Friday, May 26, 2017

Measles on the rise? 2017

Topic of the Week: Measles 2017

Measles on the rise!
Summer often means travel. I have been getting lots of calls from families who have trips planned. The question is often whether or not their baby needs to get an early MMR. At this point, it depends on where you are going, but the answer may be yes.
From January 1 to April 22, 2017, 61 people from 10 states (California, Florida, Michigan, Minnesota, Nebraska, New Jersey, New York, Pennsylvania, Utah, and Washington) were reported to have measles. Minnesota in particular has an outbreak that the officials are keeping a close eye on.
There are also increasing numbers throughout Europe.
A measles outbreak is a bit like fire. There are embers out there. It is NOT a wildfire yet. Don't panic! A few hundred cases is a few hundred too many, but that does NOT mean there is a child with measles standing on every street corner. The next couple of weeks will be very telling. It is possible that the numbers of infected patients will spread dramatically. It is also possible that the infected individuals have been identified and quarantined and everyone can all breath a little easier.
Here are some facts about measles:
Measles, also known as Rubeola, is a very contagious respiratory virus. Infected people present with high fever, cough, congestion and red eyes. After several days they will also develop a significant rash all over the body. If you have a happy child, who is fever free who has a rash, that isn’t measles. Patients with measles are clearly very ill.
One of the reasons that it spreads so easily is that people are contagious as early as 2-4 days prior to showing any signs of the virus and may remain contagious until the rash is gone, or 4 days after the symptoms are all clear. This virus is so virulent that ninety percent of unvaccinated people will catch this virus once they are exposed.  What is even more alarming is that it can remain on surfaces or even in the air 2 hours after someone has sneezed or coughed! If someone travels on a plane while they are contagious, we can see a faster spread that will be even harder to contain.
Complications are frequent. They range from ear infections to pneumonia, encephalitis and/or seizures. 1-2 out of every 1,000 cases are fatal. This is a serious illness. You really don't want your child to get the measles.The routine measles vaccine is combined with mumps and rubella and is referred to as the MMR. The individual components have not been available separately for many years. The first MMR shot is routinely given to patients between 12-15 months and again between 4-6 years. For the second dose we have the option of combining it with the chickenpox vaccine called Varivax. That combo vaccine is called Proquad or MMRV. The MMR vaccine is thought to be 95% effective. The second dose is given just to catch the occasional person who didn't get effective immunity from one dose and bumps the effectiveness up to 99%. It can be given earlier than 4 years, but we aren't too concerned about the timing of the second dose as long as our patients have gotten the first one.  
Why do we wait so long before giving the first MMR protection to our babies? Assuming that mom has been fully vaccinated (or less likely has had the actual measles) infants are born with passive immunity to the disease. This immunity starts to wane as they get older and is considered mostly gone by the time the babies are between 12 and 15 months. If a child is vaccinated when they still have the maternal protection, the vaccine does not seem to be as effective. In our office we follow the standard recommendation and generally give the MMR at either the 12 or 15 month visit. The MMR is a live vaccine and it is true that in some rare cases the reaction can be a little rough. Interestingly, most kids are just fine the day of the immunization. Typically the reaction comes along between a 7-21 days after the shot. This reaction may include high fever and rash. This is not thought to be contagious. It usually lasts only a day or so. If your child is allergic to eggs, we are extra cautious when giving the vaccine. Some folks with a significant reaction to eggs may opt to get it at the allergist's office. I have NEVER had any patient have an allergic reaction from the MMR or a serious post vaccination reaction other than about 20% who seem to get the fever the following week. 
If you are traveling to a high risk area or there has been a clear exposure, the vaccine can be given as early as 6 months, but that shot won't count towards lasting protection and your child will still need to get a 2 shot series after the first birthday.
Your insurance company also might refuse payment if the shot is given outside of the routine schedule. If that happens, be aware that getting an early, extra dose may be an out of pocket expense
It takes about 10-14 days to get any significant protection from the first MMR. For instance, getting an MMR for a 7 month old to protect them from a travel situation the same week is not going to do much of anything.
Before routine use of the measles vaccine, there were about 500,000 cases of measles in the United States each year and about 500 deaths. Measles also led to about 48,000 people being hospitalized and another 1,000 people being left with chronic disability from measles encephalitis. Study after study has shown that there is no link between the MMR and autism,, but there are still some folks reluctant to give their children the vaccination.
Since July 2016 when  SB277 was signed into law, it is now a requirement for all children attending schools in California to have the measles vaccine unless they have a medical contraindication. 
Several years ago when I was working on my very first measles post, one of my adult friends said to me, "We all got measles and survived, what is the big deal?"  My response was, "It is true enough that the vast majority of folks who get measles will recover intact and have lifelong immunity. However, one to two kids out of 1,000 will die; many more than that will be permanently harmed. That is too many when we are talking about something that can be prevented. That 1 child out of 1,000 matters."

