Friday, November 9, 2018

The Pie Theory of life 2018/ Nurse Judy's Pie shifts

Somehow or other I currently have 2,400 subscribers who now get my weekly posts. The blog has had 270,000 visits which astonishes me. Thanks to all of you who read them and share them. Writing these has been a pleasure. I am always learning. Your feedback has been something that I cherish. In honor of this being my 100th post since starting the weekly emails on Constant Contact I am running one of my all time favorite posts. My kids and I live by the “pie theory.” My personal pie is going through some shifting pieces. Detail are at the bottom of the post.
This week's Topic

Finding Balance/ The pie theory of life
Here is an update of one of my top ten favorite posts.
Scroll to the end of the post for an update in the shift in my personal PIE

The "pie theory" got its inception many years ago. For a number of years (many years ago) I was the Parent Association president at my daughters' elementary school. It took an inordinate amount of my spare time, including meetings several times a week. On many levels it was rewarding being so involved but I assure you, I was delighted to pass the reins when my stint was over. Though I was really genuinely relieved to have my time back, I felt off balance by all the sudden free time in my schedule, and at first I couldn't figure out why I was so unsettled. I finally realized that although the new empty hours were welcome, they had created a bit of a vacuum. I filled it quickly (started taking up karate a few evenings a week), but it was right around that transition period that the "pie theory" helped me make sense of things.

Imagine that your identity is a circle (or whole pie). Who you are is divided into many pieces; some pieces are large, some small, some temporary. Some are constants that are with you life long, some are optional, some are good for your soul, while still others are energy sappers that give you little in return.

Are you:

  • Daughter?
  • Son?
  • Sibling?
  • Friend?
  • Spouse?
  • Ex spouse?
  • Grandparent?
  • Student?
  • Volunteer?
  • Pet owner?
  • In a job/occupation or seeking one?
  • Doing a hobby that takes time and energy?
  • Member of a book club or any club for that matter?
  • Churchgoer?
  • Exerciser?
  • House cleaner?
  • Carpool driver?
  • Event planner?
  • Adventure seeker?
  • and of course last but not least....Parent?

The list goes on and on. What activities make up your day, your week, your month, your year? What pieces make up your pie? Take a few moments to figure it out. Get a piece of paper and a working pen (if you can find one) and create your pie.

It's interesting to think how you can be identified in different ways by the various pieces of pie. Many folks recognize me as Nurse Judy. More than once I have actually looked at a rash, or given advice from a restaurant table (as my patient husband rolls his eyes.) There was a time years ago when I came to work one day and saw a construction worker on the roof of a neighboring building. He looked awfully familiar and I was struggling to place him; was he a parent from the practice? Someone from school? I could see that he recognized me as well; we kept looking at each other and a moment passed. I could see that he had figured it out first. He gave a big grin and called out "Ahoy there Java's mom!" Of course! I ran into him several times a week with his pack of dogs when I walked my dog Java. Not only did being a dog owner dictate my daily schedule and get me out walking rain or shine, it also included me as a member of a distinct social network in the neighborhood for many years. All the dog owners knew each other by sight and all the dogs by name. Being "Java's mom" was a wonderful piece of my "pie" for 12 years. If you are a pet owner, that piece has a very special place allotted to it. I am now proud to be grandma to my daughter's giant puppy Bowie.

Your pie is finite. You can only do and be so much, as there are only so many hours in the day. Some folks have too many things competing for time and attention, and figuring out which pieces can be compressed can be quite stressful. Sometimes we make poor choices.

For busy working parents this might be a foreign concept, but some folks don't actually have enough pieces to begin to fill the shell. A big empty pie can be just as unsettling as a full one. Have you ever noticed that when you are super busy you can manage to get through an entire to-do list very efficiently? On the other hand, on a quiet day you may have only one or two things on the list but somehow nothing gets done.

A healthy pie has plenty of interesting pieces that can grow and shrink according to your needs. The more forgiving and elastic the pieces, the easier time you will have finding a good balance.
Your pie will naturally change from year to year, but some changes are enormous. Some people are comfortable having a very crowded pie, while others are quite fine and happy doing nothing at all. Part of this is figuring out what your ideal is, and work towards that.

