Monday Update January 28th

Flu is here.
As I reported last week, We are seeing some Type A that does not care whether you are vaccinated or not.
For the most part our vaccinated kids seem pretty safe.
We still have some vaccine in stock and I was able to order more today, so at this point I don't anticipate any shortage.

There are tons of kids with colds and coughs. Some are wheezy some are croupy. The coughs all seem to linger for a couple of weeks before people can shake them off.

I am seeing some kids with the tummy bug.

Last week I had a few kids with strep throat. That has been quiet this week.

Stay well,

GO 49ers

Judy

Nurse Judy Update and all about Teething

The phones have been quite busy all week with so many little illnesses. I didn't make much of it in the Monday update but today it seems like the tummy bug is back a bit. I spoke to loads of families with vomiting and loose stools.

Many of you are on my Nurse Judy Email list. I have been sending out little tips and the updated Nurse Judy class schedule.
Below is my recent summary of teething issues/ remedies.
To get on my email list shoot me an e-mail nursejudynvp@gmail.com and I will be happy to add you..

My January 30th Solid foods class is full. The next solids class will be March 13th




TEETHING
Normal infants have 20 primary (baby) teeth which have started to develop in the womb.
The teeth start to erupt through the gums around 6 months of age. The baby teeth are then shed at various times throughout childhood.


Occasionally I have a patient that scoffs at the normal schedule and does things their own way.
I know of one baby who was born with teeth! Another started out with the upper canines and looked like a little vampire. As you can imagine, those parents were so happy when the rest of the teeth popped through. There is some heredity involved. If one of the parents was very early or late it is possible for the baby to follow suit. Check with grandma to see if she remembers anything special about your teething pattern!

It is rare for teeth to actually make an appearance before 4 months. Once in a while parents will notice a smooth round white bud on a baby’s gum. This is a little benign cyst called an Epstein Pearl. It is not a tooth and it usually goes away without causing any bother.

Many parents think of teething as something they are only dealing with for their young infants. Think again.
If your 6 year old is going through an extremely grumpy phase, or has a mysterious bout of mild, clear congestion that has been hanging on for a few weeks, take a feel in the back of the mouth and see if those first permanent molars are starting to pop through.

By age 21, all 32 of the permanent teeth have usually erupted.


Just like the timing varies, the symptoms may also vary greatly from child to child and even from tooth to tooth.
By far and away the most common first teeth are the ones in the bottom middle ( and they are so cute once they come through)
Take your clean finger and run it along your baby’s gum. If the tooth is imminent you will feel the area of the affected gum feels soft and boggy
***

Lets talk about the symptoms
Fussiness: Teething is uncomfortable. Most parents report that the babies seem fussier than usual right before a tooth pops through. Do what you can to relieve symptoms, but if your baby is inconsolable ( screaming with NO break) for more than 30 minutes and there is nothing you can do to calm them down then please call to have them checked
Drooling: Drooling starts weeks and weeks before you actually see a tooth pop through. Many kids will get a drool rash on their chins and cheeks. There are two products that I find quite useful for this. Clean of the area with Cetaphil Cleanser . (No water needed, apply with a cotton ball and wipe off) Follow it up with aquaphor ( which you can use multiple times throughout the day)
Gnawing/biting: Biting on things will feel great to the baby. Not so good to your nipples if you are nursing. If your baby starts biting you during feedings I recommend a loud “ouch!!” and immediately remove them from the breast. Most babies learn quickly. Remember that you want to make the association mildly unpleasant.
Biting= loud yell and loss of breast
If you are too gentle some babies will think it is quite amusing and will continue to bite at will.
Poor Sleeping: If your little one is miserable, this is not the time for sleep training. I would go in and quietly and try one of the teething remedies listed below. If you are going through a rough patch remember that parents should take shifts. Give yourselves each a few hours where you are off duty. There is no reason for both of you to be up all night.
Bleeding/ bruised gums: It is not unusual to have a little bit of bleeding on the gums. Once in a while you may also see a purple/ bluish bruise on the gums right before a tooth breaks through. This will usually resolve without any intervention although something cold will feel good on there.
Low grade temp : Not everyone agrees that teething can cause fevers, but I see it all the time. If a fever goes higher than 100.5 I am less likely to blame it on teething. Any fever that is lasting more than three days is worth a call to the doctors office to check in.
Loose stools: You will have differing opinions on whether or not teething can be the cause of loose stools and again, I will state here that I see it all the time. Some folks speculate that swallowing all that saliva and drool might be the reason. Regardless, I do think there is a link. Anytime you have a baby with loose stools you want to go with the bland, starchy diet and make sure they are on probiotics
Rashes: If your child has sensitive skin and/ or eczema sometimes you will notice that the general rashiness flares up during active teething
Congestion: This clear runny nose and congestion can last for weeks and weeks. Sometimes it causes a post nasal drip that in turn causes a little hacky cough.
Ear tugging: When kids are working on some of the upper teeth they do tend to poke and play with their ears.
****
Uh Oh, many of these symptoms are the same thing we look out for if we suspect an ear infection.
Even though teething may well be the cause, if I have a patient who is very fussy , feverish and is having trouble sleeping, I am likely going to want to have someone take a peek in those ears.
It is worth having an arsenal of tools at the ready for dealing with the months of teething that you have ahead of you.

