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Daily Dose

Bug Bites

1:30 to read

It is the time of year for bugs and bites and I see a lot of kids with bites coming into my office.  Parents want to know “what kind of bite it is?” and in most of the kids I see, they are having a reaction to a mosquito bite. Parents are extremely concerned that the reaction may be abnormal and lead to breathing issues or that the bite it is infected. For some reason, baby and toddler skin just seems to swell more - that is not science but my observation…maybe because they are “yummier”?  At any rate, the best way to avoid “the mystery bite” is by using insect repellent.


The AAP recommends that children be protected from mosquitoes as they may not only cause discomfort and itching, but may cause several viral illnesses including West Nile, Zika and Chikungunya. Insect repellents will also prevent ticks, some of which may transmit Lyme Disease.  


Both the AAP and CDC recommend the use of DEET containing repellents for children 2 months of age and older. For young infants it is often easy to protect them from bites by using mosquito netting over their stroller or carseat when they are outdoors.  Once your child is older and hard to “contain” beneath mosquito netting you may use a DEET containing repellent and start with the lowest concentration - you will need to read the labels on each product.  The protection and effectiveness for DEET products of different concentrations is similar, but a higher concentration provides a longer duration of protection. Picardin has also been approved for use in concentrations of 5-10 %. The higher the concentration the longer the duration of protection as well.  So choose accordingly. I often have several products at our house and decide which to use based on the length of time we are enjoying the backyard, age of child or adult and method which I want to use to apply (spray, lotion, wipes).


You do not want to choose a product that contains both sunscreen and an insect repellent. Sunscreen should be applied about every 2 hours and bug spray should be applied far less frequently. I recommend applying the insect repellent with my hands rather than trying to spray a young child who is a moving target. I even put the bug spray on those precious bald baby heads (if over 2 months).  It is also important to wash the insect repellent off at the end of the day - bath time for all!


It is also important to dress appropriately if you are going outdoors. When possible dress your child in long sleeves, pants and even socks which will prevent bites. Avoid brightly colored and flowery clothes (may be boring), as these too attract insects.


It is also especially important to remove standing water around your house and yard. After a rain or watering check any standing water and empty any residual water from buckets, candles, bird baths or empty pots. Standing water is an easy breeding ground for mosquito larvae.  The type of mosquito that carries Zika also prefers to be close to houses…so it is really important drain standing water near your house. 


Enjoy the summer and don’t be afraid of bug sprays in children if you use them appropriately, as prevention is always preferable!



Daily Dose

War On Zika Virus

1:30 to read

There seem to be updates everyday on the latest cases of Zika virus both in the U.S. (to date all of which have been imported) and in more and more countries in the Caribbean. At the same time, there is more information being released  by the CDC and the World Health Organization on the virus, its effects, how to diagnose it, who should be tested and prevention.  There are also many scientists around the world who continue to work on diagnosing, treating, and preventing the Zika virus. Despite all of this there is still a lot to learn and many questions still remain about this rapidly spreading virus.

The CDC has just documented the first case of the Zika virus being transmitted sexually in this country.  The case was actually confirmed in Dallas after the patient had returned from a trip to Venezuela and was diagnosed with Zika virus. Subsequently his partner, who had had unprotected intercourse within 2 weeks of the initial patient’s return, was diagnosed with Zika virus. Fortunately, there was not a fetus involved in this case and both of the patients have recovered. Because of this the CDC has now issued new guidelines stating “men who live in or travel to areas of active Zika infections and who have a pregnant sexual partner should use latex condoms correctly, or refrain from sex until the pregnancy has come to term”.  Questions still remain about possible viral transmission from saliva and urine and further information will be forthcoming. 

The CDC also changed the guidelines for pregnant women who have traveled to areas with known Zika virus and are concerned about possible exposure.  While they had previously recommended that only those with at least 2 symptoms of the virus (which include rash, fever, joint pain or conjunctivitis) be tested, they now have more data on the accuracy of the tests and the new guidance states “pregnant women without symptoms can be offered testing between two to 12 weeks after travel.” So if you are concerned consult your Ob-Gyn. 

