Friday, March 23, 2018


If you got my recent post about altitude and were momentarily disappointed when you realized it was about going up to the high country as opposed to your teenager giving you the stink eye or your toddler being a pill, you were not alone. Somehow, even though actions speak louder than words, attitude, in its silence, speaks the loudest of all.

We tend to have such a knee jerk reaction to attitude. We are human after all. If someone is saying and doing the right things but is sullen or rude, it is upsetting. It is also frustrating that it is hard to make a concrete accusation that doesn't sound just a wee bit weak.

“Your honor, they rolled their eyes at me and then slammed the door….”

To take it a step further, the nuance and meaning of a sentence can be completely changed depending on which word gets stressed

“You would like ME to clean my room tonight?”
(why would I do do it)

“You would like me to clean MY room tonight?
( have you seen the mess that YOURS is?)

You would like me to clean my room TONIGHT?
(tonight is so inconvenient)

Tone matters. The tone we use or hear can completely change the interpretation. Absence of tone can have an equal impact.
People can also get into all sorts of trouble from a text conversation when there is no inflection.

So we can agree that attitude is silent but powerful, but here is the most important thing to keep in mind. We can try to influence others, but the only real power we have is over ourselves.

Reacting to attitude

Can you calmly be aware of how you are affected by someone else’s non verbal cues? Realize that someone else's negative energy might not actually be directed at you. If someone is tired or grouchy, you might just be in the path.

If this is a casual interaction, you might opt to simply walk away and not take it personally. This is a good example of how not to ‘sweat the small stuff’. Our measured response to someone’s attitude could possible diffuse a situation rather than escalating it. “You seem like you are having a rough day, can I help?”

If this is a Groundhog day situation that you live over and over again with a child or partner, then it is worth addressing.
‘Toddlertude’ and ‘Teentude’ (Thanks BK for those monikers) are not the same thing.

Toddlers can’t really be accused of ‘giving attitude’. They don’t usually have the verbal skills to communicate what they are feeling. If you are able to identify the cause of the frustration, it is on you as the grown up to problem solve the situation and see what fixes you can come up with. Remember that everything is worse when they are tired or hungry.
Even from a young age though, kids can be made aware that they have a choice about whether to be sunny or difficult. During a recent phone conversation, Nurse Lainey overheard Daddy Adam ask his daughter Millie," Do you want to take the rainbow road or the rocky road? You get to decide." I love it.

'Teentude' is different. When you are on the receiving end of “attitude”, but they have done what you asked, validate the appropriate words and actions but then point to the unspoken.

"Thank you for following my directions (cleaning your room, doing your homework, getting out of the house on time)
Thank you for agreeing to…….
My instinct is telling me that you are upset by this situation. "

Don’t get into an escalating attitude battle. My father was the king of letting things roll off his back. I can hear him now saying," I am going into the garden to eat worms"

Teens have a lot on their plate. A little stomping when they have to put their phone down to do some homework shouldn’t be taken personally.
Many teens are wonderful citizens to their teachers and other people that they interact with in the world outside of the family circle. They save all the pent up angst for parents because you guys are a safe place. Find the right moment to see if they are open to a team problem solving session. Writing down all of the stressors and identifying ways that the family can support them are really positive activities. You are taking the unspoken and putting a name to it.

Emitting attitude

It is typical for most people to silently broadcast our anger or frustration. We start early, telling our children to use their words, but the truth is most adults don’t always do such a good job at that.

Think about whether better communication would be preferable to stomping, eye rolling and/or stewing. Can you be self aware enough to turn your eye roll, or huffy sigh into words?

Sometimes we are faced with a choice where it is best to suck it up and not say anything.

Let's make the example that your partner wants you to go out to dinner with friends. You are really tired and would rather stay home. If that is the case, imagine that the choice is a scale.
You may weigh all the pros and cons. You choose to go out because your partner is looking forward to it. We say yes but once in a while we can’t help it, here come the tired martyr. It as if we have written all the reasons we don't want to go on little post it notes and stuck them all over ourselves. Don't be that person. Wad them up and throw them out. Once you have made a choice, own it. Leave the attitude at home.

I wish I could wave a wand and make everyone in our surrounding have a sunny and positive attitude. Alas I am not that powerful.

