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Extra! Extra! I’m Moving to Robertson Pediatrics!

Starting July 1st, 2023 I’ll be working as a pediatrician at Robertson Pediatrics in Beverly Hills!

RobPeds

1) Where is that?

The beautiful new office is located in Suite 307 at 150 N. Robertson Blvd in Beverly Hills, CA 90211. It’s just a couple of buildings North of Wilshire Blvd, and only a 5 minute drive from my old office, so I am not moving far away. There is valet parking available under the building, to keep your car away from the elements, for a fee. From the parking lot or lobby. take the elevator to the 3rd floor and the office door is immediately to your right.

2) What is special about this place?

Robertson Pediatrics is a modern medical home, which will give my patients access to top technology for their care, and a much larger array of testing that can be done right in the office during visits, so you do not need to go to another location for most labs, and results are available quickly. For example, they offer an in-house PCR test for the top 22 pathogens that cause coughs and fever in children. 1 swab of the nose and you have an answer in half of an hour, not just about the flu (although that is included), but also RSV, Covid, pertussis, adenovirus, and more. Want to know if your child has mono? There is now a simple test that takes 1 drop of blood from the finger in the office, instead of having to go to an outside labs and fill vials. These tests not only empower patients and their families with more information, but they also make my job easier, letting me provide the best, most accurate, evidence based medicine for my patients. In addition, there is a pediatric allergist in the office 3 times a week, to help those with asthma, allergies, and eczema, and a pediatric psychologist in the office twice a week, who also does neuropsychological testing, and can help children and families with their mental health needs. I am especially excited for these last 2 things, as my friends know that two of my passions are talking about allergies and neurodiversity!

3) When can I see you?

I know some people were sent a misleading email from my old practice implying that I would suddenly not be available, and this is just not true! I am going to start off at Robertson Pediatrics by being in the office all day on Tuesdays and Thursdays to get my bearings, but this is not my final schedule. And on the days that I am not in the office, I will still be able to access portal messages, emails, and even telemedicine from home. When I am not physically in the office, Dr. Sammy Kim will be seeing my patients, and there are same-day sick visits available Monday through Friday, from 8:30am to 4:30pm, for everyone.

4) Which insurance plans do you take?

Robertson Pediatrics accepts most major PPOs, including Aetna, Cigna, United Healthcare, Blue Cross, and Blue Shield. To be sure you are covered, please check with your insurance if “Robertson Pediatrics” or “Samuel Sungwon Kim” is an in-network provider within your plan (sometimes the insurance plan will mention one of the physicians in the practice and sometimes it will mention the practice name, as long as it includes one of them, you should be covered). You can also call and speak to the office manager directly for more information.

The office does not take any HMO plans or Medicare/MediCal.

If you have an HMO plan, or an out-of-network PPO, such as Oscar, you may be seen on a cash basis. Please call and speak to the office manager about prices.

5) How can I switch from another office to the new one?

To get an appointment with me at the new office, you can call the office at 310-659-8687, contact them online at www.RobertsonPediatrics.com, or email info@robertsonpediatrics.com. To transfer, please call and let them know that you are my patient, and you are transferring to them. Then send over your child’s immunization records, growth charts, and past medical history from the prior office.

You can either email the records directly yourself, or you can fill out record transfer forms at your old pediatrician office and have them fax over the records, although in CA they are allowed to charge a fee for that. If you have already paid the admin fee at your pediatric office, this should cover the transfer of all records. If you already paid the 2023 admin fee at Miracle Mile Pediatrics, please let the office at Robertson Pediatrics know.

To get records yourself from MMP, first go to their patient portal, enter your user name and password and log in. Click on your child’s name. This should take you to a page with your child’s information at the top, then “Upcoming Appointments”, then “Visits”, then “Documents”, etcetera. Scroll down to the bottom of that page and click on the pdf link to download your child’s immunization records. Then scroll up to the growth charts and take screen shots of them (for kids younger than 2 years, it should have weight, length, weight for length, and head circumference, over age 2 it should have weight, height, and BMI). Click on “measurements” to see actual numbers and get a screen shot of the last few measurements as well, with the number values for height and weight, so they can be transferred to the child’s new chart. Then scroll up to “Visits” and click on the last problem-based visit date and download the summary from that visit (the PDF button is at the bottom of the visit when you scroll down), as well as the last check-up date and download that one as well, to share. Finally, look at documents, and save whichever ones you would like or think you may need. It sounds harder than it is. Finally, e-mail all of these PDF documents to info@robertsonpediatrics.com.

5) What else would you like to know?

Just drop an email on my Facebook page or Instagram, or email me with any questions. I hope to see everyone over at Robertson pediatrics soon!

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Starting Solids with Babies

Your baby is ready for solid foods when they can lift and support their head, sit in the high chair, have doubled their birth weight, and are showing an interest in food.  Never start solids before 4 months of age, and you can wait as late as 6 months old to begin if you prefer. Different babies will be ready at different times, even amongst siblings. Early introduction of complementary food is supported because babies need to start eating the most common allergens on a regular basis by 7 months old in order to help prevent food allergies, and that can be hard to do (but not impossible) if they are just starting solids at 6 months.

