Friday, August 18, 2017

What should you have in your first aid/emergency kit?

What should you have in your first aid/emergency kit?

A new mom recently asked me if she needed to purchase a first aid kit to have in the house in preparation for the new baby. There are indeed lots of commercially available kits out there, but it is pretty simple and less expensive to put together your own.

Last week my post was all about being mentally prepared for a variety of situations. This seemed like a logical follow up.
Having some items on hand is wise. Take time to make sure these things are organized and easily accessible so that you don’t waste time scurrying around if you need something quickly.

Home:
The following link is to my December post about having an appropriately stocked  medicine cabinet.


That post gives you a hefty list for things you should keep available at home.
Here are a few additions

Every family with a young child should have a nasal aspirator: The hospital will send you home with a bulb aspirator, but many people find those awkward.
I really advise that every new parent have a NoseFrida:


or NeilMed Naspira:


If the baby has a stuffy nose, or has secretions blocking their nasal passages, these snot suckers are a simple way to clear them. Have you ever had milk come out of your nose when you are laughing, sneezing or coughing? That can happen to your baby as well. An aspirator near by can make things less chaotic.

Make sure you are prepared and own infant nail clippers or scissors. Some babies are born with very long nails and can end up really scratching themselves if you don’t clip or file them :


I asked Dr Katherine Morioka of City Optometry what folks should have on hand in case of an eye injury. She suggests that a first aid kit should include artificial tears, an eye wash kit, gauze and first aid tape.


Away from home:
CAR: Every car that you drive should have its own emergency kit in the trunk.
Some of the items I am going to add are NOT typically found on general lists.

Have a change of clothes, extra diapers, clean socks, extra layers (for every family member.) In San Francisco, the fog can come in quickly; don’t end up looking like a shivering tourist and resort to having to buy another Alcatraz sweatshirt.

A baggy with basic first aid supplies:

  • Gauze pads/ a roll of coban self adhesive wrap/ Neopsorin/ antiseptic wipes (a clean pair of socks can serve double duty in case you don't have gauze.)

  • A tweezer for removing a splinter or tick (shudder)

  • Scissors

  • Instant cold pack/ hot pack

  • Tylenol or Motrin

  • Zyrtec or Benadryl

  • Anrica (for bumps and bruises)

  • Flashlight/ Batteries

Have some durable snacks, pouches or bars and some water. If you are on a road trip double down on this and make sure you have provisions in case you get stuck.

  • An index card with important phone numbers including poison control.

Okay, here are some things that are not on the general lists:

  • Keep a pair of  heavy duty gloves on hand.

  • Have some cash. Small bills are the best. If there is an emergency and there is no electricity for credit card or ATM transactions, having cash is invaluable. We learned this tip from an uncle who was impacted by Hurricane Andrew in Florida in 1992. There was no power for days. Family members needed to wire him money and he was not even an Nigerian prince offering us millions!

  • Have a deck of cards or activity for your kids if you get stuck someplace. A fresh coloring book with crayons or something novel to keep them calm and entertained can help keeps everyone’s sanity.

  • Barf bags (every time you fly, take the unused one from your seat) These are better kept in the glove compartment than the trunk.

  • Have some empty gallon zip lock bags

  • Portable potty: You can make your own. All you need is  an inflatable ring. Find a cheap inner tube or inflatable potty from Amazon. Tuck around a tall kitchen garbage bag, When they are finished going, the poop or pee is in the bag with very little clean up needed. When your child is just starting the toilet training journey, these can be really handy.

  • Make sure you have baby wipes/ paper towels/ fabreeze or air freshener

  • Disposable blue absorbent underpads (take the one from your office visit if your baby didn't pee on it!) You will find a lot of uses for these!

  • Have some empty gallon zip lock bags


Get in the habit of checking this stash thoroughly, several times a year. Perhaps do it with the clock change when you check your smoke detector batteries. Check expiration dates, diaper sizes, battery life, phone number accuracy,... etc.

