Friday, September 21, 2018

Attention/Parenting Pearl

Attention

Let me start by making a claim that most people, at least subconsciously, appreciate attention. I am not talking about public speaking or being on stage. I am referring to something more basic, like validation or acknowledgment. If you are an attentive reader, some of these concepts will be familiar to you from previous posts.

Think about it; certain tasks are simply drudgery. Cooking dinner for an apathetic family who doesn’t appreciate the effort is not fun at all, but if you were met with a resounding YUM and Thank You (and they actually eat it and ask for seconds) it makes the whole experience more enjoyable

Perhaps even laundry would be fun if someone routinely pointed out how white your whites are (full disclosure, I can turn anything pink and shrink it in the process.)

I remember a young patient who was in for a cough. He slipped sideways on the exam table after a little coughing fit and got a little startled. He was on the verge of bursting into tears. I reacted with a big “look at that! You coughed so hard that it made you fall over!” He grinned at me, sat up..coughed again and purposefully fell over again. I laughed and we had established a pattern.

I don’t know how long we could have kept that up, but I was going to tire of it long before he did. Cough Cough/ Fall over/Look how funny you are……. I stopped reacting. He did it several more times and when he realized I was no longer paying attention to it, he simply stopped. Attention is a powerful tool.

Can you think of some patterns that you have established? The one with my little coughing friend caught on in a moment. Some of the patterns in your life have been ingrained for quite a while and it might take a bit more effort to rewrite the script.

This drive for attention doesn’t fade with age. For most kids (and some adults) attention equals attention, and we often don’t differentiate between positive or negative. Some kids will do their best to elicit a reaction, even if that reaction is yelling.

Assuming you are willing to accept the premise that we can use attention as a means to encourage good behavior and discourage what my kids daycare provider used to call the ‘inconvenient’ behavior, the next step is to consider how to do this.

Let's divide behaviors into 3 categories.

  • Behaviors we like and want to see more of
  • Behaviors we don’t like and we want to see less of
  • Dangerous behaviors that need to be dealt with immediately


Encourage positive behavior
Catch them being good! By no means am I suggesting that every little good deed needs to be showered with praise. Find a balance and use some common sense.

The Nurtured Heart is a well studied approach currently being used by many mental health professionals and therapists. Showing your child plenty of positive energy and attention can promote what they refer to as the ‘inner wealth,’ which is essential for children to build successful relationships. You are not going to spoil them by giving them attention.


Okay, if you have one of those days where the good behavior is nowhere to be found, then catch them trying to be good. A good effort is the first step.

Take picky eaters and meal times. Give positive attention when you have a child who is sitting nicely at the table:

  • I like that you tried something new (even if it is just a bite and they don’t even swallow it)

  • Look at how Max is safely eating. He is chewing and swallowing instead of shoving food in his mouth. That makes me happy.

  • Wow, You are eating nice growing food. Let me feel your muscles.

When they are doing something that you like to see, let them know that you notice. Having them hear you telling someone else that you are proud of something they did counts. It is worth noting that giving attention to another child in the room can be pretty effective.

  • “Look at how Oliver tries new things.” Wait a moment and you might get “Hey look, I am trying it also.” (You can’t count on that; Nurse Heidi says that her younger one would simply give a “good for him, I couldn’t care less")

Keep in mind that you are not simply doing the “good girl” or "good boy" stuff. You are paying attention to the action.

Try to discourage annoying behavior

Nagging or raising your voice in response to an irritating behavior is giving the attention that they crave. The more often we energize these negatives by paying attention to them, the more kids will keep trying to push your buttons. They have figured out how to get a rise out of you and will likely continue to do so as long as it works. Contemplate some situations where you get caught in a nagging cycle. We may be able to affirmatively impact behaviors by being very intentional about what situations we validate or energize. Our goal should be that our kids are getting get more attention for the good behaviors than they do for the annoying ones.

It is hard not to energize these things, but try. We want to make every effort not to fuel the challenging behaviors by giving them too much response. So many kids have realized that they can make parents nuts by NOT eating. Put food on the plate. (Small amounts are better and not as wasteful) If they don’t eat much, don’t fuss. If you like you can make a statement “ I see a little girl who is not eating.” If they toss food or throw a plate, pick it up and simply say, "throwing food means you are finished with this meal". If you think they are actually hungry, you can offer another chance in 10 minutes. Be consistent. It might be 15 times of you taking the food away before they get that you mean business. If they will only eat that one favorite food, have it available with little comment. Remember the attention is given when they are willing to eat something else.

Whining is another issue that can make us all a little nuts. This is the classic example of irritating but not dangerous.Take advantage of the rare miracle when they ask for something without the tone and pounce on it. “I love how you asked for that without whining!!!”

How about interrupting when you are on the phone? See if you can catch them being patient. Have a “test” conversation that lasts 15 seconds (you don’t actually have to have a live person on the other end of the call.) Give your patient child a big high five for not interrupting.