Friday, March 16, 2018

Travel tips 2018

Our all time most common travel related question is probably, "When is my baby old enough to fly?" There are many different factors to consider, so there is no one simple answer. Adopted babies might fly within the first few days on their way to their new home. Other folks make the valid choice to fly earlier than we are really comfortable with in order to see an aging relative or deal with a family crisis.

In ordinary circumstances, I would prefer to have the babies wait until they are over 2 to 3 months of age and have had their first set of immunizations (keep in mind that the first shot does NOT give full protection against some serious illnesses, but it is a start.) The size of the baby as well as the time of year are also factors. If there is some kind of crazy flu epidemic, I would think long and hard before taking a young baby on a plane. It isn't unusual for there to be some type of health alert circulating, so keeping current on the news is important. A couple of years ago there was a measles outbreak here in the states. Measles is still a potential issue if you are going to Europe. When I ran this post in 2016, Zika was all over the news. As of this month (March 2018) there aren't any major scares. The flu may finally be winding down. The bottom line is that my recommendations might change depending on what is going around and where you are heading. It does make planning a trip well in advance a bit more challenging.

Regardless of how old your child is, if you are planning a trip here are some tips and things to keep in mind.

Before you leave
I get calls from all over planet from parents who are dealing with a sick child during their trip. Prior to the trip, check with your insurance company to see what the best method is for having out of state or international doctor visits covered. Some plans are much easier to deal with than others. Whether the visit is covered or paid for out of pocket, you also need to figure out what your actual options are. Is there an urgent care facility near by? Do you have a friend or relative with a pediatrician who is willing to see patients who are not in their practice? Does your insurance only cover an emergency room visit?

Hopefully you won't need to use this info, but if you are dealing with a sick child away from home it is nice to have a "Plan B" in place. If your child has a history of wheezing, it is wise to bring all medications along even if they haven't needed them in a while.
Keep in mind that infrequently used asthma inhalers need to be primed before use.

If you are traveling someplace exotic it is worth checking with a travel clinic to see if there are special travel vaccines or malaria precautions necessary. The only vaccine that we routinely give here in our office that might be considered a travel vaccine is Hepatitis A. Most other special travel vaccines need to be gotten at a travel clinic. A travel clinic keeps current with all the ever changing recommendations and consideration for each country and season. Plan in advance. Lauren and Sandy actually had to get rabies vaccinations for their trip to Nepal. is a good starting point to figure out what you might need. The is one good option for getting any necessary shots. Depending on your insurance, CPMC Travel clinic is another good choice.

One of my wise readers suggests that if you are traveling out of the country it is worthwhile to register your journey with the state department . Great idea!

Surviving the flight.
Keep in mind that a car seat is the safest place for your child.
It is worth checking with your carrier to see if you can get a discounted rate.

A few years ago I sat next to a mom with a very young baby. She was so worried about the possibility of getting evil looks from the other passengers that she had actually brought ear plugs to hand out to the people sitting around her. What she didn't have was anything to soothe her baby. Please always make sure that you have Tylenol or Motrin with you on the plane (not packed away in your suitcase). It is okay to bring small bottles through security. They need to be smaller than 3 ounces. I don't tend to give it ahead of time, but I am quick to medicate during the first sign of fussiness. Does your child suffer from motion sickness? Click to review my post on that topic.

I often get questions about the use of Benadryl. This is an option for a child who is over 8 months with a long flight ahead. It helps dry up any congestion and makes 90% of kids who take it deliciously sleepy. Aha, but what about the other 10% you might ask? It turns those little darlings into hyperactive, wild hooligans. You do not want to find out on the plane that you are the parent of the 10%. There is no such thing as infant Benadryl; we use the children's liquid generic diphenhydramine.

Many labels will warn not to give to children under 4. We routinely ignore that. You may want to give a test dose a few days prior to the trip to make sure it is a viable option for you. I want parents to have the tools with them to deal with an unhappy child. Don't give any medication unless it is necessary. While I would usually err on the side of less medication, Benadryl and Tylenol/Motrin can be given at the same time.

Many babies and children may have trouble with their ears . For the younger ones, try to nurse or have them feeding during takeoff and landing. Sucking on a pacifier may be helpful as well. Have a lollipop or chewing gum for older kids. Ayr saline gel is a nice thing to have along. A dab at the base of the nostrils can moisturize the dry air and make the breathing easier (use it for yourselves as well.)

