Friday, May 18, 2018

Mosquito and insect bites/prevention

Prevention is the key when it comes to dealing with mosquitoes. The news reports are predicting that this season is looking to be a nasty one for mosquito and ticks

  • Make sure that you have intact screens on all windows. This seems like a no brainer but if you are getting bites, check for holes or cracks where the insects might be getting in.

  • Get rid of any standing water that is around your house; do a double check to make sure there are no pots, bird baths...etc. that are places where mosquitoes can breed. The larvae are dependent on water for breeding. Unfortunately just dumping out the water might not be good enough because it won’t dislodge the larvae that might be attached to the side. You really need to give a good scrub. Nurse Lainey taught me about Mosquito bits and mosquito dunks. You can add these to any water features to keep the mosquitoes from breeding.

  • There tends to be increased mosquito activity during dusk and dawn so that is when most of the biting happens. (For the travelers out there, pay heed: the mosquitoes that carry Zika don’t have a time preference.)

  • Try to wear (keep your child covered with) long pants/ long sleeves etc. Light colored clothing is recommended.

  • If you are going into a heavy mosquito area use bug spray on exposed skin and clothing. Mosquito repellent works only on the surface to which it is applied directly. They will actually bite skin only four centimeters away from where the repellent is applied, so the wristbands or just spraying clothing does not offer full protection.

  • As for the traditional electric bug zappers, some bug experts would rather that you don't use them. The violet light may be irresistible to some flying insects, (and that zap is such a satisfying noise), but mosquitoes are actually not attracted to the light. Some of the innocent and beneficial insects are the ones getting fried.

  • If you are seeing mosquitoes around your house, San Francisco's Environmental Health Department will send an inspector to investigate (415-252-3805.) They will check the area around your home (including sewers) to see if they can find any breeding areas.

Alas, longs sleeves alone aren’t going to do the trick if you are out in a buggy area.

There are plenty of natural products on the market that claim to be repellents, ranging from Vitamin B to catnip. Most of these are generally safe, but unfortunately the scientific studies show that they are mostly ineffective. We have the luxury in the Bay Area of not having some of the more notorious mosquitoes, so the bites are mostly an aggravation rather than a health risk. If you are local to the Bay Area, it is not a big deal to give something a try to see how it works on your family. However, If you are traveling to an area where there are more dangerous mosquitoes, I would stick with the strong stuff. No kidding around.

The EPA has five registered insect repellents.

DEET is likely the most well known option. It is the only product labeled safe for infants as young as 2 months old. It comes is different concentrations. The concentration of DEET in a product indicates how long the product will be effective. A higher concentration does not mean that the product will work better; It means that it will be effective for a longer period of time. Therefore, products containing lower concentrations of DEET may need to be reapplied, depending on the length of time a person is outdoors.

Oil of Lemon Eucalyptus is considered one of the least toxic options but interestingly, the age recommendation for it is for 3 years and older.(Natural lemon eucalyptus oil is not the same as Oil of Lemon Eucalyptus) Some people are sensitive to the smell of this, it is worth sniffing it before you buy it.

Picaridin  is odorless and is approved for children 6 months (recently lowered from 2 years) and older.

Avon Skin so Soft Bug Guard PLUS IR3535 Insect Repellent has been around for years but seems to be more commercially available than it used to be (also for over 6 months of age.) It comes in a highly rated product that combines Avon Skin So Soft and an SPF 30 sunscreen

Bite Blocker is a botanical formula that claims to provide protection for up to 8 hours. The reviews mention a strong odor, but otherwise it gets high rating.

Before applying anything topical to the skin for the first time, do a little test patch on the skin to make sure there is no sensitivity before you widely spritz or wipe on any of these products. You will need to read the labels to see how often you need to reapply. Avoid contact with eyes and keep all of these safely away from kids.

I would also be cautious about getting any insect repellents on the hands especially if your child is young enough that those hands are going into the mouth a lot.

If you are also using sunscreen, apply sunscreen first and insect repellent second.

