Friday, July 25, 2014

Nurse Charity blogs about thrush

Breastfeeding and Thrush
All that Burns is not Yeast

Summer is here (although in our foggy part of the world, some days it feels like a long cold winter) and this means a plethora of rashes, bug bites, and minor injuries.  For breastfeeding moms of new babies, it means a lot of diaper rashes (both bacterial, and fungal), and *possible* nipple thrush.  Candida albicans loves warm, dark places- like the mouth, the warm folds of skin covered by a diaper, and the damp inside of a supportive bra.  It is a part of our everyday human flora, held to manageable numbers by competing microorganisms; the addition of a bit more moisture, a more alkaline environment, and warmer weather are just the resources yeast has been looking for to begin !world domination! (starting with your nipples).  

Because breastfeeding involves both moms and babies- it is doubly hard to treat.   I will focus on Moms first, (because we tend to put ourselves last).

Step 1:Look for the most obvious culprit of nipple pain- LATCH!

Many books and online articles will leap immediately to yeast as a culprit for burning nipple pain- I mean why not? that stuff is everywhere, and in the warm-up phase, it is easy to treat over the counter with some inexpensive cream.  As a lactation consultant in practice for many years, I have learned the hard way that most pain, burning or otherwise, is usually caused by ~bad latch~.   It is a sad, sad fact that no amount of cream can cover.  So the first stop for any burning pain is a quick trip to a friendly lactation consultant to have a look at the latch.  Many stellar, comfortable, milk transferring, latches change over time, as babies get bigger and bigger, they start looming over the breast, tucking the chin to the chest to nurse, and not getting a wide open mouth- ouch PINCHY!!  

Step 2: Look for bacterial infection-
Yeast is very hard to grow out in culture.  The most comprehensive study of burning pain and relation to nipple thrush actually implicated low level BACTERIAL infection (meaning when we went hunting around- we found a lot more bacterial causes).  Most antifungals will also treat bacterial (not as well, but will kill off some- often enough to let the body put down the uprising).  So If I see a crusty, goopy nipple with "white stuff."  It is usually bacterial in nature, and matching the cause with the treatment means you get a faster, better solution to your nipple pain.

Step 3:  Ok- lets look for yeast-
Fungal infections of the skin (because they are not a mucous membrane) usually do not put out a lot of white stuff.  Mostly what I see is BRIGHT red/pink, and looks tight and shiny.  Sometimes it looks dry and cracked. Unfortunately, many other skin conditions also look like that:  Eczema on the nipples, contact dermatitis from soap,  etc, etc etc.  So forays into yeast treatment are experimental.  Ductal yeast (an infection on the inside of the breast  we cannot even see) usually feels like glass under the skin- very painful latch- feels like tiny cuts with glass shards, and then a very painful burning.

We came, we saw- now we want to conquer!

Try an over the counter antifungal-
Low level yeast, or probable yeast (no one is ever quite sure) can be treated with an over the counter vaginal yeast cream (clotrimazole, miconazole, that little tube of external cream that came with your vaginal yeast suppositories- it all works)  Just put it on in a thin layer after feeding or pumping.  And now I am going to shock you.  *Don't wash it off* before your next nursing.  A little bit of cream will not hurt your baby in the slightest- while the friction, and soap residue from washing your nipples compulsively every feed will definitely give you sore nipples.

Get rid of the warm, moist, alkaline environment-
Leave the nipples open to air as much as possible.  Wear a clean bra everyday, put some vinegar in the rinse water to kill yeasty bits hanging out there in the fabric.  Ditch the disposable breast pads (they have a plastic backing- holding in moisture- and they are very alkaline).  Try cotton ones, or my favorite WOOL (change them 3-4x per day).  If you like the idea of a vinegar rinse, I like a very dilute vinegar and water mix in a spray bottle (one tablespoon of vinegar, white or apple cider to one cup of water). Do not be tempted to make it stronger- too much acidity will cause dryness, burning, and nipple cracks- all signs of yeast.  Sometimes we use coconut oil on the nipples, reputed to be naturally antifungal and definitely supportive to dry looking skin (no one has done the actual research, but it seems like a good theory).  

