Are We Going to See a Summer Surge of RSV This Year?

Folks need to understand that RSV might still be coming. If not in the next few months, then maybe this summer. And if there is no summer surge of RSV, then it will likely be back even worse next year.

A summer surge of RSV?

I know, it sounds ridiculous, right?

After all, in a typical year, RSV season begins in September or October and peaks in December or January.

Of course, this hasn’t been a typical year…

Are We Going to See a Summer Surge of RSV This Year?

Except for COVID-19, rhinovirus, enterovirus, and some adenovirus, we haven’t seen most of the seasonal viral outbreaks that we typically see each year.

There hasn't been any RSV in Texas this year.
There hasn’t been any RSV in Texas this year.

There was no RSV, flu, or seasonal coronavirus, etc.

Not that anyone has been complaining…

It was one of the bright spots that came out of all of the social distancing, mask wearing, and travel restrictions to control the COVID-19 pandemic!

So why would anyone think that we might see a summer surge of RSV?!?

The news that folks in Australia started getting hit with RSV a few months ago, when it was still summertime!

Remember, Australia is in the Southern Hemisphere and their summer runs from December to February and their autumn from March to May.
Remember, Australia is in the Southern Hemisphere and their summer runs from December to February and their autumn from March to May.

What caused the summer surge of RSV in Australia?

An unexpected surge that is also being reported in South Africa

“Recent reports from Australia described an inter-seasonal RSV epidemic in Australian children following the reduction of COVID-19–related public health measures from September 2020 to January 2021.”

Delayed Start of the Respiratory Syncytial Virus Epidemic at the End of the 20/21 Northern Hemisphere Winter Season, Lyon, France

Is it because they got their COVID-19 cases under good control early and relaxed many of their COVID-19 related public health measures, including eliminating mandates to wear masks and most restrictions on public gathering, and allowed kids to go back to school?

Whatever the reason for the surge, what is most troubling is that we may not have to wait until this summer for our own surge!

“In 2020, the first RSV cases of the 20/21 season were detected in Lyon at week 46 and 47 (Figure 1) at the same time of the southern hemisphere outbreak. A sustained detection of cases was observed from week 51, which is the expected time of the epidemic peak, to week 5. On week 6, the RSV epidemic was declared in the first French region (Ile de France) while the number of RSV cases has continued to increase in the Lyon population.”

Delayed Start of the Respiratory Syncytial Virus Epidemic at the End of the 20/21 Northern Hemisphere Winter Season, Lyon, France

France is seeing RSV too – with a 4 month delay to the start of their season. And they haven’t relaxed their physical distancing recommendations as much as Australia, as they were still seeing cases of COVID-19.

And as if all of that wasn’t enough, the summer surge of RSV in Australia is at rates that are much higher than is seen in a typical RSV season!

Wasn’t that expected?

“Our results suggest that a buildup of susceptibility during these control periods may result in large outbreaks in the coming years.”

The impact of COVID-19 nonpharmaceutical interventions on the future dynamics of endemic infections

While larger future outbreaks have been expected, most people likely thought they would start with next year’s season.

“Our findings raise concerns for RSV control in the Northern Hemisphere, where a shortened season was experienced last winter. The eventual reduction of COVID-19–related public health measures may herald a significant rise in RSV. Depending on the timing, the accompanying morbidity and mortality, especially in older adults, may overburden already strained healthcare systems.”

The Interseasonal Resurgence of Respiratory Syncytial Virus in Australian Children Following the Reduction of Coronavirus Disease 2019–Related Public Health Measures

I’m not sure anyone is ready for RSV and COVID-19 at the same time. That’s not the Twindemic folks were warning us about!

But maybe we should get ready to start seeing some RSV.

March is typically close to the end of RSV season, not the beginning.
March is typically close to the end of RSV season, not the beginning.

After all, rates of RSV are starting to increase in Florida and the South Atlantic division of the United States.

While there is no way to know if we will see this trend in other states and we may just be delaying when RSV season starts anyway, parents should know that we can always protect those who are most at risk from severe RSV disease.

“Ideally, people with cold-like symptoms should not interact with children at high risk for severe RSV disease, including premature infants, children younger than 2 years of age with chronic lung or heart conditions, and children with weakened immune systems.”

RSV Prevention

At some point, we might even have to consider changing when Synagis, the monthly shot that can help prevent RSV, is given. Should we continue giving Synagis to high risk infants this Spring and Summer, for example, instead of stopping in March?

Mostly, folks need to understand that RSV might be coming. If not in the next few months, then maybe this summer. And if not this summer, then it will likely be back with an even worse next year.

More on RSV

What is the Rule of Two/Too?

The Rule of Too/Two is an easy way to discover possible risks of genetic conditions in your family medical history.

Have you ever heard of the Rule of Two?

