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Preventing Respiratory Syncytial Virus Infections

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Contributor Dr. Elise Herman

As the winter weather approaches, so does the ‘sick season’, including illness due to RSV (Respiratory Syncytial Virus). RSV typically starts in fall, peaks in winter, and causes cold symptoms including runny nose, cough, and fever in children and adults. Most kids have had RSV by age 2. Although usually mild, RSV can cause more serious problems like wheezing, pneumonia, and trouble breathing. These problems are more likely in premature babies or in kids with heart disease, lung issues like asthma, and immune system problems. Between 58,000 and 80,000 kids under age 5 are hospitalized due to RSV each year. Adults aged 60 and above are also at higher risk of more severe RSV illness. Reinfections with RSV are common.

Like other colds viruses, RSV spreads by the droplets released by coughing or sneezing. You can also get it by direct contact (for example kissing) or touching a contaminated surface like a counter or cup and then touching your eyes, nose, or mouth.

There is no effective treatment for RSV and since it is a virus, antibiotics do not help. There are, however, two new good ways to prevent RSV—vaccines for adults and antibody treatment for young children. Vaccines stimulate the formation of antibodies to help fight infection (active immunity). Antibody treatments give antibodies directly to the body (passive immunity).

RSV vaccines are available for those 32-36 weeks pregnant during RSV season and if given at least 2 weeks before delivery, will help protect the baby from severe RSV. RSV vaccine is also recommended for those 60 years and older.

Antibody therapy (Nirsevimab) is approved for babies less than 8 months during RSV season (if mom did not get vaccine at least 2 weeks before delivery). Nirsevimab is also appropriate for some infants aged 8-19 months with severe health issues including extreme prematurity, immune system problems, cystic fibrosis, and heart disease. Nirsevimab is an injection and lasts 5 months, so helps protect for the entire RSV season. There is another antibody treatment called Palivizumab that has been used for years, but this is only approved for very high-risk children under age 2 and requires a monthly injection.

Side effects of Nirsevimab are uncommon and include temporary discomfort, redness or mild swelling at the injection site, and a rash. Nirsevimab can be given with routine childhood vaccines and may be given if a child has mild cold symptoms. Children who have had RSV should still receive the antibody therapy due to the risk of getting infected again later in the sick season.

There may be some difficulty having enough Nirsevimab for all kids who are eligible this year; contact your child’s provider about this. Supplies of RSV vaccine for those who are pregnant or 60 and over seem adequate; check with your provider or local pharmacy.

Remember the routine ways we can all help prevent the spread of RSV and other viruses, such as frequent hand-washing, avoiding touching one’s face, staying home if sick, and wearing a mask when appropriate. Also, cover sneezes and coughs, do not share cups or utensils, and keep countertops and other frequently touched surfaces clean. Don’t forget your child’s other important vaccines including Influenza and COVID vaccines as these are also important to help keep your child healthy this winter season.

more about The contributor

Dr. Elise Herman

Blog Posts
Profile

Dr. Herman is passionate about community health outreach, school programs, and child/family health and wellness. She has more than 31 years of experience as a pediatrician in Ellensburg, Washington, the last 3 with KVH Pediatrics. In 2022 Dr. Herman mostly retired from practice and continues to contribute blog posts and remain a visible advocate for kids in the community.

WRITE Excellence in Teaching Award

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Congratulations Dr. Merrill-Steskal for being awarded the WRITE Excellence in Teaching Award for the Eastern/Central Washington region.

“This award aims to recognize and honor preceptors with a track record of excellence in teaching medical students as well as those that serve as a leader in their community. Nominations were collected from WRITE students across WWAMI. A selection committee then reviewed all nominations based on five criteria: commitment to student success, effective teaching methods, positive impact in the community, excellence as a role model for students, and commitment to continuous improvement. You have clearly demonstrated the qualities we look for in outstanding preceptors and recipients of this award.” – University of Washington School of Medicine

COVID-19 and Children- Infection and Vaccines

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Contributor: Dr. Elise Herman, KVH Pediatrics

Parents know too well what “pandemic fatigue” is. They are tired of it all- the masking, the distancing, the quarantining, the disruption of life, and the loss of a “normal childhood” for their kids. But this is a critical time in the COVID-19 pandemic as the Omicron variant surges; Omicron is certainly targeting the unvaccinated, and many of those are children.

