Friday, July 21, 2017

Back to School: from Vaccine requirements to Adjustment tips

Back to School: from Vaccine requirements to Adjustment tips

When I was young, Summers were sacred and school started after Labor day. I am not sure when that shifted, but it seems that these days many of our patients start school in mid August. I am putting this post out now to hopefully avoid the panicked parents who call, needing an immediate check up, sports form, or updated vaccination record prior to school entry. In our office our checkups are already very booked up, so if you haven’t done so already it is probably too late to get in under the wire, but call NOW for any chance of getting in sooner. Below  is the standard school form if you lost yours:

School Form for SFUSD
This is the most updated one that I was able to find online.
There is no charge for forms filled out at the time of an exam.
All other forms have a $10 fee and a one week turn around time
(We try to get to them sooner but there are no promises.) Rush forms  will be done within 48 business hours. There is an additional fee for this.

Take a deep breath. Most schools will accept a promise of a scheduled check up as long as they have an immunization form that is complete. We are happy to work with our families to at least get you scheduled for some of those shots that are needed even if there isn't a check up appointment with the doctor available before school actually starts.

As most of you are aware, In June of last year, California Governor Jerry Brown signed Senate Bill (SB) 277 into law. This law went into effect July 2016. For the school year beginning August/September 2016, all children going into kindergarten, seventh grade or transferring to a new school for the first time had to be fully vaccinated or have a medical exemption. Personal or religious exemptions are no longer accepted.
There is a conditional entry for children who are not fully up to date, but they must have at least one of  all of the required vaccines.

The schools will be checking in to make sure that the series are completed in a timely manner. School districts already have their own systems for tracking and following up with kindergartners who are not fully immunized. Whatever systems the districts are already using will remain in place. Check out this valuable link for a complete list of what is required: Shots for School

For our younger patients, most licensed day care facilities also have a fairly strict vaccination policy. Those requirements are also listed in the above link. That website also has a feature where you can check out your school or daycare to see how well they have been doing in their vaccination efforts.

7th grade  is also the perfect opportunity to vaccinate with the other ACIP (the Advisory Committee on Immunization Practices) recommended vaccines for 11-12 year olds, including HPV and MCV4 (meningococcal).  Students entering the 7th grade  will need to show proof of a Tdap (Tetanus, Diptheria and Pertussis) booster. They also must show proof of two doses of the MMR vaccines.

Vaccinations are only one of the requirements for school entry.
Kindergartners must have a complete physical examination within 6 months prior to entering school. We try to avoid doing the well child exams prior to March for this very reason.

We routinely check their vision, hearing and urine as well as reviewing general health and development. In my opinion, these annual visits with your primary doctor  are just as important as getting the shots.

California law also requires that by May 31st each year, students in their first year of public school must submit proof of an oral health assessment performed by a licensed dental health professional.

I haven’t come across anyone being denied entrance if they haven’t been to the dentist, but it is good idea to be current with the Dentist regardless of the laws:

Routine testing for tuberculosis is not required for SF public schools. Rather than testing every child with a skin or blood test, the San Francisco Department of Public Health strongly supports a medical provider's risk assessment for TB as the universal screening requirement for school entry.  Only children identified as having one or more risk factors for TB infection will need to be tested. The most common risk factors are

  • Contact with a family member with history of or confirmed case of TB
  • Foreign born family or adopted  from country with a high-prevalence of TB
  • travel to high risk country
  • HIV contact
  • family member who has been in jail during past 5 years
  • frequent exposure to homeless, users of street drugs or residents of nursing homes
  • Clinical evidence of TB: Cough lasting  longer than 3 weeks, coughing up blood, night sweats, fever, weight loss.
If you do get your child tested you have 2 options. The PPD is a test applied to the inner arm that needs to be checked 48 to 72 hours after it is placed. There is also a blood test available calledQuantiferon. It is a little more accurate than the skin test, so if you have a real concern, that is something I would consider.

Some of the private schools insist on TB testing for all of their students, regardless of the recommendation of the SF Public Health Department.  I have gone to the mat with one of the local parochial schools and lost.

Okay, aside from the forms and the shots, first day of school, especially if it is a new place is an emotional time. Some kids are excited while others are stressed.

