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Dr. Greene's Four Keys to Avoiding Germs

By Alan Greene, MD, FAAP

As an active pediatrician, I am exposed to every cold and flu virus in every daycare center in our community. Think about it! Sneezed on, slobbered on, examining poopy diapers that parents bring in for my educated opinion, I have a front row seat to contagious diseases. I am often asked how I manage to avoid so many of the colds, flus, and diarrheal illnesses that sweep through town.

Part of the answer is that, over the years, my immune system has met many of these microscopic invaders, learned about them, and now stands ready with antibodies to prevent infection. This has happened over time, often with no conscious help from me. Appropriate vaccines help to do this same job in a number of instances (I get the flu vaccine each year, for instance).

When possible, I try to help keep my immune system functioning in peak form. Getting good nutrition (plenty of fresh fruits, vegetables, whole grains, and supplements where my diet is not adequate) is a foundation for good health. Plenty of good sleep is vital (perhaps the toughest one for me). Plenty of activity (a brisk walk by the waterfront is my favorite), and lots of love and laughter to strengthen the immune system (read the compelling Anatomy of an Illness by Norman Cousins if you’ve missed this classic).

But whatever shape your immune system is in, it makes solid good sense to minimize the overwhelming numbers of disease-causing germs to which we are exposed. There are four key ways to do this:

1. Decrease the disease-causing germs on surfaces in the home. But where are these germs truly a problem?

Where does this really make a difference? In a number of different fascinating studies, researchers have carefully cultured every imaginable surface of typical homes to find where the disease-causing germs live. It turns out that the kitchen harbors more germs than any other room in the home — yes, more than the bathroom. And the greatest concentration is found, far and away, in the moist germ havens we call kitchen sponges and dishcloths. And these are the very same germs with which people in that household get sick. Sink drains, faucet handles, and doorknobs — either in the kitchen or bathroom — are the next highest on the list. Toilet seats had fewer germs than any other surface tested! 1 If we can keep these objects clean — especially the sponges and dishcloths, we can cut the spread of infection.

But here’s the problem: Tossing a dishcloth in the washing machine, even with a strong detergent, doesn’t appreciably cut down on surviving germs. And the micro-crevices that make a sponge such an effective cleaning device make it even more difficult to disinfect. Running a sponge through the dishwasher makes it look clean but leaves it just as infectious. Even strong chemical disinfectants often aren’t enough to disinfect them. 2

So what can you do? Wet your sponge or dishcloth and then pop it in the microwave for 2 minutes. Then you’ll have safe, germ-free tools to use. For items that you can’t microwave, such as faucet handles, a household cleaning solution containing hypochlorite is the best for cleaning, but be sure to rinse thoroughly. 3

2. Decrease disease-causing germs in the air we breathe.

I use every opportunity to teach children (and sometimes adults) to cover the mouth and nose for every cough and sneeze. This simple maneuver has spectacular results in decreasing the aerosolized viruses and bacteria floating about the room for us to inhale. Of course, this does leave the hands or tissues teeming with germs, but we’ll deal with that in a moment.

To keep the air clean, high-efficiency particulate-arresting (HEPA) filters, available at discount drug stores for about $40 to $100, can remove 99.97%+ of the pollen, dust, animal dander, even bacteria from the air. They are especially effective at preventing infections for those that get a bit stuffy from allergies but can decrease respiratory infections for everyone. I have several in my pediatric office (you know what waiting rooms are like!) and several in my home, so that the room air is completely filtered six times an hour. Houseplants can also be excellent air purifiers (if no one is allergic), albeit much slower.

3. Avoid antibacterial soaps (except for medical scrubbing).

There is no reason to believe that anything other than standard soaps is necessary since all soaps kill bacteria. In fact, antibacterial soaps may be a bad idea for people who repetitively wash their hands.

At this year’s science fair at my children’s school, young students performed an elegant experiment using antibacterial soaps. They put a few drops of the soap in one test tube, a few drops diluted 10x in water in the next, a few drops diluted 100x in water in the next, and a few drops diluted 1000x in water in the final tube.

They took normal bacteria from classmates’ hands and placed a sample in each tube. All hand bacteria were killed in the first three tubes, but a few survived in the most dilute tube.

They kept these survivors, grew them in an incubator, and repeated the experiment using these hardy bacteria. This time they were able to survive in two of the test tubes. By continuing this process, they were able to breed increasingly resistant bacteria.

