Covid-19 Part 2: More Coronavirus

April 24th, 2020

Most of what I put in my first blog post on the 2019-2020 Coronavirus (officially SARS-CoV-2, causing COVID-19) at the beginning of March still stands, but now that we have all been sheltering in place for over a month, much has changed as well. Therefore, I decided to start a new post, rather than edit the last one.

The first thing most people ask are the symptoms, and how to distinguish them from a cold, influenza or allergy.

Covid vs Cold vs Flu Vs Allergies

The second thing I am usually asked is about the how many people are affected. Currently, the best source for information on COVID-19 cases in the USA is Johns Hopkins University. The best source for local information on what to do is your local health department (this link takes you to the Los Angeles Department of Public Health coronavirus information page, for example) and your primary care physician.

StayHome

As I wrote this, California is “social distancing” and will remain so for a while. I think social distancing should actually be called physical distancing, because the point is to stay as far away from as many people as possible. When you do need to go out you can reduce your risk of catching anything, or passing on the virus, by wearing a mask (only for kids age 2 and above!), washing your hands frequently, leaving your shoes at the door, instead of tracking in whatever is on them inside your house, and bathing and changing clothes when you get home. 

20200420_144532Why you should wear a mask (click on the sentence).

How to make a mask.

How to wear a mask correctly

How to use gloves correctly.

Food safety.

Cleaning your home.

Babies and toddlers under age 2 should NOT wear a mask and should NOT have anything covering their mouth and nose, due to the risk of suffocation.

If you or your child accidentally gets cleaning fluid, or anything else that could be dangerous, in their mouth, nose, or eyes, and they are stable, in the U.S. please call poison control – a free, 24-7 service that lets you speak to a physician specializing in toxicology. The number is 1-800-222-1222, and should be in everyone’s phones. It’s also good when your child breaks a glow stick and gets the glow-juice in their eyes or mouth, for example.

A good source of information for parents is Healthy Children from the American Academy of Pediatrics. This link is to their post on parenting in a pandemic, and this one is information for families with kids with special needs.

Another common question from parents is “How did my kid get sick now, after they’ve been home for a month?!”. My colleague Dr. Iannelli addressed this in a comprehensive post here.

Finally, please be wary of where your information comes from, and what bias it might have. The pandemic has lead to a large increase in false information being passed around. NPR has a great comic (with cats!) to help us all spot faux information

FB_IMG_1587356743760

Stay home, stay safe, and be well!

The first thing most people ask are the symptoms, and how to distinguish them from a cold, influenza or allergy.

Covid vs Cold vs Flu Vs Allergies

The second thing I am usually asked is about the how many people are affected. Currently, the best source for information on COVID-19 cases in the USA is Johns Hopkins University. The best source for local information on what to do is your local health department (this link takes you to the Los Angeles Department of Public Health coronavirus information page, for example) and your primary care physician.

StayHome

As I wrote this, California is “social distancing” and will remain so for a while. I think social distancing should actually be called physical distancing, because the point is to stay as far away from as many people as possible. When you do need to go out you can reduce your risk of catching anything, or passing on the virus, by wearing a mask (only for kids age 2 and above!), washing your hands frequently, leaving your shoes at the door, instead of tracking in whatever is on them inside your house, and bathing and changing clothes when you get home. 

20200420_144532Why you should wear a mask (click on the sentence).

How to make a mask.

How to wear a mask correctly

How to use gloves correctly.

Food safety.

Cleaning your home.

Babies and toddlers under age 2 should NOT wear a mask and should NOT have anything covering their mouth and nose, due to the risk of suffocation.

If you or your child accidentally gets cleaning fluid, or anything else that could be dangerous, in their mouth, nose, or eyes, and they are stable, in the U.S. please call poison control – a free, 24-7 service that lets you speak to a physician specializing in toxicology. The number is 1-800-222-1222, and should be in everyone’s phones. It’s also good when your child breaks a glow stick and gets the glow-juice in their eyes or mouth, for example.

A good source of information for parents is Healthy Children from the American Academy of Pediatrics. This link is to their post on parenting in a pandemic, and this one is information for families with kids with special needs.

Another common question from parents is “How did my kid get sick now, after they’ve been home for a month?!”. My colleague Dr. Iannelli addressed this in a comprehensive post here.

Finally, please be wary of where your information comes from, and what bias it might have. The pandemic has lead to a large increase in false information being passed around. NPR has a great comic (with cats!) to help us all spot faux information

FB_IMG_1587356743760

Stay home, stay safe, and be well!

Coronavirus COVID-19 Information

COVID-19 information for families

This post is to summarize all of the current information and links I have been sharing regarding the 2019-2020 pandemic #coronavirus illness, as of March 11, 2020.