This is a great time to read some books or tell stories about school. If your child has some separation issues, consider giving them a hankie that smells like you that they can put in a pocket. Maybe get a set of best friends necklaces for you and your child to wear and you can look forward to matching them up at the end of the day.
It is a bonus if you know a nice friend who will be in your child’s class. Play-dates together before school starts can help smooth the transition. If you don’t know anyone, some schools will host a back to school event or offer up a roster. Don’t be afraid to cold call one of the new families and introduce yourself.

Try to carve out some extra time during the bedtime routine where you can have your kids tell you all about their day. Don't fall into this common trap:

"How was your day?"

Ask specific questions such as:
Tell me about the kids in your class.
Tell me about the teachers
Share something interesting that you learned today.

Alana loved going into the minutiae of her day so much that she never stopped (you should be so lucky!) This 27 year old calls her daddy daily as she commutes home, and tells Sandy all about her day.

Every year might be different. Some kids who didn’t even look back to say goodbye one year, might pitch a fit in another. Lauren had no trouble saying goodbye to mom and dad her first several years at school until she was in third grade and Alana was in Kindergarten. The Kindergartners day ended earlier than the rest of the school and somehow Lauren found that intolerable. If she caught glimpse of me picking up Alana, she got weepy. I remember having to sneak through the school grounds making sure that there was no way Lauren would see me until it was time for her to go home as well.

It has been several weeks since I have sent out a post that mentioned poop. so I will add one more tip. Please make sure that your kids don't get constipated.  This is pretty common during the back to school season. There are several reasons for this. Some kids tend not to drink as much. Others are simply having too much fun or don't want to get up to leave a classroom. Most kids (and some adults) simply have a strong preference for pooping at home  Some mornings are rushed and there isn't time for a relaxed pooping routine. Keep your antenna up. There are lots of kids that just won't poop at school. Don't let them get backed up.

Prepare for the onslaught of germ season. Good hand-washing habits can help.

Friday, July 14, 2017

How loud is too loud? Protecting your baby's hearing.

With the recent July 4th holiday, a few folks were asking me if the noise from the fireworks could cause hearing damage. Any noise can cause problems if it is loud, close and prolonged.

Mammals are born with lots of very tiny and delicate hair cells in their inner ears. These cells help to amplify sound. Your baby's ears are more sensitive than those of an adult. Not only do they have thinner skulls, but they also have a full complement of these little hair cells, so sounds will have full amplification. Exposure to loud noises over our lifetime damages these cells. As we get older the higher frequencies tend to be the first sounds that we lose the ability to hear.

Your baby's hearing actually starts to develop between 24-28 weeks of gestational age. It is thought that the noises they hear are slightly muffled (imagine what it feels like when you are under an inch or so of water). They can certainly hear well enough that they seem to recognize the voices of those who have been talking to them while they were in utero. I am certain that both of my babies knew my voice immediately.

So yes, we need to make sure that we protect our baby's hearing, but the fact is that all of us need to pay attention to loud noises that can lead to hearing loss.

To give you an idea of how loud various sounds are, take a look at the following list:

Whisper                                         30 decibels
Normal conversation                     60
Telephone dial tone                       80
Traffic noises from inside a car     85
Bart train                                       90 (range from 73-99)
Power mower                               107
Stereo headset                             110
Emergency vehicle siren              110-120
Sand blasting or rock concert      125 
Gun shot                                      140

There are a number of free apps for your smartphone that can act as sound meters. One that my nieces told me about is called Sound Meter  

I played around with it the other day in the office when there was a screaming child in every exam room. That meter went right up!

The longer the exposure to loud noises, the more damage that can be done. OSHA has guidelines set for safe exposure on the job.

85     decibels for 8 hours
88     decibels for 4 hours
91     decibels for 2 hours
94     decibels for 1 hour
97     decibels for 30 minutes
100   decibels for 15 minutes
103   decibels for 7.5 minutes
For those of you who recognize a pattern, good for you! For every 3 decibels over 85, the safe exposure time gets cut in half.

Okay, so what do we do with the above information?  