Friday, May 19, 2017

Ticks 2017/Expecting a nasty tick season this year

Topic of the Week:Ticks

Ah, the twisted thinking of an advice nurse. For most folks, spring brings to mind warmer weather, longer days, lovely flowers...etc. Me? I think, "Here comes tick season."  Nurse Lainey recalls finding one on her own ear last season. She considered getting rid of her dogs immediately, but they are too cute, so they get to stay.
Indeed the calls are already coming in and I have spoken to a half dozen patients about tick bites just this week. It makes sense. With the nicer weather more of my patients are out there taking walks, hiking, and enjoying the beautiful area that we live in. The extra rain this season is contributing to one of the largest tick seasons that we have seen in many years. Ticks can be an issue all year long, but the nymphs are born in the spring. These tiny little ticks are the ones most likely to transmit diseases. Of the many varieties of ticks out there, the ones responsible for the majority of  disease transmission are the deer ticks. If you want to impress folks at your next cocktail party, our local deer tick is officially identified as the ixodes pacificus.
Although only a small percentage of tick bites are harmful, the diseases can have a major health impact, so we need to pay attention. There are multiple types of bacteria responsible for tick borne illnesses.  Ticks here in California are known to transmit several different diseases, including Lyme. There are many conflicting reports, but recent studies coming out the past couple of  years suggest that the rates for tick borne diseases are  higher in California than previously thought.
The key is prevention.
Spray the clothing with the bug repellent Permethrin. This is okay for anyone over 2 months of age. Use Deet on exposed skin, avoiding hands, eyes, and mouth.
If you are looking for more natural remedies, try some of these essential oils: 
Lavender - This smells sweet to us but bugs tend to hate it. It can repel mosquitoes, flies and other insects.
PennyRoyal - this is a member of the mint family and it is toxic to insects
Lemongrass - this essential oil comes from tropical lemongrass and has a citrusy scent. It is a natural flea and tick repellent that can be sprayed directly on the skin.
Eucalyptus - use this alone or along with citronella oil to keep bugs away. According to the Journal of Medical Entomology, eucalyptus extract can reduce tick bites.
Lemon - Some lemon essential oil can work against fleas and other bugs. Slightly dilute it and spray it on your clothing and and skin.
Sorry to say that none of the above are going to work as well as the DEET.
If you are going to be walking or hiking in densely wooded areas try to stay in the middle of the path. Avoid wood piles and logs. Light colored long sleeves and long pants are recommended.But let's face it, on a hot day we are not going to have our bodies covered completely, so here is the deal....
Everyone needs to get a naked head-to-toe body check after a walk in the woods. If you are camping, do a full body check daily. Ticks can hide in out of the way places on your body. Don't forget to check the scalp. If you are dealing with thick darker hair, you can rub your fingertips along the scalp and feel for any bumps. Check in between the fingers,toes and behind the ears. Check armpits and belly buttons as well. You really need to be very thorough. Many of the ticks are very tiny and hard to see. Be familiar with little moles and freckles so you can recognize a new spot which might be a little tick.
If you are returning to your home after a hike, use a lint roller to do a quick pass over your clothes. You may be shocked at what you collect from that. Then carefully take off all clothing (try not to shake things out) and put everything in a hot dryer for 60 minutes to kill any wandering ticks. Don’t forget to check the car seat!
If you find a tick, it is very important to remove the tick as quickly as possible. If a tick is removed within 4 hours of the bite, the chances of any disease transmission are SIGNIFICANTLYdecreased. For Lyme disease, the tick generally needs to be attached for more than 24 hours to be a concern. 
If you find a tick, please stay calm. I can still remember vividly, years ago, a mom carrying her toddler into the office screaming (the mom, not the kid) "HELP ME GET THIS THING OUT OF MY BABY!"  Hey, arachnophobia is appropriate in this case, because ticks are indeed arachnids (the spider family), but put on a brave face for your child.
The best way to remove a tick is with tweezers or a special tick removing tool. Grasp the tick as close to the skin as you can and firmly pull up and away. Do not twist. The Public Health department councils that you should not try any of the folk remedies such as Vaseline, burning match, etc., but Dr. Kaplan claims success by applying peppermint oil. This should cause the tick to back out.  If you own a dog or go hiking frequently, do yourself a favor and get one of the tick removing tools. You can get them pretty cheaply from any sporting good or pet store. Amazon has a ton of different brands.
My extra daughter Rachel just used the tick tornado to get a tick off her little one and was really pleased at how easy it was:
Once the tick is out, clean the area with an antiseptic soap, apply a dab of Neosporin and then keep watch on the area to make sure there is no infection.
Okay, We got a tick bite. We removed it, but now what???   
  • watch the site for sign of local infection
  • observe for 30 days. If there is any odd rash, flu like illness, aches, or fever it is important to notify your doctor. We will want to know the date of the bite, and if possible the region where the tick came from. Any recent travels could provide important data.
Unfortunately the blood tests for tick borne diseases such as Lyme are initially not all that helpful. To start off with, you can get both false positive and false negative results (making it pretty useless.)  It turns out that once you have symptoms several weeks after the bite, the tests for Lyme are apt to be more accurate, but that isn't all that useful right after the tick encounter when we are trying to decide whether or not to treat.
Rather than testing the patient, I would focus on the tick. If you do a lot of hiking, keep a little baggy in a pocket of a backpack or diaper bag so that you have a place to stick any ticks that you remove.  
The Sonoma County Health Department will identify the tick for free to see if it is the type you need to be worried about. They will also take it a step further and test it for Lyme disease. They charge a  fee of $31 (such a deal.) They don't test the ticks for other illnesses. They do the testing every Thursday and they will have the results by Friday. They say that about 1-3% of the ticks test positive.
Read the instructions on their website for how to send the tick.
As many of you have heard me say time and time again, ask a question and get multiple opinions and answers. Kerry Padgett at the California Department of Public Health in Richmond, California has been identifying ticks for our patients for many years. The folks over there don’t test the tick. A tick testing positive doesn’t necessarily mean that it was on long enough to transmit a disease. A tick testing negative for Lyme may be infected with the Lyme like illness that we can’t test for yet.
They are happy to tell you if it is a tick that you need to be on alert for. You can send the tick to:
Kerry A. Padgett, Ph.D.
Supervising Public Health Biologist
California Department of Public Health
Division of Communicable Disease Control
Vector Borne Disease Section
850 Marina Bay Parkway
Richmond, CA 94804