No, this isn’t about Star Wars…

What is the Rule of Two/Too?

If you didn’t know about the Rule of Two/Too, you will likely be very surprised to know that there are more than one of these rules!

The Rules of Two is a quick and easy way to figure our if your child's asthma is under good control.

The Rules of Two is a quick and easy way to figure our if your child’s asthma is out of control.

Remember that one now?

What about this other one?

The rule of Two/Too.

Arthur Grix proposed the Rule of Too/Two to make things simple for primary care providers when looking for genetic conditions within a family.
Arthur Grix proposed the Rule of Too/Two to make things simple for primary care providers when looking for genetic conditions within a family.

The Rule of Too/Two can help you figure out if you might have a genetic condition in your family!

After all, filling out your family medical history is pretty easy for most people. Knowing what to do with all of that information, especially how it might translate into a risk for a genetic condition is the tricky part…

“Family health history questions that result in answers using the descriptors “too” or “two”may indicate a genetic condition.”

A Toolkit to Improve Care for Pediatric Patients with Genetic Conditions in Primary Care

And that’s where the Rule of Too/Two comes in!

It reviews many of the red flags for genetic conditions and can help you figure out if you or your kids should undergo any kind of genetic screening.

The Rule of Too/Two includes:

  • being TOO tall as compared to their genetic potential for height
  • being TOO short as compared to their genetic potential for height
  • getting sick at TOO early/TOO young an age – extreme early onset cardiovascular disease, cancer, or renal failure, etc., and developing adult disorders in childhood can be a sign of a genetic cause
  • TOO many people in a family having the same condition
  • having an unusual or extreme presentation of a common condition that is TOO different than usual, like breast cancer in a male family member
  • a family member having TWO different types of tumors
  • a condition in TWO generations of family members
  • a condition that affects TWO people in the family
  • a family member with TWO or more birth defects or congenital anomalies

When you fill out your family health history, if you are using the terms ‘too’ and ‘two’ very often, then you might talk to your health care provider to take a closer look.

“Everyone is eligible for one tumor, one birth defect (ASD, cleft lip, birth mark, etc.).”

Arthur Grix, MD

The Rule of Too/Two is an easy way to discover possible risks of genetic conditions in your family medical history.

There are other genetic risk assessment methods besides the Rule of Too/Two.
There are other genetic risk assessment methods besides the Rule of Too/Two.

Which ever method you use, if you find genetic risks in your family tree, you might want to see a genetic counselor for further evaluation.

More on the Rule of Two/Too

Lab Tests That Are Often Misinterpreted

To get the most accurate results and avoid false positive and false negative results, you want to use the right test for the right patient, and then know how to interpret the results correctly.

There are a lot of good reasons that most doctors should do fewer lab tests.

For one thing, many are simply unnecessary.

And few tests are inexpensive.

Another reason, one that you likely haven’t thought of, is that sometimes lab tests are misinterpreted, leading to unnecessary treatments.

Lab Tests That Are Often Misinterpreted

In addition to false positive and false negative test results, which are an inherent risk with almost any test, you sometimes run the risk that your doctor doesn’t truly understand how to interpret the results of the test they ordered.

How is that possible?

Consider Lyme disease testing.

Unless you live in or visited an area with ticks that cause Lyme disease and you have symptoms of Lyme disease, then you don’t need to be tested for Lyme disease. If you do get tested, you doctor should use two-tiered testing – an EIA or IFA test first, and if positive, Western blot testing.

The CDC recommends two-tiered testing for Lyme disease.

How do you know if your Western Blot test is positive?

A positive IgM Western blot for Lyme disease requires at least two of the following bands of the test to be positive:

  1. 24 kDa (OspC)
  2. 39 kDa (BmpA)
  3. 41 kDa (Fla)

And a positive IgG Western blot for Lyme disease requires at least five of the following bands of the test to be positive:

  1. 18 kDa
  2. 21 kDa (OspC)
  3. 28 kDa
  4. 30 kDa
  5. 39 kDa (BmpA)
  6. 41 kDa (Fla)
  7. 45 kDa
  8. 58 kDa (not GroEL)
  9. 66 kDa
  10. 93 kDa (2)

What happens if someone only sees one of the IgM bands or four of the IgG bands? Are they going to know it is a negative test or are they going to wonder if they have Lyme disease?

Still, that doesn’t mean that you should never test patients for Lyme disease. You just want to use the right test for the right patient, and then know how to interpret the results correctly.

What other tests are often misused or can be easily misinterpreted?

