Friday, May 30, 2014

Nurse Jen blogs about how the use of words can make a difference

(summarized from KQED's Sate of health blog, May 2, 2014. Link below)

Enlisting your kids to help out with household chores can be frustrating if not downright maddening.  Recently in the journal Child Development, researchers report a tactic that may get kids to cooperate. Rather than asking your child to help you, try calling them  'a helper' instead. It may seem small but it makes kids feel like they're embodying a virtue, says Christopher Bryan, a psychologist at the University of California, San Diego and one of the researchers behind the study.
Preschoolers who got the talk about being helpers (versus being asked to help out) actually dropped their toys to offer aid 20 percent more often than kids who heard a lesson about helping!

The phenomenon isn't unique to kids. In a previous study, Bryan found that asking grown-ups, "How important is it to you to be a voter?" was more likely to motivate them to get to the polls than asking them about the importance of voting.
Interestingly, Bryan says, "Noun-based appeals to not cheat are [also] more effective than a verb-based approach." Sure, you may not want to cheat - but you really don't want to see yourself as a cheater.
But Don't Go Too Far: Skills vs. Virtues
With kids, we should be careful not to take the approach too far, Bryan says. In some cases, it can set kids up to fall harder if they fail.
"Helping isn't something you can fail at," Bryan says. But drawing is. An earlier study from Stanford University found that kids who were told they were "good drawers" (versus "good at drawing") were much harder on themselves when they thought they had created bad artwork.
When adults put labels on kids - whether it's helper, drawer or something else - the child's identity and self-worth becomes entangled with the label, says Andrei Cimpian, a psychologist at the University of Illinois at Urbana-Champaign, who led the drawing study. "Later, down the line when they encounter difficulties, that's going to be a lot more painful," he says.
When it comes to behavior that's skill-based, as opposed to virtue-based, Cimpian says, parents might do better to use verbs instead of nouns. For example, instead of telling your little Picasso that she's a great artist, he says, "Say, 'Wow, you spent a lot of time on that. It looks great!' "
Sound confusing? Don't stress out about it too much. Unconditional love and support are really what our kids need most. But next time you fearfully anticipate your adorable toddler maturing into a self centered teenager, call your '#1 helper' over and give her some clothes to fold!

Friday, May 23, 2014

The stuck What...Where?

While it might make an amusing anecdote well after the fact (and it keeps the advice nurse job from being far from boring) it can be quite the ordeal when you find out that your child has stuck some little object into an orifice.

By far and away the hole that gets the most inappropriate things passing through is the mouth; however swallowing non food items will be addressed in a future post.

There are other interesting places that need to be explored. Oh yes, noses, ears, butts, if there is a hole...things get stuck in there.
One of my favorite stories is told by a friend who had a child that smelled fairly horrible. No amount of baths could mask a mysterious foul odor. The child was taken to the doctor who asked the magic question.

"Honey, do you ever stick anything in your nose?"
The child shrugged and then said, "just cheese..."

We get the calls fairly regularly that a child has stuck something somewhere. Often, it is the nose.

Nurse Jen recounted the time that her daughter Isa stuck something in her nose in order to find out if the nose was connected  to the throat. While a little proud of this attempt at an early science experiment, Jen recalls that a straight jacket was needed in the ER to get it removed. Isa was absolutely right - the nose is connected to the throat, but there are all sorts of sinus cavities where something could get waylaid.

Gianna Frazee, a wonderful pediatrician shared with me the story of a memorable  five year old patient who felt the need to stick her tongue inside a Barbie Doll head, The tongue swelled up and got stuck.

First of all, please please tell your children stories about other little children who have done these things and then had to go to the doctor and it was yucky getting it fixed. Perhaps a little teaching and mild scare tactics in advance might be preventative but the urge is strong. In my immediate family we told the tale of my niece Lena who stuck a raisin in her nose, and perhaps the power of the tale kept my own kids and the other nieces and nephews "raisin free"

If prevention hasn't done the trick and there is something stuck up the nose you have several options. If your child is old enough, have them try to gently blow it out. If that doesn't work, or your child is too young to have mastered the concept of nose blowing, you can try to suck it out. Whereas I did once have a mom who successfully sucked a pea out of her toddlers nose with her mouth, (good for her but...ugh), I would suggest trying the suction with a Nose Frida.