FIRST FOODS 4-6 months old

  • Most kids start with iron-fortified infant oatmeal “cereal” (because it tastes like breast milk/ formula, so it is the easiest to give, and has iron & vitamins), but you do not have to do this. You can do vegetables instead if the baby is on formula (because the baby gets iron from that) or you may start with pureed cooked meats (which is recommended for iron but hard to give). Mix the cereal/pureed veg/meat with breast milk or formula into a thin mixture- the consistency of a pureed soup- to start. I do not recommend starting with fruit due to its sweetness. I love baby-led weaning once they get used to starting solids and using a spoon, so at 6-8 months, but not at first, because infants need to learn to eat from a spoon and swallow purees before starting solid chunks, which are often used in that method.
  • Offer solid food 1 hour before the regular mid-morning breast feeding / formula session.
  • Start with 1-2 tablespoons of puree per meal (like an ice cube), going up as needed. Follow your baby’s cues for being hungry and satisfied. You will continue their regular amount of breast milk / formula when you start solids.
  • Remember that most of it will end up on the floor, the baby, and you, but not in the baby’s stomach. That’s okay. Plan accordingly. A clean trash bag on the floor under your chair can help with clean up from an exuberant baby.
  • Feed the baby from a spoon, never a bottle. The point is for them to learn how to eat, not just get calories and nutrients, although that is also important.
  • Wait for the baby to pay attention to each spoonful before feeding! Don’t force it. Watch for the baby opening their mouth, then put the spoon in.
  • Feed in between infant milk times, not immediately following.
  • Expect changes in bowel patterns (it is normal for poop to look weird, look like what they ate, and to change daily).
  • Do NOT put cereal or food in a bottle for feeding.
  • After cereal/ the first food is eaten easily, move on to other types of pureed foods.
  • If there is a strong family history of allergies or eczema, or if the baby has these, start with one new food at a time and wait 3-5 days before introducing another, to see if the baby reacts. Otherwise, you can mix and match foods!
  • Give new foods in the morning. If it doesn’t agree with your baby, you’ll know by bedtime (from a rash, vomiting, or diarrhea). This way it will also be easier to reach your pediatrician during office hours.
  • You can repeat a food already given a few times, and mix familiar favorites with new ones.
  • If the baby rejects a food, don’t force it, but try it again later.
  • Follow your baby’s cues for hunger and satiation.
  • Have fun with feeding, enjoy the art of the mess, and make meals a happy time.
  • Try feeding at the same place and time each day, without TV or distractions in the background.

FOOD ALLERGIES

  • EARLY introduction of common food allergens has been shown to help PREVENT the development of food allergies! Do NOT wait to start these.
  • The 9 most common food allergens cause 90% of food allergies in children. They are: peanut, egg, cow’s milk, tree nuts (almond, cashew, hazelnut, pistachio, and walnut), wheat, shellfish, soy, and sesame.
  • Introduce Bamba (puffed peanut snack that melts in your mouth), tahina (sesame paste, often found in hummus), and yogurt, which are common allergens, a few times a week, starting at 4-6 months old. Studies show it helps PREVENT food allergies if kids eat these regularly before 7 months old. I recommend using Bamba as the food to introduce babies to peanuts because that is the food that has been used in all of the major studies showing early introduction prevents peanut allergies. It’s also easy for babies to eat and tasty. It is sold at Trader Joes, Target, and in Los Angeles, at most supermarkets. If you do not want to use Bamba to start solids or cannot find it in your area, then start with peanut butter powder mixed into baby cereal. Do not use regular American peanut butter as the stickiness makes it a choking hazard, and it is more allergenic than other forms.
  • Continue to feed common allergenic foods 2-3 times a week for a year to prevent allergies from developing.
  • While uncommon, allergic reactions are possible when introducing food allergens to infants. The two most common signs of an allergic reaction in infants are hives (itchy spots) and/or vomiting, within 3 hours of feeding, but usually within 15 minutes. Call your pediatrician about how to manage any reactions. It is a good idea to have children’s Benadryl allergy syrup in a cabinet in case you are advised to use it, but do NOT give it without physician guidance. In the extremely rare case of a severe allergic reaction with trouble breathing or going limp, call emergency medical services (911 in the US).

bamba

ADVANCING FOODS 6-9 months

  • Move on to textures & increase proteins: start with soft, cooked, mashed or finely ground foods (e.g. avocado, squash, banana, well-done meats/poultry/fish, cottage cheese, tofu)
  • You can mix and match foods to have many different meals, for example:

     Breakfast: cereal and fruit; Lunch: yogurt and veggies; Dinner: protein and veggie

  • You can do baby-led weaning, but please AVOID CHOKING HAZARDS! Food should be bite-size (about the size of a pea) and soft. Babies chew foods with their gums, they do not have to have teeth to eat solids. I love baby-led feeding once the baby gets used to solids and spoons first.
  • Consider purchasing a device to help in case the baby chokes on something, like the “LifeVac” or the “Dechoker”.
  • Remember that your babies are also learning about texture, color, and aroma as they feed themselves, so try to offer a variety of nutritious and flavorful foods.
  • Still NO honey until after 1 year old to prevent infant botulism!
  • When the baby is eating well and having 2- 3 meals a day, offer water in a sippy-cup with meals (around 7 months old), but still continue their breastmilk or infant formula 4-6 times a day.
  • Examples of fun finger foods for babies 8 months old and above: O-shaped toasted oat cereal or other low-sugar cereal (start with them soaked in milk), lightly toasted bread or bagels (spread with vegetable puree for extra vitamins), small cubes of tofu, well-cooked pasta noodles cut into smaller pieces
  • Common choking hazards: raw hard fruits/vegetables like apples or carrots, string cheese, hot dogs, popcorn, whole nuts, fruits with peels on them, grapes.

chokingposter

More info on the new & old feeding rules at Dr Stuppy’s blog: http://pediatricpartners.blogspot.com/2011/10/starting-solids-old-and-new-and-myths.html

Please note this blog post is based on the handout I give to my patients in order to start their babies on solid foods. I got the original handout from a pediatrician friend, and then slowly and extensively revised it over the last 10+ years. 

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March Viral Madness & Covid Update

LA County Dept Pub Health Covid Stats for 3/23/23
4 year old in the ER getting medication and oxygen via a mask
4 year old in the ER getting medication and oxygen via a mask

COVID has had a significant impact on children’s lives, but the world seems to be moving on and returning to a pre-pandemic baseline. Still, there are many things we have learned from the pandemic, and should continue to do to keep ourselves, our children, and our communities safe from catching Covid-19, influenza, RSV, norovirus, adenovirus, and all of the other viruses currently spreading like wildfire through schools and daycares. Please remember that antibiotics do NOT treat viruses. We do have a medication to help treat some cases of influenza, and if you or your child is sick, please see your physician to rule out a bacterial illness, which may need antibiotics.

