Friday, June 15, 2018

The Partner's job

Father's Day seems to be the appropriate time for this post that I have been working on.

While it is true that there is a certain intimacy between the birth mother and the baby that feels a little exclusive, don’t forget that you are an essential member of the team.

When I first found out I was pregnant, Sandy started reading all the resource books. He found a recipe for a protein shake that I was supposed to drink nightly. I remember it as pretty vile. I took one sip and then handed it to him, “Here, the baby will have a healthy father.” He did convince me to drink it nightly, but he also made a double portion and swigged his own portion down in support.

As the one who gave birth, I can only imagine what it feels like to be the partner. On one hand, the magical experience of growing a baby, feeling it move, feeling that bond is something that is unique to the person who carries the child. On the other side of the coin, that same little (or not so little) fetus, is bouncing on the bladder, causing heartburn and last but certainly not least...needs to come out!

Good partners go along to the birthing classes and learn to pant and blow along with the birth mom, but being an ideal support goes well beyond being a good labor coach.

Physical support
It is essential that you help your partner physically replenish.
For those first couple of days, make sure the birth mom needs to do nothing other than nurse the baby and rest. Someone else besides mom (are you lucky enough to have a grandparent around?) can do the changing and the burping.
Your job is to keep mom well hydrated. Every time the baby nurses, make sure that mom has something to drink. Plenty of fluid is lost during the birthing process and every time a woman nurses, she is losing even more. Good hydration is also really important for establishing a good milk supply.

If you are lucky enough to have a support system, consider having a friend organize some meals for your family for the first week or so.

Having a supportive community is so helpful but you may need to be the gatekeeper. Everyone has different social needs and mom probably needs rest more than she needs company. As you moderate your visitors, you also need to make sure they are healthy. If someone has a cold, they are not doing you a favor if they come over. If you are feeling shy, tell them that nurse Judy gave you your marching orders. Nurse Charity puts it very clearly:

Anyone in your home should be able to:

1. buy/prepare food and clean up the kitchen.
2. Watch you breastfeed
3. and scrub your toilet.

Anyone you would not feel comfortable asking to do those things, or who would be incapable of those things is not good postpartum company and should leave their casserole at the door with a friendly wave! This includes family. So if your mom is a busy body with no boundaries, she should wait a bit to come and "help" with the baby.

Emotional support
Prepare for hormones. At one of my baby boot camp sessions last year, one of the postpartum moms simply couldn’t stop weeping. Her baby was lovely and she was having a reasonably easy time, she just cried….all the time. Before long, every pregnant mom in the class was also crying, just because. Sometimes crying happens. Everyone got their own box of tissues and the class went on to talk about sleep, poop, spitting up and all those things that I cover. Crying is very normal, up to a point. Postpartum depression (PPD) is very real. It has nothing to do with prior mental health issues, or level of education. It can happen to anyone.

I think it is essential to talk ahead of time about PPD. If your partner sees any warning signs, agree that you will trust them enough to reach out for help.

More wisdom from Nurse Charity about postpartum depression

The post-partum time is a marathon of newly acquired skills. No one feels certain. Everyone is struggling to get it all done. So this is a time to think about needs vs wants. (I want the kitchen table to be clear of baby clutter, I need a shower). Prioritize needs over wants.The primary caregiver cannot do everything, by the same token - neither can you. Priorities are feed everyone, sleep round the clock (this means you too!), get a shower in, and then pick ONE thing you need to feel human. That one thing is different for everyone, but it should be doable in 20-40 minutes: examples are- read the paper, take a walk, call a friend, an extra grooming task, a project you love.

Don't compare your babymoon to anyone else's. Each family has their own strengths and skills and their own set of challenges. Be like an astronaut and work the problems you have with the skills and resources you have.

Post-partum depression for partners is a REAL thing. (1 out of 4 non pregnant partners experience depression during the pregnancy or within the year after birth). 

Click for a list of possible Postpartum Depression Symptoms:

Here are some resources just in case

This is a free counseling service available through the University of San Francisco.
1-844-415-BABY (2229).
It is NOT a crisis line.

415-441-KIDS (5437)
This is a 24/7 crisis and counseling line for parents who are under any kind of stress. This includes Postpartum Depression. They have resources available for emergency respite care, parent groups etc

(415) 781-0500
Crisis Line for SF bay Area. This is commonly referred to as the suicide prevention line but it is useful for any emotional crisis. You do NOT have to be suicidal to call.

