Friday, June 27, 2014

Dealing with Bullies

  Kids can be so mean sometimes. I am not sure if it is harder to watch your child be bullied or to be the bully.

In my case, for a period of time when our daughter Lauren was four, she was getting routinely picked on by another little girl at preschool. To compound things, this girl was in my carpool. I would drive the kids to school three days a week. Carpool parents - be aware of this astonishing fact. You are invisible. You are privy to all sorts of interactions and conversations that might leave you either horrified or amused as you drive the car full of kids hither and thither.  In this case I had to watch Emily torture Lauren every single day, impervious to the fact that I was in the car. (As you can imagine it was pretty infuriating.)

This is what I would hear, with mild daily variations:

Emily:   "Your shirt is ugly"
Lauren (clearly upset):     "what? why?"

Emily: "I have a special thing I brought for show and tell and I am going to let everyone else in the car have a peek except you"
Lauren: "But I want to see it too!"

Emily: "You can't come to my birthday party"
Lauren (even more upset): "Why?"  

After a few weeks of this I realized that I needed to stage an intervention.

I drew a smiley face with pretty eyelashes and a grumpy frowny face. I then said to Lauren " Which one would you like to be?"
I was dealing with a four year old girl, this wasn't rocket science. As predicted she pointed to the smiling one. I touched the grumpy drawing and said  " Emily seems to want to turn your smiley face into a grumpy face. I wonder if you could keep the smile face on even when someone is being mean. Let's try!"

We got out the trusted barbie dolls and did some role playing. We spent a dramatic session as Barbie cheerfully let all sorts of slights and insults roll of her very shapely back.  We created an assortment of interesting scenarios. Barbie never lost her cool.
I wasn't quite ready to paint Emily as a complete bully. I liked her parents and she wasn't mean 100% of the time. I tried to give her an out. As we put the Barbie's away I said, "I wonder why Emily says mean things sometimes. Maybe she is feeling grumpy herself because she is a little tired."

The very next day in the car we I was interested to see if all of our practice would make a difference. It didn't take long to find out.

Emily: "your shirt is ugly"
Lauren (with a big fake smile plastered on her face.that I could see through the rear view mirror):      "Luckily, you don't need to wear it. I think your shirt is pretty."

Emily: "you can't see my sharing"
Lauren: "I am sure it is very interesting"

Emily. "You can't come to my party"
Lauren: "I hope you have a fun time"

From the drivers seat I watched Emily become more and more confused and upset that her power seemed to be slipping. I refrained from giving an audible whoop and driving into the bushes.

And then...
Lauren (in a sickeningly sweet voice):    "Are you a bit tired Emily?"
Emily (grumpy): "NO, I'm NOT tired"
Lauren (knowingly): "I think you must be a little tired"

No one watching could have accused her of doing anything wrong but she had discovered a way to gently torture Emily a bit, and she was running with it.

A few weeks later I was at a school event and I bumped into  Emily's dad who drove the carpool the other two days. He said to me, "something is going on in the car that I don't understand". "Oh? What would that be," asked innocent mom. "Lauren keeps asking Emily if she is tired and Emily starts getting very upset".

Finding one on one time and playing through things can be quite effective. Another thing that might be helpful is to identify the "nice kids" in the class. Ask your child who they might like to play with, reach out to that family and try to arrange some play dates outside of school time. If your child can have some solid allies in the social group, it makes it much easier to stand up to, or deal with someone else who is unkind. Keep in mind that it is a rare friend that is completely reliable. They all have days where  they "might be tired".  

Looking for other ways to empower your child? Check out  www.  This is a fabulous organization that came out of Santa Cruz.  They now have groups and classes all over the place. They have an entire section devoted to dealing with bullying with all sorts of really excellent resources:

If all of your efforts at home don't seem to be taking care of the issue, talk to your school to see if they have any anti bully programs in place. There is a wonderful program , that got its start in San Francisco. Talk to your school about looking into it. Keep in mind that most of the time you won't actually witness the bullying. Pay attention to your child's mood and behavior. If you notice any dramatic changes make sure you find opportunities for your child to communicate about what may be going on. Sitting with them in a quiet room before bedtime is a great time to do a daily debriefing about the day. In my family that was a ritual.

