Friday, January 18, 2019

The Four Month Sleep Regression/Nap tips

The four month sleep regression

Ah, the dreaded 4 month sleep regression. I get calls about it all of the time. Noe Valley Pediatrics Dr. Elizabeth doesn’t like to call it a regression and she makes a good point. Think of it as moving into a new phase. Similarly, Parentline founder and clinical psychologist Dhara Meghani says, we tend to encourage parents to think about the 4 month sleep regression as a time of reorganization, rather than a setback. An (imperfect) analogy is to compare it to when you are cleaning and reorganizing your closet or kitchen cabinets. Often times we have to pull everything out, may have to shuffle things around, discard what no longer fits, and even install some new hardware to make the storage more efficient. The brain does exactly this every few months during infancy, and even years into development -- it goes through what we refer to as phases of "synaptic pruning" in the service of increasing efficiency and speed of important neural connections. So while there is all this work occurring underneath the surface, what may temporarily go by the wayside are the infant's developing skills of falling and staying asleep, feeding fully without being distracted, and being consolable when overtired, cranky, hungry, or bored.

While your baby's brain is going through this enormous growth spurt, they are more aware of everything around them. You might find that they pop off the breast or bottle more frequently to pay attention to their surroundings. There are lots of developmental changes going on. Babies are trying their best to roll over, but usually can only flop over from tummy to back. Daily tummy time exercises are even more important now so that they can work on mastering the roll in both directions.

In the first few months of life there is usually no real set schedule. Babies eat, they snooze, they are awake for a bit, maybe another snack and then some more sleep. Ideally you have made a clear distinction between daytime and nighttime feedings and have encouraged longer stretches at night.

But here you are, your baby seemed to be doing pretty well. You were getting a nice enough stretch at night that you couldn’t tell your other friends with young kids without sounding like you were boasting. Now, just when you thought you were about to see the light after this stretch of new parent sleep deprivation, suddenly horrors, your previously good sleeper is back to waking up at night. This phase will vary from baby to baby. Sometimes it is only a night or two, and for the more unfortunate, it can last a few weeks. The not knowing how long it might last adds a degree of frustration.

Let’s consider some of the more obvious causes of what could be stopping them from going back to sleep when they have those middle of the night wake ups .

Step one is making sure that they have some self soothing skills!
The sleep cycles are becoming a bit more like those of an adult, with the light sleep, deep sleep and REM. When babies hit those light cycles they may wake up. It is essential that they have the ability to get themselves back to sleep without relying on you.

If you put your baby to sleep with help, nursing and rocking rather than letting them drift off to sleep on their own, then when they become aware of their surroundings and you are no longer present, they are going to object. Shooshing and quiet singing with a hand on their chest may be a nice compromise. Your message is, “you are fed, your are changed, I am right here. You need to sleep.”

Right from the beginning (brand new parents, I hope you are paying attention) it is essential that you allow them to do some self soothing. Of course they will fall asleep when they are feeding; that’s fine. But, when you transfer them to their crib and they stir a bit, that’s okay! Don’t return them to the breast; simply give them some little pats, and see if they can settle back down. Every single time that your drowsy baby is able to drift off to sleep on their own it should be considered a win.

My mother in law tried to gently give me that wisdom which I soundly rejected. What did she know? My baby wasn’t going to allow me to simply put her down! I nursed and vigorously rocked Lauren to sleep for at least 4 months at which point we (who am I kidding, it was all on my husband!) had to do a phase of tough sleep training to teach her some sleeping skills.

Once they are finally asleep, tiptoeing around in utter silence to avoid waking the sleeping baby gets pretty old. Some parents find that turning on a white noise machine for the sleeping period helps. A Hepa filter works well for this and serves a purpose at the same time. Soft music playing is another option. If you have Alexa she can play some nice lullabies for a set period of time. If they can learn to sleep with some background noise you won’t have to worry so much about them waking from a sudden sound.

Baby might be hungry. My sleep advice doesn’t get terribly strict until they are getting some extra calories during the day with the addition of some solid food. Until they seem ready for that, I would consider offering a dream feed before you go to sleep. If your superstar was giving you 9-10 hours without a meal before this unwelcome change in their sleep pattern, do not go down the slippery slope of offering extra meals at night aside from that dream feed. If you offer them more frequent nursing, I would imagine they will be happy to accept it. That doesn’t mean they need it. At this age, the body benefits from a break from digesting at night so that it can concentrate on other growing tasks.

Is it dark enough?
Try to make the sleeping room as dark as possible. Making sure that you have blackout shades or thick curtains can extend your mornings and help out at nap time.

