Friday, March 28, 2014

Nurse Charity on warm weather nursing

As I was listening for swallows yesterday in the tiny well baby room, a mysterious hum filled the room, making it difficult to hear.  That strangely familiar, but not heard in a long time hum was the air conditioner, alerting me to the hot weather here in the Bay Area.  While we do not get the oppressive heat of other parts of the country we do travel to them, and have enough scattered hot days to feel the heat!  Hot days at the advice nurse desk mean a lot of calls about rashes, a lot of bug bites, some playground injuries, and for me it means a flurry of calls from moms worried about milk supply.
Breastmilk supplies all the water and nutrition your baby needs to the 6th month mark.  On very hot days your baby will not stick to the regular routine you know and love, no, they will want to nurse a couple of times an hour.  This is perfectly normal.  (In fact, if you lived full time in the desert, like the !Kung, you would regularly feed your baby 4-6 times per hour, and any less would label you a terrible mother, worthy of scorn and derision).

Because your baby is nursing frequently, and your breasts are soft all day, and perhaps your little one is cranky with a rash, it is natural to think- "Ack, my milk is gone. HELP!"

I am here to be THE VOICE OF REASON.  

If it is warmer than a delicious 72 degrees (or 22 for those working in Celsius)  Expect that your child will want to nurse more.  How much more?  Depends on how hot it is!   Hot and dry conditions will need more nursing.  You do not need to offer extra water, your body actually changes the composition in hot weather to give your child more H2O, tastier than the glorious Hetch Hetchy.  Just make sure you are drinking to thirst, not walking around with a sticky, dry mouth, and a headache; water, juice, drip-drop, anything that is not caffeinated and is drinkable is what you need!

If you are mixed feeding- some boob/some formula and it is HOT, then you can offer plain safe water in a cup or bottle in addition to the regular routine.  But nursing more often also does the trick.    

Total formula feeders can increase the water offered from 3-5 oz to 6-10oz.  Don't water down the formula, just offer some water at other times. Your thirsty babes will thank you!

So relax, no need to worry, or tote around a lot of extra stuff- 


XO Nurse Charity

Friday, March 21, 2014

Tick Bites/Prevention ( updated)

Dealing with Tick bites

Ah, the twisted thinking of an advice nurse. For most folks, spring brings to mind warmer weather, longer days, lovely flowers etc. Me? I think,"Here comes tick season"
Indeed the calls are already coming in and I have spoken to a half dozen patients about tick bites just this week.
It makes sense. With the nicer weather more of my patients are out there taking walks, hiking and enjoying the beautiful area that we live in.

Ticks can be an issue all year long, but the nymphs are born in the spring. These tiny little ticks are the ones most likely to transmit diseases.
Of the many varieties of ticks out there, the ones responsible for the majority of  disease transmission are the deer ticks. If you want to impress folks at your next cocktail party, our local deer tick is officially identified as the ixodes pacificus

Although only a small percentage of tick bites are harmful, the diseases can have a major health impact, so we need to pay attention. There are many conflicting reports, but recent studies coming out this year suggest that the rates for tick borne diseases are a bit higher in California than previously thought. Ticks that have been caught and examined are testing positive for  two separate bacterial illnesses. We are most familiar with Lyme (Borrelia Burgdorferi)  but they are finding that here in the San Francisco Bay Area just as many, if not more ticks are infected with Borrelia Miyamotoi.  This second illness is a close cousin to Lyme. It has the similar flu like symptoms including headaches, nausea and muscle pain. It does not have the rash that is associated with Lyme.
They are both treated with the same antibiotics. 

The key is prevention.

If you are going to be walking or hiking in densely wooded areas try to stay in the middle of the path. Avoid wood piles and logs. Light colored long sleeves and long pants are recommended. Spray the clothing with the bug repellent Permethrin. This is okay for anyone over 2 months of age. Use Deet on exposed skin, avoiding hands, eyes, and mouth.

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 armpits and belly buttons.You really need 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 than 24 hours to be a concern.

If you do find a tick, please stay calm. I can still remember vividly, years ago, a mom carrying her toddler into the office screaming (the mom, not the kid) "HELP ME GET THIS THING OUT OF MY BABY!" Hey, Arachnophobia is appropriate in this case, because ticks are indeed arachnids (the spider family), but put on a brave face for your child.
The best way to remove a tick 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???   

*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 for Lyme 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. There are no current tests widely available out there yet for the newer B.Miyamotoi 

Rather than testing the patient, I would focus on the tick. If you do a lot of hiking, keep a little baggy in a pocket of a backpack or diaper bag so that you have a place to stick any ticks that you remove.  

The Sonoma County Health Department will identify the tick for free and test it for Lyme disease.They charge a  fee of $29 (such a deal.) 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.

707-565-4711  Read the instructions on their website for how to send the tick
Here is the bottom line. 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.

If you are a pet owner and you treat your pet with one of the flea and tick treatments, keep in mind that those ticks may leave the pet and go find someplace else to hang out.

This post is an updated version of one that was run last year.

