Avoiding, Treating Stingray Injuries

As beach season kicks into high gear, swimmers, surfers and sunbathers of all ages should be mindful that one wrong step can turn a fun beach day into a total wipeout.

Unwitting beach goers can easily get stung by a stingray when they inadvertently step on the creatures while walking though waters. Lurking stingrays are often invisible because they burrow and blend in well with the sand in shallow waters.

sting ray

When disturbed, the ray flips up its sharp tale and can pierce the swimmer’s leg, foot or ankle. Though not venomous, the stings are painful and the stinger’s puncture wound poses a risk of infection or allergic reaction, says Sheryl Riccardi, a registered nurse and clinical educator in the Julia and George Argyros Emergency Department at CHOC Children’s.

Treatment for stings is simple, Sheryl says. First, parents of children who have been stung should remove the stinger. Next, soak the wounded area in hot water until the pain is gone. Other methods to remove the stinging sensation include a vinegar rinse or baking soda paste, as well as over-the-counter pain relievers.

Stings should be reported to lifeguards, and parents of stung children should seek further medical treatment if the wound is still store or burning about 24 hours after the sting occurs, Sheryl says.

Though particularly common in areas with long beaches and shallow waters, stings can be prevented.

Try practicing what lifeguards call the “stingray shuffle.” Instead of taking full steps through shallow waters, drag feet across the sand. The goal is to gently disturb a burrowed ray so that it will swim away.  Stepping on top of the creature will frighten it and increase the likelihood of an attack.

While much less common in Orange County than in other U.S. waters, jellyfish stings should be handled in the same manner as stingray stings.

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6 summer sun safety tips

As temperatures rise and school is out of session, your family could likely be spending more time outdoors than inside. The American Academy of Pediatrics recommends limiting sun exposure (and avoiding it for babies) as the best way to prevent sunburn, but when you are spending time outdoors, keep in mind these sun safety tips:

  • Everyone over six months of age should wear sunscreen whenever they’re outdoors, every day of the year. Infants less than six months old should be kept out of the sun as their skin is especially susceptible to sun damage.
  • Apply sunscreen with SPF (sun protective factor) 30 at least 15-30 minutes before you go outside
  • The sun is everywhere, so apply sunscreen everywhere. Don’t forget your hands, nose and ears.
  • Reapply every two hours, and after swimming, sweating or toweling off.
  • Wear a wide-brimmed hat and sunglasses for extra protection.
  • Double-check medications, as some may cause a greater sensitivity to sunlight

There are other precautions you can take to minimize harmful sun exposure. Limit time spent outdoors between the hours of 10 a.m. and 4 p.m. Avoid tanning oils or salons- tanning increases the risk of melanoma and accelerates skin aging. Drink plenty of water throughout the day to avoid dehydration, which could make it harder to produce sweat and cool down your body.

Learn more safety and wellness tips from CHOC’s community educators.

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Meet Dr. Perry Eisner

CHOC Children’s wants its patients and families to get to know its specialists. Today, meet Dr. Perry Eisner, a pediatric anesthesiologist at CHOC Children’s at Mission Hospital. Dr. Eisner attended the Ohio State University School of Medicine. He studied pediatrics at the University of California Irvine including completing rotations at CHOC. He completed his pediatrics training at Harbor-UCLA Medical Center. After becoming board-certified in pediatrics, he completed a specialized program at UCLA including a general anesthesiology residency with a fellowship in pediatric anesthesia and pediatric critical care medicine. He has been the chief of surgery at CHOC Children’s at Mission Hospital for six years, and has been on staff at CHOC for over 20 years.

Dr. Perry Eisner
Q: What are your special clinical interests?

A: My interest is in making surgery as stress-free as possible for both my pediatric patients and their families.

Q: What are your most common diagnoses?

A: My patients have a range of conditions. We have everything from trauma patients with brain injuries or children with orthopaedic injuries to kids with head and neck problems. It runs the gamut.

Q: What would you most like community/referring providers to know about you/your division at CHOC?
A: At CHOC at Mission, we have four fellowship-trained pediatric anesthesiologists and ensure that children undergoing surgery have not only the safest but also the best experience possible. There is not a hospital in the county that provides a higher level of care.

