• Early Morning Drop-in Clinic:
  • Welcome Dr. Martin:
  • New Immunization Laws:
  • Whooping Cough Law:
  • Electronic Health Records:
  • Our Website:
  • Acetaminophen Changes:
  • Tdap Guidelines:
  • MCV4 Guidelines:
  • New HPV9 Vaccine:
  • Preventable Outbreaks:
  • Seasonal Flu Vaccine:

Early Morning Drop-in Clinic

Effective January 2016 we have created an urgent care early morning clinic. This is available in our office 8:30am-9:20am Monday-Thursday for our current patients (no appointment necessary).

One of our physicians will be available to see your child before regularly scheduled office hours. This service is intended to supplement the after-hours clinic, which is available at a separate location for nights and weekends urgent care.

Welcome Dr. Joshua Martin

Marin Pediatric Associates is excited to announce that we have added a new pediatrician to our staff. His official start date will be August 1, 2015.

Dr. Martin attended the University of North Carolina at Chapel Hill for both his undergraduate degree and medical school. He completed his pediatric residency training at Children’s Hospital, Los Angeles, CA. Since finising his residency, he has been honing his career objectives by getting additional training in pediatric nephrology at Lucile Packard Children’s Hospital at Stanford, and most recently as a pediatric hospitalist and general pediatrician with Sutter Medical Foundation.

Look for a more detailed bio coming soon on our web site and on our Facebook page!

School Immunization Requirements

In July 2015, Governor Jerry Brown signed into law SB 177, which eliminates the “Personal Belief Exemption” or “PBE” for vaccines for all children attending both public and private schools. This new law will take effect in the middle of 2016. Medical exemptions will still continue. Parents not wanting to vaccinate their children will have the option to home school their kids.

Here is an excerpt from the New York Times regarding this historic legislation:

“California sets a smart example for the nation by passing tough new laws that will require the vast majority of children in day care or kindergarten to be vaccinated against a slew of infectious diseases next year. The state will no longer grant exemptions based on a parent’s religious convictions or “personal belief” that vaccines might be harmful. It will only allow exemptions for children with medical conditions that make vaccination unsafe. This public health policy ought to be adopted by all states.

While all states require schoolchildren to be vaccinated, nearly all allow exemptions for families with religious objections (only Mississippi and West Virginia limit exemptions to medical necessity), and 20 currently allow exemptions based on a parent’s personal beliefs. Those beliefs are often based on irrational fears that vaccines might cause autism, a link based on fraudulent science that has long been discredited.

Vaccination rates can differ significantly among states. In Colorado, which allows both religious and personal belief exemptions, only 82 percent of children had received both recommended doses of the mumps-measles-rubella vaccine for the 2013-14 school year, while in Mississippi, which allows only medical exemptions, 99.7 percent had gotten both doses, according to the Centers for Disease Control and Prevention.

California’s previous policy had grown so lax that in some schools only half of the students have completed the required vaccinations, making those schools more susceptible to the spread of disease. A measles outbreak at Disneyland last December sickened 131 people in California, a fifth of them badly enough to require hospitalization, and infected 16 people in six other states as well. Most of those infected had not been vaccinated.

California was right to prohibit exemptions based on religious objections. Analysts have found that most religions have no objection to vaccination. Even religiously motivated parents should see the importance of vaccinations to protect the health of their child and others in the community. Experts say that 92 to 94 percent of the population needs to be immune to a disease like measles to achieve “herd immunity” to protect the whole community.”

At MPA, we believe that vaccination is one of the most important things parents can do for the health of their children. We also believe that it is part of our social contract as good citizens to ensure that the most vulnerable in our society are protected. Whether it's a newborn baby too young to have been vaccinated, or a cancer patient, or even someone taking arthritis medications, there are members of your community who are more susceptible to disease. These people are counting on you to not endanger their health by passing on a disease that could have been completely avoided with a vaccine.

School Immunization Requirement for Pertussis (Whooping Cough)

Every student entering the 7th grade will need to provide the school with documentation of their Tdap vaccine. This requirement began with the 2011-12 school year and continues annually.


In September 2010, then Governor Schwarzenegger signed into law AB354, which required all 7th through 12th graders to get the Tdap vaccine before entering school in the fall of 2011. Each student needed to submit proof of their Tdap booster before entering school for the 2011-12 school year. Now and in all subsequent school years, only entering 7th graders will need to provide this "proof".


