Friday, April 12, 2019

There is no such thing as a silly question!


Let me tell you a story...

I was a nurse with a few years of experience under my belt when I moved to San Francisco. I was promptly hired at UCSF, which was, and remains in my experience, an excellent hospital. UC, because of its excellence, is a center where patients with many of the more exotic and hard to treat conditions are sent for care.

On one of my first days on the job I was getting report from a nurse; I don’t remember much about her and don’t know that I ever interacted with her again. She was passing along information about a patient who would be under my care for the upcoming shift. This little guy had an unusual illness with a long complicated name, no doubt named after the folks who discovered it. For the purposes of this post, and since I have long forgotten what it was, I will call it Hughie, Dewie and Louis disease. Here is the thing - this wasn’t something that I once knew and had forgotten. I had never, ever heard of it. Not even a glimmer of an idea.

“ So, Your patient X has HDL disease...These are his orders”

“Hold on a moment, What is HDL? I am not familiar with it.”

There was a pause and maybe a sneer

“You haven’t ever heard of HDL?”

I imagine that this was my opportunity to get a bit shame faced and say, "Oh! HDL, of course" and continue to get the report, but I don’t work that way. One of the things I respect the most in a person is to be comfortable with what they don’t know. Now, it is easier than ever to get educated. This was long before the days where I could pull out a phone and simply google it. This was now a game of poker. Some of you may not know, but Nurse Judy plays poker in Vegas.

“I have never, ever heard of it. Can you please tell me a bit about it so that I can take better care of the patient?"

She doubled down, I think she had come too far to save face and was hoping I would cave first.

“How long have you been a nurse? Where have you worked before this”?

“Is there anyone here who can tell me a bit about HDL?”

There was a resident sitting there who was happy to tell me all about this very rare condition. EVERYONE in the break room was hanging onto every word. Is it possible that no one had dared to ask? That was an isolated case at UC, but I carried the lesson along with me.

If I am talking to a parent and they are confused about a dose, a diagnosis or anything, the LAST thing I want is for someone to be embarrassed that they aren’t “getting it” and accept the information without clear understanding.

No one knows everything. As parents this is a good lesson to pass along to our children. Being comfortable enough to acknowledge what we don’t know and learning how to find the information we seek are important skills.

Friday, April 5, 2019

Ear Infections/to treat or not to treat





As an advice nurse at a busy pediatricians office, talking about ear infections (medical lingo otitis) is among one of the more frequent calls I deal with. I feel a pang for the stressed out, busy parent who would love to throw some magic medicine at the issue without an office visit. I know it is hard to take off time from work. Alas, it isn’t so simple.

Ear infections come in different varieties and complexities. Not only is there is not one standard treatment, but many times no treatment is even needed. Some stoic kids don’t make a noise about a severe infection while others complain bitterly about a little fluid in the ear that is not actually infected. If we blindly treated every complaint about an earache, we would be wildly over prescribing antibiotics. A special instrument that looks in the ear is often needed to make a true diagnosis. Factors like lots of ear wax, or an uncooperative patient can add a level of complexity to the exam. If a patient is screaming bloody murder from the simple exam, that can make the eardrum appear redder than normal.

The most common ear issues that we see are:

Otitis media (a middle ear infection)
Severe cases are treated with antibiotics

Serous Otitis (fluid behind the eardrum)
This may be treated with decongestants or in chronic cases with ear tubes

Otitis externa (also known as swimmer's ear)
With otitis externa the outside of the ear is usually red and sore. The ears may be tender and will look inflamed. With summer coming, I usually see an increase in these cases, with more kids being in water or pools.

While the first two forms of otitis require a tool for diagnosis, otitis externa may be visible by just looking with the naked eye. This condition may be treated with ear drops rather than oral medications, depending on the severity.

Some kids make it obvious. If they are old enough, they may simply tell you that their ear hurts. If they are still young and nonverbal, they may be extra fussy (especially when put down) feverish, or tug at their ear. Many kids wake up more than usual at night. Most of the time kids are congested. Sometimes vomiting can be associated with ear infections.

Some kids seem like their balance is off. Others seem like they are having trouble hearing (I know I know, all of our kids can seem deaf when we are telling them something they don’t care to hear!)

A good number of kids don’t let you know at all. We have had patients in the office for a well child exam and have been caught by surprise when a routine ear check revealed a raging infection. I have also seen ear infections go from ‘zero to sixty’ in no time flat. A child with a perfectly normal ear exam one day can have a horrible ear infection the next.