The number of daily cases of COVID-19 in the US is over 900,000 as of January 7, 2022. 17% of these are children and most concerning is the huge jump in pediatric hospitalizations. There recently has been a 50% increase in COVID hospitalizations for kids under age 5, the biggest increase since the pandemic started. Over 82,000 kids have been hospitalized with COVID thus far, and there is now a new record for hospitalizations of kids under age 18 years- almost 800 daily. Some of these are as young as 2 months old.

Pediatric hospitals are feeling the strain, including Seattle Children’s Hospital, according to staff pediatric infectious disease specialist Dr. Danielle Zerr. Dr. Zerr noted in a recent New York Times article that the number of young children in Seattle Children’s Hospital with COVID is much higher than with previous Delta surges. Some of these very sick children have risk factors such as asthma or obesity, but many were previously healthy children without underlying problems.

Omicron seems to cause milder disease overall but can cause severe illness and is much more transmissible than the Delta variant. With so many more people getting infected, even if a smaller percentage get very sick, the total number of those who get severely ill will be very large. The unvaccinated are most at risk, and of course this includes kids under 5 years since they are not eligible for the vaccine yet. A parent’s best strategy to protect their child is straightforward: vaccinate if eligible, avoid crowded spaces (especially inside), continue masking and social distancing. Additionally, make sure all the older kids and adults in their family are vaccinated.

Those who are vaccinated can still get COVID, especially with the Omicron variant, but they are less likely to get a severe illness, and less likely to be hospitalized. If kids are fully vaccinated and exposed at school, they do not need to quarantine. Those who are vaccinated are less likely to transmit the virus, helping to keep their family healthy and their school open.

As of December 5, 2021, almost 4.8 million US kids ages 5-11 had received at least one COVID vaccine dose. There have been no cases of heart inflammation (myocarditis) in this age group which was noted to be a very rare side effect of the vaccine in young adult and adolescent males previously. It is important to remember that COVID infection itself is much more likely to cause heart problems in this age group than would the vaccine. We have had enough experience now to know the vaccine is safe and effective.

Can we imagine a time when there is ‘background’ COVID, like influenza, but not huge surges that overwhelm our healthcare systems, shutter schools and businesses, and disrupt our lives? That is the “learning to live with the virus” scenario that may be our future. To get there we need to have many more people vaccinated (including our children) to minimize the rise of new variants. Increased access to testing and better therapies to fight COVID infection will also be important. We all really do have the opportunity to help move us along towards that goal, and towards a better future for our children.

more about the contributor

Dr. Elise Herman

Blog Posts
Provider Profile

Dr. Herman is passionate about community health outreach, school programs, and child/family health and wellness. She has more than 31 years of experience as a pediatrician in Ellensburg, Washington, the last 3 with KVH Pediatrics. In 2022 Dr. Herman retired from practice and continues to contribute blog posts and remain a visible advocate for kids in the community.

Covid-19: Pediatric Insights

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medical providers that the family and the child trust can be an invaluable source of information and a big part of the decision making – Dr. Elise Herman

The AHA, American Academy of Pediatrics and Children’s Hospital Association host this panel discussion on how pediatricians and hospitals can work with parents to build trust in the safety and efficacy of the COVID-19 vaccine for children.

American Hospital Association

Insights from pediatric health care leaders on COVID-19 vaccines for children

Earlier this week Dr. Elise Herman, KVH Pediatrics, joined other pediatric health care leaders for a panel discussion hosted by the American Hospital Association (AHA), American Academy of Pediatrics and Children’s Hospital Association.

To learn more visit www.aha.org/vaccineconfidence

Resources mentioned by Dr. Elise Herman:
Speakers:
  • Yvonne (Bonnie) Maldonado, M.D., Chief, Division of Pediatric Infectious Diseases, Stanford University School of Medicine
  • Lee A. Savio Beers, M.D., FAAP, Professor of Pediatrics and the Medical Director for Community Health and Advocacy at Children’s National Hospital, President of the American Academy of Pediatrics
  • Elise J. Herman, M.D., Pediatrician, Kittitas Valley Healthcare-Ellensburg, Washington
  • Andrew Pavia, M.D., Chief, Division of Pediatric Infectious Diseases, Primary Children’s Hospital
  • Moderator: Roxie Cannon Wells, M.D., President, Cape Fear Valley Hoke Healthcare, and AHA Trustee

Tick bites in children

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Contributor: Dr. Elise Herman, MD, KVH Pediatrics

Ahhh, summer! As that much anticipated warmer weather comes, it brings with it the risk of tick bites and the diseases they can cause. Knowing how to prevent tick bites, what to watch for if your child is bitten and how to remove ticks can make us feel more ready for outdoor adventures with our kids.