All of the EPA recommendations are considered safe, and they are clearly better than getting bitten, but at the same time, let’s use them wisely. The EPA has created the following tool to help you find the proper product for you needs

Some products are more effective than others for certain types of mosquitoes, so the product you choose might depend on where you are going and what you might be most at risk for.

It is always good to check in at prior to any travel.

Mosquitoes don’t like fans! The nasty insects are lightweight enough that a good breeze may make it hard for them to zoom in on their target. The Off! Clip on  gets some folks who swear by it. If you are looking for an alternative to the DEET, it might be worth giving it a try (perhaps it is the fan aspect that makes it work…)

If you are interested, Here is some current info on some of the mosquito borne illnesses that have been in the headlines the most in the past year or so.

West Nile Virus is the one most likely to be circulating here in the Bay area

If you see any dead birds, give them a wide berth and report them to 1-877-968-2473 (WNV -BIRD) or online at That website also will give you the up to date numbers on how many West Nile virus cases there are in California, county by county. It is updated weekly.


If the prevention has failed,treat the itching. Scratching at a bite will make it worse. There is a fairly new product called a mosquito zapper that I just learned about from Nurse Heidi. Some patients are startled from the noise, but others claim that it is great for minimizing the reaction.

Over the counter hydrocortisone cream probably works the best, but other topical treatments can include calamine lotion, or mixing up a paste of baking soda with a bit of water. A cold black tea bag compress can also be very soothing. Black tea contains tannins, which seem to help.

Some kids can have enormous reactions. Eyes and ears can be remarkably swollen. Topical treatment won’t be enough for these. Give a dose of Zyrtec or Benedryl right away. Scroll to the bottom for dosing info

If the antihistamine doesn’t make a difference or if there is fever or severe discomfort, those kids need to be seen.

If your little one is getting bitten, check the bedroom carefully. Look at the mattress and all the corners of the room; bites could be from spiders, fleas or other culprits.

Here are some bonus facts about mosquitoes:

  • Both males and females make that awful whining noise, but only the females bite humans.
  • Mosquitoes are especially attracted to people who drink beer.
  • Mosquitoes love the smell of sweaty feet.
  • Mosquitoes can sense CO2 from up to 75 feet away.
  • Mosquitoes only fly as fast as 1-1½ miles per hour.
  • Some blood types may be tastier than others. O seems to be the favorite, A the least. B lands somewhere in the middle.
  • Mosquitoes love pregnant women (regardless of their blood type) possibly because they emit a little extra CO2.

Zyrtec Dosage Chart
The dose of cetirizine depends on age:

  • 6 - 12 months of age: 2.5 mg given once daily (maximum dose 5 mg daily)

  • 12 - 24 months of age: 2.5 given once or twice daily (maximum dose 5 mg daily)

  • 2 - 6 years of age: 2.5 - 5 mg given once daily (maximum dose 5 mg daily)

  • Over 6 years of age: 5 - 10 mg given once daily (maximum dose 10 mg daily)

Zyrtec comes in a 1mg/ml solution (so 2.5 mg = 2.5 ml). There is also a 10mg/ml oral drops preparation (so 5 mg is 1/2 ml). Make sure you check the strength of the solution.

Benedryl dosage will be the same volume as your tylenol dose. The liquid says for children 4 and over; we still use it for our younger patients who need it. Benedryl makes most kids sleepy but can have the opposite effect.

Friday, May 11, 2018

Lessons from my mom

My mom was a teacher. She was that favorite teacher that people never forget. After she died, ex students reached out to say how my mother was the one who steadied them, gave them a sense of what they could do and sent them off, better able to cope with the path ahead. Teaching was not only her career, but one of the main aspects of who she was.

I would like to honor her memory this Mother’s Day week to pass along some of the life lessons that she taught her children, grandchildren, friends, and students.

Reach past the grumpy countenance to find the person behind it.
My mom had a private little game. How long would it take to get on, as she called it “kissing terms” with people she met. She was pretty hard to resist and even the most sullen security guard at the bank would break out into a sunny smile when they saw her.

