Friday, December 15, 2017

Essential equipment 2017

Topic of the Week:
Essential Equipment

Essential equipment 2017
"stuff" that may make parents life easier

How old are my kids? They are so old that they slept on their tummies in cushy little cribs surrounded by tons of stuffed animals. They survived their early years without a cell phone or ipad to play with. The cell phone that I did have was as large as a briefcase and needed to be plugged into the car cigarette lighter for power. The baby swing that we owned was wound up with a crank. If you are a grandparent reading this, you are nodding as you remember the model that I am talking about. The babies loved it and would be lulled into a contented relaxed state for several minutes of clickety click, clickety clack. Then alas it would wind down and need to be cranked up again. This was a noisy process that more likely than not would wake the sleeping baby who had just nodded off.
Parents of young children have a much wider variety of “parenting hacks” to choose from. There are plenty of new things constantly coming onto the market that parents will refer to as “game changers”. These are the item that really make things feel more manageable. The following products are not personal endorsements; I am simply sharing wisdom from others that may be useful to my patients and readers. This is the third year that I am doing this post. Every year I have added more items. Thanks to all of you who have chimed in.

Having a safe place where where your baby can comfortably hang out is essential.
For the Crib:
  • Dr. Hurd suggests that all of her patients invest in a simple crib wedge. Having them on a comfy 45 degree angle is especially important for babies with digestion issues or any congestion.
  • Dr. Anne has several parents who absolutely love the Snoo Bed.This is not cheap, but it was created by Dr. Karp who wrote the Happiest Baby on the Block series. It might be cheaper than several nights of night nurses!

  • One of our patients Amy (mama of twins) told me aboutwonder bumpersThese are one of those “why didn’t I think of that” products

Putting them down outside of a crib

  • Dr. Anne likes the Boppy newborn lounger

  • Some of Dr. Hurd’s favorites are:

  • Diane, a mom of twins passed along a tip. “When I started asking other twin parents which products I should buy two of, at least 5 people told me I should get two fisher price rock and plays (with auto rock). They were all correct. The rock and plays are amazing. When my girls are a little bit congested (which has happened a lot in the first 6 weeks of life), the incline helps them sleep better. And on those challenging nights where they are both fussy, I can put them each in a rocker and turn them on and they can rock gently for hours. Make sure to buy the one with the auto rock option, because the regular one you have to rock manually”

  • If you don’t mind a manual version, You can rock this Fisher Price rocker with your foot (never run out of batteries.) One of the nice things about this is that it is reasonably priced and can transition to be used as your kids grow.

  • For kids over 4 months, my husband Sandy says I can’t leave the doorway jumpers off the list. Our daughter Lauren absolutely loved hers and would bounce and twirl in that thing in rhythm to music.These of course only work if you have sturdy door jambs. With any carrier or swing, use your common sense and don’t keep the babies in there for ridiculous stretches of time.

  • Thanks to Nurse Lainey for telling me about the DockaTot This product has some big fans

Blankets and Swaddles

  • Many parents and Dr. Anne all really like the Merlin Sleepsuitto help with the transition out of the swaddle around 3 months

  • My niece Lena says that the swaddle blankets with velcro were really useful. These give the option of snugging the arms tight while leaving the feet free to be strapped into a bouncer.

  • Wherever they are hanging out, Dr. Anne also suggests checking out the Summer Infant Snuzzler Infant Support for Car Seats and Strollers- this is terrific for small newborns or babies having a having a hard time transitioning to bassinet in first month.

For some of our toddlers and preschool kids working on their sleeping skills, thanks to Tila for sharing the sleeper heroAfter she told me about it, I have passed this tip along and many parents have called it a difference maker

Please never leave kids unattended. Just this week I had a call involving a baby not fully strapped into a little bouncer who managed to flop himself forward and bonk his head (he’s fine.)
Don’t put carriers up on a high surface. Trust me, they manage to fall. You don’t want to be the person calling me about that. This is more dangerous if there is a toddler or large dog that can 'help' the baby get knocked over.