  • Make sensible choices.
  • Make sure that all earbud or headphones that your kids use are turned down to a reasonable level.
  • Avoid environments where your child will be subjected toPROLONGED long noises (That BART platform is probably not going to cause any trouble unless you spend a lot of time down there.)
  • If you know in advance that you will be in a super noisy place, consider some of the new baby friendly volume limiting headphones...see below for some choices

I have actually had parents call me to ask if it is okay to take their baby to a rock concert. My "NO" possibly reached 100 decibels.

Even though most babies in this country are given a hearing test before they leave the hospital,  it is a good idea to have your child's hearing tested on a regular basis once they are over the age of 3 or 4 (sooner if you have concern.) 

When hearing is assessed, there are two different factors that are measured, the frequency and the loudness. The loudness of the sound is measured in decibels. The frequency is measured on the Hertz scale. The lower tones are the lowest numbers. People with the sharpest hearing may be able to hear frequencies ranging from sounds with tones as low as 20 hertz and as high as 20,000 Hertz. A sound higher that 20,000 is known as ultrasonic. Some animals, dogs for instance, can hear much higher frequencies than humans. Human speech tends to fall between 1000-5000. A patient passes our basic office test if they  can hear a range of frequencies from 500-4000 at the level of 25 decibels.

Any in-office hearing test has the risk of being inaccurate, especially for patients under the age of 4. I have had a patient who flagrantly failed the test, but when I told them I have a secret question, stand behind them, and whisper, "would you like a sticker?" They usually answered, "yes please."

If you are concerned about your kids' hearing (and remember there is a great big difference between hearing and listening), play a whispering game with them and see how they do.
If we all agree that your child is actually having trouble hearing, the next step will be a visit to an audiologist for a much more accurate exam and/or a visit to the ENT specialist.

Thanks to the ladies at Sound Speech & Hearing  for sending information about the following options for hearing protection:

  • We recommend volume limiting headphones for little ears... Puro Sound makes excellent ones which were rated #1 by the NYT Wirecutter this past year. Link here: - kids wireless headphones These are also good for teens and adults who are into really loud headphones (like the popular Beats by Dre, which can hit 110 dB, and become unsafe quite quickly). You can use code SOUND (as in our clinic) for 10% off at anytime.
  • Best hearing protection for babies - earmuffs that have a stretchy headband. We recommend Em's 4 Bubs: ems-for-bubs-baby-earmuffs
  • Lots of options for toddlers and kiddos. We like Baby Banz and Em's 4 Kids. Teenagers exposed regularly to loud sound (example, playing in a band) can invest in custom hearing protection with special filters: tru-customs

They also shared this excellent link

This post is an update of one that I ran several years ago. That one was prompted by piece that the New York times ran about sound machines in babies' rooms.

That question still comes up once in a while. As long as the sound is on a low setting and not directly up against your baby's ear, you don't need to worry. Just be sensible.

Friday, July 7, 2017

Sippy cups/ time to find a better alternative!

One of my favorite aspects about doing these blog posts is that I am constantly learning.

I recently heard and read some opinions about the downside of sippy cups. A child who completely skips the sippy cup stage is the exception rather than the norm, so this seems like something worth looking into. I set aside some time to pick the brain of Jennifer Katz, who is a well known speech therapist here in the Bay Area.

Speech therapists are expects on the movements of all of the mouth and tongue muscles. My time with Jennifer was very informative. She explained to me that as babies grow, their swallow pattern should change and mature. The way in which an infant swallows involves a tongue thrust that is necessary for sucking and latching. As the babies grow, we would expect that they should be moving away from this pattern. With the more mature swallow, the tongue rises higher in the mouth and can do wave like motions that are needed for dealing with more textured foods. Drinking from a sippy cup prolongs that infant tongue thrust.

It isn’t just about eating. When the tongue doesn't elevate, it will tend to rest forward in the mouth and this can impact speech and language development.

In extreme cases, kids can end up with high narrow palates and lower, more forward jaws. Those kids can in turn end up being mouth breathers with an increase in drooling issues. This is the proverbial slippery slope.

Most of the time this doesn’t become an issue, but if we can avoid the possibility in the first place by offering alternative to the sippy cup, it seems like a good choice.

Jody Vaynshtok, one of my favorite speech therapists here in the Bay Area agrees that she is in the anti-sippy cup camp and encourages families to explore some of the wonderful alternatives. Any cup with a retractable straw or real straw can keep liquids in the cups and out of the messy zone.