Diaper bag:
As long as you are close to the car, you don’t need to carry too much with you.
Keep a small baggie with some gauze/ antiseptic wipes/ small packet of neosporin. If you more than 30 minutes from the car, have tylenol/ibuprofen, and benedryl/zyrtec with you. If there are medications in your diaper bag, pay attention that young children don’t have easy access to them.

Friday, August 11, 2017

Problem solving skills 2017


Some of our patients are heading off to school within the next couple of weeks. It is a big adjustment for everyone. When you are no longer with your child 24/7 you want to make sure that they are prepared to deal with unexpected situations.

Today's topic is a about an important activity that you can do with your child that teaches them to be "problem solvers".  Adults need to learn to be problem solvers also. Some people are much better at this than others. For instance, if you got in a fender bender, what would you do? Many folks would just freeze and panic. Whatshould you do?

  • Assess for injury; call 911 if needed
  • If you are on a highway, wait for assistance. Getting out of the car is often dangerous!
  • Do you have an AAA membership? Know where the card is.
  • Know where your insurance info is kept (make sure you have a copy accessible)
  • Take a photo of any damage
  • Take a photo of the other driver's insurance card and driver's license...etc.
  • Always have a charger in your car for your cell phone so that a low battery is never an issue.

Having a plan in advance could help you stay calm.

But I do want to add one more benign tidbit here. What if you lost your cell phone or it ran out of batteries and you don't happen to have a charger? Do you know important phone numbers, or do you count on speed dial? Having a list of important numbers in an accessible place is a good idea for everyone.

I lived in New York back in the early eighties. It was a different city back then. At one point there were a rash of home break-ins and burglaries. A friend of mine who was an actress obsessed quite a bit about this. She went as far as rehearsing made up scenes for any given situation to avoid being frozen by fear. Go figure, one day someone did break into her apartment. She went right into her pre-rehearsed mode. Figuring that acting a bit cuckoo would get any 'bad guy' off balance, she immediately broke into the character that she had prepared. In a loud, shrill British accent she yelled, “Welcome!!! Would you like to stay for tea?" She did the Mad Hatter proud. She went on with a list of options. "Would you like herbal or black? I have delicious honey from local bees!" As expected, the intruder was completely caught off guard. He mumbled something, turned and ran. Brilliant. Not that I am recommending that particular course of action, but having a plan in advance is always a good thing.

Years ago, the concept that everyone would carry around an individual cell phone seemed as futuristic as the communicators on Star Trek. Now, of course it is hard to imagine how we got along without them. It was, however, the lack of the cell phone that prompted me to create a game that became a favorite in our family.
It must have been 1994 and I was on my way to pick up Alana from preschool. She was about 4 years old at the time. It was one of ‘those days’. I was uncharacteristically running late. Then I got stuck in terrible traffic. To compound things, I took some random turns to try to work around the congestion and ended up utterly lost. (Remember that this was also before Google maps or GPS.)  My stomach was in a knot and I wondered what my younger daughter would do when mommy was late picking her up. It turned out that she was calmly waiting for me in the office, but that was the day that the "what would you do if" game was created. It was all about building on the concept of planning in advance for an assortment of situations. It went something like this:

I would ask a question such as, "What should you do if mommy is late picking you up? What are some of the choices? Which is the best one?"
Getting a teacher or trusted grown up to wait with her or take her to the office was clearly the right answer and I praised her for figuring that out on her own. Alana loved this game. We created all sorts of situations:

" What if we were at a store and you couldn't find me?
Alana: " I would go to the check out and ask them to page you."

We never made it too simple...

Mommy :"What if they refused?"
Alana :"I would demand to talk to the manager"

Our scenarios covered any number of little emergencies including earthquakes, fires, and getting lost or separated. The better you are at problem solving, the easier it gets to improvise.

This game came in handy more than once. The shining example that comes to mind happened after years of playing this game. Alana and I were walking the dog on the beach one day. I had donated blood earlier that morning and didn't realize how foolish I was for doing anything strenuous. I got very light headed and ended up down on the sand trying hard not to completely pass out. Alana was ten at the time and she went right into problem solving mode. We did have cell phones at this point. She got the dog on the leash, patted some water on my forehead and calmly called daddy. I could vaguely hear her talking. "Mommy fainted...I think she is okay."