  • blood allergy tests – Ever been told you’re child is allergic to everything? That’s likely because instead of a simple positive or negative result, blood allergy tests are prone to false positive results
  • the PPD test – it is important to understand that interpreting the tuberculin skin test depends on the child’s risk factors and that a previous BCG vaccine can trigger a false positive
  • rapid strep tests – prone to false positive results, picking up strep carriers, especially if you test kids who do not have classic symptoms of strep throat
  • rapid flu tests – prone to false positive results if you test when flu activity is low
  • thyroid function tests
  • monospot test – this is a non-specific test, so is not just for mono and most experts recommend that it no longer be used
  • EBV titers – titers of Epstein-Barr virus (EBV) antigens, including viral capsid antigen (VCA), Early antigen (EA), and EBV nuclear antigen (EBNA) can all appear at different points in your infection, from early on to years after you have recovered. Many persist for the rest of your life after you have had mono, which some folks confuse as a new infection or a relapse.
  • vaccine titers
  • ANA – while your anti-nuclear antibody test should typically be negative and a positive ANA can be a sign of arthritis, it is also very common for kids without any problems to have a positive or elevated ANA
  • WBC
  • vitamin D levels
  • drug testing
  • tox screening
  • covid-19 tests
  • EEGs

Why are these tests so easily misinterpreted?

False Positive Test Results

For one thing, many people underestimate the risk of false positive test results.

That’s why it is important to remember that a positive test doesn’t necessarily mean 100% that you have any specific disease or condition. It just means that you have a positive test.

“EEG will be negative in a large portion of patients with epilepsy, and may be positive in patients without epilepsy. False positive EEG findings commonly lead to unnecessary use of antiepileptic drugs and may delay the syncope diagnosis and treatment. EEGs are most helpful in specific situations when there is high pre-test probability for epilepsy based on history and exam, and clinical presentation.”

Do not routinely order electroencephalogram (EEG) as part of initial syncope work-up.

The fact that you can actually have a false positive EEG test should help you understand this whole issue a little better.

So how do you reduce the chance that you will have a false positive test result – or a false negative for that matter?

“A given test will have a higher positive predictive value in those patients with a higher prior probability of disease.”

Sensitivity, Specificity, and Predictive Values of Diagnostic and Screening Tests

You have to understand the sensitivity, specificity, and predictive values of the tests you use. And the things that influence them.

“The positive and negative predictive values vary considerably depending upon the prevalence of influenza (level of influenza activity) in the patient population being tested.”

Rapid Diagnostic Testing for Influenza: Information for Clinical Laboratory Directors

For example, when no one has the flu and disease prevalence is low, you are more likely to have false-positive rapid antigen test results. So that positive flu test this year, when no one has the flu might not actually mean that you have the flu either. It is probably a false positive, which makes you wonder why the test was done in the first place…

And know that you can’t just test everyone for everything…

More on Lab Tests That Are Often Misinterpreted

Mental Health Treatment Tips for Teens

Things your teen can do to help them cope with anxiety, depression, insomnia, and other mental health issues.

What do we do when our kids are having mental health problems?

Counseling?

Medication?

There are many tools your teen can learn to help them manage anxiety, stress, and other mental health issues.
There are many tools your teen can learn to help them manage anxiety, stress, and other mental health issues.

Cognitive behavioral therapy?

Whatever we do, there are times when they might need a little more help

Mental Health Treatment Tips for Teens

Most importantly, teens with mental health issues, like depression and anxiety, should know what to do when these specific problems flare up (follow the links for detailed advice):

  1. extra anxiety – learn to manage anxiety when it attacks with different exercises, like deep breathing, focusing on their five senses, thinking positively for 12 seconds, or laughing at a video they typically find funny, etc.
  2. extra social anxiety – are there specific social situations that make your anxiety worse during which you will need extra help
  3. extra sadness – learn grounding and mindfullness skills
  4. not being able to sleep – teens who have trouble sleeping should learn about progressive muscle relaxation and guided imagery
  5. not being able to get out of bed – call your health care provider if this happens most days and have a plan in case it happens once in a while
  6. feeling lonely
  7. wanting to self medicate – see your health care professional if you are turning to drugs or alcohol as a coping mechanism to deal with stress. Overeating is another negative coping skill to avoid.
  8. getting more easily distracted – talk to your health care provider, as this can be a sign of worsening anxiety and depression
  9. getting angry
  10. coping with a breakup – how can they deal with the heartbreak after a breakup?
  11. getting bullied – you’re not alone.
  12. feeling like you want to hurt yourself – teens thinking of hurting themselves should know that they should seek immediate help

Whatever they are going through, it is especially important that your teen knows that things will get better!

Although that often doesn’t seem likely when you are in the middle of a crisis, it is true.

That can be easier to understand once you review these stories of hope and recovery!

What else can you do?

In general, things like keeping a journal, getting daily exercise, and talking to your friends and family members are positive coping skills that can be helpful.

Create healthy habits and avoid spending too much time online.

“We all need a little extra help sometimes. If you are feeling sad, afraid or overwhelmed, talk to someone you trust – whether it is a family member, close friend, therapist, or case manager. It is important to reach out for help if you need it.”