The pandemic is a fluid situation, and recommendations for children may change as more is learned about the virus. It is important to stay up-to-date on the latest information and to talk to your child’s pediatrician if you have any concerns. Below the infectious disease tips I have some suggestions on helping anxious kids.

Here are some tips on how to not catch infectious diseases:

Corsi Rosenthal Box Directions
Corsi Rosenthal Box Directions
  • Get vaccinated. Vaccination is the best way to protect yourself from COVID-19, influenza, and a variety of other diseases, like Hepatitis A, which was recently spread to a bunch of unvaccinated people through delicious frozen berries.
    • Get boosted. If you have been vaccinated with the initial two COVID-19 shots and even the original spike booster, you should get an Omicron bivalent booster shot (and later, whatever is the latest strain). The booster shot will help protect you from the latest COVID variant, as well as give you longer immunity from COVID in general.
  • Use an air purifier. Use a HEPA-grade air purifier to clean the air of any rooms you stay in for prolonged periods of time, like your office, dining room, child’s classroom, etc. You can buy one, or make your own Corsi-Rosenthal Box, which uses HVAC filters and a box fan to clean the air. Read more about why this works, and how to make one at this article from Columbia University. 
  • Wear a well-fitting, medical-grade mask. Masks help prevent the spread of respiratory viruses (any virus spread by saliva, snot, etc, like COVID and influenza). When you are in public, wear a mask over your nose and mouth. Make sure it is tight against your face – any space where air leaks also allow viruses to get in. Try to get one that is N95 grade, or as close as possible. But keep in mind the adage, “My mask protects you, your mask protects me” – if you are the only one wearing a mask, it is much less effective.
  • Wash your hands often. Wash your hands with soap and water for at least 20 seconds. This helps prevent the spread of all kinds of germs. Do not substitute hand sanitizer unless there is no water available, since there are germs, like norovirus, that are not killed that way.
  • Stay home if you are sick. If you have a fever, cough, sore throat, runny nose, or are ill, PLEASE stay home and isolate yourself from others. Even if you get over your illness quickly, there are vulnerable babies and people out there who may catch it and not recover like you. If your child has fever, vomiting, diarrhea, or any symptom bad enough to keep them home from school, they must stay home for at least 24 hours after the symptom goes away, before returning to school. This is because if they have a fever at night and do not in the morning, they are likely still contagious and will just get a fever at school and spread their germs to classmates. The same goes for vomiting.
  • Have your child bathe and change clothes when they come home from school. This one may sound silly, but most kids are bringing home germs, as well as allergens, from school, and washing them off, as well as putting on clean clothes when they get home, really can reduce the spread of both microbes and allergens.
  • Get tested if you have symptoms. If you have nasal congestion, cough, fever, fatigue, a sore throat, or do not feel well, talk to your doctor about testing for COVID, among other things, like influenza and strep. Many people have different symptoms with each COVID infection. In addition, the tests often do not come back positive until a few days into the illness, or if you have a fever, so if you tested a day before you got sick and got a negative result, it does not actually mean that you are negative for Covid.
  • Follow the advice of your doctor. If you have any questions or concerns, talk to your physician. Also check out your local department of public health for the latest recommendations. For Los Angeles, click here.

By following these tips, you can help reduce your risk of getting COVID-19, influenza, RSV, and other viruses.

While the pandemic itself has been difficult for children, there are some positive steps that can be taken to help them cope with anxiety.

One important thing to remember is that children are resilient and can adapt to change. They may be feeling anxious or scared, but it is important to reassure them that they are safe and loved. Parents and caregivers can help children cope by providing them with a sense of normalcy and routine. This could include continuing with regular activities like bedtime stories, meals together, and playtime.

It is also important to talk to children about COVID-19 and what it means for them. Children should be aware of the virus and how it spreads, but they should also be reassured that they are not in danger. Adults can help children cope by providing them with accurate information and answering their questions.

If children are feeling anxious or scared, there are a number of things that parents and caregivers can do to help. One is to provide them with a safe and comfortable place to talk about their feelings. Be patient and understanding. Another is to help them develop coping mechanisms, such as deep breathing or meditation. Adults can also help children by modeling healthy behaviors, such as getting enough sleep and eating a healthy diet.

The pandemic has been a challenging time for children, but there are many things that adults can do to help them cope. By providing children with a sense of normalcy, reassurance, and support, adults can help children weather this difficult time.

Please note that this post was written by Dr. Shaham, with some assistance from a beta version of Bard, Google’s AI. 

2 adults wearing medical masks that are fitted
Fun times with masks
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Covid Vaccine Links

As more coronavirus vaccine manufacturers have press releases touting their vaccine trial news, we all need good sources to understand what is going on. Therefore, here are a few more links to help you understand all of the information being thrown at you:

  1. My first blog post about the covid vaccines
  2. Deplatform Disease: a great website by biochemist Edward Nirenberg, primarily discussing vaccines and Covid-19.
  3. Skeptical Raptor’s blog debunking common vaccine myths, but also putting in a nice amount of skepticism
  4. Health journalist Tara Haelle’s summary post about the Covid vaccine
  5. Where we stand in testing the vaccines in children as of March 2021
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November 2020: Covid Vaccine News

Guest post by vaccine advocate Denise Kesler Olson. She currently works for an Immunization Coalition in Arizona, helping others feel as passionate about vaccines as she does. You can read how she got involved in the immunization movement here.  This information originally appeared on her Facebook wall, and she has graciously allowed me to post this edited version on my blog. I am re-editing it after we have more data in 2021 – Dr. Shaham

Vaccine_clipart2

Part I: “But How Do We Know If It’s Safe!?”

The most common criticism I get is that I keep telling you how every vaccine is safe, and therefore I must unconditionally love all vaccines and accept them all blindly. No. I – and really, we’re talking about the scientific establishment I support and not me personally –accept only vaccines that have been through the rigorous testing process and are found to be safe and effective. The vaccines on our standard schedule have cleared that hurdle. Covid vaccines aren’t in that category yet. We do not know if they work nor if they are safe. I wouldn’t recommend everyone get them yet (November 2020), and no responsible organization should either (since they have not YET undergone independent scientific review). 

