Ear Infections/All the Basics

 

One of the most common reasons that many people find themselves going in to see the doctor in person is to rule out an ear infection. It’s one of those things you still can’t accurately diagnose from a virtual visit…… or with ChatGPT.

The basic medical term for an ear infection is otitis. But ear infections come in different varieties and complexities. Although ear infections are a common occurrence, there is nothing simple about them. In 2015, the World Health Organization came up with a system to track every possible diagnosis. These are called ICD10 codes. To be clear, they erred on the side of leaving absolutely nothing out. We are not kidding. There is a code for being bitten by a dolphin and another for getting sucked into a jet engine.

When it comes to ear infections, there are hundreds and hundreds of codes, Which ear? Is there fluid? Is it ruptured? Is it chronic or the first time? The list goes on and on. We are going to focus on the basics.

The most common types of ear infections are:

• Suppurative otitis media, which is a bacterial middle ear infection.

• Serous otitis media, which is un-infected fluid behind the eardrum

• Otitis externa, which is also known as swimmer’s ear

Kids are so much more vulnerable to ear infections than adults.

Source: https://nesilv.com/ent/eustachian-tube-dysfunction/

This is because the middle ear is connected to the upper respiratory tract by a tiny channel known as the eustachian tube (above). Children’s eustachian tubes are smaller and more level than those of an adult. This means it is harder for them to drain well and easier to get blocked up even with mild swelling. Germs that are growing in the nose can climb up the eustachian tube and enter the middle ear. Because of these drainage issues, when kids are congested, they also may have fluid in their ear (serous otitis media). This is why we are more suspicious about a possible ear infection in a child who has a cold. What may start out as a virus can turn into something bacterial. That fluid is the perfect medium for bacteria to grow. It’s like a stagnant pond just waiting for the mosquitoes to breed.

The Classic Story

Using the pond metaphor, you can understand the most common story behind an ear infection: a young child who had a cold, seemed to be getting better, then 1-5 days later presented with fussiness (think frequent nighttime wakeups), ear pain, with or without fever. It’s more than likely they are now dealing with an ear infection.

Common symptoms and associated factors with ear infections:

• Most of the time, an infection in the middle ear is associated with congestion, the flu, or other types of respiratory infections including RSV.

• Young kids who are nonverbal, are making it clear that they are NOT comfortable or happy. They have extra fussiness, fever, or are tugging at their ear.

• Many kids wake up more than usual at night or have fussiness when being horizontal (i.e. for naps). They may seem more comfortable when they are upright because being flat increases the pressure.

• Vomiting can be associated with ear infections. (usually this does NOT come with diarrhea)

• Some kids seem like their balance is off.

• Others seem like they are having trouble hearing. Of course we all know that all of our kids can seem deaf when we are telling them something they don’t care to hear!

Just because your child is tugging at their ear does not mean they have an infection. Some kids do it as a habit. Nurse Judy’s grandson Elliot used to hold onto his left ear whenever he was tired (this one is super common). Others do it when they are teething, especially upper teeth. Nevertheless, frequent pulling at the ear can be a clue that is worth paying attention to, especially if it accompanies any other symptoms.

What makes it tricky?

Some stoic kids don’t make a noise about a severe infection while others complain bitterly about a little fluid in the ear that is not actually infected. A good number of kids don’t show any symptoms at all. We have seen patients go in for a well child exam be caught by surprise when a routine ear check revealed a raging infection. We have also seen ear infections go from ‘zero to sixty’ in no time flat. No, your doctor didn’t miss it. A child with a perfectly normal ear exam one day can have a horrible ear infection the next, sometimes within 12 hours. There is a correlation between the rate of the infection’s presentation and which strain of bacteria caused it. Some build slowly, others are overnight.

Diagnosis

To make an accurate diagnosis, for otitis media or serous otitis there is a lighted tool called an otoscope. Checking ears is a real skill that often takes practice to do well.

Factors like lots of ear wax, the angle of the ear canal (they’re all different) or an uncooperative patient can add a level of complexity to the exam. If a patient is screaming bloody murder from the simple exam, that can make the eardrum appear redder than normal.

Treating Otitis Media

If your child is diagnosed with a middle ear infection, you may or may not get a prescription for antibiotics.

Not only is there not one standard treatment, but many times no treatment is even needed. If people blindly treated every complaint about an earache, antibiotics would end up being wildly over prescribed and all of our guts would be in ruins. Nobody want their kids taking medication unnecessarily, and antibiotic resistance is a potential problem for everyone.