Breastfeeding support
Talking to a breastfeeding mother about her milk supply is akin to walking across a minefield.

Breastfeeding is a learning process.Rest and fluids for mom are a good start, but you are an essential part of the team that will be assessing success. The first several days are really tough. Most mom’s think that for some reason this process is supposed to be the most natural thing in the world, they put the baby up to their breast, the milk will flow and the baby will feed. Think again. It takes a good bit of learning for 90% for the mom/babies.

Aside from plumping pillows, offering a drink (not whiskey although you will be tempted) and helping with positioning, it is hard to watch the frustration of a new mom and a crying baby who are both trying to figure it all out. Having a lactation consultant set up in advance is useful. There is a lot of learning that can be done before the baby arrives that can mitigate some of the common issues. Email nurse Lainey if you are interested in prenatal support. She will schedule classes on demand.

For families that choose to breastfeed, we want to do everything we can to support the success of nursing, but it is essential to recognize when it is not working. Breastfeeding moms have so much emotional “stuff” that creeps into the equation that sometimes it is hard to hear and accept the first and most important rule of breastfeeding: It is simple. “FEED THE BABY.” If there isn’t enough breast milk or the baby can’t seem to transfer the milk, then we need to offer some form of supplementation or feeding method.

When the milk is in, you can see drops of milk coming from the nipples. You should actually also be able to hear the baby swallowing during feeding. A nice glug glug glug is a great sign. After a feeding it is typical for them to appear sleepy and almost drunk. There will be wet diapers and nice poops. The baby will be gaining weight. A satisfied baby will be calm and have periods of being alert.

If an infant is NOT gaining weight, and this is where it gets tricky, please help support your partner to accept that being a good parent is not about the breast milk. Sometimes a little bit of supplement gets things moving in the right direction. This is often a bridge to successful breastfeeding and should not be looked at as a sign of failure. More times than not, it is a baby learning problem.

You are both in agreement that you want a happy, healthy baby. Babies who are not getting enough to eat are neither of those. A mom who is spending her entire day pumping and nursing is also not getting enough rest. Exhaustion will impact her ability to produce milk, enjoy the baby and stay emotionally balanced.

Partners and daddies. You can't actually birth a baby or have breast milk flow out of your breasts, but aside from that, your role as co-parent can be anything you make it to be.

Your relationship with your partner will change (hopefully strengthen). Each parent will have a distinct relationship with each of your children. Parents often take turns being the favored parent. Don’t take it personally when you don’t get picked….go read a book. Enjoy your moment of freedom. Nurse Lainey reminds you that it likely won’t last long.

There are some great resources out there for you fathers-to-be. Armin Brott, known as Mr Dad has some books just for you. Armin also does classes monthly through newborn connections for expectant dads:

I asked him for his favorite piece of wisdom and this is was essentially his best advice.

Jump right in and start doing things. Change that diaper, soothe the fussy baby. You will become more comfortable the more you do. Mistakes will happen, and you will learn lessons. Don’t be afraid of that.

Finally, feel free to check out these Father's Day posts from Sandy, aka Mr. Nurse Judy, describing his philosophy of parenting, leading to the outstanding relationship he has with our daughters, through all stages of their respective lives:

Friday, June 8, 2018

Picky eating 2018

I get calls from moms and dads all the time who swear that their toddlers simply don't eat. These parents feel lucky if the kids eat a bite or two at a meal. Amazingly enough, these same kids are growing just fine. It is quite common for young kids to be erratic eaters. Many of them have days where they can pack it away and other stretches when they barely eat anything.

If you are lucky, you can avoid the picky eating if you start off on the right track. Some experts say that toddlers identify foods as either "familiar" or unfamiliar. If they haven't tried it before, this is not the age when they are apt to become adventurous eaters. For this reason I strongly encourage you to offer an assortment of foods to your children their first year of life. Make sure you are giving them a variety of colors, shapes and consistencies. Although I really advise about adding any extra salt, other spices are fair game. Let's add as many foods as possible to the list of things that they are comfortable with before they move into that stubborn toddler phase. If you have a child who seems to be having trouble with the mechanics of eating, that likely needs an office evaluation to see if we need to send you on to a feeding therapist.

The "quest for attention" is something that needs its own blog post, but for our purposes here, trust me, kids love attention of any sort. If they find that they can get a big rise out of mom or dad when they don't eat, well you guessed it, they will ignore the food and sit back to watch "the make my parents nuts" show. Avoid that trap if you can.