Have your child practice drinking from a straw:


There are several pop-up straw cups that don’t leak. Once they learn how to use the straw, go ahead and cut the straws so that they are pretty short.This ensures that the tongue can still elevate.

Some cups come with valved toppers. Good2Grow spill-proof bottle toppers have a good shape. The character tops are pretty cute and might encourage some kids to drink more water.  Sports bottles work as well.

 Kid Basix Safe Sippy Cup is another good option that gets good marks from the speech therapists

I understand the convenience of the sippy cup. I would even say that if you are in a situation where a spill can’t be tolerated, then occasional use of a standard sippy cup is just fine.

And calm down all of you moms and dads who have kids that have come to rely on sippy cups! We can’t undo the past. Let’s just move forward with a better plan.
 sippy cups! We can’t undo the past. Let’s just move forward with a better plan.

Here is an addendum from Superstar pediatric dentist Dr Rothman.
Thanks for the sippy cup note. I am an anti sippy cup person for many reasons. Totally in agreement with my friend, Jennifer. Let me add that it also changes tooth and jaw development and causes tongue thrust swallowing patterns. In order for the maxilla to grow in length the nasal septum pulls it forward. There is no primary growth factor like cartilage growth for the maxilla to grow in width. It widens because the tongue solidly pushes on the lateral palatal shelves and expands the upper arch with bone eventually filling in to maintain stability and prevent relapse. because the tongue loses the proprioception of tongue on roof of mouth and is displaced anteriorly, this becomes becomes the habitual placement of the tongue during all swallowing. The roof of the mouth does not grow laterally and the plastic lip from the sippy cup displaces the upper teeth forward and the lower teeth back oftentimes leaving an open bite that may or may not self correct. Optimum time to stop is before 18 months. You can see the parallel with a pacifier. So many people in healthcare just say if it calms the baby then leave it be but it has the same long term effects on the teeth and roof of mouth. Studies have shown an increase in malocclusions and crossbites in children who remain on the pacifier and sippy cup for prolonged periods of time.

Here is another PS from Mama Sarah who says she loves the following cup for her kids

Friday, June 30, 2017

Swimming 2017/An advice nurse's guide

While significant hazards from swimming are rare when safety precautions are in place, there are quite a few issues that the advice nurses deal with on a regular basis.

A common question from families going on vacation is when is it safe for a baby to go into the hotel pool. In general I don’t recommend optional travel until your baby is several months old and has had their first set of vaccines (two sets is better). I am assuming that you are sensible enough that you aren’t planning on taking your one month old on a tropical vacation. If your baby isn’t brand new, then generally my answer about getting into the pool is “sure!”, but there are several factors to consider.

For young babies, a little splashing is okay, but I wouldn’t let them submerge their heads until they are old enough to keep their mouth closed. There are claims that very young infants are natural swimmers and don’t take in a lot of water; I prefer not to test that out. A big gulp of chemical filled water is yucky.

Is the pool outdoors? We all need to be careful with sun but baby’s thin skin is especially vulnerable. Babies need to have a big floppy hat and perhaps sunglasses and sunscreen. Just this week one of our fair young babies got a rotten sunburn on his face  (and it wasn't even particularly sunny out).

Be aware that the reflection from the  water can add to the risk of burning and remember that sunscreen does need to be reapplied even more often if the kids are getting wet. Get in the habit of paying a moment of attention to everyone’s skin at least every 15 minutes. If they are getting pink, it is time to get out of the sun. Don’t wait until they are bright red. While it is true that my fairest patients are the most at risk for a sunburn, all skin pigments should be protected. Shade is best! There are some cute little umbrella baby floats that offer quite a bit of shady protection if you are in a pool.

The next factor is the water temperature. Young babies don’t regulate their body temperatures very well, so make sure that any pool water is nice and warm and that the outside temp isn’t too chilly for them. Most hot tubs and Jacuzzis are too hot for young kids. For any of my older patients and families who enjoy the hot tub, be on the lookout for any pimply rashes that shows up within the next several days. These are often bacterial and may need to be treated.

Anytime you are hanging out at a pool please wear flip flops when wandering around poolside or in the locker room. Fungal infections and athlete's foot happen! A spray bottle with some diluted vinegar solution to spritz on the feet, followed by making sure that the feet are very dry before putting shoes and socks on, are good preventive measures.