The children reasoned that whenever we wash our hands, some areas around the edges may get only dilute concentrations of soap. This is the ideal breeding ground for bacteria we want to avoid. They proved that, as is the case with oral antibiotics, antibiotic soap can produce increasingly troublesome bacteria. ed. note

In most cases, antibacterial soap is a marketing ploy that may even increase your chances of getting sick.

4. Wash hands at important times throughout the day — and try a whole new (fun) way!

Most common infections are "caught" when the germs get on our hands and then we touch our eyes, noses, or mouths. Proper hand washing is an enormously effective method of prevention. Even in 1999, lack of proper hand washing remains the number one source of infections acquired in hospitals. 4 Practicing what we already know could prevent this unnecessary suffering and misery.

And the same is true for children. In a recent study of 341 children’s daycare centers, infrequent washing of children’s or providers’ hands after nose wiping, after diapering, before meals, and before food preparation was associated with a significantly higher frequency of illness. Use of shared cloth towels instead of individual paper towels and washing of sleeping mats less than once a week were also associated with a higher frequency of illness. Hand washing and other hygiene practices actually do reduce the spread of disease 6.

The most important times for most of us to wash our hands are after sneezing or coughing, after toileting, upon leaving "high-risk" places (pediatrician’s waiting rooms, ball pits, day-care centers, fast-food-chain play structures, high-traffic door knobs, etc.), and always upon arriving home (to keep outside germs outside). And, of course, before meals and snacks is a must. Before a child picks his or her nose would be nice but is not always practical.

Lots of water and a moisturizing soap are a great way to wash, but this isn’t easily available at all the right moments. I’ve found a recent innovation, though, to be portable, practical, and fantastic.

Instant Hand Sanitizers, pioneered by Purell, are a wonder (they are now available in many other brands). Talk about convenient! A small bottle can be carried about in a purse, glove compartment, or even a hip pocket. A little dab will kill 99.99% of germs without any water or towels. It uses alcohols to destroy germs physically. It is an antiseptic, not an antibiotic, so resistance can’t develop. They’ve added moisturizers and vitamin E to counteract the drying tendency of the alcohols. A few people find it irritating to the skin, but most find it refreshing to use, with the hands feeling smooth and soft afterward. You may want to regularly use an additional moisturizer.

And here’s the cool part — it’s fun. Many kids think it’s a treat to get to use it! It’s finally actually possible for busy parents (and grandparents and day-care providers) to get those hands washed all those times you wish you could. We asked my son’s preschool to start using it, they agreed, the kids took to it quickly, and we are all happy.

These four keys are my secrets. I hope they help you and your family to never even know about illnesses you might otherwise have gotten.

Dr. Greene is currently in private practice at ABC Pediatrics in San Mateo, CA. He is the Chairman of the Department of Pediatrics for Mills/Peninsula Hospitals and on the Clinical Faculty at Stanford University School of Medicine. Dr. Greene’s web site ( http://www.drgreene.com ) was awarded four stars by Yahoo.

Ref.

1. Journal of Applied Microbiology, 1998;85(5):19--28

2. Journal of Applied Bacteriology, 1990;68(3):279--283)

3. Journal of Applied Microbiology, 1998;85(5):819--828)

4. Annals of Internal Medicine, 1999;130(2):126--130

5. Public Health, 1998;113(6):544--551

(Editor's Note: Researchers in the biochemistry department at St. Jude Children’s Research Hospital found that the use of antibacterial products may make drug-resistant strains of bacteria more prevalent. Their findings were published in the Journal of Biological Chemistry, 1999 Apr 16;274(16):11110-4.)

Immunizations:Pre and Post-transplant

Immunizations or "baby shots" are very important for all children. They are the best available defense against many dangerous childhood diseases. Serious reactions to the recommended vaccines are rare in healthy children, but if your child has received an organ transplant, or is waiting for a transplant, special precautions will need to be taken.

There are two main types of vaccines: the live attenuated vaccine and the killed or inactivated vaccine.

Live attenuated vaccines are actual viruses that are too weak to cause disease in people with normal immune systems. When a person is vaccinated with the live attenuated virus, it causes an actual infection; however, the virus isn’t strong enough to make the person feel sick. Their immune system quickly conquers the virus. Cells that were generated to fight the virus remain in the vaccinated person’s system and if that person ever comes in contact with the same virus again, they are primed to respond. The virus is eliminated before the person ever begins to show symptoms. This person is now "immune" to that particular virus.