Most of the time, an infection in the middle ear accompanies a common cold, the flu, or other types of respiratory infections. This is because the middle ear is connected to the upper respiratory tract by a tiny channel known as the eustachian tube. Germs that are growing in the nose or sinus cavities can climb up the eustachian tube and enter the middle ear. Children’s eustachian tubes are smaller and more level than those of an adult. This means it is harder for them to drain well and easier to get blocked up even with mild swelling. Because of these drainage issues, when kids are congested, they also may have fluid in their ear (serous otitis). This is why I am more suspicious about a possible ear infection in a child who has a cold. What may start out as a virus can turn into something bacterial. That fluid is the perfect medium for bacteria to grow. I compare it to a stagnant pond just waiting for the mosquitoes to breed.

Kids with chronic serous otitis who get one infection after another will usually end up at the ENT doc who may put some tubes in the ear to help them drain. Melissa Wilson, Doctor of Audiology at Sound Speech and Hearing, adds that tubes are also put in to address the hearing loss that often accompanies middle ear fluid. Fluid build-up often causes a hearing loss on the order of 30-40 decibels. Average speech is about 60 decibels, so having fluid is like listening with your fingers plugging up your ears. Everything your child hears is muffled and over time, this can impact their speech and language development, and for the school-aged children this can cause issues with listening in the classroom and academics.

An important thing to note is that when kids have goopy eyes, many times they also have an otitis, which is why we may bring them in to check out the eyes and the ears rather than just giving eye drops over the phone.

Just because your child is tugging at their ear does not mean they have an infection. Some kids do it as a habit when they are tired, Others do it when they are teething (especially upper teeth.) Nevertheless, It can be a clue that is worth paying attention to, especially if it accompanies any other symptoms. I realized after the fact that I had ignored my daughter Lauren’s first ear infection for more than a week when she was fairly young. Looking back at videos you can see the poor kid simply grabbing at her ear constantly. This was a long time ago, prior to my Noe Valley Pediatrics job, when I was working at UCSF with complicated surgical cases and thoughts of an ear infection didn’t even cross my mind.

If your child is diagnosed with an ear infection, chances are you will get a prescription for antibiotics. No one likes to overuse antibiotics, but If your child is miserable and feverish, I would follow through with the treatment. If the eardrum is bulging and looks like the membrane may rupture, the doctor will advise you that you should absolutely go ahead with the medication regardless of how your child is acting. On the other hand, if it is not a severe infection and your child seems consolable, in our office we may suggest that it is perfectly fine to watch and see for a few days. Many ear infections can indeed clear up on their own and of course we all would like to avoid the use of antibiotics if we can. My main agenda, aside from making the kids more comfortable, is preventing an eardrum from rupturing. This does happen and we can’t always stop it but we avoid it when we can. An eardrum that ruptures frequently can become scarred and this can lead to hearing loss.

A miserable screaming child might actually seem more comfortable after the eardrum finally bursts. They will also likely have lots of yellow/orange stuff draining out of the ear. The good news is that the pain of the pressure in there is gone, but the tympanic membrane (an important protective barrier) is no longer intact. Therefore, if your child does have a ruptured membrane, they need to be seen and treated even though they are no longer quite as fussy. After a rupture (certainly if there is more than one) it is worthwhile getting the hearing tested to make sure there is no lingering hearing loss after the eardrum heals.

If the treatment plan includes a course of antibiotics, make sure that you finish the entire course of medication. Most pharmacists will take a moment when you pick up the prescription to go over the directions. Don’t treat them the way we do the flight attendants who are telling us how to buckle a seat belt. Pay attention and please make sure you are clear with the dosing instructions including whether or not the medicine should be taken with or without food. Some require refrigeration. Some might cause extra sensitivity to the sun. Make sure you are familiar with what you are giving your child. Please don’t forget to brush those teeth. Liquid antibiotics tend to be sticky and sweetened in order to make them more palatable.

Some pharmacies can add flavors that might help with compliance: https://nursejudynvp.blogspot.com/2017/02/tips-for-giving-medicine-old-spoonful.html

It may take the medication at least a couple of days before you notice a significant improvement. If your child is still super fussy or feverish after a full three days, have your doctor take another look in there to make sure the meds are working. Some kids who are having a really difficult time may end up getting an antibiotic injection. These hurt a bit, but they are usually quite effective.

With or without the use of antibiotics there are several things you can do to ease the discomfort of a painful ear. Tylenol and/ or Ibuprofen are useful. There are some prescription ear drops that can numb the ear, but they have some possible negative side effects, so most doctors no longer prescribe them. Warmth usually feels good. Try a warm wet washcloth against the ear. You also can put some rice in a sock or pour water into a clean diaper, heat either of those up in a microwave for a quick heat pad that will stay warm for a while (heat in 30 second increments to make sure they don’t get too hot.) Some folks swear by a warm hair dryer held about a foot away from the ear. Believe it or not though, my favorite remedy is garlic oil. Check the ear to make sure there is no reason to suspect a rupture; I don’t like to add any drops if I have any suspicion that the eardrum may not be intact. If there is no odor or drainage (a little wax doesn’t count) garlic oil may be a good option. Saute some cloves of garlic in some olive oil. Let the oil cool until it is warm/not hot. Take a cosmetic square (these are the round or square cotton pads that often come in a stack. I like them better than cotton balls for this.) Dip one half of the pad into the oil, roll it up like a scroll and stick it in the ear. Do this as often as your child will allow. If it is the middle of the night and your child is screaming, you can try any of these pain relief options until you have an opportunity to have your child checked. Persistent unrelenting misery may warrant a trip to the ER.