Ticks have 8 legs, flat oval bodies, and vary in size from the tiny deer tick (size of a poppy seed) to the wood/dog tick (size of an apple seed). They can swell to two or three times their usual size when they have had a blood meal. After sucking blood for 3-6 days, ticks fall off on their own, often leaving a small red bump. As it feeds on the blood, some of the tick’s spit gets transmitted to the host’s body and can cause infection. Ticks must be attached for at least 36 hours to spread infection.

Washington has fewer tick-borne diseases compared to other parts of the country, but we do have cases of Lyme Disease, babesiosis, tick paralysis, and tularemia. Lyme Disease is the most common tick-borne disease in our state and the US. It is most prevalent in the Northeast, mid-Atlantic, upper Midwest, and to a lesser extent on the West Coast. It is spread by the very small deer tick. 80% of Lyme Disease starts as a circular or oval red bull’s eye rash called erythema migrans at the tick bite location within 3-30 days of a bite. It can expand to up to 12 inches and lasts 2-3 weeks. Other signs of early Lyme Disease are fever, body aches, headache, chills, and neck stiffness. If Lyme disease is diagnosed early and treated with antibiotics, progressing to later stages of the disease is very unlikely. The later stages can involve bull’s eye rashes elsewhere on the body, joint pain, temporary facial paralysis, and limb weakness.

There are steps you can take to help prevent tick bites. Avoid dense, grassy or wooded areas, and stay to the center of the trail. Ideally, everyone should wear hats, light colored clothing, long sleeves, and long pants tucked into socks. You can spray permethrin on clothing (not the skin) to decrease tick attachment. Insect repellent containing 20-30% DEET is safe for children but you should minimize its use on very young children and infants. Do not use products that combine DEET and sunscreen since sunscreen needs to be applied more frequently than DEET. Do not apply DEET to the hands of young kids or near their eyes or mouth.

Do a tick check of your child right after being outdoors where there might have been tick exposure. Look at the clothing first, then the skin and scalp. Don’t forget behind the ears, in the armpits and groin area. Showering may help prevent attachment. If you do find a tick, use tweezers to grasp it close to the skin; pull gently and slowly to remove. Try not to crush it when doing this and wash the area well afterwards.

It is important to remember that the chance of a tick bite causing any disease is extremely low. Only 2% of deer tick bites will cause Lyme Disease even in high-risk areas and here in Washington state we are at low risk of any tick disease. So, wherever your outdoor adventures take you and your kids this summer, a bit of planning to prevent tick bites and knowing how to handle them if they happen will help you to all enjoy those long summer days!

Talking about racism to children

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Contributor: Dr. Elise Herman, KVH Pediatrics

Racism is front and center now, and parents may wonder how to have important conversations with their child about diversity, equality, and discrimination. It helps to keep your discussion age-appropriate, share your feelings and listen to your child.

Under age 5 years – Studies have revealed that even infants notice different skin tones and preschool kids have been shown to view those who look like themselves more positively, so addressing racism early is important. Kids relate easily to the concept of fairness so it can simply be explained as treating someone unfairly based on how they look. Young kids may ask about why people’s skin colors are different. Explain simply that darker skin has more of the pigment melanin in it and that no skin color is ‘better’ than another. Celebrate human diversity by noting that “we are all human but can have lots of differences, too, making everyone special!”. Encourage your young child’s appreciation for diversity by reading books and playing with toys featuring people of different races.

6-11 years old – At this age, children are more aware of current events based on what they have heard and seen from adults, other kids and on the news or in social media. Ask your child about what they know and what questions they have. Kids this age understand empathy so discussing how it would feel to be judged unfairly can be helpful. Children of all ethnicities can be assured that people world-wide are upset about racism and are working to make things better.

12 and older – Kids this age are often very informed and have developed their own opinions about issues such as racism and protests. Discussing the news and current events and how it affects them opens the door to a deeper conversation. The same concepts of fairness and empathy apply, but now taking action may be a logical next step. It may be sharing something on social media, reading more about the history of oppressed peoples or attending an event.

All kids benefit from social experiences with a variety of people. Cooking food and listening to music of different cultures broadens our horizons. It is alright to let your child know that you are upset or sad about what is happening, but you also need to assure your child that they are safe in what can be a frightening time. This conversation will look different for families of color where the issue hits a lot closer to home than for whites.

As always, what we do and say speaks volumes to our children. It is vital that as parents we confront our own prejudices and biases and work to be more open and understanding. Let your kids see you speaking out against racism, embracing diversity and calling for justice for all people.