To clarify, COVID-19 is the name of the illness, and the type of coronavirus that causes this illness is the SARS-CoV-2 strain. Coronaviruses in general are quite common, and usually only cause mild colds, but this new strain attaches to receptors in our lungs, instead of just our noses/ upper airways. It is more closely related to other outbreak strains that caused MERS and SARS, the main difference being that COVID-19 is far less deadly than those, while being more easy to spread. This means that more people will get sick with the mild form of the virus, and spread it. Unfortunately, the latest numbers show it is still at least 5 times as deadly as the regular seasonal flu (influenza case fatality rate, or CFR, 0.1% in the U.S.A., best epidemiology guess on total CFR for COVID-19 is 0.5% from several sources, including the American Hospital Association, but it could be as high as 10% if spread is not controlled and there are not enough hospital beds and ventilators, so anywhere from 5 times to 100 times more deadly than influenza). For more on the CFR and risks, please look at the end of this blog.

For a great video that you can watch WITH YOUR KIDS, please see Brain Pop (the links will open in a new window). You can also click here to see a comic about this new virus, made for kids, but nice for the whole family.

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Check out the World Health Organization COVID-19 Outbreak page for the latest statistics, videos, and science.

WHO Symptom Comparison

Symptoms of COVID-19 are similar to influenza, but there is still a lot of influenza going around right now, so don’t forget to get your flu shot to reduce your chances of being hospitalized or worse with the flu! Symptoms of COVID-19 to watch out for include are fever with shortness of breath.

Case Fatality Rates for COVID19 by age

The good news for parents is that young children are much, much less likely to become sick enough to need the hospital or die of COVID-19, worldwide. Children usually have mild cold symptoms, or may be silent carriers (have the virus passed to them, but get no symptoms, but be able to pass it on to others). This does not mean to ignore serious symptoms in your kids, but at least there is some hope. The elderly, especially those with lung and heart problems, are the most at risk for getting very ill and dying from COVID-19, but everyone has some risk, and everyone can spread it to the others. Therefore, we ALL need to do our part to flatten the curve! Currently, you can help by staying home, physically distancing, wearing a mask (only age 2 years and above) if you go out, and washing your hands a lot.

handwashing1

To prevent yourself from getting sick, or even passing on germs, the most important thing you can do is WASH YOUR HANDS!!!

Coronaviruses have a fatty outer layer which makes them very easy to kill with soap. Use warm water, any regular soap (it does not have to be labeled anti-bacterial), and SCRUB for more than 20 seconds. Get all of the nooks and crannies, and create friction while washing. Then rinse and dry. This method is much better than using hand sanitizer gels. Use those if there is no access to soap and water, but use soap and water when possible.

Coronaviruses can live on some surfaces for days, if not cleaned, so wipe down surfaces and clean your home and work areas with sanitizing wipes or diluted bleach (click on the underlined words for links on how to make it at home).

Try and keep your hands off your face, and remind your kids to do the same. Face masks can prevent you from exhaling your germs onto other people (regardless of which germs you have), so if everyone wears them, even silent carriers will reduce spreading the illness. However, please do NOT hoard face masks!!! Currently, there is a worldwide shortage so bad that hospitals and clinics are unable to buy them for the people that are actually at risk.

20200420_144532

If you think you might have this virus, please CALL your doctor first, do not go straight into the office.

Most clinics in the USA still do not have tests for COVID-19, as of March 10, 2020. Some clinics, especially on the West Coast, in states whose governments have agreed to pay for testing, like California and Washington, are now able to send the test to commercial labs, like LabCorp. However, that doesn’t mean your insurance or the state will pay for your specific test with your criteria, and they could be quite expensive, so please triple check.  The department of public health is running free tests for people at high risk (such as known contact of someone with COVID-19, or hospitalized in the ICU with risk factors, or very ill and recent travel history), so your physician can help direct you to where you need to go, if you qualify for testing. If you are being tested or think you might have the virus, you also need to keep yourself totally isolated until you get a negative test result, or continue to be isolated if positive. That means no school, no supermarket, no playdates, no park, etc.

If you are very ill (such as short of breath, chest pain, dehydration), call 911 or go to the emergency room. If you have fever, cough, sore throat, or other symptoms that are getting worse, or not going away with usual care, make an appointment to see your doctor – we are still seeing plenty of influenza and strep throat. However, you must let the scheduler know if you have been traveling in the last 14 days or have had direct contact with someone who is positive for the virus.

Treatment of COVID-19 is mostly supportive – alleviating the symptoms, while waiting for the body to heal itself.

Around 80% of cases just have mild symptoms, similar to the common cold, so treat it that way: nasal saline mist in the nose, a clean humidifier with distilled water, etc. For specific tips, see this post. For a small subset of people, mainly the elderly with comorbidities, especially smokers, COVID-19 can progress to pneumonia and/or ARDS, which may be deadly. Early treatment plans included steroids and antibiotics, but we now know that steroids are not recommended for outpatient treatment in most cases because they prolong the illness, and do not prevent its progression, and antibiotics are not indicated because the pneumonias that the virus cases are viral pneumonias, and there is very little secondary bacterial pneumonia. (Antibiotics only kill bacteria. Compare this to influenza, where secondary bacterial pneumonias are much more common, and antibiotics are indicated if that happens).