Any large sudden changes to your pie will make you feel unsettled, way less so if you have a glimmer of what is going on; hence this theory. Both of my daughters have taken this to heart. In fact Alana has permitted me to share her own blog post on the Pie Theory that she wrote several years ago:

(Blogging runs in the family I guess)

When there is a large shift in your pieces my girls and I refer to this as "pie disequilibrium." Common culprits might include:

Event planner:
Folks planning a wedding or large event can spend months dealing with all the fun details. When the event is over, that planner piece is gone, your pie has a gap.

Sports Fan:
My daughter Alana has a twinge of "Pie Disequilibrium" every October when baseball season is over.

My daughter Lauren had to learn how to deal with the extra time that appears after a show run is over.
Folks that spend much of their time and energy tending to someone else’s needs might find themselves suddenly with a large vacuum when that person is gone or no longer needs them.

As your children grow up it can be a tough adjustment (don't worry, they still love you.) Luckily this happens in stages. Kindergarten...a full day of Parents who have the "parent piece" taking up the entire pie may feel a twinge when their kids don't need them in quite the same capacity.

Huge life changes will create seismic shifts. Nothing will ever match the huge transitions that take place when you add the parent piece to your pie. My best advice to you as you shuffle all your pie pieces and see how things fit comfortably is to identify pieces that need to be protected so that they don't get too small.

Protect that piece. Get creative and make sure that you have time for the two of you; have some moments being a couple.

Being the best parent that you can be includes living by example. Let your kids have parents that are multifaceted and not consumed by any one thing (be that parenting or a job.)

Best of luck finding a balanced, interesting, and fulfilling pie!

Nurse Judy's shifting pie:

As many of you know, I have been working at Noe Valley Pediatrics for over 30 years. In July of this year I opted to remove the office manager slice of my pie. I am continuing with the parts of the job that I love, which are teaching parents, giving advice and writing.
I am now in the office Mondays and Thursdays. I am fortunate to be enlarging my mom piece, as both of my daughters and now my son-in-law, live several minutes away from me.

My travel piece gets to stretch a bit in December. My husband and I will be doing an exciting trip to Southeast Asia. I don’t do the mountain climbing with him; this is his turn to do some tamer traveling with the wife.

But the big news is that I am planning to expand the “piece of pie” that involves my writing. I have been encouraged by many, (gently nagged by a few) to go beyond the blog and write a book. I am at the very beginning of the process. I would love to hear from folks who are writers, or are in the business. I am currently gathering info and advice and would appreciate any wisdom or tips that you are willing to share.

Friday, November 2, 2018



It is all well and good to want your children to tell the truth, but until they have reached a certain age, don’t let yourself get too disappointed when you realize they have been less than honest. Many young kids can actually convince themselves that what they are telling you is the absolutely as real as can be. When they get a bit older they are simply calculating which outcome will get them in less trouble.

I had to learn this the hard way with my older daughter Lauren. Even back in her earliest years, she was an actress.

The earliest whopper that I found out about happened a day after the Northridge earthquake in LA. Lauren was in 1st grade.
When I went to school to pick her up, I was surprised when multiple people came up to give me consolation hugs.
“Judy, we are so sorry” “What a tragedy” “How old was the baby cousin that died in the earthquake?”

HUH? I was more than confused. I assured them that as far as I knew, everything was fine. We didn’t have family in LA.

“Hmm, but Lauren said…”

More confusion ensued. I picked Lauren up and asked her why on earth people were coming up to me and offering sympathy.
She looked genuinely puzzled. Actress, remember...she was going for her first academy award.

“Oh, I think I know” she said, “At recess we were playing some pretend games and someone must have overheard and thought it was real.” I accepted that without a second thought.

The next morning at school I bumped into her teacher.

“Oh Judy, that is so sad about the baby”

“Oh dear” I responded, “That is all a misunderstanding. People must have overheard kids playing and thought it was real.”