Let's turn the tables. If you are hear that your child is the bully, or you get to see them in action, make sure that you carve out some one on one time to work on some skills. Some kids seem to be bullies because they simply want attention and don't know a better way of making and keeping friends.Talk about kindness. Talk about choices. Find one particular situation that you know about and work on that. "You pushed your sister and made her cry. What was going on? Were you mad, sad, frustrated? What were some other choices that you could have made? What should be the consequence if it happens again? What should be a nice treat/ reward if you make a better choice the next time you are in that situation?"

If you find that you are having issues on either side of this spectrum that are beyond your scope, the next step may be having a meeting with your child's teacher.

Sunscreen (update)


In honor of Summer's arrival, I am going to dust off, tweak, and rerun my sunscreen post.

I still maintain that a little sun exposure here or there is not the end of the world, it feels great and gives a dose of vitamin D. That being said, no one should get too much unprotected exposure. Sunburns are not only painful, they can lead to skin cancer. The scientists are telling us that too much time in the sun, even if we don't burn, should be avoided. The most recent studies are even more alarming, demonstrating that the increase in melanoma cases being seen have an absolute connection to sun exposure.

Sun can do the most damage to our skin between the hours of 10am and 4 pm. Reflection from water and/or snow can make any exposure more intense.

The link below will lead you to  a great little site that can tell you what the risk is on a particular day depending on where you are. 

Your best bet for preventing sunburn is of course is to stay in the shade when possible and also wear a big floppy hat and loose protective clothing. Have a parasol or a shade umbrella over strollers and baby carriers. Pay attention to babies in back packs; they might be getting more exposure than you are aware of. 
Eyes can get damaged from the sun. Do your best to get your child used to wearing sun glasses. The lighter the eye color, the more sensitive they are likely to be, but everyone should wear eye protection.

The fact is, even if you are very careful, if you are out enjoying life, it is very difficult to eliminate all sun exposure. If your child is under 6 months old and the choice is sunburn versus sun screen, choose the sun screen every time!  If you are using a sunscreen for the first time, do a test patch on one small area on a thigh or wrist a couple of hours before sun exposure. If you slather your child with a new sunscreen, spend a day out  in the sun and then they break out in a rash, we would have to figure out if it is heat? sun? sun screen? Doing a test patch first assures you that it is not the sunscreen that is causing the rash. For older kids, the use of a sunscreen should be routine. Nurse Jen had a great idea that works with her little girls. They apply a daily sunscreen to their face with make up brushes. What used to be an ordeal has turned into something fun. Great habits now will avoid wrinkles and potentially serious skin problems later on.

I have read quite a few studies that state that It is not worth getting any SPF that is over 30. These studies suggest that they don't offer a significant increase in protection, just more chemical exposure. This post is not going to review various brands. There are some great ones out there and new ones are coming out all the time. The cost does not necessarily correlate with the better choices. Get a lotion that protects against the UVA and UVB rays.
I suggest picking a good children's brand from a place like Whole Foods, Natural Resources or any place that examines all the ingredients of the products that they sell. Avoid the sprays. Recent studies show that inhalation might occur (not healthy) and some of them are actually flammable; stick with the lotions or sticks. Apply the sunscreen at least 15 minutes before going out. For significant sun exposure, sunscreen needs to be reapplied at least every 2 hours, even if they claim to be waterproof. 

We need to be a little more protective of our fairest kids. If your child is out with a nanny or friend, don't hesitate to remind them to be on the "sun protection patrol". Trust me, sunburns are just as painful for the grown up who lets it happen on their watch.

Friday, June 13, 2014

Is it a urinary tract infection?

Urinary tract infections are always something that need attention, but sometimes we aren't sure if we are dealing with an actual infection or just an irritation. The symptoms may overlap.

The urinary tract is the body's drainage system for removing waste and extra water. A normal body has  two kidneys, two ureters, a bladder, and a urethra. The urine should drain in only one direction-from the kidneys to the bladder and then gets peed out. Urine is usually sterile, (remember that when your baby pees in your face) but once in awhile bacteria from the surrounding skin or stool can make it's way into the urinary tract, causing an infection. If the germs make their way all the way into the kidneys it is much more serious and usually causes a much higher fever.

Holding urine for long periods of time, not drinking enough and constipation seem to make folks much more prone to infections.
In my experience, girls are much more likely to get an infection. Circumcised boys are the least likely.

UTIs will usually  come along with fever, tummy ache, back ache and maybe vomiting. You might notice your child grabbing at their crotch. Kids who are old enough to verbalize may complain that it hurts to pee. Toilet trained kids may have some accidents. Urine may have a stronger smell than usual. Young infants may simply be fussy, not feeding well and feverish. Any mystery fevers warrant a urine check to make sure that a urinary tract infection isn't the source.