Here are more links with easy to read information about COVID-19:

Summary information from Dr. LaSalle.

5 Things To Do If You’re Worried About Coronavirus In The U.S. 

Mixed Messaging – What You Need To Know

A letter from a PhD in Public Health about COVID-19. 

In conclusion, prepare yourselves and your families, but there is no need to panic. This is not the zombie apocalypse, but it will be a lot worse than a bad flu season. Do your part by physically distancing, washing your hands, staying home, and encouraging social distancing. One thing that makes things out of control is people’s over reactions, so please stay calm and help your neighbors. When in doubt, ask your doctor.

P.S. A bit about CFR / Mortality Rates – as of 3/8/2020

As we get some great news on very low death rates from places like South Korea, and predictions from some US organizations, the World Health Organization conversely has higher CFR (case fatality rates) rates published. Why the discrepancy?
To get the CFR, you take the number of people who have died from the illness and you compare that to the number of people who have been infected with the virus. The humongous difference in reported rates is because of this bottom number – the number of people infected. To get this number we use the number of positive tests. But that does not account for silent carriers and people with mild diseases, except in places where they actually test everybody. 
In South Korea, they have drive-by testing for SARS-Cov-2 (the virus that causes COVID-19 illness, aka the novel Coronavirus) for everyone- if you feel sick or you just want to, you drive up, someone comes and swabs your nose, and you get results later. They currently run 15,000 tests EVERY DAY. This way they know actual background rates of how many people are infected. They publish these numbers online at their center for disease control daily. Their mortality rate is currently only around 0.6% (that’s less than 1%, which is great, but still 6 times higher than seasonal influenza’s CFR).
The WHO is also being transparent in their math, but they use numbers from many countries where they only test the people who are sick enough to be hospitalized. This is similar to what the USA does, but here we are currently only testing a small subset of those cases, so we do not have accurate numbers of how many people are actually infected in the USA. Therefore, the WHO gets a 3-4% case fatality rate based on people who are already very sick with COVID-19, not all of the people infected or exposed.
The BMJ is publishing a report that gets a CFR somewhere in between these two reports, at 1.6% for China alone, based on statistical modeling that takes into account that people with very mild disease may not be tested at all, but still uses the numbers officially given by China, which some people say is much lower than their reality.
The CFR age stratification risk chart is based on the WHO criteria, so the risks is actually likely lower than this chart. Still, it doesn’t comfort the families of the 2 men in their 20s who are currently hospitalized with ARDS in the USA as of this posting.
Case Fatality Rates for COVID19 by age

The take away from that is that we should be testing more people, and starting to quarantine ourselves more in the USA. The more we do this, the lower our own CFR will be. So please, cancel those big parties and conferences, and play some board games or do some art with your kids. It will be healthier for the whole country. 

For more on why social distancing and canceling plans is very important, click here.

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

 

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.

Stomach bugs: what to do if your child is throwing up or having diarrhea

Vomiting and diarrhea viruses are not fun for anyone. Doctors refer to the most common cause of these symptoms as “viral gastroenteritis”. Some kids just vomit, some kids just have diarrhea, and the most unlucky have both. 

Most of these illnesses do not need to be treated with medications (antibiotics can make it worse, since they also kill the good bacteria in your tummy), and anti-diarrheal medicines (like Imodium) can be harmful to children. The most important thing is to keep your child HYDRATED (more on that below). If you suspect your child has vomiting or diarrhea from food poisoning or any other type of foreign ingestion, please call poison control 1-800-222-1222, who are free and staffed with physicians 24-7!

How can you tell if your child is starting to get dehydrated?

– their mouth/lips are very dry

– they are peeing less than usual

– they are thirsty

Now what?

You need to keep your child hydrated!

– A baby can continue to breast feed or take infant formula, if they are just a little dehydrated. If they vomit after every feeding, or are refusing the breast/bottle, then try to hydrate them with an Oral Rehydration Solution, like Pedialyte. Warning: the plain ones taste like salt water, so I suggest getting a few flavored ones and trying them out, to see which ones they will take. If they refuse the bottle completely, you can try feeding them via a syringe or spoon, giving small amounts every 15 minutes.

– A child who is getting electrolytes from food (such as chicken soup, or crackers, even if it’s just a little bit) can hydrate with water. If they are not taking in any food, or if they are throwing up the food, please hydrate them with an ELECTROLYTE solution (aka Oral Rehydration Solution, aka ORS). You can buy them at most USA markets (under brand name Pedialyte, or generic versions), you can make your own by mixing 1 liter (5 cups) clean water with 6 level teaspoons (=2 tablespoons) sugar and 1/2 teaspoon salt. You can add a little bit of orange juice or a banana for potassium. Common substitutions are rice water, congee, green coconut water, or mixing gatorade with water (although I do not recommend doing this, since it is hard to get the right balance of electrolytes this way). If your child does not want to drink, try giving them sips every 15-30 minutes, or giving them the ORS/Pedialyte in frozen popsicle form.