Cool teething rings: make sure they are made out of a safe material. Do not tie any teething rings around your babies neck. This could cause strangulation.
Frozen wash cloth: Wet half of a wash cloth and put it in the freezer. The baby will be able to hold the dry half and chomp happily on the frozen side.

Distraction: There is nothing as nice as a body massage and a warm bath by a calm singing parent.

Teething tablets: The most popular brand is Hylands. There was a recall several years ago buy they are back on the market and are considered quite safe. I confess that I am puzzled about the mechanics of how homeopathy works, but I have seen many patients get apparent relief from these

Teething gels ( homeopathic): The most common brand is also made by Hylands. Try both the tablets and the gel and see if one works better than the other for your child.

Oragel: Oragel and other commercial teething remedies work by numbing the gums.
I keep this on the list because when used properly it is safe and can be quite effective. It is nice to be able to get relief by applying something topically and not relying so much on systemic medications like Tylenol.
Before I suggest it, I usually tell parents this little anecdote.
Many years ago I had a tooth ache and saw that I had a tube of Oragel in my medicine cabinet. I took a pea sized glob and rubbed it on my gum. Within moments it felt like my entire mouth was numb. It is nice to know that this stuff really works, but the sensation was almost frightening.
If you decide to use this on your baby I want you to put a TINY bit on your own gums first so that you can see how numb the area gets.
Currently Oragel comes with a little Q-tip applicator so that it is much easier to put really small amounts exactly where they are needed.
If care is taken, I am fine when this stuff is used appropriately. As I said, it works. I also need to mention that the ingredient Benzocaine has been linked to something called Methemoglobinemia * that can be quite serious. It is exceedingly rare. I have certainly never seen it.

(*It you read the fine print on any medication you won’t want to give your child anything. Try to find a balance)

Brandy/ alcohol:
Ask great grandma what she used to do for teething and she may tell you that she used to put whiskey or brandy on the babies gums.
Obviously giving our babies alcohol is not something that most doctors would suggest now a days, but I actually wouldn’t worry if you caught grandma rubbing some directly on the gums. It probably does help. Some folks also say that rubbing pure vanilla extract on the gums is an effective home remedy. That may be from the alcohol content.

Feeding bags:(baby safe feeder, or sassy teething feeder).
If your baby has had some solid foods introduced these feeding bags are great for teething relief,
Add a cold hunk of fruit or veggie ( Pick a food that they have been introduced to already so that you don’t need to worry about any odd reactions) and let them gnaw away happily. With the mesh bag you don’t need to worry about them breaking off a piece that could be a choking hazard. You can find these bags on line pretty easily.

Acetaminophen ( Tylenol) and Advil ( Iburofen) are useful but they are my last resort.
Make sure you are using the proper dose.
Do start with the other approaches. If possible, I would prefer to keep these as remedies for night time use only.
Tylenol ad Advil are quite safe but if they are used for a long period of time they can be stressful to the liver and kidneys
If you find that you have gone more than 5 nights where you are depending on these meds to keep your child comfortable, give your doctors office a call to see if you need to make sure that nothing else is going on.

***
Once your child has teeth it is especially important to keep bottles out of the crib. Milk has sugar and can cause tooth decay if a baby sleeps with a bottle in their mouth.
It is never too early to start brushing the teeth. Lets get your baby in good dental habits.
( no fluoride toothpaste until they are over two)
Once they have a mouthful of teeth it makes sense to start shopping for a pediatric dentist that you can establish a relationship with. This will come in handy if you have any tooth questions or mouth injuries..
Your next task is to figure out what the going rate for the tooth fairy is!! I can’t help you there.
Wishing you easy teething!!

Weekly update/ Flu and general mayhem

For those of you who dealt with hours of busy signals on our phones this morning, you likely have figured out that we are going NUTS in here. ( paying the price for a 3 day weekend)

Influenza has arrived with a vengeance.
We have had multiple cases.
We are mostly seeing influenza type A (the shot is not protecting from this strain)
We have seen a few cases of type B, ( no one who has been vaccinated has gotten this one so far)
The symptoms are fever, cough and general aches. The worst of it is over in 4 days.
So far we have had two patients hospitalized with it ( both are doing fine)
One was an un vaccinated 8 year old, The other was a partially vaccinated 7 month old who had flu and croup.