The game was such a success that my sister taught it to her kids. Hers had an interesting spin because they lived in Alaska at the time:

"What would you do if you saw a bear?"
"What would you do if a moose wanders into the yard?"
There were actually times when these things happened, and my nephews were able to act calmly and appropriately!

Topics can range from handling a bully to getting separated on Muni. Being prepared for unexpected situations can be invaluable.
If your child finds themselves without you and in need of assistance, finding a grown up wearing a uniform is often a valid option for some of the difficult situations. Finding a parent who has a child with them and asking them for help, might be another safe option.

This game is meant to empower. It is wonderful for some kids, but could be terrifying for others. You need to assess your child's temperament before playing. Either way, identify a problem or situation. Start with simple, less scary ones. Discuss all the possible solutions and then agree what the best plan should be for any given situation.

Stressful situations happen. Teaching your child to take a deep breath and use their problem solving skills is one of those things you can do now that can have lasting implications for them when they grow up. Even teaching a very young child to dial 911 in an emergency can be life saving!

You have to figure out if this will be empowering for your child as it was for Alana. My daughter Lauren never liked to play it. In fact, I remember one day when Lauren and I were taking a walk, I tripped on something, stumbled and fell. I was perfectly fine, but Lauren's reaction was to start screaming. As she says, "mommies aren't allowed to fall". Every kid is different. As your child grows, the situations that you might want to bring up will increase in scope.
Preparation is power.

It saddens me we have to be prepared for things other than losing track of our kids on Muni, but that is the world we live in.
Have a family plan in place in case of emergency.  If someone other than one of the regular people is going to pick up your child, have a family “safe word” so that they know they were sent by you.

Do you have your earthquake/emergency kit ready? Does it include adequate diapers, medications, pet food? Where will everyone meet up if home is not a safe option? Find out from your school what kind of emergency plans they have in place. Teach your kids to get in the habit of looking for emergency exits, especially for your older kids who are at a concert, theater or a club.



I think that the "what would you do" exercise is actually something that you might want to do with a nanny or caretaker. Training to keep calm in any type of emergency situation is essential.

Friday, August 4, 2017

Food Heroes and Villains


Up until just recently coconut oil was considered heaven sent. It cured all sorts of things. When I saw the recent news putting it back on the list of terrible foods, I groaned out loud. I feel the need for a little rant. I hope you will bear with me!

Everyday we have different foods take turns getting a blast of media attention. We see lists of the world's healthiest foods and list of foods that should be avoided at all costs. Some things that are on the ‘wonder food’  list one day might be on the ‘avoid at all costs’ list the next. Take red wine for instance, one minute it is the best thing to help you avoid heart disease...oops but it might increase the risk of some cancers.

Of course some of these headlines are often followed by frantic calls to the advice nurse. When the organic rice was found to have measurable amounts of arsenic the phones practically exploded. In fact arsenic is pretty hard to completely avoid and is found in other foods as well.

The list goes on…..

  • Probiotics will save the world
  • Soy will cause your sons to grow breasts
  • Gluten should be completely avoided
  • Even my favorite kale and its fellow cruciferous veggies are now thought to be not as perfect as they were made out to be due to potential thyroid disrupting risks and high oxalate levels that could lead to kidney stones
  • Eggs have been moved to the good guy list. Sugar is more likely to be the cause of high cholesterol than eating eggs every  day.

You get the idea. Navigating through all of this info is so challenging when you are trying to feed your family a healthy diet.

The food pyramid has been turned upside down and there are so many fads that come and go. I asked Nurse Lainey and her internet savvy sister Katie to do a little poking around for me and within a short period of time they came up with an extensive list of dietary trends, including something that sounds particularly alarming called ‘souping’.

I am not about to sort through all of  the fads (the posts are often too long as it is.) Rather I am going to give you the message, "take a deep breath and do the best you can. Everything in moderation!"