Hey Teens! Take Care of Your Mental Health

You can also always talk to your pediatrician or other health care provider.

More on Mental Health Tips for Teens

Other Treatments for ADHD

In addition to stimulant and non-stimulant medications, behavior management therapy can help your child with ADHD.

So most people know that stimulant and non-stimulant medications are available as treatment for ADHD.

But what else is available?

Other Treatments for ADHD

Wait, why would you need to consider other treatments?

Well, believe it or not, some kids can’t tolerate stimulants.

And others either can’t tolerate non-stimulants either, or neither work for them.

So what’s left?

There’s behavior management therapy.

In fact, although it is often overlooked, it is important to remember that behavior management therapy should be the first treatment for younger, preschool children with ADHD.

“There are many forms of behavior therapy, but all have a common goal—to change the child’s physical and social environments to help the child improve his behavior.”

Behavior Therapy for Children with ADHD

And even though older kids are often treated with medication, they too might benefit from behavior management therapy.

“Under this approach, parents, teachers, and other caregivers learn better ways to work with and relate to the child with ADHD. You will learn how to set and enforce rules, help your child understand what he needs to do, use discipline effectively, and encourage good behavior. Your child will learn better ways to control his behavior as a result. You will learn how to be more consistent.”

Behavior Therapy for Children with ADHD

Typical behavior management therapy techniques might include positive reinforcement and allowing your child to earn rewards for desired behaviors and withdrawing privileges to try and decrease other behaviors.

You also want to help your child:

Some children with ADHD may also need social skills training and behavioral therapy for help controlling impulsive behavior.

Once you find a therapist, you can expect it to take time for your child to master the behavioral therapy techniques and better control his ADHD symptoms.
Once you find a therapist, you can expect it to take time for your child to master the behavioral therapy techniques and better control his ADHD symptoms.

And of course, accommodations at school (504 Plan vs IEP) can also be helpful so that your child has extra time to take tests if needed, modified instructions and assignments, and extra break time, etc.

What About Alternative ADHD Treatments?

What about all of those “other” treatments for ADHD that you might have heard about?

At those homeopathic dilutions, it is unlikely that there is any real active ingredient left in the Brillia pills. Remember, homeopathy works by the law of the minimum dose and  although it doesn't say it on the label, homeopathic medications only contain a "memory" of an active ingredient.
At those homeopathic dilutions, it is unlikely that there is any real active ingredient left in the Brillia pills. Remember, homeopathy works by the law of the minimum dose and although it doesn’t say it on the label, homeopathic medications only contain a “memory” of an active ingredient.

Restrictive diets, vitamins, minerals, brain training, and homeopathic remedies that are basically diluted to nothing…

Nutritional lithium, probiotics, and digestive enzymes…

You are actually trying to help your child with ADHD, right?

If all you have tried are alternative therapies to try and help your child with ADHD, then it's time to talk to your pediatrician about some real treatments.
If all you have tried are alternative therapies to try and help your child with ADHD, then it’s time to talk to your pediatrician about some real treatments.

Then try something that at least has a chance of working…

And if nothing works, keep in mind that your child might not actually have ADHD. Maybe something else is causing their symptoms or problems, like obstructive sleep apnea, depression, anxiety, or a learning disability, etc.

More on ADHD Treatments

Treating Hard to Control ADHD

Learn why ADHD can sometimes be hard to control and require more than just a quick prescription for Ritalin or Adderall, including adding behavior therapy, careful monitoring, and special accommodations at school.

ADHD is often much harder to treat than many people imagine.

It isn’t always just a matter of writing a script for Adderall or Ritalin and then have kids who had been failing suddenly jump to the ‘A’ Honor Roll.

ADHD Treatments

Whether your child’s ADHD symptoms include problems with inattention, hyperactivity and impulsivity, or both, the treatments are the same:

  • Stimulants – Adderall vs Ritalin based
  • Non-Stimulants – Intuniv (extended release guanfacine), Kapvay (extended release clonidine), Strattera
  • Behavior Management Therapy

Although often underused, it is recommended that behavior therapy be the first treatment for younger, preschool children with ADHD. Both medication and behavior therapy are typically recommended for older children with ADHD.

ADHD Medications

Surprisingly, there is really no one best ADHD medicine. Those that aren’t yet generic (in bold) are going to be much more expensive than the others.

  • Short Acting Stimulants – Adderall, Focalin, Methylin (chewable), ProCentra (liquid), Ritalin
  • Intermediate Acting Stimulants – Dexedrine, Ritalin SR, Methylin ER
  • Long Acting Stimulants – Adderall XR, Adzenys XR-ODT, Concerta (Methylphenidate ER), Daytrana (patch), Focalin XR, Metadate CD, Metadate ER, Quillichew ER (chewable), Quillivant XR (liquid), Ritalin LA, Vyvanse
  • Non-Stimulants – Intuniv, Kapvay, Strattera

In general, stimulants are thought to work better than non-stimulants, but again, there isn’t one stimulant that is consistently better than another.