Work on making the “patience interval” longer and longer. “Hey I really like the way you waited until I was off the phone, that makes me happy.” For the interrupting child just hold up your hand; when you are off the phone you can calmly say, “ I am now off the phone, how can I help you".

It is helpful for many kids to be clear about the rules before the phone call. You might want to have a family “team meeting” to problem solve a specific issue. Telephone interrupting is a easy one to work on. Clarify the expectation that they won’t interrupt.
Have a “practice week” that will have rewards for patience and consequences for interrupting. The team can decide in advance what these would be. Tech time is a useful commodity. Start with the basic daily allotment. Rewards add a certain amount of time, and consequences lose time. Have a special word that they can use if they feel that what they have to say is so important that it can’t wait. (for the “I need to poop right now and I can’t unbutton my pants”, it might be worth getting off the call!)

Defining the consequences for certain behaviors ahead of time is important so that if that behavior occurs, your child already knows what the possible responses may be. By doing this, you don’t have to “ignore” your child, but you also don’t have to energize the behavior. When the annoying behavior happens, sometimes it can be as simple as saying “we’ve talked about this before. Let’s calm down first, and then we can remember what our rules are so that we do better with this the next time.”

A dangerous behavior would be one that could get someone injured. That requires an immediate intervention or time out. (I will tackle with that issue for a future post)

Friday, September 14, 2018

The stigma of mental illness



It is suicide prevention awareness week. That makes this an appropriate time to address the stigma of mental illness.
I can’t cure it and I can’t fix society's shortcomings, but just perhaps I can touch the people who read my posts. Sometimes just getting the conversation started can make it less taboo and that is a reasonable first step.

The elephant in the room is Mental Illness.

Here is a startling statistic: According to the World Health Organization, one in four people will be affected by a mental health concern at some point in their life. Either you or someone close to you has dealt with or is currently dealing with this issue. You might not even be fully aware of it! There is often so much reluctance to be open about it.
Parents call me dozens of times a day to talk about physical illness. Sure, if they are calling from work, they might talk in a hushed voice if we are discussing diarrhea or an itchy penis, but there is no shame involved. Okay, perhaps head lice and pinworms have a wee bit of shame (they shouldn’t) but there is generally no stigma associated with physical ailments. I hope you get where I am going with this.

I also get the other calls. These parents are often so tentative as they reach out to share their concerns regarding depression, anxiety, or symptoms related to their child's mood or behavior. When I tell them how often I have these discussions about my teenage patients, most parents are a combination of surprised and somewhat relieved to need feel quite so alone. I am grateful that those who have known me for many years trust me enough to have the harder conversations. How is it that we have managed to suppress the acknowledgement about how common it is?

Think about our bodies. We all deal with a variety of illnesses or discomfort. Many things are mild enough that they don’t impact our daily routine. A mild sniffle probably won’t keep you home from work or school. Some little acute illnesses come and go. Some illnesses are more chronic but can be managed with medication and treatment. Regardless of what is going on, we allow ourselves to talk about it.


Mental illness has some similarities in that it has an extreme spectrum. It can be mild enough that folks can go about their daily life without letting on to the families and co-workers that they are struggling. Some could describe this as ‘managing’, but what an awful burden this places on the person who feels the need to struggle in silence.

Some mental health issues are more chronic. Life is being impacted. These folks need treatment and/or medication. With the correct medication or therapy, many folks are functioning just fine.

Find me someone who never gets anxious and depressed! You likely can’t. We all get a bit out of whack at times. If we are able to talk about it before it overwhelms, that has to have some merit.

There are certain small actions that we can take in our families and circles of friends to try to rid ourselves of the stigma.

Make sure you find the time for the conversations to happen.

With our children, let feelings be okay. ANY FEELINGS.
If someone is crying or feeling sad, don’t diminish it with a simple “ it will be okay, or don’t cry”



As a parent, I know what is is like to watch someone who we love have to deal with this. My daughter Alana suffered from some anxiety when she was in college. Until we figured out what was happening, she had a few difficult years. Alana was having a feeling of chronic “throat tightness.” This lead to the occasional feeling of breathlessness and she would wake her up gasping for air. Sleep deprivation followed. This created a spiral that understandably lead to anxiety.

Fortunately we were able to make the connection that gluten was significantly involved in her symptoms. Alana is a bit unusual in her approach. She widely announced to the world that she was having anxiety issues. Her friends responded. Shockingly high numbers, she hadn’t realized, were in therapy or already on meds. They barraged her with suggestions of various tools that had helped them. Coloring books, tapping, meditation, hypnosis. Some things gave some moments of relief, but in her case the underlying physical cause needed to be dealt with first. A wise friend once said.”You are only as happy as your least happy child”. I find that to be all too true. In the midst of her anxiety waves, I would feel like I had a fist clenched inside my gut.

My daughter is fortunate that she ultimately had something that she has some control over (although she points out that being super allergic to gluten sucks.) She is also a rare person that she never allowed herself to feel isolated or shamed.