If the eardrum is bulging and looks like it might rupture, the doctor will almost certainly advise you that you should absolutely go ahead with the medication regardless of how your child is acting. Another good reason to treat it is if your child is miserable and feverish.

On the other hand, if it is not a severe infection and your child seems consolable, guidelines state that it is perfectly fine to watch and see for a few days.

Many ear infections can indeed clear up on their own and of course we all would like to avoid the use of antibiotics if we can.

Current guidelines support a “wait and see” approach for kids:

• Who are older than 2

• Have mild symptoms (pain without fever, or pain that resolves with over-the-counter pain meds)

• Infection is only on one side.

For these kids, most doctors will provide a “safety net antibiotic prescription,” one that you can pick up and have in the house just in case, but not necessarily start immediately.

It is recommended that you start the prescription if your child develops:

• Ear pain with fever

• Ear pain that is severe (i.e. doesn’t resolve 90 minutes after Tylenol or Motrin)

• Prolonged ear pain that is worsening or fails to improve after 48 hours

• Many clinicians chose to have a lower threshold to treat with antibiotics before flying: the pressure in the cabin increases the risk of eardrum rupture if there is a potential infection.

A Note about ruptured eardrums:

Our main agenda, aside from making the kids more comfortable, is to protect long term hearing. Repeated severe infections or eardrum ruptures increase the risk of hearing loss because they can become scarred.

When there is a rupture, it is common to have a noticeable amount of thin yellow/white/green liquid draining out of the ear. The good news is that the pain of the pressure in there is gone, a miserable screaming child might actually seem more comfortable after the eardrum finally bursts.

The bad news is that the tympanic membrane (an important protective barrier) is no longer intact.

Therefore, if your child does have a ruptured membrane, they need to be seen and treated (with antibiotic ear drops and oral antibiotics) even though they are no longer quite as fussy. After a rupture, it is worthwhile getting the hearing tested to make sure there is no lingering hearing loss after the eardrum heals. This is even more important if it has happened more than once. They also need to avoid fully submerging their head in pools while their eardrum is open. Short baths and water running over the head are usually okay, but no hanging out under water.

Antibiotics

Most pharmacists will take a moment when you pick up the prescription to go over the directions. Don’t treat this opportunity the way most of us do when the flight attendants are telling us how to buckle a seat belt. Pay attention and please make sure you are clear with the dosing instructions.

• Should it be taken with or without food?

• Does it need to be stored in the refrigerator?

• Do you need to be more cautious with sun exposure?

• Are there other medication interactions?

• Are the foods that should be avoided?

• What are common side effects?

• Are you clear about the dosage and timing?

Liquid antibiotics tend to be sticky and sweetened in order to make them more palatable. Please don’t forget to brush those teeth! In case you have a compliance issue, Here are some tips for giving the meds. Unfortunately even with the added sweetness, some are pretty nasty.

Make sure that you finish the medication as directed. Don’t stop as soon as they are feeling better. That can lead to recurrent ear infections if any of the bacteria is lingering.

Some doctors offer “ear follow up” visits: an opportunity to examine the ear after treatment to ensure that it has recovered. This isn’t mandatory, but is a good idea if:

• You’ve had recurrent ear infections, especially within the last few months.

• The ear drum ruptured.

• The ears looked severe on the exam.

Antibiotics are not an instant magic wand. It may take the medication at least a couple of days before you notice a significant improvement. If your child is still super fussy or feverish after a full three days, have your doctor take another look in there to make sure the meds are working.

Some kids who are having a really difficult time may end up getting an antibiotic injection. These hurt a bit, but they are usually quite effective.

Bacterial Versus Viral Ear Infections

So far we’ve been talking about bacterial ear infections. These are collections of bacterial pus, stuck behind the ear drum, that cause significant pain and fever. A provider can tell that an ear infection is bacterial because of the way it impacts the eardrum. The eardrum will look thickened, dull, dark red and is often bulging. The anatomic landmarks can’t be seen. Dr. Ted says it looks like it’s been beaten up. By contrast, viruses can cause collections of non-infected fluid. These are examples of “serous otitis media,” which can cause some pain, but the ear drum appears shiny, the fluid is clear, and the anatomic landmarks behind the ear drum are visible.