Little girls that spend a lot of time wearing a wet bathing suit can also get irritations. It is a good practice to get the kids out of the wet suits as soon as possible. Do a good rinse off as soon as you can and then apply a nice moisturizer to avoid exacerbating dry skin.

We also get a bunch of calls about swimming and ears. If your child has had a recent ear infection they are fine to swim as long as the tympanic membrane is intact. If your child has had ear tubes or a recent ruptured eardrum, they should NOT be submerging their ears in the water (or the bathtub for that matter) without having protective ear plugs.  Sound Speech and Hearingmakes custom ones with sparkly color options that may help with compliance.

If your child has been doing a lot of water play, they may be prone to otitis externa (better known as swimmer's ear.) As opposed to an inner ear infection that requires an otoscope to make a diagnosis, an outer infection is often visible to the naked eye. The ear looks red and sore and may have some drainage. If that is happening, it is worth an office visit so that we can see what’s happening and prescribe some antibiotic ear drops if warranted. Keeping the ear canal as dry as possible may help prevent this condition. There is a simple proactive measure that can be cheaply and easily made by mixing equal parts of rubbing alcohol and white vinegar (50:50 mixture). This solution will increase the rate of evaporation of water in the ear canal and has antibacterial properties. Using this solution to rinse the ear before and after water exposure can help protect against infection.

If you are planning on swimming in open water (lake, river etc) make sure you check ahead of time to make sure there are no advisories. There are some local lakes and rivers that occasionally have some toxic algae bloom that I would not have wanted any of my patients to get near.

I mentioned that drinking pool water is yucky, but I am going to double down on the yuck factor in some lakes and rivers. These are the kids that end up with Giardia. A good rinse after swimming and making sure no water is ingested in very important.

Most of my local families know to be very wary of our local Ocean Beach, but if you are traveling to a place with a warmer and more inviting ocean, never turn your back on the water and beware of currents and strong waves.

Okay, don’t let the “Debbie Downer Advice nurse” spoil your fun. Go have fun swimming!

Some studies claim that  participation in formal swimming lessons is associated with a huge reduction in the risk of drowning. Many folks like the idea of swim lessons for their children as part of their normal routine, not just reserved for vacations. We don’t usually recommend formal lessons until your child is at least 6 months old. For the most part, swimming lessons for kids under 3 years are all about getting your child comfortable in the water. As a bonus, water play is a healthy form of exercise for the entire family and may improve motor skills.

If you are looking for swim lessons, here are some of the great options here in SF. Here are some of the more popular options

La Petite Baleen Swim School . They have several different sites. The one in SF is in the Presidio at 933 Mason St.  866-896-3603

3200 California St
San Francisco, CA 94118 Phone number (415) 292-1200

Mission Bay 1675 Owens St
Phone number (415) 514-4545

There is an indoor and outdoor pool here with all sorts of options for just swimming with your baby or doing classes.

there are several branches in SF that offer swim classes. The May/June sessions are likely full already, but if you plan ahead you may be able to join some July classes.

Stonestown  415-242-7100
Presidio 415-447-9622
Embarcadero 415-957-9622

The city pools also have some classes available but they also fill up fast. Register at to sign up for swim lessons ( and other great classes). This website will also give info about the city pool hours if you are interested in just having some pool time with your kids and skipping the expensive lessons. You may want to go by yourself first to scope out the water temperature.

My kids grew up going to the Janet Pomeroy Center. This is out by the zoo at 207 Skyline Blvd. It used to be called the Recreation Center for the Handicapped. The lovely thing about it is that the pool is very warm. They have several slots every week where you can go and play in the pool with your child. It is reasonably priced, but you need to call to enroll in advance, They don’t have any drop in sessions. The phone number is 415-665-4241

Do you have a pool that should make the list? Please share the info and I will add it to the post.

If your child is enrolled in swimming classes and they have a mild cold or cough, they can probably still go swimming if they are feeling up to it. If they are vomiting or have diarrhea, do everyone a favor and keep them out of the pool!