Because transplant patients have suppressed immune systems, they may not be able to respond to a live vaccine normally. A live vaccine might actually be strong enough to cause the real disease. For this reason, live vaccines are not given to organ transplant patients.

The other type of vaccine, the inactivated vaccine, is safe for transplant patients. It consists of only portions of the virus or organism and will not cause even the most severely immunosuppressed patient to develop an actual infection.

Children with organ transplants are given the inactivated poliovirus vaccine (IPV) and never the live oral vaccine (OPV). The IPV vaccine is given by injection and is just as effective as the traditional oral polio.

Unfortunately, there is no inactivated version of the MMR vaccine. Children who are transplanted before finishing both doses of the MMR vaccine (MMR #1 is given at 15 mos.; #2 at 4–6 yrs.) will have to rely on "herd immunity." This means that because most other people in the community have been vaccinated, their chance of ever being exposed to measles, mumps, or rubella will be minimal.

Children may receive live vaccines prior to transplant, but they should wait a minimum of two months before they are transplanted. This will insure that the live vaccine has been completely eliminated from the child’s system prior to transplant.

After transplant it is important to check with your coordinator before resuming your child’s vaccination schedule.

Siblings of transplanted children should receive the inactivated polio injection and never the oral polio. The oral polio is shed in the stool for two weeks or longer and the vaccine virus can be passed to others through contact with the stool. This usually doesn’t pose a threat to anyone, but a transplant patient might get sick from the oral polio virus if they come into contact with the it (dirty diaper, etc.). Siblings may, however, receive the live MMR vaccine, which is given by injection and not shed in the stool.

Acceptable vaccines post-transplant:

  • DPT (Diphtheria/Pertussis/Tetanus)
  • Hib
  • TB Tine
  • Hepatitis B
  • Polio Injection ONLY (IPV)
  • Flu shot

Vaccinations that should not be given post-transplant:

  • MMR (Measles/Mumps/Rubella)
  • Varicella (chicken pox)
  • Oral Polio (OPV)
  • Small Pox
  • Yellow Fever

If at any time your transplanted child is exposed to measles, mumps, chicken pox, or any other infectious disease, notify your transplant team immediately.

Making Lab Visits More Bearable

by Alan Greene, MD, FAAP

The amount of information that can be gleaned from a small amount of blood is truly amazing. This information can literally make the difference between life and death. Unfortunately, for many children, their fear of the needle stick required to obtain that small amount of blood is greater than their fear of death itself.

A child’s degree of needle fear changes at different developmental stages. Additionally, each individual child’s fear is affected by his or her past experiences. Most children who require frequent blood draws will inevitably have a bad experience—a technician misses the vein, digs to find it, then the child begins to cry and tries to escape from the pain, the technician tries harder, and so on. Finally someone gets the needed blood and the child is no longer tormented, but the terror of the experience goes with the child. The next time someone attempts to draw blood from the child, the whole experience revisits the child’s emotions, bringing tension into every muscle of his or her body.

In general, it is much more difficult to draw blood from children than from adults, due to the relative size of their veins. Additionally, most adults can reason with their fears. As adults we can understand the need for the tests our doctors recommend. We may not be able to completely divorce ourselves from negative past experiences, but we can tell ourselves that it probably won’t be as bad this time as it was last time. We know that if it is not going well, we can demand a different technician, and as a last resort, we can get up and walk out. That level of control makes the experience far more manageable for adults than for children. At most developmental stages, most children don’t have the ability to reason with their fears. As children they can’t demand better service, and they feel powerless to change the course of events. As parents we not only have power over our own medical care, but also over that of our children. As your child’s guardian, there are several things you can do to make the experience better for your child:

Mirror your child’s emotions back to him or her

If your child begins to act out before you even get to the lab, stop and talk about how he or she is feeling. You might begin by saying, "You are acting as if you are angry." Usually a child will respond to these kinds of statements with something like, "Yeah, I'm mad." You can keep the conversation focused by drawing out further emotions: "It really doesn't seem fair, does it?" "No. Why do I have to always get stuck?!" Let your child know that you accept her emotions. Don’t say something like, "Now it’s time to be a big girl." Instead say, "I understand why you are angry."