It is not unusual for us to find a little surprise when we look in the ears. I kid you not, we have found little beads, unpopped popcorn kernels, and even the occasional insect.

Friday, March 29, 2019

Chickenpox/Shingles exposure guide




Chickenpox/Shingles exposure guide

Zoster is one of the eight herpes viruses known to infect humans. The primary illness is varicella zoster, more commonly referred to as chickenpox. After the course of the chickenpox illness, the virus goes dormant in the nerves. It can resurface years later as Herpes Zoster, more familiarly known as shingles.

While there have been some exposures at various schools, I haven’t had an actual case of chickenpox among my patients for over a year. These days I get way more calls about shingles than I do about actual chickenpox. Of course it isn’t my little patients with the illness. Usually it is a relative who has been diagnosed with shingles and the parents are wondering if it is safe to visit or if their child has been exposed. This post will give you the scoop about both Shingles and Chickenpox including exposure information.
Don’t try to read this when you are sleep deprived, it might make your head spin.

When the Varivax (chickenpox vaccine) came out in 1995, it took us a few years before we started giving it widely. We did an about face one season when we had hordes of chickenpox patients who were absolutely miserable. There didn't seem to be a sensible answer as to why we shouldn't simply give the shot to prevent it. The answer that "we had them and survived" seemed a little weak. While it is true that most chicken pox sufferers simply have a very unhappy week, complications do occur. Even the moderate cases can have painful lesions in the genitals and mouth. Some folks get them in the eyes and need round the clock eye drops. Some of the lesions end up leaving scars. At the very least you have a sleepless, itchy week and will need to take time off of work. One of the bigger concerns about the disease is the potential for future shingles. Here in California, as of July 2019, if you are going to be in the school system, 2 doses are now required before getting into kindergarten.

One of the best things about getting the chickenpox vaccine and avoiding the misery is the fact that studies indicate that future occurrence of shingles may be less likely in a patient who had the Varivax than someone who had the actual chicken pox. In all honesty that question probably won't be answered for another 40 years or so, when the first wave of kids who got the vaccine become middle aged. Keep your fingers crossed. At the very least, in our office, almost all of our patients are vaccinated and cases of shingles are exceedingly rare.

Infants are thought to have some maternal protection to the chickenpox virus that starts to wane when they are about 7 months. The protection is probably gone by a year. The first dose of the shot is usually given between 12-15 months. Unlike the MMR, Varivax is not recommended before the age of a year even if traveling or your child has been exposed. A booster is given between 4-6 years. For children playing catch up who are getting the Varivax for the first time, the minimum interval between doses for children 7-12 is 3 months. For kids who are over 13 the minimum spacing between the 2 doses is only 4 weeks.
If you are a parent who isn’t sure if you have had them as a child, there is a blood test that can determine if you are immune or not.

Kids are contagious a day or two before they get any lesions. They may have a low grade fever and be cranky. It is very likely that they are out and about in school, daycare or activities during this period spreading this virus to anyone who is not immune. It is what it is. No reasonable person expects you to keep your child home every time they are cranky. They remain contagious until all of the lesions have crusted over. That usually takes about a week. Most kids these days are vaccinated so there is good herd immunity working in our favor.
So there you were in the park, playing with patient X. You get an apologetic call the next day from patient X's parent that their child seems to have come down with chickenpox. If the kids were having close interaction with each other, it is likely that your child was indeed exposed. The chickenpox virus is very contagious. It is airborne and can live on some surfaces. If your child is vaccinated or already had the illness, you likely don't need to worry too much. The vaccine is about 85% effective, however the CDC bumps that up to 98% after the second dose. The rare vaccine failures tend to get much lighter cases. If your child in not immune you are now on alert.

From the first moment of exposure, the incubation period is usually 2 weeks but can range from 10-21 days. If 3 weeks go by with no sign of anything you are likely in the clear. Just because your child has been exposed is not a reason for you to keep them home from school or daycare and for you to miss work. They may or may not catch it. Someone who is immune is not likely to carry it.

If your child has been exposed, be on the lookout for any signs that your they might be succumbing. The words "I want to go take a nap now" may be a red flag. If they get a fever you should probably issue a warning to any friends or caregivers as you wait to see if spots appear. If your child does come down with it they are now patient X and were likely contagious a day or so before the first sign of a rash.

