Dr. Elise Herman

Pediatric food allergies

HealthNews · Sep 12, 2019 ·

KVH Contributor*

Dr. Elise Herman
KVH Pediatrics

We seem to hear a lot more about food allergy lately – and for good reason. Food allergy is more common in kids than adults, the prevalence of it is increasing, and 8% of all kids under the age of 6 have food allergies. Understanding food allergy and the newest recommendations about peanut allergy is important for parents and anyone interacting with children.

A food allergy is an abnormal immune response of the body to a particular food. You must be exposed to a certain food at least once (either by eating directly or via breast milk) in order to have an allergic reaction. An allergic reaction occurs when the immune system’s IgE antibodies react with the food, which releases histamines. These histamines cause the signs and symptoms of food allergy that range from mild to life threatening.

90% of all food allergies are caused by the following foods: milk, eggs, wheat, soy, tree nuts (walnuts, almonds, etc.), peanuts, fish, and shellfish. In children, eggs, milk and peanuts are the most common causes of food allergy. Severe reactions are usually caused by peanuts, tree nuts and seafood. Children often outgrow their allergies; 80-90% of milk, egg, wheat and soy allergies resolve by age 5 years. Allergies to peanuts, tree nuts and seafood are more likely to persist. Approximately only 1 in 5 children will outgrow their peanut allergy.

An allergic reaction to a food usually occurs within minutes to hours of eating it. In addition to hives and wheezing, a child may also have itching, swelling of lips/ tongue, shortness of breath, stomach pain, lowered blood pressure, vomiting, diarrhea and/or anaphylaxis (a severe shock-like reaction). Testing for food allergy is only done if there is a strong suspicion of allergy; an abnormal test does not always mean the child is truly allergic. Testing may include blood tests or a skin prick test.

Treatment for food allergies most importantly means avoiding that food (and similar foods) – not easy in today’s world of processed foods that may contain many ingredients. Even a tiny amount of the offending food can trigger a reaction. Epinephrine is the only treatment for severe allergic reactions and comes in the form of an auto-injector called Epi-Pen. Allergy specialists typically do allergy testing and decide if a child should have an Epi-Pen. It is crucial that anyone who will have contact with a child who has a severe food allergy is aware of this and has access to (and knows how to use) an Epi-Pen.

There has recently been exciting news about peanut allergy, which affects 2% of all children. Previously the recommendation was to wait until at least age 1 year for peanut products but it has been shown that earlier introduction actually decreases a child’s risk of peanut allergy. New guidelines from the National Institute of Allergy and Infectious Diseases state that for those children at highest risk – those with severe eczema and/or egg allergy – blood testing should be done by age 4-6 months, and if abnormal the child should see an allergist.

For children who have mild to moderate eczema, peanut products may be introduced and given regularly starting at age 6 months. If the infant has no eczema or food allergy, peanut products may be introduced “freely” into the diet and given regularly with other foods at age 4-6 months (ideally solids are begun at 6 months for breast-fed infants). It is important to remember that peanut products may be a choking hazard. A small amount of smooth peanut butter blended into other foods such as applesauce or oatmeal is ideal. If a rash or any sign of allergy occurs, a doctor should be contacted.

*Opinions expressed by KVH Contributors are their own. Managed by Kittitas Valley Healthcare, HealthNews does not provide medical advice. For medical advice, please see your healthcare provider.

Chores and Children

HealthNews · Sep 5, 2019 ·

KVH Contributor*

Dr. Elise Herman
KVH Pediatrics

Chores for Children — Little girl washing dishes in the kitchen

As parents, one of our goals is to raise our kids to become responsible, independent adults. Part of this process is having kids do chores, although it is safe to say most kids do not see the value in this activity. Besides becoming proficient at basic household duties, chores also teach kids responsibility and the importance of making a contribution. Doing chores makes kids feel needed and valued – even if they complain about it!