Dealing with Serous otitis

Because the fluid trapped in the ear is often viral, many of these will resolve with time as the virus passes. However, the trapped fluid is the necessary precursor to a bacterial ear infection (see above with the stagnant pond metaphor). We want to encourage drainage to prevent it from becoming infected. It is considered chronic when it lasts for at least three months.

Kids may or may not have obvious symptoms.

It’s a good idea for kids with chronic serous otitis or kids who get one infection after another to establish a relationship with an ENT doc. Among other treatment options, they may consider inserting some tubes in the ear to help them drain.

Melissa Wilson, Doctor of Audiology at Sound Speech and Hearing, adds that tubes are also put in to address the hearing loss that often accompanies middle ear fluid. Fluid build-up often causes a hearing loss on the order of 30-40 decibels. Average speech is about 60 decibels, so having fluid is like listening with your fingers plugging up your ears. Everything your child hears is muffled and over time, this can impact their speech and language development, and for the school-aged children this can cause issues with listening in the classroom and academics.

General management of serious otitis often includes nasal saline flushes/rinses and humidifier use. Some providers might recommend decongestants or nasal steroids like Flonase if they suspect that allergies are involved.

Chinese Medicine

Traditional Chinese Medicine (TCM) can be a great and effective way to address ear pain and infections in some little ones. Acutherapy treatments (non-needle methods are available!) purport to help the body to reduce inflammation and mucus, relieve pain and increase the necessary drainage. According to TCM practitioners, early treatment is your best shot at avoiding antibiotics! Acutherapy treatments also try to help prevent future infections, so they may be good for kids who tend to get an ear infection with every cold.

There are also safe pediatric Chinese herbal tinctures available and easy to use. For kids prone to ear infections, San Francisco’s Dr. Den recommends keeping them on hand, so you can start giving them to your child at the very first signs of ear discomfort or infection. Reach out to your local pediatric TCM practitioner for specific products or advice.

Thinking outside ‘the box’

If you are open to other alternative options, Nurse Judy has seen some of her patients benefit from gentle chiropractic treatment for some stubborn cases of serous otitis.

Thank you to SF Chiropractor Sanra Roddy Adams for sharing this study that explores how adjustments/craniosacral therapy can help with drainage.

Otitis externa (also known as swimmer’s ear)

This is where we draw a distinction between inner and outer ear infections.

Remember that photo of the eustachian tube, above? The ear drum, or tympanic membrane, is a waterproof covering that divides the components of the middle ear from the outside world. The eardrum is why swimming does not cause inner ear infections. An intact eardrum keeps water out.

With otitis externa the outside of the ear is usually red and sore. The ears may be tender and will look inflamed. They may smell funky. These can be associated with time in water or pools but not always.

This condition may be treated with ear drops rather than oral medications, depending on the severity. As opposed to the other forms of otitis, this one impacts plenty of adults as well.

Comfort measures/symptomatic treatment

With or without the use of antibiotics there are several things you can do to ease the discomfort of a painful ear.

• Tylenol and/ or Ibuprofen are useful. Here is a dosage post .

• Warmth usually feels good and can promote drainage. Some folks swear by a warm hair dryer held about a foot away from the ear.

• Warm compresses are another option. Try a warm wet washcloth against the ear.

• Little microwavable heat packs are great for this. If you don’t have one on hand you can make your own. Pour enough water into a clean diaper to get it nice and wet. Heat it up in a microwave for a quick heat pad that will stay warm for a while.

• Dr. Den recommends putting some uncooked rice in a sock, and then tie the sock off (if it’s long enough), or close it with an elastic band. Unless it becomes soiled, the same sock can be reheated many times, making this an easy, no mess method. Warm it briefly in the microwave.

Whichever kind of heat pack you choose, warm it up in 30 second increments to make sure it doesn’t get too hot. Always test the temperature carefully before placing it against your child’s ear. It should be a comfortable warm/slightly hot temperature.

• Believe it or not, Nurse Judy’s favorite remedy is garlic oil. Check the ear to make sure there is no reason to suspect a rupture; she doesn’t like to add any home remedy drops if there is any suspicion that the eardrum may not be intact. If there is no odor or drainage (a little wax doesn’t count) garlic oil may be a good option for relief. This is a comfort measure: the warm oil can soothe a pained ear. It is not meant to treat a suspected bacterial ear infection. Remember: make sure there is no rupture before using it. If there is any drainage from the ear, don’t take the chance.