We are seeing lots and lots of kids with a flu like illness that are testing negative.
These folks have moderate fevers and coughs.

I am still seeing a bit of croup.

We have seen quite a bit of conjunctivitis. If kids are fussy, feverish and have cold symptoms with this we want to check their ears

I have heard that strep is going around. We haven't seen any cases in here today, but if your child has fever, sore throat ( stinky breath) with NO congestion, it would be wise to have then checked. Strep can also cause head ache, tummy ache and rash.

I am starting to see a bit of slap cheek. This is a virus where the kids will present with a very red cheek that comes and goes. Some of the kids will have high fevers. Other kids have a lacy rash that moves up and down the arms and legs.
This virus comes around a couple times a year. Some kids seem quite miserable with it, others have a red cheek and don't seem sick at all.
I have had several kids with hives and a red cheek.
If you have a child with suspected slap cheek and you are pregnant, please check with your obstetrician.

Stay well ( do your best!!)
Judy

Monday Update January 14th

First of all let's start with the good news.
For those of you who didn't know, Dr Anne is expecting twins. She will be taking her maternity leave effective February 1, 2013.

She has already slowed down her schedule and will be trying to work Tuesday and Friday afternoons for the rest of this month depending on how she feels.

She plans to be off until July. In her absence, Kristina Beardsley MD will be covering Dr Anne's patients.

****

The media has certainly be banging it's drums and stirring people up this week.
Our families have remained calm for the most part...Thank you.
There is nothing terribly unusual in the flu that we have seen this season.
I would agree with the reports so far that most of the strains seem to be a good match with the vaccine, but there is a Flu strain A that is still getting folks who got the shot.

What I have seen in terms of symptoms are not fun, nor particularly worrisome.
Parents report feeling like they "got hit by a truck" They have lots of aches, fever and some congestion.

Most folks are down for 4 days or so and it is another 3 before they are ready to get back to business.

We still have vaccine available for our patients who may be rethinking their choice to skip the shot.

****
I am seeing an assortment of illnesses this week.

We are seeing RSV, a nasty harsh cough with moderate fever
I have had a bunch of kids with ear infections
The tummy bug is still out there.

I have one little patient who looks like she has hand foot mouth.

****
We are closed in observance of the MLK holiday on Monday January 21st.
Patients can be seen at the after hours clinic if needed.


Stay well
Judy

Calling all Nebulizers

If you have borrowed a nebulizer from our office and haven't returned it Please bring it back ASAP!

We are missing eight of our loaner nebs!!!

If your child is still using it, We can set you up with a brand new one for you to keep. More often that not this is covered by insurance ( Worst case cost is $80)

Thanks!
Judy

Tummy Bug 101

As you can imagine, when the tummy buy is going around the nurses here find ourselves giving the same tips and information to one call after another,

I have tried to write down some of the more important pointers.
I hope you find it useful
**********



If you or your child has fever, chills, bloody diarrhea and vomiting, this could be food poisoning. You likely need to be seen

If you or your child are just back from travel or camping and have awful gassy, incredibly stinky stools, we should make sure that you don’t have giardia or some other parasite


However, by far most of the tummy bugs that we see are caused by a virus. Time will fix this.
The typical symptoms are vomiting, loose stools and sometimes fever.

Your main job is to keep your child hydrated. It is okay and even expected for them to not have a normal appetite for a few days. Unless they are extremely slender, we are not too worried if they lose a bit of weight. They will fatten right back up when this passes. Don’t stress about the food intake. We just need to make sure that they are getting adequate fluids.

A dehydrated child has very low energy, the urine is dark and way less frequent, They don’t have lots of wet tears and drool. Their mouth feels dry. These are the kids that get carried into our office draped over their parent’s shoulder. If your child is running around I am not too concerned and they probably don’t need to be seen.

If you are not able to win the hydration battle then a trip to the emergency room is appropriate. Once there your child may get some IV fluids which often perk them right up.

Right before they are going to vomit, it is normal for them to look quite miserable. Some kids actually look greenish. Once they throw up, most of the time they feel a bit better.


This month most of the afflicted folks started with some vomiting. This particular illness swept through the entire families. Mommies, Daddies and Nannies all came down with it.
Luckily it only lasted for a few days.

There are no hard and fast rules here.
I typically wait at least ten minutes after they have thrown up before I offer anything to eat or drink.
Ideally you will be giving them clear fluids ( breast milk is also perfect if you have it)

Because we lose lots of electrolytes when we vomit or have diarrhea, it is best to replace the fluids with something that replaces the electrolytes as well. Water is not your best choice.
There are products on the market that are specially formulated for this purpose.
Pedialyte has been around for quite a while. There are pedialyte popsicles that are terrific for older kids, Unfortunately regular pedialyte tastes a bit like soap.
If you can get your child to take it, consider yourself lucky.
There is a new product out there now called Drip Drop that promises to taste a little better.
Coconut water is another fine choice.