Take the time to reach out to people.
Mom was a letter writer. She stayed in steady contact with older relatives and friends who were otherwise alone. If someone was ill, they would get a card or a call.

Take a moment to give positive feedback.
My mom had cancer the last years of her life. I remember going with her to her chemo appointment once when I was visiting home in Pittsburgh. She was hugged by everyone we encountered. She knew everyone by name. She brought seeds from her garden.

We were called back to get her blood drawn. The phlebotomist reached into her drawer to show me a letter that my mom had written to the facility, telling them what a good job this woman did. She still had the letter, many years later. The valet parker pulled out a similar letter when we went down to get the car.

Wonder about things
Mom was known far and wide for her story telling ability. She could have a roomful of energetic kids quiet and hanging onto her words within a moment. If she saw something odd, like a pair of shoes left at the playground, it would be fodder for a story. How did those shoes get there? Who left in such a hurry and why?

You don’t have to follow a script
Her stories would take random and unexpected turns. No story was ever the same. There was always an underlying theme of kindness.

You CAN teach an old dog new tricks.
My younger sister is a National Park Ranger. My parents took full advantage and turned all vacations into opportunities to visit the parks where Amy was working. Mom was exceedingly proud that for her 60th birthday she got her first pair of hiking boots.

Stay active
When she could no longer go for walks, she did chair yoga or got on her stationary bike.

Find a way to relax
She was a reader and read an assortment of genres, but she unashamedly plowed through the harlequin romances. You know the ones with the shirtless, muscled, long haired Fabio types on the cover? Yep. Those. She always had one in her purse. I bought her a couple from her favorite author and Amazon has never let me forget it. (if you ordered this, you also might like…..)

Having a sense of humor is imperative

Be self aware and recognize your own needs
Mom was very social, but in her mid adult years she realized that she needed to carve out some alone time. She became a morning person. She used to say that the dawn belonged to those who chose it. She relished her quiet time while the rest of us were still asleep.

Get involved
Mom was the block watch captain. It is also no surprise that she was the girl scout and Brownie troop leader. She also became the accompanist, playing piano for all sorts of school shows.

Give your kids the opportunity to learn an instrument
Both of my parents were amateur musicians. I confess that I took it for granted that there was often chamber music going on in my living room. My mom thought that it was a special gift to learn an instrument that could be part of an orchestra. I only learned piano. My older sister Marjie played all sorts of things and sat next to my mom in the cello section for the local Gilbert and Sullivan troupe. (My dad sat right in front of them playing the violin.)

Have a family pet (say yes to the stray that finds you)
Unless there are horrible allergies, let your children grow up with the love of a pet. My childhood house had cats, birds, fish and gerbils. Marjie attracted strays like magnets (still does), and somehow they were allowed to stay.

Don’t be a pushover, if you see an issue, say something or do something about it. Yours might be the voice that ultimately makes the change happen. Potholes? Speed bumps? Mom wasn’t shy about taking her letter writing to her congressman or newspapers,and oh by the way, the congressman and the mayor?... Kissing terms!

It was ingrained in me early that you should never skip an election, regardless of how insignificant the issues might be. Our right to vote is sacrosanct. Some of my earliest memories are accompanying my parents to the voting booth. When she was no longer able to get out of the house, she had an absentee ballot.

Be kind to the earth
Mom was an avid gardener. Her favorite plants were her “silver dollar” money plants. She would pass out the seeds to anyone with a garden. If there are any gardeners out there who want some, let me know. Her seeds live on. I think they can grow just about anywhere.

She also hated waste, She could spot potential treasure or art projects in the most mundane articles. My parents were recycling many years before it came into fashion.

“Don’t be too hard on yourself”
She was never too worried about perfection. Giving a good effort, rather than a successful outcome, was what mattered.
“It is what it is, and you do the best you can” is a motto that I continue to live by.

In that vein, mom herself was of course, not perfect. She could hold a grudge like nobody’s business. I can still hear her saying “When I turn off, I turn off.” No more kissing terms for THEM.
In an interesting twist, this was just as important of a lesson as all of the others. From it, I learned the importance of forgiveness. Releasing all the negative energy is something I find essential.