  • Once the babies are over 4 months old, Noe Valley Pediatrics' Lily relied on her infantino flip advanced convertible baby carrier

  • For the babies who are starting to take their first steps, Nurse Lainey loves to recommend Little balance box

Food related

This is especially helpful for a family with twins who are mixing larger quantities of formula at a time

You can wipe it clean and it cuts down on messes

  • My super adorable neighbor and patient Sean loved his Zo li sippy cup. His mom Sara says she tried a bunch before they found this winner and that it helped them transition away from the bottle. (Welcome to baby Kate, Sean’s new sister!)

Other Random tips

My lovely patients Rita and Ricardo spend a recent date night trying to brainstorm for me. They reminisced and thought about the most essential baby equipment (especially the first time around). Here's their list:

  • For the tall parents out there -- the Uppa Baby stroller line is great.They have the Uppa Baby Vista and the Uppa Baby G-Lite strollers and both are great for Riccardo (who is 6'8').

Other parents let me know about

  • The Frenchie Mother towell - is a towel that velcros around mom or dad's neck and makes it easier for you to take the baby out of the bathtub (and keep you dry at the same time.) So simple but such a good invention!

Thanks Caroline for letting me know about another towel suggestion: I have a pretty random suggestion for essential equipment, but it made my life so much easier that now it’s my go-to gift for new parents. I absolutely loved my apron towel. Especially when Jack was a squirmy, wet baby. It made me feel so much more comfortable bathing him by myself.
You clip the towel around your neck before the bath, and after the bath you just pick up the baby to your chest and flip the hood up.

  • Mama Regan let me know about the Oogie bear, little scoop for removing little boogies

  • Noe Valley Pediatrics Eileen reminded me that this list isn't complete without the nose frida or other nasal aspirator. Having one of those is a must have for every parent

I couldn’t do a post like this without checking in with Jennifer of Hint Mama. She sent along the following tips

Clive’s mom Kylie says favorite toy as infant and now great distracter in car seat is baby Einstein take along tunes.

(Bells and whistles are fine and entertaining. Not everything needs to be high tech. There is nothing as great as a cabinet full of food storage containers and lids!)

  • Thanks to Pediatric Dentist David Rothman for chiming in with a bit of wisdom. His says that his kids favorite was the different colored stacking blocks that kept them happily playing for hours.

  • Dr. Schwanke's favorite item Sophie the Giraffe would be in this category. This is a classic favorite that has been loved by several generations.

  • Noe Valley Pediatric's Lily reminded me how important asimple doctors kit can be at getting kids more comfortable during their visits here.

Beyond equipment, there are now all sorts of apps

  • Robert, the daddy of baby Noah says that they found thebaby tracker app really useful

Other products

I don't advocate trying to live in a germ free world, but I imagine that most of us have disgustingly dirty cell phones that would benefit from a good cleaning, especially before we let our babies chew on them.

The book "Baby Bargains" another recommendation from Rita and Ricardo was a great resource to help them find general baby equipment (strollers, car seats, cribs, etc).  It's not just about bargains - it's about quality, and they test and know about all the latest products.

Bonus Wisdom tip from mama Megna

One of the things I realized when I was nursing was that if I was stressed my son almost always 'absorbed' the tension especially when I was nursing. This was one of the most direct osmosis affects I've seen of stress hormones. It was a reminder of always being cool calm and composed especially when around your child.

We traveled a lot with our son the first year and although traveling with the a baby it's no picnic, each time we did a trip he grew emotionally so much. We never regretted a single trip that we took whether it was Europe or to see great-grandparents. Traveling is an amazing thing for a child even that age. It made us as parents more flexible and not as regimented about having things a certain way, and socialized our son at a very early age.

This post lives forever on my blog. If you have some magic tips to share, let me know and I will update the post.


Friday, December 8, 2017

The Best Present is your Presence

I saw a bumper sticker a while ago that said:

Good parenting requires twice as much time and half as much money.

So true!

This is the season for gift giving, but we all actually could do with a lot less stuff!! The best present I think that families can give to each other is the gift of self (otherwise known as time and attention.)

For kids who are old enough to understand, give a certificate that promises a special activity that you might do some time in the future. For older kids, escape rooms are a ton of fun. A membership to one of the local museums or the Exploratorium is another good gift to give to the family.

It is great for families to do outings all together, but one-on-one time is so important if you can manage it. Mix and match so that you make sure that everyone gets special time with one other family member. This includes one on one time for you parents as well.