Here’s how to do it:

Saute some cloves of garlic in some olive oil. Let the oil cool until it is warm/not hot. Take a cosmetic square or cotton ball. Dip into the warm oil and stick it in the ear. Do this as often as your child will allow.

• Dr. Den likes garlic mullein oil drops. These are soothing and will help fight the infection. (and you don’t need to fuss). Roll the bottle between your hands to warm it slightly, and then place 1 drop in the affected ear, up to three times per day.

If it is the middle of the night and your child is screaming, you can try any of these pain relief options until you have an opportunity to have your child checked. Persistent unrelenting misery may warrant a trip to the ER.

We feel a pang for stressed out, busy parents who would love to avoid dragging their sick kids out into this germy world for an in person office visit, but as we mentioned above, virtual care is usually not adequate for an ear check.

An important thing to note is that when kids have goopy eyes, they may also have otitis, which is why a visit to your pediatrician may be needed in order to check out the eyes and the ears rather than just giving eye drops over the phone.

Dr. Ted’s Tidbit

This story, of a kid with goopy eyes and a parent that just wants eyedrops, is one of the most inconvenient things we have to deal with, because it really feels like a phone call and some eye drops should be the end of it. But there is a connection between eyes, tear ducts, and ears. About 20-30% of the time there is an eye infection, there is also something to be seen in the ears.

Because many bugs will infect eyes and ears together, and chatting over the phone or via a screen won’t tell you the full picture. Unfortunately, a combo eye-ear infection often needs more powerful antibiotics, so it is important to get a look at the physical ear.

And because pediatrics is never boring:

It is also not unusual for pediatricians to find a little surprise when the ears are checked. Back when Nurse Judy was working at the pediatricians office, the team found an assortment of little treasures in there, including little beads, unpopped popcorn kernels, and even the occasional insect.

Will the real Santa please stand up. How to have the 'Santa chat' with your child

 

Everywhere you go this week you are likely to bump into more than one Santa Claus. Many years ago when my daughter Lauren did a stint as a server at a large New York City bar, Santa-Con was her least favorite event. Having thousands of drunk Santa’s hitting on her lost it’s charm very quickly.

Of course, everywhere you go this week you are likely to bump into more than one Santa.

While most kids may not give this phenomenon too much thought, some earnest true believers might wonder what's going on.

Hey Mommy or Daddy, how can Santa be in more than one place a one time?

What is the best way to keep the magic alive while not endangering the trust that is so important in any relationship?

For the young kids who ask if the mythical creature is real, you might deflect the questions fairly easily without telling a falsehood if you want to extend the magic for another year.

A simple,“What do you think?” works some of the time. Or, “It is fun to believe in magic sometimes and Santa is part of the holiday magic.”

Keep in mind that once your child gets to kindergarten, believing that Santa is actually going to try to fit down your chimney, rather than the ‘spirit of the holiday magic,’ may result in a shocking disappointment for them when they learn the truth.

There are lots of kids at school, who are eager to share the cold hard facts with your innocent child. It is much better if this discussion comes from you before your kids find out a harder way.

I spoke to several people who recounted that they believed in Santa with all of their hearts and were completely devastated when they learned the he wasn’t exactly a real man. They felt deceived. One person told me that finding the truth was the moment they stopped believing in all magic. How sad!

Letting them know the truth gently doesn’t have to be a negative experience.

For older kids, consider telling a story. Perhaps this one has an element of historical truth:

“Once upon a time in a far off country there was a man named Nicholas. He loved to do good things for other people. What was special about him is that when he gave people presents or did nice things, he didn’t do it because he wanted something in return. He simply wanted to do good things. Lots of times he did it in secret and no one even knew who did something nice for them. Maybe this Nicholas was big and jolly and had a white beard. He became known as Santa Claus. Santa is a symbol of love and magic and hope and happiness. He teaches children how to believe in something that they can’t see or touch.

I am on his holiday kindness team and now you can be too. Really little children might believe that there is one Santa who manages to be everywhere at once. Big kids like you get to know the secret. Team Santa is all the big kids and grown ups who want to help make other people happy. “

Perhaps take the opportunity to help your child be an active member of this awesome team; an initiation of sorts. Is there someone in your life that seems like they need a little kindness? What could you do for them? Is there a little gift that might make a difference? Plotting a secret kindness is the thing that wonderful lasting holiday memories are made of.

Every kid and family are unique. There are families that make the choice to protect the ‘Santa is real’ narrative as long as it is possible. Make whatever choices feel right for you, but if your child asks a direct question, my advice is to find a gentle way to be honest.