Saturday, June 24, 2017

Water safety/Secondary and Dry Drowning

When frightening stories make the news, I know that I can anticipate some calls about whatever the issue is. There were some recent stories in the media about secondary drowning. Several parents have reached out and asked me to address the topic in a blog post. Next week I will continue the swimming theme. I had it all rolled into one but it was way too long. You would be surprised how many different body parts we get calls about that are swimming related. You can read all about those next week.

Let’s get the scary stuff out of the way first. Drowning is the second most common cause of death in children in the United States. Prevention is key. A person who is drowning may not thrash about and call attention to the fact that they are having trouble. They can slip silently under the water without being noticed until it is too late. Even if your child has proven themselves to be solid swimmers, you need to stay actively focused and engaged on watching them like a hawk while they are in the water.
If you are staying anywhere with a pool, make certain that your child has absolutely no access to the pool area when there is no adult present. If you do have pool access, there are lots of pool alarms and safety monitors on the market. Hotels or apartments with fountains need to be treated with caution as well.

We had a scare with one of our families a few summers ago. Several adults and children were enjoying a day at a friend's pool in the East Bay. They got out of the pool to have some lunch. Some of the oldest kids started to bicker. While the adults turned their attention to the squabble, a one year old got back into the pool unnoticed and submerged. Thank goodness another of the adults looked up, noticed and was able to get her out and perform CPR. The little girl is perfectly fine, but this was terrifying for everyone. Dr. Karen Makely, one of the wonderful urgent care physicians over at St. Lukes, says that sometimes having a lot of adults around lends a false sense of security. Consider having each adult take turns being on a shift as the designated lifeguard.
Drowning is horrible, but the recent stories that scared the bejesus out of my families were about delayed drowning. You may have heard of dry drowning as well. They are not the same thing.
The primary difference between dry drowning and secondary (or delayed) drowning is the presence or absence of water in the victim’s lungs.

Dry drowning is something that can be brought on in several different ways. The first theory is that a sudden rush of water into the throat causes the airway to go into spasm. During this event, although no water enters the lungs, no air enters either, so the victim dies of asphyxiation. Another explanation is that  the shock of a swimmer’s suddenly entering extremely cold water causes the heart to stop.

Distinct from “Dry Drowning” is secondary or delayed drowning. This is also very rare, but  is something that parents need to know about. Symptoms usually develop within 6-24 after an incident. If someone had a near drowning or accidentally swallowed a lot of water, they are at risk for pulmonary edema from the fluid imbalance to the lungs. They may seem fine initially but then present with cough and increased labored breathing. This usually shows up within 24 hours of the event.

Caregivers of young swimmers should try to head off some of these issues by training their kids to keep their mouths closed when jumping into water and to enter very cold water slowly.  This should help avoid aspirating large amounts of water. There is a big difference between water in the lungs and water in the belly. If your child swallows a lot of water they may end up with a tummy ache but it is rarely dangerous. The recent tragic news story about a child who died in Texas with this diagnosis is a bit of a puzzle. He had days of vomiting and diarrhea. Every physician that I spoke to says that it is respiratory, NOT tummy symptoms, that they would be on the lookout for. There is likely more to that story than is getting reported. It is the outliers that make the news.

Here is the takeaway message. It is important to closely monitor any child who has come out of the water coughing and sputtering. Especially keep an eye out for any further difficulties in breathing, extreme tiredness, or marked changes in behavior, all of which are signs that a swimmer may have inhaled a dangerous amount of fluid. If there is any concern, an emergency room or immediate medical intervention is needed. The first 24 hours are probably the most critical period. It is important to know what to look for, but to reiterate, in over 30 years with a practice full of swimmers, I am not aware of any of our patients having any serious complications from a mouthful of water. 

I spoke to Dr. Tamariz from the CPMC ER. He reiterates how extremely rare this is, but stresses that if any CPR or resuscitation was needed, a follow up emergency room visit is essential regardless of how well they may appear. For the majority of swimmers that accidentally get a mouthful of water, observation at home is fine unless they are showing the obvious symptoms that are listed above. If you are concerned, go the the emergency room. They will check the oxygen level, listen to the lungs, and keep an eye on things until everyone feels comfortable. If clinically indicated they might do an x-ray but it is not automatic.

I am going to close with a little tidbit of common sense. Labored respirations should ALWAYS prompt you to seek medical attention, even if there is no concern about recent swimming.