The public health department team shared the link below for all sorts of tick related info:
Public health department tick info

Here is the bottom line. Regardless of whether or not you get the tick tested....
Watch the person who has been bitten very carefully for the next 4-5 weeks. If there are any suspicious symptoms within the month following a tick bite you absolutely want to speak to your doctor about doing a course of antibiotics. Reactions that are a cause for concern would be a bulls eye rash around the tick bite site and/or any type of flu symptoms. Some of the less frequent tick borne illnesses might have a more diffuse rash. Not everyone gets all symptoms.
We don't want to treat every tick bite with antibiotics for obvious reasons. As with everything, we need to strive for balance. We can't keep our kids in a box. Go out there and enjoy the hike, but then do that thorough body check and you should be fine. If you are a pet owner and you treat your pet with one of the flea and tick treatments, keep in mind that those ticks may leave the pet and go find someplace else to hang out!

Friday, May 12, 2017

Mother's Day Musings

Maternal -  How would you define that word? For me it evokes, unconditional love, guidance, nurturing.
For those of you in that middle generation, savor these years. You have your mom and your kids. If you are lucky, maybe there are some grandparents in the mix. Being the magic middle of the sandwich might present some challenges, but please TREASURE these years.
For the daughters and sons looking for the perfect gift, give the gift of time.
Go on a special outing, take lots of photos. The memories are more valuable than jewelry. Okay go ahead and throw in some chocolate covered strawberries, but you get the idea.
Actually forget the strawberries; give mom a nap!  Or a candle lit bubble bath (remove the bath toys!)
Make it a Mother’s Day tradition to tell your kids stories about your mothers, grandmothers, and great grandmothers. Did they have some favorite pieces of wisdom? Share them! Did they have some favorite songs? Sing them! 
On the other side of that coin, and not to put a dark cloud on the day for folks who are fully celebrating, but for many people Mother’s Day is one of those made up Hallmark Holidays that can range from being moderately uncomfortable to downright painful.
For me, it has been looming for weeks now like an impending shadow. This will be my first motherless Mother's Day. I am very aware and grateful I still get to revel in the wonderful relationship that I have with my daughters (and many of their friends), but but but but……..
Every time I turn on the TV or the radio, there it is, Mother’s Day, Mother’s Day, Mother’s Day. What are you going to buy your mother this year?  Where will you take your mother?  Show your mother how much you love her. Newspapers, magazines, Muni signs; Richard, my brother-in-law, calls it a capitalist plot.  It got me thinking. There must be so many of us out there. People who never had a mom, people who have lost a mom. Moms who lost a child, women who couldn’t have children, women who made the choice not to have kids but feel a twinge every once in awhile.
There are also so many wonderful families with no mommy but two amazing daddies.  How about immigrant families who are forced to be separated? The list goes on and on. Ouch!
What would my mom do? She would reach out and touch people who needed some love this week.
Let’s go back up to the word maternal at the beginning of this post. In my mind that word has very little to do with gender or biology. Who are the maternal figures in your life?. Reach out and give them a little acknowledgment (or a chocolate covered strawberry!)