The chicken pox rash is pretty distinctive. Once the chickenpox rash appears, it goes through three phases:

  • Raised pink or red bumps (papules), which break out over several days
  • Small fluid-filled blisters (vesicles), which form in about one day and then break and leak
  • Crusts and scabs, which cover the broken blisters and take several more days to heal.

New bumps continue to appear for several days, so you may have all three stages of the rash — bumps, blisters and scabbed lesions — at the same time. They usually start on the trunk but then spread. When they scab over they are very itchy.


Be aware if you are traveling out of the country that there are many places in the world where vaccination for chickenpox is NOT routine. Dr Schwanke is frustrated that we are not supposed to give an early shot for travelers. Most of the cases we see now a days are folks that were exposed while visiting family abroad.

As I mentioned earlier, after you recover from chickenpox, the virus can enter your nervous system and lie dormant for years. Eventually, it may reactivate and travel along nerve pathways to your skin - producing shingles. It is most common in folks when they are older adults. It may be stress related. One easy diagnostic trick is that the blistery and usually painful rash will usually not cross the midline of the body. About 10-20% of folks who had the chickenpox will end up with shingles.

Shingles can be spread only if someone comes into direct contact with the lesion. A healthy person who has immunity to chickenpox is generally not considered to be at risk. Someone with a compromised immune system or someone who has never had the chickenpox needs to be a little more cautious. If infected, they would catch chickenpox, not shingles, from the infected person. Over the years we have had a couple of patients who came down with cases of chickenpox that we traced back to a shingles exposure, but again, that is most unusual. It is NOT airborne. If the shingles patient keeps the lesions covered you can still go visit grandma.

For those of you over the age of 50 there is a new shingles vaccine that looks quite promising. It packs a punch. This is a 2 shot series. Most people complain of a sore arm and feeling fluish (hit by a truck) That is still better than getting the shingles, as most people who have ever had it will tell you.

Friday, March 22, 2019

Cleaning up made simple 2019


Here is a post from several years ago that might help you out with your own version of Spring cleaning. If you start good habits early on, you will benefit on many levels.

Some time ago I had a phone chat with one of the moms in my practice about some behavior issues. Her daughter was 2&1/2. At home, there was an unpleasant amount of parental nagging and child tantrums.
Mom was astonished when she spent a few hours at her daughter’s daycare co-op. She watched in awe as the kids all immediately followed the request to clean up the toys. After lunch, this little group sat nicely, eating their healthy meal and then got up to clear their plates. What completely knocked this mom over was watching all of the kids line up to compost whatever food scraps there were. Composting! Really?!? As she told me, this was a completely different child than the one she had living with her. This is a really clear example of how important rules and consistency are. It is, in fact, not at all uncommon for kids to behave beautifully in some situations and completely act out in others.
If rules are clear and simple, most kids will follow them. As long as rules are in the child’s best interest and reasonable, kids thrive in a consistent environment. Kids need to understand what the rules are. If there are rewards/incentives what are they? What are the consequences for not following through? Once the kids are old enough, have them be involved in negotiating the new “official guidelines.” What do they think would be a reasonable consequence. Are there certain incentives that they would like to work towards?
How can you implement this at home? Think small. Not everything has to be regimented but let’s address one common area of conflict, such as cleaning up toys, and make it simple.
Easier said than done, but try to have an organized system so that putting toys away is straightforward. Know where they came from so that they can be returned to where they belong. If you can’t do that, you possibly have too many toys and you should take some of them out of circulation.
Large toy boxes/trunks are okay for really large items, but they tend to become a dumping ground. You are better off investing in shelves with different bins. Low shelves are for toys that kids can have easy access to. Have a designated high shelf area for setting aside toys that need adult involvement.
Take a photo of the toy that lives in the bin and glue the image on. This can be a family project. (Great rainy day activity!) Maybe the picture can include your child holding the toy. There can be a box for little cars, a box for dolls, a box for crayons...etc.
Perhaps have a rule about only 2 or 3 boxes being down at a time until your child shows you that they can manage cleaning up more of a variety. Sorting can be a game. Give a transition time:
“Ten minutes until clean up."
“Five minutes until clean up."
Some kids may do well with a timer.
Everyone needs to understand what the new clean up rules are:
  • When playtime is over, it is time to do the full clean up.
  • Put on some music or have a clean up song.
  • Children have a set amount of minutes to put the toys away.
While you might start out by helping out and setting a good example, the ultimate goal is that your kids can do this on their own. Make sure that they are doing most of the work. When the time is up, make sure you give positive feedback. The toys are safe and ready for the next time they want to play with them. If they did NOT clean up, now it is your turn. Anything that you clean up is yours to do with as you please. You can put it high up where the kids don’t have access until they agree to do a better job cleaning up. Tell some stories about children who did a good job cleaning up. Parents were so proud! Their toys stayed safe and organized. Tell a parallel story about a less successful outcome. Parent ended up doing the clean up and the toys went high up and away.
This process eliminates potential sources of nagging:

  • These are the clean up rules; they are clear and simple.
  • Cleaning up is easy. It takes a few minutes. It can even be fun!
  • Kids remain in control of the toys that they put away.
  • Or mommy/daddy can clean up but the toys are gone for a while.
Many of our kids have so much stuff (mine were no exception) that you may wish to consider rotating toys. If you take something out of circulation for a while it might feel new and fresh when you bring it back. Doing a toy swap with friends is another good way to have an assortment of things to play with that feel new and exciting. Keep in mind that some kids are rougher than others. Don’t lend out anything that you care too much about. It may not come back in the same shape that it went out! As Marie Kondo from the popular Netflix series would say, it if doesn't bring you joy, get rid of it.
Start small, be clear and consistent, problem solve so that you don't end up in nagging cycles to kids who ignore you. Who knows, the next step might be composting!

Friday, March 15, 2019

Standard and Alternative Colic Treatments


Among the most common calls I get are the ones about fussy, gassy babies (although I sure do talk about poop a lot; perhaps it's a tie.) Often these colicky kids have wretched periods during the late afternoon and early evening when it seems to be especially hard to settle them.

What is colic? Colic is typically associated with abdominal discomfort, but it has become a catch-all term for babies who seem uncomfortable and are difficult to soothe. With most of my patients this usually seems to improve, at least a little, once you hit the 3 month mark (keep your fingers crossed.)

If one of those gassy babies is yours and you are breastfeeding, the first thing I will ask about is your diet. I know that not everyone agrees that there is a connection, but in my case I swear to you that if I even looked at cabbage my kids cried for a week.

What I suggest you do is see if you can establish a connection between an extra fussy day and something that you recently ate. Yes, I have some moms that know perfectly well that coffee is a problem but drink it anyway because they can't face the day without it. As always, it is a balance. It is worth finding out if there is a connection between your diet and your baby's gassiness, but then make whatever choice works best for you. In my experience the biggest culprits are:

  • coffee
  • caffeine (in tea and chocolate among other things)
  • dairy
  • gassy foods (like cabbage, onions, broccoli)
  • spicy foods

If you are able to establish a clear link, you may be able to ease your baby’s fussiness with some simply diet tweaks.

The other thing that breastfeeding moms should pay attention to is hind-milk. The last bit of milk that the babies get as they empty a breast is helpful with digestion. Sometimes greenish stools (not necessarily something that I worry about) and increased gas issues are because they are switching breasts too soon and never getting to that valuable hind-milk.

Make sure you have a good latch. If you have concerns about this, finding a lactation consultant who you feel comfortable with can be very important. If a baby is not latching well, they can get more air in as they gulp, and that leads to more gassiness.

If you haven't found any magic cures from a diet elimination or adjusting the latch, it is perfectly fine to experiment with some different colic remedies. Simethicone is the ingredient found in most of the OTC gas drops that you can get at a drugstore. Some of the name brands are Mylicon or Little Tummies. Simethicone drops are very safe and helpful in about 70% of my patients. The gas drops are certainly worth a try.

Homeopathic colic remedies come in a few products. I am most familiar with Colic Comfort drops (made by the Boiron company with new name) and Colic Tablets by Hylands. These seem to help about 60% of the time. I consider them fairly harmless if used properly. They too are worth having in your arsenal. Grippe Water is an herbal remedy that can be found in many health food stores or Whole Foods. I find this helps about half of the time. Stools might get a bit green with this (not to worry.) Brew some chamomile tea, add a few grains of sugar and give a dropperful or two to your baby. This also helps about half of the time. Remember not to add honey or give your baby any products that contain honey.
Colief is a product specifically for babies who may have a lactose intolerance. Regardless of the directions on the box, it is fine to administer directly to the baby without mixing with breast milk. If you are going to give this a try, you need to make sure you give it with each feeding for a few days to see if it is helping. (You may have a couple of months of colic ahead of you; you will have plenty of time to try all of these.) Dr. Schwanke once speculated that part of the reason any of the above remedies work is because they have sugar in them. I think there is probably more to it than that.