Irritation around the urethra can also cause quite a bit of discomfort when peeing. This is fairly common among the newly potty trained girls. They are just not all that good at wiping.
Have you done any bubble baths lately??? Those are a very common culprit. Besides bubble baths, any harsh soaps can be irritating. Get in the habit of letting your child do their bath play without sitting in soapy water. Let them play and then when they are almost done do the gentle soap, rinse, exit the tub and towel off. If there is no fever, your child seems quite well but is complaining about pee pee hurting, check to see if you notice any redness in the area.

I am fine doing a one day watchful waiting combined with some natural treatment to see if things clear up. I would suggest:

*A nice soak in a tub with a splash of apple cider vinegar.
*After the bath apply some Vaseline or gentle ointment that can act as a moisture barrier and protect the irritated skin from the urine. 
*Increase their fluid intake; diluted urine is much less likely to sting.
*Probiotics/ less sugar in the diet will make the body less yeast prone.
*Cranberry juice.There are a lot of mixed studies out there, but most of them agree that cranberries may be useful at preventing UTIs. They have properties that prevent the bacteria from taking hold and hey, fluid is good. You may as well make it cranberry juice if they will drink it.
*Loose cotton panties; watch out for tight tights that little girls like to wear.

If your child is complaining that it hurts to pee, and there is any fever or tummy ache, they need to be seen and have their urine checked that same day.

For young babies that are not able to pee in a cup we will apply a sterile urine bag on the area and wait...and wait...and wait, to get a specimen. It is okay if the bag leaks a bit. We don't actually need much more than a teaspoon of urine. Murphy's Law loves this process - there is nothing like a good urine bag in place to make a great big messy poop come along. Sorry folks, even if it looks like the poop didn't get into the bag, we can't use that specimen. We will need to clean them off and try again.

For older kids, we will try to have them pee into a cup. Make sure they are cleaned off thoroughly before urinating. It would be great to get a mid stream specimen, but that often poses too much of a challenge and we will take whatever we can get (as long as it is clean.) If you are obtaining the specimen at home, any clean jar or tupperware that has been through the dishwasher will be fine.
If you don't relish the job of being the "cup holder" reach in with a clean ladle to collect the urine. (I learned that from my niece Molly who was a vet tech at a time when I needed to get a urine specimen from my dog. It works!) Urine poured out of a potty is NOT okay, no matter how clean you think that potty is.

Once we have the urine we will do a couple of tests. The first test, is with a dipstick that we can do in the office. The second step is a culture that takes a few days for the results. In our office we usually do a little basic culture that gives us some info the next day, but we also send the urine off to the lab where they can identify the bacteria and check which medication it will be sensitive to. That first dipstick checks for an assortment of qualities including blood, bacteria, protein, and urine concentration. This test can give us clues but is usually not conclusive. Many little girls have a bit of bacteria in the area that shows up on the test even if there is no infection. Some irritations may also cause a bit of blood and protein. I have also seen specimens that look perfectly clear on the dipstick, but still grow something  on the culture. We will have to weigh all of the symptoms and information when making the decision about whether or not we immediately treat.

If it is an infection, Your child will need antibiotics. If we aren't assured that your child is feeling MUCH better after 48 hours or so, we may also ask for some urine mid treatment to make sure they are on the right medication. We will almost always want a follow up specimen after the course of medication to make sure things have completely cleared up. If your child has a history of even one UTI, you need to be a little more suspicious whenever they don't feel well  and it is probably worth checking urine for any future fevers.

Also, kids who get  urinary tract infections usually need a follow up with the urologist to make sure that all is well with the "plumbing". With little girls, we may give them a pass until they have had more than one, but little boys usually should be checked out the first time it happens.

Be aware of something called "urinary frequency syndrome".  I see it enough that it is worth mentioning. Your young potty trained child suddenly needs to pee all the time. It doesn't actually hurt to pee. They are otherwise well. There is NO fever. There is NO irritation that you can see. Once they are asleep, they sleep quite well and don't seem to have the urgency at night. With any  sudden frequency, we do want to do a dipstick and culture just to make sure there is nothing up. If everything looks fine with the urine, it is likely this odd little syndrome. It goes away after a few weeks. Patient X was actually my daughter Alana. She often played  the "stump the doctors and nurses game". When she was four years old, she suddenly needed to pee all the time. All the workup was normal. I actually ended up driving with an inflatable potty* in my car because otherwise we couldn't go anywhere. With all the doctors mystified, we ended up at the urologist who gave us the instant diagnosis. I think with us it lasted about 2 weeks. If it was longer than that I blocked it out. It was an aggravating several weeks to say the least. Since then, I have seen it multiple times....thank you Alana as always for educating me. If this is your kid, just let them pee whenever they need. It will pass. Remember we are not going to use this diagnosis until we have a negative urine culture.