Friday, May 5, 2017

Toilet training tidbits/Poop series Chapter three

Poop Chapter 3/ Toilet Training tidbits
Toilet training is one of those hot button topics that seems to have lots of very differing opinions. The most basic thing to pay attention to is how unique each of our children is.
My kids were no exception to this.
My first daughter Lauren was fast at everything she did. She was singing show tunes at 18 months. She was interested in the potty and was mostly trained well before she was 2.
But sure enough, she went through a period of horrible constipation. Watch out for those early kids. I see this happen ALL the time!
Alana took her time with all of the milestones. Having my older kid do everything so quickly made it feel even slower. She was slow to walk, slow to talk and not in the least bit interested in getting rid of the diaper.
Be careful how you ask the questions!
Me: " Hey Lani, don't you want to be a big girl? Do you want to wear these wonderful big girl undies?"
Alana: " Nope. I like being a baby. I like my diapers."
Hmmm, for some reason, that wasn't the response that I was expecting and I didn't have a follow up.
Just when I was figuring that this 'big for her age' almost 3 year old would need to start wearing "depends" all of a sudden she was magically ready. She asked for underwear and barely had an accident after that. As with everything, Alana waited until she was good 'n ready before doing anything and then simply mastered it.
(her first poop in the potty was 5/31/93 How can I possible know this???? Check out the "keep a journal post!" )
All the kids will get there sooner or later. If you wait until they seem ready, they can be trained within a week. If you start too soon, expect several months of aggravation. Watch your child's cues.
For all kids I suggest getting a selection of the children's books and videos about potties training. Let them get familiar with the concept that some day, big kids pee and poop in the potty or toilet.
Dr. Schwanke’s favorite is an old book called Toilet Learning, by Allison Mack. He likes that the sensible title helps parents recognize that it is learning, not training. He points out that this book might be especially good for boys. It is still available on Amazon.
Dr. Anne has had many of her parent’s report back that they have liked the Oh Crap potty training guide (also available on Amazon).
Regardless of which ones you choose, books can be a fun part of the learning process. There are lots of cute ones out there.