Make sure you give all that positive attention for behaviors that you want to see more of. "Wow, I like the way you tried something new." "Hey, let's feel your muscles because you just did such a good job eating that nice 'growing food." If there is another child nearby, take full advantage of the opportunity and praise good eating observations; chances are your child won't want to be left out. If they see you making a fuss over someone else it usually doesn't take long before they are modeling the same behavior "Look, I ate my broccoli too, feel MY muscles." You can also encourage safe eating by pointing it out when you see it. " I like it when you take one little bite at a time."

Behaviors that you want to see less of should be ignored within reason.
"Oh, you are tossing your food on the floor, that means you aren't hungry. I am going to take the food away now." Make sure you are quiet and matter of fact. Don't make a huge fuss. You can give them another chance in a bit. With many behavior challenges, consistency is key. It might take a dozen times until they realize you mean what you say.

Below are some tried and true tips that may help you along.

Give your kids very small amounts that they can actually finish. You can always add more. Many kids will get overwhelmed by a large portion and won't even have any of it.

Not every meal has to be a performance, but there are things you can do to encourage kids to try new things. Make a face out of the food, 2 peas for the eyes, a piece of chicken for the nose,... etc. Make it a game, and laugh when they eat part of your design. There are plates that you can buy that have pictures or faces that can get uncovered when they eat. You can also consider making your own place mats. Blow up some photos of your family, laminate them and use them accordingly. "Let's see if we can eat the tofu and find mommy's face."

Other creative ways to encourage eating are cookie cutters to make your sandwiches into interesting shapes. Make a meal with a theme. One meal can be things that are orange, another day you can do things that are curly. Make smoothies with all sorts of wonderful ingredients. See if your toddler wants to help drop things into the blender and help turn on the power. Pour the smoothie into a special super hero cup that is used only for the super hero drink. Many kids like to dip things. Little sticks of assorted veggies that they can dip into some hummus or yogurt dip makes a nice healthy snack. Muffin tins make great little food trays, especially for those kids that don't want their different foods to touch, heaven forbid.

Kids like to eat things that they have helped with. Allow them to sprinkle spices (again, try to minimize the use of salt) or stir the food while you are preparing it. When your children are old enough (this is especially useful if you have more than one) let them take turns being on the "make the meal team". No one else is allowed in the kitchen except the chefs. Make an event out of it. They can even decorate a menu.

Sugar and Dessert
I like to refer to food as “growing food” or not. If your child eats a reasonable amount of growing food, it is fine to offer an occasional dessert. Please don’t associate it with a reward or “being good”. It's a delicate balance. I have found that If you completely make sweets unattainable, they become much more interesting

Nothing but Noodles
If you have one of those kids that is set on only one meal, prepare it in advance and allow that with no comment. Perhaps have a rule that they need to try one bite of what the rest of the family are eating. If they end up eating more, that gets a round of positive attention.

If you are concerned that your picky eater is not getting a balanced diet, a multivitamin is a safe option. During cold and flu season, A and C become especially important. Vitamin D is ALWAYS a consideration. If you are not assured that they are getting enough from fortified milk products, they should be getting a supplement

Hopefully by starting off with good habits you can avoid having one of the super picky eaters on your hands, but here is the bottom line.If your child looks well and is tracking on the growth chart, you can trust them.

Your job is simply to offer a nice assortment of healthy food and drink. Their job is to decide how much they want to eat.If your child at the end of the equation is doing well, relax and trust that they are getting what they need.

Keep in mind that toddlers do not grow nearly as rapidly as they do when they are infants, but if you have a concern about poor weight gain or other diet related issues, don't hesitate to check in with your doctor.

Different offices use different growth charts. In our office we use the one from the CDC. Click on the above links if you want to see where your kids are at the charts.

If you are trying to get more calories into your picky eater, check out for a list of nutritious product options

Friday, June 1, 2018

Talking to your child about homelessness

Last month as I was sitting at my desk, (probably talking to someone about their child’s poop if we’re being honest) a frantic passerby rushed into the office. She told us that someone had fallen and was bleeding profusely, and thought that since we were a medical office, perhaps we could help. My medical assistant, the amazing Josie, had the sense to grab some gloves and gauze, and we rushed out to see what was going on.There were several other people already at the scene assisting an elderly woman who was on the ground.

As luck would have it, one of the helpers, who happened to be a mom with a child in this practice, was a doctor. She was holding pressure to the wound with a nice, large towel that another passerby happened to have with him. He was on his way to the gym. (Any Hitchhiker’s Guide to the Galaxy fans out there? Always carry a towel!) Somebody else had already called 911. This supportive group of onlookers were holding her purse, talking to her, and keeping her calm until the ambulance arrived (a disappointing 11 minutes wait).