Here is a lesson from me...Turn the mad into sad, turn the anger into disappointment, bank any wisdom earned from the interaction, communicate as needed (or not), and then move on.

It is my pleasure to forward her ripples of positive energy. The world is in dire need.

I asked my sisters, daughters and nieces to take a peek at this list to see if there was anything glaringly missing.

Alana laughed out loud when she thought about the list she would have to make if she was creating her own “lessons from mom.”

I did have a very specific list of “strong suggestions” for my girls that had a very different flavor than the list above. My list included:

  • No getting on a reality tv show
  • No taking a job that requires the wearing of a humiliating hat
  • Don’t eat french onion soup on a first date
  • Check your blind spot
  • Floss

And a few other easily R (X?) rated suggestions that are not suitable for sharing in this venue!

Friday, May 4, 2018

Diaper Changing tips

Mama Jennifer was dealing with a baby who was doing a lot of fussing during diaper changes. I LOVE that she searched my blog to see if there was a post that dealt with that. This was not, in fact a subject I had even considered covering in the past. I am always happy to to get topic suggestions and the more I gave it some thought, the more there was to write about. Thanks to Jennifer for the topic suggestion and to the contributors who shared their wisdom on the subject.

There is so much new stuff to get used to when you have a new baby. One of the first things to get comfortable with is that you are going to come in intimate contact with an array of bodily fluids (that are not yours) and you will learn not to think twice about it. In my baby boot camp I sometimes tell one of my favorite pee stories.

Prior to moving out to San Francisco, my husband and I spent a few years in New York City. Anyone who has experience with hot sticky summers (the reason I can’t ever leave my city by the bay) knows how miserable that weather can be. Our upstairs neighbors had a fairly new baby. This was August and it was sweltering. The little baby boy was in his infant seat, completely naked, getting a little air. The exhausted couple needed to go shopping, but that evening they were making the very last bit of food that they had on hand (Grub Hub was but a future dream.) The pasta was being strained when the baby peed an arcing stream of urine that went several feet across the room and landed directly into the colander of spaghetti. The parents looked at each out in shock and awe, and then said at the same time, “rinse and eat?” which they proceeded to do. The next morning when they told us what happened, we laughed, gave a big yuck, and told them they were nuts; they should have called us, we would have gone out and gotten them food.
Here is the thing. We didn’t have kids yet. Every one of their friends who were parents, went over to the “rinse and eat” team immediately. Most of you will get there.

Of course, the goal of diaper changing is to keep the pee and poop safely contained and disposed of without getting it all over the place.

It has been thirty years, but I still recall the Poopageddon event of Sandy’s first attempt at changing Lauren. In a rookie move, he opened the diaper and didn’t take the step of carefully folding the front over to cover and contain the poop before starting the cleanup. With the soiled diaper open, Lauren managed to get her kicking feet right in there. Her feet, now smeared like a nasty paintbrush, managed to get poop on the walls and just about everywhere else. That was the night of her very first bath in the big tub. Sandy ultimately became much better at the mechanics of diaper changing and swaddling than I ever was.

When babies are young, most parents manage to get pretty adept at changing the diapers without too much ado because even though they may fuss, the babies don’t have the motor skills to do anything but put up with it. If your baby really seems to hate it, see if you can make some adjustments.

Make sure the room is warm and that the wipes are not freezing cold. There are wipe warmers available on Amazon that are not terribly expensive. Please make sure that the wipes are free of unnecessary ingredients such as scents or alcohol that might cause stinging. Make sure you have everything within reach and ready to use before you start the process (don’t forget the box of tissues for blotting the area dry after using the wipes.) Nurse Heather's tip is to put the clean diaper down first. When all the wiping up is done, you just slide the old one out. Have a washcloth or something right at the ready to protect yourself from getting peed on. Babies love to pee within a moment or two of when the diaper comes off.