If you are lucky and you have a child who will eat plenty of different foods, make a valiant effort to give variety and not to binge on any one thing.

Below is my take on some obvious current heroes and villains.

Organic and Non GMO: Hero
We probably can’t really count on any labels to be completely accurate anymore, but if you can  afford it, I prefer organic produce if it is available:


Sugar: Bad Guy! Try to minimize added sugar. You might be shocked by how much sugar is added to things. Be a good label reader. Agave, which used to be considered a healthier alternative is no longer on the “good guy” list.  If you are looking for a natural sweetener, current consensus would put honey at the top of the list for healthiest option. Remember that this is NOT a good choice for any baby under one year. No honey for them!

My preference would be that sugar and dessert not be used as a reward on a regular basis. If our body has had enough “growing food”, an occasional sweet treat is fine.

Gluten: Mixed. I get aggravated when folks dismiss this. More and more people can really not tolerate gluten, regardless of what testing shows.  Both of my kids ate plenty of bread their entire lives but developed fairly severe gluten reactions as young adults. I have had many patients do an elimination diet and find that they feel much better when they cut it out of their diets. Not everyone suffers the same symptoms. It makes no sense to get rid of gluten if you show no signs of being impacted by it. That being said, in general white flours, breads and pastas are pretty low on the nutrition scale. 
Rice/arsenic: just don’t overdo! There are in fact measurable levels of arsenic in rice. There is more found in the brown rice than white. Rinsing the rice well prior to cooking it might reduce some of the levels. I would not recommend more than a couple of servings of rice per week. We are fortunate that there are plenty of other options. Most other grains out there that don’t have this issue:


Trendy food Pouches: Read the labels!
Just because something is organic, doesn’t mean it is good for you. I know all the pouch foods are quite popular. The are convenient and the kids generally like them, but some are loaded with ingredients that you really don’t need.

They are also a nightmare for the landfill.


As with anything, find some balance.

Wise words from Nurse Lainey. If you want to do some creative eating for yourself, please keep in mind that your children have different nutritional needs. They are not just little adults!

Friday, July 28, 2017

Car seat information 2017

Car Seat Guide: New Laws 2017



The Rules

Car seats are an essential part of keeping your child safe. Countless children’s  lives are saved annually by being properly installed in a carseat during a crash. Governor Jerry Brown  signed a law that went  into effect on January 1st, 2017. This law requires children be rear facing to a minimum of 2 years old:


It is recommended that they remain rear facing until as close to age 4 as possible!  More and more studies are showing that rear facing is the safest place and position in the car. In fact, it is 5 times safer than forward facing.

In the case of an accident, a child's head and spine are better protected if the car seat is rear facing. One study shows that children ages two and under are 75 percent less likely to die or be severely injured in a collision if they face the back. I know kids might appear to be squished but most children are actually quite comfortable sitting criss-cross, or with their legs up the seat.  For those parents/caregivers who are concerned about leg room, Graco has released the Extend2Fit, a new seat which has a 4-position extension panel that provides 5" of additional leg room.

Children who are 40 pounds or 40 inches are exempt from the law and can face forward, but while they may be exempt from the law, they are not exempt from the laws of physics. Rear facing is safer. Please take a moment to click the link below. This video is a good illustration about why rear facing is so important:


Toddlers who have outgrown the rear facing weight or height limit for their car seat should use a forward facing car seat with a harness for as long as possible, up to the highest weight or height allowed by the car seat manufacturer.

The current California Law also requires a car seat or booster seat until your child is 8 years or 4 ft 9 inches. Height parameters make more sense than the previous weight ones. For a child to safely transition into a booster,  we look beyond the child's age/height/weight. There's another set of criteria to help determine if your child is ready to transition to a booster. There is a '4 Step Test', in which all criteria should be met; don’t dismiss the importance of Step 4!

1. Child is an absolute minimum of 40 lbs
2. Minimum of 4 yrs old
3. There is a lap & shoulder belt in child's seating position
4. The Child can be trusted to sit properly for the entire trip, every trip - even while asleep. This means no slouching (back straight up against seat), no leaning to either side, no playing with the belt, etc... even unsupervised.