Treating Hard to Control ADHD

What do you do when your child’s ADHD treatments aren’t working?

While it is important to “initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity,” it is important to remember that not all kids with academic or behavioral problems have ADHD.

So the first thing you should do is confirm that your child really does have ADHD. Is it possible that your child was misdiagnosed and doesn’t have ADHD at all? Or could your child have ADHD and another co-morbid condition, including “emotional or behavioral (eg, anxiety, depressive, oppositional defiant, and conduct disorders), developmental (eg, learning and language disorders or other neurodevelopmental disorders), and physical (eg, tics, sleep apnea) conditions.”

Next, ask yourself these questions and discuss the answers with your pediatrician:

  • Is your child taking his medicine?
  • Does your child need behavior management therapy?
  • Are you not getting your child’s ADHD medicine because of how expensive it is? Ask your pediatrician about a lower cost generic ADHD medicine.
  • Has there been a sudden worsening of previously well controlled ADHD, which might indicate a problem with bullying, social changes at home, abuse, or depression, etc.?
  • Are you relying on restrictive diets or other alternative treatments for ADHD that have been proven to not usually work?
  • Does your child need a different dosage of his current stimulant, either a higher or lower dose?
  • Is your child’s medication wearing off too soon?
  • Does your child’s medication take too long to work?
  • Does your child need to switch to a different stimulant or to a stimulant with a different delivery method?
  • Does your child need to switch from a long-acting stimulant to a short-acting stimulant?
  • Does your child need to switch to a non-stimulant, keeping in mind that these are often used in combination with a stimulant and not by themselves.
  • Do you need to adjust your expectations for what kind of control you can get from even maximal treatment?
  • Does your pre-teen or teen with ADHD not want to take his medication anymore?
  • Are side effects keeping your child from taking his ADHD medicine everyday?
  • Does your child need 504 plan accommodations at school and/or an IEP?

And perhaps most importantly, what is making your child’s ADHD hard to control? Is he just still having some ADHD symptoms or are those lingering ADHD symptoms causing an impairment? If they aren’t causing an impairment, such as poor grades, problems with friends, or getting in trouble at school, etc., then your child’s ADHD may be under better control than you think.

What To Know About Treating Hard to Control ADHD

ADHD can sometimes be hard to control and require more than just a quick prescription for Ritalin or Adderall, including adding behavior therapy, careful monitoring, and special accommodations at school.

More Information About Treating Hard to Control ADHD

Pediatric Referral Guidelines

These referral guidelines can help you figure out when to refer a sick child to a specialist, how quickly you should get the child seen, and what to do as part of your pre-referral workup.

As much as we like to create a medical home for our kids, there are times when we have to refer them to specialists to help diagnose or manage an issue.

It is sometimes hard to know when that time is though.

Or what you can do before you start the referral process.

Do you know what to do as part of pre-referral workup for a child with short stature?
Do you know what to do as part of pre-referral workup for a child with short stature?

Reviewing our collection of pediatric referral guidelines can help to make sure that you send the right patient to the right specialist at the right time. And can help avoid unnecessary referrals and testing!

Pediatric Referral Guidelines

This is especially important because it can sometimes take time to get a pediatric patient in to see a specialist, so you don’t want a sick child to wait months only to discover that you could have or should have done something else.

Most importantly, these types of guidelines can help you figure out when to refer a sick child to a specialist, how quickly you should get the child seen, and what to do as part of your pre-referral workup.

Do the specialists you routinely refer to have their own guidelines you can look to before referring a patient?

If not, consider reviewing these referral guidelines for:

  • adolescent medicine – abnormal uterine bleeding, eating disorders
  • pediatric allergy & immunology – allergic rhinoconjunctivitis, anaphylaxis, asthma, atopic dermatitis, drug allergy, eosinophilic esophagitis, food allergy, immunodeficiency, insect hypersensitivity, sinusitis, urticaria/angiodema
  • back pain
  • pediatric cardiology – heart murmur, palpitations, arrhythmia, abnormal ECG, chest pain, syncope, hypertension, Kawasaki, genetic disorders, premature and term infants, hyperlipidemia
  • concussions
  • developmental-behavioral pediatrics – speech/language delay, delayed milestones, ADHD, preschool behavior disorder, autism
  • eating disorders – anorexia nervosa, bulimia, avoidant/restrictive food intake disorder
  • pediatric endocrinology – hypothyroidism, hyperthyroidism, goiter, thyroid nodule, diabetes, obesity, acanthosis nigricans, short stature, failure to thrive, precocious puberty, premature thelarche, premature adrenarche, delayed puberty
  • pediatric gastroenterology – abdominal pain, celiac disease, chron’s disease, diarrhea, hematochezia, food allergy, peptic ulcer disease, GER, vomiting, constipation, failure to thrive, eosinophilic esophagitis
  • GI conditions – abdominal pain, constipation, reflux, failure to thrive, vomiting, diarrhea, celiac disease, Crohn’s Disease / Ulcerative Colitis, Suspected Eosinophilic Esophagitis (EoE)
  • pediatric headaches
  • pediatric hematology – anemia, thrombocytopenia, neutropenia, coagulation defects (bruising and bleeding)
  • infectious diseases – recurring fevers, recurrent sinusitis, FUO, recurrent abscesses
  • metabolic disorders – developmental regression, hypotonia, stroke like episodes, recurrent seizures, failure to thrive, hypoglycemia, abnormal labs, positive newborn screen
  • menstrual irregularity
  • pediatric nephrology – microhematuria, gross hematuria, proteinuria, acidosis, cystic kidneys, hypertension
  • pediatric neurology – recurrent seizures, febrile seizure, first seizure, developmental delay, tics, autism, concussion, headaches
  • pediatric ophthalmology – visual acuity, ptosis, dacryostenosis, glaucoma, nystagmus, strabismus,
  • pediatric orthopaedics – flat feet, intoeing, chronic knee pain, acute knee pain, scoliosis
  • physical or occupational therapy/hand therapy
  • pediatric pulmonology – apnea, asthma, BPD, chronic cough, cystic fibrosis, recurrent pneumonia
  • psychiatry
  • pediatric rheumatology – arthralgias, joint swelling, weakness, back pain, malar rash, extremitiy color changes, positive ANA
  • umbilical hernia
  • pediatric urology – balanitis, bladder stones, dysfunctional voider, dysuria, frequency, hematuria, hernia, hidden penis, hydrocele, hydronephrosis, incontinence, kidney stoney, labial adhesions, meatal stenosis, paraphimosis, penile adhesions, phimosis, testicular pain, varicocele, vesicoureteral reflux
  • urology – undescended testicle, phimosis, UTI, hydronephrosis

And if you’re lucky, you might learn enough in the referral guidelines to save your patient a referral!

More on Pediatric Referral Guidelines

A Diet Plan for Teens

Need a diet plan to help your teen make healthier choices when they eat?

Have your teenagers picked up some bad eating habits and put on a little extra weight during the pandemic?

A Diet Plan for Teens

To get them back on track, in addition to encouraging them to be more active, it might help to teach them some healthy eating habits.

So no, this isn’t about putting your teen on a diet…

It’s about a diet plan that can lead to a lifetime of healthy eating, an active lifestyle, and a healthy weight.

It’s a diet plan that:

  • focuses on eating and drinking a variety of nutrient dense vegetables, fruits, grains (half should be whole grains), dairy products (can include fortified plant based alternatives to cow milk), protein foods, and oils
  • advises we stick within calorie limits and avoid oversized portions
  • limits added sugars (should be less than 10% of calories per day), saturated fat (should be less than 10% of calories per day), and sodium intake (should be less than 2,300mg per day)
  • goes along with an hour of more of daily moderate-to-vigorous physical activity for an hour or more with a mix of aerobic, muscle training, and bone-strengthening activities

Sounds easy, right?

It’s actually not that hard.

A customized MyPlate Plan will help you find your child’s food group targets so that you will both know what and how much your child should eat to stay within their calorie allowance each day.

Sound too easy?

Well, maybe it is… After all, we often already have some idea of what we should and shouldn’t be eating, that we need to be more active, and if we are eating too many things unhealthy things.

The real trick is getting motivated to eat healthier and be more active!

Need some easy things to start your path to a healthier lifestyle?

  • avoid soda, fruit drinks, and other drinks with added sugar and little or no nutrition
  • get more exercise and physical activity than you have been, even if you start with just 15 minutes a day
  • eat smaller snacks and be more mindful of how many calories you are getting from your snacks
  • don’t skip meals
  • eat your meals at the table, avoiding mindless snacking while you are on a screen
  • decrease your screen time if you are frequently on a screen
  • avoid adding high-calorie, high-fat dressings and toppings to all of your food, some of which might have started out fairly healthy
  • eat more meals at home, which has likely gotten easier during the pandemic
  • take supplements if you aren’t confident that you are getting enough calcium, vitamin D, and iron from the foods you are eating each day
  • if you have been gaining too much weight, consider decreasing your portion sizes, as you are almost certainly getting too many calories each day

And then once you are on a healthier path, you can try to follow an age appropriate MyPlate Plan! Or if still need some reinforcement and more tips for healthy eating, read these articles:

And of course, your pediatrician and/or a registered dietician can also be a good source of help for your teen who needs a healthy eating plan.