Chores seems to be a waning part of family life, squeezed out by pressure for kids to compete academically and be involved in lots of extracurricular activities. It has been shown, however, that giving kids chores early (starting at age 2-3) leads to good relationships with family and friends, as well as academic and early career success. Besides creating a sense of self-sufficiency, doing chores teaches empathy and consideration for others, according to psychologist Richard Weissboud of the Harvard Graduate School of Education.

So how to make those kids do chores? Ideas abound, including household chore apps and chore charts. Just the way we adults phrase the concept can make a difference. Saying, “Thanks for being a helper” was much more persuasive to kids than “Thanks for helping,” according to a recent study in the journal Child Development. Emphasizing the child’s identity as a ‘helper’ was very motivating. Telling kids that they “get to help” as opposed to “have to help” feeds into a child’s desire to be ‘grown up’.

We all like to have a choice in life – and the same holds true for kids and chores. Listing all jobs to be done and letting kids choose from the list each week increases the odds they will feel positively about their tasks. Rotating jobs is a fair way to divvy up responsibilities. Tying chores to allowance has actually been shown to be counterproductive; when paid to do housework, kids actually are less motivated to work hard and help out the family. When creating a chore chart, remember to be specific, stating the steps to a job. “Cleaning the bathroom” is vague; “scrub the toilet, clean the sink and tub” is more precise and easy to follow.

Being consistent with a time for the family to do chores together makes it more of a group activity – everyone pulling together for the greater good. Phrasing it as a time to do “our” chores as opposed to “your” chores emphasizes that doing chores is a way we take care of each other. Listing time for chores on the calendar makes the expectation very clear. Kids are also more likely to have a good attitude if we remember not to complain about our own household duties – those little ears are listening!

Start kids out early in terms of household responsibilities. Toddlers can help by putting away toys, clearing unbreakable dishes from the table and putting clothes in the hamper. Preschoolers can sweep, wash plastic dishes and empty wastebaskets. By age 8 or 9 kids can load a dishwasher, vacuum, pull weeds, etc. The child “gets to do” more and more as they get older, and you get the satisfaction of raising a self sufficient and responsible child! There might be some grumbling along the way, but doing chores is an important part of childhood and ultimately kids feel good about contributing and becoming more self-reliant.

*Opinions expressed by KVH Contributors are their own. Managed by Kittitas Valley Healthcare, HealthNews does not provide medical advice. For medical advice, please see your healthcare provider.

Childhood Obesity

HealthNews · Aug 29, 2019 ·

KVH Contributor*

Dr. Elise Herman
KVH Pediatrics

Childhood obesity is truly an epidemic. In the past 30 years, the percentage of American kids who are overweight has tripled to 17%, or about 1 in 5 children. Additionally, the very heaviest children are even bigger than previously. Adults also have an increasing rate of obesity, but it is especially sad to see kids now dealing with what used to be adult-only health issues due to obesity: Type 2 diabetes, high blood pressure, high cholesterol and lipid levels, fatty liver, sleep apnea and joint problems. Obese children are more likely to grow up to be obese adults, with increased risk of stroke, heart disease, high blood pressure and diabetes.

The emotional and psychological side of obesity is significant as well. These children have greater occurrence of depression, low self-esteem, poor body image and eating disorders. Overweight kids are also more likely to be bullied, compounding their distress.

There is no single cause of childhood obesity, but there are know factors that contribute, including the child’s diet. Diets higher in fats and simple sugars and lower in fruits and vegetables are linked to obesity. Drinking sweetened liquids such as soda and juice can count for lots of extra calories with minimal nutrition. Even diluted juice can give a child extra calories and sugar they do not need and is not recommended on a regular basis. Milk, although a good source of calcium and protein, should be limited to 16 ounces per day.

Snacking can be a major source of calories for American kids, as snacks are increasingly processed and high calorie. Some kids snack almost continuously and can take in more than a quarter of their daily calories in this way; this is especially true in 2-6 year olds. Having regular family meals with minimal snacking decreases the risk of childhood obesity.