One more piece of Santa advice. The photo on Santa’s Lap should be voluntary. If your child isn’t eager to go sit on a stranger’s lap, please don’t force them.

At some point the veil will be lifted from the easter bunny as well as the tooth fairy. If your kids are like mine were, they are going to keep that tooth fairy gravy train going as long as you are willing to play along. The magic doesn’t need to end.

Holiday Safety tips 2025

 The lights are twinkling and the radios are playing the holiday tunes. People are putting up the holiday decorations. It is time for the holiday safety post. Take a moment to give this a careful read. There may be some things that haven’t occurred to you.

For most people, the holidays are a time for celebration. That means more cooking, home decorating, entertaining, and an increased risk of fire and accidents.

For every aspect of holiday celebrations, I can tell you the story of a patient who called with a related accident. It is not my intent to scare folks with my tales. If you know ahead of time what accidents can happen, you have a way better chance of avoiding them. I have seen some wild and improbable things over the years.

Below are some safety considerations for dealing with the holiday season ahead. Some of these may seem like common sense but there might be a few tidbits in here that I am betting you haven’t thought about.

Baking cookies is just one example. A patient’s mom called to tell me that her 10 month old had sustained a burn on his hand. She was holding him in the crook of one arm as she removed the cookie sheets from the oven. As she recounted, he turned into a cartoon character with a telescoping reach and he was able to stretch across her body and grab a hold of the piping hot tray. Simple solution - don’t hold your child when you are working with hot stuff in the kitchen. Their arms are longer than you think. If even one accident has been prevented, this post was worth it.

Candles are another hazard. It was a winter evening many years ago in a cabin at Lake Tahoe. Dr. Jessica (who is currently at Town and Country Pediatrics) and family lit some holiday candles and went to sleep. Somehow one of the candles ended up burning a hole through a plastic mat that was on the table. Luckily the smell of burning plastic woke them up before any real damage was done, but it was a frightening lesson. This was a vacation rental. In this instance, there seemed to be no working smoke detector. She had no idea if and where there was a fire extinguisher. There are several obvious lessons here. Never go to sleep with candles or a fireplace still burning. Get acquainted with the safety features of any place your family is staying.

Beware of button batteries. They are everywhere nowadays in all sorts of small electronics (and musical cards) and can be quite hazardous if swallowed. Take time in advance to do a mental inventory of items that you have around that may be powered by these. Put a piece of duct tape over the battery compartments to make sure they can’t fall out.

Certain holiday plants like poinsettias can be mildly toxic (especially to someone with a latex allergy). You may not have them in your own house, but if you are visiting a friend or even a supermarket make sure little hands don’t grab the pretty red leaves and put them in their mouths.

Be very careful transporting hot food to a holiday potluck. I have patients who have been burned from hot food spilling on them in a car.

WARNING TO PET OWNERS!

One of my patients had a tragedy several years ago. An eight year old healthy dog got into a wrapped package that was filled with chocolate. The amount ingested proved to be too toxic for this little dog to handle and they didn’t make it. Please don’t let this happen to you. Make sure that any mystery packages are nowhere near where a pet can get to them.

Christmas tree checklist:

• When purchasing a live tree, check for freshness. A fresh tree is less of a fire hazard

• Cut 1-2 inches from the base of the trunk immediately before placing the tree in the stand and filling with water to ensure absorption. Don’t add chemicals that might be toxic to kids or pets. A dash of plain 7-up can help keep the tree healthy.

• check the water level daily to avoid the tree drying out

• When purchasing an artificial tree, look for the label “Fire Resistant”

• Never use electric lights on a metallic tree. The tree can become charged with electricity from faulty lights and a person touching a branch could be electrocuted.

• Place your tree at least 3 feet away from all heat sources, including fireplaces, radiators and space heaters

• Make sure the tree is steady enough that it can’t be pulled over by a toddler. You may need to attach it to something solid. Trust me, trees get knocked or pulled over. Older kids running around can cause this issue, it isn’t just toddlers.

• Trim your tree with non-combustible or flame resistant materials.

• Before using lights outdoors, check labels to make sure they have been certified for outdoor use.

• Make sure all the bulbs work and that there are no frayed wires, broken sockets or loose connections.

• Plug all outdoor electric decorations into circuits with ground-fault circuit interrupters to avoid potential shocks.

• Strings of lights and garlands are a staple of holiday decorating, but they can also pose a strangulation hazard.