Mrs Calhoun paused, and then gently informed me that in fact, in ‘sharing’ yesterday when everyone was going around the circle telling their news, Lauren stole the thunder by announcing that her baby cousin had died in the Northridge earthquake. There was no misunderstanding or overhearing recess pretend games.

My daughter had given me a ‘look you in the eyes bald faced lie’ and I was mad.

We had a talk that evening about the importance of honesty (which likely went right over her head.) She continued to be caught in little lies, and promises meant little.

That week Goldie the fish was found floating. You might be disappointed to know that sweet Nurse Judy’s initial response was “Maybe if she thinks that breaking promises has consequences that isn’t such a bad thing

Fortunately, her daddy took it upon himself to make sure that she wouldn’t have to feel the guilt of having killed her fish with a lie. In fact there would be no mourning needed this time around. He took the dead fish to a pet store that kept late hours, found a fish that matched the general look and size, and Goldie II started her reign in the tank. Lauren was none the wiser.

The irony that this fish tale in included on a post about honesty is not lost on me. It is complicated. While my opinion might be tossed out in a court of law, I maintain that shielding someone from a difficult truth is sometimes the action that feels like the right thing to do. If Lauren had asked me directly about Goldie, I would have insisted on telling her the truth.

Scroll on down for a bonus tale of Lauren and her lying phase.

Children and adults might lie for a variety of reasons. These include trying to get out of trouble, attempting to impress someone or even to be polite. At the age of five, trying to avoid a punishment is often going to take precedence over the concept of honesty.

It is so important to let them know that you put more emphasis on their telling the truth than on the consequence for their dishonest behavior.

What can you do?

Model honesty.
“Tell them I’m not home” is a good example of an easy lie that we call can get trapped in. Be thoughtful enough to tweak it to “I’m not available.” If your kids catch you lying, there is no reason to expect them to act differently from the adults in their lives.

Talk about how being truthful often takes a lot of courage.
Read some of the great books out there that are all about telling the truth. Books are a good launching point for further discussion.

Help them avoid the lie by not asking questions that will get them into a defensive situation; instead state what you see:

Rather than “ Did you eat a cookie after I told you not to?”


A cookie is missing. I see crumbs on your face. I will be more disappointed in you not telling the truth, than I would be about the missing cookie

Help them avoid the lie by not asking questions that will get them into a defensive situation:

Rather than “did you break that vase?”


“I see that the vase is broken. Do you want to tell me what happened? Remember that telling the truth is more important to me than the broken vase.”

If you get through the years without a lying phase, wow! Most likely there will be a time when your children are not going to tell you the truth. Take a moment to figure out if there is an obvious cause for the lie and form your response based on that. Please don’t ever label your child a liar, even if they have some lapses.

Let’s be real. The true value of honest communication and trust between you and your child goes way beyond the missing cookies. It is essential to be able to be truthful with each other when your child becomes a teenager. They need to know that they can call you for a pick up, no questions asked, when they find themselves in a tricky situation. Hopefully they can feel free to talk to you about important issues and ask you difficult questions.This won’t happen without a trust that goes both ways. Consistent message about how you value honesty will hopefully help foster the trusting relationship that we are striving for, now and in the future.


Here is the bonus Lauren story that went down in family lore.
This was soon after my 'family tragedy' in the earthquake.
Lauren got a new teaching assistant who she adored. He had very long hair that he wore in a ponytail. His first name was Sotweed. His last name was also odd enough that when she first told me his entire name, I thought she was making it up.
I giggled and she admonished me “It isn’t nice to laugh at someone’s name”

You are right, I shouldn’t laugh

Shame on me though, when she would say his name over the next few weeks, I confess to an occasional giggle. Okay, so there we were in the car on our way to a school event where I was going to meet the famous Mr. S for the first time.

I told Mr S that you laugh every time I say his name.”

Let’s describe me as annoyed. ” Lauren, you are right that I shouldn’t have laughed at his name, but if it only happened in private, nobody’s feelings were hurt. Now I am embarrassed and perhaps Mr S feels badly about it. I am upset that you told him this”

Lauren mulled this over, you could see the wheels turning. She was clearly trying to figure out which path was going to get her in less trouble.