A little background information will go a long way to help us here. Vaccines are a special type of medical product because they are given to healthy people instead of sick people. This might seem like a small thing, but it’s actually a HUGE difference. Pharmaceuticals are only ethically given when the possible benefit outweighs the possible risk. If you are already sick, it may be worth risking side effects, especially when they rarely happen or if they are less serious than the problems you already have. A vaccine given to healthy people must never make them into really sick people, or the whole point of preventing illness is defeated! Any effects need to be better than the alternative of not getting the vaccine at all. 

Vaccines need to pass through four specific development phases to be proven safe and effective (preventing the disease). If any serious side effects are found throughout this process, the vaccine will not be approved for mass use – about 60% of vaccines fail to be approved in the end (compare this to 84% of other pharmaceuticals which fail). First, various vaccines that have worked in the laboratory setting, and look good on paper and computer modeling, are tested on animals to prove that the formulation isn’t harmful to live beings and see which candidates are the most promising. The vaccines that work safely and as expected in animals can then move forward to be tested in humans in phase I, II, and III clinical trials. Pediatric vaccines (the ones we use in kids) usually undergo phase IV clinical trials as well, which are formal studies that occur after the FDA approves a vaccine. Check out this infographic from the CDC about how a vaccine gets to market (click on the sentence to open the link in a new window) or click here for a short YouTube video about the process. 

There are currently Covid vaccines undergoing phase I, II, and III trials in adults all over the world. The phase III studies on people are double-blind. That means the participants are divided into groups, and half of the people are randomized to receive the real vaccine that is being tested, and half receive something else (a placebo), such as a saltwater injection or a different vaccine. Neither the patient nor the medical staff administering the vaccine knows if the real vaccine was given. Only the data analysts have this information, and it is kept separately from any information identifying people in the trials, such as their name, birthday, street address, or characteristics. This is important because not everything that happens to people after getting a shot will be because of the injection. People in both groups will get sick or injured by random chance -especially when following up with them for a long time. Scientists look for patterns. If one thing shows up repeatedly in the group of people who got vaccinated, then that may be a sign that the vaccine caused it.

This knowledge will help you understand scary headlines in the news. Recently, there were wide reports that someone in Brazil had died while participating in a vaccine trial. When the researchers paused the trial, they used emergency protocols to unblind his records.  It turned out that he was not given the real vaccine during the trial, so the vaccine they were testing could not be the cause of his death.

Obviously, you test vaccines not just to prove that they are safe but also to prove that they prevent people from getting sick. There are two ways that people can go about this. One way is to continue watching phase III trials (currently around 30,000 people or as many as they can get for vaccine trials) for a very long time until enough people are naturally exposed to the virus. Over time, you hope to see a pattern of people who were given the real vaccine not getting sick, hardly ever getting sick, or only getting mildly sick. If the vaccine does not work, then the people who got the real vaccine and the people who got the placebo will get sick roughly in the same amount and severity overall. Remember this when you hear numbers like “this vaccine is only 50% effective,” because it means people in the vaccinated group were half as likely to get ill with COVID-19 compared to the placebo group. While that would not be the best, it would be a huge reduction of disease overall.

The other way to see if vaccines work is controversial, but it did get approval for use in the UK recently in healthy and willing volunteers. This is the old-fashioned challenge trial. In a challenge trial, you give the vaccine and then deliberately try to infect those people with the disease you are trying to prevent. The advantage is knowing right away if people get sick in the same numbers and skipping months of waiting around for people to become exposed. Still, infecting people on purpose with a disease, when you do not know if you have a safe or effective vaccine, has many disadvantages and is considered unethical by many people. 

Part II: Operation Warp Speed

There are a couple of hurdles that keep vaccines from coming to the market quickly, even if the idea is good and it works. 1: There may not be enough money to continue research and development. In that case, work must be paused as researchers try to obtain new grants/investors/sources of funding. 2: It’s hard to scale up the production of an effective vaccine so that there are enough doses to immunize everyone in a large population. It costs quite a bit of money to build or retrofit a factory and obtain all of the necessary materials to make millions of doses of a new vaccine.

Operation Warp Speed was passed as part of the CARES act in March 2020 to speed up a successful Covid vaccine’s availability. Ten billion dollars went into funding a public-private partnership that gives R&D money to companies with candidate vaccines, as well as supplying funding to scale up factories to manufacture those vaccine candidates, even when we are not sure they will ever be approved. They did this with the knowledge that some of them would probably not be proven to be effective in the trials and would ultimately have to be tossed out, but that if one worked, then there would be millions of doses sitting ready to be shipped out as soon as final approval was given. The reasoning behind this effort was set out by top economists who supposed that a delay of even one year could cause much more economic damage and turmoil than simply funding the vaccines upfront and getting things back to normal.

Like everything that comes out of Congress, the law is very complicated and full of fine print. It leaves a lot of questions, such as:

  • What loopholes could pharma companies exploit to inflate their stock prices?
  • Should the American people have to pay for a vaccine funded by taxpayer dollars?
  • Should we be awarding money to foreign companies under this program?
  • Were contracts awarded fairly and subject to enough scrutiny?

And on and on and on. We will probably be talking about what went right and what went wrong with Operation Warp Speed for decades to come. However, that is an argument for somewhere else. I brought it up because I want to help everyone understand that Operation Warp Speed does not fundamentally change the clinical trial process I talked about before, where we check the safety and efficacy of vaccines. It has a dramatic name, but it should really be called “Operation Fund COVID Vaccines.” There are legitimate reasons to critique the operation, but they have nothing to do with the safety and effectiveness of the eventual vaccines produced. Questions about pharmaceutical companies, including how much money they should be allowed to make if they receive public funds, are economic and political questions at heart. The companies participating still have to prove that their vaccines are safe and work; otherwise, their whole tax-payer funded factory will just sit there gathering dust.