After college, Alana went on to work for several years as a counselor and trainer at the SF Suicide Prevention hotline, before getting her Masters in Social Work. After graduating, she worked for several years in a community mental health center with clients of all ages. She acknowledges that as a therapist now, her firsthand experience with anxiety gives her extremely valuable insight.

Here are some tips that she shares:

  • proactively do some psycho-education about emotions. You can do this using games like Uno, where each color represents a different emotion. When you play a red card, you can prompt your child to talk about a time that they felt angry, or explore different coping skills around how to deal with feeling mad. Blue can represent a time that they felt sad. Green, a time where they felt excited, etc…

  • Often times parents are afraid to ask their kids directly if they are feeling suicidal, because they are afraid that it may trigger these thoughts. On the contrary, research demonstrates otherwise - that talking about depression and suicide openly helps individuals feel more supported and more open to explore alternative ways to cope.

The internet is full of some really solid suggestions.



If you are concerned that you are seeing behaviors that are impacting daily life, please be open to therapy. My opinion? Everyone would probably benefit from therapy. Therapy equals tools...who doesn’t need tools? Sometimes you might need to try a few different providers before you find someone who feels like a good fit. Don't give up.

A good therapist can help you identify an issue that might need further treatment. They might advise seeing a psychiatrist to get started on some medication. Medication is not always necessary but in some cases can help achieve the balance that is lacking.

The American society for suicide prevention states:

Although there is no single cause of suicide, one of the risks for suicide is social isolation, and there’s scientific evidence for reducing suicide risk by making sure we connect with one another. We can all play a role through the power of connection by having real conversations about mental health with people in everyday moments – whether it’s with those closest to us, or the coffee barista, parking lot attendant, or the grocery store clerk. It’s also about the connection we each have to the cause, whether you’re a teacher, a physician, a mother, a neighbor, a veteran, or a suicide loss survivor or attempt survivor. We don’t always know who is struggling, but we do know that one conversation could save a life.


I love to take urban walks with my friends. One of my walking partners is my amazing friend DeeDee. Not only does she pick up litter from the sidewalk and stop to ask anyone who is holding a map to see if they need directions, but she always has her antenna up to see if there is someone out there in need of that one conversation or outreached hand. She was moved by the story of a man who survived a suicide attempt from jumping from the Golden Gate Bridge.

This brave man is sharing his story widely in the hope that he can help others. He talks about the day he jumped. He had told himself that if someone had noticed him and said, “Hey, are you okay?” he likely wouldn’t have gone ahead with it, at least that day. Instead, although he was surrounded by many, he felt completely alone. Finally someone spoke to him.

“Hey, can you take our photo?”
He jumped.

Ever since she heard that story, if DeeDee sees someone alone and looking sad, she stops and reaches out.
“Are you okay?”


SF Suicide Hotline 415-781-0500

If you would like to take a class in Youth Mental Health First Aid here is a link: https://www.mentalhealthfirstaid.org/.../course-types/youth/

Friday, September 7, 2018

Measles 2018/Traveler update

Things to know about measles:

Measles, also known as rubeola, is a very contagious respiratory virus.

  • This virus is so virulent that ninety percent of unvaccinated people will catch this virus once they are exposed. What is even more alarming is that it can remain on surfaces or even in the air for 2 hours after someone has sneezed or coughed! If someone travels on a plane while they are contagious...that is a potential nightmare. One of the reasons that it spreads so easily is that people are contagious as early as 2-4 days prior to showing any signs of the virus and may remain contagious until the rash is gone, or 4 days after the symptoms are all clear.

  • Infected people present with high fever, cough, congestion and red eyes.
.
  • After several days they will also develop a significant rash all over the body.

  • If you have a happy child with a rash, my guess would be that it isn’t measles. People with measles will look sick and likely have a high fever. The rash will not be one of the first symptoms.

Complications are frequent. They range from ear infections to pneumonia, encephalitis and/or seizures. 1-2 out of every 1,000 cases are fatal. Take a moment and reflect on what that means. This is a serious illness. This is not one of those illnesses to wish your child would catch in order to get natural immunity.

The routine measles vaccine is combined with mumps and rubella and is referred to as the MMR. The individual components have not been available separately for many years. The first MMR shot is routinely given to patients between 12-15 months and again between 4-6 years. For the second dose we have the option of combining it with the chickenpox vaccine called Varivax. That combo vaccine is called Proquad or MMRV. The MMR vaccine is thought to be 95% effective. The second dose is given just to catch the occasional person who didn't get effective immunity from one dose and bumps the effectiveness up to 99%. It can be given earlier than 4 years, but we aren't too concerned about the timing of the second dose as long as our patients have gotten the first one. The schools just count the doses and don’t mind if the second is given early. If you are traveling to a high risk area, the CDC will suggest getting the second shot early. The 2 shots simply need to be given at least 28 days apart.

Why do we wait so long before giving the first MMR protection to our babies?