Make sure they are not over tired!
This is also when you can start establishing a more regular nap schedule. A 4 month old should be getting a total of 13 -16 hours of sleep in a 24 hour period.This ideally includes 3 naps a day. More often than not, 2 of the naps tend to be shorter and there is one longer one. Some babies absolutely don’t seem to need quite as much sleep as others, but if you have a cranky kid on your hand, I am going to suggest you make sure that their sleep schedule is adequate. You might think that a baby who didn’t nap well will catch up with a great night sleep, but you would be wrong. When a baby is overtired you are trapped in a nasty cycle.

The first nap is usually about 2 hours after their morning wake up. The second nap is about 2 & 1/2 hours after they wake up from nap number 1. The third nap is 2 & 1/2 hours after nap number 2, but it is essential that the 3rd nap is over before 5 pm or it will interfere with bedtime.

If you are lucky you can get into a grove with this for a couple of months. At some point between 6-9 months they usually get rid of the third nap and go down to 2.

Naps don’t need to be written in stone. I don’t think you need to be pinned to the house because of a nap schedule. Second babies don’t have that luxury and nap on the go. If you are lucky enough to have a baby who snoozes in a stroller or carrier, that can count as a nap as you go about your day and get some errands done or go for a walk with a friend.

I would try to have at least one nap that is in the crib. That nap is great practice for letting them drift off on their own. Make it dark, turn on the Hepa filter, sing a song while you do a little massage and then leave them be. Some babies need to fuss a bit as they go down. If they are absolutely screeching when you leave, go back and soothe them. Starting good habits from the start will make everything much easier.

Trust me on this. Sleep begets sleep. If your baby still doesn’t seem to be getting enough sleep, you might need to start your bedtime earlier. I understand that this isn’t always easy to do. Working parents want to have time with their babies for a bit in the evening and it can be a challenge.

Have a bedtime routine that signals that the day is winding down. Make sure it is calm, this is not the time for jumping around. Having a special song and massage routine right before bed is also a nice way to wind down. Hands, ears, feet are especially relaxing.

I am fine if they use a pacifier to fall asleep. DO NOT get into the habit of replacing it every time it falls out. That is akin to a dog with a ball, it never stops.

Room Temperature/sleep suit options
Keep the baby’s room somewhat cool and use a sleep suit when swaddling is no longer an option.

Because this is the age when babies are growing out of the swaddle, many of my families have found the Baby Merlin's Magic Sleepsuit will help you out of this transition. Dhara sent a few other links to share that look like they are worth checking out.

2. Zipadee Zip: zipadee-zip

3. Puck-A-Baby: puckababy

The Puck-A-Baby has a higher price but can follow your child through their early toddler years and through seasons.

Try to be as consistent as you can.
Remember, any time that your baby has an extended period of tough nights, it could also be an ear infection or something else going on. It is worth calling about a fussy baby if you aren’t able to get things under control.

Dhara reminds you:
--Get support. If baby's not sleeping, chances are you aren't either. Can you find a neighbor, family member, or friend to come by and help with the dishes or the laundry? Can they take the baby for 15 minutes so you can get a shower in? If you have a partner to split up the shifts at night that can also reduce the burden on any one person.

Don’t forget that Parentline is one more terrific resource for parents who are trying to figure things out. It is a free service hosted by the University of San Francisco. More info down in the bulletin board section

Thanks so much to Dhara Meghani from the University of San Francisco Parentline for her valuable input and feedback on this post!

Friday, January 11, 2019

Whooping Cough/Pertussis 2019

Whooping Cough/Pertussis
Pertussis has been a steady presence since the early 2000’s, but it has been back in the news recently with a rise in numbers since the fall of 2018. If you watch the news you have heard that there are quite a few cases currently in Marin County.

Commonly known as whooping cough, pertussis is a very contagious respiratory illness caused by a type of bacteria calledBordetella pertussis. These bacteria attach to the cilia (tiny, hair-like extensions) that line part of the upper respiratory system. The bacteria release toxins, which damage the cilia and cause inflammation.

Despite generally high coverage with childhood pertussis vaccines, pertussis is one of the leading causes of vaccine-preventable deaths worldwide. It is estimated that there are 16 million pertussis cases, and about 195,000 pertussis deaths in children per year. By far, most of the deaths occur in young infants who are either unvaccinated or haven't had at least 2 shots in the series.