– For every age, and everybody in the house, WASH YOUR HANDS A LOT to prevent spread/transmission of the stuff that gets you sick. Teach everyone to wash their hands in warm water, scrubbing for at least 20 seconds (2 rounds of the Happy Birthday song). Try and use real soap and water, instead of no-rinse hand sanitizers, since they do a better job at killing the tummy microbes.

But what if they keep vomiting?

– Let their tummy rest.

– Call your pediatrician, or go to the hospital, if they have signs of dehydration tat are not resolved by giving fluids by mouth (see more below).

– Ask your pediatrician if your child is old enough and healthy enough for a medication against nausea/vomiting.

– Start with no food, but still give an electrolyte fluid (like pedialyte or ORS above), for the first 12 hours.

– When they are ready/want to eat, give bland foods (e.g. the popular rice, toast, soup broth, apple sauce) and avoid foods that are fried, acidic, oily, or contain milk.

But what if they have icky diarrhea?

– Change the diaper or bring them to the toilet frequently. Use a LOT of diaper cream to keep the area from getting chapped/sore. Put on a zinc cream (like the purple desitin) as if you are icing a cake – this acts as a barrier layer, to prevent acidic poop from sitting on the skin.

– Feed them binding foods, like rice.

– Sometimes the microbes that cause diarrhea, also cause a temporary lactose (the sugar in cow’s milk) intolerance, so avoid lactose-containing stuff, like cow’s milk and cheese. You usually have to do this for 2-4 weeks after the onset of the illness, until their GI system is back to normal.

– Try a children’s probiotic with lactobacillus once per day, such as children’s culturelle.

When my patients get sick this way, I often refer them to the great patient resources at UpToDate, such as this one on nausea and vomiting in children:

http://www.uptodate.com/contents/nausea-and-vomiting-in-infants-and-children-beyond-the-basics?detectedLanguage=en&source=search_result&search=patient+information&selectedTitle=7~150&provider=noProvider

or this one on diarrhea in children:

http://www.uptodate.com/contents/acute-diarrhea-in-children-beyond-the-basics?source=see_link

How can you tell if your child is dehydrated enough to warrant intervention (like an urgent care or ER), or at least a call to your pediatrician?

– they are not urinating (peeing)  often enough (every 4-6 hours for a baby, every 6-8 hours for a toddler/child, every 8-12 hours for an older child/teenager)

– they are crying, but can not make tears

– they are an infant whose fontanel (soft spot on top of the head) is more sunken than usual

– eyes look very sunken

What are some other signs that I should call my pediatrician about, or head over to the local urgent care/ER?

– persistent high fever (above 102.5 F)

– any fever in an baby younger than 3 months old

– severe abdominal (tummy) pain

– abdominal pain that moves to the lower right side

– lethargy or decreased responsiveness

– bloody (red or black) or bright green (like pea soup) vomit or diarrhea

– diarrhea not improving after 1 week

 

The good news is that most of these illnesses pass quickly without any medications, so hang in there, and keep washing your hands with soap and warm water!

Coughs, Colds and Croup

Even though it’s a beautiful Spring here in Southern California, we are still seeing some coughs, colds and croup, so here are my tips to help keep your family comfortable as they clear their viruses:

Helping a child with nose congestion:

–          Use a nasal saline mist (the kind that comes in a metal can, not drops) to spray moisture into each nostril and help clear her out. I like the mists more than the drops because you can hold the canister right below her nose and spray it in, without touching the canister to the actual nose, and without sticking anything directly up the nose. These are also sterile, so you don’t have to worry about the water source. The mist is gentle and cleans out the nose better than the drops.

–          Use a humidifier. Only put distilled or sterile water into it (not tap water). Clean it at least every 3 days. Do NOT use the menthol or eucalyptus discs/drops that come with some humidifiers.

–          If your child suffers from allergies and is over age 4, you can use an over the counter antihistamine to help dry her up (e.g. children’s Benadryl). Under age 4: ask your pediatrician about these. Do NOT use the over the counter medications known as “decongestants” or “medicated cough syrups”, as these have been shown to have more risks than benefits in children under age 6 years old.

–          If your child is very congested you can steam up your bathroom and sit in the bathroom with your child. Make sure the air is okay and the child does not have any access to the hot water. Never leave a child alone in the steam!

–    If you want to, you can use a vapor rub on the feet or chest of a child. It has not been proven to help or hurt. However, do not let the rub get near her nose or mouth! Vapor rub placed under the nose has been reported to cause wheezing in some children, and it is dangerous to ingest. Call poison control if your child eats any of this, or gets it in their eye 1-800-222-1222 (an important number to keep in your cell phone for emergencies).