This vaccine protects against Tetanus, Diptheria (bacterial croup) and Pertussis (Whooping Cough). In 2010, Whooping Cough was epidemic in California at rates not seen for over 50 years, and resulted in 10 infant deaths. Marin County had the second highest rate of infection in the state! In 2012 the state of Washington is experiencing a Pertussis epidemic!


This vaccine is typically given between the ages of 11 -12. In response to the 2010 epidemic, 10 year olds were encouraged to get the booster that year. The vast majority of our patients have had their Tdap vaccine and we can provide you with the proof needed by the school. For those who have not yet received their Tdap, (~15% of our 11 year old patients) please contact us to see if your child needs a check-up and this vaccine can be given at that time. But fee free to call us any time to verify your child's Tdap status.


We can provided you with a copy of your child's immunization records which will constitute "proof" of having received their Tdap booster.


(Our practice does not participate in the Vaccine Registry (PC based) due to the fact that our computer system is Mac based. Unfortunately this means your School Nurse will not be able to get your immunization records off the registry).

Electronic Health Records

MPA has entered the electronic health records age. While we hope to see the benefits of this shift soon, the reality is that everything is actually much slower to begin with. To this new system every child is a new patient and needs to be registered. We apologize for the extra time and paperwork (talk about ironic) this means for our patients when they come to the office. All the data from the paper chart system needs to be manually entered as well. This is a huge undertaking so for a while you'll see us carrying both our laptops and the charts at each visit.

Our New website!

Welcome to our website. Hopefully you've found valuable information here, and will return frequently if you need to access important facts about the practice, reliable online medical links for the health of your children, or just to check in with the latest news.

Our practice continues to thrive and grow. As part of our efforts to better serve you and your children, we have planned and implemented this new website. We have put together a site where you can easily find information about our practice and providers, trustworthy links to useful medical and parenting information, our latest news, and much more.

And now, we need you to help build our site. You may have noticed that our Home page displays artwork created by some of our patients. If you'd like to contribute, just submit a colorful picture, in portfolio orientation(up and down), on a white background - Your picture might get chosen for our site!

Important changes in infant and children's liquid acetaminophen medication preparations:

Acetaminophen products include several over-the-counter brands, including Little Fevers, PediaCare, Triaminic, Tylenol, and store brands or generic versions of the drug.


The drug is used to temporarily reduce fever and relieve minor aches and pains from the common cold, flu, headache, minor sore throat, and toothache.


In an effort to reduce dosing errors when giving acetaminophen you will now find only one concentration of the drug available on store shelves: the 160mg / 5mL (tsp) preparation.


Why the New Version?:

Until recently, liquid acetaminophen marketed for infants was available only in the stronger 80 mg per 0.8 mL concentrations that doesn't require giving infants as much liquid with each dose. Meanwhile, the less concentrated 160 mg per 5 mL version was marketed for children.


So for example, if you accidentally gave your typical 3 year old a 1 tsp (or 5 ml) dose of the infant acetaminophen preparation, you would have given a 500mg dose instead of the intended 160mg. In other words, over 3 times the intended dose could be given in error!


Less dangerous, but problematic would be giving an infant only ~1/3 of your intended dose if using an infant dosing dropper to draw up medication from a children's acetaminophen preparation. No wonder the fever wasn't going down or the pain subsiding!


In 2011, a report from the FDA showed that confusion caused by the different concentrations of liquid acetaminophen for infants and children was leading to repeated overdoses that made infants seriously ill, and some died from liver failure.


So please take the following measures to ensure you are giving the proper dose of acetaminophen!


Double-check the label on liquid acetaminophen before giving it to a child or infant to avoid giving your child the wrong dose.


The FDA is urging parents and caregivers to carefully read the label on liquid acetaminophen marketed to infants and children as a new, less concentrated form of the popular pain reliever arrives on store shelves.


While the new 160 mg per 5 mL concentration is now arriving in drugstores, much of the older, more concentrated 80 mg per 0.8 mL versions may still be in people's medicine cabinet. Giving too little liquid acetaminophen could cause the drug to be ineffective. Giving too much over repeated doses could possibly lead to overdosing (or even death).