Get your child involved in a solution

"Since we’ve got to get this blood test, how can we work together to make it as easy as possible?" Even very young children can brainstorm, and when they are involved in coming up with a solution, they try harder to make it work. Here are some things you might suggest during the brainstorming session:

  • Your child could sit on your lap during the blood draw.
  • You could hold his or her "other" hand.
  • You could hold your finger up like a candle and let your child blow it out when the needle goes in. Make a game out of it—that pesky flame won’t go out easily, so your child needs to blow and blow until the blood draw is over. (This is similar to Lamaze breathing.)
  • You could do a tap dance during the draw to distract him or her (this is especially good if you can’t dance and your child knows it!)
  • You could let your child pretend to draw blood from his or her teddy bear. Be sure to ask how the teddy bear is feeling. If the teddy bear hurts (which I’m sure he will!), ask your child to think of things that could be done to make teddy feel better.
  • You could leave the room—sometimes older kids would prefer this; it makes them feel grown up.

Do everything you can to get your child to relax before the blood draw

  • It is much easier to get the stick if the child is relaxed:
  • Leave plenty of time to get to the lab. If you are tense in traffic, your child will get tense, too.
  • Play soothing music in the car on the way to the lab.
  • If possible, make it a one-on-one time with the child who is getting the test—leave siblings with a sitter.

Make friends with the lab technicians

This one is important! Lab technicians dread aggressive parents. It makes them tense and they miss more often.

  • Learn the names of the people who work in the lab. If one seems particularly good, ask for him or her by name. People are always honored when you do that, and they try to give you better service.
  • Treat the people who work at the lab with respect.
  • Bring them goodies from time to time.
  • Thank them for their time and work.

In general, I recommend two (maybe three) tries before requesting someone new. If your child is dehydrated the veins may be particularly difficult to find. It is better to let someone who has "gotten to know" the current status of your child’s veins try a third time than to get a new person involved.

Sometimes, even when your child’s veins are in great shape, your favorite technician will miss. Maybe he or she is having an off day. There is nothing wrong with requesting that someone else take over—IF you do it nicely. "I’ve promised my son that I won’t let anyone stick him more than twice. I know you usually get it the first time, but I really need to keep my word to my son, so I hope you won’t mind getting your supervisor. If she’s busy, we’ll be glad to wait."

If your child becomes upset during the blood draw, give him or her options (if your child is old enough to understand what’s going on). Ask if he would feel better if you all took a little break, or would it be better just to get it over with. Let your child know that not doing it at all isn’t an option.

There is a topical anesthetic, called "EMLA Cream" that will numb the skin and make needle sticks more comfortable. It must be applied one to two hours before the procedure. EMLA is not routinely used for blood draws. It can add to a child’s anxiety, because he or she may begin to think about (and often dread) the lab visit during the preparation period.

Frequent blood draws can become a major emotional issue for children. If your child is already "deathly" afraid of needles or if he or she comes to that point, you may want to seek the help of professionals. Most children’s hospitals have a Child Life department with trained specialists. These departments often offer classes for their patients and may be able to facilitate participation for out-patients as well.

Dr. Greene makes housecalls! Visit his website at www.drgreene.com

Dr. Greene is in private practice at ABC Pediatrics in San Mateo, CA. He is the Chairman of the Department of Pediatrics for Mills/Peninsula Hospitals and on the Clinical Faculty at Stanford University School of Medicine.

Over-the-Counter Medications

by Debbie Smith, MS, RN, CPNP

See the chart at the bottom of this article for recommendations on some specific brand names.

During flu and cold season parents may find themselves reaching for those readily available over-the-counter (OTC) cold remedies. But which ones are safe to give your child? It’s always a good idea to check with your liver team on which over-the-counter medications are recommended and which are not recommended for children with liver disease or children who are immunosuppressed. Remember, the best therapy for the common cold is fluids, humidity and time.

Here are some general guidelines on ingredients commonly found in over-the-counter cold and cough remedies:

Antihistamines

Antihistamines can help relieve cold and allergy symptoms such as sneezing, itchy or watery eyes, and scratchy throat. Antihistamines can also slow down bile flow. If your child has reduced bile flow, it is recommended that you push fluids whenever giving antihistamines.

