Friday, April 13, 2018

Constipation 2018/Because the poop has to come out!

Constipation - The poop, the whole poop, and nothing but the poop

One day your kids will be completely out of diapers. Believe it or not, the day will come when they no longer want you to wipe their butt after a poop (that age tends to vary greatly from child to child.) The years pass and while at some point you tend to lose track of your child's bowel movements, it is the rare parent that gets a completely free pass. If you are a patient of Noe Valley Pediatrics, I am betting that at some point before your child goes off to college, you are going to have a conversation with the advice nurse team about your child's BMs.

It is quite common for kids to occasionally complain about tummy aches. In my experience, a full 90% of these are constipation related. Of course we never want to ignore other possibilities. Abdominal pain could be all sorts of other things that need attention. Tummy aches that come from constipation tend to be very sharp, but also intermittent. Sometimes the pain can radiate to other parts of the body.

If we have a patient with a complaint of a tummy ache, we are going to want to know the frequency and consistency of the stools. Here is the tricky part. If your kid is really backed up (and it is unbelievable how much poop they can have inside of them) sometimes the solid poop can't get through. What they will pass is some very runny substance that is getting around the solid mass of impacted stool. Because of this, your first thought might be that your child has diarrhea. Sorry kids, but the parents now need to know way more than you might be comfortable sharing. When was the most recent poop? Was it normal size? Smaller than usual? How often are they pooping? Are they sitting for a long time trying to get it to come out? Are the stools coming out in little hard pieces? If your older child is feeling a little bit shy about it, consider having them take a picture. There is something called the Bristol Stool chart that can help with the description.

Having a regular poop routine is helpful (particularly for boys who stand to pee). They should get into the habit of sitting on the toilet for 5 minutes at least 2 times per day, even if they don't think they have to go to the bathroom. Ideally this will be done after meals. Sitting on the toilet should be limited to 5 minutes and there should be no straining! (Maybe take the Harry Potter book out of the bathroom.) After 5 minutes, just get the kids up - if they have the urge again, then they can sit back down. Many children don't like to poop at school or camp. (Hey some adults have strongly prefer the privacy of their home bathroom as well.) If they happen to get off schedule and the urge hits them at an inconvenient time, they will often hold it until the urge passes. Some kids become very adept at this and can hold onto a remarkable amount of stool. They may pass a tiny little hard pellet every day or so. If you ask them if they pooped, the answer will be "yes".

I like to do a little 'Nurse Judy poop math' (this can't possibly surprise any of my regular readers.) Figure out how large your child's average size stool might be. Let’s say it is the size of a hot dog. Assume your child doesn't have a BM for 3 days. For the next 6 days after that, they pass only 1/2 of a hot dog size poop. Within 9 days, just a bit over a week, they now have poop in there the size of 6 hot dogs. No wonder they are having a tummy ache!

It is time to sit and talk to your child about a very important rule.

There are many choices that we will face in our lives with very few incontrovertible truths, but this is one of them: THE POOP HAS TO COME OUT! Have your younger kid play with some play dough and a toilet paper tube. Only a certain amount can fit through before something rips. Not pooping is not an option. These kids need to be cleared out. All the prune juice into the world is not going to be able to blast through an impacted mass of stool.

Thanks to Dr Wild for telling me about the following video!

Parents can take a look and see if you think it might be a good teaching tool for your child.

Massage and a warm bath are a good starting point. Some kids actually maybe able to pass some stool while in the tub because they are relaxed. I know it sounds gross, but if you are ever in this situation with an utterly miserable child who is holding onto their poop as though it is a treasure, you will be happy to see them poop anyway that you can make it happen. Some people find that adding a few teaspoonfuls of either baking soda or epsom salts to the warm bath water will can also help.

If they still haven’t pooped, it is time to try some glycerin into the butt. You have several options. A glycerin suppository is a hard stick of glycerin, usually found at most drugstores in the baby aisle. You can break off a piece, lube it up with some KY jelly, Vaseline or Aquaphor and just stick it in there. Hold the butt cheeks together so that your child doesn’t push it right back out. Another option (which I prefer) is a liquid glycerin called Pedialax. The directions on the box advises that these are for use in kids over 2, but I have no concern about using them on infants. With these, you end up inserting the lubricated tip of the applicator into the butt, squeeze in the small amount of liquid glycerin and then remove the applicator. They usually work some magic within 30 minutes.

Chronic constipation is not a quick fix. The first step is obviously to get rid of the poop, but then the muscles need some time to be retrained.
Once you get some of the hard stool out, we can start to focus on making some adjustments to the diet. Alas, the favorite foods are often the starchy breads, cheese and pasta that do nothing but block them up even more. The BRAT diet (bananas/rice/applesauce/ toast) is what we use to firm up stools if a child has diarrhea. When dealing with constipation issues we will want to avoid those until they are having softer stools. Some kids seem to have a much easier time if you eliminate milk. Try that for a week and see if it helps (if you do this, make sure they are getting enough calcium.)

Fruits and veggies are great. Smoothies might be useful if they won't eat them raw. Make sure they are drinking plenty of healthy fluids. Sometimes simply the addition of extra water or prune juice are all that is needed to get you back on track. Pineapple, peeled grapes, figs and raw crunchy red peppers can be especially helpful additions to the diet. See if you can somehow hide some molasses and flaxseed oil in some oatmeal or baked goods. Kids will often eat something if they had a hand in baking it. Do a daily dose of probiotics. These help keep a good balance of healthy bacteria in the gut which is good for digestion.
Fiber is essential. The usual rule of thumb is that a child should be consuming their age + 5 in grams of fiber (For instance, a 10 year old needs 15 grams of fiber, a 15 year old needs 20 grams of fiber per day). This is up to a maximum of the adult dose of 25-30 grams per day. It is important to make sure that all this fiber is washed down with lots of water. Too much fiber and too little water will actually bulk up the stools and worsen constipation. If you are finding it a little tricky trying to get enough fiber into their diet, try offering FiberOne bars, fiber gummies, fiber powders (Metamucil, benefiber, citrucelle, etc) to get to their goals.

Make sure your child is getting enough magnesium. Natural Calm (available at Whole Foods and natural food stores) is source that many folks like. An appropriate dose can get even the most stubborn gut moving. There is no way to “overdo” magnesium by eating magnesium rich foods, but you don’t want to take too much in a supplement form.
Kids ages 4-8 can take 130mg/day; kids ages 9-13 can take 240mg/day. The Natural Calm adult dose is 175 mg/tsp (mixed in other liquids.) Big kids can easily take 1 to 1-1/2 tsp. Smaller kids a bit less. If they take too much it might cause cramping. Start with a small dose and see if it helps.

Posture makes a difference! Go online and check out the Squatty Potty. Some of the reviews are quite amusing, but the overwhelming verdict is that many people are finding this a deal changer. In other cultures, people squat to poop and have no issues. Talk about your “third world problem”. It turns out that our sitting position is not really helping our body with elimination. You might want to experiment with a little footstool in front of the toilet or potty that gets your child in a better position. You can try it too!

If you have a young child, check out the book Itsy bitsy Yoga. Some of the stretching positions might help move things along.

Acupuncture is another option. Check

We have had some success sending folks for biofeedback. Alas this may or may not be covered by your insurance.

If massage, position and good diet don’t seem to be doing the trick, talk to your doctor about getting your child on Miralax. Miralax is an over the counter fiber that is heavily used by pediatric GI specialists to deal with constipation. Miralax has recently had some articles about it that made some folks uncomfortable about it’s use. There are no studies about its safety for long term use and one of the biggest concern is the lack of testing in pediatrics. While that is true, official studies aside, it has been used for years and years without any known contraindications The specialists don’t seem to have concern about the safety. Miralax doesn't get absorbed into the system. What it does is pull the fluids into the intestine to make sure the stools are softer. We have some patients who are on it for an extended period of time with no ill effects. That being said, I never want anybody on medication that they don't need.

If your child has been given a dosage for a course of Miralax, I am perfectly happy if you do a daily adjustment of the dose depending on that day's stool. If it feels like you are already achieving softer stool, it is okay to decrease the dose and perhaps skip a few days. The minute the poops become less frequent or more solid it will be time to bump back up the dose.

If you are pretty sure you child is not constipated and they have an abdominal pain that is more steady than intermittent, they need to be evaluated!

Thanks so much to the wonderful UCSF GI specialist, Dr. Wild, for helping me update this post!

Friday, April 6, 2018

Urgent Care Options 2018

Urgent care/emergency options 2018

Murphy's Law generally seems to make certain that the fever spikes or the vomiting starts right at 5:01 pm when the average doctor's office turns their phones off. It is important to be familiar with your after hours/urgent care options.
Some of the common calls that folks need help with after hours are dosage questions. Here is the link to a post with that info:

Waiting until you or your child is ill is not the best time to start learning about what choices exist in your area. Does your insurance plan have a preferred option that won’t cost as much? Are there after hours advice nurses available? Where is the closest emergency room? Is it staffed with pediatricians?
If you are traveling, plan ahead and figure out local options for care before the trip.
For Noe Valley Pediatrics patients who need help after hours, we ask you to start with the pediatric after hours clinic/triage nurse line:415-387-9293
If the nurse is NOT able to help, you will be directed to our answering service where the Noe Valley Pediatrics physician who is on call that night will be paged. The answering service number is415-753-4697

Here in the San Francisco Bay Area we are lucky to have very good options for after hours care.

In San Francisco 3490 California Street, Suite 200                         415-387-9293
In Berkeley 3000 Colby St Suite 301 (New Location 7/2017) 510-486-8344  
Patients are seen by appointment:
Monday through Friday 6:00 pm - 9:30 pm, (phones open at 5:00for appointments)
SaturdaySunday and holidays 8:30 am -9:30 pm (Phones open at7:30 am)

Weeknight pediatricians are made up of participating private pediatricians, including several of our doctors who work an occasional shift in the clinic there. Weekend doctors are fully trained and board certified pediatricians.
On weekdays the phone lines turn on at 5 pm. The advice nurse triage team is available through the night, even after the clinic is closed. The availability of the triage nurse makes this our number one choice.

The Pediatrics After Hours Care at St Luke’s Hospital is affiliated with Sutter/ CPMC and is located at 1580 Valencia Street, 7th Floor #701 This clinic has been open for about two years now.
It is now open 7 days a week.
Monday-Friday 5:00pm-10:00pm
Saturday-Sunday 8:30am-10:00pm
Phone: 866-961-8588

This service does not currently have an advice nurse team, but the person answering the phone can help do some basic triage when making the appointment and help redirect you to an emergency room if that seems necessary. This clinic has some advantages besides the convenient location. They start the scheduling process as early as 2 pm, which may make it easier to make a plan if we are already solidly booked here in our office and can’t get you in to see us that same day. They also offer weekend weight and bilirubin checks for our newborns. As a bonus, there is a special waiting area so that the healthy newborns aren’t exposed to the other sick kids.

The two options listed above are the only urgent care facilities with which our office has a close relationship.
When things are going as they should, both of the above after hours options send a report to the primary doctor's office. In our office, the nurse team reviews the reports and follows up to see how you are doing to maintain a sense of continuity. Most of the insurance plans that we are in network with are accepted, but not 100%. Do yourself a favor and know your best covered options before your child gets ill!! No one will be able to get you accurate coverage information outside of business hours, which is when you might be needing it.

I am listing the others below as a convenience.

If you are not in San Francisco, on the Peninsula you have several good options. is a pediatric urgent care facility. There is no appointment needed.
210 Baldwin Ave in San Mateo. Telephone 650-579-6581

The Palo Alto Medical Foundation has several pediatric urgent care options:
They have a choice of appointment or drop in. The website gives info about the various locations and current wait times.

In Marin
6:30 pm-9:30 pm Monday through Friday
9:00 am-9:00 pm Weekends and Holidays

There are plenty of general urgent care places popping up all over the place as well. Keep in mind that with most urgent cares, there is no such thing as an appointment and folks just show up and get seen in the order that they come in. There is risk for a much longer wait. They are also not usually staffed with pediatricians. For a teen, this is usually not much of an issue, but for my younger kids, I would try to stick with one of the pediatric after hours clinics. If you do end up at another urgent care, please ask them to send over a report so that we stay in the loop.
Emergency Rooms
In a true emergency of course call 911. If it is less urgent, but you are certain that you child needs immediate medical attention we are lucky to have excellent options here in SF.
When given the choice I will generally opt for one of the true pediatric emergency rooms. You are not competing for care with the elderly heart attack and stroke victims that may be populating the waiting room and getting ranked higher on the triage scale. You will also be assured of seeing a pediatrician and having appropriate pediatric equipment. If an admission is needed, my preference would be either CPMC California campus or UCSF Mission Bay, so there also won’t be any transport needed if you are already at one of those ERs. I think it is worth the extra ten minute drive across town and may save you time in the long run.
The UCSF Pediatric ER in Mission Bay is located at 1975 Fourth Street:
This emergency room has scored very high in a nationwide ranking for getting patients seen in a timely manner.

CPMC pediatric emergency room is located at 3700 California Street/ at Cherry:
This ER generally gets high marks from our patients.


While we strongly prefer to have our youngest patients be seen by a pediatrician, there are ‘those days’ when our office is completely booked up early. If there is something going on that is not worthy of an emergency room visit and you don’t want to wait until the pediatric urgent care offices open, here are some options.
With any urgent care, make sure they send a report to your primary doctor’s office. If you were not seen by a pediatrician, it is always a good idea to touch base with your own doctor the next day to review the diagnosis, treatment plan and follow up needs.

Care Practice
This place is not terribly far from our office on 14th and Guerrero.
They are a fee for service practice.
They will see all ages.
Visits are appointment only. They are currently open 4 days a week.
They do not have X-ray or Ultrasound capabilities

Golden Gate Urgent care

There are several locations. These folks do take some insurance They do see pediatrics for basic issues. They also do x rays.
You can drop in, but it makes sense to book an appointment online to minimize the wait time.

If you get labwork or Xrays done at an urgent care, please realize that you will need to follow up with them for the results.

Friday, March 30, 2018

Vision Health/ eye doctor resources

Topic of the Week:
Vision Health/ Eye Doctor resources

Early intervention for eye abnormalities is very important.
Parents are often the first to note if there is something going on that doesn’t seem quite right.
Are the eyes watery or gooey? This could be a blocked tear duct.
That usually resolves in a few months, without any intervention.

There are always individual variations with developmental milestones, but many babies' eyes don’t track too well until they are about 3 months. Once they are old enough, parents should pay attention and see if the baby can follow an object with both eyes. If one eye wanders, that is something we want to get checked out.
Check the pupil size. Are both about the same size? There are some kids with normal variations, but it is worth noting this ahead of time. I have had parents frantic after a mild head injury when the pupils were noted to be a bit unequal. It turned out that this was just the baseline. Noting it in advance would have saved some stress!

If you take a photo with flash and there is “red eye,” look to see if the reflection seems to be hitting both eyes in the same general area.

In our office we actually start doing eye screenings for our patients as early as 6 months. We can screen for a variety of abnormalities with our iscreen machine.

Several years ago when I did this post for the first time, Dr. Good, a popular pediatric ophthalmologist, said he has been fairly impressed so far with issues that have been discovered early. While most of the conditions don’t actually require any intervention, having the patients identified so young is very valuable, because we can now know to monitor them closely

Once the kids are four or five years of age and old enough to cooperate, we do the Snellen eye test. This screening for nearsightedness is usually done in conjunction with the routine annual well child check up. The operative word here is screening. Farsightedness or astigmatism are usually not picked up without a full eye doctor exam.

The gold standard recommendation is a complete eye exam by an eye doctor at 3 and 5 years. At that point, the decision for how often routine exams are needed may depend on your child. Obviously if your child seems to be squinting it is worth getting them in sooner.
There is a genetic component to eye issues, but kids should be checked even if the parents have perfect vision.

What is difference/ need between ophthalmologist or optometrist for basic child eye health?

Ophthalmologists are specialists that deal with the full range of eye care, but they are also surgeons who can deal with any eye abnormality or condition. Optometrists might be your best bet for any simple vision issues. Finding someone who regularly works with kids is pretty important.

If there is a medical diagnosis some insurance companies will cover the cost of an eye exam.

It is worth checking in advance with the eye doctor's office as well as your insurance or vision plan to see if there is an advantage to seeing one or the other.

I don’t think people necessarily need to add vision and dental plans for the kids during the first year, but after that, especially if they come bundled, it is probably worthwhile.

If your child does need glasses, make sure they get their vision checked yearly (or more frequently as needed) to make sure the prescription is correct. If the myopia is getting progressively worse, believe it or not multi-focal contact lenses may help slow things down. They can be started with some cooperative children as young as 5!

You might not make an obvious connection, but headaches, dizziness, motion sickness, and ADD can all be associated with eye problems. Even anxiety can be related!

There are likely plenty of good eye doctors in the Bay Area,
The folks on my list are ones that I am familiar with. If you are aware of someone excellent who should be on this list, please let me know.


  • Dr. David Grisham and Dr. Jeremy Shumaker at Vision Academy and Rising Star Optometry are top notch and do see pediatric patients.


  • Both UCSF and DR Good have a fairly long wait time for an appointment so planning ahead is a good idea. Both offices will require a referral from your primary pediatrician before they will make an appointment. Be aware that when we send the referral it might take a week or so before they make contact with you to schedule an appointment

  • Kim Cooper Check out her website. It is more fun than most! Dr Cooper is down on the Peninsula but many folks feel that it is worth the drive to see her. She shares that her most important eye tip is the need for quality safety goggles. If your child is playing any sport where there is danger of getting hit in the eye by a ball or body part, they should be wearing eye protection. Not a week goes by that she isn't dealing with a sports related eye injury. Most are minor, but the serious ones are devastating.Her office happens to be great resource for getting quality goggles.

Free E-Book Helps Kids Get Ready For An Eye Exam

Howard the Hedgehog visits the eye doctor for the first time. Initially he's doubtful, but he ends up having a great time and seeing much better thanks to his new glasses! During show-and-tell, he shares with his classmates what he learned about vision tests.
That's the plot of an e-book you can download for free and share with your children. Not only is Howard and the Amazing Eye Examfun to read, it's very educational and reassuring for kids who may be worried about visiting the eye doctor.
The e-book has cute illustrations and was created by Alcon's The Eye Solution team and Dr. Catherine McDaniel, an optometrist who teaches and practices at The Ohio State University. You can download the e-book for tablets and computers on Amazon  andGoogle Play .

There are some common sense things you can do promote good eye health.

  • Get outside! Get in the habit of wearing sunglasses when outside during the day. Ideally they should be made out of a strong poly-carbonate plastic that is shatterproof. Floppy hats or visors are also a good idea.

  • Recent studies show a 30-40% decrease in myopia (nearsightedness) with daily time outdoors.

  • Try to minimize the “blue lights” that we are surrounded with by screens in our world.

  • The American Academy of Pediatrics recommends no more than 2 hours of recreational screen time/day.

  • Eat well!

  • Carrots and foods with Vitamin A are good, but the dark green leafy vegetables are the real super helpers of the eye because they have lutein and zeaxanthin (go ahead and impress people at your next cocktail party with that one)

  • These two eye nutrients help replenish the pigment in the retina and can prevent diseases of the eye. Peppers turnips and paprika are also a good part of an eye healthy diet.

  • Avoid smoking or exposure to secondhand smoke.

Fun Facts:

  • You may not be able to know your child's ultimate eye color until they are a year!

  • Your baby might be crying, but they usually don’t develop actual tears until they are between 4-13 weeks

  • The eyes are the fastest muscle in the body and blink an average of 17 times/minute

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!