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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

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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 March 2021:

We now have independent analysis of the data for four Covid vaccines, from Pfizer, Moderna,  Astra Zeneca, and Johnson & Johnson. 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, so we know they are safe, as well, with the usual caveat of side effects for 48 hours after vaccination, like fever and muscle aches, and the warning of very rare allergic reactions. I received 2 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 all adults who are eligible and able to, to do the same, so that this pandemic can end.

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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.

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Traveling With Children

Fortunately for us modern moms and dads, anywhere we want to go is just a plane, train, or automobile ride away. Despite the conveniences of modern transit, traveling with children can be a difficult endeavor if you’re not prepared. So here are a few tips to make your journey smoother:

1) Know your rights.

This sounds funny, but a lot has recently changed in U.S.A. airport security rules. For example children under 12 do not need to remove their shoes during screening. According to the TSA’s website, you may carry as much juice and milk for toddlers as you “need until you reach your destination”. The precise definition of how much you need varies by who is screening you at security.  During one trip with my then 1 year old, the security agent at LAX insisted that 3 small juice boxes was too much for a 5 hour flight, and threw all of our drinks away. I did not know enough to argue and instead I spent $$$ buying some non-dilute juice for my child at the airport 🙁 This also brings up the point to remember to be flexible, and give yourself extra time for the unexpected.

For the latest information, check out the TSA website. For information on car seat travel rights, see this post by TheCarSeatLady.

2) Know your company.

Certain airlines and hotel chains are better at hosting children than others. Conversely, some airlines have recently banned children from first class on their flights, so don’t expect an upgrade (or even friendly service) on those airlines. In general, European and Asian companies are considered friendlier to children on flights than North American airlines, often providing coloring books, special snacks, small toys, and other treats for families.

Some airlines offer pre-boarding for families with infants and toddlers, while others have none. This may be more annoying than you think. When traveling with our then 2 year old, we had to wait until first class, business class, and everyone with a silver/gold card from the airline boarded (more than half of the passengers) before we were allowed to get on with a toddler, car seat, and hand luggage. Trying to get past the tiny aisle with people everywhere and a large car seat was not fun, and I think it disturbed the other passengers as well. Allowing us to board early, install the carseat and settle in would have prevented a lot of hassle for everyone. However, when we got to our destination we stayed at a hotel that provided us with squeaky bath toys and other amenities in the room that made us feel like family.

Check out this article on the most family friendly airlines.

 

3) More tips just for flying with children:

– Try and book a flight with as few stops as possible, as take-off, landing, and boarding are the toughest times.

– Make sure you have assigned seats together in advance. Many companies have been separating families on flights, and then you rely on your fellow passengers to switch seats so you can sit together, or charge extra money to seat families together (but a July 2016 ruling by Congress outlawed this for kids under 13 years old). This LA Times article gives tips on how to stay together.

– I take our car seat when flying with my son, to make sure he is strapped in securely during our flight (even turbulence can be dangerous to a lap child). This also ensures that he has a safe seat for automobile travel when we arrive at our destination. It is also easier for him to fall asleep during the flight in his car seat, and more difficult for him to annoy other passengers by kicking them or climbing on the chairs. We use a GoGo Kidz Travelmate to turn the car seat into a stroller at the airport. Booster seats are not necessary (or allowed) on flights, since there are no chest straps.

excited by the stuff he sees through the window
My son sitting in his carseat happily staring out the plane window

– To avoid pain from the changes in pressure in the ear during flights, teenagers and adults can chew gum or drink water to encourage swallowing, and thereby open up the eustachian tubes in their ears to relieve the pressure. For babies the best way to do this is breast or formula feeding. Breast or formula feeding has the added bonus of being a natural pain reliever. For toddlers, diluted juice in a straw cup works well. Older children can suck on lollipops to get them swallowing (and happy and distracted by candy). Nasal sprays can also help relieve congestion and prevent pain during the flight, but speak to your pediatrician about this (salt water sprays can help babies with stuffy noses, while kids with ear infections or sinus problems may need a prescription nasal spray). If all this ear tube talk is confusing, check out the ear anatomy pics on my pinterest page.

– I recommend waiting as long as possible before flying with infants. The younger an infant is, the less developed their immune system, and the more likely they are to get sick. The air on airplanes is re-circulated so it is very easy to pick up germs from other travelers, even ones who are seated far away from you. Infants younger than 2 months old who catch an illness with fever may have to undergo extensive testing, including blood, urine, and spinal fluid exams if they get sick. I know this is not possible for many families, but waiting until your infant is 9 months or older can save you a lot of hassle.

I advise checking the CDC travel web page, and making an appointment with your pediatrician at least 2 months before any foreign travel, so you can get any needed vaccinations or medications for your trip. You can also check out travel clinics in Los Angeles.

4) Have your bags packed with items that will keep your child calm, quiet and comfortable. 