“I am just kidding, Of course I didn’t tell him”

I looked at her for a bit.

“I don’t know if you are telling me the truth. I am going to have to ask Mr. S if you said something to him or not. This is your opportunity to tell me what is true” (I was sorely tempted to threaten her new fish, but that was still a secret.)

Pause, more thinking...

“I did tell him that you laugh”

“Thank you for telling me the truth”


Hello Mr. S, I am afraid I owe you an apology.

Mr S immediately let me off the hook.
I have the kookiest name in the world, of course it makes people laugh.”

Mr. S, if you are reading this post, thank you for being such a great guy!

Friday, October 26, 2018

Acute Flaccid Myelitis

Acute Flaccid Myelitis

There are three categories of urgency levels when we get notices from the public health department:

  • Health Alert conveys the highest level of importance and warrants immediate action or attention.

  • Health Advisory provides important information for a specific incident or situation, this may not require immediate action

  • Health update provides updated information regarding an incident or situation. This is unlikely to require immediate action

This week we got a Health Advisory from the California Department of Public Health regarding the national increase in reports of suspected Acute Flaccid Myelitis cases. The Media has been all over this and it is scary indeed. It is hard not to get nervous. Of course I have had some calls about it.

It is NOT my intent to fan the flames and make folks panic, I just want to give you some basic knowledge and share what is currently known about it.
Acute Flaccid Myelitis (AFM) is a very rare neurological condition that is characterized by sudden onset of weakness in one or more limbs. An MRI will show distinct abnormalities of the spinal cord gray matter.
Nationally, from January 1 through October 16, 2018 the Center for Disease Control and Prevention (CDC) has reported 62 confirmed cases in patients from 22 US states. They are investigating other possible cases at this time, so the numbers will likely change.
More than 90% of the cases occur in patients who are under the age of 18 years old. Some lucky folks have recovered quickly and completely while others continue to experience paralysis and weakness.
There were similar episodes making the rounds a few years ago that were associated with Enterovirus D68 .

This time around patients have been tested for that strain of enterovirus. It has not been consistently detected in every patient with AFM, so there isn't a clear connection, but many experts still think that D68 is the most likely cause and that the virus has mutated to make it harder to detect. Other thoughts are that it could be connected with a mosquito borne illness. The investigations continue.

AFM is NOT thought to be contagious from person to person.
While I don’t want folks losing sleep over this, (our odds of winning the current giant lottery are on par with having to deal with this)
seek immediate medical attention if you see any of these symptoms:

  • Difficulty moving the eye or drooping eyelid
  • Facial droop or weakness
  • Difficulty swallowing or slurred speech
  • Sudden arm or leg weakness
If we are suspicious of AFM, further testing and likely an ER visit would be the next steps.

Friday, October 19, 2018

Halloween safety and activity guide 2018

Halloween can be such a fun holiday, but as you can imagine, as advice nurses we tend to hear about some of the misfortunes that can along as part of the festivities.

Carving a pumpkin can be a very fun tradition. Please make sure that your child's level of participation is consistent with their age and ability. Watch out for the sharp implements and make sure you assign your younger child to the safer tasks (young kids can draw on the pumpkin rather than carving.)

Clean up the mess. Pumpkin flesh is slippery and can cause falls and injuries when dropped on the floor. Layer newspaper or old cloths under your carving work space and clean up spills right away so no one slips or trips. Skip the candles, which may cause fires. A burning candle in a pumpkin may become a blazing fire if left unattended. Instead, use a glow stick (available in many colors) or flame-less candle to safely illuminate your jack-o'-lantern.

Choosing a costume
Children are more than twice as likely to be hit by a car on Halloween than on any other day of the year!

Decorate costumes and bags with reflective tape or stickers and, if possible, choose light colors. Have kids use glow sticks or flashlights to help them see and be seen by drivers. Is your dog going along with the trick or treaters? Have them wear a glow in the dark collar!