The list of Nurse Judy's inexpensive and creative activities has some old and new ideas.

  • Collect and decorate rocks with colorful paints and glitter for a rock garden.

  • This is a great one to use as a reward for good behavior. When they see the pretty rocks, they will remember that they earned them.

  • Make a collage. Old magazines and old photos are great for this activity.

  • Make a musical instrument. Use your imagination: a shoe box with rubber bands can be a guitar; glasses filled with different levels of water make different tones; tapping different surfaces with chopsticks makes different sounds.

  • Go on a 'use all your senses' walk. What do they see, smell, hear, and feel?

  • Make personalized place mats. Take some family photos, glue onto cardboard, and cover with clear contact paper. Kids will love to use these with meals.

  • Create a scavenger hunt walk. Plan a list ahead of time of thing to a dog, an airplane, or even a girl with purple hair.

  • Go on an ABC walk. Find things that start with all the different letters...or find the actual letters on signs and license plates. This is a great game in a supermarket.

  • Download free coloring pages from the internet. With a little searching, you can get a picture of just about anything.

  • Draw with chalk. Make a hopscotch board.

  • Make your own play dough. You can find the recipe on line.

  • Make a fort using the couch cushions,

  • For a really special occasion, set up the tent and have a backyard camp out.

  • Write a story and illustrate it together.

  • Decide on a recipe and bake or cook something. Kids will often try foods more eagerly if they helped with the cooking. Let them help sprinkle in different spices and be the taste-tester.

  • Have a Tea party. Invite the dolls, and get out the good china that you never use.

  • Trace your hands and feet and color them in.

  • Have some down time while watching a video or a special TV program. There are some lovely educational TV programs and videos out there.

  • Play a computer game. Don't be afraid of controlled use. Children that don't learn how to be comfortable on computers at a young age are at a distinct disadvantage in this high tech culture.

  • Okay, now put that screen away and get some fresh air! Families can play some sports outside. Find a patch of grass, a basketball hoop or one of the city tennis courts and get active.

  • Blow bubbles

  • Playing board games with the family is the stuff that great memories are made of

  • There is little out there that is as much fun as a giant box to get inside of . If you buy a new appliance or see a neighbor buying one, ask for the box.

  • Let’s be optimistic: make a rain gauge!

  • Play dress up. In my opinion, every house needs a good dress up box, (after Halloween is a great time to pick up costumes and things on sale)

  • Read!

  • If you can manage to make it work, try hard to have at least one meal of the day sitting down with the entire family. Have everyone say a little about their day.

  • Take advantage of where we live, there are always fairs, festivals and museums that are going on.

  • Make a scrapbook with keepsakes and photos of all the fun activities

  • Unless you are using the phone or tablet as part of the activity make sure you put them down and be fully engaged in what you are doing (emails can wait)

For Those lucky enough to live in or near the Bay Area, here is my list of quirky, only in SF things to do.

  • Fort Funston: Bring some dog treats and take a walk. You are pretty much guaranteed to see lots of fuzzy friends to pet. If you are lucky you will see hang gliders. (Free)

  • Take a ferry ride. The route from the Ferry building to Jack London square is super easy, and there are snacks and a bathroom available!

  • Turrell Sky dome: For this you need an admission to the De Young museum. Many folks have no idea that this magical place exists. Go out to the garden by the cafe and follow the path and signs down to the sky dome. Once you are in there, make sure you sing and listen to the acoustics

  • The camera below the cliff house: Lots of folks don’t bother stepping in there, but it is worth it. The Camera Obscura gives a real time 360 view of the surrounding area. It is only open when the weather is clear. It isn’t free, but it is reasonably inexpensive

  • The Wave Organ: This is an old exploratorium exhibit that remains out at the end of a jetty behind the St Francis Yacht club. When the tide is right (good luck, I have rarely been there are the right time) pipes will play music. It is an enchanting place regardless, especially if you are there when no one else is out there. It is free

  • Musee Mecanique If they love it there...consider earning points for future play there

  • Labyrinth down at Land’s End is worth checking out.

  • Walking tours are free and plentiful. These are a fun way to get outside and learn a little history of the city.

  • The Gingerbread house in the lobby of the Fairmont Hotel is worth a trip. It is only there until the New Year. This is free unless you opt to splurge on the very expensive tea.