Assuming that mom has been fully vaccinated (or less likely has had the actual measles) infants are born with passive immunity to the disease. This immunity starts to wane as they get older and is considered mostly gone by the time the babies are between 12 and 15 months. If a child is vaccinated when they are younger than a year old and still have the maternal protection, the vaccine does not seem to be as effective for long term protection.

The MMR is a live vaccine and it is true that in some rare cases the reaction can be a little rough. Interestingly, most kids are just fine the day of the immunization. Typically the reaction comes along between a 7-21 days after the shot. This reaction may include high fever and rash. This is not thought to be contagious. It usually lasts only a day or so. If your child is allergic to eggs, we are extra cautious when giving the vaccine. Some folks with a significant reaction to eggs may opt to get it at the allergist's office. I have NEVER had any patient have an allergic reaction from the MMR or a serious post vaccination reaction other than about 20% who seem to get the fever the following week.

Before routine use of the measles vaccine, there were about 500,000 cases of measles in the United States each year and about 500 deaths. Measles also led to about 48,000 people being hospitalized and another 1,000 people being left with chronic disability from measles encephalitis. Study after study has shown that there is no link between the MMR and autism,
but there are still some folks reluctant to give their children the vaccination.

In July 2016, SB277 was signed into law. It is now a requirement for all children attending schools in California to have the measles vaccine unless they have a medical contraindication. Since the law passed, I have seen a steep increase in vaccination rates. This law probably has saved lives.

Measles has been in the headlines recently.There have been a few cases here in the Bay Area, but the fact is, this is not considered an true “outbreak”. The CDC defines an outbreak as “a chain of transmission that includes 3 or more cases linked in time and space.” So even though we have had a few small isolated cases, not enough of them are connected to cause a red alert here.

As of August 2018 there have been 124 cases confirmed in 22 states and the District of Columbia. The states that have reported cases to CDC are Arkansas, California, Connecticut, Florida, Illinois, Indiana, Kansas, Louisiana, Maryland, Michigan, Minnesota, Missouri, Nevada, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, and Washington.

Even a few cases can make parents of young kids nervous. It goes without saying that if you have a young baby in a crowd they are at risk. You never know where the next outbreak will be. We live in a global world and San Francisco, especially is a destination for travelers who are coming from some of the high risk countries. However, at this time, unless there is a health alert, babies should follow the routine schedule and get their first MMR at either the 12 month or 15 month appointment.


Europe is a different story

Due to poor vaccination rates and policies, cases of measles have reached a record high in Europe this year, with more cases recorded in the first six months of 2018 than any other 12-month period this decade, according to the World Health Organization (WHO). Romania (4,317), France (2,488), Greece (2,238) and Italy(1,716) have the highest number of cases and there have been 31 deaths.

We don’t need to cross the ocean to be exposed. On July 24, 2018 The Pan American Health Organization updated their numbers and reported a total of 2,472 confirmed cases of measles from 11 countries in the Americas so far this year. The majority of the 2018 measles cases occurred in Venezuela ( 1,613) and Brazil (1,053), followed by the 124 here in the US that I noted earlier.

PLAN IN ADVANCE!

If you are traveling to a high risk area or there has been a possible measles exposure, the vaccine can be given as early as 6 months. You need to be aware that this early shot can’t be counted on for lasting protection. Your child will still require two shots after the first birthday. Your insurance company also might refuse payment if the shot is given outside of the routine schedule. If that happens, be aware that getting an early, extra dose may be an out of pocket expense.


It takes about 10-14 days to get any significant protection from the first MMR. For instance, getting an MMR for a 7 month old to protect them from a travel situation the same week is not going to do much of anything.

Several years ago when I was working on my very first measles post, one of my adult friends said to me, "We all got measles and survived, what is the big deal?" My response was, "It is true enough that the vast majority of folks who get measles will recover intact and have lifelong immunity. However, one to two kids out of 1,000 will die; many more than that will be permanently harmed. That is too many when we are talking about something that can be prevented. That 1 child out of 1,000 matters."

Friday, August 31, 2018

Anaphylaxis/Epipen options

Anaphylaxis/Do you need to carry injectable epinephrine?
Anaphylaxis is a very severe allergic reaction that can occur within moments of exposure to an allergen. People can die from this if it isn't treated. It can be triggered by an allergy to a particular food (peanuts or shellfish are among the most common), biting or stinging insects (like bees), medication (like antibiotics), latex (the type of rubber many balloons are made from) or a variety of other allergic triggers. Allergic reactions occur when the body mistakenly identifies something as harmful and overreacts. With anaphylaxis, this reaction can be life threatening. Symptoms usually start within seconds or minutes of the exposure, but there are exceptions. Once in awhile, a reaction can be delayed by several hours. This of course makes it much harder to figure out the culprit.


In an anaphylactic reaction there may be different parts of the body involved.