Genetics may play a role as well, although the bigger issue may be the environment—high calorie snacks, inadequate exercise and lack of regular family meals probably contribute more than actual genetics.

Exercise helps kids maintain a healthy weight by not only burning calories but also by keeping them busy and elevating their mood. Like adults, kids may eat out of boredom or for emotional reasons; exercise works against this. Due to computer, TV, personal electronic devices and video games, however, kids are more sedentary than ever. Limiting the usage of electronics and encouraging kids to get at least 1 hour of exercise a day (with most of this being aerobic exercise) is important.

A surprising contributor to childhood and adult obesity is lack of sleep. This may be due to hormonal alterations, less regular meals and poorer food choices when sleep-deprived. It is recommended that kindergartners get 10-12 hours of sleep a night, with the amount decreasing as kids get older, with the goal for the teen to be 9-10 hours per night.

So what’s a parent to do? Like many issues, setting a good example is important. Regular family meals, minimal snacking of healthy foods such as fruits and vegetables, routine exercise (ideally outside to elevate the mood and keep us away from the kitchen!) and regulated use of technology all help. The goal should also be a healthy lifestyle and healthy habits, not a number on the scale or the desire to be thin, as this could backfire and predispose to an eating disorder. Have fun with your family as you enjoy regular meals together as well as getting out and being active, and preventing childhood obesity will be a natural healthy side effect!

*Opinions expressed by KVH Contributors are their own. Managed by Kittitas Valley Healthcare, HealthNews does not provide medical advice. For medical advice, please see your healthcare provider.

Safe Sleep for Baby

HealthNews · Jul 3, 2019 ·

KVH Contributor*

Dr. Elise Herman
KVH Pediatrics

Many parents are familiar with the recommendation that newborns should sleep on their backs, but ‘safe sleep’ is more than just the positioning of the baby. The American Academy of Pediatrics (AAP) has addressed sleep safety both in the 2016 original safe sleep policy (for newborns and infants up to age 1) and in a recent update April 2019. The Family Birthing Place at Kittitas Valley Healthcare is making safe newborn and infant sleep a focus with materials given to parents in prenatal classes, those delivering at KVH and those whose young child is seen in the KVH Emergency Department.

The fact that annually more than 2,500 babies in the US die unexpectedly while sleeping is tragic. These deaths are often due to SIDS (Sudden Infant Death Syndrome) or accidental suffocation or strangulation. The “Back to Sleep” campaign in 1994 recommended babies sleep on their backs and as a result the SIDS rate decreased by half. This continues to be the recommendation both for nighttime sleeping and naps. The crib should be free of blankets, pillows, bumper pads, stuffed animals, etc. – some call this “the naked crib”.

If desired, babies can sleep in a wearable blanket or sleep sack to keep them warm enough at night – but not too warm. It is better for babies to ‘sleep cool’ than get overheated while sleeping. Swaddling with a thin breathable cotton blanket is fine until 1-2 months of age. The swaddle should be snug around the chest but looser around the legs so the baby can move her hips freely. It is important that the swaddling blanket cannot get up around her face.

The sleeping surface should be flat and firm- it should not indent when baby is lying on it. Devices that aim to position the baby a certain way for sleep (like the “Rock N Play”) have been found to be dangerous and are not recommended. Babies should sleep close to the parents’ bed but in their own space (i.e. crib, bassinet, portable crib). The AAP recommends room sharing ideally for the first year of life but at least for the first 6 months.

Although room-sharing is recommended, bed-sharing is not. Baby may come into the parents’ bed only for feeding and comforting and then be returned to his own ‘sleep space’ when the parent is ready for sleep. Babies should never sleep on a couch, armchair, or other soft surface as these pose a significant suffocation risk.

Smoke exposure is associated with an increased risk of SIDS; if a parent is a smoker they should smoke outside of the home and change clothes before being near the baby. Ideally, they should quit smoking for their own health as well as that of the baby’s.