I am also getting questions from young woman who have been “trying to get pregnant” or who are even “thinking about getting pregnant” and they want to know if they should “delay getting pregnant”?  While I am concerned about the spread of the Zika virus, I do not think that women in the U.S. should alter their plans to become pregnant.  But, at the same time, I am advising these women to change their plans and to cancel any and all travel to the Caribbean, Central and South American countries with known Zika virus until after they have conceived and given birth…so in other words for at least 9 -12 months and maybe more. Why risk an exposure when not necessary? 

While this virus is expected to spread to the U.S. this summer there is some thought that it may be our southern states with hotter and more humid weather who will have the greatest likelihood of seeing significant Zika virus. Again, this is based on historical as well as ongoing research.  What is known, is that the Aedes mosquito (the type that carries Zika) has previously been found in most states in the United States. I have had one mother who is pregnant call and ask if I thought she should leave the state of Texas this summer, and move north to a cooler climate!  While that seems a bit extreme,  no one knows what impact Zika will have here until the temperatures warm up. In the meantime I advised her to start wearing insect repellant that contains DEET or picardin, as well as to wear long sleeves and pants and to try and stay inside during peak mosquito hours (dawn and dusk), as we still have mosquitos in Texas even at this time of year.  Might as well get in the routine now.

Stay tuned…

Daily Dose

More Zika News

1:30 to read

There continues to be more and more information being published about Zika and the continued concerns over side effects of the viral infection. So there are several new key facts that every parent needs to know.

Based on more research the CDC and WHO have now confirmed the link between Zika virus infection and birth defects. Two interesting studies were just published further substantiating the link. The first was in the journal Stem Cell in which researchers found that the Zika virus selectively infects cells in the brain’s outer layer which makes “ those cells more likely to die and less likely to divide normally and make new brain cells.” In other words, Zika preferentially affects tissues in the brain and brain stem of the fetus.  While this does not prove that Zika causes microcephaly it certainly points to the fact that brain cells are very susceptible to the virus and if the cells don’t divide to make new cells….one would think the brain would be smaller as would the head (microcephaly).

Another article in the New England Journal of Medicine reported on research that had been done on 88 pregnant women in Rio. The article stated, “infection during pregnancy has grave outcomes including fetal death, placental insufficiency, fetal growth restriction and central nervous system involvement.”  They also stated that “major fetal abnormalities were found in nearly a third of the women who had been infected and had undergone ultrasounds.” This virus seems to act like some other viruses (rubella) that have caused congenital infections and brith defects as well. The study also showed that the Zika virus may affect the placenta as well, which could cause miscarriages and/or still births.

While much of the Zika virus news has focused on pregnant women and associated birth defects, countries with high rates of Zika infections have also seen an increase in the number of cases of Guillian Barre Syndrome (GBS), a neurological disorder which causes muscle weakness and varying degrees of paralysis.  A study published in The Lancet reviewed results of blood tests from patients who had Zika and GBS in French Polynesia, which was the site of an earlier Zika outbreak. Of the 42 patients that had been diagnosed with GBS, 41 had antibodies to Zika, which is more evidence that Zika may be the cause of the serious neurological condition. While GBS has been seen in children and adolescents post Zika, it tends to be seen more frequently in older adults and is actually a bit more common in men.

Although it seems that the virus affects pregnant women and older adults in different ways, the severe side effects of Zika are in both cases related to the nervous system. There is still much research to be done to elucidate the how and the why, before any type of cure or vaccine is available, but all of these studies are getting scientists one step closer.