Addendum from Dr. Shaham: Operation Warp Speed is allowing manufacturers to reduce the typical 2-year long phase II clinical trials and 2-year long phase III clinical trials into an overlapping 6 month trial period before assessing the vaccine safety and efficacy, due to the urgency of getting a vaccine out to halt the pandemic, and a large number of people in the trials. However, this does shorten the time we have to determine the long term side effects of the vaccine. For Covid-19 we also do not know the long term effects of the virus itself, since it is new to humans (but has been in animals for years); therefore, there will be ongoing data collection and research long after initial approval of a covid vaccine, and we will be learning about both what the virus itself does, and the vaccine does, for years to come. To make up for the shortened trial period, many more people were enrolled in these trials, with many more comorbid conditions than in regular trials, so we can catch any potential side effects in the general population. 

Part III: Big News in Big Pharma: Pfizer says their vaccine is 90% effective. 

Two large but competing pharmaceutical companies, Pfizer (of Germany) and Moderna (of the U.S.A.), are attempting to make their covid vaccine candidates a new way. Not only are these two vaccine candidates designed to fight a new infection, Sars-CoV-2, but they are designed using mRNA (messenger RNA).

A typical vaccine takes a virus (or bacterial) toxin, or parts of the microbe that were grown in a lab, harvests it, kills it, chops it up, and purifies it until only 1 part is left, which we call the antigen. The antigen is mixed with things that help your body recognize it and defend itself against it, and that vaccine is injected either under your skin or into a muscle. Your body then mounts an immune response under the belief that these inert germs pose a real threat. Later, when the body actually encounters the real germ, it is easy for your immune system to retrieve the antibodies created in response to the vaccine, copy them, and use them to prevent or blunt the real thing’s effects.

The mRNA vaccines work by skipping the part where the lab makes an antigen. They are counting on the fact that our own body is as good as any lab at manufacturing parts of a virus. After all, that is the reason that viruses want to infect you in the first place. They can’t duplicate themselves the way bacteria can, so they trick your cells into making more viruses by hijacking their ability to make proteins. First experimented with for cancer treatment, the idea of the mRNA vaccine is to trick a few of your cells into manufacturing parts of the virus – NOT the whole virus, so it can’t give you Covid. It tells some of your cells to make the Sars-CoV-2 spike protein, for example, which is enough to make your body mount an immune response against the real virus.

Does this actually work? We don’t know yet, but in a press release on November 9, 2020, Pfizer claimed that it is working well in their data so far. Remember, in trials, half of the people receive the real vaccine they are testing, and half of them receive something else. Then everyone has to wait around and monitor the participants until people get exposed to Sars-CoV-2. They have regular visits with researchers, have blood and nasopharyngeal swabs examined, keep symptom journals, and report everything. Pfizer claims that out of the more than 44,000 people in their trial, only 94 people so far have been sick with Covid-19. When the researchers analyzed the data, they found that only nine of the people with Covid got the real vaccine candidate. The other 85 people were in the control group. That certainly looks like a pattern starting to develop. A group of different researchers ran a statistical analysis and found that if this rate continues, the vaccine would be >90% effective. This is well above the 50% floor the FDA set for approval of any COVID vaccine, moving it from being as efficacious as the influenza vaccine to put it more in line with the far more effective polio vaccine. For more information on the statistical side, check out the tweet threads linked here. 

So what are the catches? The most important is this trial is not finished, and this data came from a press release, not a journal. Only once is published can independent researchers run more analyses to validate the claims. There also haven’t been enough Covid-19 cases in the participants to know if this pattern will hold, and the FDA has said that they would not even consider an emergency application for use until there had been at least 161 confirmed cases of Covid-19 in the trial. We don’t yet know if the vaccine prevents severe disease because it was reported that no one so far has gotten seriously ill. Since this was a press release, they did not address the biases in their research, such as volunteers for the vaccine trial being more likely to wear masks and socially distance, nor confounding factors, like the participants’ socioeconomic status. Another consideration for this new vaccine type is that it must be kept very cold at -80 degrees C, and once the vaccine is thawed, it must be used very quickly. It won’t be easy to distribute it outside of a large hospital setting since it has unique storage requirements.

Another potential effect for people to be aware of and that is vaccines of this type by their very nature stimulates both the nonspecific and specific set of immune responses our body has. Your body may try to fight this “infection” with a fever and make you feel achy and tired for a few days before it gets down to building specific antibodies. That wouldn’t be dangerous, but it would be something to be aware of, or you may be afraid you’d gotten ill from the vaccine. The side effects are likely to be a bit worse than those from the annual flu shots.

In the end, it is hard to know if this is the vaccine that turns out to be the most widely used. Assuming the trend holds; however, I think it could be a useful measure to vaccinate healthcare workers who are most at risk.

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A final thought added by Dr. Shaham – Update 2023:

We now have independent analysis of the data for many different types of Covid vaccines. They are all effective enough to be useful in preventing severe covid disease (covid getting you sick enough to be hospitalized), with the mRNA vaccines being the most effective. They have also been used in millions of people at the time I write this, including children 6 months old and above, so we know they are safe, as well, with the usual caveat of side effects after vaccination, like fever and muscle aches, and the warning of very rare allergic reactions. I received 4 doses of the Pfizer mRNA vaccine (since that was the one given to me by my hospital, I did not favor any brand), and encourage everyone who is eligible and able to, to do the same, so that they protect themselves and their community.

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Covid-19: What We Know & What We Should Do Fall 2020 Edition

We are learning new information about the pandemic and Covid-19 everyday, so this information is what I know as of October 1, 2020. Please check out all of the linked articles – they are underlined in this blog post, and should open in a new window when you click on them.

As a reminder, here is a good website for general information about coronavirus and the pandemic: Johns Hopkins Medicine.

