, so drink up! Perhaps start your day with one of the large water bottles that measures the amount. Fill it at the start of the day and it makes it much easier to track your intake.

Someone who is dehydrated will have:

• Less urine, and the urine will be dark

• Low energy

• Dry mouth

• No tears

Even if they are no longer in diapers, pay attention to how often your child is peeing and look at the color. Darker, infrequent urine might be your first clue that they need to be drinking more.

Ideas for staying hydrated:

Set a timer on your phone as a reminder that it is time for everyone to take a sip.

• Maybe have an iced-tea party.

• Pedialyte comes in popsicle form which can be a big hit.

• Other good hot weather treats are watermelon and some mildly salty snacks.

• Frozen breast milk can make a wonderful ‘milk-sicle’

Ideas for staying cool at home:

• Heat tends to rise, the coolest room in the house might be downstairs.

• Families may end up sleeping on the living room floor if it is less oppressive. Make it an adventure and call it camping.

• Keep the shades down during the day.

• Have a fan going if you are lucky enough to have one. Make sure the fan is placed in an area where curious kids can’t poke their fingers in there. Even better, get one of the fans that is toddler safe. For those of you without fans, put your order in now. Often in the midst of a heatwave there are none available. It is worth owning at least one so you are prepared for the next heatwave.

• Baths are great. Unless the water is obviously dirty, don’t drain it and you can get in and out throughout the day.

• Keep wet washcloths in the freezer and offer the frozen clothes throughout the day. Sponges are also fine to freeze.

• There are cool little ‘cooling towels’ that can make a big difference. Once you wet them, they stay nice and chilly for hours.

• If you have a yard or a place to put it, investing in one of the little plastic wading pools can give your kids hours of cooling fun. (even if it is very shallow, remember that adult supervision is required.

• Dress in minimal lightweight clothing.

Come up with some fun indoor activities that don’t require a lot of running around. Lots of kids love water play. Cover an area with a plastic sheet (a shower curtain is a great cheap option). Fill a plastic bin with water and then there are unlimited options (including cleaning the bin with a big sponge!)

An extended heat wave may require a little bit more screen time than you like; don’t stress about it. Try to be clear that there are some ‘hot weather’ rules that can be a little more relaxed.

If you don’t have air conditioning, see if you can find local places where you can hang out for a cooling break. Malls and libraries are often good options.

If you do go outside...

Beware of hot metal. Make sure you test the temperature of any slides or metal equipment before you let your child play on them. We have had patients get burns on their fingers from pressing a metal doorbell, so we are not kidding around. Seatbelts can be pretty bad as well! Metal can get very hot.

Shade is best, but if you are in the sun, make sure your kids have a big floppy hat, sunglasses and sunscreen.

Don’t forget about your pets. Make sure they have plenty of water (add some ice cubes.) If possible when walking them, keep to grass. Extremely hot pavement can actually burn their paws.

Also…never ever leave kids and pets in the car. This is especially critical when the weather is hot. Folks with some modern cars do have pet comfort settings (but it’s not okay to leave kids in there).

Keep in mind that in many hot areas of the world, the cultures have embraced the concept of the siesta. They take a collective break during the hottest part of the day. That sounds like a plan that most parents would be soundly in favor of…. Now we just have to get the kids on board.

Remember that heat is the normal for babies in many countries

Bay Area parents, this section is especially for you. We see a lot of anxiety around the idea that babies must exist only in a perfectly climate-controlled environment between exactly 68 and 72 degrees at all times or else catastrophe will strike. Deep breath.

Yes, we want babies to be comfortable and safe. Yes, overheating is something to take seriously, especially for newborns. But it is also important to remember that babies are born and raised all over the world in a huge range of climates. There are babies in Cambodia. There are babies in India. There are babies in Arizona in August. Not all of them have AC. Humanity has not survived exclusively in homes with central AC and a Nanit room-temperature alert.

What we are generally trying to do is optimize comfort and reduce risk, not maintain laboratory conditions. A room drifting up to 75 degrees for part of the afternoon does not mean your baby is suddenly unsafe. A baby taking a stroller walk on a warm day is not automatically in danger. Parents can become so anxious about achieving the “perfect” temperature that they lose sight of the bigger picture and stop trusting their own observations.

The most important thing is how your baby actually looks and behaves. Is your baby feeding okay? Making wet diapers? Reasonably alert when awake? Not flushed, lethargic, or drenched in sweat? Those clues matter more than obsessively refreshing the weather app every seven minutes.

Try to think in terms of flexibility and common sense rather than precision engineering. Dress babies lightly in the heat. They can even be naked. Avoid direct sun exposure. Use fans safely. Offer feeds frequently. And remember that a loving, attentive caregiver matters a whole lot more than whether the nursery briefly hit 75 degrees.

Other heat-related considerations:

Fungal diaper rash

With increased heat and sweating, fungal rashes can become a problem. Fungus loves damp dark warm places, so a sweaty diaper area (or underwear area for potty-trained kids…or adults) is the perfect breeding ground for fungal rashes. Fungal rashes in diapers can look like discrete red dots, occasionally coalescing into lumpy bumpy raised patches. Unfortunately, this can mimic the red papules of hand-foot-and-mouth. Dr. Ted has seen kids with diaper rashes sent home from daycare to get assessed for hand-foot-and-mouth. For any concern for a fungal rash, air out the diaper area and add over-the-counter Lotrimin three times a day. It’s extremely safe and well tolerated at all ages. You can also add some apple cider vinegar to the bathwater, which is antimicrobial and balances the pH (white vinegar is probably fine, but skip the balsamic).

Swimming considerations

The excessive heat warming fresh waters has created some unfortunate growth of naturally occurring bacteria, such as pseudomonas. Pseudomonas can present in a couple of ways. It can live in poorly controlled hot tub waters, creating a red spotty rash called hot tub folliculitis, but more importantly it can cause an excruciatingly painful swimmer’s ear. Luckily, pseudomonas can’t grow outside of wet environments, so drying the ears fully after swimming will not allow the bacteria a place to grow. We do not recommend Q-tips as they can traumatize the eardrum. Try using Debrox drops after swimming to dry out the ear, and any bacteria inside won’t be able to grow.

Blue green algae

If you’re going to any rivers or lakes, check your local resources to make sure there aren’t any dangerous blooms. He is the website for California, but it is easy enough to google wherever you are.

This is important for your pets as well as the humans.

Dr Ted’s Tidbits: Time to nerd out with science!

Young infants don’t regulate their body temperature very well, so this puts them at greater risk. “Heat regulation in newborns is fascinating. We rely on sweating to get rid of heat. Water from our skin absorbs heat and carries it away with evaporation (see Nurse Judy’s bit of this, above), but newborns don’t make a lot of use of those valuable sweat glands for at least the first couple of weeks. Newborns also have an immature part of the brain that regulates body temperature called the hypothalamus. Without input from the hypothalamus, babies rely on outside forces to control their core temperature. In particular, babies are bad at cooling themselves off. So if you’re in a place with a heat index over 90, it’s important to be proactive about keeping your baby from overheating.