Decongestants

Pseudoephedrine hydrochloride (PH) is a decongestant that also elevates blood pressure and could potentially elevate the portal or liver blood pressure. A great many over-the-counter cold and sinus medications contain PH. For children with portal hypertension or those taking medication for high blood pressure these products are not recommended. Check with your doctor first if you are unsure about your child’s risk.

Nonsteroidal anti-inflammatories (NSAID’s)

Many over-the-counter cold remedies contain NSAID’s to help relieve aches and pains. Generic names include ibuprofen, naproxen, and ketoprofen. Brand names include Advil, Motrin IB, Nuprin, Medipren, Pediaprofen, Aleve, Orudis and others. Like aspirin, NSAID’s can be irritating to the stomach and may cause gastrointestinal bleeding. If your child has high blood pressure, portal hypertension or esophageal varices, this could be dangerous. NSAID’s can also be toxic to the liver.

NSAID’s can cause kidney dysfunction in patients who are taking cyclosporine or tacrolimus (Prograf). Occasional use of NSAID's for transplant patients may be permissible, but you should check with your transplant physician or nurse first.

Aspirin

Aspirin is not recommended for fever in children because of the possible risk of Reye’s syndrome. Aspirin can also be irritating to the stomach. (Under close supervision, many children take aspirin post-transplant to prevent clotting of the hepatic artery.)

Acetaminophen

For children with liver disease or transplant, acetaminophen (Tylenol) is recommended for fever. Do not exceed more than 4 doses per day and for no longer than 3 consecutive days. For high fever (over 102°) or fever that persists for more than 24 hours in children with biliary atresia or post transplant, your doctor or transplant coordinator should be notified.

The main thing to remember is that even over-the-counter medications can have harmful side effects or interactions with other medications your child is taking. Your liver specialist is always the best source of information regarding which over-the-counter medications are safe for your child.

Okay for Use Not Recommended

The following ingredients are usually safe for children with liver disease:

  • Acetaminophen
  • Chlorpheniramine Maleate
  • Phenylpropanolamine
  • Dextromethorphan DM
  • Guaifenesin

The following OTC cold medicines are usually safe for children with liver disease. There are new medicines coming out all the time, check labels carefully:

  • Allerest Children’s Chewables
  • Benadryl Elixir
  • Cholortrimetron Allergy Tabs
  • Dimetapp Elixir
  • Naldecon DX Children’s Syrup
  • Robitussin DM

These ingredients are generally not recommended for children with liver disease:

  • Pseudoephedrine hydrochloride (PH)
  • Aspirin
  • NSAID’s

The following is a partial list of OTC cold medicines which contain the above ingredients and are therefore not recommended:

  • Actifed
  • Benadryl Cold
  • Children’s Tylenol Cold
  • Dimetapp Cold & Fever
  • Dimetapp Sinus Tabs
  • Nyquil
  • Pediacare (all)
  • Robitussin Cough & Cold
  • Robitussin Night Relief
  • Robitussin PE
  • Sudafed
  • Triaminic AM, Cold & Allergy, Nite Lite, Infant Drops
  • Vicks Formula 44d

Ms. Smith is a pediatric nurse practitioner at The Children’s Hospital Pediatric Liver Center and Pediatric Liver Transplantation in Denver, CO.

Smart Solutions for Painful Situations

By Suzanne Flint

It's time for another blood draw or procedure and you're not sure who dreads it more... you or your child. Here are some ideas to help you get through the tough stuff.

Positive Feedback

Children should be praised for doing their best. Cooperative behavior should be encouraged. Statements like: "I was pleased to see you trying to stay still" or "It was good you told the nurse exactly how you were feeling" can be helpful. Minor misbehavior should be ignored, although, at times, a no-nonsense approach may help your child to cooperate.

Setting Limits

Even children with serious illnesses need limit setting and expectations of "good" behavior. Setting limits is an essential part of parenting a child through any difficult situation. It also conveys a great deal about how you view your child's capabilities. Good limit setting is impersonal and understandable to the child. It is supportive not punitive, and planned not arbitrary. Being too lenient or inconsistent in setting limits can convey a lack of confidence in your child's ability to cope. Whereas, being overly authoritative prevents a child from getting the chance to learn about his or her own capacity for self-regulation. Good limit setting, on the other hand, creates a nurturing environment in which your child's own developing sense of self can emerge and flourish.