To avoid these dosing errors, some manufacturers voluntarily changed the concentration of liquid acetaminophen for infants to the same concentration as the liquid acetaminophen marketed to children.


The new, less concentrated 160 mg per 5 mL liquid acetaminophen for infants has new dosing instructions and may have a new dosing device in the box, such as an oral syringe rather than a dropper.


What You Should Do:

The FDA advises parents and caregivers to read the "Active ingredient" section of the Drug Facts label on liquid acetaminophen marketed to infants or children to tell the difference between the two products.


Other tips for ensuring safe and accurate dosing of liquid acetaminophen include:


  • Do not depend on a banner proclaiming that the product is "new" to determine the drug's concentration. Some medicines with the old concentration also have this word on their packaging.
  • Uses only the dosing device provided with the purchased product in order to correctly measure the right amount of liquid acetaminophen.
  • Consult your pediatrician before giving this medication and make sure you're talking about the same concentration.
  • If the dosing instructions provided by your health care provider differ from what is on the label, check with a health care professional before administering the medication. Do not rely on dosing information provided from other sources, such as the Internet, old dosing charts, or family members.


FDA officials say it is important to note that there is no dosing amount specified for children younger than 2 years of age. If you have an infant or child younger than 2 years old, always check with your health care provider for dosing instructions.


We have updated our acetaminophen dosing charts to reflect these new changes so you can click here to go to our updated dosing guidelines.

Updated guideline for Tdap Vaccine

Tdap vaccine

This vaccine protects against Tetanus, Diptheria (bacterial croup) and Pertussis (Whooping Cough). Changes in the indications for this vaccine include:

  • expanded age range: age 7 to 100+
  • recommending the vaccine for pregnant women
  • eliminating any restrictions based on
    a Td (tetanus and diptheria only) vaccine given in the past

  • These recommendations were added to the existing indications of:
  • Age 11-12, and older teens if this booster was missed
  • All adult caregivers of infants

In 2010, Whooping Cough was epidemic in California at rates not seen for over 50 years, and resulted in 10 infant deaths. Marin County had the second highest rate of infection in the state! We believe this was largely due to the high rate of "personal belief exemptions" causing especially low vaccination rates. NO vaccine provides a 100% guarantee of protection and the effectiveness can wear off in time. To counter this, we rely on "herd" immunity: the more people out there who are vaccinated the less chance of an infection finding traction in a community of susceptible individuals and starting an epidemic.


In September 2010, then Governor Schwarzenegger signed into law AB354, which required all 7th through 12th graders to get the Tdap vaccine before entering school in the fall of 2011. Each student needed to submit proof of their Tdap booster before entering school for the 2011-12 school year.


Now in 2012 and in all subsequent school years, only entering 7th graders will need to provide this "proof." We can provide you with an official copy of your child's vaccinations that will fulfill this requirement.


Tdap has been available since the end of 2005 to everyone age 10-64. This vaccine is typically given between the ages of 11 - 12 as a booster to the DTaP last given around kindergarten entry, and to any adult caregivers of young infants.


In response to the epidemics, kids as young as 7 are now eligible for the vaccine under certain circumstances. In addition, pregnant moms are advised to get the vaccine to protect themselves and to provide "passive immunity" or antibodies to the fetus that will continue to protect the child into early infancy.


What we don't yet know about the Tdap vaccine is just how long the immunity it provides lasts. We know from recent experience that the 5 dose DTaP series given from ages 2 months to 5 years wears off 5-8 years from the last dose, which is why we recommend the Tdap booster at age 11. We also know that immunity from the actual illness wears off in a similar time frame. Will we come to recommend a Tdap booster every 5 years? Every 10 years? Since the Tdap vaccine is only 7 years old, we will only now be able to study how long its effectiveness will last. So stay tuned!