Q: What inspires you most about the care being delivered here at CHOC?
A: What inspires me the most is the dedication of the entire team that CHOC Children’s has assembled to care for pediatric surgical patients. From the surgeons and the nurses to the critical care physicians and the hospital-based physicians, it is a team that cannot be matched. We have practitioners that were trained in the finest facilities in the country and who care not only about delivering state-of-the-art care, but also care equally about reducing the stress of an illness or surgery for both our patients and their families.

Q: Why did you decide to become a doctor?
A: I became fascinated with medicine when I was in high school and worked in an emergency room in downtown Cleveland as an orderly. I have also loved interacting with children. I found that when one works with kids, you can take a horrifying and stressful situation and transform it into a minor event. That is my goal each day in the operating room.

Q: If you weren’t a physician, what would you be and why?
A: Honestly, I don’t know. It’s all I’ve ever wanted. I didn’t have a back-up plan. It’s not something I’d recommend, but it’s not something that I did. I didn’t have a plan B.

Q: What are your hobbies and interests outside of work?
A: My hobby is playing racquetball. I began playing 40 years ago and play two to three times per week.

Q: What have you learned from your patients?
A: With kids, when they’re going through something stressful, I find that you can divert their attention by doing something that they think is funny or makes them laugh. I’ve learned though that this works for adults too. It seems so natural with kids, but it works just as well with adults as kids. When there’s something stressful going on, if you can divert your attention to something light or funny, it can get you through anything.

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The Dangers of Secondary Drowning

By Dr. Georgie Pechulis, pediatric hospitalist at CHOC Children’s

Dr. Georgie Pechulis

With Memorial Day weekend right around the corner, it generally signals the beginning of summer and the opening of the much-anticipated pool season. Our kids will undoubtedly be awaiting their water time with endless excitement, and we as parents will do our best to keep them safe. Amidst our best efforts to educate ourselves and our children on water safety, drowning still tends to peak in these summer months. Secondary drowning is another danger, albeit rare, that parents should be aware of.

What is secondary drowning?

We as pediatricians actually don’t like this term, since it creates a lot of confusion.

Drowning is defined by the International Liaison Committee on Resuscitation as, “a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium.” So what does that mean? Any event from being in water that causes problems breathing, whether it is primary, secondary, wet or dry, or any other forms of drowning.

Secondary or delayed drowning refers to the phenomenon of water inhalation, followed by presumed recovery, and respiratory problems that appear afterwards. Often the story involves being underwater or inhaling water with immediate symptoms that appear to go away.  However, vague symptoms persist and cause breathing problems long after the event, to the surprise of parents. It is a subset of drowning and thankfully, is relatively rare.

Here are a few of the most common questions I receive from parents about secondary drowning:

My child coughed after accidentally swallowing some water- should I bring him to the ER?

Fortunately, most simple aspiration events are not serious. Parents will need to look for the persistence of symptoms. In other words, you’ll notice your child hasn’t returned to his or her normal breathing or behavior after the incident.

  • Breathing: Your child is working hard to breathe by using his belly muscles or if you notice her nostrils flaring or head bobbing. Also, look out for persistent coughing even long after the event, and darkness or blue coloring of the lips.
  • Behavior: You notice your child is not acting right. He or she is lethargic, irritable, or not their usual self. This will be different from what you’re normally used to. Use your parental instinct.

My child seemed fine. What happened?

If water irritates the lungs, it can cause inflammation, fluid buildup, and difficulty for the body to receive the oxygen that you breathe. Sometimes these effects happen long after the event has occurred. We expect these symptoms to show within 24 hours after aspiration of water.

 If you have any of these concerns, please seek medical attention with your pediatrician or even the Emergency Department if your child appears in distress.

How can I keep my child safe?

As always, the best way to keep your child safe is to monitor them at all times in the water and to ensure they do not have any access to potential water hazards.  This includes not only pools, but filled bathtubs, hot tubs, lakes, koi ponds, and fountains.