• Avoid trimming the tree with things that look like candy which may pose a temptation to the kids.

• Keep sharp, glass or breakable ornaments out of reach of small children.

• Holly berries and other small decorations can be choking hazards.

• Don’t overload extension cords; make sure that your extension cords are high quality.

• If you are going to use your fireplace, make sure that you have the chimney checked and cleaned if it has been awhile since you built your last fire. (make sure that it isn’t a spare the air day)

This is not a safety issue, but it is worth mentioning. Is your child exhibiting any new allergy symptoms? Take a minute to consider whether or not they started during the holiday season. Trees, scented candles and other seasonal extras can trigger some allergies.

Hanukkah doesn’t fall on the same date every year since it is based on a lunar calendar. Many folks laughingly refer to it as coming either “early or late”. It also has more spelling variations than any other holiday. This season the first candle will be lit on the evening of Sunday December 14th.

• Make sure that all candles are safely out of harm’s way.

• The menorah should be on a glass tray or aluminum foil.

• Make sure candles are not close to wrapping paper.

• Don’t go to sleep with candles still burning.

• Don’t leave the matches or lighters hanging around where curious kids can get ahold of them

If you are frying latkes (fried potato pancakes that are a holiday tradition, yum) make sure that no one gets splattered by oil. Never leave the hot oil unattended.

Remember that adding water to a grease fire will make it worse! Baking soda is okay, but a fire extinguisher is best. Make sure you know where it is and how to use it.

Kwanzaa may be the safest of the holidays, (no hot oil or stressing the electrical outlets) but there are still candles involved, so make sure they are placed in a safe place and toddlers don’t have access.

If I missed any holidays, let me know! I will add them to this post in the future.

This is also a great time to test your smoke alarms and carbon monoxide detectors!!!

Stay safe and have a wonderful holiday season.

A story about thank you notes, wedding gifts and an epic prank

 When I was young, I took after my mother and was exceedingly conscientious with correspondence and thank you notes. My sister Marjie was not quite as ‘on it’ as I was and she would occasionally have to deal with nagging from our grandmother and grandma’s sister Aunt Nellie, who tended to be the etiquette police

Sandy and I got married in Pittsburgh in August 1983. We were living in New York at the time. Wedding gifts poured in from friends and family members. Some were sent to our apartment in NY but many others were sent to my parents house in Pittsburgh.

Of course, I was on a mission when it came to getting thank you notes out in a timely manner.

After the wedding I remember having all hands on deck. Sandy and I sat on the floor of my childhood bedroom and methodically opened the gifts. Other family members joined the team and helped make a list of who had given what. We were a little pressed for time before we needed to head to the airport.

The plan was to leave all of the gifts in Pittsburgh for the time being. We would get them all the next time we did the seven hour drive. At that point we would load up the car and bring everything home.

One gift added a lot of levity to the moment. We opened the wrapping, and we read the card from some of Sandy’s cousins.

Dear Judy and Sandy,

We are sorry that we weren’t able to join you on this special day

Yada yada yada

We opened the box. Inside was a bowl (we got a lot of those).

Inside the bowl was a card addressed to those cousins

Dear So and So

Happy wedding..etc etc etc

It was a re-gift with the card still inside!

We had widely shared the story, so we couldn’t resist bringing it to the next wedding that we attended. Along with our gift, they also got the regifted bowl, now with both cards inside. That bowl made the rounds for years, collecting all of the cards along the way, until we lost track of it. Maybe someone actually liked it enough to keep it.

After our wedding, gifts continued to trickle in. Back in New York, I was working nights at a local hospital and I took advantage of any downtime while the patients were sleeping; this is when I would do most of the thank you notes.

Sandy’s job was to address the envelope and write what the gift was in the top right corner where it would get covered by a stamp.

He kept me entertained.

The notes on the envelope would be:

6 useless bowls that we will never use

A very ugly plate

Oh yay, a blender

My job was to write the actual thank you note.

I would take a stack of cards and envelopes with me every night. I was a machine. I was going to get this done in record time….until I ran into a problem.

There was a gift (a bowl, shocking) from someone called Baruch Levy. The name wasn’t familiar and we didn’t have an address.

I asked my grandmother if this was someone she knew. Nope

We checked with Sandy’s parents along with his three remaining grandparents.

“Is Baruch Levy a friend of yours? We got a wedding gift from him and I need to send him a thank you card.”