Next week I will continue the swimming theme, sharing all the possible swimming related call that the advice nurse team receives!

Friday, June 16, 2017

And now a word from Mr. Nurse Judy - Father's Day 2017

Happy Father's Day to all who are celebrating this weekend. 

Warning: Last year when Sandy wrote his first Father's Day Post for my blog, I got reports of parents sniffling all over Bart. Welcome to "Mr. Nurse Judy's" annual post.
XOXO  Nurse Judy

I want to thank you all for the kind comments I received after last year’s post about my wonderful relationship with my children, a relationship that continues to get better, even now as I close in on the end of my 6th decade of life, and my daughters near the end of their 3rd decade. It is a role that is paramount to me, and I refuse to let time and distance interfere with my efforts to continually improve it. So far, I think I’ve been pretty successful, and the rewards are immeasurable. Certainly it’s a lot easier when they are young, living in your home, and “need” you to be involved in their lives. But the foundation you create early for how you want that relationship to be makes it a lot easier to enable it to grow, flourish and blossom at any stage of life, even now as they establish their own lives, careers, and relationships. For those of you who didn’t have the chance to reads last year’s post, you can find it here:

I want to make clear that I have no special training or educational background in this area. What follows are simply my own philosophies about fatherhood; you may disagree with some or all of them. But this is what has worked for me and I cannot really imagine a father with a better relationship with his adult kids than I have!

So first an update on my relationship with my daughters.  At this time last year, Lauren and I were weeks away from traveling to Tanzania for the challenge of a lifetime. AND WE DID IT!!! We summitted Kilimanjaro on the morning of July 19th, an absolutely grueling climb that took me to the very limits of physical, intellectual, and emotional endurance. In fact, I couldn’t have done it without Lauren’s support, and I was quick to make sure she knew that. We spent two weeks together in very close quarters, most of that time unwashed, extremely sleep deprived, and cold. Summit temperature was 24 below zero! The only cross words that were exchanged were over a misplaced towel (I both misplaced it and spouted those cross words!) I never want to face an ordeal like that again!! At least not until April 2018 when we climb to the base camp on Mt. Everest! See – the relationship just keeps giving!

If you are an avid reader of Nurse Judy’s blog, you may remember that when she was in grade school, Alana ended every night by telling one of us all about her day…in exquisite, and often lengthy, detail! The big, the little; the important and the minutiae. Well, more than 20 years later, I get to do that with her all over again. Every day. And I look forward to it and resent it when another friend has a need for Alana’s time! After obtaining her MSW last June, Alana is now a practicing therapist in a community mental health center in Michigan. She has about a 30-minute commute in each direction and on her car ride home, I get to keep her company!!!! And we talk all about our respective days. The time flies past and she is home before we both know it, but not without each of us learning a little bit more about something in each of our lives. What I have primarily learned is that her counseling clients are the luckiest people in the world because they have Alana as their therapist. I listen in wonder and respect as I get to share in the progress they make dealing with the issues that brought them to her in the first place. She is changing lives on a daily basis and I get to be the fly on the wall. I am overjoyed that she still wants to spend that time of her day with me. I frequently tell her that I am in awe of what she is doing and remind her that she has to take the time to sit back and reflect on that also, and not just move on to the next client…  which brings me to my first point of this year’s father’s day recommendations for building that relationship with your children:

Find reasons to be proud, and praise them whenever you can!  From the first time they can lift their head by themselves, to the first crawl, to standing up, and that first use of the potty, let them hear your voice filled with pride and encouragement. Let it become ingrained in them that you are their number 1 supporter, for both the little and big accomplishments in life.  As I mentioned last year, that’s why I took a day off of work to go see a very shy 2nd grade Alana (right now, all her friends are saying “who the heck are you talking about?”) get up on stage just to say one line in a play; it was a grand small accomplishment that deserved to be recognized. When younger, even though they can’t understand the words, they can hear and feel the sentiment in your voice, and for the rest of their lives, that sound will provide great sources of satisfaction and comfort, and it will provide a lifetime of encouragement for future exploration. Now, I am not one of those in favor of participation trophies and I am not saying that everything they do should get this level of exuberance. But be generous with the praise, especially in their formative years.  This brings me to my next recommendation:

Value the efforts too, not just the successes! There is an old saying that good judgement comes from experience; experience comes from bad judgement! It is a cycle that cannot be completed without falling down. So let them fall down, but don’t bemoan the failure; commend the attempt, and any part of the effort that will help them gain “good judgement” next time. It is quite easy for children to focus on your critical evaluation of whatever it is they are attempting, while underappreciating the praise you may simultaneously be conveying. For example, if you’re trying to teach them to throw a ball, don’t focus on the fact that the ball landed by their feet. Appreciate that there are things they may simply be incapable of at any given age. It’s up to you to understand that, not them, so focus on the things that they can do well (gripping the ball, placing the feet, shifting the weight…) and celebrate these building blocks that will one day end up in those ultimate tasks being that much easier, and enjoyable! Simply focusing on the failure of achieving the end result will certainly lead to frustration, and possibly anger and resentment.

It's ok to be wrong. In fact, it’s good! Admit it, and apologize!It is sad when I see a parent who either insists they are never wrong, or twists circumstances to make it seem that they were not wrong in a specific situation. It’s very easy to play that mental game with a child in an effort to demonstrate that you always know what’s best, or think you will be respected because you are always right. Satisfied that you out-strategized a child in this mental arena? Get over it; it’s not that hard. And it’s not that smart. I (and I think my daughters would agree,) created some of our most profoundly important relationship building moments by admitting I was wrong about something, and apologizing for it. Think about it – is there anything more empowering to your young child than having a person in a position of authority implicitly say to them “I not only heard you but I really listened to what you had to say. I thought about it with all my years of advanced experience, education, and knowledge, and I realized that you were right and I was wrong.” Trust, confidence, consideration, kindness, communication…. there are innumerable benefits to acknowledging your own fallibility to your child! And it tells them it’s ok to be fallible too! You don’t expect/need/want perfection, and they don’t have to live up to that standard. And it teaches them that being wrong is a part of life, not something to be defensive about, and can be dealt with responsibly and respectfully.

Tolerance! I mentioned above that you should “appreciate that there are things they may simply be incapable of at any given age. It’s up to you to understand that, not them…”  You must acceptvery early on that you are incapable of thinking like a child, nor they as an adult. Kind of like the “Men are from Mars, Women are from Venus” paradigm, you and your children speak the same language, live in the same environment, are familiar with the same behavioral mannerisms, yet you have such different frames of reference, experiences, emotions, intellect…that at times it will seem to each of you that the other is speaking a foreign language. And you are!! It is so very easy at those times to get frustrated, and even worse, angry. But it is unrealistic for you to expect them to be able to think, analyze, and express themselves at the level you do. They don’t have your emotional and intellectual development and it is unfair to simply use your advanced capabilities as the measure of their intent. When you feel that coming on, take a break, remind yourself of this, and try your best to see things as they do. You most surely won’t completely succeed, but every little bit of empathy you can muster will bridge that gap just a little. It’s also never a bad idea to voice this self-realization; let them know that you are consciously aware that you are cross communicating and invite them to help think about how each of you can get your respective thoughts out. They’ll develop patience, compassion and problem solving skills!

Establish ground rules for how to disagree! My girls and I had a very useful rule – we weren’t allowed to go to sleep mad! The rest of the argument or disagreement could proceed along its natural course, but ultimately it had to end at this rule. It was really quite simple in its effectiveness since it forced (encouraged?) us to resolve our differences. There were times long after bedtime that one of them would either come out of their room to say “I’m still mad” or amusingly, would slip notes under our door detailing the issue (Alana was the talker; Lauren the writer!) This led to frequent comical exchanges of notes going back and forth under each other’s doors but it was such an easily understood rule that it almost always worked! The key though is to take it to heart! As my brother-in-law sometimes says “gravity, it’s not just a good idea, it’s the law,” my daughters and I made this a law, and if one of us was “violating” the law by claiming fatigue, or anger, or issue complexity, or…etc., the other party was free to demand that we follow the law, sometimes leading to late nights and missed bedtimes! But always successful resolutions of the issue. And guess what? Most of what I wrote above represents the philosophies that I tried to use to help make sure each day ended on a happy note.

Happy father’s day to all. See you next year when we get back from Everest!