If you have a child with a history of ear trouble, have some of the little gel heat packs in your bag. You can activate them as needed and the warmth feels great to a sore ear. For adults and older kids, you can equalize the pressure by holding the nose and gently blowing until the ears pop.

Take WAY more diapers with you than you think you need for the trip. I was on another flight not too long ago when we sat on the tarmac for three hours. There was an unfortunate family behind me who had planned on a short little trip and was out of diapers long before we took off. It wasn't pretty. Plan accordingly.

Many folks automatically bring a change of clothes for their baby. It is also worth bringing an extra outfit for yourself. If you have a long flight ahead of you with a child on your lap, it may come in handy (I learned that one the hard way and sat for several hours covered with poop.)

Changing your baby on the plane can be a challenge. It is helpful to have little changing packs, with a diaper and some wipes, in individual zip lock bags. This will prevent you from having to take the entire bulky diaper bag with you into the tiny bathroom.

Bring some disinfectant wipes along and give the tray table and any surfaces a nice wipe down before you use them.

You can't count on airlines giving you any reasonable snacks, so it is important to bring along enough provisions in case of delays.
Kari, one of my mom readers added this tip. "-remember being surprised that airlines didn't have a way to heat up bottles either. Trying to heat a bottle in a tiny airline cup full of "tea" temperature water was rough. After the first flight, we took a large, insulated plastic Jamba Juice mug that would easily hold a bottle and water."

My daughter Lauren says that a hydroflask is another good option for keeping a bottle warm for hours.

Download some activities or shows ahead of time for your laptop or tablet. None of us want to overdo screen time, but if you have managed to keep it special, a long flight is the perfect time to make use of this tool.

Don't forget about the old fashioned low tech options! If you are visiting family, print out a bunch of photos of the people you are going to see. You can use these for all sorts of art projects on the plane. Make a paper doll family! This can help your kids recognize folks that they don't see too much of. Wikki sticks are also a great activity to bring along. They are lightweight and not too messy. Reusable stickers will stick on the window. Don't bring anything that will make you sad if you loose it in between the seats.

Once you get to where you are going, make sure the place is adequately child proofed (this is also a discussion that it is worth having with your hosts before you get there.) I had one situation where a 3 year old opened a drawer and got into grandma and grandpa's medications.

Is there a pet where you are going? Make sure that any dogs are safe with children.

If you are staying in a vacation home, do a quick safety check. Do they have working smoke detectors? A fire extinguisher?

Time zones are tricky. My best suggestion is eat when you are hungry, sleep when you are tired and just do your best. Staying hydrated and getting fresh air are essential. Sunshine is a bonus.

The link above has wonderful information for dealing with jet lag. Even the best sleepers may have a period of needing a sleep training tune up when you get home.

You can have lots of fun while you are away and it is wonderful to see family. But, in my opinion, if you are traveling with children under the age of seven, don't call it a vacation. It's not. It is a TRIP (we used to call our visits to the various grandparents the "bad bed tour.")

A little preparation goes a long way and remember that some of the more challenging moments make for the best stories!

Here is one of mine...

Many years ago when my daughter Lauren was two, I got creative as I was planning for an upcoming flight as a solo parent. I had seen a craft in a magazine (long before Pinterest existed) where a necklace had been made of cereal and I thought that this seemed like a fabulous thing for an airplane trip. Unfortunately, not all ideas turn out to be good ones. Lauren and I strung some Cheerios onto elastic and she proudly wore her new necklace onto the plane. Soon after take-off Lauren decided to eat some of the Cheerios. I noticed with some dismay that as she bit off a Cheerio, some would go into her mouth while other parts would shoot off like little spitty projectiles. They were landing (unnoticed by anyone but me) on just about everyone within three rows of us. As soon as I realized what was happening, I tried to see if there was a way for her to nibble them off without making a mess. When that didn't work, I tried to take the necklace off to make it easier or to have her stop eating them at all. But as mentioned, she was two. My choices were clear... tantrum on the plane or unsuspecting fellow passengers having little pieces of spitty Cheerios in their hair.

I opted for peace (besides, ignorance is bliss, right?)

Have safe travels and make great memories!

Friday, March 9, 2018

Dealing with Altitude 2018

This is the time of year when we get a lot of calls from folks wanting to take a road trip up to the mountains and asking about whether or not altitude is a problem for the baby. Keep in mind that many babies are born in places quite a bit above sea level and live their lives in high altitude year round.

