Saturday, March 16, 2013

sleep tidbits

PLEASE SEE THE UPDATED SLEEP POST August 2019...That post will have links to all the other sleep sections..

Due to popular demand, here are a few sleep tidbits

For the most part I am a big believer that decisions involving sleep  are a very personal choice made by each family to figure out what fits their own unique situation.
Some folks all sleep in the same bed.
Others have the baby in a separate room and the parents are comfortable letting them cry it out if they wake up during the night.
Everyone needs to figure out what works best for their family (and hopefully both parents have figured out a compromise)

I tend to fall somewhere in between the two extremes  (I do NOT worry that your baby will have future psychological damage or attachment issues from some fussing at night)

There are many books out there on the subject and many of them make good points,
Dr Ferber (who tends to be one of the“cry it out guys”) says something that really resonated with me. We ALL have sleep cycles and may have periods during the night where we semi wake up.
You might fluff your pillow, go pee or have a sip of water and then go back to sleep.
But….if you woke up and your pillow was missing, you wouldn’t simply turn over and go back to sleep. You would be up!! Where the heck is your pillow??

Guess what. If you are nursing your baby, they fall asleep and you sneak them into their bed, it is no surprise that when they come to a light sleep cycle they wake up fully. Hey, where is that breast, bottle, pacifier, rocking body?

As much as our instincts lead us to PUTTING the baby to sleep, we are better off letting them soothe themselves down.
It is certainly okay to pat them and make loving shoooshing noises, but every time you are able to put your baby down while they are still drowsy, you are a giant step closer to getting a baby who can sleep through the night.

Feeding at night

Once your baby is over 3 months of age and at least 11 pounds, they can start giving you a longer stretch at night.
I would encourage you to feed every 2 ½ -3 hours during the day. Don’t let any nap go longer than 2 ½ hours.
At night, let them give you a longer stretch. Their little bodies have a lot of growing to do while they are sleeping. It is actually better for them to not be spending the energy digesting.
Watch their pattern. Once they have shown you that they can go 4 or 5 hours at night. Try not to back slide. It is okay to comfort if they wake up, but I would do my best to avoid falling into the “feeding because it is easy” trap.
One of the things I like to say is,  imagine if you were up in the middle of the night and having a hard time getting back to sleep. Someone is trying to help you. They might rub your back or stroke your hair. They might offer  you a sip of water. They would likely not offer you a turkey sandwich.

Eventually we want your baby’s nighttime to be food free.
There are lots of lessons that get taught in a quest for your child to sleep through the night.
In my opinion, let us let the first lesson be that night time is NOT the time for a meal.
I don’t know of ANY sleep training that doesn’t involve some fussing, but my method is fairly gentle.
 I tend to start with fairly low expectations. If a baby is getting adequate milk during the day, no one should need to eat more often than every 3 hours during the night. (let’s consider night time as soon as you go to bed and until the sun comes up)
 If they wake up sooner than 3 hours, someone can check in on them (best not a mom who is nursing) but food is simply not an option until the magic 3 hours mark. After a few days stretch it to 3 ½ hours and so on.
You can certainly check on them, change the diaper, even offer ½ ounce of water. If you think they might be teething go ahead and try some homeopathic teething gel. You are present for them, just not offering food ( think turkey sandwich).  If you want to sit next to the crib and sing, that is up to you. The main lesson is that night time isn’t meal time.

The Ferber method involves going in to check on them and try to settle them in increasingly longer increments. First time might be 5 minutes, then waiting 10, then waiting 15 etc

I have actually found that some babies tend to get much madder if you go in at all and  many parents just leave them awake and crying until the next feeding opportunity has come. You guys need to figure out what works best for you

Night time feedings should always dark, quiet, business like.
Once babies learn to fall asleep on their own and don’t expect to eat at night, you will start to roll in the right direction.

Listen, it is really wrenching to let your baby cry. In my case I had to do some hard rationalization until I was able to go through with it (My husband was the main sleep trainer in our family)

Here are some of the factors that convinced me that it had to happen..
  • Many people are lousy sleepers their entire lives. If you can potentially give your child the tools that it takes to be a good sleeper and it only costs a week or two of crying, it is worth it
  • You have to “put your own oxygen mask on first”. Sleep deprivation is an awful thing. In order to be the best parent that you can possibly be, you need to be rested.

Take shifts.
If you are lucky enough to be in a two parent household, there is no reason for both of you to be up all night. Figure out a way for each parent to get a three or four hour shift of being OFF DUTY.  Once you have spread out the feeding expectations this will get easier to figure out. It is amazing how wonderful that little stretch of being off duty feels. NO guilt. You each get a turn.

Even the best sleeper will need a tune up once in a while. Traveling babies almost always need an adjustment but these little tweaks are almost always way easier than the first go round of sleep training.

If you suspect that your baby may be ill, in my opinion that is not a good time for ‘crying it out’ . I often get folks in to the office for a quick visit with their doctor so that we can make sure they are well. (sometimes ear infections can cause sleep disruption)

Worried about disturbing your neighbors with night time noise? Sometimes a proactive bottle of wine, some ear plugs and little note explaining that you are sleep training goes a long way.

May the force be with you. You will get through this..

milk/ calcium

This post has been updated: 7/2015

The Milk transition.

If you are breast feeding and it works for you to continue to nurse beyond the first birthday, good for you. There will be times ahead when  you are grateful for that breast milk.

Many moms (myself included) wean sooner for any number of reasons.
The first birthday is often the time that the switch is made to whole milk.
If your baby is on formula and tolerating it well, there is no hurry to get off, except for the expense and the hassle.

Formula does have more iron than cow’s milk, so if your child is a fussy eater we often will do a blood test at this age that checks the iron level. Assuming the iron  levels are adequate, it is okay to make the switch.

We want to use whole milk (full fat). If you can afford it, buy organic if possible.

Most kids who were on a milk based formula have no trouble moving on to cow’s milk. It is fine to do it gradually so that they get used to the taste. (Add a few ounces to the formula and see how they do)

Trouble will likely show up as tummy aches, poop changes or rashes if they aren’t tolerating it.
My older daughter got a terrible flare up of eczema when we first got her on milk (it loves to flare up behind the knees and the insides of the elbows).
I put her back on her formula for a couple of months and when we retried the milk she was just fine with it.

Milk is a great source of calcium, protein, vitamin D and the fat that your child needs for brain development. If you have a hard time getting milk into them it is important to make sure they are getting those nutritional needs met by eating/ or drinking other things. If you choose to use a different kind of milk such as goat, soy, rice, almond, coconut…read the labels and see how they compare.

We want kids at this age to be getting at least 700 mg of calcium per day.
You can see from the chart below that this should be reasonable easy if they are eating cheese and yogurt.

I personally don’t feel the need to be completely done with a bottle at 12 months.
I NEVER want a bottle in bed (if they fall asleep and keep the bottle in their mouth it can rot their teeth),  but I am perfectly fine with a snuggle bottle when first waking up, or going to sleep for an extra couple of months.
Do try to transition most of the fluid intake to a cup.

The thing is, once you start moving away from the bottle and transitioning to sippy cup many kids significantly decrease their milk intake amount. They just don’t like to drink as much milk from a cup. I couldn’t tell you why. Some parents feel a little better assuring at least some milk by giving it in the bottle



I have been having a high call volume about rashes this week, so I figured that  this is a good time for the review on rashes.
Lots of rashes come along as part of a virus. This past couple of weeks we have seen a lot of “slap cheek” otherwise known as fifth disease. With that particular illness we have kids with rashes that come and go. This time around some of my patients have had on and off hives. Many times the cheeks are very red. In a future email I will discuss more about the specific virus, but today I want to answer the general question, “When should I worry about a rash?

I divide rashes into one of two categories;
*Rashes that I am worried about

Someone should take a look sooner than later
-If a rash comes along with a high fever,
-If the rash is oozy and crusty
-If the rash seems very painful or itchy
-The rash looks purplish ( doesn’t lighten when you press on it)
(You need immediate attention if there is a purplish rash/ high fever/child who appears ill)
-Your child has hives that come along with a puffy face and difficulty breathing ( this could signal an allergic reaction and needs immediate attention)

*Rashes that I am curious about

If you child seems okay but has a random rash, ask yourself the following questions
-Are there any new medication?
-Are there any new foods? ( pay attention to citrus and berries)
-Are there any new soaps, detergents, bubble baths?
-Have you used a new sunscreen or lotion of any sort?
-Has there been an exposure to a new animal?
-Has your child been in a hot tub?
-Is the weather very warm?
-Has your child been laying in the grass or sand?
-Check the blog, are there any viral syndromes going around that cause a rash?

If your detective work has lead you to an answer, make the common sense adjustments.

For example,
 Your child seems very rashy
Possible cause: They have been eating lots of the little seedless easy peel tangerines this week
Solution: stop the citrus for a couple of days and see if the rash calms down.

My first stab at clearing up many a rash is with two basic staples that are  worth keeping on hand.

*cetaphil cleanser ( no water  needed, apply and wipe off)
If a rash is persistent and your best attempts at clearing it with a variety of OTC creams isn’t helping, it is worth having someone take a look. If the docs are baffled, the next step may be the dermatologist.

creative and inexpesive things to do with your child

I saw a bumper sticker the other day that said good parenting requires Twice as much time and half as much money.
I agree!!  Below is one of the hand outs from my parenting class.

Nurse Judy’s Inexpensive and creative activity list

  • Collect and decorate rocks with colorful paints and glitter for a rock garden.
This is a great one to use as a reward for good behavior. When they see the pretty rocks, they will remember that they earned them.

  • Make a collage. Old magazines and old photos are great for this activity.

  • Make an musical instrument... Use your imagination: a shoe box with rubber bands can be a guitar; Glasses filled with different levels of water make different tones; Tapping different surfaces with chopsticks makes different sounds.

  • Go on a ‘use all your senses’ walk. What do they see, smell, hear, and feel?

  • Create a scavenger hunt walk. Plan a list ahead of time of thing to find…like a dog, an airplane, or even a girl with purple hair.

  • Go on an ABC walk. Find things that start with all the different letters…or find the actual letters on signs and license plates. This is a great game in a supermarket.

  • Download Free coloring pages from the internet. With a little searching, you can get a picture of just about anything.

  • Draw with chalk. Make a hopscotch board.

  • Make your own play dough. You can find the recipe on line

  • Make a fort using the couch cushions

  • Write a story and illustrate it together.

  • Decide on a recipe and bake or cook something. Kids will often try foods more eagerly if they helped with the cooking. Let them help sprinkle in different spices and be the taste-tester.

  • Have a Tea party. Invite the dolls, and get out the good china that you never use.

  • Trace your hands and feet and color them in.

  • Have some down time while watching a video or a special TV program. There are some lovely educational TV programs and videos out there.

  • Play a computer game. Don’t be afraid of controlled use. Children that don’t learn how to be comfortable on computers at a young age are at a distinct disadvantage in this high tech culture.

  • Blow bubbles

  • There is little out there that is as much fun as a big appliance box to get inside of . If you buy a new appliance or see a neighbor buying one, ask for the box.
  • Wash the car!

  • Read!

Teething ( teething tablet coupon)

Please see the updated post October 2016


Normal infants have 20 primary (baby) teeth which have started to develop in the womb.
The teeth start to erupt through the gums around 6 months of age. The baby teeth are then shed at various times throughout childhood.  
Below you will find a chart with the normal range of ages when most teeth start to come and go.
Occasionally I have a patient that scoffs at the charts and does things their own way.
I know of one baby who was born with teeth! Another started out with the upper canines and looked like a little vampire. As you can imagine, those parents were so happy when the rest of the teeth popped through. There is some heredity involved. If one of the parents was very early or late it is possible for the baby to follow suit. Check with grandma to see if she remembers anything special about your teething pattern!
It is rare for teeth to actually make an appearance before 4 months. Once in a while parents will notice a smooth round white bud on a baby’s gum. This is a little benign cyst called  an Epstein Pearl. It is not a tooth and it usually goes away without causing any bother.
Many parents think of teething as something they are only dealing with for their young infants.  Think again.
If your 6 year old is going through an extremely grumpy phase, or has a mysterious bout of mild, clear congestion that has been hanging on for a few weeks, take a feel in the back of the mouth and see if those first permanent molars are starting to pop through.

By age 21, all 32 of the permanent teeth have usually erupted.

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

Lets talk about the symptoms:

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

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

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

Poor Sleeping: If your little one is miserable, this is not the time for sleep training. I would go in and quietly and try one of the teething remedies listed below. If you are going through a rough patch remember that parents should take shifts. Give yourselves each a few hours where you are off duty. There is no reason for both of you to be up all night.

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

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

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

Rashes: If your child has sensitive skin and/ or eczema sometimes you will notice that the general rashiness flares up during active teething
Congestion:  This clear runny nose and congestion can last for weeks and weeks. Sometimes it causes a post nasal drip that in turn causes a little hacky cough.  

Ear tugging: When  kids are working on some of the upper teeth they do tend to poke and play with their ears.
Uh Oh, many of these symptoms are the same thing we look out for if we suspect an ear infection.
Even though teething may well be the cause, if I have a patient who is very fussy , feverish and is having trouble sleeping, I am likely going to want to have someone take a peek in those ears.
It is worth having an arsenal of tools at the ready for dealing with the months of teething that you have ahead of you.
Cool teething rings: make sure they are made out of a safe material. Do not tie any teething rings around your babies neck. This could cause strangulation.
Frozen wash cloth: Wet half of a wash cloth and put it in the freezer. The baby will be able to hold the dry half and chomp happily on the frozen side.
Distraction: There is nothing as nice as a body massage and a warm bath by a calm singing parent.
Teething tablets:  There are several brands.
 Hylands. There was a recall several years ago buy they are back on the market and  are considered quite safe.  
 Boiron brand is Camilia
Click below for a coupon

 I confess that I am puzzled about the mechanics of how homeopathy works, but a lot of my patient's parents feel that they are quite helpful.
Teething gels ( homeopathic):  The most common brand is also made by Hylands.  Try both the tablets and the gel and see if one works better than the other for your child.

Oragel:  Oragel and other commercial teething remedies work by numbing the gums.
I keep this on the list because when used properly it is safe and can be quite effective. It is nice to be able to get relief by applying something topically and not relying so much on systemic medications like Tylenol.
Before I suggest it, I usually tell parents this little anecdote.
Many years ago I had a tooth ache and saw that I had a tube of Oragel in my medicine cabinet. I took a pea sized glob and rubbed it on my gum. Within moments it felt like my entire mouth was numb. It is nice to know that this stuff really works, but the sensation was almost frightening.
If you decide to use this on your baby I want you to put a TINY bit on your own gums first so that you can see how numb the area gets.
Currently Oragel comes with a little Q-tip applicator so that it is much easier to put really small amounts exactly where they are needed.
If care is taken, I am fine when this stuff is used appropriately. As I said, it seems to give relief to some patients. I also need to mention that the ingredient Benzocaine has been linked to something  called Methemoglobinemia * that can be quite serious. It is exceedingly rare. I have certainly never seen it.

(*If you read the fine print on any medication you won’t want to give your child anything. Try to find a balance)
Brandy/ alcohol:
Ask great grandma what she used to do for teething and she may tell you that she used to put whiskey or brandy on the babies gums.
Obviously giving our babies alcohol is not something that most doctors would suggest now a days, but I actually wouldn’t worry if you caught grandma rubbing some directly on the gums. It probably does help. Some folks also say that rubbing pure vanilla extract on the gums is an effective home remedy. That may be from the alcohol content.

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

Acetaminophen (Tylenol) and Advil  (Iburofen) are useful but they are my last resort.
Make sure you are using the proper dose.
Do start with the other approaches. If possible, I would prefer to keep these as remedies for night time use only.
Tylenol ad Advil are quite safe but if they are used for a long period of time they can be stressful to the liver and kidneys
If you find that you have gone more than 5 nights where you are depending on these meds to keep your child comfortable, give your doctors office a call to see if you need to make sure that nothing else is going on.

Once your child has teeth it is especially important to keep bottles out of the crib. Milk has sugar and can cause tooth decay if a baby sleeps with a bottle in their mouth.
It is never too early to start brushing the teeth. Lets get your baby in good dental habits.
(no fluoride toothpaste until they are over two)
Once they have a mouthful of teeth it makes sense to start shopping for a pediatric dentist that you can establish a relationship with. This will come in handy if you have any tooth questions or mouth injuries..
 Your next task is to figure out what the going rate for the tooth fairy is!!  I can’t help you there.
Wishing you easy teething!!

Tummy bugs 101

Topic of the Week:
Tummy bugs 101/dealing with diarrhea and vomiting
This is the updated post from January 2018
By far most of the tummy bugs that we see are caused by a virus. Time will generally take care of these. The typical symptoms are vomiting, loose stools and sometimes fever. Not everyone has every symptom. Vomiting without the loose stools could also indicate something else going on, like strep throat, a urinary tract infection, an ear infection or even appendicitis. When the diarrhea comes along, the good news is that it usually signals that we can narrow our attention to some type of tummy issue. The bad news of course is that when the patient is losing fluids from both ends, dehydration now becomes more of a concern. I also don’t want to minimize how miserable it is when you are in the full throes of an acute GI episode and don’t know whether to sit on the toilet or kneel at it.

If your baby is under two months old and you suspect that they have a tummy bug, we will want to monitor them closely. Young babies can get dehydrated much more easily than a larger child.

If you are breastfeeding, smaller more frequent feeding will often be much easier for the baby to keep down. Of course it is not always easy to know what's up. Many babies spit up on a regular basis daily and normal baby poop is very liquidy. But, if you are worried, they are spitting up more than normal, and have increased fussiness I would suggest getting them evaluated. For a young infant, watery/clear stool would also get my antenna up. With a dehydrated infant, the fontanel (soft spot) may appear more sunken, and they will be significantly sleepier or fussier than usual. If they are nursing well, and peeing fine that is very reassuring.

With any age, the main focus for someone suffering from a tummy bug should be hydration. It is okay and even expected for the patient to have less of an appetite for food for a few days. Unless the person is extremely slender, we are not too worried with a bit of weight loss. Most folks will gain it right back up when this passes. Don’t stress about the food intake. Pushing food will likely just aggravate the situation if they aren’t ready. We just need to make sure that they are getting adequate fluids.

Start by giving clear fluids (breastmilk is fine you have it.) Because we lose lots of electrolytes when we vomit or have diarrhea, it is best to replace the fluids with something that replaces the electrolytes as well. Water is not your best choice.There are products on the market that are specially formulated for this purpose.

Pedialyte is the classic brand that has been around for many years.. There are Pedialyte popsicles that are terrific for older kids. They recently improved the flavor quite a bit, which has improved compliance. It still has a mild soapy taste so not everyone will take it. There is also product out there called Drip Drop that some folks feel tastes a little better. The exercise drinks like Gatorade are another option but have more sugar than the Pedialyte. Consider keeping a Pedialyte product on hand so that you are prepared if a tummy bug strikes. Pedialyte now comes in a little tube of powder that you mix yourself. I would have it as part of your travel emergency kit as well.

I don’t have any hard and fast rules about fluid amounts. Electrolytes are the better choice, but you have to do the best you can if they simply refuse those. Try some diluted juice, coconut water, ginger ale, or colas that have lost some of the fizz . Whatever they are agreeing to drink, I typically wait at least ten minutes after they have thrown up before I offer anything.Think of a drip irrigation system. If all you can get in there is a dropper full, that’s okay! Get that fluid in, drop by drop, ice chip by ice chip. Do the best you can.

If they are thirsty, don’t let them guzzle. Stick with an ounce at a time. If you have a tiny tea set, or a fancy shot glass, those are fun ways to measure small amounts. You can have a star chart for the reluctant drinkers.

Please note, so that you don’t freak out, right before someone is going to vomit, it is normal for them to look quite miserable. Some kids get very pale and shaky. Some folks actually look greenish. Once they throw up, most of the time they feel a bit better and the color normalizes.

If your child has an elevated temperature as part of this illness, a tepid bath can help get the fever down. If the bath hasn’t done the trick, the fever is over 101, and your child is miserable it is worth giving some fever reducing medicine. Ibuprofen tends to be a bit harder on the stomach so I would choose acetaminophen (Tylenol) when I have an illness that includes tummy symptoms. Another advantage to the Tylenol is that it comes in suppository form, so it is more easily tolerated by a vomiting kid. Dosage chart

How to assess hydration

If your child is running around and has good energy, I am usually not too concerned. There is a big difference between subdued and lethargic. Some kids are well hydrated but still feel lousy and are quieter than usual. We can call them subdued. If you have a kid with big juicy tears and lots of drool, they are probably not terribly dehydrated. The body doesn’t waste the fluid.

On the other hand, a dehydrated child is lethargic. They do not want to play. The urine is more concentrated (darker and smellier) and way less frequent. Their mouth feels dry. Their breath might be stinky (of course if they have been vomiting that is probably a given.) Their skin may be dry. Normally if you pinch up a bit of skin on the wrist, it will immediately correct itself. If someone is dry, it may remain up in the pinch for a moment.

If they are refusing fluids or can't keep down anything, you need to check in with your doctor’s office. If they are vomiting up bile (bright green) that is another signal that their tank is really on empty and they need a little help turning things around. These are the kids that sometimes get carried into our office draped over their parent’s shoulder.

If I am giving phone advice, and it sounds like a child is dehydrated,I am usually going to skip the office visit. If the child is lethargic and you have been attempting small amounts of fluids and failing, then a trip to the emergency room is appropriate. Once there your child may get some IV fluids which often perk them right up.

Most of the time the ER is not necessary. Frequent but tiny amounts of fluids is a remarkably effective approach. Generally the vomiting is the first thing to ease. If they remain nauseated, there is a magic pill called Zofran. This is an effective but strong medication. We don’t like to give it without an office visit, to make sure we are not ignoring an underlying cause that needs treatment.

Once your child has started keeping down fluids, it is okay to advance the diet if they are interested in food. More often than not, we expect the stools to continue to be looser than normal for a bit longer. Trust your kids to some extent. I find that most of the time they crave the foods that their bodies can handle. If you have an outlier asking for a hotdog, follow your instincts and say no.

Bland starchy foods are your best bet. I suggest a modified BRAT diet. Bananas, rice, applesauce, crackers, toast, potato, pasta, boiled chicken and watermelon are all okay.
I find that folks have a quicker time getting over this if they avoid dairy (some folks can stay on yogurt and tolerate that fine).

In my experience, getting started with probiotics right away is the key to getting over this quickly. We need to get the gut healthy again so that it can tolerate a normal diet and the good bacteria in the probiotics is critical to this.

There are plenty of good brands out there. One of my favorites is Florajen for kids which you can get from the Noe Valley or Diamond Heights Walgreen’s. It is kept in the back in the refrigerator, but there is no prescription needed. Baby Jarro Dophilus (Whole Foods or health food stores) is another brand that we have had success with. If you have a trusted brand on hand, it is fine to stick with that.

One of the most common calls to our advice nurse team is when a patient seemed like they were improving and have had a bit of a relapse. This is usually caused by advancing the diet a little too quickly (especially dairy.) You may need them dairy free for a week before things return to normal. Yes, this includes cheese....

If your child is keeping food down but has loose stools, I have had great success using the Similac expert care for Diarrhea (it used to be called Isomil DF) It is difficult to find this locally. Amazon might be your best bet. For older kids, I still use this soy based formula as the base for a smoothie:

   -   Similac DF or other Soy based formula
   -   Banana
   -   Frozen yogurt (if not tolerating dairy, find a non dairy alternative)

Mix the ingredients in a blender. This smoothie is usually easily accepted, well tolerated and helps form up the stool. Watch out that it doesn’t do too good of a job. We don’t want to let the poop get hard.

What if it isn’t a virus?
If you or your child has fever, chills, bloody diarrhea and vomiting, that could be food poisoning. The most common culprits are Salmonella, Shigella and Campylobacter. Sometimes the symptoms might not show up for a few days, making it hard to identify the source.

Even though many of those illnesses are self limiting, getting seen is a good idea. We may send a stool sample to the lab to check for a bacterial stool culture. There are special containers required for this. You can get those from the office or the lab. Mom or dad, it is your job to get the poop into the specimen container and to the lab (thank you for your understanding.)

If you or your child are just back from travel or camping and has awful gassy, incredibly stinky stools, we should make sure that you don’t have giardia or some other parasite. If that is a possibility, we would send another type of stool sample to the lab that requires a different set of specialized containers. This is called an O&P (ova and parasites.) As opposed to many of the other tummy issues, these do not usually resolve without help of some medication. If you have a pet with loose poops, that can be an important clue.

With any ongoing tummy issue it is important to get some routine weigh ins.

Many times tummy pain is from constipationGas pains tend to be sharp and intermittent. Any steady abdominal pain that is lasting more than several hours should be evaluated.

With anything poop related, often defense is your best offense. Wash your hands!!!

keep a journal

Welcome to January, the month when people often find themselves making all sorts of resolutions for how to live better.

I have a suggestion for one that is easy to keep and that will potentially bring plenty of smiles in the years ahead.

Start keeping a journal!
Sure, we all take a lot of photos and movies these days, but there is nothing like the written word. 

My daughter 25 year old daughter  Lauren has been on #277 flights.
If you give me a moment I can also retrieve all sorts of odd facts, like the first movie she ever saw in the theatre and when she lost her first tooth.

I started keeping track of things when I first found out I was pregnant. Clearly you don’t need to write things daily, but keeping track of milestones and fun things that kids come up with can create a wonderful database of stuff that you are sure to refer to and enjoy as your children grow

If you like you can create a shared document that both parents can add to.
In our journal ( both kids share the same one) Daddy’s voice was  written in Italics.

My husband had the wonderful habit of documenting conversations.
The following was from when Alana was seven and Daddy was picking her up from school.

Alana:   I'm doing a picture in reds and pinks.
Sandy:   Why?
Alana:   Because Van Gogh had a red period.
Sandy:   You're learning about Van Gogh?
Alana:   Yeah. And then I'm going to do a painting in different shades of
Sandy:   Why
Alana:   Because Van Gogh also had a blue period.
Sandy:   Well that's terrific.
Alana:   And Miss Price is going to bring a real artist to class so he
can teach us.
Sandy:   Well that will be very exciting.
Alana:    But it won't be Van Gogh because he's dead!

It is never too late to start.
In our case I am delighted that we were able to track early milestones like first words and motor skills. Over the years random facts like teachers names, the revolving door of boyfriends and life events have all been documented.

Especially if you have multiple kids keeping track of various illnesses and allergies is something that is useful to be able to refer back to.

When does it stop?? My kids say never. They especially insist that I keep up with their flight tallies!

Warning, time zips by.
The on line journal is a great way to capture moments forever.

Winter holiday safety tips

The winter holidays are a time for celebration, and that means more cooking, home decorating, entertaining, and an increased risk of fire and accidents.

Below are some safety checklists for dealing with the holiday season.
Some of these may seem like common sense but there might be a few tidbits in here that you haven’t thought about.

For instance…button batteries. They are everywhere nowadays in all sorts of small electronics ( and musical cards), These can be quite hazardous if swallowed. Take time in advance to do a mental inventory of items that you have around that may be powered by these.
We have had to X-ray a patient not too long ago, because there was the possibility that a button battery was missing. (They had indeed swallowed it)

Certain Holiday plants like poinsettias are toxic ( especially to someone with a latex allergy). You may not have them in your own house, but if you are  visiting a friend or even a supermarket make sure little hands don’t grab the pretty red leaves and put them in their mouths

Be very careful transporting hot food to a holiday pot luck. I have patients who have been burned from hot food spilling on them in a car.

Since Chanukah comes first this year
*Make sure that all candles are safely out of harms way
*Make sure candles are not close to wrapping paper
*Don’t go to sleep with candles still burning
*Don’t leave the matches or lighters hanging around
*If you are frying Latkes make sure that no one gets spattered by oil

Christmas tree checklist
*When purchasing a live tree, check for freshness. A fresh tree is less of a fire hazard
*Cut 1-2 inches from the base of the trunk immediately before placing the tree in the stand and filling with water to ensure absorption
*check the water level daily to avoid the tree drying out
*When purchasing an artificial tree, look for the label “Fire Resistant”
*Never use electric lights on a metallic tree. The tree can become charged with electricity from faulty lights and a person touching a branch could be electrocuted
*Place your tree at least 3 feet away from all heat sources, including fireplaces, radiators and space heaters
*Make sure the tree is steady enough that it can’t be pulled over by a toddler
*Trim your tree with non-combustible or flame resistant materials
*Before using lights outdoors, check labels to make sure they have been certified for outdoor use
*Make sure all bulbs work and that there are no frayed wires, broken sockets or loose connections
*Plug all outdoor electric decorations into circuits with ground-fault circuit interrupters to avoid potential shocks.
*String of lights and garlands are a staple of holiday decorating, but they can also pose a strangulation hazard.
*Avoid trimming the tree with things that look like candy which may pose a temptation to the kids.
*Keep sharp, glass or breakable ornaments out of reach of small children
*Holly berries and other small decorations can be choking hazards
*Don’t overload extension cords

This is a great time to test your smoke alarms!!!

Stay safe and Have Happy Holidays!

Tylenol dosing charts/ understanding dosages


It is very important to understand the proper dosing of the fever reducing medications on the market.
Acetaminophen is often found under the Brand Name Tylenol.
Ibuprofen is often found under the names Motrin or Advil.
Recent changes by Tylenol to eliminate their concentrated drops have made things a bit more confusing.
A proper dose is calculated by your child's weight. Below you will find a dosage chart to refer to as your child grows.
The number that I want you to focus on is the Milligrams.
If you took a 500mg Tylenol tablet, crushed it and then dissolved it in a teaspoon full of water, You would have 500 mg of Tylenol. If you took the same 500 mg tablet and dissolved it in a cup of water you would still have 500mg...Simply in a different concentration.

Once you know how many milligrams are appropriate for your child, your next step is figuring out what volume of fluid will deliver the proper dose. That will depend on the concentration of the medicine.
The most common form of Tylenol suspension available now has a concentration of 160 mg/ 5 ml
*(one teaspoon is 5 milliliters or ml s)
Double check the bottle to make sure that's what you have and follow the dosing chart below
There are still some brands of acetaminophen out there that are more concentrated and come as 80mg/per dropper (each dropper is .8 ml). It is perfectly fine to use this. Just pay attention to how many milligrams we want to give for your child's weight and calculate the dose
You may need to brush off your high school math skills.
Acetaminophen also does come in suppository form. This is a terrific option for an uncooperative or vomiting child.
Acetaminophen is usually dosed every 4-6 hours.
Ibuprofen is usually dosed every 6-8 hours and should be given with food when possible.

*If your child is under 2 months of age, and you feel that they need these medications, check with your doctor's office. Any young infant with an elevated temperature needs to be evaluated.

Doses are every 6-8 hours

Milligram Dosage

Advil/Motrin Drops
Children's liquid
Chewable Tablets 50mg each
Junior strength Caps or chews 100 mg each
9-10 lbs >3 months

1/3 dropper(0.625ml)
11-16 lbs

2/3 dropper(1.25ml)
1/2 tsp (2.5ml)
17-21 lbs

1 dropper(1.875ml)
3/4 tsp (3.75ml)
22-26 lbs

1 1/3 dropper(1.875ml + 0.625ml)
1 tsp (5ml)
2 tablets
1 tablet
27-32 lbs

1 2/3 dropper (1.875ml + 01.25ml)
1 1/4 tsp (6.25ml)
2 1/2 tablets

33-37 lbs

2 syringes (2 x 1.875ml)
1 1/2tsp (7.5ml)
3 tablets
1 1/2 tablet
38-42 lbs

2 1/3 dropper (2 x 1.875ml + 0.625ml)
1 3/4 tsp (8.75ml)
3 1/2 tablets

43-53 lbs

2 2/3 dropper (2 x 1.875ml + 1.25ml)
2 tsp (10ml)
4 tablets
2 tablets
54-64 lbs

Use liquid or tablets
2 1/2tsp (12.5ml)
5 tablets
2 1/2 tablets
65-75 lbs

3 tsp (15ml)
6 tablets
3 tablets
76-86 lbs

3 1/2 tsp (17.5ml)
7 tablets
3 1/2 tablets
87-95 lbs

4 tsp (20ml)
8 tablets
4 tablets
> 95 lbs



Milligram Dosage

Children's liquid 160mg/5ml

Junior strength Caps or chews 160mg each
5-8 lbs

1/4 tsp
9-10 lbs

1/3 tsp (1.8ml)
11-16 lbs

1/2 tsp (2.5ml)
17-21 lbs

3/4 tsp
22-26 lbs

1 tsp (5ml)
2 tablets
1 tablet
27-32 lbs

1   1/4 tsp
2 1/2 tablets

33-37 lbs

1 1/2 tsp (7.5ml)
3 tablets
1 1/2 tablet
38-42 lbs

1 % tsp (8.75ml)
3 1/2 tablets

43-53 lbs

2 tsp (10ml)
4 tablets
2 tablets
54-64 lbs

2 1/2
5 tablets
2 1/2 tablets
65-75 lbs

3 tsp (15ml)
6 tablets
3 tablets
76-86 lbs

3 1/2 tsp (17.5ml)
7 tablets
3 1/2 tablets
87-95 lbs

4 tsp (20ml)
8 tablets
4 tablets
>95 lbs