Updated guideline for MCV4 Vaccine

Meningococcal Vaccine (MCV4)

MCV4 protects against meningococcal disease, a serious bacterial infection that can cause meningitis or serious blood infections. Changes in the indications for this vaccine include:

  • A booster at ages 16 -18 or 5 years after the initial vaccine

  • These recommendations were added to the existing indications of:
  • Age 11-12, and older teens if this dose was missed
  • Any person age 2-55 at high risk due to:
    • travel to areas where meningococcal disease is common
    • exposure during an outbreak
    • living in a dormitory
    • military recruits
    • certain types of immune deficiencies

Meningococcal disease, though rare (1,000 -2,600 cases/yr in the US) is a very scary disease. Even with antibiotic treatment, the disease is often fatal and survivors may require amputation(s) and suffer from permanent neurologic damage. Anyone can get this disease but it is seen most commonly in infants, teens, especially college freshmen, and people with certain medical conditions affecting their immune function, such as lacking a spleen.

At the present time, we don't have a vaccine that has been shown to be safe and effective against this disease for infants. We do currently vaccinate this age group against other causes of meningitis and serious blood infections by providing the HiB and Pneumococcal (Prevnar13) vaccines.

New for 2015- the new HPV9 vaccine providing expanded protection against cancer!

This vaccine protects against cancers caused by the human papilloma virus, the most common sexually transmitted virus in the US. Changes in this expanded vaccine include protection against 5 additional strains of the cancer producing variety. This new and improved vaccine continue to protect vaccinated people from strains 6 and 11 which are responsible for over 90% of venereal warts. With the addition of the added strains, the vaccine protects against 7 of the cancer producing variety.

Cancers know to be caused by the HPV:
  • most cases of cervical cancer
  • many vaginal and vulvar cancers
  • many penile cancers
  • many anal cancers
  • many head and neck cancers
... and the list is growing as we learn more about this nasty virus.

In the United States, an estimated 75 to 80 percent of males and females will be infected with HPV in their lifetime. For most, HPV will clear on its own. However, for those who don't clear certain types, HPV can cause cancer: cervical, vaginal and vulvar cancers in women and anal and some head and neck cancers in both men and women. HPV can also cause genital warts in both men and women. There is no way to predict who will or won't clear the virus.

In our office we offer the HPV9 vaccine called GARDASIL9™ which helps protect against the 9 types of HPV, specifically types 6, 11, 16, 18, 31, 33, 45, 52, and 58, that cause the most disease. It is estimated that HPV accounts for more than 80 percent of anal cancers, nearly 100% percent of cervical cancers, over 70 percent of vaginal cancers and the majority of vulvar cancers. HPV types 6 and 11 cause approximately 90 percent of all genital warts cases.

Each year, more than 20,000 HPV-associated cancers occur in women; cervical cancer is the most common. In the U.S., about 12,000 women get cervical cancer every year, and about 4,000 women die from it. Gardasil-9 can prevent most of these cancers. More than 11,000 HPV-associated cancers occur each year in men; oropharyngeal cancers are the most common.

Anal cancer affects both men and women, with approximately 60 percent of cases occurring in women. According to the American Cancer Society, it is estimated that approximately 2,000 men and more than 3,000 women will have been diagnosed with anal cancer in 2010. There is no standardized screening recommended for the general population for anal cancer and many people are diagnosed when the disease is more advanced.

HPV is the culprit for serious disease, especially for women, even if is caught early. Cervical surgery is required to treat and remove precancerous changes in the cervix. This can affect the ability of a cervix to stay closed throughout a pregnancy until the expected full term.
So protect you kids from cancer!!!
Get vaccinated!

3 doses are recommended, with the 2nd dose given 2 months after dose 1, and the final dose given 4 months after that. But if your child has fallen behind in this schedule, there is no need to repeat doses; we just pick up where you left off. For patients who have already completed the HPV vaccine series with the older HPV4 vaccine, we are awaiting official recommendations on using the HPV9 vaccine as an additional booster.

The HPV vaccine is licensed for ages 9-26.
It only works in prevention mode. If you’ve already been exposed the vaccine cannot do it’s job.

Recommended age to start the vaccine: ages 11-13. Older teens and young adults should catch-up if they are behind.

Outbreaks of Vaccine Preventable Diseases

No vaccine itself is100% effective at protecting your child against the disease it is designed to prevent so "herd" immunity is a very important part of reducing the potential for community outbreaks. Marin has one of the state's highest rates of personal belief exemptions (PBE), parental waivers that allow children to enroll in kindergarten without receiving vaccinations against diseases such as measles, polio or whooping cough. In some schools such as Marin Waldorf and San Geronimo Valley, more than 50% of the children have PBE's and so are under-vaccinated.