Developmentally, most children don't meet all of these steps until somewhere between 5-7 years old, and generally closer to 6 or 7 than 5. A lot of this has to do not only with physical maturity, but emotional maturity.
This is one of those times in your parenting life where your child NOT graduating is actually a good thing. The longer your child is harnessed, the safer and more protected they'll be.Your child needs to be tall enough so that the seat belt goes across the chest, not across the neck.  The purpose of a booster is to properly position a child in the adult-intended seat belt. What you’re looking for is proper belt fit across the lap and shoulders - the belt should be low and tight on the hip bones (not on the belly), and should be hitting the shoulder bone, not the child’s neck.

Be aware that most newer car and car seat models use the LATCH system ( Lower Anchors and Tethers for Children). The Latch system attaches the car seat to the vehicle through anchor points that are installed in the car and connectors on the car seat. This is supposed to make the installation easier as well as eliminating potential errors that can result from installing a car seat with a seat belt. The LATCH system has a 65 pound weight limit. What many parents are surprised to find out is that this limit includes the weight of your child as well as the weight of the car seat (some can weigh up to 25 pounds!).

When children are old enough and large enough to use the vehicle seat belt alone, they should always use Lap and Shoulder Seat Belts for optimal protection. To determine if your child is ready to sit unassisted, they must pass the 5-Step test:

The 5-Step Test:

1. Does the child sit all the way back against the auto seat?
2. Do the child's knees bend comfortably at the edge of the auto seat?
3. Does the belt cross the shoulder between the neck and arm?
4. Is the lap belt as low as possible, touching the thighs?
5. Can the child stay seated like this for the whole trip?

If you’ve answered NO to any of the above, your child should remain safely boostered!

If your children complain about this rule, show them photos of race car drivers all bucked up in their restraint system. Be matter of fact about it and explain that there is no compromise for safety (there is also a mighty large fine if you are caught breaking this law.)

All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection. Airbags can actually be quite dangerous to a child so it is worth making sure that this isn't an issue with your car and the placement of your child's safety seat.


Picking the right car seat

If you are looking to buy a new car seat, check out these helpful links:



If you are someone who doesn’t own a car and is popping the car seat in and out of car services, finding one of the cars that is easier to install becomes even more important

Making sure it is installed correctly

The AAA states that 75% of car seats are installed or used improperly. As your child grows, there are services offered here in the San Francisco Bay Area that will check out your car seat or booster seat and make sure it properly installed. Have the infant car seat checked before the baby is born and then again with each transition to a larger seat.

Below are some local resources for making sure that not only is your car seat properly installed but that it is the right fit for your child's size and age. They can make sure that all the straps are where they need to be and that you pass the "pinch test", making sure that the seat's harness is tight enough

To be super safe, consider having the car seat fit and installation checked every 6 months. Fortunately there are lots of places to help.

AAA  553-7208          2300 16th St suite 280
The contact person is Ingrid. Appointments need to be made ahead of time. You do not need to be a AAA member to take advantage of this free service. If you want to take the trek up to Mill Valley, the AAA office there is at 750 Redwood highway. The technicians there are Fernando 415-380-6015 and Kyelynn 415-380-6032. Please make appointments in advance.

CHP (California Highway Patrol)                  415-557-1094
This is very popular and is by appointment only. Please make an appointment as far in advance as possible. The current wait when I called to update this post was pretty short, but it varies and sometimes can be longer than a month.

SFPD                415-575-6363
They try to have an officer at all of the local police stations who is trained to do the car seat safety inspections. Call the number above for more info.

The Colma police department will do a car seat inspection for free(650-997-8321). By appointment only.

Willing to pay to have someone come to you?

ON-LINE RESOURCES

The following links can you assist you in finding the right car seat:

The National Highway Traffic Safety Administration website has a place to click to find updated local car seat inspection stations for those of you who are not in the Bay Area:


  • Car Seats for the Littles - Car Seats for the Littles gives lots of great info about the specific brands of car seats on the market
Other considerations

Car safety doesn't end with being safely buckled. I know it is hard to avoid distraction with a baby fussing in the back seat. Consider getting one of the specially made mirrors so that you can keep on eye on your rear facing baby. Make certain that they can't reach anything that is a choking hazard.