Historically there is a cycle associated with whooping cough. It seems to peak every 3-5 years. In 2010, here in California there were more than 9,100 reported cases and at least 10 infant deaths. In 2014, 11,209 cases were reported which included two infant deaths and hundreds of hospitalizations. The Public Health department was expecting another peak to happen last summer when in July, California had its first infant death from pertussis since 2016, but no surge of illnesses occurred as anticipated. We may be at the beginning of the next cycle this coming year, as the timing fits.

For the most up to date info from the public health department click this link:

This illness usually starts with a week or two of a runny nose and cough. There may or may not be a low grade fever. Those patients with their little runny nose and not much fever are quite contagious. This is why every effort should be made to keep kids with colds away from young infants. We never know if it is going to turn into something worse. At week two, the cough becomes much more troublesome. The patient will often have coughing fits...and I mean FITS!! This is spasms of coughing for minutes at time that make even the hardiest person feel like they can't catch their breath. Newborns often do not have the intercostal muscles to cough so their symptoms could be cyanosis (lips turning blue) due to lack of oxygen. Patients may or may not have a high pitched "Whooping" sound with the cough (hence the name). Some folks will vomit after these coughing fits. Sweating, gagging and choking episodes are common. Some people cough so hard from this that they can break ribs.

This cough lasts and lasts...and then lasts some more.
In Chinese medicine this is referred as the "Hundred day cough" and they aren't kidding. This is a miserable illness for anyone, but for young infants pertussis can be deadly. Babies routinely get their first vaccination for this around 2 months of age. The primary series is given at 2, 4, 6, months and at 12-18 months, and again before kindergarten entry. Significant protection isn't achieved until the 4th shot at the 12-18 month visit. The four doses gets them up to 75% protected. This goes up to ~90% after the 5th dose (known as the booster.) Thankfully, ever since the state law passed requiring vaccination for school entry, we don’t have many patients trying to avoid getting this immunization.

Because babies are so vulnerable to this illness, current practice recommends giving all pregnant moms
a Tdap (Tetanus/Diphtheria/Pertussis) with every pregnancy. The Tdap vaccine was licensed in the US in 2005. This immunization should be done in the third trimester between 27-36 weeks. Studies have found that since this program began there has been a whopping 75 percent reduction of infant pertussis hospitalization and a 46 percent reduction of any infant pertussis cases.

For folks who will have a newborn in their lives,If it has been more than 2- 3 years since you had the shot OR the actual illness you should get another booster. The immunity wanes. Researchers claim that three out of four babies who get pertussis get it directly from family members or caregivers. It is essential that all the family contacts have current vaccine protection. This means partners, grandparents, caregivers and siblings or anyone who anticipates spending any time with your new baby. This way everyone will be able to remember the date of their most recent tetanus shot; it will be right around your baby's birthday!

People who have been exposed to whooping cough will usually start showing symptoms 7-10 days after the exposure and are contagious by the time they give that first sneeze. If someone is diagnosed, a course of antibiotics will help limit the spread and may minimize the symptoms. It won't make your cough go away, but the illness won't be quite as severe and you won't be contagious.

Testing for Pertussis is far from perfect. We usually send a culture obtained by a swab stuck up the nose. (as pleasant as it sounds.) The results may take more than a week, depending on the lab, so the decision about whether or not to treat often needs to be made based on the clinical history and symptoms rather than a lab result. If you do test positive, the Department of Public Health will be involved to make sure they get all of the contacts treated.

If you have pertussis, symptomatic treatment includes a cool mist humidifier and drinking plenty of fluids. Smaller more frequent meals may help make vomiting less of an issue.
Smoke exposure will make things much worse. Cough medicines don't seem to be of much use alas, although honey might be soothing (no honey for babies less than a year old.)

As I noted earlier the vaccine is not 100% effective, but folks who are vaccinated tend to get a much milder case than those who have no protection. The studies are actually fairly discouraging and see a big drop in protection after the first year or two, but aside from being around an infant, there is currently no plan for requiring a booster dose. There is no current call for routine TDaP boosters if you don't have a newborn in your life, But since everyone should get a Tetanus shot every 10 years, there is no good reason not to make that the Tdap.

A big Thank you to Sheila Zarate from the SF Public Health Department for her input and oversight to make sure I am passing along information that is accurate.

Friday, January 4, 2019

Vaporizers/Humidifiers: What's the difference? Do you need one?

Vaporizer vs humidifier

A lot of folks who live in San Francisco keep their homes fairly cool. My husband actually prefers the cold and our own house is usually pretty chilly. Our out of town guests and my daughters are likely rolling their eyes at that blatant understatement. Having visitors is a fairly regular occurrence and I confess that they tend to keep their coats on as they shiver on our couch while wrapped in a blanket. East Coast folks aren't used to cool houses in the winter time; they keep the furnaces are on steadily for the colder months making making the indoors actually warmer and dryer than I like.