Another issue that scientists continue to work on is how to best test for Zika virus.  It is still not clear how long the incubation period is after being exposed to Zika virus, and remember about 80% of people will not even realize they were infected. With that being said, one of the tests ( called a PCR test)  requires that the patient’s blood be drawn within 4 - 7 days after being bitten by the infected mosquito. Another test ( Zika MAC-ELISA) , may be the better test as it may be used for a longer period of time after being bitten. Both of these tests are being used for diagnosis and are now being sent to qualified labs to help speed up the diagnosis of Zika. 

In the meantime as warmer, humid weather is approaching the United States, we all need to be pro-active about using insect repellant, reduce standing water (it has been raining in TX for days), and wear long sleeved clothes and pants when possible. Stay tuned for further updates as the CDC expects to see cases of Zika in the U.S. over the coming months. To date all of the Zika cases that have been diagnosed in the U.S. have been imported and not acquired here.  

Daily Dose

War On Zika Virus

1:30 to read

If you are an avid reader of my Daily Dose, you know I have been keeping a close eye on Zika virus.  I continue to get phone calls, texts and e-mails from anxious parents about the Zika virus.  While most of the previous questions were regarding travel to areas in Mexico, Central America, South America or the Caribbean and were from women who were pregnant or who were thinking about becoming pregnant, I am now getting questions about even getting pregnant - period.

I understand that there continues to be a lot of anxiety surrounding Zika due to the fact there is much that is still not known about the virus. Even though the virus was first isolated in 1947, it was not until 2015 that the virus spread across the Pacific Ocean to French Polynesia and ultimately to The America’s. Since that time there have been documented outbreaks of the Zika virus and to date mosquitos infected with Zika have been found in 33 countries (and counting ). The possible connection between Zika and the congenital malformation microcephaly (a brain malformation causing a small head ) continues to be studied and most recently the CDC identified the Zika virus in the tissue of two babies who died in Brazil with microcephaly.  

But with the some of the best and brightest minds working day and night on learning more about how this virus is transmitted, how to treat and prevent the virus, and the link between Zika and birth defects, the current goal is to protect pregnant women and advise that they not travel to areas with known endemic Zika transmission.  As Tom Frieden who is the director of the CDC stated, “the virus is not a major threat to the rest of the population”.  

So with that being said, while Zika is new and can be scary, it seems unrealistic for young women in the United States of America to postpone becoming pregnant out of fear alone.  While it seems likely that mosquitos with Zika may ultimately reach the southern areas of the United States once the weather gets hot and humid, that is still just a prediction.  At the same time, the U.S. government and many brilliant scientists are working to combat the Zika virus preemptively with mosquito control, education about preventing mosquito bites and ongoing fast tracking of a possible vaccine against the virus. It is hoped that a vaccine may be available by the end of 2017….which is lightning speed when looking at the typical timeline for vaccine development.

Unfortunately, there have been many times in past history when there has been fear about a new and emerging disease…some of which were also thought to be related to birth defects or were especially harmful to young children. Fortunately, scientists ultimately found cures or vaccines or drugs to combat these diseases. That is my hope for the Zika virus as well…but it will take time.

But to think that women of child bearing age are going to delay a pregnancy due to the Zika virus seems to be an emotional decision rather than a decision based on current knowledge and facts.  As one of my patient’s mothers said to me, and she is currently pregnant with her second baby due later this summer, “I cannot live my life in fear as so many things change on a daily basis….but I do need to be smart.  So I am not going to go to the Bahamas for a vacation as planned”. I agree with her and my advice is this: if you are planning on a pregnancy there is currently no reason not to continue with those plans (I am giving that same advice to my own children as well).  

Daily Dose

War on Zika Continues

1:30 to read

After heavy rains in many of the southern coastal states and warmer temperatures arriving, the mosquito population is going to be thriving. I know that after a week of pouring rain in Texas, despite best efforts, there is still a lot of standing water.  It doesn’t take much water for mosquito larvae to breed. So, with that being said, the local health departments and the CDC are going to be on high alert and monitoring for any Zika infected mosquitos. While there have been 168 pregnant women in the United States infected with Zika which was acquired from outside the United States, to date there have been no documented cases of mosquito transmission of the virus in the states. 