Once your child has started keeping down some fluids, it is okay to advance the diet.
More often than not, we expect the stools to be looser than normal.
This month the vomiting has rarely lasted for more than 24 hours.

Bland starchy foods are your best bet.

Bananas, rice, applesauce, crackers, toast, potato, pasta, boiled chicken and watermelon are all okay.
I find that folks have a quicker time getting over this if they avoid dairy.
(some folks can stay on yogurt and tolerate that fine)

In my experience, getting started with probiotics right away is very useful.

There are plenty of good brands out there. One of my favorites is Florajen for kids which you can get from the Noe Valley or Diamond Heights Walgreen’s. It is kept in the back in the refrigerator, but there is no prescription needed
Baby Jarrodophilus ( whole foods or health food stores) is another brand that we have had success with.

If your child has a fever, a tepid bath can help get it down. If the bath hasn’t done the trick, the fever is over 101 and your child is miserable it is worth giving some fever reducing medicine.
Ibuprofen tends to be a bit harder on the stomach so I would chose acetaminophen
( Tylenol) when I have an illness that includes tummy symptoms.
Another advantage to the Tylenol is that it comes in suppository form, so it is more easily tolerated by a vomiting kid.


Many folks call me because their child seemed like they were improving and have had a bit of a relapse.
Most of the time this is caused by advancing the diet a little too quickly. ( especially dairy)

If your child is retaining fluids but has loose stools, I love the Similac DF ( diarrhea Formula) The Walgreen’s in Noe Valley and Diamond Heights try to keep this in stock for me. You may need to ask the pharmacist if you don’t see it on the shelves.
For older kids you can still use this soy based formula as the base for a smoothie.
Similac DF
Banana
Frozen yogurt
Mix the ingredients in a blender,
This smoothie is usually easily accepted, well tolerated and helps form up the stool.


If your baby is under 2 months old and you suspect that they have a tummy bug, we will want to monitor them closely. Young babies can get dehydrated much more easily than a larger child.

Many babies spit up on a regular basis daily and normal baby poop is very liquidy. If they are nursing well, and peeing fine that is very reassuring.

What we would be watching out for would be stool that looks watery/ clear, increased amounts of vomiting and any concern about their energy level.

With a dehydrated infant, the fontanel ( soft spot) may appear more sunken, and they will be way sleepier or fussier than usual.


Regardless of their age, If you have a vomiting child for more than a day, with perfectly normal stools it is worth checking in with your doctor’s office, especially if they have a fever!



Good Hand washing is your best defense.

Nurse Judy

Monday update January 7th

It is your basic mad house in here.
In other words if your child is sick you have plenty of company.

There are lots of colds and coughs going around. Some of these viral syndromes are accompanied by a moderate fever.
We do have one case of documented Flu type A where the baby did have the first flu shot,but hadn't had his second one yet. That is the only flu shot failure that I know of in our practice so far this season.

I do think we have a few more cases of influenza floating around but we haven't been testing most kids. They haven't been sick enough to be worried about.



Croup is still out there.
Most of the time with Croup the first night is the worst. Get into the shower or pop outside for a bit. The night out often helps the breathing ease.
Having a humidifier at night and keeping fluids flowing will usually make the next few nights much easier.

We are still seeing the same little tummy bug making the rounds. This starts with vomiting and moves along to loose stools the next day.

There are lots of kids with sore throats. No positive strep tests today.

The schedule is very busy. If you are worried about your child and think that you need an appointment please make sure that you call early ( and even then there is no certainly of getting an appointment.)
The nurses are here using our triaging skills to the best of our ability making sure that the kids that need to be seen get the care that they need.

Most of these illnesses can be managed at home. But never hesitate to call. That's what we are here for.
The wait for a call back may be a bit longer this week because the call volume is very high.
If you are very worried, please let the girls at the front desk know, so that we can try to get back to you a bit sooner.

Stay well
Nurse judy

Welcome to 2013

Happy New Year to all.


It has been fairly easy to get acute care appointments and the phone call volume is not too awful, so there isn't anything particularly active out there.

The most common illnesses this week are

*Croup

*A tummy bug ( often intense but doesn't last long. Parents are getting this one)

*A cold/cough/ moderate fever that is lasting for several days ( the kids don't seem as fussy as we would expect with this one)

Reminder that we are holding our flu/immunization clinic on Saturday morning January 5th from 9:30-12:30. This is for Noe Valley pediatrics patients and families. No appointment is needed.

So far it seems that this years Flu vaccine is giving good protection to the strain that is starting to go around.

Stay well!

Judy