Don't let them hold the keys; they can lock you out!! 

If your child is asleep in the car seat and you have arrived at your destination, leaving them snooze for a few minutes is fine, but keep them tightly buckled. Having a baby in a car seat without being tightly strapped in not safe. The loose straps can be a safety hazard.

WINTER CAR SEAT TIP: The straps need to be tight up against your baby; puffy coats or blankets need to be OVER the straps!

Never leave your child unattended in a vehicle. Children can die from prolonged exposure to excessive temperatures in a hot car.
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Most accidents happen within a few miles of your house. Even a short trip down the block requires the full "buckle up". Hey parents, model good behavior and always make sure you fasten your own seat-belt!

Did you know that car seats expire? Most of them have a 6-9 year life span. This date can usually be found underneath or behind the seat. Buckles and straps can wear out. Prolonged exposure to sunshine can weaken the plastic. Also, the technology is always changing and this ensures that nothing gets too out of date. Save the instructions/registration in a safe place. Make sure you register your car seat. If there is ever a recall this will ensure that you are notified.

If you have an old car seat that you want to get rid of, Alioto's Garage has been offering  a Recycled Car Seat Program. Anyone, not just regular customers, can drop a car seat off at any Alioto's location during regular business hours. They will recycle the usable parts and keep it out of our landfill:


Let me close by confessing that I am NOT a car seat expert. The seats that my children grew up with were much simpler (but not nearly as safe). When I see new parents struggling with all the straps and trying to figure things out, I am often as clueless as they are.

Here is the takeaway message. This is an essential skill  that you need to learn in order to keep your baby safe. Find an expert to help you master this and make sure that you are using the car seat restraint properly.

Safe travels!

Friday, July 21, 2017

Back to School: from Vaccine requirements to Adjustment tips

Back to School: from Vaccine requirements to Adjustment tips


When I was young, Summers were sacred and school started after Labor day. I am not sure when that shifted, but it seems that these days many of our patients start school in mid August. I am putting this post out now to hopefully avoid the panicked parents who call, needing an immediate check up, sports form, or updated vaccination record prior to school entry. In our office our checkups are already very booked up, so if you haven’t done so already it is probably too late to get in under the wire, but call NOW for any chance of getting in sooner. Below  is the standard school form if you lost yours:

School Form for SFUSD
This is the most updated one that I was able to find online.
There is no charge for forms filled out at the time of an exam.
All other forms have a $10 fee and a one week turn around time
(We try to get to them sooner but there are no promises.) Rush forms  will be done within 48 business hours. There is an additional fee for this.

Take a deep breath. Most schools will accept a promise of a scheduled check up as long as they have an immunization form that is complete. We are happy to work with our families to at least get you scheduled for some of those shots that are needed even if there isn't a check up appointment with the doctor available before school actually starts.

As most of you are aware, In June of last year, California Governor Jerry Brown signed Senate Bill (SB) 277 into law. This law went into effect July 2016. For the school year beginning August/September 2016, all children going into kindergarten, seventh grade or transferring to a new school for the first time had to be fully vaccinated or have a medical exemption. Personal or religious exemptions are no longer accepted.
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There is a conditional entry for children who are not fully up to date, but they must have at least one of  all of the required vaccines.

The schools will be checking in to make sure that the series are completed in a timely manner. School districts already have their own systems for tracking and following up with kindergartners who are not fully immunized. Whatever systems the districts are already using will remain in place. Check out this valuable link for a complete list of what is required: Shots for School

For our younger patients, most licensed day care facilities also have a fairly strict vaccination policy. Those requirements are also listed in the above link. That website also has a feature where you can check out your school or daycare to see how well they have been doing in their vaccination efforts.