We believe the large number of whooping cough cases in Marin during the 2010 epidemic may be linked to the growing number of parents who refuse vaccinations for their children. More recently outbreaks of measles and mumps have been linked to unvaccinated children who returned from foreign travels.


Measles/Mumps/Rubella: (prevented by the MMR vaccine)


Measles elimination has been maintained in the United States for more than a decade through high population immunity secondary to high MMR vaccination coverage. Coverage with 1 dose has been >90% among children aged 19–35 months since 1996. The increase in measles importations and outbreaks during 2011 serves as a reminder that measles remains endemic in many parts of the world and unvaccinated U.S. residents continue to place themselves and others in their communities at risk for measles and its complications.


This hit especially close to home with the 2014-15 measels outbreak at Disneyland. These diseases may not usually be common in the United States, but this is absolutely not the case for the rest of the world. In this instance, a tourist from the Philipines unwittingly carried measels from their home country, where the disease is much more common, and infected over 130 people. A similar incident caused the 2011 outbreak on Cal's campus, which personally affected many of our patients. Even if you and your family do not plan on traveling to these at-risk areas, these diseases can still find their way to your community, and it is important to make sure your children are protected! Another outbreak could just be a single plane flight away!


The increase in importations reflects recent increases in the incidence of measles in countries visited by U.S. travelers. The source of almost half of the measles importations in 2011 was Europe, which reported >30,000 cases of measles, including 27 cases of measles encephalitis, a complication that often results in permanent neurologic damage, and eight measles-related deaths in 2011. Five countries (France, Italy, Romania, Spain, and Germany) accounted for more than 90% of cases reported to the European Centers for Disease Prevention and Control. 2011 also saw smaller outbreaks of measles in Ecuador and New Zealand and large outbreaks in Africa (South Sudan and the Congo).


Importations of measles virus into the United States will likely continue and cause outbreaks in communities that have clusters of unvaccinated persons. Maintenance of high MMR vaccination coverage is essential to prevent measles outbreaks and sustain measles elimination in the United States. Despite the relatively small number of reported cases in the United States, the public and the health-care providers must remain vigilant. A drop in MMR vaccination coverage in a community can increase the risk for large, sustained measles outbreaks, as experienced recently in San Diego, Canada and France, or reestablishment of endemic transmission, as experienced in the United Kingdom.


Mumps: In 2006, the United States experienced a multi-state outbreak involving 6584 reported cases of mumps. This resurgence predominantly affected midwestern college students with the highest attack rates occurring among those living in dormitories. The next 2 years had few reported cases.


However, beginning in July 2009, the largest U.S. mumps outbreak since 2006 has occurred. The index case was an 11-year-old boy who had returned on June 17 from the United Kingdom where an ongoing mumps outbreak involves more than 4000 cases.


Mumps came home to Marin in December 2011 when an unvaccinated child returned from travel to Japan. Fortunately the winter school break limited the transmission but the next time we might not be so lucky.


Why should you worry about mumps? Rare complications of mumps include sterility and permanent neurologic damage such deafness.


Pertussis (Whooping Cough) Outbreak:

As kids get older, protection from some childhood vaccines can begin to wear off. Teens also develop risks for different diseases as they get older. Help your child transition into adolescence in a healthy way by staying up-to-date on pre-teen vaccines.


Currently, Washington State is in the midst of a Whooping Cough epidemic with over 1000 cases reported as of mid April 2012.


In 2010 there was a Pertussis, or Whooping Cough outbreak in California, the highest number of cases in over 60 years with very high rates of infection in Marin. You may have gotten information about a case of Pertussis in your child's preschool, school or camp.


Pertussis is caused by a bacteria (Bordatella Pertussis) that is spread by coughing or sneezing. Infants under the age of 1 and the elderly will suffer the most from Pertussis, and often need to be hospitalized due to the disease and its complications. In very small infants, Pertussis can be deadly (10 infant deaths were reported in the 2010 California outbreak).


A typical case of whooping cough may appear similar to a common cold, and starts with a cough and runny nose for one to two weeks, followed by weeks or months of rapid coughing fits that sometimes end with a whooping sound, or by vomiting from the severe cough. Fever is rare.