Giving Control

Offering children some control about their treatments can help reduce feelings of helplessness and uncertainty. This, in and of itself, can often help to reduce a child's experience of pain. Even very young children can be allowed to decide some parts of their treatment, for example: whether to sit on your lap or in a chair, which finger to have pricked, and/or whether to have a Band-Aid. Even how much preparatory information they receive should be up to the individual child's choice.

Rewards

It is okay to give a child a small treat for cooperating with a procedure but it should be given based on a skill or behaviors exhibited and not just for enduring the procedure itself. It should also be negotiated beforehand with the reward contingent upon an agreed upon specific behavior. If feasible it is best when the child can select the behavior and the reward. The reward and behavior should be both specific and simple to understand. A good rule of thumb is to make sure the child always wins something for trying and something extra for succeeding. Avoid negotiating or changing the rules after the fact. If you make the target behavior too easy, your child may feel you lack faith in his or her abilities.

Physical Restraint

Be prepared for the possibility that the procedure could become just too scary or difficult for your child. If physical restraint is needed, learn how to provide it in a non-punitive way. For example, "This shot is just too hard for you to hold still for, even though you are trying your very best. I know how much you've tried, and I can see that you don't think you can hold still any longer without my helping you a bit." In this example the use of physical restraint is introduced as support, not punishment and the child is held in a comforting and non-combative way.

Positioning for Comfort

Non-aggressive holding positions can be very useful in helping a child through a painful procedure without forced physical restraint. Forcibly restraining a child often in-creases their pain experience, compromises their sense of dignity, and can even traumatically damage their self-esteem. On the other hand, positioning for comfort can provide:

  • A secure, comforting, hugging hold - e.g. the child sits astride their parent's lap, facing and hugging their parent's chest; or a child sits on their parent's lap, facing forward but being hugged and held by their parent from behind.
  • Close physical contact with the parent or caregiver.
  • Parent participation which is focused around positive assistance rather than forced restraint.
  • Successful immobility of an extremity without force.
  • A more relaxed child since sitting positions (whenever possible) promote a greater sense of control in the child than lying down positions.

Thought-Stopping and Self Talk

Thought stopping teaches children to catch themselves as they begin to exaggerate or catastrophize the unpleasant aspects of pain and to deliberately substitute a positive, self-calming thought. The positive and reassuring aspects of the situation are condensed into key points. From these points, children make up a positive statement, which they then memorize and repeat to themselves. For example, during a feared blood draw, a child might say, "This will be over quickly. I have
good veins. The nurse who is doing it is nice."

Another such statement might be, "I can handle this. I know how to breathe out any discomfort. My mom is here and I'm not alone." Or, "It's tough but I'm doing well. This will help me in the long run." Children above about six years of age can be coached during a procedure to utilize this technique. After about 10 years of age, children can learn to do this independently, even when no "coach" is there to assist them.

Suzanne Flint is a Child Life Specialist, Health Educator, Interactive Imagery Guide, and Program Director of "Reach Out and Read" at Lucile Packard Children's Hospital in Palo Alto, California.

ABC's of Sunscreen

by Kathleen Falkenstein, MSN, CRNP, CCTC

Recent information has shown some unhealthy effects of sun exposure, including early aging of the skin and skin cancer. The ultraviolet light rays cause invisible damage to skin cells and over time, wrinkles, age spots, and skin cancer can occur.

Children who have received an organ transplant have an increased sensitivity to the sun because of medications they are taking. These medications include cyclosporine or Neoral, Prograf, prednisone and certain antibiotics.

Sun protection should begin in very early childhood. We can begin by following the ABC’s for fun in the sun:

A is for AWAY

Stay away from the sun in the middle of the day, between the hours of 11 a.m. to 3 p.m.

B is for BLOCK

Use a sunblock with an SPF of 30 or higher. The higher the SPF number the better the protection. This number also indicates the length of time a person can stay out in the sun without burning. White-colored sunblock usually contains zinc oxide or titanium. These ingredients are helpful for high risk areas such as nose, lips and shoulders and may be used on babies.

C is for COVER UP

Wear a T-shirt and hat or sun visor. Closed shoes are best.

Keeping in mind the ABC’s of fun in the sun will help prevent problems later in life. Also remember that when it is hot, children should drink more fluids because many anti-rejection drugs are toxic to the kidneys. Lots of fluids and proper sunscreen will make your summer fun and safe.