When selecting a costume make sure it is the right size to prevent trips and falls. Be sure to wear flame-resistant costumes. Remind your child that they need to pay very close attention to their surroundings and avoid walking near any candles or flames, especially if they have loose flowy costumes. If a sword, cane, or stick is a part of the costume, make sure it is not sharp or too long. A child may be easily hurt by these accessories if he or she stumbles or trips.

Make sure that no part of the costume is covering their ears solidly enough that their hearing might be impacted. Since masks can sometimes obstruct a child's vision, try non-toxic face paint and makeup as another option. Face paints have been in the news lately. Some of them have some toxic ingredients like lead. Be familiar with the ingredients before you apply anything to your child’s skin. Always test the makeup in a small area first. Always completely remove it before bedtime to prevent possible skin and eye irritation.

Make sure that your child doesn't have any latex sensitivity before you do too heavy of an exposure. Many masks are made of latex. We actually had a patient who had an allergic reaction to the hair tinsel. You may want to do a test run of the costume and make up a couple of days ahead of time to rule out any allergies.

Trick or treat rules
Children under the age of 12 should not be alone at night without adult supervision. If kids are mature enough to be out without supervision, remind them to stick to familiar areas that are well lit and trick-or-treat in groups. Never go into a strangers house without supervision.

Popular trick-or-treating hours are 5:30 p.m. to 9:30 p.m. so be especially alert for kids during that time if you are out driving.

A good meal prior to parties and trick-or-treating may discourage youngsters from filling up on Halloween treats.

Bring plenty of water along when you go trick or treating. Just trust me on this one.

Make sure that your children know that after trick or treating, the grown up needs to pick through trick or treat bag and toss anything that looks suspicious. There is a warning out in Colorado this year about "pot laced" treats. That could happen here just as easily. Anything that looks like it has been tampered with should get tossed. Some candies are real choking hazards. If you have a younger child in the house, make sure they don't have access to the stash.

If you have a child with nut allergies (I am sure this is NOT your favorite holiday) make sure that they turn over ALL the candy so that you can separate out anything that might cause trouble. My favorite allergist adds another piece of advice. Most of the time nuts may be just one of the ingredients, but as a general rule, kids who are allergic to nuts should also be able to identify the nuts that they are allergic to. If it is peanuts, make sure they know what an actual peanut looks like.

Expecting trick-or-treaters or party guests?
Consider purchasing non-food treats for those who visit your home, such as coloring books, stickers or tattoos. Provide healthier treats for trick-or-treaters such as low-calorie treats and drinks.(Okay, fine...maybe you don't want to be "that" house, but I had to put it on the list.) Be sure walking areas and stairs are well-lit and free of obstacles that could result in falls. Keep candle-lit jack o'lanterns and luminaries away from doorsteps, walkways, landings, and curtains. Place them on sturdy tables, keep them out of the reach of pets and small children, and never leave them unattended.

Now what do we do with all this candy???
Make a plan about how much candy they can eat at one time. It is okay to be a little more liberal than usual for a day or two, but come to an agreement about a reasonable candy intake over the next few weeks. Some dentists and orthodontists have buy back programs, where they will give your child a reward for turning in their candy. Check with your dentist to see if they participate.

Bibi, one of our mom's, doesn't bother with the dentist and has instituted her own buyback program. Her kids can exchange candy for new lego pieces.

You may need to be extra vigilant with teeth brushing this season.

Remember that candy freezes (and some of it is actually better that way; frozen snickers bars, yum!)

My daughter Lauren was about 6 when she caught on that mom and dad were pilfering through her trick or trick bag and stealing all the good stuff. After that she guarded her stash more carefully.

Here are some tips that some wise mamas have added to this post over the years:

"Once Cleo was out of the stroller and walking, we put glow stick bracelets and necklaces on her so we could see her more easily when out and about in crowded spaces in the dark (we do this at things like the Dia de Los Muertos parade, too.) Cliff's sells them in a big 100-stick bulk container. Not terribly eco, but gives a little extra "eyes on" help when navigating the crowds."