I prefer small, light items. If you are used to distracting your child with your phone or other electronic items, keep in mind that you will not be able to use them on take-off or landing, and they might run out of batteries on long car trips, so make sure to pack low-tech items as well. I recommend packing a carry-on or car bag with:

  • baby wipes (good for cleaning up messes for kids of all ages, cleaning up yourself, and cleaning up icky surfaces)
  • snacks
  • your own sippy cups or bottles
  • more diapers than you think you need
  • several different sizes of ziplock bags (for messes, soiled clothes, soiled diapers, and they are just generally handy to have)
  • a medical bag (children’s acetaminophen, children’s ibuprofen, children’s benadryl, disinfectant, bandaids)
  • sunscreen (the sun through a car’s windows can burn a child, and then sun through a plane’s window has more radiation than down on the ground, so slather yourself and your child with sunscreen to avoid sunburns and -much later- skin cancer)
  • lollipops for older kids
  • extra clothes (even for older children, as it’s easy to get spilled-on during a flight or car trip, and you never know if, when or where you’ll get stuck)
  • books
  • re-usable stickers
  • dry-erase crayons/markers and board
  • a soft blanket
  • your child’s lovey (favorite blankey, stuffed animal, or other comfort item).

I’ve linked to a few of these items, as well as book suggestions, on pinterest.

Eat Pack Go has many more great travel tips, and the link is for a funny story illustrating why you shouldn’t feel bad about that huge carry on with extra supplies.

Traveling with children can be more stressful than traveling alone, but with patience, planning, and a large bag it can be a fabulous adventure.

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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!

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Private Parts: Talking to Your Child About Their Bodies, Behavior, and Babies

It is important to start speaking with your children about their bodies and behavior at an early age. If you create an open dialogue, without shame, your children will feel free to bring you their questions throughout their lives. This is often an uncomfortable topic for parents, so I have created a list of books and resources to help you get through it (scroll down). I also encourage you to discuss any questions you have on the topic with your child’s pediatrician (we are always here to help!).

Some tips:

  • Watch out for everyday opportunities to teach your child about privacy and hygiene.
  • Encourage your child to ask you questions, to learn that they can feel comfortable coming to you with their thoughts.
  • Try to be calm and open about the topic (pay attention to your body language and tone of voice).
  • Give simple and short answers.
  • Make sure your answers are age appropriate.
  • Young children take everything you say literally, so avoid metaphors.
  • Use anatomically correct terms for their body parts (i.e. penis and vulva, not “weewee”)
  • Avoid shame and ridicule.
  • Become closer to your child by showing them that you accept & support their feelings.
  • Set rational and consistent limits.

Here is a great blogpost by Dr. Claire McCarthy on getting started with the conversation: “6 Tips For Talking To Your Kids About Sex.”

I also recommend looking at the website “Empowering Our Children,” which is designed to teach parents how to protect their children from sexual abuse.

The “ScaryMommy” website has a good post on what these conversations with toddlers may look like.

My Book Recommendations:

For parents to read overall:

This is the best book for parents to read on the subject. It tackles every sexual stage of development from infancy (yup, some babies masturbate) through adolescence, as well as age-less topics, such as homosexuality. I recommend starting to read this book when your child is young, although it’s never too late to learn.

Books to read with your children (or for them to read by themselves), by age group:

Toddlers & Pre-Schoolers:

My favorite overall book for toddlers. Teaches basic anatomy, privacy, and even how babies are born.

A very simple book on pregnancy and birth to read to young children. No lies (e.g the stork), but no anatomy or private parts mentioned either.

This book is great for families that conceived via IVF, adoption, surrogacy, or traditional means. It talks about sperm, egg, uterus, and birth, but each as its own thing, and at the end it asks, “Who was waiting for you to be born?” Technically accurate, but simple, with cartoonish illustrations.

This is the classic “how babies are made” children’s book, but take a look through this book before buying it, as it is may be too explicit for some families (see the anecdote at the end of this blog post).

This book discusses inappropriate touching/abuse. It does not discuss development or how babies are made.

School Age Children:

Covers all of the basics, including proper anatomy, mostly with diagrams, and a little cartoon guidebird.

Tweens:

Very similar to the school-age version by Harris (above), but with more words, less illustrations, and more details.

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. This book includes discussions on hygiene and how to use menstrual products. There is a version for boys. There is also a version with the number 2 at the end for teenagers.

Dr. Stuppy and the Mighty Girl website also have good posts on discussing puberty.

A Funny Story About Me:

When I was 3 years old, my mother (who is a pediatrician as well) read me the book “Where Did I Come From?” I went to my religious nursery school and proceeded to tell everyone, “I was the fastest sperm!” Some of the other parents were not happy when their own children went home and repeated the same thing to them. My mom got a stern ‘talking to’ by the school. We still laugh about it, to this day. The moral of the story? Teach your children about their bodies and development before anyone else does, or you may not be happy with what they learn 😉

For newer blog posts on the subject, as they come out, you can also follow my pinterest boards on Teenagers, Parenting, and Kids’ Health.