7th grade  is also the perfect opportunity to vaccinate with the other ACIP (the Advisory Committee on Immunization Practices) recommended vaccines for 11-12 year olds, including HPV and MCV4 (meningococcal).  Students entering the 7th grade  will need to show proof of a Tdap (Tetanus, Diptheria and Pertussis) booster. They also must show proof of two doses of the MMR vaccines.

Vaccinations are only one of the requirements for school entry.
Kindergartners must have a complete physical examination within 6 months prior to entering school. We try to avoid doing the well child exams prior to March for this very reason.

We routinely check their vision, hearing and urine as well as reviewing general health and development. In my opinion, these annual visits with your primary doctor  are just as important as getting the shots.

California law also requires that by May 31st each year, students in their first year of public school must submit proof of an oral health assessment performed by a licensed dental health professional.

I haven’t come across anyone being denied entrance if they haven’t been to the dentist, but it is good idea to be current with the Dentist regardless of the laws:


Routine testing for tuberculosis is not required for SF public schools. Rather than testing every child with a skin or blood test, the San Francisco Department of Public Health strongly supports a medical provider's risk assessment for TB as the universal screening requirement for school entry.  Only children identified as having one or more risk factors for TB infection will need to be tested. The most common risk factors are

  • Contact with a family member with history of or confirmed case of TB
  • Foreign born family or adopted  from country with a high-prevalence of TB
  • travel to high risk country
  • HIV contact
  • family member who has been in jail during past 5 years
  • frequent exposure to homeless, users of street drugs or residents of nursing homes
  • Clinical evidence of TB: Cough lasting  longer than 3 weeks, coughing up blood, night sweats, fever, weight loss.
If you do get your child tested you have 2 options. The PPD is a test applied to the inner arm that needs to be checked 48 to 72 hours after it is placed. There is also a blood test available calledQuantiferon. It is a little more accurate than the skin test, so if you have a real concern, that is something I would consider.

Some of the private schools insist on TB testing for all of their students, regardless of the recommendation of the SF Public Health Department.  I have gone to the mat with one of the local parochial schools and lost.

Okay, aside from the forms and the shots, first day of school, especially if it is a new place is an emotional time. Some kids are excited while others are stressed.

This is a great time to read some books or tell stories about school. If your child has some separation issues, consider giving them a hankie that smells like you that they can put in a pocket. Maybe get a set of best friends necklaces for you and your child to wear and you can look forward to matching them up at the end of the day.
It is a bonus if you know a nice friend who will be in your child’s class. Play-dates together before school starts can help smooth the transition. If you don’t know anyone, some schools will host a back to school event or offer up a roster. Don’t be afraid to cold call one of the new families and introduce yourself.

Try to carve out some extra time during the bedtime routine where you can have your kids tell you all about their day. Don't fall into this common trap:

"How was your day?"
"fine"

Ask specific questions such as:
Tell me about the kids in your class.
Tell me about the teachers
Share something interesting that you learned today.

Alana loved going into the minutiae of her day so much that she never stopped (you should be so lucky!) This 27 year old calls her daddy daily as she commutes home, and tells Sandy all about her day.

Every year might be different. Some kids who didn’t even look back to say goodbye one year, might pitch a fit in another. Lauren had no trouble saying goodbye to mom and dad her first several years at school until she was in third grade and Alana was in Kindergarten. The Kindergartners day ended earlier than the rest of the school and somehow Lauren found that intolerable. If she caught glimpse of me picking up Alana, she got weepy. I remember having to sneak through the school grounds making sure that there was no way Lauren would see me until it was time for her to go home as well.

It has been several weeks since I have sent out a post that mentioned poop. so I will add one more tip. Please make sure that your kids don't get constipated.  This is pretty common during the back to school season. There are several reasons for this. Some kids tend not to drink as much. Others are simply having too much fun or don't want to get up to leave a classroom. Most kids (and some adults) simply have a strong preference for pooping at home  Some mornings are rushed and there isn't time for a relaxed pooping routine. Keep your antenna up. There are lots of kids that just won't poop at school. Don't let them get backed up.

Prepare for the onslaught of germ season. Good hand-washing habits can help.