PROBIOTICS


Evivo is something fairly new and worth paying attention to.https://www.evivo.com/


There are many strains of probiotics, but this one has something called B.Infantis. In perfect circumstances a baby would have proper levels of this strain naturally. The research has found that the transfer of good bacteria from mom to baby during birth is not always happening as it used to. Antibiotic usage in this day and age is likely responsible for this change. Babies born via C-section are even more likely to be missing the B. Infantis that babies born vaginally are exposed to.
Without the B.Infantis in the baby’s gut, bad bacteria can thrive. Some of the unwanted bacteria are linked to a higher risk of short and long term health issues like colic, eczema, allergies, diabetes and obesity. Evivo is mixed with a bit of breast milk and given daily. Babies who are digesting the milk properly are less likely to be gassy and fussy. Babies tend to have less frequent stools on the Evivo. You will likely notice a change on day 3-5. Evivo is specifically formulated to be used in conjunction with breastmilk, but they have gotten some good reviews from parents of babies on formula. A baby on the B. infantis probiotics has an 80% positive change in their gut bacteria.
At this point the best way to get evivo is through their website. It must be kept in the refrigerator so they are careful with the shipping. Enter COUPON10 for $10 off a 4 week starter kit; Enter COUPON20 for an 8 week supply.



Soothe probiotics drops: This is yet another strain of probiotics being studied called L. Reuteri. These claim to cut crying time by 50% after a week of use. They should be given daily.

There is no potential harm in using both kinds of probiotics if you are already on one and still dealing with some gassiness.



Dr Loo’s Chinese medicine patch.
We were fortunate enough to meet the inventor Dr. Loo and do some beta testing on some of our patients. I had positive feedback.

These little patches are simply applied over the belly button area.


Don't forget about massage! Go online and check out baby massage techniques on YouTube or take an infant massage class. Make gentle clockwise circles on the baby’s palm with your thumb. Bicycle their little legs. Doula Jennifer from the Golden Gate Doulas reminds her clients to really move those little legs, The thighs should push all the way up to the belly. (Don't force this)
Get up and dance. Hold your baby over your shoulder with their knees tucked up in fetal position. Give firm pats on the back. Sway, bounce and sing. (I teach the "shuffle" at my baby boot camp class.) Warm (not too hot of course) baths are very soothing for some babies.


Windi
When I updated this post a few years ago, Mama Val chimed in to tell me how much she loves this product. At that point I didn’t have much feedback about it. I had some samples sitting on my desk for months. I offered it to no avail. “Stick a tube in my kids butt? I don’t think so!”
But it does work. Now that is is on this list, I have had many parents use it and swear by it. Obviously you need to be very gentle when you insert it. If it feels like you need to force it, stop right away. When you doing it properly it should slide in easily and not cause any more discomfort than taking a rectal temp.


Ready to think outside the box? Advanced Allergy Solutions (http://aasclinics.com ) treats babies as young as 2 weeks old and has success with colic. Their services identify possible foods your baby is reacting to through breast milk or formula and then helps resolve these sensitivities naturally to relieve symptoms.Their treatment is completely non invasive. I have seen them work what seems like complete magic on some of my own family members for things like cat allergies. I don't completely understand how it works, but I have seen them make a big difference.

Craniosacral therapy and chiropractic treatment has been helpful for some of our fussy babies. My favorites is Sandra Roddy Adams 415-566-1900. As Sandra says, It is the rare baby who manages the birthing process without some alignment issues. Here is a nice link that talks about the safety and usefulness of a chiropractic treatment.

Acupuncture is another option. Den Bloome Bremond sees patients as young as newborns.

Here is a message from Den:
I’ve been seeing so many babies with colic over the last handful of months. They respond really well to acupuncture (and the various modalities I use). I have a very safe herbal tincture which some of my moms are really grateful for. I also teach parents a few simple massages they can do at home to help soothe their fussy babies.

Some other things I have been seeing a lot of lately: constipation, night terrors, coughs/colds/flu/ear infections, stress/anxiety, ADHD/ADD, headaches, stomach aches, asthma.


The migraine connection
Interestingly, recent evidence suggests there may be a relationship between infant colic and migraines. Mothers with migraine are more likely to have a colicky infant, and colicky infants are more likely to grow up to have migraines as adolescents.

If there is a family history of migraine, it is possible that migraines could be playing a role in your baby’s colic. If there is a family history of colic, think about things like how to limit light and sound stimuli etc during the evening "witching hours". 

Here are a few suggestions for overwhelmed parents from the folks at the Parentline:

  • Allow yourself emotional space: Cry, vent to friends/family/partner or professionals. It is okay to be honest
  • Avoid anything that makes your feel ineffective as a parent, including advice from people, books and the web that do not apply to your or your baby.
  • Find the helpful help: Who can relieve you for a bit to give you time to sleep, eat, take a bath or do anything else you like-no strings attached?
  • Acknowledge that this will pass. Being with your baby during the trying times is just as important as sharing in the joyful moments.
  • Call the Parentline: The is a free service sponsored by University of San Francisco. They are there to listen and support you. 1-844-415-2229


There are lots of experts who are convinced that the worst of the colic cases slowly build up to the 6 week peak and then slowly subside. As mentioned earlier, by the time three months comes around, most of our families can see the light at the end of the tunnel. One study that I read years ago postulated that kids with lots of colic symptoms ended up with higher IQ's. Hold that thought....