*Inflatable potty - Take an inflatable inner tube ( think pool toy) , tuck it under a kitchen size plastic garbage bag  (place the garbage bag over it as if you were placing it over a very very shallow garbage can)....voila, instant potty, the pee or poop are ready to dispose of in the bag. We subsequently used this idea for camping trips or long car rides.

Friday, June 6, 2014

They put WHAT in their mouth?

A few posts ago I wrote about the fact that kids like to explore. Many times this involves sticking things where they don't belong.
Being fairly oral critters, most of the time the object they are handling gets placed in the mouth. When this happens there are two passages that it might go down.

If it goes into the esophagus it hopefully will make it's way down into the stomach, through the intestines and then get pooped out.

If something was swallowed, here are things to consider: 

Is it stuck?
How does the child look? Are they able to take a sip of water? Can they swallow just fine? Is their breathing relatively normal?

If something has gotten stuck in the esophagus they will look uncomfortable, There will  be frequent coughing and throat clearing going on. You will know that something is amiss. This will necessitate a visit to the ER.

Is it poisonous?

If you have any doubt about that, call the poison control center

Is it a battery?
Any battery can be trouble, but button batteries can be a tremendous hazard because they can be easily swallowed and they seem to be everywhere these days. Last year I got a call from a mom of 15 month old twins. There they were, sitting on the floor with mom's pedometer right in between them. It was open and the battery was gone. Because of the uncertainty involved, we did have to send them to get x-rays.  Indeed there it was that little battery, sitting in the stomach of one of the kids. In this case it passed safely, but if a battery gets stuck anywhere on the way it can cause a dangerous amount of damage. Please know where all the button batteries are in all of your little gadgets and make sure that your kids have no access to them. Keep a strict inventory and perhaps stick a piece of duct tape across any battery compartments.

Other objects that you need to be wary of are magnets. I am not talking about the little letters that you may have on your fridge. The ones that cause concern are the industrial strength magnets that you may find in some "grown up"  toys  like buckyballs  or jewelry.
If more than one of those get swallowed it can wreak havoc on the intestines and be deadly. Keep them away from your kids!

Is it sharp?
If it is something that has a point or sharp edge, keep an extra close eye on your child. Make sure the tummy stays nice and soft. If your child seems to have a rigid painful belly, they will need to be seen right away. Keep an eye on the stools. Any dark, tarry poop or bright red blood would be a reason to get immediate help.
One of the sharpest things that we were keeping an eye out for some years ago was one of a Grandma's one carat diamond stud earrings. That passed through and was retrieved with no harm at all to the swallower (Grandma didn't want it back; it was reunited with the mate and is in a safe deposit box waiting until the little girl is 18.)

Most of the time, it is simply a matter of watching for the whatever it was to pass through. I have seen all sorts of stuff get swallowed and pooped out without incident. I think I have seen enough change to put a kid through college. Most coins smaller than a quarter go through fairly easily.

Let's encourage a quick passage! Increase the amounts of fluids that your child drinks. Perhaps add prunes. If your child is old enough that they are beyond simple pureed food, consider giving some corn kernels  (You won't see that in any textbook). Have you figured it out yet? For those of you who need spelled out, corn kernels are usually fairly recognizable after they have been pooped out. They can act as a marker.

If it goes into the trachea it may block the airway and you have a choking situation on your hands or it could get aspirated into the lungs. Neither is good. Your child will clearly be having breathing difficulties if this has happened. They will likely have a color change is they are fully obstructed. Of course with any emergency you should call 911, but it is my hope that all parents and caregivers are trained to do a choking rescue.

To avoid this happening on your watch, it is SO important to keep little items away from the young kids. Anything that can fit into a toilet paper tube is too small for an infant or young child to be handling. Dr Kaplan advises that a rule of thumb to keep in mind is that the size of your child's airway is about the same diameter of their pinky finger or ear canal. That is pretty small!
All parents should be able to do a choking rescue.