  • I love the Stairway walks of SF book. If you child is old enough that they don't start asking to be carried half way through the walk, these are a great family activity.

Happy Holidays...go out and make some wonderful memories!

If you have something that you think would be a good addition to this list, let me know!

Friday, December 1, 2017

Reactive Airway/Wheezing/Inhaler tips

We get calls all the time from parents worried that their child is wheezing. I am always going to pay attention to this complaint but not all breathing noises are the same. A whistling noise from congested nasal passages is not always something that we need to worry about. The wheezing that is going to get my antenna up is the noise from down in the lungs. Any squeak, crackle or wheeze can be a sign of inflammation.

When a person is well, air can move easily in and out of the lungs through a network of airways. There are several things happening during a wheezing attack.

The airway becomes irritated and inflamed; this produces mucus which can clog up the airway. The inflammation also causes the lining of the airways to swell and the muscles around these airways tighten; this is called a bronchospasm.

Wheezing is actually quite common in infants; it is estimated that up to 25 to 30 percent of infants develop wheezing in their first year of life. Wheezing may be more common in babies because of their smaller airways. Also, children under two are susceptible to a common, but easily treatable condition called bronchiolitis. This is caused by a viral respiratory infection and is a frequent cause wheezing.

If your child has multiple episodes of wheezing they may get diagnosed as having a reactive airway. Reactive airway is exactly what is sounds like. Something is “triggering” the lungs, and the airway gets inflamed. Triggers range from a new cold, a change in the weather, secondhand smoke, dust, pets and or other allergens.
Having a season or two of wheezing does not mean they have a lifetime of asthma ahead of them. Some kids can grow out of this.

If your child is wheezing it is important that they get prompt medical attention. If this is a first time event it is even more critical to get educated about medications and treatments so that you are prepared to recognize and deal with it in the future.

In general, having a doctor take a good listen with a proper stethoscope is a good idea, but you will have important clues if you know what to look for. Pay close attention to the patient’s breathing. Is it faster than normal? Getting a sense of what normal looks like when they are well is a good idea.

Age Category Age Range Normal Respiratory Rate

Infant 0-12 months 30-60 per minute
Toddler 1-3 years 24-40 per minute

Preschool 4-5 years 22-34 per minute

School Age 6-12 years 18-30 per minute

Lift up the shirt and watch. Do the respirations appear labored? Look for the tummy going in and out, or any retractions. How are they feeding? If your baby needs to take more frequent breaks from eating that can be a warning signal that they are ill.

For older kids, can they take a big deep breath without it triggering a coughing fit?

If a patient is wheezing they are likely to get some special medicine prescribed. Albuterol (Ventolin/ Proair) and levalbuterol (Xopenex) are the common “fix it” medications. These help open up the airway by relaxing the tight muscles. Unfortunately it is not uncommon for patients to get a little amped up from the treatment. These medications should start to work within 6 minutes or so. Some parents report that the kids seem to cough even more after a treatment. Remember that this medication is loosening up an airway that was previously very tight. All of a sudden there is more room for the mucous to rattle around. A productive cough is normal.

We would use either albuterol or Xopenex, not both at the same time. Some folks find that Xopenex is less likely to make them jittery. Insurance companies will often need to see documented failure with albuterol before the Xopenex is covered. These medications can be given through a nebulizer machine or through an inhaler. Most young kids do better with the machine, but as soon as they are old enough to cooperate with the puffer it is a quicker and much more convenient way to give the medication.

If this is a short little illness, sometimes a few days of the albuterol-type medication will see you through. If you are requiring albuterol for longer than a week or find that you need to use it more than several times a month, it is a sign that the situation is not well controlled.

An absolute key treatment for a reactive airway is the use of inhaled steroids and other anti-inflammatory drugs. In our office we use something called budesonide (Pulmicort) in the nebulizer, but switch over to an inhaler when the kids are old enough. Common brands are Flovent and Qvar. These can control and prevent future attacks. The steroids work by reducing the inflammation, swelling, and mucus production in the lungs. As a result a person is less likely to react to the triggers.