Traditional vs. Electronic Books and Your Child

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Contributor: Dr. Elise Herman, KVH Pediatrics

Simply put, reading to your child daily is one of the best things you can do as a parent. But does it need to be a traditional (paper) book or is an electronic book pretty much the same experience for your child? There have been studies that suggest reading a traditional book does have some advantages.

The Journal of the American Medical Association published a study in September 2019 that showed fewer ‘back and forth’ interactions between parents and toddlers when using an electronic tablet. This type of interplay is important as it builds connections in the brain and helps develop communication and social skills in children.

A recent study from the University of Michigan found that parents and kids interact more when reading a paper book and that communicating this way helped encourage healthy child development. Parents often asked how the story related to the child’s experiences or about the story and its characters. They also posed more open-ended questions, such as asking what the child liked about the story, which created more opportunities for a conversation between the two.

When parents and children are reading from a device, be it a table, computer or smart phone, interactions tend to be more focused on the technology itself. Comments about the device, instructions to not push buttons, how to set the volume if applicable, etc., can dominate the conversation. There has been research showing that “enhanced” digital books that have sound and animation can be distracting and therefore children do not remember the content as well.

So how best to read with your child? Although there seem to be real advantages to traditional books, reading from electronic books is still fine in addition to paper books. Here are some tips to make reading to your child the best experience:

– Read daily including at bedtime – and try not to rush
– Let your child choose the book at least some of the time (going to the library together also builds excitement for reading)
– Let your child hold the book and turn the pages
– Avoid electronic books that are “enhanced” with sound and animation
– During reading, ask questions about the story (“What do you think will happen next?”) and relate the story to your child’s life (“Remember when we went to the park and played like that?”)
– Encourage your child to point to things in the book (“Where is the rainbow?”)
– Read books with simple rhymes and repetition; your child will be more likely to ‘read’ along with you
– Make it fun! Silly voices and acting out the story makes reading very engaging to kids of all ages
– It is also good to encourage your child to look at books independently regardless of whether they can actually read yet

Be a good role model to your child, and read a lot at home. Since we don’t want our kids to see us always looking at electronic devices or a computer, make it a habit to read from traditional books, magazines and newspapers. And remember that whether it is a traditional book or at times an electronic book, it is wonderful that you are sharing reading with your child. Well done, Mom and Dad!

Managed by Kittitas Valley Healthcare, HealthNews does not provide medical advice. For medical advice, please see your healthcare provider.

Positional Plagiocephaly Prevention and Treatment

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“‘Tummy time’ while awake should start right away…”

Contributor: Dr. Elise Herman, KVH Pediatrics

When your infant is seen for a Well Child Exam, checking growth and development are the top concerns. Additionally, careful attention should be paid to your young child’s head shape. We are now in the middle of an ‘epidemic’ of head flattening, medically known as positional plagiocephaly, meaning a change in head shape due to positioning of the baby. Typically this is flattening of either side of the back of the head or symmetric flattening of the entire back of the head. This is not just a cosmetic concern as significant health issues can result from the altered head shape.

The flattening that can develop is related to a baby’s skull being relatively soft until about age 5-6 months. Babies spend a lot of time on their backs between sleeping (the recommended sleep position is on their back to decrease the risk of SIDS) and while awake until they are old enough to be rolling, sitting up,etc. If the head is turned to one side when sleeping (for example if the baby is turning to look towards a parent), this can result in localized flattening of one side of the back of the head. With this flattening on one side, it is then harder for the baby to turn their head to the opposite side. Over time the neck muscle on the flatter side can become tighter and shorter, causing the neck to stay in a twisted position (this is called torticollis). This may affect the shape of the face with jaw asymmetry and other changes. In some cases it can be related to problems with development if left untreated.

It is important to be pro-active to minimize the risk of infant head flattening. Your baby should absolutely sleep on their back, but otherwise should be up and off the back of their head a lot. ‘Tummy time’ while awake should start right away and not only helps head shape but increases the strength in your baby’s neck, chest and arms. Options for tummy time include having baby lay with their face/ chest on your chest or baby laying down over your lap. You can also have baby lay on the floor with a rolled small blanket to prop up their chest only until they are strong enough to push up on their arms. Begin with 5-10 minutes 3 times a day with a goal of about 60-90 minutes total a day by age 4 months. Babies often don’t like tummy time at first (it’s a lot of work for your little one!) but it gets easier as they get stronger.