See if you can put the changing area on a bit of a slant, This might help for those babies who just hate to be completely flat.

Dr Schwanke reminded me that there are some changing pads that have an indentation that makes it harder to wriggle around but make the babies feel secure and comfortable.

Preventing diaper rash is so important:

Once diaper changes become uncomfortable it is tough to remove the “negative association” associated with the diaper change.

My friend Sari, a Cranial Sacral therapist in Arizona, says that parents should consider slowing down the pace dramatically. Our instinct is to hurry up and get it over with, but many babies actually react better to a slow and quiet pace. While you are at it, she loves the upside-down U movement. Gently stroke from the top of the right hip, up to the ribs, across the ribs and down to the left hip. Lift up and start again at the right hip and repeat. This stimulates the direction of the colon and is often relaxing to babies. Have some interesting things nearby for them to look at. Mobiles, and other toys or rattles are good options. Make sure that anything in the changing area is completely washable.

And then the babies start to roll... Of course try everything you can to distract them, sing a song and let them hold a toy. How you handle this will have an impact on future diaper changes. You need to be the alpha here. It is okay to be firm and get down to business; the wet or dirty diaper needs to be changed. Your baby won’t be psychologically scarred if they aren’t getting their way. Sometimes if you are firm and matter of fact, they will stop struggling when they realize that fighting and squirming doesn’t get them very far.

Then they start to crawl and pulling themselves up on things. I have vivid memories of chasing little naked butts across the room and learning how to do a diaper with them in a standing position, but is there a better way? Once they are crawling they can start playing games. Perhaps play a game where everyone does a silly dance and when you say “stay still” everyone freezes. Count to a number (your choice, high or low, slowly or quickly) and people can move again. If they learn the ‘stay still game’... just maybe you can play it when you are changing diapers. Counting to ten, if you do it slowly enough, should be enough time to do a quick change. Not that I am equating your little one to a dog, but the stay still command is one that might have other future uses.

Nurse Lainey makes an excellent point. Teaching your child to cooperate during a diaper change becomes even more important when you are away from home. Having a child lay still rather than touching nasty surfaces on a rickety changing table in a public bathroom drastically reduces the risk of injury and cooties.

NEVER EVER leave the baby on the changing table to step away even for a moment, even if they are strapped in.

Make sure you wash your hands AND the baby's hands after each change.

Since one of the goals of these posts is to address questions that we get frequent calls about, it is worth mentioning the following:
When the diaper is off, it is completely natural for babies to explore the areas of their body that they don’t usually have access to. Make sure that nails are trimmed so that they don’t scratch themselves. If there are any signs of rash or infection, there may be some irritation that is worth the doctor seeing. If their hands are getting in the way of the changing, give them something interesting to hold on to (although, nothing is really quite as interesting as genitalia, but do the best you can.)

There are times in the office when the advice nurse team doesn’t have the time to have long chats with parents about issues such as diaper changes. We often refer non medical questions to the folks over at the Parentline. This is a valuable, and currently free, service. I reached out to the very wise Dhara Meghani for her feedback about this topic and she had some worthwhile things to add.

Developmentally, for babies 9-15 months or so who are getting to be quite mobile, adding a mirror against the wall where the changing table is can help distract them. They may want to touch/poke the “baby in the mirror,” not recognizing that it’s themselves until about 15 months or so, which can be a fun game to further engage them with something else while you’re changing them. You can ask them to point to baby’s nose, eyes, etc. A similar ‘game’ can be done with other pictures or art on the wall. Some parents may also feel less anxious about potential injuries or falls if they have an especially active baby at this stage by moving the changing area lower or to the floor, as long as this is comfortable for the caregiver. You can still store the changing supplies at a higher level or in a childproof container.

Slightly older toddlers thrive on predictability and feel proud when they can help or do something themselves. In this case, letting them know what’s coming up (‘e.g., it’s going to be diaper changing time after we finish coloring’) or walking them through what you are doing during the change can help them get that ‘this is the drill’ and that it’s easier to go and play again when they help by being very still and patient.