There are also all sorts of potty seats. Some have steps and fit over the toilet. Others play music. Talk about all of the options that are out there. Which one would your child like to try?
Let them watch you do your business. Although, most kids start out by sitting down, little boys and dads...go play the "sink the cheerio game" (I don't really need to spell that one out, do I?)
Do everything in your power to keep the stools soft. If you don't pay attention, you can be heading for trouble. Check in with all the different care givers for a daily poop report so that you are all aware if your child skips a few days.
Toddlers are now physiologically able to hold their poop. If they hold it too long, it will be uncomfortable coming out; this will make them want to hold it even more.
Make sure they are getting plenty of fluids and fiber. Perhaps have them help you bake some muffins full of prunes, and molasses and all of those wonderful 'make you poop' ingredients. Kids tend to like to eat what they help bake. See if they will drink a smoothie that they helped make in the blender. It is worth your energy to make sure those stools don't get hard enough to hold. Be creative!
Many kids will easily make the transition to the potty between 2 and 3. Wave a new package of big kid superhero or princess undies around and they may be sold.
Watch out for reward backfires. With Lauren we were offering some little M&M for each poop in the toilet. She proudly squeezed out a pea size piece of poop, pointed to the ‘no longer clean’ potty and received her treat...."but wait Mom and Dad...look there's more!"
Some parents have success offering limited use of the ipad or phone for potty sitting. Sometimes a simple star chart is all you need.
Aside from show and tell and talking about it, I usually leave the more recalcitrant kids alone until they are 3-ish. If they are in a tolerant daycare, exposure to some little friends who have made the transition makes a difference.
Disposable diapers are very absorbent and make it very comfortable for kids to hang out with a dirty one.
When your child seems ready, some folks find that they can fast track the toilet training on a warm week when they can have the kids run around naked. Most kids are not inclined to just pee anywhere when the diaper is off.  If a deadline is forced on you, such as acceptance to a preschool that only accepts kids who are potty trained, drawing a firm line in the sand and just getting rid of the diapers is the fastest way to do this. Make sure that you carve out several days at home where you don't need to be anywhere. Ideally you are not forced into this before you are all ready.
You may opt to allow this to happen in stages. For some reason most kids are way more comfortable tackling the pee issue but are much more reluctant to poop out of the diapers. Go ahead and work on peeing in the potty first. If necessary, let them tell you when they need to poop and then put a diaper or pull-up on for that.
Kids get involved in playing and often don't pay much attention to their body's cues. Get in the habit of taking them to the potty every hour or so. The adults who are watching them need to be consistent.
Make sure that they are wearing outfits that they can pull up and down easily so that when they do remember on their own they are not hampered by difficult buttons.
For your older kids, consider having them go to the store with you when you buy the diapers. Use cash. Singles if you have them. Show them the money that you give to the store every time you buy some diapers.
Look at some toys and discuss that when they are ready, instead of a box of diapers, you can perhaps use some of the money to buy that toy instead, but only when they think they are ready. Obviously this tactic works better when the kids are old enough to understand the concept.
As far as consequences, older kids are also ready to deal with stinky poop. I think they need to help you with a bit of the clean up process. Talk about how nice it would be if the poop went right into the toilet.
I would give some nice positive attention for any attempt at sitting on the potty and giving it a real effort. Set a timer and have them sit on the potty or toilet for five minutes when they are working on a poop. Give them a little place for their feet so that the knees are bent a little.
Consider having a written poop agreement that spells out any rewards that have been discussed. 
Dr Anne adds that language is important.
“What can we do to keep your new undies dry”
Being out and about with a newly potty trained child is an adventure. You will quickly learn which friendly merchants have clean and accessible toilets that you can run in and use.
You will learn to watch out for the tell tale signals. The hand down at the crotch and the jiggling up and down usually mean you have a minute or less to find a bathroom. I used to have an inflatable potty in my trunk that came in handy on many occasions.
Do not shame or yell at a child who isn't quite ready. If your child is over 3 ½ and you don't feel that you are making progress, it might be time to talk to the pediatrician to see if we can help you move forward.
Night time is a whole different issue. I suggest working on the toilet training for during the day and using pull ups at night. Wait until your child is waking up dry or asking to get rid of the night time pull ups before you tackle this.
Below is a drawing that my 4 year old nephew Andy drew during the process.
For those of you who have trouble translating the message, the left side is pee and poop on the floor and the right side is the successful poop in the toilet.