–          Children under age 2 years usually can not blow their noses, so help decongest them (e.g. get the boogies out) by using a snot sucker device such as the Nose Frida (http://www.fridababy.com/) -you put in the nostril and use to literally suck the snot out. Sounds gross, but there is a filter (which needs to be changed every day) which prevents you from getting any snot in your mouth. You can do this before feeds and before sleep, or just as needed to clear out the mucus in your baby’s nose. I like this better than traditional nasal aspirators because it’s much easier to clean, is difficult to put it too far into the baby’s nose, and it gets a lot more of the snot out. The key to good suction is to hold the other nostril closed, when you suck out boogers from the first nostril (should take less than 1 second).

Helping a child with a “wet” or “phlegmy” cough:

Do all of the above for nasal congestion plus the following:

–          Have your child sleep propped up at 30 degrees so the mucus drains easily.

–          Give children over age 1 year a big spoonful of honey twice a day. The honey has been shown to help relieve cough symptoms in kids & help them sleep, in published randomized control trials (scientific studies). The honey they used was NOT “raw”, which can have dangerous bacteria in it. nor was it Menuka. Just plain pasteurized honey from the store works.

–     Warm liquids, such as chamomile (caffeine-free) tea and lemon, or chicken soup, can help people feel better.

–          Zinc may help shorten colds and soothe sore throats, but this has not been proven conclusively. You can get this in some non-medicated cough syrups, such as Zarbees (for over age 1 since it also contains honey), or in zinc lollipops (over age 2, observing child while they eat them). If your child is over age 6 years you can give him the zinc cough drops that are available at all pharmacies, but please supervise to prevent choking.

Helping a child with a dry, barking, or croupy cough:

Do all of the above for nasal congestion & wet coughs plus the following:

–          Use a cool-mist humidifier. Use distilled/sterile water in it. Clean it at least every 3 days by rinsing out the water tank with distilled vinegar and then washing that out. Do not put oils in the water.

–          If the child is having a coughing fit, or breathing like Darth Vader, take him/her for a walk outside in the cool air, or hold him/her in front of an open freezer for a few minutes, to reduce the swelling in the throat. If that is not helping, call your pediatrician for immediate medical advice, take the child to the office or ann ER. Please call 911 if (s)he is actually having trouble breathing.

Check out other mom pediatrician blogs on the topic, such as this one from Dr. Stuppy:

http://pediatricpartners.blogspot.com/2013/12/but-snot-is-green-or-how-can-we-treat.html

Other Important Stuff:

–          If your child is wheezing, noisy breathing, breathing hard, breathing quickly, breathing with flared nostrils, or other signs/symptoms not mentioned, please call your pediatrician or 911, or take them to the ER immediately. This information is not intended to act as a substitution for speaking to your physician or using common sense!

–          If your child is breathing so hard that they have trouble walking or talking, or if their lips or fingernails turn blue, please call 911 for immediate medical assistance.

Wheezing: Tips for Kids Using Inhalers

There are different kinds of metered dose inhalers (“MDI”):

1)      A “rescue inhaler” contains Albuterol or Levalbuterol, which opens up the lungs and reduces inflammation for quick relief. Brand names include Ventolin, ProAir, Proventil, or Xopenex. 6 puffs of these are equivalent to putting 1 vial of Albuterol or Xopenex in a nebulizer and sitting with the mask on your child for 15 minutes. These are usually used on an as-needed basis, up to every 4 hours. If your child needs to use this every 4 hours for more than 24 hours, needs it more often than every 4 hours, or needs this more than twice every week, please call your pediatrician.

2)      Some inhalers are used to prevent asthma, wheezing, and breathing trouble. These are only effective when used every day on a continuous basis. They are not used for fast-acting relief of an acute breathing difficulty, but may help when used during cold or allergy season, or if started right at the beginning of an asthma exacerbation or when a child is exposed to known triggers. Brand names of some of these medicines include Flovent, Qvar, Symbicort, Dullera or Advair. Flovent and Qvar are like using the Pulmicort/Budesonide in the nebulizer. Symbicort, Dulera and Advair also have other medicines in them for stronger asthma prevention. Please discuss if and when you should use these with your physician.

3)      There are also inhalers that contain powder or are not used with a spacer. Some brand names are: Maxair autohaler, Proair RespiClick, Asmanex Twisthaler, or Pulmicort Flexhaler. None of these need a spacer to work effectively, but these are only for older children who can control breathing in the medication and not breathing out into the device.

Please see the “Asthma Education For Kids” playlist from BoosterShotComics on YouTube, especially episode #1: “Iggy & The Inhalers” to better understand the roles of different medications used for wheezing or asthma. Episode 4 explains how to use a spacer with mouthpiece.

There are 4 main brands of spacers. They may be cheaper online than from a pharmacy, but always require a prescription.