My little patient Franny, bent a glow stick in order to activate it and it broke. Some squirted in her mouth. While you do want to avoid unnecessary contact with the insides of a Glow sticks, they are non toxic

Here are some local Halloween activities for the 2018 season.

bayareakidfun Halloween events

Friday, October 12, 2018

Strep throat 2018

Strep throat is a bacterial infection caused by the Group A streptococcus germ.

This illness is most common in people between 5-15 years of age but people of any age can get it. For some reason is is quite unusual for babies under 2 years of age to have it, but there are always exceptions.

Someone with strep throat will usually present with one or more of these symptoms:

  • Sore throat
  • fever
  • body aches
  • headache
  • stomach ache
  • nausea
  • a red sand papery rash all over the body

Strep with the rash may be referred to as Scarlet fever...sounds scary right?? Indeed it used to be. Now that we have antibiotics to treat it with Scarlet Fever is not much more alarming than simple strep.

Get out your little flashlight and do some checking. If you are lucky enough maybe they will actually open their mouth; most of the time the throat will look quite red. You may see red or white patches in the throat or on the palate (the back part of the roof of the mouth.)
The tongue might have red and white patches. This is referred to as strawberry tongue for obvious reasons. Feel around the neck and see if the glands feel swollen. Sniff the breath. Often parents call me and say that is smells like their kids swallowed a 'swamp creature'. The breath smells yucky.

Not everyone has all the symptoms.

Be aware that children under 5 often say that their "mouth" or “neck” hurts, but they are talking about their throat.

Some folks don't even complain about a sore throat and some cases don't present with an elevated temperature.

This week in the office we have had many patients without a sore throat who are testing positive. The chief complaints have been tummy ache and head ache.

It is quite contagious, but it is not uncommon for some family members to have it, while others escape. I would say that in my experience the odds are about 50/50. (The minute someone in your family gets that sore throat I would suggest sucking on a zinc lozenge and some sambucol; maybe you will get lucky.)

The incubation period ranges from 1-5 days but most of the time folks show the first symptoms about 2-3 days after exposure. You can catch it from being in close contact with someone else who has it. If you treat with antibiotics (which is recommended) you are not contagious once you have completed 24 hours of the medication. If you don't treat, you remain contagious and can spread the illness for about 3 weeks.

Given enough time, strep can resolve by itself but the antibiotics absolutely shorten the severity and duration of the illness as well as significantly decrease the risk of complications. Untreated strep throat can lead to complications later on, such as rheumatic fever and heart valve problems.

It is impossible to have real statistics about this. Most folks don't jump into the doctor's office every time they have a sore throat. There are likely millions of untreated cases of strep out there at any given time and of course most of them will have no issues in the future. However, better safe than sorry. If we know you have a case of strep throat, we will strongly advise that you do a course of antibiotics.

Typically the strep throat 'package' does not come along with a lot of congestion. If I am hearing about someone with lots of coughing, clear mucus and sore throat, it is more likely viral.
On the other hand, a sore throat with fever and not a lot of congestion gets my antenna up. I am not kidding when I mention stinky breath. A lot of the parents that I talk to can tell strep from the smell and they are almost always right!

Nausea and tummy aches are quite frequent with strep, but add some diarrhea to the mix and I am no longer as suspicious. Nausea plus loose stools is usually more of a tummy bug of sorts.

We test for strep in the office with a rapid strep test that we find fairly reliable. If the test is negative, but the symptoms are very suspicious for strep, we will send a culture to the lab to double check the result.

Our test is specific for Group A strep. There are different strains of the strep bacteria that can cause various infections.
If the in office test is negative, the lab test may still come back positive with another strain. 

Some folks are carriers. This means that they have a small amount of the bacteria living in their body all of the time and it doesn't make them ill. Those folks may show a very faint positive on the quick test. Some patients also seem way more susceptible to strep than others. I used to get it all the time until I had my tonsils out. That is not an uncommon story. 

If you do end up being treated, it is important that you finish your course of antibiotics. If you are not seeing an improvement within 72 hours of starting the medication, make sure you check in with your doctor. It is rare, but strep can lead to serious complications including abscesses on the tonsils, ear infections as well as kidney problems.

Change your toothbrush 24 hours after starting the antibiotics so that you don't get reinfected!