I also like to remind parents that it’s essential to “catch your child being good” - toddlers especially love being praised even for things that we expect them to do. So with a diaper change, I’d let your little one know it right away when she did a great job laying down, not wriggling around, staying still, handing you the diaper, etc. (it’s important to be specific in your praise so that they are reinforced to do it again!).

Thanks to all the readers who shared their tips.

Susan says "diaper changes have been among Milo's least favorite things for about a year now, so I'm really looking forward to what you hear from other parents and what you advise as well! That said, I finally struck upon something in the last few months - from when he was about 14 months, or so: enlisting his help. I have him help unfold the diaper, place the fresh diaper where it needs to go, help by remembering/showing me how the fresh diaper goes under his bottom (I like to have the fresh one in place under the dirty one before I open that one up). For Milo, the objections I believe are mostly to do with his strong desire for autonomy and for figuring out how things work and participating in them. I'm actually looking forward to potty training because I think he'll be really into being able to take care of something that's so fundamental and frequently occurring himself."

Rachel S. says "When my guy is squirmy and being changed, we sometimes pick a toy or stuffed animal to hold before going on the changing table, or we start a song to sing, or count in either Spanish or English. Sometimes I talk with him and tell him we do it all the time and it’s quick, and if he’s still (sometimes I use the word cooperative) then it goes faster."

Amanda and Randall - "Best idea we have for diaper squirm - Randall put a collection of books on the shelf next to the changing table so we do a book rotation. I can't believe it works, but it does. She looks at the pictures and each one buys me about 45 seconds which is sufficient if I move quickly. Plan B - we sing ABCs, but far less effective. Dad's book plan is a better one."

Friday, April 27, 2018

Warts and Molluscum

We get calls about warts on a fairly regular basis. Warts are usually caused by a virus. These tricky little skin growths have evolved over time so that they have the ability to invade the body without triggering the immune system.

Dr. Grogan, a terrific local podiatrist tells his patients to imagine that their body is a castle that has guards, but somehow the wart has sneaked through the defense system and is already at the castle walls.

Plan A for getting rid of them is to gently remind the body that there is a wart and we want it gone. Make the body pay attention to this unwelcome guest by causing a bit of irritation to the area. Think of this process as an “Intruder Alert” signal to the body.

Warts have an easier time getting onto skin that is not intact. If your child has eczema or is a nail biter, they are more prone to warts. A person whose immune system has been going through a tough time, one illness after another, may also be a bit more prone to getting warts.

A wart is on the bottom of the foot is referred to as a Plantar wart. Because there is so much pressure from walking on it, those warts tend to be deeper and probably will do better with help from the specialists. Dr Grogan's office uses something call cantharidin (fun fact, this is a substance secreted by blister beetles.) It may take 4 or 5 applications; most kids tolerate the treatments pretty well.

For warts on other parts of the body, Dr. Cheung my ‘go to” dermatologist, prefers the 40% salicylic acid patches (Mediplast.) These are used for any age. Cut the patch to the size of the wart and cover the area with duct tape.
Do the application after a shower or bath. Even if you skip a daily bath,the patch should be changed every 24 hours or so. When you remove the patch, it is quite normal for part of the wart to peel off. You can also use an emery board to gently debride the area in between patch changes.

Go ahead and make an appointment for the dermatologist to take a look at things and evaluate treatment options, but it is fully possible that if you make an appointment a month in advance, the home treatment will take care of it and then you can just cancel the appointment (of course give a 48 hour warning.)
Dr Schwanke is also happy to see a wart here in the office to help with a treatment plan.

If you do end up at the dermatologist, they will base the treatment on the age of the patient. For older kids, Dr. Cheung finds that freezing them off with cryotherapy is the most effective treatment. Most warts require multiple visits, spaced about a month or two apart.

If you are seeing clusters of warts, another possibility is a fairly common wart related skin disease called Molluscum (muh-luhs-kum) contagiosum (kən-tā-jē-ō-səm). Just like common warts, this is caused by a virus and can easily spread from person to person.