Friday, March 14, 2014

Siblings/Along comes a new baby

Imagine your partner says to you, "Honey, I really love you. You are one of the most important people in my life. Please don't be concerned that a younger, very cute person will be spending a lot of time with me. They will possibly be sleeping with me in my bed for a while. There may be some sucking on my breast."


The oldest child was the center of the world for a time. Moving over to make room for a new member of the family isn't always easy.

Some big brothers and sisters are actually eagerly expecting the baby's arrival. Others are too young to really understand what is going on. Regardless, there is a big adjustment to be made.
Many parents report that the big siblings are quite sweet to the baby, but act out horribly to the parents. Once in a while, but less often they will also act out towards the baby. Nurse Jen remembers the time that her oldest daughter dropped a medicine ball on her new sister. Others have no malice but don't have a sense of how to be gentle.

Below are some suggestions that may help ease the transition.

Do some gentle preparation by including some books about new babies among your reading choices. Please keep reading other favorites that have nothing to do with a new baby as well.

Once the baby has arrived give your older child  plenty of opportunity to talk about what if feels like to have a baby in the house. Validate that it is very normal for the big sister/brothers to sometimes feel mad, sad or aggravated. (kids might feel guilty about the way they feel.) Many children need to be told that the new brother or sister is here to stay as a part of the family. Sending the baby back in not an option.

Have the new baby come along with a gift for the big sibling. I am not sure what the age cut off for getting away with this is. Lauren was a remarkably clever almost 3 year old when Alana came along. Never the less when we gave her a little present from her baby sister, she accepted it without question. She was delighted and was quite pleased with the very thoughtful baby.

Some big siblings feel very important if you let them be "helpers". Find some safe baby related tasks for them to assist you with. 

The most  important tip of all is to make sure that you carve out one on one time with the older child. Often they are craving mom right now. If mommy is breast feeding, make sure that in between feedings she hands the baby off to the other parent or support system for burping, diaper changes etc and make a fuss about having "special big boy/girl time." Nurse Jen says that lots of people gave her this advice but she didn't realize that having a sleeping baby in a sling doesn't count. She wanted me to make sure to add that If you are holding the baby, it doesn't count as the "one on one" time.

As your kids get older, the oldest child will always feel a bit entitled to some solo time.

If you can manage it, take just one child with you on routine errands and turn them into adventures. Perhaps you can have only one child at a time allowed to "help" with a meal. Even a walk around the block or some special time at bedtime makes a difference. Do try to make sure that each parent should make sure that they get special time with each kid. My husband made it a tradition to take Lauren out for breakfast every Sunday morning. Eventually Alana was old enough that she went along too, and mommy got to sleep in (heaven).

Once the second child comes along you will feel like simple math no longer adds up. One plus one must surely equal five. You will manage to find the balance, but those first few months are challenging to say the least.

With the first child you had the luxury of focusing on schedules and nap time as if they were set in stone. Unless you are remarkably lucky or hire someone, a true schedule doesn't really exist with this second child. Naps? Maybe while you are driving from here to there. (They survive.)

Do your remember how careful you were with the first one? You avoided crowds and made sure that no one came around if they weren't completely healthy. The new baby will simply be developing that immune system a bit earlier. There is almost no avoiding it, unless you never go out and you quarantine your older child to an unreasonable degree. Second kids get exposed to things quite a bit sooner. (They survive.)

I do like to make the big siblings the deputies of the Hand Washing Patrol. Have Purell around (you can also get the kind that is alcohol free;) call it magic soap. Tell your deputy that they are in charge of making sure that anyone who is going to touch the baby washes their hands first. This may help make sure that they don't feel like they are constantly being nagged at.

Keep in minds that all of your kids will reach their milestones on their own timeline. It doesn't pay to compare them to each other or to the other kids in the play group. My baby Alana, for the record, doesn't mind when I use her as an example.She just got her eighth grad school acceptance this week, so she has nothing to worry about. She is a super star all around, but goodness was she slow starting out.

Talking:    Lauren was singing Rogers and Hammerstein musicals at a remarkably young age. She not only knew the lyrics, but she sang them in tune. (I have video proof of this.) Alana barely had ten articulate words before she was two. Lauren would translate for her and act surprised that we didn't know that  "gbabpgpsmp" meant, "I want popcorn please."

Lauren took her first steps at a year. Alana waited until she was about 16 months and then carried a chair across the room within a day of mastering walking.

Toilet training: Lauren was an early 15 months. Alana had no interest until she was 3. I thought we were going to have to buy depends.

They will all get there.

Siblings will have days when they are best friends and days when they torture each other. My older sister and I were fast friends until 4:00pm like clockwork every day when she started to pull my hair while saying "Jeep Jeep".   My daughters interspersed periods of intense closeness with periods of mild bickering.

Fast forward 20 years.