While trying to predict if and when Zika might spread to the contiguous United States, the World Health Organization and the CDC have found that the “Zika virus remains in the body longer that initially thought”.  Due to this, the recommendation is now that anyone who has traveled to areas with endemic Zika virus should “practice safe sex or abstain from sex for at least eight weeks”. At the same time it is now recommended that men who have shown Zika symptoms  are advised to “wait six months before trying to conceive with their partners.” 

Many of the families I care for are in their child-bearing years and continue to be confused as to the latest recommendations and why they are continually changing. I have explained that there will be ongoing updates and probable changes in recommendations as more data becomes available. As with any new disease, the doctors and researchers “in the trenches” are discovering new information about the virus, and the effects of Zika on pregnant women and  their fetuses. Unfortunately, the latest news seems to be more concerning with the length of viremia as well as the effects on the brains and the eyes of newborns born with infection.  

In the meantime, I do not think you can stop having a family as this is not an infection that will be gone quickly….in other words, you can’t say, “just way 6 months to get pregnant”.  No one can predict how long we will be dealing with this virus.  Although there are hopes that a vaccine will be developed sooner than later, realistically it will probably be two years at minimum before there is a vaccine that is ready to go to trial.   

So, my recommendation is that if you do travel this summer to any of the countries that have known Zika, you wait for at least 8 weeks before becoming pregnant….and you must be diligent,  condoms, birth control, or abstain….why risk it?  I would be taking a lot of bug spray with me wherever I travel, especially to the beaches in the Caribbean, South America and the southern U.S. and I would wear long sleeves and pants whenever possible. I would keep my doctor informed of any travel that I have had and I would watch for symptoms which include: fever, rash, pink eye, joint pain in order that your doctor may order the appropriate tests to determine if you indeed may have contracted Zika.  

Your doctor is receiving information almost daily on how to test for Zika, who to send specimens to, and how to report any patients with suspected Zika. There are also “hotlines” available for doctors to use to discuss their questions with an expert on Zika infections. Everyone is ready, and trying to stay ahead of this mosquito….but for now,  it is tough battle with nature.  Surveillance and awareness are the keys for the summer months.

Daily Dose

Stop Bugs from Biting!

1:30 to read

We are in the throes of mosquito season and with concerns about Zika, West Nile Virus and ckikungunya it is a good time to revisit insect repellents.  The mosquito threat from Aedes mosquitos is especially relevant in the southern and southeastern parts of the United States as these are the mosquitos which carry both Zika and chikngunya. The Culex mosquito species which carries West Nile Virus has been found in all of the continental United States. 

One of the best way to prevent disease is by controlling the mosquito population which means eliminating areas where mosquitoes breed. This means draining standing water!! I find myself outside draining flower pot saucers after watering or an unexpected summer thunderstorm. I am also always changing the dogs water bowl. I am trying to be vigilant about eliminating standing water.

It is also important to try and limit exposure to mosquitos during dusk and dawn which is the prime time for getting bitten, but with that being said, the Aedes mosquitoes seem to be around all day. Wearing protective clothing which is light in color with long sleeves and long pants is  helpful, but is hard to do when it is over 100 degrees everyday and your children want to play outside. 

So, insect repellents are an important part of protecting your children from bites and possible disease exposure ( although children typically do better with these mosquito born viruses than pregnant women, adults and the elderly). There are many products out there to choose from but the insect repellents with DEET have been studied for the longest period of time.

When picking an insect repellent you want to make sure they have been proven to work (efficacy), they should be non-irritating and non toxic and preferably won’t stain your clothes. Cost is also an important consideration.