People can get molluscum by sharing towels and clothing. Wrestlers and gymnasts may get it from touching infected mats. Skin-to-skin contact also spreads the virus. Often the only sign of molluscum is pink or flesh-colored bumps on the skin. These bumps can appear anywhere on the skin.(usually not on the palms of the hands or the soles of the feet.) Most people get about 10 to 20 bumps on their skin. If a person has a weakened immune system, they may have way more than that.

Bumps on the skin can be the only sign that a person has molluscum contagiosum. These bumps often appear about 7 weeks after being exposed to the virus that causes molluscum. Sometimes, the bumps do not appear for many months. When the bumps appear on the skin, they often:

  • Begin as small, firm, dome-shaped growths.
  • Have a surface that feels smooth, waxy, or pearly.
  • Are flesh-colored or pink.
  • Have a dimple in the center. The dimple may be filled with a thick, white substance that is cheesy or waxy.
  • Are painless, but some bumps itch.
  • Turn red as the person’s immune system fights the virus.
  • Appear on other areas of the body after a person scratches or picks the bumps. Scratching or picking can spread the virus.
This condition usually goes away by itself within a year, but I would probably give the same advice as I do for warts; go ahead and make that non-urgent dermatology appointment. If it isn’t clearing up on it’s own within a month or two, it is worth seeing what treatment options are available to you. Unfortunately folks can get this more than once. Having a prior case does not seem to give immunity.There are lots of internet 'cures' for this including coating the body with silver....., but they are likely a waste of time and money.

Warts are viral - shoes, socks and anyplace where bare feet have been in contact with should get sprayed or wiped down with Lysol. It is best not to share baths with siblings if they have warts or molluscum. Swimming in a pool is fine because of the chemicals.

There are loads of other the counter suggestions out there. Most are harmless but probably ineffective. Keep in mind that the goal is to irritate the wart enough that the body’s immune system is stimulated to come in and help get the job done. I will equate the natural remedies such as tea tree oil to using a watering can to fight a fire. The OTC wart patches are your fire extinguishers. The dermatologists and podiatrists have the fully equipped fire trucks!

Any lesion, wart or otherwise, on the body that isn’t gone within a month or two is worth an evaluation by a specialist. Dr. Cheung cautions that although it is very rare, some warts can turn into skin cancers, so get them checked out. Early intervention can make all the difference.

Friday, April 20, 2018

Temper Tantrums 2018

It is the rare parent who hasn't had to deal with the occasional tantrum. Here are a few tips for managing them.

If you have called me to talk about behavior, it is a good bet that you have already heard this analogy, but here goes: When you are a parent, imagine that you are the coach of a football team. Keep in mind that most of the coaching takes place before and after the games. Your team may win big or they might completely screw up. During the game you are mostly just a spectator. Leading up to the game you strive to prepare your players the best you can. After the game you can be the Monday morning quarterback and identify ways to improve.

I have found it very helpful for parents if they can recognize the difference between "game time" and "coaching opportunities." If we follow my theory, transition times, mealtimes, getting out of the house in the mornings and bedtimes are considered game time. You can't do any effective coaching or teaching during these moments. Hopefully you have created a "game plan" so that generally things go smoothly. When you encounter a situation that sets off a tantrum, do your best to just get through it as calmly and creatively as you can. If you notice that you are stuck in a rut and you can identify routine behavioral issues, you need to work on creating a new plan.

Here's an example of a "game time" situation. Many years ago I was a solo parent on a flight, returning home from grandparent visit/family visit. My sister Marjie had bestowed each of my daughters with a "my little pony" gift to entertain themselves on the flight. Alana the two year old had chosen the pink one, and Lauren the five year old was happy with the blue one. Mid way through the long flight, Alana wanted to make a trade. Lauren wasn't interested and quite within her rights, she soundly refused. Alana was usually a fairly mild mannered child, but I could see the tantrum brewing and she was about to cause a serious disruption. I did a quick negotiation with Lauren: "Hand over the blue pony now, and when we get home they are both yours." Lauren took only a second or two to recognize the value of this and gave Alana the blue pony. Crisis averted. This wasn't the moment to teach about sharing, or fairness. This was game time. Get off that plane intact. If we had been at home I may have handled it quite differently. It is absurd to think that you will handle a tantrum in the middle of a crowded public area the same way you would in your home. Home field advantage???