All the studies agree, inflammation in the lungs is bad and can lead to scarring. The choice between allowing persistent inflammation or using proper dose of inhaled steroids is an easy one. Please don’t be reluctant to use the inhaled steroid if it is appropriate. The word steroid sounds scary, but when they are inhaled, they are not generally absorbed by the body, but are going straight to the lungs.

If your child is given a prescription for inhaled steroids,It is not unusual for them to be on them for weeks or months, especially during the winter cold and flu season. Both of my kids had a few seasons of using the Pulmicort. As soon as I would try to wean off the daily dose, the dry hacky irritated cough would start right back up.

Here are some tips regarding inhaler use:

For younger kids, I start with some really basic teaching. Get a tissue and hold it up to their mouth. Have them practice blowing on it and then inhaling so that it sucks up to their mouth. This can help them to understand the difference between inhaling and exhaling.

It is really important to shake the canister before each use. For the first use and any subsequent use if you haven’t used it for more than a week, the inhaler needs to be primed by spraying 2 to 3 puffs into the air. I know it seems wasteful, but it is necessary. If you child is having trouble, you want to make sure that you are actually giving the medication. Read the directions carefully for the specific information about each inhaler!

Hold the medicine upright so that it doesn’t stick to the tongue.
Breath coordination is difficult. Using a spacer will make the inhalation much more effective. For younger kids, the spacers come with a mask. Keep lips firmly around the mouthpiece. The spacers should not make noise. If there is a whistle, try to make the breath slower.

Activate the medication and make sure to keep the spacer at the mouth for at least 5 breaths. Wait about 30 seconds in between puffs.

If you are using albuterol and an inhaled steroid, give the albuterol first.
It is a good practice to rinse the mouth out after the medication. This is especially true after the steroid.

If your child has a history of wheezing, it is a good idea to keep track and make sure that you have un-expired medication on hand. If you are traveling have them with you!

Most inhalers have counters now so you can see how many doses are left, but if yours does not there are some tricks for figuring out how much is left. Take the canister and place in glass of water. A full one will stay mostly upright. If it floats at a 45 angle, it is time to replace it. If it goes sideways, it is probably empty. Shaking it is not a reliable indicator because there is propellant inside, so it is hard to tell how much is in there.

It is good practice to keep the inhalers in their box. When you come to a doctors appointment, please bring them with you so that you can show the doctors exactly what you have been taking.

If you are using a nebulizer machine, make sure that you change the tubing at least every 6 months. If it is the disposable tubing, that should be used for no more than 15 treatments.

I have found that a little tech time or videos are very useful in getting your child to sit still. This is one of those situations that bribery might come in handy.

I shouldn’t have to add this, but please remember that the correct call for a child in true respiratory distress is to 911, not the doctor’s office.

Friday, November 24, 2017

The impact of a single sentence

Social media in general and Facebook in particular have their benefits and drawbacks There is no doubt that it is way easier to reconnect with long lost friends than it used to be.

Recently my husband got tagged in a 6th grade class photo from his good old PS 32 in New York City. This started a flurry of conversation between people who hadn’t been in touch for many many (many) years. There is really nothing quite like an old friend who knew you when. I believe he may actually stay reconnected with some of these folks.

With all the catching up that was going on, there was a comment from a girl in his class that caught my attention. She wanted to let Sandy know that after all this time, she still thought about his mother.

It turns out that way back when, after a school performance, my mother-in-law had made a bee-line straight over to this girl just to tell her what a wonderful job she had done. It wasn’t the simple “good for you”; mom had told her how moved she had been and that this young lady should be very proud of the performance. Fortyeight years later, this woman says that she still remembers how impacted she was by the interaction. Wow!

There are more people out there than we can count for whom a crumb of positive feedback is rare and important. Words, either kind ones or mean ones, are often put out there without much thought and the speaker moves on. This story illustrates how much a message can sometimes stick and make a profound impact.

Go out there on this Thanksgiving weekend and make a lasting positive impact with your conversations!

Friday, November 17, 2017

Carbon Monoxide 2017

Carbon Monoxide

Carbon monoxide (hereafter referred by its chemical symbol CO)
This post could save your life. How many of you own a carbon monoxide alarm? If you do, good for you. Make sure that it is in good working order. The units do not last forever. IN some of the older units, batteries need to be changed annually (at least) and some units suggest that you vacuum the cover monthly to remove accumulated dust. If you are one of the many who do not yet own one, please remedy that immediately. It has been the law since January, 2013, with few exceptions.