Some folks in general are more sensitive to altitude issues than others, but there is no real difference between adults and children.Most people can tolerate altitudes below 2500 meters/8200 feet with only mild discomfort. If your child has significant heart or lung issues if is worth checking in with your specialist prior to travel. For the majority of my patients, Tahoe is generally okay for any age.

Mild symptoms can still have an impact. Folks may have headaches, tire easily and be a bit short of breath. Dr. Kaplan adds that tummies can get upset because the gas in your gut expands. Make sure your bring gas-X or simethicone along to help deal with this.

It is essential to make sure that you and your kids stay hydrated. Breastfeeding moms should take extra care that they are drinking enough.

Sunburn can happen easily in the high altitude. This is even more of an issue when there is snow or water to reflect the sun. Make sure you have appropriate sun protection for skin and eyes.

In the winter time, the air tends to be drier. The need to use heat in your accommodations can exacerbate that. It is worth bringing along your humidifier. (If you are flying, consider purchasing an inexpensive one when you get there.)

The biggest difference between adults and young children is that the adults can communicate what they are feeling. Babies can’t. If your baby appears pale, fussy or has labored breathing, get them to a travel clinic to be assessed. Make sure they have the oxygen level checked. On the other hand, young babies aren’t generally hiking around or doing anything strenuous so in some cases, they may have an easier time.

If you are traveling to a place that is higher than 8,200 feet, see if you can get there in stages so that your body has a little bit of time to acclimate. Know ahead of time what medical services are available should any family members run into trouble. Dr. Kaplan has had some patients, traveling to Colorado high country, who needed supplemental oxygen.

I personally am an altitude wimp. I like my oxygen and have trouble if I am anywhere over 5,000 feet. I will NOT be accompanying my husband and oldest daughter on their next adventure this, month when they go to Everest Base camp. They successfully summited Mt. Kilimanjaro… just a bit under 20,000 feet in 2016. Base camp is only a measly 18,192...piece of cake.

Friday, March 2, 2018

The Back to work transition 2018

The first couple of weeks home with your baby is a tumultuous time to say the least. It is full of so much amazement, sleep deprivation, joy, learning, and love. You might be in such a haze that you may or may not even remember this period very clearly.

It is the minority of families in our practice who have the luxury of having one parent stay home with the baby full time. Most families are faced with the huge transition that hits when one or both parents need to return to work. The luckiest families have flexible, understanding jobs and a local grandparent who can’t wait to babysit. If you can work part time, that is often the perfect balance. The rest of you are left trying to figure out the best option.

One of the biggest issues that many of the breastfeeding moms face is how to successfully continue to nurse. If your baby has never taken a bottle, try to give yourselves enough time for them to get used to one. Babies may simply refuse to take the bottle from mom. They know that breast is right there! They can smell it! It is best to have the other parent or caregiver be the one to offer the bottle. Ideally offer fresh breast milk, so that there aren’t too many changes at once. Try the bottle a bit before the baby is genuinely hungry. Some babies are remarkably easy and go back and forth between breast and bottle with ease. Others like my daughter Alana, can make it much more stressful. Alana screamed for an entire day. Luckily she was with a very patient and experienced caregiver who eventually had success. They all figure it out when they get hungry enough. I know that this battle of wills is a tough one.

If you are planning on pumping and keeping the baby on as much breast milk as possible, local lactation guru Nurse Charity shared some successful pumping tips. She suggests that you start pumping 7-10 days prior to going back to work.

Yes, this will bump up your supply, but going back to work usually does tend to decrease the supply over time, so starting at a higher level is good. Prior to pumping do an all over breast massage. Bring a photo of the baby or an outfit with that wonderful baby smell. Hopefully your job will be supportive of your need to pump and you will have a comfortable area. Frequent short pumps are just as good as trying to carve out one or two long sessions. Nurse Kenlee suggests making a “nursing playlist” or having some strong association with nursing that you can take with you when you are pumping away from the baby.

In general in order to protect your supply, make sure you drink plenty of fluids. Eat a healthy diet and make sure you get adequate rest. (I know, I know, but I had to add that)
Do lots of skin to skin contact when you are with your baby. It takes some effort but many moms are able to successfully produce enough milk that supplementing is not needed.