While I never got follow up, (and I hope the accident victim was okay), I was struck at the time by how quickly a group of people acted like caring human beings and stopped to help. They put their busy lives on hold for the moment and waited until it was clear that they were no longer needed. Sadly, this response is not something to take for granted.
I have been thinking about doing a post on this for quite awhile, but the issue is so big and tricky.

The streets of San Francisco often are filled with people who need help and we all walk past them, myself included. It doesn’t always feel safe to intervene. Mental illness and drug use are real issues. So sometimes it is scary, or overwhelming, or we have nothing to give, or we want to choose carefully how we do give and choose not to offer random handouts. Regardless of the reason, walking past someone who is on the ground simply feels wrong!

Having a child with us often compounds this issue. What do we say when we see people who are so much less fortunate than we are?

I think it is safe to say that anyone living with a child in an urban area is likely to get the question at some point.

“Why is that person lying on the street? Why don’t they have a home? Why? Why? Why???”

Consider putting some thought into your answer now so that you can be prepared with a response that you feel comfortable with. Beware, words are powerful and kids can make connections that are not intended. If a child hears you point to poverty, job loss, or illness as the simple cause, they could worry that if someone they love gets sick, or complains that they are having trouble paying a bill, they might end up on the street too. Kids under five need to be reassured that they are safe, that they have a warm bed and plenty of food.

Keep the discussion age appropriate. You can wait until they ask, rather than initiating the conversation. A simple “they don’t have a place to live” might be enough. They will learn quite a bit simply by seeing your actions and reactions.

Five to eight year-olds are transitioning to seeing themselves as part of a community rather than having the world revolve around ‘me’. They are becoming interested in solving the problems they see. Beyond reassuring them that they are safe, invite them to ask questions and think about options.

Just like every single person is unique, every situation is different and everybody has their own story. Your answers might include talking points such as

Maybe bad luck; no money, no job in combination with no family or friends to help, not enough housing. Societal marginalization also plays a part (sadly, society isn’t set up the same way for all people from all walks of life).

Mental illness:
Maybe the person is not well. Bodies can get sick and so can minds. Often there is medicine that can help make things better, but some people get so confused that they don’t know how to get help.

Drug use:
Medicine can be very good when it is used for the right reasons. Some people use drugs they shouldn’t use and ended up not being able to make good choices.

If the opportunity presents, listen to their stories.

In any case, it is important not to make sweeping generalizations. The goal of this discussion is to cultivate feelings of empathy and action, not shaming.

We want to help, but Safety First

The Neighborhood Emergency Response Team ( NERT)holds classes, free to the public, to train us for how to deal with an emergency such as a large earthquake. They spend several weeks teaching people how to help, but
NERTs first rule is the most important one: Don’t go in to rescue someone if it feels unsafe.

This same rule needs to be taken to heart here. If you are walking and have any concerns that an interaction with a stranger on the street could pose a danger, then walk right by.

If there is someone who looks like they need help call 311 and report it:


Most of you have probably heard this tale, but if not, now it is time for the starfish story (now known as the sea star)

A young girl was walking along a beach upon which thousands of starfish had been washed up during a terrible storm. When she came to each starfish, she would pick it up, and throw it back into the ocean. People watched her with amusement. She had been doing this for some time when a man approached her and said, “Little girl, why are you doing this? Look at this beach! You can’t save all these starfish. You can’t begin to make a difference!” The girl seemed crushed, suddenly deflated. But after a few moments, she bent down, picked up another starfish, and hurled it as far as she could into the ocean. Then she looked up at the man and replied, “Well, I made a difference to that one!”

How can we prepare our children for these inevitable encounters with people who are homeless? We want our kids to have compassion, to be safe, to feel empowered. We can’t help everyone, but even simple kindness can make a difference for one person. Most people appreciate even the gesture of a smile, but here are some more tangible things that you can do with just a bit of planning.

First of all - don’t assume anything, ask a person if they would like the help.

  • Have some extra socks to hand out
  • Give small containers of hand sanitizer
  • Get some starbucks cards or gift cards that can be redeemed for food
  • Donate part of an allowance to a homeless shelter
  • Restaurant portions are so big, perhaps split your meal and box it up before you start eating and give it to someone on your walk back to the car. Somebody with poor teeth might not be able to eat that bagel; don’t be offended if your gesture is rejected.