1)      Aerochamber with flow-vu. This brand is a clear tube with colored ends and teddy bears on the side. It has a two-way valve (to get the medicine in and air out) and is anti-static (so the kid can inhale all of the medicine and it won’t stick to the sides). The flow-vu allows you to see when a child gets a breath with a good seal. There is a small orange one for infants, yellow medium one for age 1-5 years old, blue one with mask for older children that still need a mask, and blue one with mouth-piece for older kids that can seal their lips around it instead of having to use a mask (more comfortable, kids can usually start doing this around age 6).

2)      Vortex Non-Electrostatic Valved Holding Chamber. This device also has a two-way valve and is anti-static. It is metal, so it is more durable and machine-washable. It comes in 1 size with different sized masks that fit on the end. This has the advantage of only needing one device as the child grows older (you just switch the mask on the end, not the whole device).

3)      Optichamber. The original device is a plastic tube with 1-way valve that most pharmacies try to give our patients. Some versions are NOT anti-static, therefore much of the medicine sticks to the plastic, instead of being inhaled by the child. The single valve can make some children feel suffocated when breathing into the mask. I do NOT recommend this device. However, there is now an Optichamber Diamond version, which is anti-static, has a 2-way valve, and can be used comfortably. It comes with different size masks or a mouth piece, all clear, and very soft.

4)      InspiraChamber. This is a clear, anti-static, valved chamber, with purple ends. It offers very soft masks with a special place in the small mask to fit a pacifier, to calm the child while they inhale. It also has a flap that moves, so you can see if the child is taking a breath with a good seal and getting the medicine.

How to Use Your Inhaler:

Before using a new inhaler for the first time, shake it up, then put it into the spacer and press it 10-15 times to prime the device (e.g. makes sure the medicine is coming out in an even dose, and not just the propellent). The next time you use it, shake it first, but you do not need to prime it.

My son playing with his inhaler and spacer to get used to it

To use a spacer with a mask:

  • Shake the inhaler before each use.
  • Put the inhaler mouthpiece into the spacer.
  • Hold the mask over your child’s nose and mouth and create a good seal. Holding your fingers like the letter C can help. If you’re using a device with flow view, you should see the flap move with each breath the child takes. Otherwise look at the child’s chest to count breaths.
  • Press the inhaler.
  • Have your child breath in and out six times (about 30 seconds).
  • Remove the mask and let your child breath normally for a minute.
  • Repeat if more than one puff was prescribed (most inhalers need 2 puffs per dose, but some use more or less).

While your younger child may not like the spacer and mask being held over his mouth and nose, it will go much quicker than using a nebulizer. Let the child play with it and practice putting it on stuffed animals or family members to make them comfortable. Some children will allow you to use it if they get to be the ones to hold it or press the inhaler (just make sure the seal is tight over their face so they get all of the medicine).

To use a spacer with mouthpiece (older children and adults):

  • Shake the inhaler before each use.
  • Put the inhaler into the spacer.
  • Have your child seal their lips around the mouthpiece and exhale.
  • Press the inhaler.
  • Have your child breath the medicine in and hold their breath for about 30 seconds. If they can’t hold their breath, they can take another breath or 2 in to get more medicine from that puff (any extra medicine should be sitting in the chamber).
  • Take the spacer out of their mouth and have the child breath normally for a minute.
  • Repeat if more than one puff was prescribed.

Keep in mind that while many experts believe that an MDI with a spacer is as good as, or better than, a nebulized treatment, some parents prefer a nebulizer, and that is okay.

If you are not sure if your child is actually wheezing, or what they have, this blog from Dr. Stuppy can help, with descriptions of different kinds of coughs and breathing, along with youtube video links.

If your child does NOT have asthma, reactive airway disease, wheezing, bronchospasm, or difficulty breathing, my post on Coughs, Colds and Croup may be more helpful.

Please note that this guide is NOT intended to diagnose or treat any illness or condition. Always speak to your own physician for advice. 

Tips for Sensitive Skin & Eczematous Kids

Part of the information is from UpToDate.com, but has been extensively revised by Dr. Shaham.
What is eczema? — Eczema is a skin condition that makes your skin itchy and flaky. Doctors do not know what causes it. Eczema often happens in people who have allergies. Another term for eczema is “atopic dermatitis.”

What are the symptoms of eczema? — The symptoms of eczema can include: intense itching (even before the rash starts), redness, rough patches of skin, small bumps, skin that flakes or skin that forms scales.

What can I do to reduce my symptoms? — Use unscented thick moisturizing creams (ointments preferred) to keep the skin from getting too dry. Also, try to avoid things that can make eczema worse, such as: being too hot or sweating too much, very dry air, stress, sudden temperature changes, harsh soaps or cleaning products, perfumes, wool or synthetic fabrics (like polyester), things that you may be allergic to (often foods for infants or pets for older kids).