Recently the weather got chilly enough that even the most stubborn of us cranked up the heat. When the heat goes on, I know that I will be getting more calls about nosebleeds, snoring, night coughing and even worsening eczema. If you have sparks and static electricity in your house or apartment, I am talking to you. Getting out the Humidifier/ Vaporizer will make sleeping much more comfortable.

Humidifying the air is also one of the first things I recommend for patients who have colds/cough and congestion. Added moisture will usually ease irritated airways. I find it essential for kids with croup and RSV (both of which are going around). As a bonus, some researchers have found that humidity levels above 40 percent might help deactivate virus particles, making them less infectious

It’s important to match the humidifier to the room size. A small room is roughly considered 26-299 square feet and a medium room is 300-499. Do a quick measure of the rooms that you are shopping for. The ideal indoor humidity should be 30 to 50 percent. If you want to be a real science nerd, invest in a hygrometer. They are available for less that $15 on Amazon and they can help you fine tune the humidity level in your house.

Even without the hygrometer, if the air in your house or apartment feels dry, it is time to invest in a machine.

Using a humidifier that’s too small won’t be as effective, and using one that’s too big can cause indoor allergies. Dust mites are the number one indoor allergen and they thrive on moisture from any source. It is a fine balance. We really don't want to keep the rooms overly damp. In San Francisco you can grow mold very quickly, which is another allergy trigger for many people. My suggestion would be that you don't run the machines 24/7. Make sure you turn them off during the day and dry up any dampness on walls or around windows.

Many of the machines will recommend using distilled water instead of tap. Unfiltered tap water usually contains higher levels of minerals and other particles. The humidifier can push these particles into the air. They will either get inhaled or settle around the room as dust. Neither is ideal. The harder the water, the bigger the issue but using distilled or purified water is always the better option.
Aside from the health issues, the minerals from hard tap water will build up in the machine and cause it to wear down much faster.

Vaporizers and Humidifiers essentially do the same job, but they have a few differences that you should be aware of. The world has changed a bit since I last updated this article in 2013. Now when you look for vaporizer ratings, it is more likely that they are cannabis related. (calm down, it is legal here!)You may have to scroll down a bit in the google search to find the type that I am referring to.

Vaporizers heat the water to make steam. The downside for them is the potential for getting burned (and it does happen, trust me, I get the calls.) On the plus side, Vaporizers have LESS chance for growing bacteria (still change the water please.) On a cold night, I find the warm mist more comforting but if you opt to use a vaporizer it is essential that you have it placed so that kids and pets can’t get close enough to knock it over or even get burned by getting too close to the steam. Make sure you place the machine on a level surface that can’t get knocked over. It should be at least 4 feet away for a crib or bed.

Humidifiers use a cold mist. A humidifier has a greater chance of growing bacteria if not cleaned properly. The technology is always improving and you can get machines that claim to kill the bacteria.
There are a lot of great machines out there with huge price ranges. I have seen some for under $30. If you are just going to bring out the machine for the occasional cold symptoms, you should be fine with an inexpensive machine. In a recent Consumer Reports ratings, one of their favorites, and best buys, is a $30 unit from CVS. You don’t have to spend a lot.

There are tons of sites out there that rate different machines. I do not have a favorite and you should have no trouble finding a list of the most highly recommended units.

A few features that I would pay attention to would be the ease of cleaning and an auto shut off. Some machines also give you the choice of hot or cold mist.

Many of my patients travel with theirs, especially if driving up to the mountains where the air is even dryer, so you might also consider how portable it is when choosing a machine.

Some machines give you the option of pairing with Vicks or other inhalants. When you are doing your shopping, you might want to pay attention to that. You should not add anything to a vaporizer or humidifier unless it specifies that you can. I find that Vicks smell quite soothing, but I wouldn’t use if for babies under 3 months.

Don't be lazy! When you use a humidifier, you need to at least change the water every day no matter what type it is. Not all manufacturers make that recommendation, but Consumer Reports does. They have done quite a bit of testing to lead them to that conclusion. Here’s a good routine to follow:

  • Every day: Empty, rinse, and dry the base tray or reservoir before refilling.
  • Every week: Remove water scaling with vinegar, and disinfect the unit with a bleach solution following the manufacturer's instructions.
  • Before storing: Clean to remove scaling, disinfect with a bleach solution, and dry thoroughly.
  • After storing: Before using again, clean to remove scaling, disinfect with a bleach solution, and dry thoroughly. Don’t fill it before you need to.