More on Teen Healthy Eating Plan

Is Handwashing Drying Your Child’s Skin?

A rash on their hands might mean that you have to change how your kids wash their hands and not that they have to wash less often.

Do your kids get dry, red, and itchy hands, especially during the winter months when it gets cold?

Hand sanitizier and handwashing may be drying your child's skin.

Believe it or not, it’s probably because they are washing their hands very frequently, which is a good thing these days.

Is Handwashing Drying Your Child’s Skin?

Of course, many other things could be causing a rash on your child’s hands, but if the rash is on both hands, is worse each winter, and there are no other symptoms, then it is probably from handwashing.

Is it from excessive handwashing?

Not necessarily.

“The best way to prevent the spread of infections and decrease the risk of getting sick is by washing your hands with plain soap and water, advises the Centers for Disease Control and Prevention (CDC). Washing hands often with soap and water for at least 20 seconds is essential, especially after going to the bathroom; before eating; and after coughing, sneezing, or blowing one’s nose. There is currently no evidence that consumer antiseptic wash products (also known as antibacterial soaps) are any more effective at preventing illness than washing with plain soap and water. In fact, some data suggests that antibacterial ingredients could do more harm than good in the long-term and more research is needed.”

Q&A for Consumers | Hand Sanitizers and COVID-19

You might just need to change up how your child washes their hands, making sure that they:

  • use a moisturizing soap (Dove, Basis) or soap-free cleanser (Cetaphil, Vanicream Free & Clear), avoiding harsher, antibacterial soaps
  • apply moisturizers (Aquaphor, Vanicream, Cetaphil, Cerave, Eucerin) within a few minutes of washing, keeping in mind that greasy ointments typically are the best, followed by creams, and then lotions, although kids sometimes don’t like the feel of greasy ointments
  • avoid the frequent use of hand sanitizers, as they contain high concentrations of alcohol and can be drying, so limit the use of hand sanitizers to when soap and water isn’t available and even then, try to use a hand sanitizer with a moisturizer

But what if your child’s hands do get red and irritated? Simply applying a moisturizer probably isn’t going to be much help then, is it?

Probably not, so that’s when it’s time to also apply a steroid cream to calm the flare up. While you can start with over-the-counter hydrocortizone cream twice a day (don’t apply at same time as the moisturizers), you might need a medium strength prescription steroid cream for all but the mildest cases. In some cases, a more potent steroid might even be needed for a short time.

And of course, you should think about what else might be causing a rash on your child’s hands, especially if they aren’t quickly getting better with steroids and moisturizers:

  • does your child also have ulcers in their mouth or a rash on their feet, which might indicate Hand Foot and Mouth disease?
  • has your child recently been bitten by a tick?
  • does your child have a honey colored crusty rash on one hand, a sign of impetigo?
  • is your child working with new chemicals, solvents, wearing gloves, or doing anything else that could be triggering an allergic reaction or contact dermatitis on their hands?
  • do other people in the house have an itchy rash on their hands and arms, which could be a sign of scabies?

Fortunately, hand dermatitis from excessive hand washing and cold winter weather is typically easy to diagnosis and treat and isn’t often confused with other pediatric conditions.

More on Hand Dermatitis

Are Baby Foods Tainted With Dangerous Levels of Heavy Metals?

Review easy ways to reduce your child’s risk from heavy metals in baby food.

Why do some parents think that baby foods are tainted with dangerous levels of toxic metals?

A staff report from the US House of Representatives showed that "commercial baby foods are tainted with significant levels of toxic heavy metals, including arsenic, lead, cadmium, and mercury."

It’s likely because they recently read articles and posts about a staff report from the US House of Representatives which showed that “commercial baby foods are tainted with significant levels of toxic heavy metals, including arsenic, lead, cadmium, and mercury.”

A report that was prompted by a study last year, What’s in my baby’s food?, that found 95% of baby food tested contained lead, arsenic, mercury or cadmium.

Are Baby Foods Tainted With Dangerous Levels of Heavy Metals?

Wait, what?

Commercial baby foods really are “tainted with significant levels of toxic heavy metals, including arsenic, lead, cadmium, and mercury?”

Yes, it seems that they are.

As compared to the maximum allowable levels in bottled water that are set by the FDA, the latest report found that baby foods and their ingredients tested at up to 91 times the arsenic level, up to 177 times the lead level, up to 69 times the cadmium level, and up to 5 times the mercury level.

How has this happened?

“FDA HAS FAILED TO CONFRONT THE RISKS OF TOXIC HEAVY METALS IN BABY FOOD. THE TRUMP ADMINISTRATION IGNORED A SECRET INDUSTRY PRESENTATION ABOUT HIGHER AMOUNTS OF TOXIC HEAVY METALS IN FINISHED BABY FOODS.”