Symptomatic treatments until the antibiotics kick in include

  • Tylenol or Motrin (we are treating pain, not necessarily fever)
  • Lozenges
  • Tea with honey (no honey for kids until one year old)
  • Check out Manuka honey if you can find it. Not all honey is created equal.
  • Gargling with salt water
  • Popsicle s
  • Cold fruit nectar
  • Having a humidifier running at night.

Friday, October 5, 2018

Colds/coughs/congestion 2018 (symptomatic treatment/when do you need to be seen?)

We are right at the beginning of the cough and cold season. It is useful to have some guidelines to help you figure out when a trip to the doctor's office is indicated. Many times, there is nothing to do but wait it out, so I am including some tips to help you and your child get through the illness as comfortably as possible.

Studies say that most children will have an average of EIGHT colds within the first 18 months of life. Even if we don't have young children, colds and coughs are a common issue for all of us. Most of the time the congestion is caused by a viral syndrome. Allergies and teething* can also be culprits causing you to be congested.

{*Most medical literature disputes whether or not teething is connected to any symptoms, but I still maintain that there surely feels like there is an x in the equation.}

All that mucus is the perfect breeding ground for bacteria, which is why something that starts as a virus can turn into an ear infection, sinus infection, or lower respiratory infection fairly quickly. Be warned, we can see a patient one day with clear lungs and no ear issues, and the very next day they can seem a lot worse and have a raging infection.

When to come in 
If you are dealing with a congested family member, here are the questions to consider:

Do they seem to be having any labored breathing? Babies with labored breathing will look like their little tummies are going in and out more than usual. Respiration will be more rapid (I am more concerned with the lungs than a stuffy nose.) Noisy breathing alone is not a very good indicator as it may be caused by upper airway issues that we aren't too worried about.

  • How is their mood?

  • Do they have a fever?

  • How is the appetite? If your baby is nursing well, that is very reassuring.

  • Are they sleeping well at night?

  • What color is the mucous?

  • How long has this been going on?

If you have any labored breathing, wheezing, a child who is much grumpier or fussier than usual, and/or a fever that is hard to control or has lasted more than 3 days, an office visit is needed. I am also interested in mucus that is getting thicker and greener. Green mucus does not automatically signal a problem. It is just one more clue.

It is okay to play the wait and see game if we have a reasonably consolable child with clear mucus who is eating and sleeping well, whose breathing isn't alarming and who has no significant fever.
Of course if the symptoms show no signs of improvement, please check in with your doctor's office. Many colds and coughs can last between 1 and 2 weeks. Some coughs can really hang on.

If you find that you are having a hard time assessing the respirations, try sticking your ear up to their lungs and see if you can hear anything. If you can hear nice clear air noises, that is great. If you hear whistles or squeaky noises, that may mean the congestion has spread down to the lungs. Using your ear as a stethoscope doesn’t always work; more than half the time you won't be able to hear anything, but once in awhile parents are able to get some important clues from the "ear to chest" evaluation. If your child is old enough to cooperate, have them take a great big deep breath, in and out.

If they are wheezy or have any inflammation in their lungs, that deep breath will often trigger a bit of a coughing fit. If that happens, it is probably worth an office visit.

It is not a bad idea to get an idea of what “normal” looks like. If you are lucky enough to be reading this when your child is healthy, lift up their shirt and watch them breathe for a minute or two. How fast are their normal breaths?

Any baby less than 2 months old is probably worth a visit to the office with their first cold, unless they are eating really well and seem completely happy. It is certainly at least worth a call to the nurse.

Sometimes a big mucus plug may be momentarily blocking an airway, causing a minute of distress that clears with a big cough. If coughing and steam are able to clear things up, it is more likely that it is upper airway congestion.

Management tips
The best way to manage congestion at home is to make sure your little patient is getting plenty of fluids (this will help to keep the mucus thinner.) Breast milk is perfect if you are lucky enough to have it.

With some older kids, cow's milk may not be the best choice because it can increase the amount of mucous (it doesn't impact everyone the same way.) I have plenty of patients who love their milk and taking it away for a couple of days is not a reasonable option. Sometimes thinning it will a bit of extra water is a good compromise.