If that doesn't work, I have another method for you that I learned from  local pediatrician Sheva Tessler. Assuming the something  is in the right nostril, push the left nostril closed with your finger and do a firm rescue breath into the mouth. If it doesn't blow the object out, reposition and try again. This works more than 50% of the time. I have seen all sorts of interesting things go into noses....peas, beads, little wads of paper, raisins, a starburst candy. Kids are creative!

It is fully possible that whatever it was was sucked up was subsequently swallowed, but never the less, if it went up in the nose and you weren't able to get it out, someone needs to look in there. As Dr Kaplan says, "if it is an object, say for instance the #3 key from a toy telephone, it needs to be removed." If it is a small organic thing like a piece of rice, she doesn't get worried if it isn't retrieved as long as it doesn't seem to be causing any issues. 

If you aren't quite sure if they stuck something in there or not, kids are often not the best historians when it comes to finding out the truth. If you ask them if they put something in their nose and they think that answering yes will either get mommy or daddy mad, or land them at the doctors the answer may well be an emphatic "Me? Something in my nose? I don't remember!"

Keep that in mind, as a constant running nose, foul odor, or signs of irritation in or around the nose could be signs that a foreign object is the source of the trouble.

The docs in our office are  willing to try to get something out, but we might not be your best choice. If there is a way to  get onto the schedule of an ENT that is usually the  better option, They have better tools for getting the job done right the first time.

We also have our share of patients who stick things in ears.
One of the more memorable  for me was the little boy whose brothers had convinced him to see how many unpopped popcorn kernels could fit in his ear. Of course this was 4:30 on a Friday...right? As he came into the office I could hear him crying "I don't want them to have to cut off my ears." Those same brothers of course were behind that as well. Ah siblings. That little fellow also ended up at the ENT, although we may be able to remove something simple from the ear.

Just the other day Dr Jessica saw a little blue bead in an ear during a routine exam which she was able to safely remove, while a little silver pellet from an ear of a different patient was referred out.  

Yes, we have had the occasional thing stuck in the butt (in fact it was a tube of mascara most recently;) those are fairly rare.

Friday, May 16, 2014

Spitting Up

Most babies spit up. It is just a fact of life. Of course some of them do it more than others. I would still crown my daughter Alana the queen of spitting up. I often didn't bother changing my shirt unless there were 15 splots of spit up all over it; it simply wasn't worth it. Sandy, the clean freak in our family, would follow after her with a spray bottle of Resolve carpet cleaner and a scrub brush, so that she didn't completely stain the carpets with the constant regurgitation. (No, he isn't for sale.) Lauren rarely spit up. Kids do things differently.

Lani was a happy spitter. It didn't bother her in the least and she grew in leaps and bounds.

With large babies like Alana, sometimes the spit up is simply  the overflow. I know that it is very hard to estimate how much milk your baby is actually spitting out. I have parents calling all the time reporting that the baby seems to spit up the entire meal. If you aren't sure about a steady weight gain, we are going to want to have the baby officially weighed to make sure they are doing okay, but do relax; the spit ups are not nearly as much volume as you think they are. When we weigh them, most of the time they are still gaining weight beautifully.

When babies spit up it is not unusual for it to also come out of the nose. This can be scary. Having a Nose Frida or aspirator handy will help you clear them if they seem to be having a moment of difficulty when this happens. (I find the Nose Frida to be more effective for this.)

Once in a while you might note some blood in the spit up. To no surprise this tends to freak many parents out, but take a deep breath. Most of the time this is simply a symptom of mom's sore nipples. There is a good chance that if the nipples are cracked at all, the baby might get a little blood when they are sucking. There is a way for a lab to check the blood to see if it from the baby or the mom. If the baby is swallowing some blood during nursing it is also possible that you may see some show up in the poop. It will no longer look like fresh blood by the time it makes its way through the system but would more likely look very dark and tarry. If the baby seems perfectly fine, it is very unlikely that they have any type of active bleeding going on.