Baby Foods Are Tainted with Dangerous Levels of Arsenic, Lead, Cadmium, and Mercury

We have been hearing about arsenic in rice and baby food for nearly 10 15 years, so it is hard to make this a Trump problem…

“In the context of arsenic in baby food, there are only two FDA regulations for specific products—an unenforceable draft guidance issued in July 2013, but never finalized, recommending an action level of 10 ppb for inorganic arsenic in single-strength (ready to drink) apple juice, and an August 2020 final guidance, setting an action level for inorganic arsenic in infant rice cereals at 100 ppb.”

Baby Foods Are Tainted with Dangerous Levels of Arsenic, Lead, Cadmium, and Mercury

How about we just look at it as a problem that needs to be fixed?

Do you want the FDA to add more regulations for baby foods, ensuring that they are all safe and free of heavy metals?

To understand why that wouldn’t be a quick fix, you have to understand how these baby foods likely became tainted with heavy metals. After all, it’s not like the baby food manufacturers are adding them as an ingredient…

The problem is that the rice, vegetables, and fruits that they use to make baby food are actually tainted with arsenic and other heavy metals!

“Step one to restoring that trust is for manufacturers to voluntarily and immediately reduce the levels of toxic heavy metals in their baby foods to as close to zero as possible. If that is impossible for foods containing certain ingredients, then those ingredients should not be included in baby foods.”

Baby Foods Are Tainted with Dangerous Levels of Arsenic, Lead, Cadmium, and Mercury

Yes, let’s hope that the companies stop making baby food that is contaminated with heavy metals and if they don’t, let’s set high FDA standards for baby food to make sure that they do.

Either way, we are going to need a food supply that isn’t tainted with heavy metals…

“On August 1, 2019, FDA received a secret slide presentation from Hain, the maker of Earth’s Best Organic baby food, which revealed that finished baby food products contain even higher levels of toxic heavy metals than estimates based on individual ingredient test results. One heavy metal in particular, inorganic arsenic, was repeatedly found to be present at 28-93% higher levels than estimated.”

Baby Foods Are Tainted with Dangerous Levels of Arsenic, Lead, Cadmium, and Mercury

And no, simply switching to organic foods isn’t the answer.

What Parents Should Know About Heavy Metals in Baby Foods

So what should parents do?

One obvious thing is to keep pressure on politicians and the companies that make baby food to fix this problem.

But that’s a long term fix…

Right now, you should understand that while baby foods do likely contain these heavy metals, it is not at toxic levels that will cause immediate harm.

And understand that many of the studies on exposure to heavy metals and risks for children were not necessarily specific to baby foods, but were often on general environmental exposure.

Children are exposed to heavy metals from many sources, including parents who smoke, lead in paint and water, and mercury in seafood, etc.
Children are exposed to heavy metals from many sources, including parents who smoke, lead in paint and water, and mercury in seafood, etc.

Still, you should work to decrease your child’s risk of exposure to heavy metals from food by:

  • avoiding apple juice, as like rice, apples can take up arsenic in the soil they are grown in, although keep in mind that infants shouldn’t be given any juice anyway
  • feeding your kids a variety of rices and grains, including oatmeal, barley, multi-grain rice, basmati rice, millet, and quinoa, etc. – remembering that iron-fortified cereals are a good source of iron, so typically shouldn’t be avoided all together
  • looking for rice-free baby snacks and limiting how many rice crackers and rice cakes your older kids eat
  • avoiding teething biscuits, as they are typically made with rice flour
  • offering your baby a variety of vegetables, understanding that carrots and sweet potatoes are often the ones that are most heavily contaminated with heavy metals, so continue to give since they are also high in nutrients, but mix in with a lot of other veggies
  • offering a variety of plant based milks if your older child has a milk allergy (giving breastmilk or an iron fortified infant formula until 12 months), so that they aren’t just drinking rice milk

What else can we do?

“Chemicals are part of our daily life. All living and inanimate matter is made up of chemicals and virtually every manufactured product involves the use of chemicals. Many chemicals can, when properly used, significantly contribute to the improvement of our quality of life, health and well-being. But other chemicals are highly hazardous and can negatively affect our health and environment when improperly managed.”

Action is Needed On Chemicals of Major Public Health Concern

We can focus on real risks, instead of the never ending parade of things that we might be told to worry about, from pesticide residues and sunscreen ingredients to vaccines and GMOs.

Instead of allowing yourself to be overwhelmed and scared of made up risks, focus on things that really might affect your kids, like this news about heavy metals in baby foods.

But even then, understand that the risk isn’t so high that you have to throw out of the jars of baby food you just bought and start making your own. Just give your child a good variety of foods, so that they don’t get too many of the same foods that might contain heavy metals.

And no, you don’t have get your kids tested for heavy metals if your main concern is exposure to heavy metals in baby food…

More on Heavy Metals in Baby Foods