Bathing Tips— Use warm water for bathing and washing hands. Use a mild, non-drying cleanser that is fragrance-free, dye-free, and allergy tested. Avoid body sponges and washcloths (friction can make the skin worse).  Gently pat skin dry with a towel, do not rub the skin. Kids with frequent eczema flares or infections can benefit from bleach baths, but ask your pediatrician first if this treatment should be used for your child.

Moisturizing Tips— Apply any special skin medications prescribed for you and then liberally apply a moisturizer. Use a moisturizer within 3 minutes of getting out of the bath, to lock in the moisture. Re-apply moisturizer throughout the day, whenever your skin feels dry or itchy. Regular petroleum jelly works very well for this. A recent study showed applying petroleum jelly 3 times a day to infants who had a family history of eczema helped prevent eczema in those babies.

More Tips— Use dye-free and fragrance-free detergents. Use an extra rinse cycle on laundry to get rid of any soap remnants. Keep fingernails short to avoid scratching. Consider weekly bleach baths if the eczema gets infected often. Check out www.eczemacenter.org  and the national eczema association for more information and videos.

How is eczema treated? — There are treatments that can relieve the symptoms of eczema. But the condition cannot be cured. Even so, about half of children with eczema grow out of it by the time they become adults. The treatments for eczema include:

  • Moisturizing creams or ointments – These products help keep your skin moist. An ointment (such as aquaphor or vaseline) can be soothing, lock-in the moisture and act as a barrier to environmental allergens. Other lotions (such as Cetaphil) help repair your skin’s barrier. These need to be applied at least 3 times per day!
  • Steroid creams and ointments – These medicines are different than the steroids athletes take to build muscle. They go on the skin, and they relieve itching, redness, and inflammation. (In severe cases, you may need to take steroids by mouth, but only under physician supervision).
  • Antihistamine pills – Antihistamines are the medicines people take for allergies and also relieve itching. Many people find that itching is worst at night, which can make it hard to sleep. If you have this problem, talk with your doctor or nurse about it. He or she might recommend an antihistamine that can also help with sleep, such as Children’s Benadryl (aka diphenhydramine HCl).

Preparing for a Perfect Pediatrician Experience

Taking your precious baby to the doctor can be a harrowing experience, but with a little preparation, it can go as smoothly as a baby’s bottom. Here are some tips for getting your children, and yourself, ready for your next visit.

Lior has his own real stethoscope
My baby gets used to the stethoscope

1)      Prepare your children in advance by reading books about going to the doctor, so they know what to expect. This is especially important for toddlers, who are old enough to remember prior visits involving shots, but is also good for older children.  Try to do this far in advance of any appointment, such as having a regular bedtime story about visiting the doctor, so your child considers it a regular thing. If your child loves a certain character, e.g. Elmo or Dora, read them a book involving that character’s visit to the doctor. Otherwise, I recommend books like the Usborne First Experiences series. I pinned links to these books (and others) on my pinterest boards (http://pinterest.com/motek42/).

2)      Get a doctor play set and have your child practice using the stethoscope, otoscope (ear light), and other tools on their family members and stuffed animals.

3)      If your child has a “luvvy” (special blanket or toy to make them feel comfortable), be sure to bring it with you to the visit, even if they only use it in bed at home. This will help comfort them.

4)      For young children, bring a doll, so the physician can check the doll first, lessening the fear the child may have about the medical tools. You can also have the doctor check mommy or daddy first, but in my experience children are comforted more by having their doll checked then their parents. It works even better when the doll has ears and a mouth that opens.

5)      Bring snacks and drinks. You never know if you will have to wait a while for the doctor to see you, or just sit and wait for a test result. Sugar has been found to be a natural pain reliever in babies, and I find that breast milk or formula for babies, juice or a lollipop for toddlers, calms them down faster than anything else after shots. One caveat- do not let them eat/drink during the visit, especially if they will have their throat checked (like for sore throat or tummy pains), as the food pieces can get in the way of the doctor having a good look, and can interfere with tests, such as the one for strep throat.

6)      Bring diapers, wipes and baggies for soiled items (these are good things to have in your bag at all times, prior to school age). You can not rely on your pediatrician having the size or brand of diapers your child uses on hand. Wipes come in handy for many things, not just cleaning little butts, and the pediatrician visit often brings out the snot, spit-up, and other fun stuff. Help the next patient have a more pleasant experience by placing any soiled items in a sealed bag, so the room does not smell bad. An extra baggy also comes in handy for soiled clothes and toys.

7)      Dress your child appropriately, and bring a blanket. Clothes that are easiest to remove or lift-up are best. No need to dress fancy. You should also bring a small blanket to cover your baby, since they will likely have their clothes removed for vitals signs (measuring) by the nurse, and you don’t put them back on until after the physician has checked your child. If you have an older child, at least have them remove any jackets and tight or complicated clothing.

8)      Bring ANY MEDICATION you have given your child, even if your doctor prescribed it, it is herbal, or over-the-counter. This is the best way to avoid diagnosis and medication errors.