All parents are tired, all parents want their newborns and infants to sleep well, but sleep safety is vital. Having babies sleep in their own space, on their backs, not over-bundled, on a firm, flat surface, and without anything else in the bassinet or crib is essential for sleep safety.

For more information here is the link to the AAP’s policy:
SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment https://pediatrics.aappublications.org/content/138/5/e20162938

*Opinions expressed by KVH Contributors are their own. Managed by Kittitas Valley Healthcare, HealthNews does not provide medical advice. For medical advice, please see your healthcare provider.

How to Raise a Great Kid

HealthNews · Mar 18, 2019 ·

KVH Contributor*

Dr. Elise Herman
KVH Pediatrics

There are lots of parenting books and websites out there, but in trying to keep it simple, here are some tips on how to raise a great kid:

Talk and sing to your baby while you hold, feed or play with him; eye contact and face to face interaction promotes brain development.

Start books early with your baby and read to her every day – make it part of the bedtime routine. If you speak a second language at home, read books in that language, too.

Get outside with your child every day (unless absolutely too cold, icy, etc.) – good for kids and adults! Getting outside is healthy exercise and good for us emotionally as well.

Start family meals with your child as soon as she starts eating solids (4-6 months) and continue through adolescence. Family meals promote healthy eating, connection with each other and have been shown to decrease risky behaviors in teens.

No screens (other than looking at photos or doing video chat such as Skype, though even this should be limited) until 2 years. Avoid fast moving content such as cartoons and stimulating videos, which has been shown to lead to trouble paying attention later in life. Slow moving content such as Mister Rogers/Daniel Tiger makes more sense to kids. Avoid YouTube especially if you are not watching with your child since you do not know what will be ‘recommended’ for him to ‘watch next’.

Put your phone or other devices away when with your child. We adults miss out on valuable interactions with our kids when we are distracted by technology. We are sending a clear message to them that they are not as important as the phone, etc. And of course our kids want to imitate us and be on a phone, too – not what we want to encourage!

Establish routines for meals, naps and bedtime. We all thrive with a predictable routine.

Play with your child – really play! Channel your inner child, pretend, be silly, play dress-up, play tag. Let your child lead and encourage unstructured play with her peers; the adults can be nearby but not directing/controlling what happens. Play has been called “the work of childhood” because it is so important to kids.

Praise good behavior right at the time you see it. Ignore the little things he does “wrong” but be consistent if there is a real problem – hitting, disrespect, etc. Spanking is not effective discipline but having a “time-out”, taking away privileges and natural consequences (for example if a child throws food off the high chair tray and he has been told not to, meal time is over) are. Stay calm; yelling is scary and bewildering to kids.

Chores make kids feel valued and also encourage a sense of family responsibility. Kids learn how good it feels to help out and to be counted on. When they (eventually!) leave home, we want them to have the skills to be independent adults. Yes, that means scrubbing the toilet!

Wait until your child is at least 14 years old to have a cell phone (Microsoft CEO Bill Gates’ recommendation!), and many experts suggest a flip phone (no Internet) for at least one year to see if the child is responsible enough for a ‘smart phone’. Better yet, ask why she ‘needs’ a smart phone. Given the risks of social media (anxiety, depression) and the negative effect on reading, getting outside, family time, etc. it is reasonable to avoid the smart phone until much older. Your child may not be happy, but is a parent’s job to do what is best for the child, not to make him happy.

Elise Herman, MD, is the mother of 2 terrific kids who are by no means perfect!

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

The truth about vaping

HealthNews · Sep 13, 2018 ·

Contributor: Dr. Elise Herman, KVH Pediatrics

As parents, we are vigilant about so many things- alcohol, drug use, Internet and technology issues. Here’s one more, and one that can fly under the parental radar. Vaping (using an electronic cigarette to inhale a vapor usually containing nicotine) is increasingly common among youth and has become very popular over the last 5 years.