As with everything, this stage will pass. Enjoy the calm moments. If you have tried everything on the list and your baby is still very uncomfortable, I would suggest that it is time for an office visit with your primary pediatrician.

Friday, March 8, 2019

SF School vaccination requirements /effective July 1, 2019

New vaccine requirements for school

March 3-9 is Preteen immunization week.
In our office, March is also the time when we start opening up the schedule for routine checkups that have been put off due to the winter illness season. I am hoping that the colds, coughs and flu have the courtesy to take a break now; alas this week that hasn’t been the case. When you come to the office for your annual exam, check to see if there are any school forms that you need for school entry next year. We waive form fees for most paperwork that is done in conjunction with a visit.

There are some new changes in the school requirements that you need to pay attention to.

Effective July 1 2019
Here are the school requirements. These apply to all students admitted to transitional Kindergarten as well as Kindergarten through 12th grade.

Diptheria, Tetanus and Pertussis- 5 doses
4 doses are adequate if one was given on or after the 4th birthday. 3 doses are accepted if one was given on or after the 7th birthday. For 7th-12th graders, at least 1 dose of pertussis containing vaccine is required on or after the 7th birthday.

Polio - 4 doses
3 doses are okay if one was given on or after the 4th birthday

Hepatitis B - 3 doses
Everyone should have these before kindergarten however this is not a requirement for 7th grade entry. If you had waived this series early on, it is now time to seriously consider protecting your child from this disease. It is much more high risk as they move into their teenage years.

MMR - 2 doses
In order to count, both doses need be be given on or after the 1st birthday. Some folks do the second one early due to travel. That is perfectly fine. If you gave an MMR before your child turned one, that does not count towards the required 2 doses

Varicella (chickenpox) - 2 doses
This is new. In the past only one shot was needed.


California schools are required to check immunization records for all new student admissions for transitional kindergarten/kindergarten through 12th grade, and all students advancing to 7th grade, before entry. Parents must show their child's Immunization Record as proof of immunization.

Personal belief exemptions are no longer valid for school entry here in California: https://www.shotsforschool.org/laws/

Other pre-teen vaccinations that are not required, but strongly recommended:

HPV - 2 or 3 doses
The human papilloma virus is recommended for both preteen girls and boys. It prevents warts and more importantly several cancers of the reproductive system. The HPV vaccine works best when all of the doses are given well before the start of sexual activity, which can spread the HPV infection. Studies are suggesting that the younger you start this the better it works.

This vaccine is given as a series of 2 shots for kids who start the series before their 15th birthday. The two shots should be separated by 6-12 months. For folks who started it late, the 3 dose series has the second dose given 1-2 months after the first and the third dose 6 months after the first. The minimum interval between the first and second doses of vaccine is 4 weeks. The minimum interval between the second and third doses of vaccine is 12 weeks. The minimum interval between the first and third doses is 5 calendar months. If the vaccination series is interrupted, the series does not need to be restarted.

Menactra
Meningococcal vaccines protect against the devastating bacterial infection, meningococcal meningitis. The infection can lead to brain damage, arm and leg amputations, kidney damage, and death. It is more common among teens and young adults who are in close contact with others at home or school. Preteens need to get immunized now and again at age 16.

Flu
I know, the flu shot was no magic wand this year, but the folks who had the shots, while they still ended up with the flu, were not nearly as ill. Influenza can be deadly. During the 2017/18 season 80,000 people in this country died from the flu and flu complications such as pneumonia! Make sure your child has some protection. For the shot phobic out there (you know who you are!), keep your fingers crossed, but I am pretty sure the flu-mist nasal vaccine will be back next season.

Friday, March 1, 2019

Urgent Care options 2019

Urgent Care Options 2019

Murphy's Law generally seems to make certain that the fever spikes, or the vomiting starts, right at 5:01 pm when the average doctor's office turns their phones off. It is important to be familiar with your after hours/urgent care options. At the bottom of this post I have some blog links that may help you decide if you need to be seen or not. I put the dosage chart link down there as well since that is a common question that many folks have after hours.
Please try to keep track of any refill needs. We are happy to help with that during routine business hours.

Waiting until you or your child is ill is not the best time to start learning about what choices exist in your area. Does your insurance plan have a preferred option that won’t cost as much? Are there after hours advice nurses available? Where is the closest emergency room? Is it staffed with pediatricians? If you are traveling, plan ahead and figure out local options for care before the trip.

For Noe Valley Pediatrics patients who need help after hours, we ask you to start with the pediatric after hours clinic/triage nurse line:415-387-9293

If the nurse is NOT able to help, you will be directed to our answering service where the Noe Valley Pediatrics physician who is on call that night will be paged. If your child needs a prescription, it is unlikely that the on call doctor will be able to prescribe without an evaluation. The answering service number is 415-753-4697

Here in the San Francisco Bay Area we are lucky to have very good options for after hours care.