Friday, April 28, 2017

The poop series chapter two/ Along comes solids

Topic of the Week: chapter two of the Poop Series

Baby Poop: Along comes solids
Baby poop is a fairly benign substance. Once you start feeding your little one solids, everything is about to change.
I remember an email that I got one Sunday morning. I should have known better then to open it when I was sitting down to eat breakfast. The subject line was “undigested carrots, is this normal?”
The answer was yes, but there needed to be a much stronger warning for the attached photo.
As your child learns to digest substances other than milk, the consistency of the stool will change. As I tell the parents who come to my solid foods class, "You are the Conductor of the Poop Orchestra."
What I mean by this is that you are in charge of how much milk, how much solid food and how much extra fluid goes into your baby. You should pay attention to the outcome and make adjustments as needed. You don't want watery stools and you certainly don't want formed little pellets.
The goal is for the stools to remain soft. At at the risk of ruining your appetite or changing your dinner plans,( if I haven’t done so already),  think hummus.
Unless you are in a very hot climate, until your baby starts solids, it is unlikely that they need extra water in their diet. Once they start eating food,it is time to get in the habit of offering water throughout the day. If the stool is getting thicker, the first thing to do is add a little extra fluid to the diet. Plain water or very diluted prune juice are good options.
Most foods are fairly neutral but some  will help keep the stools soft.  Many fruits and veggies fall into this category. Prunes, pears and peas are some of my favorites. A little molasses can also get things moving.
On the other hand, some  foods tend to make the poops more solid. Keep in mind that if your older child ever has diarrhea, we will suggest the BRAT diet. This is a diet with bland starchy foods such as bananas, rice, or applesauce (the apples have pectin with tends to be binding) and toast.
Those foods are certainly fine for your beginning eater, but if the stool is getting thick, there are better choices for first foods.
Some organic formulas seem to bind up my patients, so keep an eye on that. 
With the addition of new foods, the poops can be quite fascinating. Different colored foods can give you a rainbow of different poop shades. My daughter Alana once unbeknownst to me ate a pint of blueberries and had a bright blue load in her diaper that caught me by surprise to say the least. Anything with red color can stain it red. Beets are the obvious culprits, but watermelon can least to an interesting shade.
Bananas can cause little brown thread-like substances to be in there; imagine a piece of banana cake. When I get the frantic “there are little brown worms in my babies poop” call, the first question is whether or not they had bananas.
Most babies start the solid food journey with pureed food. As soon as they are able, I like to do a combination of feeding styles and introduce some “Baby led weaning”. With this method, babies can simply pick up soft pieces of food and feed themselves.  Once they start eating little pieces be prepared to see some of those same pieces pass through without being digested. This is normal.
Constipated kids are really miserable. Please be proactive with diet, fluids and fiber and make sure it doesn't happen on your watch. If you know there is a bunch of hard stool in there, all the prunes in the world aren't going to help you. You may need to go in from the bottom and help get the plug out (see the earlier postregarding the glycerin options.) Once the hard piece comes out, focus on finding your balance with fluids and solids so that you aren't dependent on a suppository; I have no problem with occasional use.
If you ever see blood in the stool at this age, it can be caused by poop at either end of the consistency spectrum. A very hard stool can cause a little tear near the anus. Lots of diarrhea can cause irritation that can bleed. If you are seeing blood with no obvious cause, or very mucousy stools, check in with your doctor.

Thursday, April 20, 2017

The Poop Series/ Chapter one/ Baby Poop

Most folks don't realize when they sign up for this "parenthood" gig that poop is going to be the frequent subject of many conversations. I am not kidding when I tell you that I have poop related phone calls every single day. It helps to know what is normal so that you don't worry.
I remember as if it were yesterday, my husband Sandy's first real experience changing a poop laden diaper. He soon became an expert, but that first one was a disaster. Lauren's little feet managed to get covered in poop, and before he knew it there was poop all over the place, including most of the baby and part of the walls. 
When babies are first born the stools are very dark and tarry. This is called meconium.
The meconium is very sticky and can be a bit challenging to clean. Vaseline, Aquaphor or Cerave ointment can help you gently remove the meconium from your child’s gentle skin.
Once babies start to successfully feed, the stools will gradually transition to a lighter color.
Normal colors range from yellow, orange, green or brown. I rarely pay much attention to color unless it is accompanied by a fussy baby or other symptoms that are telling us that something is off.
Those first bowel movements help signal us that the system is working and that the baby is actually getting milk. We certainly want to encourage breast feeding, but I understand that it is not an option for everyone. If you can make nursing work, there are a lot of benefits. If it feels overwhelming, try to give it at least 2 weeks before you give up. Take advantage of the excellent lactation assistance that is out there.
One of the real challenges for a nursing mom, is that It is harder to track the milk intake for the breast fed babies. It can be hard for new parents to be certain that the baby is successfully nursing. The baby might be hanging out on the breast for hours, but not reliably transferring adequate milk. The not-being-able-to-know-for-sure how much the baby was getting drove me nuts with my firstborn. Listening for swallowing and watching mom's breasts to see that the milk is coming in will give important clues, but when we see those first yellow stools I always want to give mom a big congratulatory hug. Yellow stools are proof that the baby is getting milk. If a baby is fed from a bottle, then of course we can track how much they are eating fairly easily.
Normal breast milk stools are very squirty and yellowish. Some may have little seeds. Think Mustard. (You may want to change your plans for having lunch at the deli today)
It seems that almost every new parent gives me a call to make sure it is okay for the stools to be so runny. Yes it is. Diarrhea would be clear watery stools with only flecks. Baby poop is routinely very liquidy. Remember, they are not eating any solid food, liquid in/liquid out!  Some babies seem to have loud squirty poops every time they eat (or as soon as you have put a fresh diaper on them). As long as it has a color, it is likely fine.
There are many factors that can impact the color. Stools from a formula fed baby tend to be a bit greener than the yellow ones we get from breast milk. Grippe water can also make stools greenish, as can the lack of hind milk. (see the colic post)
If blood is noted in the stool, we certainly want to be notified, but most of the time it is not something I am alarmed about as long as the baby looks good...(Is their color fine? The belly nice and soft? Are they eating well?)
Red blood is usually fresh and comes from near the anus. It can be caused by the gentle skin down there getting irritated.
Darker blood is not as fresh and comes from higher up in the digestive tract. My first question will be about mom's nipples. If they are very sore, it is likely that there was some bleeding and the blood we are seeing in the stool is mom's blood. (I know, yuck.)
If stools are mucousy with some fresh blood it can also be connected to mom’s diet. Often removing dairy completely will alleviate the issue.
Once we see that the baby is gaining weight and having a regular pooping pattern we are no longer concerned about monitoring the frequency.
It is quite common for babies who used to have frequent poops, to suddenly shift to way less frequent stools.
As long as the stools remain soft it is not something that concerns us. Some babies go as infrequently as once a week.
It is also quite normal for babies to grunt, groan and turn bright red as they work on a bowel movement.
It is considered constipation when the actual stool is hard, formed and pellet-like. If that is the case, check in with your doctor's office. This is very unusual for a breastfed baby. I have found some organic formulas to be the culprit.