This was long before the internet. I was stuck. And yet, it gnawed at me. I had gotten a gift and not sent an acknowledgement.

Months passed.

Over Thanksgiving, Sandy and I drove to Pittsburgh. At dinner Marjie had an odd twinkle in her eye.

“So, did you ever finish all of your thank you notes?”

“No!, in fact it is driving me crazy, I have no idea who Baruch Levy is.

At this point she was cracking up.

“OMG, you didn’t!!!”

Surely enough, she confessed, She had picked a random name (of an old Jewish Man, so as not to raise suspicion) and had just stuck the gift in the pile.

She got me.

Family members caught on quickly whenever odd gifts would show up; we pretty much assumed that we knew the origin.

Food Safety/Thanksgiving musings 2025

 Food Safety

We don’t live in a sterile world. As soon as they are able, your baby will start putting anything that they can reach into their mouths. You can’t even begin to imagine the phone calls I have gotten about icky things that some of my past little patients have managed to get their hands and mouths on. Chap-stick, particles from an exploded hot pack, kitty litter, the little packet in shoe boxes that says do not eat. You name it, they lick it.

My grandson Coby has continued to add things to that list.

So yes, the world is full of germs, and while I don’t generally get too concerned about a little dirt here or a big sloppy dog kiss there, food-borne bacteria can be nasty, and we need to minimize any exposure.

The CDC reports that every year 1 in 6 people get sick from something they ate or drank. Were you one of them? It’s NO fun.

The upcoming holiday season is what prompted me to update this post, but food contamination issues can happen all year round.

Consider the recent situation for infant formula being contaminated with Botulism. If your baby has had any ByHeart formula, and you have been too tired to pay attention to the headlines, make sure you stop using it immediately. If you do happen to have any of that on hand and it’s open, don’t throw it away. The CDC recommends keeping opened formula stored away for a month in case your baby develops symptoms so that it may be tested. Unopened formula can be discarded or sent for a refund.

Keeping your kids and family safe feels a bit like a minefield, doesn’t it?

Here are some general guidelines.

Wash hands for at least 20 seconds before food preparation. Soap is best. Hand sanitizer will do (let it dry thoroughly or that taste might wind up in your food). Re-wash hands as needed after handling food that might carry germs.

Dr. Ted’s Tidbit

When it comes to food poisoning in this country, most people fear poultry, meat, and eggs more than produce like fruits and vegetables. As a matter of fact, produce is responsible for just about as much of food-borne illness as poultry and meat, causing almost half of all disease. Food poisoning from poultry and meat may be only slightly more common, but when it happens, it’s much more severe, leading to more hospitalizations or deaths; this is because of the germs that live on those surfaces. Produce carries more Norovirus and E. coli (bad but not lethal), while poultry and meat are more frequently linked to Salmonella and Campylobacter.

Make sure kitchen towels and sponges are changed and cleaned frequently. Sponges can go through the dishwasher. Cloth can get easily contaminated and then spread germs. Don’t ignore potholders or other cloth items that come into contact with raw food.

Wash your reusable grocery bags especially after they are used for milk or chicken.

Keep your refrigerator temperature at 40 degrees or colder. This is essential for keeping the bacteria from multiplying. An appliance thermometer can help you keep track.

Your freezer should be below 0 degrees. To ensure the safety of your frozen food, you need to be sure that it has been actually kept constantly frozen.

One clever hack to make sure that there hasn’t been a thaw is to keep a small baggie filled with ice cubes in the freezer. If the ice remains in cubes, you are in good shape; if they melt and refreeze as a block of ice that means that at some point your freezer was not cold enough. This can happen in a power outage or even if the door wasn’t kept tightly closed. I am sad to say that if there was stored breast milk in there that has thawed and refrozen, I would no longer consider it safe.

Label things in your freezer and rotate so that you are using up older stuff first.

Make sure that foods are properly cooked. A food thermometer is the best tool for this.

Cook beef, pork, veal, and lamb (steaks, roasts and chops) to 145°F and allow to rest for 3 minutes. Hamburgers made of ground beef, pork, veal, and lamb should reach 160°F. All poultry (including ground) should reach a minimum of 165 °F. NEVER partially grill meat or poultry and finish cooking later.

Eggs should not be runny. (In Japan you don’t need to worry about it!)

For all of you “older kids” who will be baking this holiday season, watch out for the batter. Even one lick from raw food containing a contaminated egg can get you ill.