KellyMom is an excellent source for guidelines on storing the milk. If you have fresh milk, use it prior to defrosting your frozen stores. I always suggest putting a baggy full of ice cubes in the freezer. As long as they stay frozen as cubes, you are assured that the freezer has maintained the correct temperature. If the ice cubes refreeze into one clump, the milk can no longer be trusted.
Get in the habit of clearly dating all the milk and rotating the stock. Use up the oldest stores first.

Make sure that your milk freezes well. Some moms have an excessive amount of the enzyme lipase in their milk. The milk remains safe but has a nasty smell. Scalding the milk prior to freezing it will eliminate this issue. You don’t want to be the one who discovers this after you have a freezer full. The lipase has some health benefits, so if it isn't causing problems, don't bother scalding the milk.

While many moms have no trouble keeping up with their supply, others are not so lucky. Please don’t spend even a minute beating yourself up. Do not be the parent who limits the amount of milk the baby is allowed to have due to supply. Do not be the parent who is incredibly stressed out if they are an hour late home from work because the baby will starve. Simply do the best you can and take advantage of the fact that there are many excellent formula supplements out there. Being a good parent is not only about the breast milk.

Be careful that your child doesn’t swap their days and nights. If moms aren’t careful, some babies refuse the milk from the caregiver during the day, but wake up every couple of hours to nurse during the night. Sure, the baby is getting the milk they need, but mom will lose her mind from sleep deprivation. Let me repeat myself. An intact mom is more important than breast milk.

Beyond the issue of feeding is the huge question of finding a loving caregiver in your home or a safe place to send the baby while you are at work.

Many of our parents have success with small family day cares or nanny shares. Once kids are away from the safe relative quarantine of your home, they are going to start getting all of the little childhood colds and viral syndromes that are a rite of passage for most kids. Having a solid conversation with the daycare, other parents and/or nanny is essential so that everyone is on the same page regarding which symptoms necessitate staying home.

Take a moment to click on one of my all time favorite blog posts. It is all about striving to find balance between all the various aspects of your life. It is never more relevant than during this transition.

Friday, February 23, 2018

We could all use a little dose of Mr Rogers

A couple of headlines intersected this week. First of all was the horrible school shooting in Florida. That put me in a mind to rerun my “horrible headline” post from a year ago when some similarly terrible event happened.  But in a smaller headline was the reminder that Mr. Rogers aired his show 50 years ago. In my post about talking to our children about scary situations, I actually quote Mr. Rogers. He shared a lesson that he learned from his own mother, “look for the helpers”. Those might be a person in uniform, or another parent with children. That remains great advice and is one of his more well known pearls of wisdom.

Since I have some extra time on my one hand this week, I decided to give my own shout out to Mr Rogers. Most of you may not know this, but I was fortunate enough to interact with him several times while I was working at my first job as a nurse at The Children's Hospital of Pittsburgh. Mr Rogers routinely visited my little patients there. He also created several movies there that we would use for patient education. He was the real deal. There was nothing fake about that man. A generation of children grew up better people because of the lessons he taught. Here are some of my favorite pieces of Mr Roger's wisdom:

  • "There are three ways to ultimate success: The first way is to be kind. The second way is to be kind. The third way is to be kind."

  • “There is only one thing evil cannot stand, and that is forgiveness.'"

  • "There's a part of all of us that longs to know that even what's weakest about us can ultimately count for something good." It is okay not to be perfect!

  • “Solitude is different from loneliness, and it doesn't have to be a lonely kind of thing.”

  • Accept people as they are

  • Look and listen carefully
  • We all have feelings.” Talking and acknowledging them is the first step towards finding ways to deal with them that don’t hurt anyone

  • Anything that's human is mention-able, and anything that's mention-able can be more manageable. When we can talk about our feelings, they become less overwhelming, less upsetting, and less scary. The people we trust with that important talk can help us know that we're not alone.

  • Wonder about things

  • “You can’t go down the drain in the bathtub” Don’t be shy about sharing things that might be scary

  • “Be yourself.” It is not how you look, what you wear or what toys you have that make you special

  • What can you grow in the garden of your mind? Use your imagination.

  • You rarely have time for everything you want in this life, so you need to make choices. And hopefully your choices can come from a deep sense of who you are.

  • One of the most important things a person can learn to do is to make something out of whatever he or she happens to have at the moment.

Mr. Rogers was a gift to generations of kids but I wonder if any of my patients know who he is? I believe that Daniel Tiger is making sure that the whisper of his gentle message lives on!