While most spitting up is fairly benign, projectile vomiting is something that warrants attention. There is a fairly uncommon condition called pyloric stenosis that usually shows up between 2-6 weeks of age. For some reason it is more common in little boys. I am fine with the occasional more forceful spit up, but with pyloric stenosis think exorcist. The spit up literally flies out of your baby and this happens multiple times a day. Of course you never want to have anything wrong with your baby, but on the scale of things, this finding is relatively benign with a simple surgical fix.
We rarely see this, but I have had two cases so far this year and things always happen in threes, just saying....

If you have a baby who is a big spitter and is also fussy, it might be some reflux. These babies tend to arch their backs a lot. They seem more uncomfortable when they are lying flat. With reflux, the spitting up seems uncomfortable. If you suspect reflux , consider the following:

*Smaller more frequent feedings
*Keep your baby upright as much as possible, but especially the first 20 minutes after the feeding
*There are some wedge pillows available that some parents find helpful.
*Breast feeding moms should see if there are any dietary factors that impact the spitting.
*Babies getting formula might consider using one of the sensitive formulas
*Some babies are very burp dependent. You will notice that if you aren't patient enough to get a good burp, part of that meal is going to come back up. Other babies never seem to burp and have no issues.
*Probiotics may be useful

If nothing is helping, the doctor may prescribe Zantac; make sure you bring this up at your next well child exam. If the baby is really miserable call for a sooner evaluation. More often than not, the copious spitting slows down significantly by the time they are seven months or so.

Friday, May 9, 2014

Finding Balance/ one of my favorite bits of wisdom...the Pie Theory

Pie Theory

Our Uncle Davey made up a song that he used to sing every May; it went something like this:

If it weren't for your father, your mother wouldn't be your mother,
so don't forget to thank your father on Mother's Day.

Anyway, in honor of Mother's Day, for all of you mothers and fathers out there I will share one of my favorite pieces of wisdom, which I refer to as the "pie theory of life."

It is actually quite useful for everyone, parents and non-parents alike.

It is all about finding balance.

The "pie theory" got its inception many years ago. For a number of years I was the Parent Association President at my daughters' elementary school. It took an inordinate amount of my spare time, including meetings several times a week. On many levels it was rewarding being so involved but I assure you, I was delighted to pass the reins when my stint was over. Though I was really genuinely relieved to have my time back, I felt off balance by all the sudden free time in my schedule, and at first I couldn't figure out why I was so unsettled. I finally realized that although the new empty hours were welcome, they had created a bit of a vacuum. I filled it quickly (started taking up karate a few evenings a week), but it was right around that transition period that the "pie theory" helped me make sense of things.

Imagine your identity is a circle (or whole pie). Who you are is divided into many pieces; some pieces are large, some small, some temporary. Some are constants that are with you life long, some are optional, some are good for your soul, while still others are energy sappers that give you little in return.

Are you:
Ex spouse?
Pet owner?
In a job/occupation or seeking one?
Doing a hobby that takes time and energy?
Member of a book club or any club for that matter?
House cleaner?
Carpool driver?
Event planner?
and of course last but not least....

The list goes on and on. What activities make up your day, your week, your month, your year? What pieces make up your pie?
Take a few moments to figure it out.

It's interesting to think how you can be identified in different ways by the various pieces of pie. Many folks recognize me as Nurse Judy. More than once I have actually looked at a rash, or given advice from a restaurant  table (as my patient husband rolls his eyes). But there was a time years ago when I came to work one day and saw a construction worker on the roof of a neighboring building. He looked awfully familiar and I was struggling to place him; was he a parent from the practice? Someone from school? I could see that he recognized me as well; we kept looking at each other and a moment passed. I could see that he had figured it out first. He gave a big grin and called out " Ahoy there Java's mom!" Of course! I ran into him several times a week with his pack of dogs when I walked my dog Java. Not only did being a dog owner dictate my daily schedule and get me out walking rain or shine, it also included me as a member of a distinct social network in the neighborhood for many years. All the dog owners knew each other by sight and all the dogs by name. Being "Java's mom" was a wonderful piece of my "pie" for 12 years. If you are a pet owner, that piece has a very special place allotted to it. 