  • Never leave them unsupervised. For toddlers or any children who are not able to swim, an adult should be within arm’s reach at all times. Never leave the child unattended, even if it is to quickly run in the house and grab something. Commonly, drowning occurs when caregivers briefly leave the child unattended to grab cameras, phones, food or drink, etc. Appoint dedicated and qualified adult supervisors to substitute watch if you need to leave.
  • Supervise without distraction. Your job as the supervisor is to do so without distraction. No cell phones, no reading materials, and no distracting conversations. Those brief lapses of attention are when incidents can occur. It’s an important job to supervise your kids in the pool and really key to ensuring your child’s safety.
  •  Drowning is usually silent. The typical drowning scenario in a movie usually depicts arm flailing, screaming, and water splashing in all directions. The truth is that most drowning occurs without noise. Often the child struggles quietly and slips under the water without a sound. Always be alert and on the watch, for it may not be obvious.
  • Be aware of your environment. If you are visiting a family or friend’s home, be aware of any potential water dangers nearby. Homes that do not usually have children often have open access to pools, spas, and natural bodies of water such as ponds and lakes. Children are curious and will want to explore new environments. Be alert.

As a hospital pediatrician and as a mother, often I hear the stories of caregivers shifting their attention to engage in conversation, running in the house to grab something, or other forms of quick distractions that lead to these accidents. If I could ask anything, it’s that we just take time to really focus on protecting our kids by being their undistracted monitor.  We want them to enjoy many endless summers of water time to come.

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Warnings signs of depression and suicide in children

All children experience days or periods of sadness or other deep emotion. It’s when those feelings are persistent and last longer than a several weeks that it may be time to seek professional help, according to mental health experts at CHOC Children’s.

Suicide is the second leading cause of death for individuals ages 10-24 in the United States. Suicidal children and adolescents may have depression, or a combination of other mental illnesses such as anxiety disorder, attention deficit disorder, bipolar disorder, or child-onset schizophrenia, says Dr. Heather Huszti, chief psychologist at CHOC Children’s.

Dr. Heather Huszti

Other signs that children may be depressed include:

  • Changes in behavior, including appetite
  • No longer enjoying activities they used to like
  • Changes in sleeping pattern
  • Always feeling tired,
  • Isolating themselves socially
  • These changes may be especially concerning if connected to a significant loss or change

“It’s difficult to imagine that children as young as 10 could attempt to end their lives, but unfortunately it can happen,” says Huszti. “The first thing parents can do to help their children is talking openly about mental health issues and any concerns they might have, including talking about the potential warning signs.”

Download your copy of CHOC’s “Let’s Talk About It” guide and learn how you can help start a conversation about mental health.

Warning signs that a child may be considering suicide include:

  • Giving away possessions or making a will
  • Threatening, planning, or joking about suicide
  • Sending despairing texts or online messages
  • Expressing feelings of failure or shame
  • Avoiding friends and social situations
  • Engaging in risky behavior

Always take warning signs seriously, advises Huszti. If your child, or anyone else, is in immediate danger of self-harm, call 911. Other local and nationwide resources are available, such as 24/7 suicide prevention lines and 24/7 crisis response services.

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4 Water Safety Tips for a Safe Summer

As temperatures start to rise, your family may be spending more time at the pool or the beach. Keep these water safety tips, straight from CHOC Children’s community education department, top of mind to ensure your family has a safe and worry-free summer.

  1. Assign a water watcher

Children need supervision at all times near the water, even if there is a lifeguard on duty. Designate an adult who knows how to swim and how to perform CPR as a ‘water watcher.’ Accidents often happen during a lapse in supervision, rather than during a total lack of supervision, says Amy Frias, CHOC community educator. CHOC offers ‘Water Watcher’ tags that can be worn by the assigned adult. If your water watcher leaves the water area, even for a short time, have them first pass along the ‘Water Watcher’ tag and duties to another responsible adult. To request a tag, contact the community education department.

water watcher tag

  1. Never assume your child is drown-proof

Don’t give your child a pass on safety protocols even if he has had swimming lessons and is an experienced swimmer.  A child can drown in as little as two inches of water. Keep an eye on all bodies of water, such as bathtubs, toilets, buckets, ice chests, and dog dishes.