Friday, February 16, 2018

The misadventure of Nurse Judy/Managing Stress

The misadventure of Nurse Judy

Last Sunday I was taking a hike along Land’s End. I tripped and fell forward. My right wrist took the brunt of the fall. The triage nurse part of my brain knew that bones were broken. What an impact one little misstep can make!

  • I didn't fall off a cliff, break a leg or sustain a head injury.
  • I was with sensible people who helped hike the mile back to the car.
  • One person had a large scarf that we were able to fashion into a sling.
  • All of the passing hikers stopped and offered to help. Humanity put on it’s best face.

  • I had no id or insurance cards with me.
  • It’s time to update the first aid kit in the car and make sure it has arnica and instant cold packs.

I spent a few hours in the Davies ER. It's OK to call ERs to see how long the wait is for non-critical care. UCSF was 3 hours. Davies was none! That is a gem of a resource for adult patients. I was able to get an early Monday appointment with an orthopedist. Both of the bones in my right forearm are broken. Yes OUCH

  • I have a wonderful support system (thank you Sandy), family, friends, good insurance, and access to good health care (way to meet the deductible early in the year!)
  • Noe Valley Pediatrics is a very supportive work environment and is trying to muddle along the best they can with the office manager mostly out of commission.

  • Ongoing trying to figure out how to manage for 6 weeks without use of right hand.
  • Trying to Learn how to say yes to the friends who have reached out with offers to help

Impact on the office
Nurses will be short staffed. Every effort will be made to return calls in a timely manner, but please understand we won’t have the luxury of time for longer conversations. The turn around for emails may be as long as a week. Please call if you need to speak to a nurse.

I have cancelled February classes. I will update this after my next ortho appointment. I may end up requiring surgery, so it is difficult to plan.

Don’t count on weekly emails, but I will try to keep them coming. 
This post is short and simple, but hopefully it can give you a new awareness or way of looking at things.

  Topic of the week: Managing Stress
My kids grew up having to deal with all of mom’s theories. One of the classics is the “stress theory”. My daughter Alana, who is now a therapist at a community mental health center in Michigan, finds herself referring to some of these with her clients.

She let me know that she used this one the other day and I realized that I had never put this one in a post. So here goes.

Is there a water bottle near by? Take a look at it, Imagine that you are that bottle. There is a thick label. You can not easily see how much liquid is inside. Elements of your life are varying amounts of fluid. Every aspect of your life adds liquid to the bottle. Some things may add a few ounces, others only a tiny drop (drops can add up!) Being a sleep deprived parent is easily a couple of ounces. A new job? An illness in the family? Moving? Ounces! Large changes or stresses are of course equated to larger amounts. Breaking your wrist - half a cup!

We generally don’t pay too much attention to how full our bottle is until it is near the top. The smallest drop of water, something that normally you could handle with no problem, may make the entire bottle overflow.

This is the proverbial straw that broke the camel's back. Are you crying because you burnt your toast? Take a moment to figure out what is going on that has your bottle so full that the littlest thing can set you off.

One of Alana’s clients found that this way of looking at things really resonated with him. He coined the term “dump the cup,” which in turn resonated with me.

What can you do to dump out your bottle a bit? Arrange a little time for yourself? Take a walk? Have the perfect cup of tea? Sometimes making a list of all the things you feel like you need to do helps quite a bit.

With your young kids, they can’t hold as much. Simply being tired or hungry will fill their little ‘bottle’ right up to the top. That’s when the temper tantrums and meltdowns happen.

Everyone who you interact with has their own stress level. It is good to keep that in mind if someone seems to be ‘overreacting’.

Are you past the sleep deprivation hell? Do you have a friend with a new baby? If you are thinking about giving a gift, consider skipping the outfit that the baby will grow out of in a minute. Give them a certificate or two that can be redeemed for a 2 hour nap while you watch the baby.

Helping your friends "dump their cup" feels pretty good.

Friday, February 9, 2018

When is your child contagious? 2018

Some of the most common questions the come to the advice nurses revolve around when kids are contagious and at what point are they ready to go back to nanny-share, daycare or school.
The answer is almost never clear cut. In a black and white world, this is my 50 shades of gray.  In order to logically best make these decisions there are many issues that we need to consider.
Of course we want to be a responsible parents and not expose others to our sick child. We also want to protect our own recovering child from going back into the 'germ pool' too quickly. If they are just getting over something, their immune system may a bit diminished and they are vulnerable to coming down with something new.