Birthdays and holidays are a great time to talk about how fortunate we are. Some kids ask their friends to donate to a non-profit instead of getting presents, or do a “toy-purge” – giving outgrown toys and games to charity before receiving new presents.

We can’t cure homelessness, but we can brighten the day of one person at a time with some simple kindness and teach our kids how to have compassion.

We can also learn a lot from our children. Thanks to my daughter Alana (now a social worker…who could have predicted? ) my family has a warm relationship with an older gentleman who spends his days on the sidewalks of West Portal. About ten years ago Alana was still in high school and had left the local movie theater on a dark drizzly night waiting for her dad to pick her up. Mr R decided to wait with her because she shouldn't be out ‘alone’ and they began a friendship that lasts until this day. He calls her bright eyes and tosses his cane in the air and runs into her arms for a big hug every time she visits home.

Check out this heart warming story that has been on the news recently. With all the rough stuff in the media, this was a breath of fresh air:

A little boy in Birmingham Alabama puts on a superhero cape and makes sandwiches for the homeless folks:

Thanks to Kara for telling me about a book, See you.

It has become a family favorite, check it out.

Friday, May 25, 2018

Teething symptoms and remedies/ Dos and Don'ts 2018

Topic of the Week:
Teething management/ Dos and Don'ts

Normal infants have 20 primary (baby) teeth which have started to develop in the womb. The teeth start to erupt through the gums around 6 months of age. The baby teeth are then shed at various times throughout childhood. At the end of this post,you will find a chart with the normal range of ages when most teeth start to come and go.

Occasionally I have a patient that doesn’t seem to like to follow rules, ignores the charts and does things their own way. I know of one baby who was born with teeth! Another started out with the upper canines and looked like a little vampire. As you can imagine, those parents were so happy when the rest of the teeth popped through. There is some heredity involved. If one of the parents was very early or late it is possible for the baby to follow suit. Check with grandma to see if she remembers anything special about your teething pattern!

It is rare for teeth to actually make an appearance before 4 months. Once in awhile parents will notice a smooth round white bud on a baby’s gum. This is a little benign cyst called an Epstein Pearl. It is not a tooth and it usually goes away without causing any bother.

Many parents think of teething as something they are only dealing with for their young infants. Think again. If your 6 year old is going through an extremely grumpy phase, or has a mysterious bout of mild, clear congestion that has been hanging on for a few weeks, take a feel in the back of the mouth and see if those first permanent molars are starting to pop through. By age 21, all 32 of the permanent teeth have usually erupted.

Just like the timing varies, the symptoms may also vary greatly from child to child and even from tooth to tooth. By far and away the most common first teeth are the ones in the bottom middle (and they are so cute once they come through.) Take your clean finger and run it along your baby’s gum. If the tooth is imminent you may feel that the area of the affected gum feels soft and boggy.

Let's talk about the symptoms:

Many healthcare providers and dentists dispute that there is any real relationship between teething and any of the symptoms below, but I have been at this job for a long, long (long) time and I maintain that I see a connection.

Fussiness: Teething is uncomfortable. Most parents report that the babies seem fussier than usual right before a tooth pops through. Do what you can to relieve symptoms, but if your baby is inconsolable ( screaming with NO break) for more than 30 minutes and there is nothing you can do to calm them down then please call to have them checked. That would be an extreme reaction and we want to see if there is something else going on.

Drooling: Drooling starts weeks and weeks before you actually see a tooth pop through. Many kids will get a drool rash on their chins and cheeks. There are several products that I find quite useful for this. Clean off the area with Cetaphil cleanser . (No water needed, apply with a cotton ball and wipe off.) Follow it up with aquaphor or cerave ointment (which you can use multiple times throughout the day.)

Gnawing/biting: Biting on things will feel great to the baby; not so good to your nipples if you are nursing. If your baby starts biting you during feedings I recommend a loud “ouch!!” and immediately remove them from the breast. Most babies can be trained to stop this. Remember that you want to make the association mildly unpleasant so that they will stop the habit quickly. Biting = loud yell and loss of breast! If you are too gentle some babies will think it is quite amusing and will continue to bite at will.

Poor Sleeping: If your little one is miserable, this is not the time for sleep training. I would go in quietly and try one of the teething remedies listed below. If you are going through a rough patch remember that parents should take shifts. Give yourselves each a few hours where you are off duty. There is no reason for both of you to be up all night. If you have the option, it is often best for the NON breastfeeding parent to go in, unless it is time for a feeding. This is a slippery slope; I would try not to feed for comfort throughout the night.