Watch for clues and do your best to ward off an impending tantrum if the warning signs are clear, but once your child has already entered the meltdown zone, it is time to change tactics. There is a popular parenting book that counsels parents to get down on the child's level and loudly evoke their inner caveman by chanting "You are mad, you are mad, you are mad mad mad!" When that book first came out, I would routinely hear parents out in our waiting room making more of a racket than the fussing kids. I must confess, that when I still hear the occasional parent grunting "you are mad" I roll my eyes a little bit, but the premise is actually a solid one. When your kid is having a tantrum, acknowledging that you are trying to understand what is going on in the first step."You seem mad, sad, frustrated etc" are often exactly what your child needs to hear.

If you told me that you have a headache and I responded by discussing the weather, it would not be very satisfying. Distraction is all well and good, but not until they get it that you are trying to understand what has them so upset. Validating a feeling is not the same thing as giving in to an unreasonable request. Try to hold them close, get them on your lap and wrap your arms around them so that they can't thrash around. Make shushing noises. Keep it simple. This is not the time for lots of words. Those come later.

If your child has frequent tantrums, see if you can figure out what is setting them off. Look for patterns. Many parents realize that kids get more fragile when they are getting hungry. Try having little snacks on hand and pay attention to any cues that might be leading up to a melt down. Are they tired? If tantrums are routine, you need to examine your child's nap/sleep schedule. Make sure that they have adequate Iron and Vitamin D intake; both of those can impact mood and sleep. Are they frustrated by something? In a calm moment, if your child is old enough, help them work on their problem solving skills.

Problem solving activities work very well after a situation has happened. Talk about what went wrong. See if they can help plan a better way to deal with it the next time.

Step one is always identifying the problem. Break it down to a small but manageable issue. Rather than the diffuse "fighting with sister" get down to a very specific issue, such as "sister won't the share yellow crayon."

Step Two is talking about some choices one might have in that situation. Some are good choices, others not so much. They all make it to the list. Adding a silly one is just fine and makes this feel more like a game. Choices could include:

  • Using a different color;
  • Using words and asking sister nicely to share (may need to wait a minute for her to finish coloring her own yellow parts.)
  • Asking a grown up for help;
  • Start screaming;
  • Grabbing the crayon;
  • Draw a frowning face on your hand with a black crayon;
  • Use your "walking away power" and take some deep breaths.

Hopefully with some gentle guidance they can identify the more positive choices on the list.

Problem solving exercises are very empowering for your child. The age range for when kids are able to take part in these is fairly variable, but they will all get there.

For kids over 3, see if they can recognize their own warning signs before losing control. This is a tool that will serve them so well for their entire life. Perhaps create a song together that they can sing when they are approaching tantrum stage. Mr. Rogers has a song about dealing with mad feelings:

Any time that you see your child get calm without losing control give them loads of positive feedback.

Kids can also get a lot out of a well told story. Create two little children that you can tell tales about. They are the same age as yours, with very similar family circumstances. One tends to make good choices and the other also gets into trouble often. Allow your child to chime in and talk about why these other children had a tantrum and what they ended up doing about it. Kids do much better talking about these very relatable characters than they do about their own actions. Once they come up with a plan for the made up child, you can bring it back around; "Maybe you could try that also."

Even the best kids have occasional meltdowns. Do NOT let your kids beat up on you. This might be the time for you to calmly use your own,”walking away power” if you are able to do so safely. This is a good message and a good consequence. Later on you can talk about how you are choosing not to stay in a situation where you might get hurt. Typically, kids are looking for some attention. You leaving the room is rarely the action they were going for.

All tantrums can be turned into learning experiences for you and your child. Stay calm and be consistent.