  • Mouth: itching or swollen lips or tongue
  • Lungs: cough, wheezing, shortness of breath
  • Heart: weak pulse, dizziness, fainting
  • Skin: hives, itching, redness, swelling
  • Face: flushed, swollen (eyes and ears common)
  • Throat: itching, tight feeling, swelling
  • GI system: vomiting, diarrhea, cramps, nausea

The first time that someone has a severe allergic reaction is very frightening. Unfortunately subsequent reactions can be even more severe. It is essential to recognize symptoms that need immediate attention.

Several years ago, a patient in our practice had been given yogurt for the first time.The child’s face began to swell and she started to have labored breathing. Mom’s first instinct was to call me; I redirected her to call 911 immediately. If it feels like an emergency situation, 911 beats the advice nurse. Of course, we want to be kept in the loop and help with any follow up. This child turned out to be severely allergic to milk. Interestingly she had no trouble with breast-milk. It is very important that folks figure out what the trigger is so that the you can try to avoid future reactions, although there are cases that remain a mystery.


Knowing that your child is at risk for anaphylaxis is very unnerving to say the least. It is very important to educate your child (age appropriate) and all teachers and caregivers about how critical it is to keep your child from being exposed to the allergen.

One case comes to mind of a school aged patient who was at Costco with some friends. The child was allergic to nuts. The friends parents allowed him to taste something from one of the samples. They had done a cursory check of the ingredients and thought it was safe. It turned out the the knife used to cut the samples had also been used to cut something with nuts, and the child ended up in the ER. Some kids are so sensitive that cross contamination (in this case, the knife) can cause a full reaction.


Here is another story of one of our patients with an anaphylactic reaction:

This little 9 month old was already teething and fussy, which complicated things. She also is prone to eczema, so rashes are not unusual. The family had had a recent checkup and had come home motivated to increase solids and calories to fatten up their slender child. Dinner that evening was some Chinese take out. Our little patient was offered bits of foods from the various containers. They didn’t offer any foods that struck the parents as obviously new, but one of the containers was a shrimp dish. Although the baby didn’t actually eat any shrimp, she started to get very fussy and swiping at her face and ears.

After several moments of excessive fussing from no overt cause, mom and dad opted to give her a bath and start the bedtime process. When they removed her clothing they saw that she was covered with hives. At that point they wisely opted to go into the ER. It had been about 20 minutes since the food. The baby was fairly inconsolable and her face and ears were swelling. Luckily she did not appear to be having labored breathing (that would be a reason for a 911 call.) Once in the ER she vomited. She was given epinephrine and kept overnight for observation. She was singing and happy the next morning with no seeming ill effects. The current plan is to avoid any mystery foods and follow up with an allergist within a few weeks. The family will have an epipen on hand just in case.

As a caution, I recommend to try all first time foods when there is time to observe for a little while to make sure there is no reaction. Giving something brand new and then putting a baby straight to bed is not a good plan. This is especially important with high risk foods like nuts, milk, eggs, shellfish, and any medication. It is also a good idea for every household to own Zyrtec liquid (scroll down for dosage chart.)

If your child is old enough,talk to them about the fact that just about everyone has a little something special going on, and it their case they need to be careful about whatever their trigger is. Check out this book, available on Amazon. Perhaps pick one up for the class and make sure the teacher reads it out loud. No Nuts for Me

Make certain that any babysitters or friends caring for your child know what allergens are potential hazards so that they can be certain to avoid them They should also have an injector handy just in case.

If you go to a restaurant, ask to speak to the chef so that you know the restaurant understands the importance of avoiding the ingredient in question. In serious cases, you might want to call ahead to make sure they are willing and able to accommodate you.

If your child has any mystery reaction to something, it is worth having a visit with the doctor so that we can help pinpoint the cause. In some cases we will refer you to see an allergist. Mild allergic reactions can be treated with a dose of Zyrtec or Benadryl. Keep in mind that Benadryl might make some kids sleepy and it could muddle your assessment. For an anaphylactic reaction epinephrine is the only first line treatment. It relaxes the muscles in the lungs to improve breathing. To quote Dr. Fast, a local allergist, “Epinephrine is what saves lives. It is never wrong to give epinephrine."

One of my mom readers shared her story with me after this post first went out. She recently spent five days in the hospital due to an allergic reaction. She had 4 of the 7 symptoms (including full body hives), but was NOT given epinephrine early because she wasn't having respiratory distress. It took several days to get the allergic reaction under control.
Not only does epinephrine help with the respiratory distress, but it lessens the release of the chemicals that are causing the reaction in the first place. The world health organization  would agree with Dr Fast that using epi early is a "no Brainer"

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666145/

Auto injector options


Epipen comes in 2 strengths. The junior (0.15mg) is for anyone under 66 pounds. Anyone over 66 pounds gets the full adult strength (0.30 mg) .Epipens have been in the news due to high cost and recent shortages. If you have an epipen, check out the lot numbers, some of them have extended their expiration date


Auvi Q is a competing product that I always preferred. I liked it because it is flat and easy to stick in a pocket. It also actually talks you through the steps. When you are in the midst of a patient having a reaction, that can be more helpful than you would imagine. It was recalled several years ago due to trouble with the needles. I was thrilled to find out that AuviQ is available again, and believe it or not...drum roll please…. It has a ZERO copay to anyone with commercial insurance or a household with income less than $100,00.00.