Homes with a fireplace, attached, garage, or any gas appliances are at higher risk, but there are many different factors that can cause an elevated level. A friend of mine is a lawyer who was involved in a heartbreaking case where a guest at a Bay Area hotel sustained long term health impairment from an exposure. The victim’s room was above the hotel pool and a faulty boiler used to heat the pool vented carbon monoxide into his room. When he didn't show up for dinner, his friends found him unresponsive. It was a very alert physician in the emergency room who figured out the cause. It was only at that point that the hotel was evacuated. This is not an isolated incident. As a result, my lawyer friend takes a portable detector along with him on all of his travels!

Because heaters and fireplaces are often involved, exposure is usually higher during the winter months.

Carbon monoxide is a colorless, odorless and tasteless poison gas that can be fatal when inhaled. CO binds to hemoglobin with much greater affinity than oxygen, forming carboxyhemoglobin (COHb). It is hundreds of times more efficient than oxygen at attaching to the cells, so even small amounts can deprive our bodies of vital oxygen. In severe cases, for folks who survive an exposure, it can cause irreversible brain damage by starving the brain of oxygen.

Normally if someone is deprived of oxygen they may look pale or cyanotic (bluish); in the case of CO poisoning, the color will remain nice and pink. A standard pulse oximeter may not be an accurate indicator of where or not there is a problem. If carbon monoxide exposure is suspected a blood test can be done to check the carboxyhemoglobin level.

One of our local ER docs who allowed me to pick his brain added that one of the tricky things about CO poisoning is that the symptoms are very vague and nonspecific. A faster than normal heart rate (tachycardia) is the only really reliable physical exam finding.

Mild exposure might cause slight headache, nausea, vomiting and fatigue. This can easily be mistaken for flu or viral syndrome. Medium exposure symptoms would be a throbbing headache, drowsiness, confusion and a rapid heart rate. Extreme exposure will lead to unconsciousness, seizures, and cardio-respiratory failure that usually is fatal.

The effects of exposure can vary greatly from person to person depending on age, overall health, and the concentration and length of exposure. Young children and pets are thought to be especially vulnerable. Pregnant women should also be especially careful because the fetus can be seriously impacted.

A carbon monoxide alarm is similar to a smoke detector because it monitors the air in your home and sounds a loud alarm to alert you of trouble. However, the way you respond to a CO alarm is very different than a smoke detector. When a smoke detector goes off, it is pretty easy to to judge the level of danger. You can see or smell the smoke. On the other hand, because CO is completely undetectable to your senses, you are dependent on the alarm to let you know there is a problem. If the alarm sounds:

  • Operate the test/reset button
  • Call 911
  • Immediately move to fresh air (make sure that everyone in the household is accounted for.)
  • Do not go back in until you have the all clear from the emergency responders.

Concentrations of CO between 1 and 30 ppm can often occur in normal, everyday conditions. See the chart below for CO levels and corresponding symptoms.

If your unit is coming to the end of it’s life it may give off multiple chirps to notify you that you need to replace the device or change the batteries. Newer alarms might be good for as long as 10 years. Ours has a digital display that will signal when it is time to replace it.

Last year my daughter Alana had her CO alarm go off in her apartment in Michigan. She knew enough to get outside and call 911 immediately. After the fact she recounted her conversation with the fireman who had responded:

“I am worried about my cats, can you help get them out?”
“What do they look like?
“They are CATS, they are furry, have 4 feet and tails!”

Happily the kitties were all safely brought out of the apartment.

The best guess for what set off the alarm was something faulty with the air conditioning system. It went off several times with no clear source identified, which prompted her to move.

You may not think that your home is at risk, but there is NO downside for investing in an alarm (plus you are complying with the law.) They are inexpensive. If you are renting and there is not a unit in your apartment, call your landlord immediately and get that remedied. in January of 2017, in the Bay area, there was the tragic instance of a young couple and their pets all found dead with no obvious cause. It turned out that it was CO exposure from a malfunctioning 3D printer. A functioning alarm would have saved their lives. Don’t mess around with this. Please make sure you are protected.