  1. Be aware of beach hazards

Watch for rip current and weather condition signs at the beach. Swimming in the ocean should only be allowed when there is a lifeguard on duty. Never swim alone- even good swimmers need buddies.

  1. Establish multiple layers of protection

Kids can get into things quickly, even if an adult is distracted for just a few seconds. Fences, gates, alarms and covers for your pool and spa are just a few ways that you can reinforce your home as a safe environment.

Download a tip sheet with more water safety information.

KohlsCares

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Speech and Language Pathology Empowers CHOC Patients

In honor of Better Speech & Hearing Month, we spoke to Nicole Paine, who has been an outpatient speech therapist at CHOC Children’s for 4 years, working with patients with feeding and swallowing disorders, speech delays, brain injuries, and vocal cord dysfunction. She also works in CHOC’s Early Developmental Assessment Center , a resource for families with children born early or who had difficulties at or shortly after birth, who are concerned about their child’s development. Speech and language pathology at CHOC helps children develop or improve their speech, language, memory and attention, breathing, and feeding and swallowing in a state-of-the-art rehabilitation center.

Q: Why did you want to become a speech therapist?

A: I have always had a passion for working with children and the special needs population. One of my previous jobs was a special education classroom assistant and one-on-one aide. I was able to see speech therapy firsthand with my student every week. I loved how functional, beneficial, and enjoyable it was for him. I asked his speech-language pathologist questions about the field, borrowed textbooks from her, and sought out additional observation time. I went forward with pursuing a post-baccalaureate degree in communicative disorders and eventually my master’s. Each class and internship I completed made me more confident that this was the field for me!

Q: What part of being a speech therapist are you most passionate about?

A: I love the individual time I get to spend with each patient and their family. It is so rewarding to work together as a team to overcome difficult issues like oral feeding aversions, behaviors, and communication difficulties. Being a part of patient progress is the best part of my job. Whether the progress is big or small, it is all about helping each child reach their best potential. I am also incredibly lucky to work with such a talented team of speech-language pathologists, occupational therapists, and physical therapists  that share my same passion. I love the collaboration on multidisciplinary teams that takes place here at CHOC.

Q: What advice would you offer someone considering pursuing a career in speech therapy?

A: I would suggest interviewing and observing speech-language pathologists in action as much as possible. Our scope of practice is so broad that there are endless opportunities, therapy approaches, and settings to work in. Some college or graduate school programs will allow prospective students to sit in on a class or two. It doesn’t hurt to ask!

Q: What attracted you to CHOC?

A: While in graduate school I was lucky enough to be accepted into CHOC’s full-time outpatient internship program. I knew CHOC was well-respected for many reasons, but was finally able to see that first hand. For 12 weeks I observed, learned, and worked alongside my speech-language pathologist supervisor, treating patients and diagnoses of a wide variety. I lived and breathed what working at CHOC would be like. It was challenging, rewarding, and a ton of fun! There are endless learning opportunities here and I always felt supported by the rehabilitation services team.

Q: What else should people know about speech therapy?

A: People often think we exclusively treat articulation disorders, like making ‘r’ or ‘s’ sounds. We actually can treat a variety of different deficits including fluency (stuttering, cluttering), language (spoken and written), literacy, social skills, cognition (attention, memory, problem solving, reasoning), voice, resonance, auditory rehabilitation (speech delays due to hearing loss), feeding, swallowing, and breathing. It’s typical in a medical setting such as a children’s hospital for speech-language pathologists to treat many patients with feeding and swallowing disorders. Speech-language pathologists need specific education and specialized training by mentors and continuing education courses to work with such patients. We’re able to treat feeding and swallowing disorders in addition to speech because we have extensive knowledge of the mouth and throat anatomy and physiology.

Learn when to ask your pediatrician for a referral for speech or language therapy.