Auvi Q comes in 3 strengths:

  • 0.1 for infants from 16.5-33 pounds
  • 0.15 children 33-66 pounds
  • 0.30 for anyone over 66 pounds

It is NOT available in stores, you need to go to the Auvi Q website and download the prescription. Have your doctor sign and fax it over to them and they will deliver it directly to your door: https://www.auvi-q.com

The customer service phone number is on the website and I found them extremely helpful.

Regardless of which one you use, the auto-injector should be administered into the upper outer thigh. It can be given through thin clothing. The leg should be restrained and the injector should be held against the thigh and then compressed, rather than jabbing it.

In the case of a severe allergic reaction, give the immediate dose of epinephrine but then head over to the ER for some observation. It is possible for the symptoms to rebound. This is called a biphasic reaction. Hours after a patient seems stable, the symptoms can flare up again. Since it is always better safe than sorry, keeping a close eye on the patient is essential for the next 24 hours

Children with reactive airway disease and/or eczema are more at risk for allergic reactions, but they can happen to anyone.

No, of course not everyone needs to carry around epinephrine, but it is SO important to recognize the symptoms and act quickly if you are concerned about the possibility of an anaphylactic reaction.

There is a law, SB 1266, effective January 1, 2015, that mandates all schools keep an epinephrine auto-injector on hand and that someone on site has been trained. Check with your child’s school to make sure that they are complying.

Zyrtec Dosage Chart

The dose of cetirizine depends on age as below:

  • 6 - 12 months of age2.5 mg given once daily (maximum dose 5 mg daily)

  • 12 - 24 months of age2.5 given once or twice daily (maximum dose 5 mg daily)

  • 2 - 6 years of age2.5 - 5 mg given once daily (maximum dose 5 mg daily)

  • Over 6 years of age5 - 10 mg given once daily (maximum dose 10 mg daily)

Zyrtec comes in a 1mg/ml solution (so 2.5 mg = 2.5 ml). There is also a 10mg/ml oral drops preparation (so 5 mg is 1/2 ml). Make sure you check the strength of the solution.

Friday, August 24, 2018

2018/19 flu season and vaccination information



Here is information about the flu vaccine for the upcoming 2018/19 season:

Some flu seasons are worse than others. It is important to keep in mind that influenza is one of the deadliest vaccine-preventable childhood diseases. Each year, influenza kills more children in the United States than meningococcal infection and whooping cough combined.

The 2017/18 season was a nasty one. According to statistics from the CDC, last years season set the record for the highest number of flu-related deaths in children reported during a single flu season (excluding pandemics). Approximately 80% of these deaths occurred in children who had not received a flu vaccination for that season. One hundred and seventy two children died.Thank goodness I don’t know of any local children dying, but in our office at Noe Valley Pediatrics, we had a fairly large number of kids who ended up with pneumonia as a consequence from the flu. Kids were SICK! So were the parents.

It is recommended that all children over the age of 6 months get the flu protection. Infants can’t get the shot until they are 6 months old. If you have a baby at home who is too young to get vaccinated for the flu, please take extra care to make sure that all the household contacts are protected so that you don’t bring the virus home. Children, especially those younger than 5 years, are at higher risk for serious flu-related complications. Folks of any age with chronic health problems like asthma, diabetes and disorders of the brain or nervous system also are at higher risk of serious flu complications.

Children under the age of nine, who are getting the flu vaccine for the very first time, need to receive two doses of the vaccine in order to be considered fully protected. The first dose “primes” the immune system; the second dose provides immune protection.The two doses need to be separated by at least four weeks. Over the years I have seen patients who have had only their first shot come down with the flu. One dose will not fully protect them.

If your child has ever had more than two previous doses of any flu vaccine, they only need one this year. It takes about 2 weeks for the shot to take effect. Children under the age of three get half of the adult dose. The nasal flu mist is still not being recommended because studies show that it doesn’t protect as well for the H1N1 which is once again expected to be one of the strains going around this year.

Every year the disease trackers do the best they can to predict which strains of the virus will circulate and try to match the flu vaccine to the anticipated strain. Typically the vaccine changes from year to year. This year's vaccine is not the same as last seasons. Some years have better matches than others.

Last season we saw plenty of people get the flu and have a miserable week. The media was claiming that the shot was not terribly effective. There were indeed some vaccine failures but the folks who had the flu shot did not seem to be nearly as ill as an unvaccinated person. In our office almost no one got the late season B strains if they had received the shot. It didn’t seem to be as much as a barrier for the A strains. We actually had a few folks who got the flu twice with different strains. I don’t remember that happening in the past. Starting Tamiflu quickly seemed to help.