Your pie is finite. You can only do and be so much, as there are only so many hours in the day. Some folks have too many things competing for time and attention, and figuring out which pieces can be compressed can be quite stressful. Sometimes we make poor choices

For busy working parents this might be a foreign concept, but some folks don't actually have enough pieces to begin to fill the shell. A big empty pie can be just as unsettling as a full one.

Have you ever noticed that when you are super busy you can manage to get through an entire to-do list very efficiently? On the other hand, on a quiet day you may have only one or two things on the list but somehow nothing gets done.

A healthy pie has plenty of interesting pieces that can grow and shrink according to your needs. The more forgiving and elastic the pieces, the easier time you will have finding a good balance.

Your pie will naturally change from year to year, but some changes are enormous. Some people are quite comfortable having a very crowded pie, while others are quite fine and happy doing nothing at all. Part of this is figuring out what your ideal is, and work towards that.

Any large sudden changes to your pie will make you feel unsettled, way less so if you have a glimmer of what is going on, hence this theory. Both of my daughters have taken this to heart. In fact Alana has permitted me to share her own blog post on the Pie Theory that she wrote several years ago:

(Blogging runs in the family I guess)

When there is a large shift in your pieces  my girls and I refer to this as "pie disequilibrium"

Common culprits might include

Event planner:
Folks planning a wedding or large event can spend months dealing with all the fun details. When the event is over, that planner piece is gone, your pie has a gap.

Sports Fan:
My daughter Alana has a twinge of "Pie Disequilibrium" every October when baseball season is over

My daughter Lauren had to learn how to deal with the extra time that appears after a show run is over.

Folks that spend much of their time and energy tending to someone elses needs might find themselves suddenly with a large vacuum when that person is gone or no longer needs them.
As your children grow up and don't need you in quite the same capacity it can be a tough adjustment (don't worry, they still love you) 
Luckily this happens in stages. Kindergarten...a full day of Parents who have the "parent piece" taking up the entire pie may suffer.  

Huge life changes will create seismic shifts. Nothing will ever match the huge transitions that take place when you add the parent piece to your pie. My best advice to you as you shuffle all your pie pieces and see how things fit comfortably is to identify pieces that need to be protected so that they don't get too small.

Protect that piece. Get creative and make sure that you have time for the two of you  have some moments being a couple


Being the best parent that you can be includes living by example.
Let your kids have parents that are multifaceted and not consumed by any one thing (be that parenting or a job.)

Best of luck finding a balanced, interesting, and fulfilling pie!

Friday, May 2, 2014

You baby's growth/link to growth chart

At every routine checkup one of the things that we do is to measure the weight, the height and for the first several years, the head circumference as we follow your child's growth. Of course measuring the growth rate  is only one aspect of the visits. We also will be monitoring developmental milestones and administering age appropriate vaccinations.
The first 3 years the routine visits are as follows:

NB (within several days of getting home from the hospital and then careful monitoring as needed until your baby is back to birth weight)
1 month
2 month
4 month
6 month
9 month
12 month
15 month
18 month
24 month
30 month (check with your insurance to see if this visit is covered)
36 months
and then yearly
Once your child is over 6 years of age, some folks opt to come in every other year if there are no issues or concerns, but you are welcome to do an annual visit.

We will check the weight at other visits as well, especially if there has been any vomiting, diarrhea or feeding issues.
Having a current weight on file is important in case the need arises to prescribe medications. Even giving an accurate dose of Tylenol depends on knowing the weight.

When your baby is born one of the things  that folks focus on is the baby's birth-weight. Although most of the time this data point quickly becomes irrelevant , it tends to be something we remember.
For the record,  my firstborn Lauren was 8 pounds ½ ounce at birth.
Three years later, when I was trying to figure out why it was taking so long to push out baby number two, along came Alana  at a whopping 9 pounds 8 ounces. (Nurse Judy takes a bow)

Here in the office we focus on the weight as a symbol that everything  is going in the right direction, your baby is getting fed and growing.
Many breastfeeding moms can find themselves feeling frustrated and somewhat vulnerable that they don't know exactly how much milk  their baby is getting.
*Can you hear a swallow when they are nursing?
*Are they peeing?
*Are they pooping? Are the stools  turning yellow and seedy?
*Are they having some calm alert time (even a few moments counts) in between feedings?
If you answer yes to these questions, most likely everything is great, but proof will be found on the scale.