Children are immunized against Pertussis (the DTaP vaccine) at 2, 4, 6, and 15 - 18 months, and are given a booster dose before starting kindergarten. Another booster (the Tdap vaccine) is given to middle school students (age 11 - 13 years). The reason so many booster doses are needed is that Pertussis immunity (from both the vaccine and illness itself wears) off after 3 - 5 years. This is why so many adults, teens and 8, 9 and 10 year olds are susceptible to Pertussis. Moms delivering at Marin General are vaccinated for Pertussis after their delivery if they have not already been vaccinated. Pertussis vaccination for dads, and all household contacts is urged as a way of cocooning newborns against exposure to this disease.


Because infants, especially newborns, are at such high risk, the State of California is now recommending a Pertussis vaccine in the third trimester to boost mom's immunity in time for delivery. State law now requires documentation of a current Tdap vaccine for all students entering the 7th grade.


The Pertussis vaccine itself is not 100% effective at protecting your child against Pertussis so "herd" immunity is a very important part of reducing the potential for community outbreaks. Marin has one of the state's highest rates of personal belief exemptions, parental waivers that allow children to enroll in kindergarten without receiving vaccinations against diseases such as measles, polio or whooping cough. We believe the large number of cases in Marin may be linked to the growing number of parents who refuse vaccinations for their children.

For more information visit these web sites:

Marin County Health Dept


Seasonal Flu Vaccine

2015-2016 Seasonl Flu Vaccine is Here!

Since 2010, the CDC and AAP recommend flu vaccines for ALL people 6 months and older!

We recommend flu vaccine for ALL our patients 6 months and older, and parents and caretakers of infants or kids at higher risk from complications of influenza.

NEW for 2015-16 season: Quadrivalent flu vaccine protects against 4 different flu strains, two A and two B strains:
  • - an A/California/7/2009 (H1N1)pdm09-like virus
  • - an A/Switzerland/9715293/2013 (H3N2)-like virus
  • - a B/Phuket/3073/2013-like virus (This is a B/Yamagata lineage virus)
  • - an additional B virus (B/Brisbane/60/2008-like virus). This is a
  •       B/Victoria lineage virus.
Many pharmacies are only stocking the older style, trivalent vaccines (two A strains, and one B strain).

We offer flu vaccination to all our patients (and we will bill your insurance for this).

We offer flu vaccination for parents and caretakers (as supplies permit). We offer this service as a convenience to our patient's families. Payment is expected at the time of service and we will not bill your insurance for the service. We will provide you with the necessary paperwork to submit to your insurance if you would like to try to get reimbursed, but we cannot guarantee your insurance will cover the service.

We offer seasonal flu vaccine as soon as the product becomes available. Vaccine coverage should last through the entire flu season, which is very unpredictable, so we strongly encourage getting vaccinated as soon as possible!

We are currently offering the 2015-16 Quadrivalent vaccines only, most of which are preservative free. This year, we have the following types of flu vaccine available:
  • - the nasal spray preparation which is used for healthy individuals
  •       aged 2 – 49. ($40) (not expected until late September)
  • - injectable flu vaccine for children ages 6 - 35 months. ($40)
  • - injectable flu vaccine for people ages 36 months to 64 yrs. ($30)

There is an additional type of flu vaccine, which we do not stock. A high dose flu vaccine for adults 65 and up became available with the 2010-11 season. This formulation provides a better immune response in this age group. So ask your own physician or pharmacist if this vaccine might be best for you.

Please call to schedule your child, and household members for their flu vaccine. If you are just interested in flu vaccines, you will be scheduled during one of our flu vaccine clinics. If you would like to get other vaccines as well at this visit, or have questions about the best vaccine for your child and family, we will schedule a brief visit with your PCP.

Why we recommend influenza vaccination:
Influenza results in close to 40,000 deaths a year and 300,000 hospitalizations per year. H1N1 seemed to have particular affinity for the pediatric age group and pregnant moms with slightly higher than usual complication rates in these groups. Though most of our patients will experience the "flu" as no worse than a particularly bad cold, the children under age 2 and those kids with underlying medical conditions are especially vulnerable to complications. Even healthy individuals with no risk factors can have surprisingly severe illness or complications from influenza. To protect all our patients, and especially the most vulnerable, both individual immunity and "herd" immunity works best. For more information please visit the links section, flu information web sites.