Every year we get calls from people taking the old machine out from the bottom of the closet, finding it covered in mold and freaking out. Alas, we don’t have a magic wand to remedy that. It is easily avoided if you follow the directions above.

Friday, December 28, 2018

Keep a journal & document your milestones!

Keep a journal &
document your milestones!
It’s almost the New Year. This is often the time when people find themselves making all sorts of plans for how to generally improve aspects of daily life. I have a suggestion for one resolution that is fairly easy to keep. This will be useful and has the potential to bring plenty of smiles in the years ahead.

Start keeping a journal!

Sure, we all take a lot of photos and movies these days, but there is nothing like the written word. If you haven’t done it from the first, it is never too late to begin. Start keeping track of milestones and illnesses. Having things written down can be a valuable resource. I am not advocating keeping a list of every bowel movement (yes there are parents who do that; you know who you are) but knowing how often your child has had strep throat, an ear infection or any significant illness can be quite handy. Especially if you have more than one child, it is often easy to get things mixed up. I have more that one parent who has said, “I know one of my kids gets a rash on Amoxicillin, I am just not sure which one.”

Keeping record of milestones and illnesses alone makes keeping a journal worth the effort, but immortalizing memories and anecdotes is what makes it fun and even more valuable. We have tracked all kinds of odd statistics. My 28 year old Alana has been on 262 flights. 31 year old Lauren will be completing #379 later this week when she returns from her honeymoon. Two of Lauren’s flights were skydiving expeditions and both of my girls have managed to be at the controls flying a private plane. (This mom knows how to feel somewhat proud and somewhat horrified at the same moment.)
If you give me a moment I can also retrieve all sorts of random facts, like the first movie they ever saw in a movie theater and when they lost their first tooth.

I actually started keeping track of things when I found out that I was pregnant for the first time. Clearly you don’t need to write things daily, but keeping track of milestones and fun things that kids come up with can create a wonderful database of stuff that you are sure to refer to and enjoy as your children grow. My journal unfortunately does have some huge gaps, when I never got to it; just do the best you can.

What started out as my personal musings written in a notebook, morphed into a family journal when I transferred it to a word document. If you like you can create a shared document that both parents can add to. Google drive would be perfect. (Make sure you backup any important documents!) In our journal (both kids share the same one) daddy’s voice was written in italics. My husband had the wonderful habit of documenting conversations. The following was from when Alana was seven and daddy was picking her up from school:

Alana:  I'm doing a picture in reds and pinks.
Sandy:  Why?
Alana:  Because Van Gogh had a red period.
Sandy:  You're learning about Van Gogh?
Alana:  Yeah. And then I'm going to do a painting in different shades of blue.
Sandy:  Why
Alana:  Because Van Gogh also had a blue period.
Sandy:  Well that's terrific.
Alana:  And Miss Price is going to bring a real artist to class so he
can teach us.
Sandy:  Well that will be very exciting.
Alana:   But it won't be Van Gogh because he's dead!

In our case I am delighted that we were able to track early milestones like first words and motor skills. Over the years random facts like teachers names, the revolving door of boyfriends and life events have all been documented.

One of my favorite posts recounts about the time that 5 year old Lauren and I took a family ceramics class at the local Randall museum. At the start of the first class, the instructor had everyone get a feel for the clay. We stretched and pulled in into all sorts of shapes. As we played, the teacher asked ”Who knows where clay comes from?” Lauren was never shy. Without missing a beat, she called out the answer in a loud, authoritative voice. “Cows! Clay comes from cows!” There was a moment of stunned silence as all the grown ups at the table did our very best not to break out in laughter. “Hmmm”, said the teacher, handling it very nicely. “Great guess, but it actually comes from the earth.” Cows?? I remember that being one of the hardest giggles I ever had to stifle. Laughing in the face of my five year old was not something I wanted to do. Kids do come up with some wonderful stuff. Another one that became part of family lore was the time that 3 year old Alana bit her sister:

Mommy: “Alana, why did you bite your sister?! You know you shouldn’t bite!”

Alana: “I forgot not to.” 

That “I forgot not to” line still comes up every once in awhile.

When does it stop?? My kids say never. They especially insist that I keep up with their flight tallies! (We still count every take off.)

You might be dealing with any of the more challenging aspects of parenting like sleep deprivation, the “terrible twos” or teens that are giving you a run for your money. Warning, time zips by. Blink and they are out of the nest. Carpe Diem! The online journal is a great way to capture moments forever. Grandparents might want to start their own version.