Bleeding/ bruised gums: It is not unusual to have a little bit of bleeding on the gums. Once in awhile you may also see a purple/ bluish bruise on the gums right before a tooth breaks through. This will usually resolve without any intervention although something cold will feel good on there.

Low grade temp : Not everyone agrees that teething can cause fevers, but I see it all the time. If a fever goes higher than 100.5 I am not likely to blame it on teething. Any fever that is lasting more than three days is worth a call to the doctor's office to check in.

Loose stools: You will likely get differing opinions on whether or not teething can be the cause of loose stools and again; I will state here that I see it all the time. Some folks speculate that swallowing all that saliva and drool might be the reason. Regardless, I do think there is a link. If you have a baby with loose stools you want to go with the bland, starchy diet and make sure they are on probiotics. Breast milk is safe, but other milk-based products may aggravate the situation.

Rashes: If your child has sensitive skin and/or eczema sometimes, you might notice that the general rashiness flares up during active teething.

Congestion: This clear runny nose and congestion can last for weeks and weeks. Sometimes it causes a post nasal drip that in turn causes a little hacking cough. 

Ear tugging: When kids are working on some of the upper teeth they do tend to poke and play with their ears.

Uh oh, many of these symptoms are the same thing we look out for if we suspect an ear infection. Even though teething may well be the cause, if I have a patient who is very fussy, feverish, and is having trouble sleeping, I am likely going to want to have someone take a peek in those ears.

It is worth having an arsenal of tools at the ready for dealing with the months of teething that you have ahead of you.

Cool teething rings: make sure they are made out of a safe material. Do not tie any teething rings around your baby's neck. Strangulation has occurred.

Frozen washcloth: Wet half of a washcloth and put it in the freezer. The baby will be able to hold the dry half and chomp happily on the frozen side.

Distraction: There is nothing as nice as a body massage and a warm bath by a calm singing parent.

Homeopathic drops: The ones I am familiar with are Camilia by the Boiron company. Click the Boiron link for a coupon.

Boiron was NOT impacted by the recall and their product is perfectly fine to use!

Brandy/ alcohol:
Ask great grandma what she used to do for teething and she may tell you that she used to put whiskey or brandy on the baby’s gums. Obviously giving our babies alcohol is not something that most doctors would suggest today, but I actually wouldn’t worry if you caught grandma rubbing some directly on the gums. It probably does help. Some folks also say that rubbing pure vanilla extract on the gums is an effective home remedy. That may be from the alcohol content. (I am referring to a tiny amount applied topically, no swigging booze!)

Feeding bags:  (baby safe feeder, or sassy teething feeder). If your baby has had some solid foods introduced, these feeding bags are great for teething relief. Add a cold hunk of fruit or veggie (pick a food that they have been introduced to already so that you don’t need to worry about any odd reactions) and let them gnaw away happily. With the mesh bag you don’t need to worry about them breaking off a piece that could be a choking hazard. You can find these bags online pretty easily.

I have had multiple parents tell me that these beads seemed to help.

Acetaminophen (Tylenol) and Advil (Ibuprofen) are useful but I prefer not to overuse them. Make sure you are using the proper dose.

Start with the other approaches first. If possible, I would prefer to keep these as remedies for night time use only. Tylenol and Advil are quite safe but if they are used for a long period of time they can be stressful to the liver and kidneys. If you find that you have gone more than 5 nights where you are depending on these meds to keep your child comfortable, give your doctor's office a call to see if you need to make sure that nothing else is going on.

Oragel or any product that contains benzocaine. They are no longer recommended due to safety concerns:

Hylands teething tablets were recalled several years ago. Even if you can find them somewhere they are no longer considered a safe option:

Once your child has teeth it is especially important to keep bottles out of the crib. Milk has sugar and can cause tooth decay if a baby sleeps with a bottle in their mouth. It is never too early to start brushing the teeth. Let's get your baby in good dental habits. It is important to use a soft toothbrush and non abrasive toothpaste. The current recommendation is to use fluoride toothpaste; just a teeny bit the size of a grain of rice.

Once they have a mouthful of teeth it makes sense to start shopping for a pediatric dentist that you can establish a relationship with. This will come in handy if you have any tooth questions or mouth injuries..

Your next task is to figure out what the going rate for the tooth fairy is!! I can’t help you there.

Wishing you easy teething!!

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.