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Brighter Futures for Families with PKU

May is PKU Awareness Month

By Mary Sowa, MS, RD, CSP, CNSC, CLEC and Jan Skaar, RD, CSP, CNSC, CLE, clinical dietitians at CHOC Children’s

Did you know that one in 10 Americans is living with a rare disease? Phenylketonuria (PKU or PAH) is a rare genetically-inherited disorder that occurs in one in 10,000 to 15,000 newborns in the United States. PKU was the first disorder to be identified at birth by the California Newborn Screening (NBS) program, which now screens for over 70 rare disorders. The main focus for NBS is to detect conditions that can be treated with diet or medications to prevent intellectual and other disabilities.  NBS has been identifying babies born with this condition, allowing early treatment and improved outcomes, for five decades. In decades past, treatment options were limited, often resulting in severe intellectual disabilities.

Individuals with PKU are unable to process the amino acid phenylalanine (Phe), which is an essential amino acid found in foods with protein. Children with the “classic” form of PKU need to avoid meat, chicken, fish, eggs, nuts and other foods with high protein content. They may also need to avoid regular breads, pasta, cereals and grains. It is not just a vegetarian diet. Daily intake of a specialized formula, which provides a source of Phe-free protein, vitamins and minerals, is essential for regulating blood Phe levels. Compliance with the specialized formula and low protein food products is the cornerstone to help prevent complications associated with high Phe levels in the brain. Elevated Phe levels can affect school performance, sleep, disposition and executive functioning. Experts recommend that individuals with PKU follow a “Diet for Life.”

“A disorder that is treatable with a special diet?” That must be the end of the story, you might think. Far from it. Besides having more taste-friendly options on the market for specialized PKU formulas, there have been advances in treatment options that were not available to PKU families a couple of decades ago. These include a medication called sapropterin to lower Phe levels in the blood, therapy with large neutral amino acids, and enzyme substitution.

Sapropterin dihydrochloride is a FDA-approved medication that helps the phenylalanine hydroxylase (PAH) enzyme work more effectively to break down Phe in the body. A trial period of close patient monitoring with frequent blood tests is conducted while initiating the sapropterin. Those individuals that are responders to the medication are able to control their blood Phe levels and have a more liberalized protein intake.

For some patients, it may mean the difference between tasting a hamburger or just dreaming about it.

Large neutral amino acids (LNAA) are another treatment option. They are most often used with older teens or adults who have problems controlling their Phe levels with diet or do not respond to the sapropterin. The individual with PKU has a “flood” of Phe in the blood from protein ingestion and the inability to breakdown the Phe into Tyrosine. The LNAA compete with Phe for transporter cells in the GI tract and later transfer across the blood-brain barrier. The LNAAs are considered “safe” amino acids for the brain and reduce the amount of Phe that enters the brain. A decrease in blood Phe levels may not be evident in the blood, however a decrease in brain Phe may help improve the neurocognitive deficits and executive functioning challenges seen in PKU.

In addition, human trials with an enzyme substitute called phenylalanine ammonia lyase (PAL) have been underway as a new treatment option. This is an injectable form of alternate enzyme found in plants and bacteria that can break down Phe into harmless components. The active compound is coated with ethylene glycol to protect it from the body’s immune system or is “pegylated.” The compound known as “PEG-PAL” must be injected daily and has been shown to lower blood Phe levels.

Significant challenges remain for individuals and families with PKU to achieve and maintain optimal blood Phe control and improved health outcomes. However, there are many more available tools for success than in previous years. Gene therapy is also a potential option on the horizon.

The CHOC Metabolic Clinic team, under the direction of Dr. Jose Abdenur, consists of dedicated staff to help patients with PKU and their families adhere to “diet for life” and other therapies. The team provides ongoing treatment, support and education for our PKU families and includes dietitians with specialized training in medical nutrition therapy for PKU and a variety of other metabolic disorders.

Learn more about CHOC’s Metabolic team.

Meet Dr. Sarah S. Field

CHOC Children’s wants its patients and families to get to know its specialists. Today, meet Dr. Sarah Samimi Field, pediatric allergist and immunologist at CHOC Children’s. Dr. Field attended Saint Louis University School of Medicine, and trained in Internal Medicine and Pediatric/Adult Allergy and Immunology at the University of Kansas Medical Center. She has been on staff at CHOC for four years.