A new friend that I met on my recent trip recounted an experience. Her twin grandsons were visiting. Clearly she wasn't in the habit of locking the bathroom door. One of her 5 year old grandsons showed up in her bathroom while she was in the shower. He was wearing a hat and carrying a fishing pole:

Grandma, You need to stay where you are for a bit. There is a triceratops in your bedroom, but don’t worry about it, I’ve got this.

Capture your moments!!

Friday, November 30, 2018

Holiday safety checklist 2018

Holiday safety checklist

Have you thought of everything?
The lights are twinkling and the radios are playing the holiday tunes. People are putting up the holiday decorations. It is time for the holiday safety post.

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

Call me a Debbie Downer if you must, but the mind of an advice nurse is a skewed one. For every aspect of holiday celebrations, I can tell you the story of a patient who called with a related accident. It is not my intent to scare folks with my tales. As I tell parents who attend my safety class, if you know ahead of time what accidents can happen, you have a way better chance of avoiding them.

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

Candles are another hazard. It was a winter evening several years ago in a cabin at Lake Tahoe. Dr. Jessica and family lit some holiday candles and went to sleep. Somehow one of the candles ended up burning a hole through a plastic mat that was on the table. Luckily the smell of burning plastic woke them up before any real damage was done, but it was a frightening lesson. This was a vacation rental. In this instance there seemed to be no working smoke detector. She had no idea if and where there was a fire extinguisher. There are several obvious lessons here. Never go to sleep with candles or a fireplace still burning. Get acquainted with the safety features of any place your family is staying.  
Below are some safety considerations for dealing with the holiday season ahead. Some of these may seem like common sense but there might be a few tidbits in here that I am betting you haven't thought about.

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

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

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

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

Christmas tree checklist:

  • When purchasing a live tree, check for freshness. A fresh tree is less of a fire hazard
  • Cut 1-2 inches from the base of the trunk immediately before placing the tree in the stand and filling with water to ensure absorption. Don’t add chemicals that might be toxic to kids or pets. A dash of plain 7 up can help keep the tree healthy.
  • check the water level daily to avoid the tree drying out
  • When purchasing an artificial tree, look for the label "Fire Resistant"
  • Never use electric lights on a metallic tree. The tree can become charged with electricity from faulty lights and a person touching a branch could be electrocuted.
  • Place your tree at least 3 feet away from all heat sources, including fireplaces, radiators and space heaters
  • Make sure the tree is steady enough that it can't be pulled over by a toddler. You may need to fasten it to something solid. Trust me, trees get knocked or pulled over. Older kids running around can cause this issue, it isn’t just toddlers.
  • Trim your tree with non-combustible or flame resistant materials.
  • Before using lights outdoors, check labels to make sure they have been certified for outdoor use.
  • Make sure all bulbs work and that there are no frayed wires, broken sockets or loose connections.
  • Plug all outdoor electric decorations into circuits with ground-fault circuit interrupters to avoid potential shocks.
  • Strings of lights and garlands are a staple of holiday decorating, but they can also pose a strangulation hazard.
  • Avoid trimming the tree with things that look like candy which may pose a temptation to the kids.
  • Keep sharp, glass or breakable ornaments out of reach of small children.
  • Holly berries and other small decorations can be choking hazards.
  • Don't overload extension cords; make sure that your extension cords are high quality.
  • If you are going to use your fireplace, make sure that you have the chimney checked and cleaned if it has been awhile since you built your last fire. (make sure that it isn’t a spare the air day)
  • Nurse Lainey actually has TWO trees. One has the beautiful hand crafted glass ornaments. That one is OFF limits. Her other tree in the tv room where people hang out is kid and pet safe.

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

Hanukkah doesn’t fall on the same date every year since it is based on a lunar calendar. Many folks laughingly refer to it as coming either “early or late”. It also has more spelling variations than any other holiday. This season it is on the early side and the first candle will be lit on the evening of December 2nd.

  • Make sure that all candles are safely out of harm's way
  • the menorah should be on a glass tray or aluminum foil
  • Make sure candles are not close to wrapping paper
  • Don't go to sleep with candles still burning
  • Don't leave the matches or lighters hanging around
  • If you are frying latkes (fried potato pancakes that are a holiday tradition, yum) make sure that no one gets splattered by oil
  • Never leave the hot oil unattended

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

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

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

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

Stay safe and have a wonderful holiday season.

Friday, November 23, 2018

Assessing the impact of the recent smoke exposure

Assessing the impact of the recent smoke exposure
Everyone living in the Bay Area or anyplace within 100 miles of the recent fires has been exposed to unprecedented poor air these past couple of weeks.