Special considerations for babies:

Infants and young children are particularly vulnerable to food-borne illness because their immune systems are not developed enough to fight off infections. This is especially critical for infants under 6 months of age. Extra care should be taken when handling and preparing their food and formula.

• If you are using any baby food from jars (no need to apologize), check the expiration dates and make sure the lid pops when you open them.

• Remember that once saliva has come into contact with the food it is no longer sterile and some bacteria can grow quickly. To avoid waste, consider putting a small amount in a bowl, adding more as needed using a clean spoon.

• Don’t leave open containers of liquid or pureed baby food out at room temperature for more than two hours. Bacteria thrive in temperatures between 40-140 degrees

• Don’t store opened baby food in the refrigerator for more than three days. If you are not sure that the food is still safe, remember this saying: “If in doubt, throw it out.” See links below for guidelines on how long food stays safe.

• Powdered formula is NOT sterile. Don’t mix up more than you need in advance. If the infant is less than 3 months, I would mix it with boiling water and let it cool.

Below are some common misconceptions:

Myth: Freezing food kills harmful bacteria that can cause food poisoning.

Fact: bacteria can survive freezing temperatures. When food is thawed, bacteria can still be present and can begin to multiply. Cooking food to the proper internal temperature is the best way to make sure any bacteria is killed.

Myth: vegetarians don’t need to worry about food poisoning.

Fact: Fruits and vegetables are an important part of a healthy diet, but like other foods they may carry a risk of foodborne illness. Always rinse produce well under running tap water. Never eat the pre-washed ‘ready to eat’ greens if they are past their freshness date or if they appear slimy.

Myth: Plastic or glass cutting boards don’t hold harmful bacteria on their surfaces like wooden cutting boards do.

Fact: Any type of cutting board can hold harmful bacteria on its surface. Regardless of the type of cutting board you use, it should be washed and sanitized after each use. Solid plastic, tempered glass, sealed granite, and hardwood cutting boards are dishwasher safe. However, wood laminates don’t hold up well in the dishwasher. Once cutting boards of any type become excessively worn or develop hard-to-clean grooves, they should be discarded.

Myth: Locally-grown, organic foods will never give you food poisoning.

Fact: Any food, whether organic or conventional, could become unsafe with illness-causing bacteria at any point during the chain from the farm to the table. Consumers in their homes can take action to keep their families safe. That is why it is important to reduce your risk of food-borne illness by practicing the four steps: Clean, Separate, Cook, and Chill.

Full disclosure, and the irony is not lost on me; this evening while I was working on this post I took a break to make myself some dinner. I was trying out a new recipe that called for white beans.

I pulled out a can from the back of a shelf and brought it in to show Sandy

“This can expired in 2021, it looks fine, do you think it’s safe.

He laughed and said no.

I poked back into the cabinet and found one more can, The expiration date was no where to be seen.

I used the beans. They looked fine. They smelled okay. I think they were safe. If I don’t check back in for awhile, you can suspect the beans.

On top of the other suggestions in the post, this is a good reminder to go through your pantry and fridge to get rid of anything suspect. If something is more than a year old, probably toss it.

Here are some excellent resources for food safety:

www.foodsafety.gov This site keeps track of any food recalls

www.Stilltasty.com This is as great site for seeing how long food will last. I used it just this week to figure out if an open can of chickpeas was still good. (After a week, the answer was no)

www.fightbac.org This site has loads of kid friendly activities

Breastmilk storage guide

http://www.eggsafety.org

And Finally, here are some of my personal Thanksgiving musings

Holidays can be triggering.

Social media illuminates festive gatherings of friends and family enjoying their turkey dinner..that is lovely for the lucky few.

The truth is:

Some people don’t have a group to join. Kids grow up and move away.

Some people are expected and welcome to the family/friend dinner, but find it overwhelmingly stressful.

Some yearn to be with their loved ones, but can’t easily manage the trip for one reason or another. The fact is that traveling for the holidays is way more expensive, hectic and crowded.

And some people just hate turkey

Things to consider:

Thanksgiving is a made up holiday. I know plenty of families who choose a different date to celebrate.

We all should take some time to pay attention to things we are grateful for every day, not just the last Thursday in November.

Families can be tricky, especially with the divisive politics these days. Make an agreement in advance that some topics of not welcome to the table

Are you lucky enough to have a gathering? Is there room at the table? Pay attention to the couples or single people who may not have a place to go and invite them.

Wishing everyone a safe and happy holiday