Don't fret, it is typical for babies to lose a bit of weight during that first week.
If the weight loss is larger than 10% of the total weight, we pay closer attention and may feel the need to add supplement if you are breast feeding.

We like to make sure that someone is keeping tabs on things those first couple of weeks and that the weight is being monitored. If you have a home nurse visit, or a scale at home we don't necessarily need to see you in the office, we just want to be assured that the weight gain is steady.
After that initial drop, we like to see an increase of ½ ounce-1 ounce a day.
Once they are back to birth-weight, things usually start to roll in the right direction.
This rapid gain usually lasts for a few months before things tend to slow down a bit.
From 4-7 months you might see an increase of roughly 1 to 2 pounds a month

The scales in our office are calibrated and are accurate enough that  except for rare exceptions, it really doesn't matter which scale your baby is weighed on.   

If you come in for a lactation consult it is likely that will be weighed on Charity's special gram scale 

Human errors can occur, so if a weight seems really off, lets take the baby off the scale, make sure the scale is perfectly balanced and try again. Maybe this weight is accurate but the last one was off.
Keep in mind that a large stool or a big feeding can have a measurable impact on the weight.
If your baby just ate 2 ounces, expect them to be 2 ounces heavier. On the other extreme if they just had enormous poop, they will be lighter.
We usually measure the babies with no clothes or diaper for better accuracy.
Trust us, if we are worried about the result of the weighing , at that point we will double check it on the original scale if possible.

Once you are safely back to birth weight I am way less focused on the actual numbers.
Look at your baby, not the scale!! If the baby seems well, but the numbers aren't backing that up, relax and lets make a plan to recheck in a week or so.

Another measurement that we follow is the height.
Parents are often confused at the first visit if it looks like the baby has shrunk in the height department.
No one is going to accuse you have having put them in the dry cycle for too long.....
there are a few reasons that this happens.
If you had a vaginal birth, the heads can be elongated....remember the Cone Heads from the early years of Saturday Night Live???
As the head shape normalizes, your baby may actually lose an inch or so.
Also, I hazard a guess that newborn height measurements are somewhat inaccurate.
Often babies still tend to be more comfortable in fetal position, and rarely is it worth stretching them out fully if it is uncomfortable, the measurement simply isn't that critical.

As we collect these numbers we watch the trend of the height and the weight together as your child grows.
If there is a dramatic change in just one of them, it bears watching.
We track these by plotting the numbers on the growth chart that is kept in your child's file
Feel free to ask to see it during the visit. Many parents like seeing where the kids are on the curve.
In my experience about ⅔ of my patients actually follow the curve and by the time they are 2 or so we can roughly predict how tall they will end up.
On the other hand, about ⅓ of the patients don't like to follow the rules and they bounce up and down the chart, having slow growth periods that make the parents nuts and then having wild growth spurts.
Again, what we are watching is that the height and weight are increasing with the same tendency.

We also measure the head circumference. This one can be challenging on an uncooperative baby, and therefore the measurement might vary somewhat. The Head circumference should be measured  from the middle of the forehead  around to the widest part of the head.
This measurement is not usually critical at birth but becomes more important as your child grows.
What we are looking for is the rate at which the head is growing. If it seems like it is growing out of proportion the the height and the weight, that could indicate some fluid in the head that shouldn't be there and would need further evaluation. Big heads are fine. Big heads that are growing way more rapidly than the other measurements warrant attention.

More often than not, if we have a patient with a large head, they are perfectly normal. Look in the mirror, this runs in the family and usually one of the parents also has a big head (ego irrelevant).

It may be worth checking in with Grandma to see if there was anything interesting about mom and dad's growth rate. It is not unusual for your kids to follow the pattern of one of the parents. If one of you started out small and then sprouted as a teen, the apple may not have fallen far from the tree.

If you would like to print out a growth chart, you can find the appropriate one for you child's age and sex  by clicking on this link.