Aside from dealing with the tight lungs, burning eyes, sore throats and stir crazy kids and pets, families are worried about potential lasting impact that this might have on their children’s health.
Chronic exposure to pollution can lead to issues with our hearts, our bones, and our lungs among other things. There are some anxiety provoking studies out there suggest that a fetus is not immune even though they are not directly breathing the air. I tend not to let different studies cause too much of a stir. Studies on things that we have no control over can get people spinning. One headline this week claimed that exposure to this unhealthy air was the equivalent of smoking 10 cigarettes. Gee, thanks for that extra dose of terror. Of course we would have had to have been outside, without a mask for an extended period of time to be affected like that.

Please keep in mind:

Millions of people live in large cities where this terrible air is the norm. Here in Northern California, we only had to deal with it for just a few weeks. I imagine that we all breathed some nasty air, but hopefully most of us were able to limit our outdoor exposure.

Assuming that the air quality index is no longer in the red zone, take a deep breath and prepare to review an important life lesson;
my mom had a saying that she would repeat frequently “It is what it is. You do the best you can.”

There are some things that are within our control and some things that are not. We need to be able to identify which is which

Lets focus on things that are in our control.

  • Being kind
  • Being honest
  • Friends we choose
  • Taking care of ourselves
  • Working hard
  • Apologizing
  • Asking for help
  • How we respond to others
  • What we do in our free time

Things Out of our control

  • Others being kind
  • Others being honest
  • Others forgiving us
  • Who likes us
  • The family we were born into
  • The color of our skin
  • Past mistakes
  • Natural disasters
  • Death
  • Taxes

Are you beating yourself up because you stayed in town? Really? Assuming you had the time, the money, the ability and the fortune telling magic to know how long this bad air was lingering, was hightailing it out of here the right solution?

Are you feeling like a terrible parent because you couldn’t stand being cooped up and you let your kids run around outside for a bit and now you are worried? It’s easy enough to be the Monday morning quarterback. ‘Woulda Coulda Shoulda’ are simply not worth much. My husband was an executive for many years and his employees knew that after bitching about something or another that had happened, they would inevitably hear him say: “you can’t manage the past”

My daughter Alana who is now a therapist here in SF taught me that Dialectical Behavior Therapy (DBT) refers to my mom’s “it is what it is” as radical acceptance. There are an infinite number of things that cause pain, suffering and anxiety, but only 4 different actions that we can take:

  • Problem solve: Is there something within your control that you can do?

  • Find the silver lining or lesson :There is always a lesson but sometimes the silver lining doesn’t become apparent until sometime in the future, if at all. If you look hard enough there is usually at least a sliver.

  • Practice radical acceptance: It is what it is and you do the best you can (Just like mom...repeat this frequently) , or

  • Stay stuck

While we can’t problem solve past exposure to poor air quality away, what we can do is learn any lessons that may come in handy in the future. It is safe to say that this could happen again. We need to make sure that we are prepared.

Order masks in advance so that you have them on hand if the need arises. Have a HEPA air cleaner (change the filter periodically. We just changed ours and it was beyond gross). My sister-in-law and brother-in-law just purchased one of the newer ones that gives you a reading of the air quality in the area of the machine. Before they even plugged in it, the air in their house rated just fine. Being inside does make a huge difference.

Have an evacuation plan for your family. Earthquakes are just as much an issue as fire. Now is the time to check your earthquake kit and update it as needed.

Get familiar with local resources that can help you out in an emergency. For those of you in the Bay Area, this is an important site for guidance in case of all sorts of emergency situation:

If you are looking for some more benign and possibly helpful actions?

  • Lets tend to our bodies.
  • Stay hydrated
  • Decrease mucus producing foods (Dairy products are often the biggest offenders)
  • There are multiple sources that claim different foods can help keep lungs healthy. That list includes pineapple, garlic, ginger, turmeric, dried figs, tomatoes, apples, green tea
  • A steamy shower with essential oil (like eucalyptus)
  • Get or give a massage with warm oil. This will relax and open the airways
  • Do some good deep belly breathing

Be a voice for to help protect our ailing planet from climate changes. This should not be a partisan issue. If there are tangible, sensible things that we can do to minimize pollution everyone should be on the same page. I reached out to my dear friend Brenda Ekwurzel who is a senior climate scientist and the director of climate science at the Union of Concerned Scientists and asked her for advice on a good fund to donate to. She suggested theNature Conservancy

Climate Changes Everything is another good site to check out. This is a friend of a friend who has taken on climate change as his personal mission. Check it out.