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Covid-19 is still much rarer in children than it is in adults, but cases have risen sharply since schools have opened, and overall cases have gone up. As this AP article pointed out, younger children were less likely to be affected, but teenagers were more likely than young kids to get sick, and cases are really going up in young adults (age 18-22).  Children are also less likely to be hospitalized, but if your child is one of the rarer cases to get sick enough to require hospitalization, to get MIS-C from exposure to covid-19, to get heart damage from covid-19, or even die, then exposure was not worth it. This is why I am currently NOT recommending in-person school or daycare for anyone. Another thing to consider with daycare or in-person school, is that for every regular cold/fever your child gets, they will likely need to stay at home and isolate for 14 days (this varies, please see the chart below and speak to your doctor for individual advice), since covid tests still have a pretty high false negative rate, and it is difficult to rule out covid without a 2 week wait. This generally means paying for daycare/school, but still needing to find alternatives for your child at home for weeks at a time. For a good blog post going over most scenarios of illness in a state with open schools, please see Dr. Stuppy’s recommendations. Here are 2 images copied from her blog about common scenarios for her school district:

I know virtual school is not fun – I’m having a very hard time with it myself! However, the risks of my child getting covid-19 are not worth the benefits of learning or socialization at this time. I enjoyed this comic from Vox about the stress of remote learning on parents. school_meme_18_1

Another reason you do not want your child (or anyone) having covid is that it can damage the heart. Even if someone just has a fever and sleeps it off at home with covid, and does NOT need to be hospitalized, the American College of Cardiology recommends a gradual return to play protocol. This is similar to what we do after someone has a concussion, so please see your pediatrician, and have them do a cardiac exam (listening to heart with a stethoscope, checking pulses with their hands, looking over the child in person), before resuming any strenuous physical activity.

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The safest thing everybody can do at this time, is continue to stay home and limit contact with other people. The biggest risk is spending time together with other people – the virus is spread by breathing in germs that are breathed out by other people, especially “superspreaders”, – so wearing masks and staying away from others is the only way to prevent the spread right now. Cleaning surfaces is nice, and may help prevent other infections, like staph, e coli, and RSV, but it is not a good defense against covid. Some even refer to this obsessive surface cleaning as “hygiene theatre“. UCSF has a nice summary of how masks protect us, and Johns Hopkins Medicine has a good blog with graphics on how to properly wear masks.

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Finally, now (as always), is a good time to talk to your kids about living a healthy lifestyle. Virtual school can lend itself to too many hours of screen time, too little time being active, and overeating. Combat this by setting up limits on your devices, using apps like Family Link on Android devices / Chromebooks (I like the features on this, espeically the ability to make time limits on individual apps), parental controls on Apple devices, Family Safety on Microsoft/ Windows devices (I find these controls to be very limited, and work best from the website, but not the app), and the Bark App for overall monitoring (I like the ability to designate certain apps during school hours, certain apps for free time, and the monitoring of text messages and websites by the app for dangerous content).

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Encourage kids to be physically active for at least an hour a day. Take walks, jump around, do free yoga classes on zoom, or whatever you can manage. Remind your tweens and teens of the dangers about smoking or vaping, and that it can be especially harmful if they get covid (see the article linked here).  Encourage them to drink a glass of water instead of reaching for a snack. When they do want a snack, make fresh fruit and vegetables readily available. Encourage them to eat the rainbow! Don’t forget to keep everyone in your family up to date on all of their vaccinations! The last thing you want is to have a fever or cough or rash for any reason during a pandemic – even if you don’t have covid, you will miss school / work, and increase your chance of catching covid by needing to go out to the pharmacy and other places for help.

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Understanding American Health Insurance

Health insurance in the U.S.A. frequently changes and is never to simple. Two different people may both have “Aetna PPO”, for example, but with different plans within that insurance company, because they work for different companies, or signed up for different levels. Therefore the same plan name may cover different physicians, procedures, and medications, and have different deductibles or fee schedules, so that two people who think they have the same insurance actually have very different medical bills.

For PPOs: Before seeing your physician for anything, check with their office as to the officially billed name or doctor’s name (often only the main doctor that owns the practice) that is billed to your insurance, then check with your insurance that this physician is covered. Ask ahead about any regular procedures for your child’s next check-up (like vision screening at 6 months old, and lead screening at 9-12 months old), then you can check with your insurance company ahead of time to make sure those individual procedures are covered benefits, and if not, how much they will cost.

For HMOs, your primary care physician name is on your insurance card, and you can only go to that person’s office for your primary care. You must also see this doctor in order to get an official referral before seeing a specialist or having any imaging or lab tests done.

Here are some handy blog links to help you learn more about insurance. Good luck!

Health Insurance Overview: Here and here.

Health Insurance Basics from the U.S. Government

U.S.A. Insurance Today

Prior Authorization Calls

 

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Books For Tweens & Teens

Parenting a tweenager (around 9-12 years old), when puberty begins can be a stressful time for the whole household, with hormones running rampant, bodies sprouting hair, new smells, and kids trying to figure out what is normal. Below is a list of books (with information about them below each one) for you and /or your child to read during this time, to help everyone out.

Some more tips before having “the talk” with your child (or any talk, really):

  • Try to be calm and open about the topic (pay attention to your body language and tone of voice).
  • Avoid shame.
  • Accept & support their feelings.
  • Set rational and consistent limits.
  • Encourage your child to ask you questions, and to learn that coming to you with their thoughts is never bad.

THE BOOKS

  • “Everything You NEVER Wanted Your Kids To Know About Sex (but were afraid they’d ask)” by Richardson & Schuster

This is really the best book for parents to read on the subject. It tackles every stage of development, as well as other topics, such as homosexuality. I recommend starting to read this book when your child is young, although it’s never too late to learn.

  •  “The Care & Keeping of YOU 1: The Body Book for Younger Girls” by Natterson, from AmericanGirl

This is the most popular puberty book in the market. My tween patients report that they love this book. It goes over what to expect in puberty, and how to take care of girls’ changing bodies. It is full of illustrations. Rated age 8-10, this book is best before puberty really starts. Once puberty is in full swing, the 2nd version of this book is better (see below).