Currently, more high school students use e-cigarettes then standard cigarettes. Although often touted as helping smokers quit, there is no evidence to support this, and when used by non-smokers, vaping may lead to nicotine addiction. In fact, youth who vape are more likely to use cigarettes or other tobacco products.

E-cigarette liquid typically includes nicotine (although not always), chemicals to vaporize the liquid (like propylene glycol) additives and flavoring. There are also other potentially harmful ingredients, including ultrafine particles that can be inhaled deep into the lungs, formaldehyde, heavy metals (lead, tin, nickel) and flavorants such as diacetyl, a chemical associated with serious lung disease.

Of course nicotine is the biggest concern with vaping because it is clearly a habit-forming drug that has harmful effects on the heart, lungs, kidneys and more. Immediate effects include increased blood pressure, heart rate and breathing. It is a stimulant so gives the user a surge of adrenaline as well as dopamine, a brain chemical that affects sensations of pleasure and pain. This increased dopamine makes people feel more contented—easy to see how this could become addictive! Additionally, there is a lot of research showing that nicotine causes cancer.

As e-cigarettes do not actually contain tobacco, use of these has been largely unregulated in the US, but this is changing. Some cities have banned their use wherever smoking is prohibited, and other regulations are in the works. States differ in term of who may buy e-cigarettes. In Washington state, the sale of these devices is prohibited to people age 18 and younger. Online sites, however, may not ask for proof of age. The use of vapor products is prohibited in schools, on playgrounds, on elevators, etc. in our state as well.

Youth frequently favor an e-cigarette is called “JUUL” (pronounced “jewel”). It is popular because it has sleek, small packaging that resembles a flash drive, all the better to easily carry and use. Easy to hide in a pocket, easy to use even in a school classroom. It is appealing due to its kid-friendly flavors such as mango and mint. JUUL is very addictive as it contains twice the concentration of nicotine of other ‘e-cigs’. Each JUUL pod contains the same amount of nicotine as an entire pack of cigarettes. Because of its ease of use, it is increasingly common on high school and college campuses, and users often share with peers, encouraging non-users to try it. Like JUUL, other e-cigarettes may look like household items- an asthma inhaler, a car key fob, a pen.

In terms of having a conversation with your child about vaping, it is good to approach the subject non-judgmentally and not to lecture. The topic might come up more naturally if it is response to seeing someone vaping or passing an e-cigarette shop. Acknowledge that you realize it is common, often due to the mistaken idea that it is risk free. Remind your child that his/her brain is still developing and that no tobacco product or nicotine is safe. There is a real risk for people who vape to also use tobacco products. If you do use tobacco yourself, being upfront about the health risks to you and the challenge of quitting is important. Emphasize that you do not want your child to face the same problem.

More information including a tip sheet for parents is available at the websites for the U.S Surgeon General and the American Academy of Pediatrics.

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

Heins

HealthNews · Mar 1, 2013 ·

Carter Hein is just 6 months old, too young to realize that long before the day he was born, his parents were already looking out for him.

Like many first-time parents-to-be, Penny and John Hein experienced a whirlwind of emotions when they learned in November 2011 that they were expecting. This was, after all, uncharted territory for them. Both believed that top-notch prenatal care from a doctor they could count on to personally guide them through the pregnancy was key to ensuring Carter the best possible start in life. Friends recommended Dr. Bruce Herman of KVH Family Medicine – Ellensburg.

Herman and his nurse, Debbie Perry, are old hands at calming the nerves of expectant parents – and there’s good reason. He delivers about 120 babies a year and has been at the clinic 23 years. She’s got 38 years as a nurse under her belt, 28 of them at the clinic, 13 of them working side-by-side with Herman.

Perry, says Penny, “was nurturing and motherly. As for Herman, “Within ten minutes of meeting Dr. Herman you could tell he really was interested in his patients, that he loved people and cared about them,” John says. “He was warm, personable and informative. Any nervousness we had quickly disappeared.” Herman and Perry both encouraged Penny to call at any time if she had questions or concerns. More than once, Penny did.