DEET has been the most widely used ingredient and has been studied and has good safety and efficacy data. DEET works not only against mosquitoes but also ticks, chiggers, fleas, gnats and some biting flies.  Repellents contain anywhere from 5 - 100% DEET, but the AAP recommends that children use products containing up to 30% DEET. There is no evidence that DEET concentrations above 50% provide any greater protection. DEET has also been shown to be safe when used in pregnant women which is particularly important with possible Zika exposure.

Picardin is another repellent that has been widely studied. It comes in concentrations of 5-20% and is odorless, does not damage clothing and has low risk for skin irritation.  The AAP recommends using products for children that contain up to 10% picardin. 

Oil of eucalyptus has been shown to be effective in preventing mosquito bites but it is not approved for use in children under 3 years of age.

Citronella and other oils have shown very little efficacy against mosquito bites and are not recommended.

So, when choosing a product I would start with a lower DEET or picardin concentration depending on your child’s exposure and go up in concentration as needed. Typically, the higher the concentration of DEET or picardin the longer the protection. As you know, some people seem to be bitten more often than others (all sorts of hypothesis about this) so you may use different products on different family members depending on age, frequency of getting bitten and expected exposure ( i.e.. playing in the yard vs a camping trip).

Once again, start reading the labels and then apply the repellent to skin and clothing. Do not use a combination insect repellent and sunscreen, they should be applied separately.  After the kids come in from playing at the end of the day a good bath with soap and water is important  to wash off the repellent.

Daily Dose

Zika Warning in United States

1:30 to read

The Zika virus is now here….that is, in the continental United States and specifically Miami, Florida.  There are now 4 confirmed cases of Zika infections in Florida, all thought to have been contracted from the bite of mosquitoes in early July. The cases are clustered in a northern area of Miami.  Although there have not been any mosquitoes in Miami that have tested positive for the Zika virus, epidemiologists do not think that is unusual, as the mosquitoes that were presumably infected may have already died (they have a short life cycle). Large scale testing of trapped mosquitoes in Florida is continuing.

Because the Zika virus only causes symptoms in about 20% of those infected (80% of people will never show symptoms although being infected) the health department is working to see if there may be even more cases in the Miami area. They are doing door to door surveillance in some zip codes and obtaining screening urine specimens checking for the virus….there should be more information available in the near future. At the same time, due to the fact that the Zika virus may be spread from blood and body fluids, the donated blood supply in Miami is being screened for Zika prior to being used. 

So…many of the families I care for vacation in Florida in the summer, especially along the Gulf Coast. I have received a number of phone calls in the last week from expectant mothers, as well as some who are trying to conceive, asking if they should even go to Florida?  This is a tough question, but for the time being, seeing that Texas does not YET have any locally acquired Zika virus I told them that I would probably err on the side of caution and change my beach travel plans. (England has recommended that their pregnant citizens “delay or postpone” all non essential travel to Florida).  

Here is my rationale.  Why risk going to the beach, with your family and children (who are going to spend most of their time outside), in a state known to have the Aedes aegypti mosquito and now confirming the first cases of locally acquired Zika?  The anxiety that is associated with the possibility of getting a mosquito bite ( despite using insect repellent and trying to wear protective clothing - which is difficult at the beach??), is just not worth it. Worrying for weeks after returning from vacation and never truly knowing if you might have been exposed (remember most people will not become ill when infected), and wondering if you should not conceive? Or worrying at every OB appointment that your fetus is developing normally…..because you went to the beach in Florida a month ago….? I just can’t think of a reason to go through all of that…for a week at the beach.

With that being said, I now have 4 mothers who have decided to cancel their vacation plans at the beach, and to stay home and not “take any chances”. The effects of the Zika virus on a developing fetus are life long and a vacation is just a fun filled week - so why not make a few  memories this summer with a stay-cation?  No anxiety…right?  Let’s see what happens in Florida and other southern states over the next few weeks and months as this situation continues to evolve. 

In the meantime - get rid of standing water and use your insect repellent wherever you live!

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