  •  “The Care & Keeping of YOU 2: The Body Book for Older Girls” by Natterson, from AmericanGirl

Rated age 10-12, this book is the second in the series, not a newer version of the first. It is for girls with some understanding of puberty, who need more details. It goes over the physical and emotional changes of puberty, but also practicalities, such as how to insert a tampon. It still has a simple writing style and lots of illustrations, so it is not recommended for older teenagers.

  •  “Guy Stuff: the Body Book for Boys” by Natterson

This is the boy’s equivalent book to the popular girl version “The Care and Keeping of YOU 1” mentioned above. It is rated age 9-12, but having read it, I think it is more for 8-10 year olds. Every page is full of illustrations, and it covers just the basics of puberty: changing body, changing voice, mood, bullying, shaving, eating well, exercising, but not sex. Unfortunately, there is no part 2 for older boys.

  • “Boy’s Guide to Becoming a Teen” by Middelman & Pfeifer, from The American Medical Association

This is the book I like to use for older tween and teen boys. It has simple, but thorough, medically accurate information about growing, puberty, and sex. There is a chapter on masturbation. There are still some cartoonish pictures and it does not go into a lot of detail, so it is probably best for ages 10-13.

  • “Let’s Talk About S-E-X” by Gitchell & Foster, from Planned Parenthood

Rated for ages 9-12, this book is meant to be read by tweens and their parents, to help with understanding and open discussion. The end of many sections have questions to open discussion and learn. The end of the book has a section to help parents talk to their kids about sex. It also lists websites for tweens, teens, and parents, to further the discussion, with good, age-appropriate information. Despite the name of the book, it does not go into depth about sex, but does provide basic, medically accurate information, without shame. I highly recommend this book for all families with kids starting puberty.

  • “A Smart Girl’s Guide: Knowing What to Say: Finding the Words to Fit Any Situation” by Criswell, from AmericanGirl

Tips, techniques, and actual suggested conversations for how to handle more than 200 situations common for tweens. Rated age 8-12. Helps kids handle real life. Part of the Smart Girls series, but good for all genders.

  • “A Smart Girl’s Guide: Drama, Rumors & Secrets: Staying True to Yourself” by Holyoke, from AmericanGirl

Reviews indicate younger kids and those starting middle school tend to get the most out of this, but a lot of the book talks about social media or phone etiquette, which may not be useful to younger girls. Rated age 8-12. Best read by both tweens and their parents, to help open up discussion, as well as help kids with the drama they may face at school. My only critique is that this is written for girls, when it could be written regardless of gender.

  •  “It’s Perfectly Normal: Changing Bodies, Growing Up, Sex, and Sexual Health” by Harris & Emberley

This book is rated for age 10 and up, and is the best selling book in “children’s sexuality” on Amazon, but it is not my favorite. It has a lot of information, including topics such as birth control and abortion, but still uses cartoons, which may make it unappealing to older kids. It is good for younger tweens, if you do not mind them reading about all topics on sexuality, and want to discuss it with them afterwards.

For books recommendations for younger children, please see my previous blog post on the topic: Private Parts.

For information on protecting your child from sexual abuse, as well as talking about sex, I recommend The Mama Bear Effect. 

For families of trans youth, I recommend starting with The TransYouth Family Allies, as well as the resources from one of  the large trans youth centers at most major children’s hospitals. Here in Los Angeles, both CHLA and UCLA have centers to help trans children. 

Note: cover photo borrowed from https://www.commonsensemedia.org/blog/how-to-talk-to-kids-about-difficult-subjects

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A Spoon-full of Sugar Helps the Medicine Go Down

Lots of parents have trouble getting their children to take medicine, so here are some tips to help:

Some techniques to help medicine go down easier:

Marry Poppins was right- a spoon-full of sugar helps the medicine go down! More accurately, a spoon-full of chocolate syrup will cover up the taste of most yucky medications. Apple sauce and yogurt are other common foods used to mask bad tastes. Many medications can be made to taste like your child’s favorite flavor by the pharmacist before you even pick it up, so ask about this when you submit your prescription. Some medications come in “orally dissolving tablets” which kids (age 3 and older) can put in their mouth and they will dissolve without having to chew or swallow.

Liquid meds are often easiest to give to babies with a syringe (a tube that looks like shot, but does NOT have a needle on it), which you can get at any pharmacy, baby store, or from your physician. Squirt small amounts of medication into your baby’s cheek and they’ll usually swallow it. Don’t squirt it directly onto their tongue or into the back of their throat, as this can lead to gagging. Follow-up with breast milk or formula (whatever they normally drink), before giving the next part of the dose. Alternatively, you can put the liquid medication in a bottle nipple along with a little breast milk/formula, and have them suck directly from the nipple, without the bottle attached. I do not recommend mixing the medication in a whole bottle, unless you know the baby will take the whole thing regardless of taste.

Most baby stores also sell special devices to help kids swallow medications,such as something that looks like a bottle, but keeps the medication separate, so you know exactly how much the child takes. I do not recommend giving children medications with droppers, because it’s difficult to measure the amount you’re giving, difficult to get all of the medication out of the dropper, and difficult to clean and dry the dropper fully between each use.

Learning how to swallow pills:

Once your child is ready to swallow pills (often by age 5!), it’s a great help to teach them how, since many medications are easier to take in pill form, the older they get, the bigger the dose, and some medications are not available in liquid/ chewable form. Starting young can also be beneficial in preventing anxiety associated with swallowing pills. Adolescents and adults often have trouble swallowing pills because they fear that the pill will get stuck in their throats. Relaxation techniques and deep breathing can help. Looking in a mirror, sticking your tongue out, and saying “aaah” out loud (this lifts the palate so you can see your throat), can help people see that their throat is much bigger then the pill, and ease some of the anxiety.

The first step in learning how to swallow a pill is to practice with something that is NOT medication. I recommend starting with small, smooth, round candies (such as mini m&m’s), and progressing to slightly larger candies (such as regular m&m’s). People with anxiety may want to start with tiny candies, such as sprinkles. Other people prefer to start with tiny bread balls (made from mashing a tiny piece of bread between your fingers), and go progressively bigger, since the bread dissolves easily in the throat. You will also need a big glass of water, juice, or carbonated beverage (such as plain soda water, which the pill can float on).