Ms. Falkenstein is a liver transplant coordinator at St. Christopher’s Hospital for Children in Philadelphia, PA.

Ages and Stages

The following is a basic guide to the kinds of needs and concerns a sick child will have at different ages:

0-3 YEARS

Babies and toddlers need parents with them during procedures for handholding, to allow protest, for comfort, and to play it out with them later.

4-7 YEARS

Illness and painful procedures are seen as punishment. All diseases are thought to be contagious. Procedures that hurt are not considered therapeutic. Fears of separation, mutilation, and pain are strong.

8-12 YEARS

Children feel a sense of inferiority toward their healthy peers. They can’t grasp the numerous variables in disease. Mood changes and other side effects are not understood as related to disease or treatment. Grasping the role of the different organ systems is still difficult.

13-18 YEARS

Concerns about body image, independence, and sexual identity predominate. The tendency to deny illness is strong. Adolescents need more information and a greater role in decision making.

The Chicken Pox Vaccine

by Jorge Vargas, MD

Children who are candidates for a liver transplant, and their siblings who have not yet had the chicken pox, should ALL be vaccinated before a transplant.

C.L.A.S.S. Notes, Spring 1996 -- Most of the time, varicella (chicken pox) is a very benign and mild disease. In some cases, however, children in particular may become severely ill from this highly contagious viral infection. Chicken pox occurs year around with no major seasonal variations; however, it is mostly seen from January to May. In this country, almost four million cases occur every year and between four to nine thousand cases require hospitalization. In a very small number, the infection proves to be fatal.

Severe complications of varicella include pneumonia, encephalitis and other bacterial infections, and may occur in normal, healthy children. Obviously, children who are taking medications to suppress the immune system or undergoing chemotherapy are at a higher risk of developing more severe infections or complications. It was with this group in mind that a vaccine was developed which has proved to be very efficacious.

This vaccine is generally recommended for toddlers between ages 12 to 18 months who have not had chicken pox, as well as older children, adolescents, and adults who may be exposed. Although the vaccine does not provide 100% protection against varicella, cases that occur after vaccination are generally very mild. Several studies have addressed the issues of the length of immunity, which is not permanent, and on the safety and need for booster doses of varicella vaccine 4 - 6 years after the initial immunization.

A major discussion is underway because of the lack of good data on the safety of the vaccine in children receiving immunosuppressive agents. Studies have been carried out in countries like Canada, Japan, and the European Union, and the results are being analyzed. There are studies showing the safety and efficacy of the vaccine in children with debilitating diseases, or children who receive chemotherapy. The Academy of Pediatrics is developing clearer policies and better guidelines for the use, schedule and need of monitoring regarding the efficacy of the vaccine. But it is important to understand that at this point in time, children who are potential candidates for a liver transplant, children who are already on a waiting list for transplantation and their siblings who have not had chicken pox, should ALL be vaccinated before a transplant.

Varicella virus has an incubation period of 11 days to three weeks. Even before the infection is apparent by the presence of skin lesions, it is transmitted in the air by respiratory particles and secretions. Patients are most infectious during the 24 hours before the skin lesions appear and until all lesions are dry and crusted-over completely.

If a child has not had the vaccine or the illness and is receiving immunosuppressive agents to prevent rejection of a transplanted organ, and this child comes in close (and I emphasize close) contact with a child who subsequently develops chicken pox, it is advisable that the child receive a special dose of antibodies to fight the potential infection, to be administered within 72 hours of the contact. This is a specific antibody against the varicella virus called VZIG, and it is given by intramuscular injection in an amount proportional to the child's weight. It is not 100% efficacious, but administered on time may completely prevent the disease or make it much milder. These antibodies, as they were not actively produced by the patient, do not last and only cover a period of approximately 5 - 6 weeks, making it necessary re-administer the treatment in cases where new contact occurs beyond this time.

If a child on immunosuppressive agents develops the disease, we always suggest treating the child in the hospital with intravenous medications designed to kill the virus. We also reduce the amount or dose of immunosuppressive agents while the disease is active, and keep a close eye on potential complications and treat them quickly as they are presented. Frequently an antibiotic treatment for bacterial infections of the skin lesions is also prescribed.