Steam is great. Hang out in the bathroom when anyone takes a shower. Running a humidifier or vaporizer at night is a good idea. Turn it off during the day and give the room a chance to dry out so that you don't grow mold. Make sure you change the water daily. As long as you follow those rules, I don't have a preference between warm or cool mist.

Keeping the head elevated makes a huge difference. Some of the younger babies will do best napping in their car seats, bouncy seat or swing. Make certain that they are in a safe place. For night time, try a crib wedge or place a towel underneath the mattress to raise it up a bit. Some parents place a book underneath two of the crib legs to get it on a mild slant

You can put saline drops or breast milk into the nose (and then suck it out with a Nose Frida or snot sucker). This is the most natural way to clear the nose. Your baby will no doubt hate this, but if you can manage to do it about ten minutes before a feeding, it may clear the nose up enough to make eating much easier. Do not torture your baby with the nasal irrigation if they are managing just fine.

Some of my parents really like the Oogiebear nose and ear cleaners. These are safe, soft little plastic scoops that allow you to remove stubborn little boogies.

For patients over 6 months of age, ask your doctor about Windbreaker or Pipecleaner. These are Chinese herbs that we use to dry up congestion. Many of our families swear by these. They are sold at the Chinese medicine works on 25th and Noe. For convenience our office tries to also keep it them stock.

Consider acupuncture! One of our neighborhood acupuncturists gets some good results from her treatments for your basic coughs and colds. Her treatment of children often does not use any needles. The Acupuncture Den

Still in the realm of Chinese medicine, there is a new product on the market. Dr. Loo, a local physician, has created a patch to treat the symptoms of congestion. These are safe for any age!
Her website is a work in progress but you can learn all about the products by clicking below. It is possible that we will have some of the patches available for purchase.

For older kids and adults, don't minimize the value of chicken soup! There was a fun study done a few years ago that found that soup drunk out of a mug was actually statistically better than soup out of a bowl.

So, what about the over the counter cough medications? I have been an advice nurse here at Noe Valley pediatrics for a shockingly long time (1988.) For many many years the nurses and docs were pretty quick to prescribe over the counter cough and cold remedies to our patients over 6 months. The rules and recommendations kept changing. First they moved the age to 2 and over, the next thing I knew the age was 6 and over. In my experience, those meds were useful and harmless. It was nice to have an option for the younger patients to help them get over the hump of a nasty cold, but the powers that be are pretty firm that the labels remain for older kids only.

There are some homeopathic remedies out there that are considered completely safe. Chestal and Zarbees are are two of the brands I have had parents give good reports about. Make sure that you don’t give anything honey based to a child under one year of age. The Zarbees does have an infant formula. Boiron came out with something new this year called ColdCalm. This is a homeopathic remedy that comes in a little dropper that can be given to patients as young as 6 months of age.

Here in our office our docs may recommend a dose of Zyrtec or Benadryl at night to help dry the kids up and get them a good night's sleep. Before I would do that, I would want them checked out to make sure the lungs and ears are clear.

For night coughs, without taking anything orally, you might try a bit of  Vicks Vaporub on the feet! Trust me, I scoffed at that as much as anyone, until I asked my patients to test it out and was shocked at how much it seems to help.

For parents and big kids I really like Sambucol and zinc lozenges. They may be placebos, but in my case I say " bring it on" because they seem to work. Remember that I work in the germ factory and (knock wood) I manage to avoid many of the things I tend to be exposed to. The second I feel that little tickle in my throat or any tell tale signs of an illness I take a zinc cold therapy lozenge Walgreen's generic taste better and are cheaper) and a Sambucol lozenge twice a day. Ester C is also a good supplement to add.

Another very good thing to do for folks who are old enough is to use a Neti Pot or sinus irrigation. Make sure to use distilled water.
NeilMed has quite a few excellent products to help clear out the nose. For nursing moms, this is my absolute favorite remedy. If you have a deviated septum, this may not work well for you.

Good hand washing is of course essential.

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