My family was on a cruise, savoring time together. We were in Cozumel, My husband Sandy was off on a real dive, while the girls and I went Snuba diving. Snuba is a combination of Scuba and snorkeling. With Snuba you breathe through a 30 foot tube that is connected to an oxygen source the floats along the surface.
My daughters were swimming along the ocean floor. I was about 10 yards above them watching them animatedly communicate with each other through hand gestures and some signing. I remember proudly thinking...Look at my daughters. They are both  intelligent, funny, kind and lovely. See how well they can communicate in that secret language that siblings share. I love them so much. I am so glad they have each other and that they have gotten so close as they have gotten older. Our time was up and the guide gestured to all of us that it was time to go up to the surface. They removed the mouth pieces and.......the fight continued:

"You were getting tangled in my hose"
"You were kicking too hard and making too many bubbles"  and so on.

Oh well, a mom can dream

Friday, March 7, 2014

Pertussis/ Whooping cough

* Please see the updated Pertussis post for current numbers (4/2015)
This week I am going to talk about yet another very relevant and nasty disease. My loyal readers are going to be afraid to go outside! Sorry about that, in my next post I will try to take a break from things that are contagious or itch producing.

Pertussis, commonly known as whooping cough, is a very contagious respiratory illness caused by a type of bacteria called Bordetella pertussis. These bacteria attach to the cilia (tiny, hair-like extensions) that line part of the upper respiratory system. The bacteria release toxins, which damage the cilia and cause inflammation.

Worldwide, it is estimated that there are 16 million pertussis cases and about 195,000 pertussis deaths in children per year. Despite generally high coverage with childhood pertussis vaccines, pertussis is one of the leading causes of vaccine-preventable deaths worldwide. Most deaths occur in young infants who are either unvaccinated or haven't had at least 3 shots in the series.

Historically there is a cycle associated with whooping cough. It seems to peak every 3-5 years.
In 2010, here in California there were more than 9,100 reported cases and at least 10 deaths.
Last  month the first infant death from pertussis was reported for the first time since 2010. We may be at the beginning of the next cycle. The timing fits.

This illness usually starts with a week or two of a runny nose and cough. There may or may not be a low grade fever. At week two, the cough gets much worse. The patient will often have coughing fits...and I mean FITS!! This is spasms of coughing for minutes at time that make even the hardiest person feel like they can't catch their breath.
They may or may not have a high pitched "Whooping" sound with the cough (hence the name). Some folks will vomit after these coughing fits
Sweating, gagging and choking episodes are common.
Some people cough so hard from this that they can break ribs.
This cough lasts and lasts...and then lasts some more.
In Chinese medicine this is referred to  as the "Hundred day cough" and they aren't kidding.
This is a miserable illness for anyone.
I have spoken to parents who had chosen not to vaccinate and had to deal with several months of this horrid illness. Every one of them says they rued the decision to pass on the protection.
For young infants Pertussis can be deadly.
Babies routinely get their first vaccination for this around 2 months of age.
The initial series is given at 2 4 and 6 months* There is a booster dose given at 12 months and again before kindergarten entry.
They don't seem to have adequate protection until they have received the 3rd shot at the 6 month visit.
Once they have had 3 doses they are roughly 75% protected. This goes up to ~90% after the 4th  dose.  (Doses 1 2 3 are the initial series. Doses 4 and 5 are referred to a boosters)

*In our office, the vaccine that we use is the Diphtheria/Tetanus/Pertussis combined with Hib and Polio in a shot called Pentacel.

Hib, Polio and DTaP are all available as separate vaccines.
The Pertussis component of the vaccine does not come separately.

Because babies are so vulnerable to this illness, A fairly new and current practice recommends giving all pregnant moms a TDAP  (Tetanus/Diphtheria/Pertussis) with every pregnancy. This should be done in the third trimester between 27-36 weeks. Please talk to your OB if you have questions about that.
It is also essential that all the family contacts have current vaccine protection. This means Dads, grandparents, caregivers and siblings or anyone who anticipates spending any time with your new baby.
If you had the shot OR the actual illness more than 5 years ago the immunity wanes. You should get another booster.

People who have been exposed to Whooping cough will usually start showing symptoms 7-10 days after the exposure and are contagious by the time they give that first sneeze.
If someone is diagnosed, a course of antibiotics will help limit the spread and may minimize the symptoms. It won't make your cough go away, but the illness won't be quite as severe and you won't be contagious. 

On a similar note, as I noted earlier the vaccine is not 100% effective, but folks who are vaccinated tend to get a much milder case than those who have no protection.

Testing for Pertussis is far from perfect. We usually send a culture obtained by a swab stuck up the nose. (as pleasant as it sounds)
The results may take more than a week, so the decision about whether or not to treat often needs to be made based on the clinical history and symptoms rather than a lab result.

If you have Pertussis, symptomatic treatment includes a cool mist humidifier and drinking plenty of fluids.
Smaller more frequent meals may help make vomiting less of an issue.
Smoke exposure will make things much worse.
Cough medicines don't seem to be of much use, alas.
For older kids, honey might be soothing.

I wouldn't wish this one on anyone....even that grumpy woman at the DMV who seriously waited until I stopped smiling to take my drivers license photo.