For older kids,sometimes they have an important test that they are reluctant to miss. Some are reluctant to miss school. (others not so much.....)

Another consideration is that some parents have an easy time taking time off to stay home with their little sick child and others simply can't afford to. It is naive to think that these aren't real factors.

What makes it all so tricky  is that most viral syndromes can be spread a day or two before the kids show clear signs that they are ill. Many kids may be a little fussier than usual. Perhaps they don't eat quite as much. Most savvy parents know enough to be suspicious when their 5 year old who fights naps with a vengeance announces that they are going up to have a daytime snooze. Your antenna might be up that something is brewing, but are those reasons to miss work and keep your child at home??? Of course not!

The fact is, if you child comes home from school in the afternoon and is sick that evening, most likely everyone they were with earlier that day has already been exposed and I am going to take that into consideration when we try to come up with the most sensible plan on when they can return.
It is nearly impossible to isolate siblings. Of course be scrupulous with your hand washing, avoid sharing utensils and sloppy wet kisses, but it is likely that they will catch each other’s cooties. Breastfeeding moms, sorry to say that by the time you realize you are ill, it is too late to prevent an exposure. Hopefully the magic of breast milk will protect your baby, but it is rare that we would suggest that you avoid nursing. Most of the time we will recommend that you keep on with the feedings. (Make sure that you are getting plenty of fluid. If you are given medication, check with your nurse or doctor’s office to see if it is compatible with breastfeeding.)

If you are in a small share care situation, it is essential to have a talk with the nanny and the other families involved to make sure you are all on the same page.
I would suggest that you agree that the kids will have  a "sibling" relationship. This simply means that you all accept that the kids are most likely going to get each other’s mild illnesses.

As far as common colds go, the average child under 2 years of age has EIGHT colds a year. Frankly, if you plan on keeping your child at home until your little toddler is free from a runny nose, you will be waiting a very long time before you leave the house.
Remember that some clear runny noses are not contagious. Teething as well as some allergies can be the cause. (There is debate about whether or not teething is associated with congestion. Nurse Judy votes yes.)

While I would strive to keep my youngest and most vulnerable patients free from viral syndromes and colds as long as possible, exposure to these common viruses is in fact developing the immune system. At some point they are going to have to deal with the myriad of  illnesses that make the rounds. Think of it as a rite of passage. It is actually better to get some of the childhood illnesses out of the way. Unfortunate adults that lack immunity and catch these illnesses are pretty miserable.

Typically if I have a child with a fever over 101, a  new case of diarrhea, or a brand new cold that has them spewing green mucus it is worth keeping them home for at least a day or so to see what  is coming next.

If your child has an infection that is being treated with antibiotics, we generally consider them no longer contagious after they have been on the medication for at least 24 hours.

Bacterial conjunctivitis is also usually given the all clear after 24 hours of eye drops (of course you need to finish the course.)

Hand Foot Mouth issues come up a lot. I respect that schools want to keep this yucky virus from getting spread around. Patients can shed that virus in their stool for several weeks. I would suspect that there is a reasonable chance that the infected kids likely got it from school in the first place and/or were contagious before they were identified and segregated.Since I don’t think schools are able to genuinely keep them out until they are completely clear, I suggest common sense guidelines. If they have a fever keep them home. If they are fussy and miserable, they will be much happier home with mom or dad. If they seem to be feeling okay and are fever free, for the above reasons, I don’t think it is reasonable to exclude them from daycare/school until all the blisters are gone. Kids are going to get this.

If you are questioning whether or not to go on an upcoming play date, explain your situation to the other parents. They may be perfectly fine hanging out with you and your snotty nosed child, or perhaps they have an important event or vacation coming up and want to be more cautious. Let them decide. Full disclosure ahead of time is the best practice.

We wish there were a magic light that signaled the "all clear." Alas, there isn't.
I wouldn't even completely trust the rapid tests that we do for strep, RSV or Flu. If the test says negative, but the child looks sick we have to remember that the tests aren't 100% accurate.
There is never any complete assurance that can be given that your little one is "not contagious".
Use your best common sense. When in doubt avoid contact with anyone who is vulnerable. This would include newborns, or someone with a compromised immune system.