Let's keep our fingers crossed that this year has the magic combination. Our office will again be supplied with the quadrivalent vaccine that covers two A strains and two B strains. All of the flu vaccine in our office is preservative free. For any of you interested, the strains in the quadrivalent vaccine for the 2018/19 season are:

- A/Michigan/45/2015 (H1N1)pdm09-like virus
- A/Singapore/INFIMH-16-0019/2016 (H3N2)-like virusa
- B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage)a
- B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage)
aIndicates a strain change

Since we never really know when the flu season will start with a vengeance, getting your child vaccinated early in the season is your best bet. The manufacturers claim that the protection is supposed to last through the entire season. My personal sense is that it does seems to lose it's oomph after 7 months or so. As soon as a baby turns 6 months old we can get them started with their first dose. Because we don’t have experience with this particular flu vaccine, I don’t have a sense of what kinds of reactions to expect. We don’t generally see any major reactions but every year it is different. Last year some of our patients had low grade fevers for a day or two, but for the most part the vaccine was tolerated very well. A day or two of fever is still better than a full-blown case of the flu.

If your child has a sensitivity to egg, it is okay to give the shot, but we want to be cautious. I would recommend that you keep the patient in the office for at least half an hour or so to make sure they aren’t having any issues. Please advise the nursing staff if you have any concerns. I have been giving flu shots for almost 30 years and in that time I have only seen ONE patient with an allergic reaction to the vaccine (and that patient has no history of egg intolerance, so you just never know.) This happened several years ago. The patient left the office and started complaining about an itchy feeling throat. Mom brought him right back in and he got a dose of epinephrine. I am sharing that as a reminder that it is important to keep a close eye on your child for at least 30 minutes after the shot. If they seem to be having any breathing issues or exceptional fussiness they should get checked out immediately (an emergency room is the best choice.)

The safest way to prevent having an issue with a potential shortage is to get the shot on the early side. Fortunately we had plenty of vaccine right up until the end this past season. That isn’t always the case and it is impossible to predict. In some years there have been delays and shortages with the supply, but so far everything seems like it will be smooth this season. We have already received our first shipment of the vaccines. For Noe Valley Pediatrics patients we will be booking flu shot appointments starting September 5th. The appointments will be available on Tuesday, Wednesday and Thursday from 10:00 until 11:30 am and then from 2:00-4:00 pm. Call the same day for an appointment. Please understand we can only manage a set number of patients on any given day. Flu shot appointments are for shots only. If you have a reason to see the doctor, it is important to have an appointment on the main doctor schedule. I tell parents that “we can add a shot to any doctor appointment, but we can’t add a doctor to a shot appointment.” If your child is especially fearful of shots, let us know in advance and we can schedule a longer visit for them during office hours.

If your child isn’t feeling well, ideally we would wait until they are better before giving them the shot. That is another reason to plan to get it done early. Last winter when we were late in the season with a scary flu circulating, we did end up giving the shot to kids who were already a little sick. They were just fine, but it isn’t my first choice.

We will be holding several evening flu shot clinics throughout the season. I will post about the dates as soon as they are firm. The first evening clinic will likely be mid September.

When you come for a shot appointment, it is helpful if your child is wearing short sleeves or clothes that will allow us easy access. We can offer ice packs by request. Give yourself a bit more time for some icing in advance. The shot usually doesn’t hurt too much but an ice pack gives some kids a little boost of confidence.

We will not be offering immunizations to parents during normal business hours because the staff is usually too busy. You may be able to get the shot from your place of business or from Walgreens and save a few dollars, but for your convenience, we are happy to immunize parents during the evening clinics. Parents will be charged $45 at the time of service. We will not be billing your insurance. We are happy to give you a bill that you can submit on your own.

I will update vaccine supply and any info about the clinic dates in my weekly emails and also on our Facebook page. I will also let you know what type of reactions I am seeing, and what the actual flu looks like when it starts knocking on the door this season.

Click below for the 2018 Flu Vaccine information statements from the CDC. This is the same statement that has been active since 2015. They did not feel that there were any significant changes to report.


Friday, August 17, 2018

Dealing with Motion Sickness/Something new on the horizon



It is not unusual for us to get calls from folks who have a child or family member that suffers from motion sickness. Females are more likely affected than males. People who suffer from migraines tend to be especially susceptible. While the majority of people who have the most issues with this are between 2-12, some younger babies seem to have trouble as well. We have some unfortunate moms who have babies that vomit every time they go out in the car.


If you know in advance that motion sickness is an issue, here are a few natural remedies that you may want to try. If you are someone who deals with this a lot, you will have plenty of car rides ahead to do your experiments and see what works for you.

Getting fresh air by having a window open is the first course of action. Do some distraction by playing a game that has your child looking out the window. Experts say to specifically look at the horizon. For those kids who are not super sensitive, you can play some 'I Spy' games. See if you can find interesting license plates or different colors or letters on signs. Don't sabotage your trip by bringing along trip activities that have your child focusing on things inside the car. Even the best passengers might be fine until they start reading or looking at a phone or map.