The UCSF Benioff Children’s Physicians Pediatric After Hours Clinics and Advice Service:

In San Francisco
3490 California Street, Suite #200                         
415-387-9293

In Berkeley
3000 Colby St Suite 301 (New Location 7/2017)
510-486-8344  

Patients are seen by appointment:

  • Monday through Friday 6:00 pm - 9:30 pm, (phones open at 5:00pm for appointments)
  • Saturday, Sunday and holidays 8:30 am -9:30 pm (phones open at 7:30 am)

Weeknight pediatricians are made up of participating private pediatricians, including several of our doctors who work an occasional shift in the clinic there. Weekend doctors are fully trained and board certified pediatricians. The advice nurse triage team is available from 5 pm through the night, even after the clinic is closed. The availability of the triage nurse makes this our number one choice.

The Pediatrics After Hours Care at St Luke’s Hospital is affiliated with Sutter/ CPMC and is located at 1580 Valencia Street, 7th Floor #701 This clinic has been open for several years now:


It is now open 7 days a week.
  • Monday-Friday 5:00pm-10:00pm
  • Saturday-Sunday 8:30am-10:00pm

Phone: 866-961-8588

This service does not currently have an advice nurse team, but the person answering the phone can help do some basic triage when making the appointment and help redirect you to an emergency room if that seems necessary. This clinic has some advantages besides the convenient location. They start the scheduling process as early as 2 pm, which may make it easier to make a plan if we are already solidly booked here in our office and can’t get you in to see us that same day. They also offer weekend weight and bilirubin checks for our newborns. As a bonus, there is a special waiting area so that the healthy newborns aren’t exposed to the other sick kids.

The two options listed above are the only urgent care facilities with which our office has a close relationship. When things are going as they should, both of the above after hours options send a report to the primary doctor's office. In our office, the nurse team reviews the reports and follows up to see how you are doing to maintain a sense of continuity.

I am listing the others below as a convenience.

If you are not in San Francisco, on the Peninsula you have several good options:

http://www.afterhourpeds.net/ is a pediatric urgent care facility. There is no appointment needed.
210 Baldwin Ave in San Mateo.
Telephone 650-579-6581

The Palo Alto Medical Foundation has several pediatric urgent care options:


They have a choice of appointment or drop in. The website gives info about the various locations and current wait times.

There are plenty of general urgent care places popping up all over the place as well. They are not usually staffed with pediatricians. For a teen, this is not much of an issue, but for my younger kids, I would try to stick with one of the pediatric after hours clinics.
Children are not just little adults. Some general practitioners are not versed in the treatment modalities of the pediatrics patient.

If you do end up at another urgent care, please ask them to send over a report to your primary pediatrician so that they can stay in the loop. If you are Noe Valley Pediatrics patient our fax number is 415-826-1308

EMERGENCY ROOMS

In a true emergency of course call 911. If it is less urgent, but you are certain that you child needs immediate medical attention we are lucky to have excellent options here in SF. When given the choice I will generally opt for one of the true pediatric emergency rooms. You are not competing for care with the elderly heart attack and stroke victims that may be populating the waiting room and getting ranked higher on the triage scale. You will also be assured of seeing a pediatrician and having appropriate pediatric equipment. If an admission is needed, my preference would be either CPMC at the new Van Ness campus or UCSF Mission Bay. There also won’t be any transport needed if you are already at one of those ERs. I think it is worth the extra ten minute drive across town and may save you time in the long run.

The UCSF Pediatric ER in Mission Bay is located at 1975 Fourth Street:


This emergency room has scored very high in a nationwide ranking for getting patients seen in a timely manner.

On March 3, 2019, the CPMC Pediatric Emergency Room relocated from California Street to the new Van Ness Campus in San Francisco at 1101 Van Ness Avenue


DAYTIME URGENT CARE

While we strongly prefer to have our youngest patients be seen by a pediatrician, there are ‘those days’ when our office is completely booked up early. If there is something going on that is not worthy of an emergency room visit and you don’t want to wait until the pediatric urgent care offices open, there are more and more urgent care options popping up all of the time. Many of these are conveniently located throughout the bay area. It is worth checking the prices, they can vary greatly.  Check with your insurance to make sure that the place you go is considered in network. Places that offer appointments are also a bonus so that you are not sitting around a crowded waiting room.
With any urgent care, make sure they send a report to your primary doctor’s office. If you were not seen by a pediatrician, it is always a good idea to touch base with your own doctor the next day to review the diagnosis, treatment plan and follow up needs.




Some of the common calls that folks need help with after hours are dosage questions. Here is the link to a post with that info: