Friday, May 31, 2013

Dealing with a tick bite/ prevention

The weather is warm, the families are out enjoying some hiking and unfortunately the ticks are out there biting.

Of the many varieties of ticks out there, the ones that can transmit diseases to us are the deer ticks.   

Although only a small percentage of tick bites are harmful, the diseases can have a major health impact, so we need to pay attention.

The key is prevention.

If you are going to be walking or hiking in densely wooded areas, light colored long sleeves and long pants are recommended. Spray the clothing with the bug repellent permethrin. (Okay for anyone over 2 months of age) 
Use Deet on exposed skin.

But let's face it, on a hot day we are not going to have our bodies covered completely, so here is the deal....
Everyone needs to get a naked head-to-toe body check after a walk in the woods. If you are camping, do a full body check daily.
Ticks can hide in out of the way places on your body. Don't forget to check the scalp. If you are dealing with thick darker hair, you can rub your fingertips along the scalp and feel for any bumps. Check in between the fingers and toes, check arm pits. You really want to be very thorough.
Many of the ticks are very tiny and hard to see. Be familiar with little moles and freckles so you can recognize a new spot which might be a little tick. 

If you are returning to your home after a hike, take all clothing and put everything in a hot dryer for 60 minutes to kill any wandering ticks.

It is very important to remove the tick as quickly as possible.
 If a tick is removed within 4 hours of the bite, the chances of any disease transmission are SIGNIFICANTLY decreased. For Lyme disease, the tick generally needs to be attached for more then 24 hours to be a concern.

If you do find a tick, the best way to remove it is with tweezers or a special tick removing tool. Grasp the tick as close to the skin as you can and firmly pull up and away. Do not twist. The Public Health department councils that you should not try any of the folk remedies such as Vaseline, burning match etc.
If you own a dog or go hiking frequently, do yourself a favor and get one of the tick removing tools. You can get them pretty cheaply from any sporting good or pet store. Amazon has a ton of different brands. I do not have a favorite.

Once the tick is out, clean the area with an antiseptic soap, apply a dab of Neosporin and then keep watch on the area to make sure there is no infection.

Okay, We got a tick bite. We removed it, but now what???  Of course it is easy to get a little freaked out.

*watch the site for sign of local infection

* observe for 30 days, If there is any odd rash, flu like illness, aches, or fever it is important to notify your doctor.
We will want to know the date of the bite, and if possible the region where the tick came from. Any recent travels are important data.

Unfortunately the blood tests for tick borne diseases such as Lyme are initially not all that helpful. To start off with, you can get both false positive and false negative results.(Making it pretty useless) 
It turns out that once you have symptoms several weeks after the bite, the tests are apt to be more accurate, but that isn't all that helpful right after the tick encounter when we are trying to decide whether or not to treat.

One option you have is to get the tick tested. 

The Sonoma County Health Department will identify the tick for free and test it for lyme disease for a very reasonable fee. (They don't test the ticks for other illnesses) They do the testing every Thursday and get you the report by Friday. They say that about 1-3% of the ticks test positive.

Read the instructions on their website for how to send the tick 

Essentially what I suggest is:
Regardless of whether or not you get the tick tested....
Watch the person who has been bitten very carefully for the next 4-5 weeks.
If there are any suspicious symptoms within the month following a tick bite you absolutely want to speak to your doctor about doing a course of antibiotics.

 Reactions that are a cause for concern would be a bull's eye rash around the tick bite site and/or any type of flu symptoms.
Not everyone gets all symptoms.

We don't want to treat every tick bit with antibiotics for obvious reasons.
As with everything, we need to strive for balance.
We can't keep our kids in a box.
Go out there and enjoy the hike, but then do that thorough body check and you should be fine.

Thursday, May 16, 2013


Please see the updated version of this post  August 2015
Believe it or not, one day your kids will be completely out of diapers. Then the day will come when they no longer want you to wipe their butt's even after a poop. (That age tends to vary greatly from child to child).
The years pass and you at one point you may lose track of your child's bowel movements completely. That being said, 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 me about you child's BMs.

It is quite common for kids to occasionally complain about tummy aches. In my experience a full 90% of these are from constipation. 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.

If I have a patient with a complaint of a tummy ache, I am 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 liquidy 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?

I have a theory that many children don't like to poop at school. 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 do. 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 followers)
Figure out how large your child's average size stool might be. Lets 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. Massage, a warm bath and sometimes a pedialax will help. (some kids actually maybe able to pass the stool while in the tub because they are relaxed. I know it sounds gross, but if you are ever in this situation, you will be happy to see them poop anyway that you can make it happen)
Once you get some of the hard stool out, we will need to concentrate on getting them onto a more comfortable poop schedule as well as focus on diet.

Alas, the favorite foods are often the starchy breads, cheese and pasta that do nothing but block them up even more. Until they are having softer stools, you will likely have to make some adaptations to the diet.
Some kids seem to have a much easier time if you eliminate milk.
Try it for a week and see if that 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. Pineapple, figs and raw crunchy red peppers might be especially helpful
See if you can somehow hide some Molasses and flax seed oil in some oatmeal or baked goods.
Do a daily probiotic. These help keep a good balance of healthy bacteria in the gut which is good for digestion.

If being on a good diet doesn'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. It is considered quite safe. It doesn't get absorbed into their 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 give a dosage for a course of Miralax, I am perfectly happy doing 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 have a young child, check out the book itsy bitsy yoga
Some of the stretching positions might help move things along.

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!

Saturday, May 11, 2013

Toilet training tidbits

Please see the updated post May 2017

Poop Chapter 3 

Toilet training is one of those Hot button topics that seems to have lots of very differing opinions.

The most basic thing to pay attention to is how unique each of our children is.

My kids were no exception to this.
My first daughter Lauren was fast at everything she did. She was singing show tunes at 18 months. She was interested in the potty and was mostly trained well before she was 2.
But sure enough, she went through a period of horrible constipation. Watch out for those early kids. I see this happen ALL the time!

Alana took her time with all of the milestones. Having my older kid do everything so quickly made it feel even slower. She was slow to walk, slow to talk and not in the least bit interested in getting rid of the diaper.

Be careful how you ask the questions.
Me: " Hey Lani, don't you want to be a big girl? Do you want to wear these wonderful big girl undies?"

Alana: " Nope. I like being a baby. I like my diapers"

Hmmm, for some reason, that wasn't the response that I was expecting and I didn't have a follow up.

Just when I was figuring that this 'big for her age' almost 3 year old would need to start wearing "depends" all of a sudden she was magically ready. She asked for underwear and barely had an accident after that. As with everything, Alana waited until she was good 'n ready before doing anything and then simply mastered it.
* the first poop in the potty was 5/31/93 How can I possible know this???? Check out the "keep a journal post!"

Watch your child cues.

For all kids I suggest getting a selection of the children's books and videos about potties training. Let them get familiar with the concept that some day, big kids pee and poop in the potty or toilet.

There are all sorts of potty seats. Some have steps and fit over the toilet. Others play music. Talk about all of the options that are out there. Which one would your child like to try?

Let them watch you do your business. Although, most kids start out by sitting down, little boys and dads...go play the "sink the cheerio game" (I don't really need to spell that one out, do I?)

Do everything in your power to keep the stools soft. If you don't pay attention, you can be heading for trouble.
Toddlers are now physiologically able to hold their poop. If they hold it too long, it will be uncomfortable coming out...this will make them want to hold it even more.
Make sure they are getting plenty of fluids and fiber. Have them help you bake some muffins full of prunes, and molasses and all of those wonderful 'make you poop' ingredients. Kids tend to like to eat what they help bake. See if they will drink a smoothie that they helped make in the blender. It is worth your energy to make sure those stools don't get hard enough to hold. Be creative!

Many kids will easily make the transition to the potty between 2 and 3.
Wave a new package of big kid super hero or princess undies around and they may be sold.

Do watch out for reward backfires. With Lauren we were offering some little M&M for each poop in the toilet. She proudly squeezed out a pea size piece of poop, brought the potty and received her treat...."but wait Mom and Dad...look there's more!"

Aside from show and tell and talking about it, I usually leave the more recalcitrant kids alone until they are 3ish.

Disposable diapers are very absorbent and make it very comfortable for kids to hang out with a dirty one.
When your child seems ready, some folks find that they can fast track the toilet training on a warm week when they can have the kids run around naked. Most kids are not inclined to just pee anywhere when the diaper is off.     

Another thing to try is to do this in stages. Work on peeing in the potty first. It is fine to let them tell you when they need to poop and then put a diaper or pull-up on for that. For some reason most kids are way more comfortable tackling the pee issue but are much more reluctant to poop out of the diapers.

Kids get involved in playing and often don't pay much attention to their body's cues. Get in the habit of taking them to the potty every hour or so. Make sure that other adults who are watching them are consistent.
Make sure that they are wearing outfits that they can pull up and down easily so that when they do remember on their own they are not hampered by difficult buttons.

For your older kids, Consider having them go to the store with you when you buy the diapers. Use cash. Singles if you have them. Show them the money that you give to the store every time you buy some diapers.
Look at some toys and discuss that when they are ready, instead of a box of diapers, you can perhaps use some of the money to buy that toy instead...but only when they think they are ready.

As far as consequences, older kids are also ready to deal with stinky poop. I think they need to help you with a bit of the clean up process. Talk about how nice it would be if the poop went right into the toilet.

I would give some nice positive attention for any attempt at sitting on the potty and giving it a real effort. 
Set a timer and have them sit on the potty or toilet for five minutes when they are working on a poop.

Consider having a written poop agreement that spells out any rewards that have been discussed.

Being out and about with a newly potty trained child is an adventure. You will quickly learn which friendly merchants have clean and accessible toilets that you can run in and use.
You will learn to watch out for the tell tale signals. The hand down at the crotch and the jiggling up and down usually mean you have a minute or less to find a bathroom. I used to have an inflatable potty in my trunk that came in handy on many occasions.

Do not shame or yell at a child who isn't quite ready. If your child is over 3 ½ and you don't feel that you are making progress, it might be time to talk to the pediatrician to see if we can help you move forward.

Night time is a whole different issue.
I suggest working on the toilet training for during the day and using pull ups at night.
Wait until your child is waking up dry or asking to get rid of the night time pull ups before you tackle this.

(Bed wetting is certainly a topic that I will put on my list for a future post)

There is a new trend that had parents starting toilet training when their kids are only a few months old.
Some of my patients are having success with it, but I can't quite wrap my brain around that concept, so I haven't included that in this post

Thursday, May 2, 2013

Poop part 2/ Along comes solid food

The poop series chapter two/ Along comes solids

Topic of the Week: chapter two of the Poop Series

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