9)      Entertainment. Quiet books, reusable stickers, or even movies on your phone are a good way to keep children quiet while waiting for the physician or nurse. These can also be good tools for calming children down if they get upset during the visit. I do NOT recommend these as temper tamers for everyday use, but they are fine on special occasions.

10)   Don’t forget a list of questions to ask the doctor, so you make sure to get the most out of your visit. You may also want a paper and pen to write down any diagnoses or instructions, so you don’t forget how much ibuprofen you are supposed to give when your toddler wakes up screaming at 3am. If your doctor has not brought it up, you may want to ask them what do if your child worsens, and when to return.

11)   If you need a copy of vaccination records or school forms, contact the office in advance, and do not forget your paperwork! You should also bring your insurance card (if you have one and expect the insurance to cover your visit) each time.

12)   When possible, try to schedule your visits for the first time slot of any shift, so that you can avoid a possible wait if the office gets backed up. You should also try to schedule visits for the middle of the week, or early afternoon, as Mondays, Fridays, weekends, and evenings tend to be the busiest times in the office. Alternatively, you may want to try the last appointment of the day. This will have the greatest chance of having to wait, but then neither you nor the physician feels rushed.

13)   Give yourself an extra 15 to 30 minutes to get to the appointment, find parking (or deal with public transportation delays), and complete any forms.

14)   Finally, try to relax! When you have a positive attitude, your child will feel better too.

Interviewing A Pediatrician

Originally posted on my old blog in 2012.

Recently, one of my friends asked me what questions she should ask when interviewing a prospective pediatrician, so I thought I’d share my answer with everyone.

My son is too young to be your pediatrician right now, but he’s trying.

1) What insurance do you take?

Of course, this is only important if you’re using insurance. The BEST way to make sure you are covered by your insurance is to go to your insurance and ask them directly, as some plans, even with a large network and PPO, exclude some doctors directly.

I know several families now that have health insurance for emergencies, but pay for regular doctor visits out of their own pockets, due to very large deductibles. This reduces their overall medical expenses (because they have a cheap insurance plan, only for emergencies), and allows them to see whatever doctor they like, but only as long as nobody gets sick. These families usually use free clinics for vaccinations, or pay out of pocket. If you choose this option, ask about “cash” visit prices instead.

2) What hours is the office open for well visits? For sick visits? When is your chosen primary pediatrician actually in the office during the week? Who is there to see you when they are not in (a doctor or NP)?

Keep in mind that the smaller the office, the less hours they are usually open, but the better service and more personalization you usually get. So if you want to do well visits at night or on weekends, you will probably have to go with a very large practice, but usually see a different doctor (or nurse practitioner or physician assistant) each time.

3) Who covers for your physician when they are not in the office, not on call at night, or they are on vacation?

For night call, is the person on the phone your physician, a physician from your practice, a physician from another practice, or a physician extender (NP or PA) or a phone triage nurse (someone who has a book of triage protocols that they read from)?

4) Do you use electronic medical records?

These can allow the physician on call (if they are a doctor from the same practice) to access your chart at night and on weekends, if needed.

5) Can I get a same day sick visit appointment?

These should be reserved for urgent matters, not chronic medical problems.

6) Who answers regular questions by phone during the day?

Does your pediatrician call you back even for non urgent questions? Does a nurse handle most questions about illnesses on the phone? Does another physician answer the phone when your physician is not available?

7) Are there any physician extenders (nurse practitioners or physician assistants)?

Are they the ones to see you for same-day sick visits or phone calls, or will your physician or their partner see you?

8) Are there separate sick and well waiting rooms? How long is the typical wait in the waiting room?

Recent studies have shown that this does not actually matter, as most kids do not get sick from the waiting room, although the elevator and pharmacy near the office may be bigger germ pools. However, I have included it because people like it. An alternative question to ask, is how long someone typically spends in the waiting room. Some small practices get everyone into exam rooms very quickly, whereas other places have you waiting there for an hour.

9) What is your vaccine policy?

If the physician allows un-vaccinated children in their practice, consider that your baby (who is too young to be vaccinated for certain diseases) may be exposed to somebody in the waiting room with measles, chicken pox, etc…

10) How often do you see the baby or child for regular check-ups?

This can actually vary quite a bit between pediatricians for the first 3 years of a child’s life. After that, your child is seen for an annual well check every year.

11) Do you have a website? Do you use email to communicate with patients?

12) What hospitals do you cover?

Will your chosen primary physician be the one to see your baby everyday in the hospital (when they are born and if they are admitted later) or will one of the covering physicians see them?

13) Where is the best place to park or closest public transportation stop?

I have found (at least in big cities, such as LA and NY), that the best place to park for my doctor appointments is often somewhere other than the valet parking in the medical building. The administrative assistants at your pediatrician office should be able to tell you the best place to park, as well as help you get there by public transportation, if that’s your preferred mode of transport.