A pooping baby tends to be a happy baby. If you have one of those infrequent poopers it is hard to watch them struggle.
Massage their tummy. Go on youtube and search out some Infant Massage techniques. A good belly massage can help stimulate peristalsis (which is the movement within the intestines that moves the poop along.)
The tummy may be the most important area, but doing an entire body massage will help them relax. 
Don't forget their little hands! Take your thumb and make firm little circles on their palms. This is a reflexology technique that grandmas have been practicing for generations.
You can also bicycle their legs. Let gravity help them out. Hold them in an upright position and pull their little legs up to a squat position. Nobody poops as easily in a reclining position.
Sometimes a little rectal massage will also help. To do this you can put a dab of KY jelly or Vaseline on a Q-Tip and stick it a tiny bit of the way (just the cotton tip worth) into the butt. In the office when we take a rectal temp, more than half of the time this will make the baby poop right on the thermometer.
The Windi is another gentle way to stimulate pooping and help relieve gas at the same time.
There is no intervention needed for infrequent stools as long as you have a happy baby.
If it has been many days in between poops, your baby seems quite uncomfortable and massage has not helped, our next step will be glycerin. With the glycerin you have 2 options.
Glycerin suppositories are little sticks of glycerin (over the counter in most drugstores.) You break off a piece and stick it into the butt (KY jelly helps.) This stimulates the babies to poop fairly soon.
The other option is a product called Pedialax. These are little bulbs full of liquid glycerin. You pull off the cap and insert the pre-lubricated tip into your baby's butt and squeeze the liquid in. These works really well. The box says that these are for babies 2 and over, but I have found them safe and quite effective for younger folks.
Often just going out and buying glycerin will make your kid poop. It is a useful product to have on hand. Someday within the next couple of years it will come in handy.
Baby poop is a fairly benign substance. This will change.....
Next week’s post will address the changing stools as solids are introduced. )

Friday, April 14, 2017

Siblings (2017)