Herman, the Heins say, has a talent for making expectant parents feel special. “We learned something new at each visit and he explained things in a way we would understand, outlining our options, recommending what he thought would be best but ultimately let us decide what was the best fit for us,” Penny says. “It was very personal.”

With normal pregnancies, patients meet with Perry and with Herman in the clinic about fourteen times prior to delivery. Regular office visits involve blood pressure monitoring, weight checks, growth measurements, checks of fetal heart tones and checks for sugar and protein in the urine. At certain points, there also are checks for increased risk of congenital abnormalities and gestational diabetes. In addition, Herman sees the patient twice at KVH Hospital for ultrasounds.

Despite the number of pregnancies handled annually in the practice, Perry says there’s something special about each one. “Pregnancy is such an amazing, incredible process and unique every time,” she says, noting that often something as simple as a touch on the arm or lending an ear helps build connection with patients. And while she helps educate and guide patients, she also learns from them, she says.

By the time Penny entered KVH Hospital last July 30, Penny and John felt well prepared and grateful for prenatal care they say was everything they’d hoped for. The following day, Carter weighed in at solid eight pounds five ounces.

“I couldn’t take my eyes off him,” John says proudly.

Truth is, sometimes he still can’t.

Sydney Skistad

HealthNews · Dec 1, 2012 ·

She’s only 6 years old but Sydney Skistad already knows that you don’t have to get sick to visit the doctor. Sometimes you go to get shots so you won’t get sick. Sometimes you go just to make sure you’re really as well as you’re feeling.

That’s why Sydney, a bright-eyed heartbreaker in the making, visited Dr. Bruce Herman’s office at KVH Family Medicine – Ellensburg for a check up this fall. “It was good,” she says.”He checked my heart. He checked my ears. He checked down my throat – it tickled. He checked everything to make sure it was good. Everything was good!”

And then?

“Then I got a sticker,” Sydney says, flashing a smile as her 3-year-old sister Charlotte – decked out as Rapunzel – dances through the living room of the Skistad home.

Dr. Herman and his staff, as it happens, are no strangers to stickers. Debra Perry, who has spent 27 of her 37 years as a registered nurse at KVH Family Medicine – Ellensburg, has handed out plenty of them. “In our practice alone we use about 1,200 stickers per year, one sticker per shot and a sticker for each child after visits,” she says.

Kids get the exams and the stickers. Perry gets the joy of working with the kids and their families. “Kids teach me something new every time I interact with them and with the people they love,” she says. “I love their honesty. Because I’ve been at the clinic as long as I have it’s been an incredible ride watching them grow up.”

Dr. Herman says well child care begins in the hospital with a newborn exam, hearing screening, screening for genetic diseases and immunization planning. Regular office visits soon follow, the first just a few days after birth, the next a week or so later. Then come exams at two, four, six and sometimes nine months followed by exams at fifteen and twenty-four months. Barring problems, visits are annual after that.

The aim is to follow the infant’s growth and development, catching significant problems as early as possible. Regular well child exams can reveal a wide range of conditions from delays in growth or development to undescended testicles, hernias and hip dislocations or other problems. Along the way, Herman and his staff provide support and guidance for new parents on issues ranging from immunizations to preventing illness.

Denee Skistad, Sydney and Charlotte’s mother, as adept at wielding a thermometer or tackling an upset tummy or earache as any mom, understands why parents sometimes find it difficult to make a well child checkup a priority. But even when a child isn’t sick there’s a certain assurance that comes from a well child checkup, she says.

“It’s tempting not to go because there’s no immediate problem,” Skistad says. “But it’s an opportunity for the doctor to check a child’s health for things that aren’t always obvious. “It’s knowing that there’s not something there that you’re missing or you can’t see. It really is about peace of mind.”