Younger kids can be told to just try swallowing the candy without chewing, because they are often successful without thinking about it. Older children, or those without a natural tendency to swallowing whole pieces, can start by visualizing the item floating down their throat on water, like a little boat. They should start by making sure the mouth is moist, by salivating or taking a sip of their drink. Nest place the candy as far back on the tongue as possible, using the teeth to scrape the candy to the back of the tongue (a mirror helps some people see how far back it is). Then take a big gulp of the liquid, which should float the candy and allow it to be swallowed, just as you would usually swallow any regular drink. Some children will swallow the candy (and later pills) more easily by drinking the liquid through a straw.

When it comes to taking real medicine, some people hide their pills in mini-marshmallows, which are slippery when wet, and therefore easier to swallow. I recommend trying this without medication first, since these are bigger then most pills. You can also try covering the pills in chocolate syrup, applesauce, yogurt, or jam (but see the warnings below before trying that).

I suggest experimenting with these techniques in a relaxed environment until you find something that works for you.

Warnings:

These techniques are for generally healthy children, with normal anatomy and mentation! They should not be used for children with any anatomical abnormalities, dysphagia (trouble swallowing regular foods or drinks), or any medical conditions that effect swallowing, the head/face, the GI system, or the neurological system.

All children should be supervised when practicing swallowing candies, and when taking ANY medication. NEVER tell your child that the medication is candy, as this can cause them to sneak some more when you’re not looking (many medications these days actually do taste like candy). Always keep medications (over the counter and prescription) and vitamins/ supplements out of reach AND in a LOCKED container. Kids are good at climbing and getting into high cabinets, purses, closets, and other hiding places.

Please speak to your pharmacist (who is usually in the back of the store, who has spent at least 5 years in post-graduate university studies, getting a doctorate degree in pharmacy), about what you can take your medication with, and whether you can cut, crush, chew, or open the medication. Many medications should NOT be taken with grapefruit juice. Some medications should NOT be taken with anything dairy. Some pills can be crushed and mixed with foods, where as others can not. Your pharmacist and/ or physician are the best people to speak to before taking your medication with anything but water.

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Car Safety

Motor vehicle injuries are the leading cause of preventable death and disability in children in the USA. Using the right car seat the right away can prevent your child from getting hurt!

Vehicle Safety Information & CarSeat Review Sites:

The CDC 

The CarSeat Lady (PICU mommy doctor who specializes in car safety)

CarSeats For the Littles

The CarSeat Blog

Safe Kids Worldwide

Bureau of Highway Safety

NTHSA Car Safety

Tips for traveling with children in general

The Biggest Mistakes Parents Make:

1) Not installing the carseat properly

Most parents think they have installed the car seat correctly themselves, but 71% of car seats are not installed or used correctly!

The best thing to do is have your car seat installed and checked by a certified professional. You can find car seat inspection locations here and here.

You can get advice on how to install all types of car seats here.

2) Putting the baby/child in with straps too loose, too high or low, and the chest clip not at the chest

Many parents place their child in the seat, but leave the chest clip too low and/or the straps too loose. The Car Seat Lady has a nice video explaining how to get your new infant in the seat just right. Remember, the chest clip should always be at armpit level. See above graphics (borrowed from the internet) for more information.

3) Turning a toddler forward facing too soon

Children should be at least 2 years old and have reached the maximum weight or height for rear-facing in their chair, before being turned around. Regardless of age or size, it is 5 times safer to be rear-facing!!

This video demonstrates why kids under 2 years old are in greater danger when facing forward in a crash.

This blog post by Dr. Stuppy is my favorite explanation on why kids should be rear-facing and stay in car seats as long as possible.

This website goes over common car seat direction myths.

This infographic goes over how car seats work, including forward vs rear-facing.

4) Putting a child in a booster, instead of a car seat, too soon

Parents often want to move their kids to booster seats as soon as possible, for the convenience of having a lighter, more portable, cheaper seat, but it’s NOT convenient if your child is hurt in a minor accident because you moved them too soon (and it will cost you a lot more money than a new car seat, too).

Children will always be safer in a 5 point restraint (aka harness system), than using a regular seat belt. I often remind my patients that race car drivers use a harness system, and don’t rely on simple seat belts to keep them safe.

More information on how to decide when your child can move to a booster can be found on CSFTL and TheCarSeatLady.

5) Letting the child use a regular seatbelt too soon

This is also a matter a cost and convenience, as well as peer pressure, but don’t let what other people do put your child at risk. Most children need to ride in a booster seat until at least age 10, since they need to be at least 57″ (4 foot 9) to fit with a regular seatbelt. TheCarSeatLady has another good explanation on how and why booster seats work. Aside from height, they also need to be mature enough to sit straight and still i  the car, since if they are leaning over in a crash, the seatbelt will not be in the proper place, and may not protect them as well as it can.

6) Letting a child/tween sit in the front seat

Children that are not fully skeletally mature (e.g. have not gone through puberty yet), and are younger than 13 years, should not sit in the front seat. Dr. Burgert does the best job explaining why on her blog. Regardless of age, size, or type of seat, everyone is safer in the back seat.

7) Using an old carseat

Carseats from online sites, such as Craig’s List, may have microfractures in them from unreported accidents or being too old. For your first baby, use a new carseat, or one you can guarantee has never been in a car that had an accident and has not expired. For more information on car seat expirations check out BabyLic’s post.

No one wants to think about getting into a car accident, especially when you’re transporting your most precious cargo. But with tens of thousands of deaths from motor vehicle collisions every year, no parent can afford to take chances. The odds are reasonably high that you will be involved in some kind of car accident before your littlest one turns 18. If your children are with you, you want to have done everything in your power to reduce the risk that they will suffer serious injury, and you will demonstrate to them the importance of car safety for when they have families of their own.