Imagine your partner says to you:
“Honey, I really love you. You are one of the most important people in my life. Please don’t be concerned that a younger, very cute person will be spending a lot of time with me. They will possibly be sleeping with me in my bed for a while. There may be some sucking on my breast.”
The oldest child was the center of the world for a time. Moving over to make room for a new member of the family isn’t always easy.
Some big brothers and sisters are actually eagerly expecting the baby’s arrival. Others are too young to really understand what is going on. Regardless, there is a big adjustment to be made.
Many parents report that the big siblings are quite sweet to the baby, but act out horribly to the parents. Once in a while, but less often they will also act out towards the baby. Nurse Jen remembers the time that her oldest daughter dropped a medicine ball on her new  sister.
Others have no malice but don’t have a sense of how to be gentle.
Below are some suggestions that may help ease the transition.
Do some gentle preparation by including some books about new babies among your reading choices. Please keep reading other favorites that have nothing to do with a new baby as well.
Once the baby arrives give your older child plenty of opportunity to talk about what if feels like to have a baby in the house. Validate that it is very normal for the big sister/brothers to feel mad, sad or aggravated sometimes (some kids might feel guilty about the way they feel.)
Many kids need to be told that the baby is here to stay as a new part of the family. Sending them back in not an option.
Have the new baby bestow a gift on the big sibling; I am not sure what the age cut off for getting away with this is, but you might be surprised.  Lauren was a remarkably clever almost 3 year old when Alana came along. Never the less when we gave her a little present from her baby sister, she accepted it without question. She was delighted and was quite pleased with the very thoughtful baby.
Some big siblings feel very important if you let them be “helpers”. Find some safe baby related tasks for them.
The most  important tip of all is to make sure that you carve out one on one time with the older child. Often they are craving mom right now. If mommy is breast feeding, make sure that in between feedings she hands the baby off to the other parent or other support system for burping, diaper changes... etc. and make a fuss about having “special big boy/girl time”
Nurse Jen says that lots of people gave her this advice but she didn’t realize that having a sleeping baby in a sling isn't the same. She wanted me to make sure to add that If you are holding the baby, it doesn't count as the “one on one” time.
As your kids get older, the oldest child will always feel a bit entitled to some solo time. If you can manage it, take just one child with you on routine errands and turn them into adventures.
Perhaps you can have only one child at a time allowed to “help” with a meal.
Even a walk around the block or some special time at bedtime makes a difference.
Try to make sure that each parent should make sure that they get special time with each kid.
My husband made it a tradition to take Lauren out for breakfast every Sunday morning.  Eventually Alana was old enough that she went along too, and mommy got to sleep in (heaven!)
Once the second child comes along you will feel like simple math no longer adds up. One plus one must surely equal five. You will manage to find the balance, but those first few months are challenging to say the least.
With the first child you had the luxury of focusing on schedules and nap time as if they were set in stone. Unless you are remarkably lucky or hire someone, a true schedule doesn’t really exist with this second child. Naps? Maybe while you are driving from here to there (they survive.)
Do your remember how careful you were with the first one? You avoided crowds and made sure that no one came around if they weren’t completely healthy. The new baby will simply be developing that immune system a bit earlier. There is almost no avoiding it, unless you never go out and you quarantine your older child to an unreasonable degree. Second kids get exposed to things quite a bit sooner (they survive.)
I do like to make the big siblings the deputies of the 'Hand Washing Patrol'. Have Purell around (you can also get the kind that is alcohol free.) Call it magic soap. Tell your deputy that they are in charge of making sure that anyone who is going to touch the baby washes their hands first. This may help make sure that they don’t feel like they are constantly being nagged at.
Keep in mind that all of your kids will reach their milestones on their own timeline. It doesn’t pay to compare them to each other or to the other kids in the play group.
My baby Alana, for the record, doesn’t mind when I use her as an example. She is now a licensed social worker and is an amazing super star all around, but goodness was she slow starting out.
Talking: Lauren was singing Rogers and Hammerstein musicals at a remarkably young age. She not only knew the lyrics, but she sang them in tune. (I have video proof of this.)
Alana barely had ten articulate words before she was two. Lauren would translate for her and act surprised that we didn’t know that  “gbabp[ps[p” meant, “I want popcorn please”
Walking: Lauren took her first steps at a year. Alana waited until she was about 16 months and then carried a chair across the room within a day of mastering walking.
Toilet training: Lauren was an early 15 months. Alana had no interest until she was 3. I thought we were going to have to buy depends.
They will all get there.
Siblings will have days when they are best friends and days when they torture each other. Mine interspersed periods of intense closeness with periods of mild bickering.

 Fast forward 20 years...
My family was on a cruise, savoring time together. We were in Cozumel. My husband Sandy was off on a real dive, while the girls and I went Snuba diving. Snuba is a combination of Scuba and snorkeling. With Snuba you breathe through a 30 foot tube that is connected to an oxygen source that floats along the surface.
My daughters were swimming along the ocean floor. I was about 10 yards above them watching them animatedly communicate with each other through hand gestures and some signing. I remember proudly thinking...Look at my daughters. They are both intelligent, funny, kind and lovely. I love them so much. I am so glad they have each other and that they have gotten so close as they have gotten older.
Our time was up and the guide gestured to all of us that it was time to go up to the surface.
They removed the mouth pieces and…….the fight continued:
“You were getting tangled in my hose”
“You were kicking too hard and making too many bubbles”  and so on.
Oh well, a mom can dream.

Fast forward 25 years -  I think that my daughters could now enjoy an excursion without bickering. Of course no more silly 'Snuba' for Lauren. She has since gotten certified to do real diving.
And  we each got a kid to keep us company on our travels.  Alana loves to come with me shopping or sipping a beverage in a small cafe while Lauren climbs mountains with her dad (they're planning their next climb now!)