Most kids do best when their tummies are not too full or too empty. Little crackers to snack on might be useful.


There are wristbands that provide pressure to some acupressure points that seem to give relief. You can find these on Amazon. There are several brands. A popular one is called sea-bands. They come in multiple sizes and colors. Otherwise simply massage the wrist and lower arm area. The magic spot is located on the inner arm about 1.5 inches above the crease of the wrist, between the two tendons there.


Ginger seems to be very helpful. For older kids, there is a ginger gum specifically made for nausea (also available on Amazon). Find your favorite ginger cookie or candy. Trader Joe's has a wide assortment. Of course don't give anything to a young child that might be a choking hazard. Check out ginger lollipops (often marketed towards pregnant women.)


Motion Eaze is a topical aromatherapy that some folks swear by. You just dab a drop behind the ears and it provides relief within a few moments. Don't do this one for the first time before you embark on a long car ride. The smell is fairly pungent and other folks in the car might have a hard time with it. If you prefer not to apply a scent directly, there are several essential oils that have been found to help with nausea. Peppermint, spearmint, ginger and lemon are all on the list. Consider letting your child chose the favorite scent. You can apply a few drops to a cotton ball and put it in a baggy. The kids can take sniffs whenever they feel the need.


Hylands and Boiron both make a homeopathic motion sickness remedy. As with many homeopathic remedies they gets mixed reviews. Homeopathy does seem to be the ticket for some folks, and is unlikely to cause trouble as long as it is used as directed. It might be worth a try. My husband likes to cry "placebo"
I say, "Bring it on, whatever works!"


If you are going on a long car ride, plane ride or boat trip and you have struck out with the natural remedies there are some medication options. Benedryl is an antihistamine that often works quite well for motion sickness. It comes as a liquid. The bottle says for children over the age of 6, but in our office we do use it for younger kids. The dose usually agrees with the tylenol dose volume. Kids over 22 pounds would get 5 ml or one teaspoon. Always check with your own doctor's office to see what their policy is. Benedryl makes most kids sleepy, but don't count on that. It gets some kids hyper. You probably don't want to find that out on a cross country flight.


Dramamine is another choice. It is an over the counter medication specific for motion sickness. Children 2-6 years of age can take ½-1 tab; children 6-12 years of age can take 1-2 tabs. These chewable tablets can be repeated every 6 hours, no more than 3 doses in a 24 hour period. Start with the smaller dose first to see if it works. Giving the dose 30-60 minutes before travel is recommended. For kids over 6, Bonine is another reasonable choice. This medication can be given at the first sign of nausea and is less sedating.


For patients over the age of 12, if all else has failed some people use a scopolamine patch. This is a much stronger prescription medication that I would never use as a first line drug. Some of my motion sensitive older patients have found these valuable for cruises.


Luckily, kids do tend to grow out of it...except for an unfortunate few. If you or your child have chronic motion sickness issues, it can be eye related. Cover one eye for several moments to see if the symptoms ease. If this works, you may have something called vertical heterophoria. It is worth having a consult with an eye doctor. My favorite eye expert in this is Dr. Vincent Penza


Some people with chronic motion sickness have also gotten relief from chiropractic treatment.

There is a new product on the horizon that got my attention. The media is abuzz about special glasses that have been reported to be real game changers for folks who have tried them.

Unfortunately, I haven’t been able to find out how to get them in this country quite yet. If you are interested, it seems that pre ordering a pair is possible if you have connections in Europe who are able to send them to you.
In the meanwhile, if you or a family member suffers from this very annoying ailment, See if any of these other methods will help you out until those magical glasses become available

If you are on a car ride, assuming the kids are old enough to comply, have them try very hard to give you as much warning as they can. Ideally they should try to get in the habit of warning the driver at the first twinge. The initial signs are usually paleness, yawning and restlessness. They may feel a little sweaty. This is quickly followed by the nausea and vomiting. With enough warning you might have time to pull over and get them out of the car for a couple of moments until the motion sickness eases. Being stoic is not a good plan; it usually backfires.


In my car, I actually kept barf bags in the glove compartment. I used to collect unused ones from my airplane travels.They may come in handy. If you don't have an actual barf bag, have a container or plastic bag that you can whisk out at a moment's notice.


Your trunk should be prepared:

A change of clothes (don’t forget socks)
A clean towel
A plastic bag for putting the soiled clothes in
Some wet wipes
A lollipop to get the yucky taste away
Febreze for cleaning off the seats (you will bless me)


While kids are usually the ones most apt to barf in your car, motion sickness can afflict any of us at different times. I hope that some of these tips can help you out.

I remember my days as a carpool driver.
One of my little passengers had Emetophobia ( fear of vomiting) and would quite literally open the car door and leap out if anyone so much as made a gagging noise. It kept things interesting!