If a baby has flattening on one side of the head, the baby can be laid down to sleep alternating their head in opposite ends of their crib or bassinet each night. This means they will have to turn their head the opposite way to continue to look at their parent and can improve head shape. Parents should alternate which arm they hold the baby in for feeding as well. Upright chairs like the Bumbo for babies not sitting yet are recommended at age 3-4 months. Front packs also help your baby be upright during the day.

If a baby has significant head turning with neck twisting (torticollis), physical therapy is usually started and can be very helpful to restore normal movement of the neck. If by 4-5 months there is significant flattening despite increasing tummy time, etc., a referral may be made for helmet therapy. Wearing a custom soft helmet with a foam liner that is adjusted over time, the head shape becomes more rounded. Helmet therapy is most effective between 4 and 12 months of age, and babies usually accept the wearing of the helmet very well. Most babies are treated with helmet therapy for 1-4 months.

Having some degree of head flattening even with lots of tummy time and upright positioning is fairly common and is not a problem if it is mild. Talk with your health care provider if you have concerns about your baby’s head shape; they can help determine if any specific treatment is needed.

Managed by Kittitas Valley Healthcare, HealthNews does not provide medical advice. For medical advice, please see your healthcare provider.

Let’s talk about vaping

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Contributor: Chelsea Newman, PA-C, KVH Family Medicine – Cle Elum

The news has recently been inundated with stories of a mysterious illness affecting those who use vaping products. The illness has led to serious lung disease and death in several previously healthy individuals. The CDC and FDA are currently investigating these vaping-linked illnesses and as of October 8, 2019 there are more than 1,299 lung injury reports and 26 confirmed deaths in the US linked to vaping products. Many of these cases involve vaping products containing nicotine and THC, the principle psychoactive ingredient of cannabis. Symptoms of the illness include coughing, shortness of breath, chest pain, fever, nausea, vomiting and diarrhea. Currently, no specific ingredient or chemical has been identified as the cause of the lung disease but all those affected have used vaping products.

Rates of vaping have been on the rise for several years and the most rapid increase has been with teenagers. Among the current vaping associated epidemic, more than 1/3 of reported lung injuries are in those 18 and younger. The 2018 National Youth Tobacco Survey found alarming increases in e-cigarette use among middle and high school aged students and 68% of kids using e-cigarettes are using flavored vape products. Manufacturers of these devices are directly appealing to children with flavors like bubble gum, cotton candy and watermelon. Devices are also made to resemble USB drives in order to discretely use without notice and deceive parents and teachers. Most e-cigarette and vapes contain nicotine, an extremely addictive substance that only reinforces the desire to smoke or vape. Nicotine also has a host of negative health impacts in the body and can alter the development of the maturing adolescent brain.

So what can be done? How can we as healthcare providers, teachers, parents, family members and friends help discourage vaping and e-cigarette use among those that we care about?

One strategy is to talk about it. Don’t assume the sweet, 14-year-old volleyball player sitting in front of you wouldn’t do that kind of thing. Kids are impressionable and easily swayed by peer pressure. Whether you are talking with your patient, student, child or friend, don’t be afraid to ask about vaping use. Be non-judgmental and give advice out of concern. Learn about the variety of vaping products and delivery systems available so that you can recognize them.

We should also be talking with adults who vape. Vaping has been touted as a smoking cessation aid for some but there are significant health risks associated with continued use of nicotine and with so called nicotine-free vape. There are several carcinogens in the agents used to aerosolize the vapor. Also, kids with parents that vape are more likely to think it is safe or acceptable.

Another strategy to curb use is to make these products less appealing and less available. Earlier this month, the Washington State Board of Health passed emergency legislation to ban the sale of all flavored vape products. This legislation lasts only until February 2020 and will be up for renewal. While it helps to address some current safety concerns, it is also a strategy to curb adolescent use and to make these products less appealing and less available while investigators look for the cause of this vaping epidemic.

If you or someone you know is vaping and would like to quit, there are abundant resources to help. Washington also has several resources including counseling with a smoking cessation coach at 1-800-QUIT-NOW or www.quitline.com. There is also a new free app called 2Morrow cessation with a customized quit plan with lessons, daily messages and reminders and access to a live coach. Healthcare providers are on the front line of treating nicotine addiction and a great resource for behavioral and medical strategies to help abstain. Please contact your local health care provider or health department for more help on smoking cessation.

Managed by Kittitas Valley Healthcare, HealthNews does not provide medical advice. For medical advice, please see your healthcare provider.