Or you might give money to folks impacted. Charity Navigator can help you research effective organizations to make donations to.

In any event, taking some sort of positive action can help us not 'stay stuck.' Don’t be afraid to have conversations with your kids.
Here is the situation. These are the things we can do.

The review of things in and out of our control is an important one. It is the rare child under 5 who will get it, but you are the model. They will learn by example.

Friday, November 16, 2018

Food Safety Guidelines/Just in time for turkey leftovers

Food Safety guidelines/Just in time for Turkey leftovers

Thanksgiving is a holiday associated with lots of yummy leftovers so it's usually my signal to update my food safety post. If you ever watch the news you know that food contamination issues can happen all year round. This post will give you some safe guidelines for foods that you buy and cook. If you do a lot of eating out, restaurants are supposed to have their cleanliness rating publicly displayed. Check the bottom of the article for some great links on food storage guidelines; everything from egg safety and turkey leftovers to breastmilk storage.

It is certainly not a sterile world. As soon as they are able, your baby will start putting anything that they can reach into their mouths. You can't even begin to imagine the phone calls we get about the more disgusting items that some of our little patients have managed to get their hands and mouths on. Just this week we talked to parents of various kids who had possibly had a nibble or taste of the following things:

  • chap-stick
  • essential oils
  • particles from an exploded cold/hot pack
  • kitty litter

So yes, the world is full of germs, and while I don't generally get too concerned about a little dirt here or a big sloppy dog kiss there, foodborne bacteria can be nasty, and we need to minimize any exposure.There were over 300,000 reports of children under the age of five being impacted by tainted food last year alone.

Infants and young children are particularly vulnerable to foodborne illness because their immune systems are not developed enough to fight off infections. This is especially important for infants under 6 months of age. Extra care should be taken when handling and preparing their food and formula. Here are some basic food safety guidelines:

Wash hands for at least 20 seconds before food preparation. Soap is best. Hand sanitizer will do. Re-wash as needed after handling food that might carry germs. The most common offenders are poultry, meat, raw eggs.

Make sure kitchen towels and sponges are changed and cleaned frequently. Sponges can go through the dishwasher. Cloth can get easily contaminated and then spread germs. Watch out for potholders or other cloth items that come into contact with raw food.

Keep your refrigerator temperature at 40 degrees or colder. It is worth investing in an appliance thermometer so that you can keep track. All the science says that the 40 degree number is essential for keeping the bacteria from multiplying.

Your freezer should be below 0 degrees. To ensure the safety of your frozen food, you need to be sure that it has been actually kept constantly frozen. One clever trick to make sure of this is to keep a baggie filled with ice cubes in the freezer. If they remain cubes, you are in good shape; if they melt and refreeze as a block of ice that means that at some point your freezer was not cold enough. This can happen in a power outage or even if the door wasn't kept tightly closed. I am sad to say that if there was stored breastmilk in there that has thawed and refrozen, I would no longer consider it safe. Label things in your freezer and rotate so that you are using up older stuff first.

Check the dates of baby food jars and make sure the lid pops when you open them.

Don't put baby food back in the refrigerator if your child doesn't finish it and you used the "used" spoon to take the food directly from the jar. Your best bet - simply don't feed your baby directly from the jar. Instead, put a small serving of food on a clean dish. Add more as needed with a clean spoon. Remember that once saliva has come into contact with the food it is no longer sterile and some bacteria can grow quickly.

Powdered formula is NOT sterile. Don't mix up more than you need in advance. If the infant is less than 4 months, I would mix it with boiling water and let it cool.

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

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

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

  •  Beef...160
  •  Chicken ( white meat/ dark meat)...170/180
  •  Fish......160
  •  Eggs....not runny

For all of you "older kids" who will be baking this holiday season, watch out for the batter (I am a notorious offender.), Even one lick from raw food containing a contaminated egg can get you ill.

For all of you travelers: RESIST THE TEMPTATION. This is not an ideal time to have your baby try all sorts of new foods. This time of year we get calls from around the country from 'Pecan pie gone wrong' It is best to take your time with new foods in the comfort of your own home.( and emergency room)
"They had a taste of stuffing"
"What was in it?"
" I have no idea, oysters? chestnuts? eggs?"

You get the idea.....

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

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

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

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

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

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

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

Some excellent resources for food safety tips can be found at:  This site keeps track of any food recalls  This is as great site for seeing how long food will last. I used it just this week to figure out if an open can of chickpeas was still good. (After a week, the answer was no)   This site has loads of kid friendly activities

Enjoy your Thanksgiving!