Lastly, having the infection generally confers a child or patient with sufficient immunity to be protected for life. However, in patients whose immune system is depressed by medications, this is not always the case. It is not rare to see either recurrence of the chicken pox or recurrent episodes of the so-called "shingles," which is caused by the same virus.

Dr. Vargas is an associate professor of pediatric gastroenterology/nutrition at UCLA Medical Center and a member of the C.L.A.S.S. Scientific Advisory Committee.

Surviving the Daycare Jungle

by Jerri J. Kropp, Ph.D. and Marianna A. Voiselle, M.Ed.

It seems to be a parental rite of passage to go in search of the perfect child care program. You’ve probably been there. You have talked with friends who’ve gone before you, taken the recommendations from pediatricians, you’ve read every copy of Parenting magazine for the past six months, and even made appointments to visit the site and interview the caregiver. To an outsider your actions may seem to border on obsessive; after all, this is one of the most important decisions you will make in your child’s young life.

But what if you have a special needs child? How do you determine who will be responsible enough to keep your child on the correct medication regimen every day? To inform you immediately if there is a case of the chicken pox or flu? Who will report lethargy or other symptoms?

Children who are transplant recipients, as well as those living with liver disease in all its various stages, need caregivers who will be vigilant where their health and well being is concerned. As daunting a task as this is, it will pay to use common sense in finding the right program for your child.

In order for any child to have a positive experience in a group setting it is crucial for the parents and caregiver to maintain open lines of communication. This is especially true for children whose health is compromised; their support team includes not only parent and teacher, but doctor as well.

Beverly Kosmach, a clinical nurse specialist at the Starzl Transplantation Institute in Pittsburgh, Pennsylvania, recommends that post-transplant children stay at home for the first three months after surgery. "It is during this time that the child’s immune system is most compromised. After that point though we like for our kids to resume as many normal activities as feasible." Ms. Kosmach also notes that some children may need to ease into daycare slowly by going half days for a few months. Since children heal at different rates and experience varying degrees of complications post-surgery, parents should always check with the transplant team before enrolling their child in a school or daycare center. Once the medical all-clear has been given, the search for the perfect daycare center can begin in earnest.

It is possible that you will come across daycare directors who feel uncomfortable in accepting your child due to his or her health history. According to the Americans with Disabilities Act (1992), children with special needs cannot be denied care at any public child care program (centers, preschools, family child care homes). Each child’s needs must be evaluated on an individual basis to determine whether a program can reasonably accommodate the child’s needs. Reasonable accommodation may include changes in policies, practices, and procedures. Planning prior to enrollment should include educating the staff on the illness itself, coordination of home and school regarding medication, and special care instructions.

Above all, be certain that your child care center is state licensed. Licensing regulations provide minimum health and safety standards for children. All states in the U.S. have some type of licensing regulations but they vary widely. In most states, licensing is supervised by social service agencies or departments of education, public health, or child welfare. There may also be state, federal, and local requirements. You should note that some child care centers are exempt from licensing requirements. In general, programs covered by other regulations may qualify for exemption (such as centers within the public school system). In some states, churches and/or family daycare homes are not required to be licensed. Licensing guidelines serve as a baseline for minimum standards. Laboratory schools in colleges or universities, Head Start, and other federally funded agencies have their own standards which are usually higher.

For additional assurance in your search, look for a center that is accredited by the National Academy of Early Childhood Programs (a division of the National Association for the Education of Young Children - NAEYC). Accreditation is voluntary. These centers are held to higher standards in several categories. The most important reasons to try to find an accredited center is that they pay particular attention to health and safety, the teacher-pupil ratio is low, and the teachers are required to possess more training and qualifications. To request a listing of accredited centers in your state, you can call the Academy in Washington, D.C., at 1-800-424-2460.

While child care centers have a responsibility to your child, remember that you do too. The health lessons your child must practice in order to live must be learned from you and be second nature to him or her. Handwashing should be as natural as breathing.

Be sure to keep the lines of communication open with your child’s caregiver and consult your transplant coordinator with any questions or concerns. Joint communication between the three of you will provide the best opportunity for your child to flourish in a daycare setting.

Dr. Kropp is an associate professor of Family and Child Studies, and Director of the Georgia Southern University’s Family Life Center which is accredited by the National Academy of Early Childhood Programs.

Ms. Voiselle is a certified elementary school teacher and mother of two-year-old Sarah, a liver transplant recipient.

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