Dr. Sarah S. Field

Q: What are your special clinical interests?

A: Eosinophilic esophagitis, asthma, urticaria, food allergy and allergic rhinitis.

Q: Are you involved in any current research?

A: We have been actively enrolling patients in research trials for asthma, chronic urticaria, eczema and allergic rhinitis for many years.

Q: Are there any new programs or developments within your specialty? 

A: Yes, in our EoE (eosinophilic esophagitis) clinic; see CHOC’s EoE website. I collaborate with gastroenterology and nutrition to offer a one-of-a kind EoE clinic for Southern California and beyond.

Q: What are your most common diagnoses?

A: Asthma, seasonal and perennial allergies, food allergy and eczema.

Q: What would you most like community/referring providers to know about you/your division at CHOC?

A: As allergists we also treat and manage asthma. We also encourage any patient with food allergy to be evaluated in our clinic for management and testing. We do a lot of education that patients and families can benefit from. In addition, we see both adult and pediatric patients in our practice.

Q: What inspires you most about the care being delivered at CHOC?

A: As a parent myself of two young children, I am always motivated to treat my patients with the same care I would want for my own family. I like to empower our patients with the information and newest research available to make the best decision for the treatment of their specific conditions or diseases. I am always humbled to take care of patients who have been part of our practice since they were children; some of them have been with us for over 30 years. Many times they bring their children, even grandchildren!

Q: At what moment did you decide you wanted to be a doctor?

A: I decided at a very young age I wanted to pursue medicine, motivated in part by my father who is also a physician.

Q: If you weren’t a physician, what would you be and why?

A: I would pursue a creative job. I love stationery and invitations. I love the sentiment and whimsical nature of a handwritten note as paper seems to be obsolete these days.

Q: What are your hobbies and interests outside of work?

A: I love spending time with my family. I’ve recently also started Pilates, and it has fast become my new favorite activity.

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Hearing Loss and Its Effects on Speech and Language Development

By Yomna Elsiddig, speech-language pathologist; Calyn Russ, audiologist; and Lori Wagner, speech-language pathologist, Providence Speech and Hearing Center

Have you ever noticed that our lives are never truly silent? If you think about it, we are surrounded by a range of sounds we’ve grown accustomed to tuning out: the air conditioner humming, doors closing, pens clicking. Now think about the conversations in your world: on the television or radio, in the next room, a mother reading to her child nearby.

Children with hearing impairments aren’t just missing out on environmental sounds- substantial language exposure and incidental learning are also absent. A child’s speech and language development is highly dependent on his ability to hear. Resulting developmental delays depend on how early the hearing loss occurred and how quickly intervention takes place. It is best to see a specialist as soon as a concern is identified. This is where speech-language pathologists and audiologists can help. Early intervention is designed to:

  • Identify hearing loss, as well as speech and language disorders, as early as possible, that impact development of communication, reading, writing, and social skills
  • Help speech-delayed children catch up to their peers through individualized treatment plans and therapy
  • Teach parents tools and techniques to help encourage communication and language development in their children

There are varying degrees and causes of hearing loss. It could be a temporary challenge or a permanent loss. Consequences on speech and language development include limited language skills such as a smaller vocabulary and speaking in short and simple sentences, as well as decreased speech intelligibility.

Children with hearing loss have difficulty hearing higher frequency sounds like those in the letters ’s’, ‘f’, ‘sh’, ‘t’, or ‘k’ as well as speech markers like nasality in ‘m’ or ‘n.’ Because we speak what we hear, these sounds and markers are missing from their own speech. These children also have difficulty hearing the ends of words where grammatical information is found (plural –s, possessive –s, past tense –ed).

CHOC Children’s and Providence Speech and Hearing Center collaborate with families to address any speech therapy and advanced audiology services to best meet a patient’s needs. Speak to your pediatrician about a referral to a speech-language pathologist and/or audiologist.

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