Check the baby's mouth-
Most white tongue is actually milk tongue not yeast.  Even low level oral candida albicans usually requires no treatment, we just let it go. If your nipples, and breastfeeding start to suffer, however, we often treat the baby as well.  When I first started at Noe Valley Pediatrics, the oral Nystatin worked pretty well for most cases.  We still use it, it requires a trip into the office, so the Docs can have a look at the mouth! Probiotics cant hurt, might help.  For oral thrush, I like a powdered probiotic, ¼ teaspoon, dampen a finger roll it around in the powder, then put the finger in the babies mouth 1 time per day. Pro tip- Can also be dusted on the nipples.

I did everything you told me, now where is my relief?
Sorry Moms- sometimes even if you did all that, we need to do more:-(  Sad Story.  

Oceans of potions-    

All Purpose Nipple Ointment (APNO)- When we are not quite sure, we tend to throw this concoction at it.  It is RX, is expensive (if not covered by your insurance, most current plans DO, but the pharmacy may call you to check)  and needs to be compounded.  The Walgreens near our office stocks the stuff for us (bless them!) but otherwise it needs to be filled at a compounding pharmacy (Like Four-Fifty Sutter downtown, or The Rexall in the Sunset).  It is an antibacterial, an antifungal, and has a corticosteroid.  We also use it for stubborn diaper rashes  on occasion, so some of you have tubes at home.  Directions: Thin layer after each nursing/pumping.  *don't wash it off.* Follow-up if it does not work in 7-10 days, don't just keep using it.  

Gentian violet- It is a purple, dye, clings well in tincture form to skin, STAINS!  This is sold over the counter at the 20th and Mission walgreens in the "latino" section (that is what the Walgreens calls the section- sometimes they will tell you they don't carry it at all- ask for the latino section, and have a look- it is usually there- in spite of what the staff says).  Like many medicines, it can be toxic in large quantities.  In the level we are using it, probably non-harmful.  It does WORK reliably, as it treats both the nipple and the baby!!.  New and improved Directions: Applied one time a day!!  I recommend at night.  Strip down mom and baby.  Put some aquaphor, or cream around, not in the babies mouth to minimize staining.  Open the tincture, put in a clean q-tip, then put that q-tip inside the babies mouth and let them suck on it.  I find trying to paint the white parts is messier than just the q-tip in the mouth.  It coats well, and as a q-tip does not actually hold very much tincture, they will not swallow much of anything (usually just saliva).  Throw that q-tip away, get out a new one, and use it to paint your nipple and areola. (do not double dip the baby q-tip, get your own clean one).  Air dry the nipples.  Now you have two purple nipples, and a purple mouth baby.  The baby will start off looking like a member of Kiss, by the am, they will look like you are a terrible parent, and are feeding your baby purple otter pops.  By the afternoon, they look slightly cyanotic.  Then you will repeat for 5 days THEN STOP.  If there is no improvement in 3 days, please give us a call.  IF it is mostly better but not all clear at the five day mark you can go to 7 days, THEN STOP.  If in doubt, please call us!  Weird sores?  STOP and call (has never happened on my watch, but before my time, there was such a case).
Thanks to our model Shannon for showing off her purple mouth in the photo 

Grapefruit seed extract GSE- (lifted, with permission, from Jack Newman) Use instead of vinegar and water spritz.  Mix very well 5- 10 drops in 30 ml (1 ounce) of water.  Use cotton swab to apply on both nipples and areolas after the feeding. Let dry a few seconds, and then apply "all purpose nipple ointment". If also using Gentian Violet, do not use GSE on that particular feed but use after all other feeds. Use until pain is gone and then wean down slowly over the period of at least a week. If pain is not significantly improving after two to three days, increase the concentration by 5 drops per 30 ml (ounce) of water. Can continue increasing concentration until 25 drops/ 30 ml of water.

Diflucan- This is for Mom for ductal yeast, (after we have ruled out other more rare causes like Raynauds, and bad latch).  We prefer you go through your PCP or OB/GYN. The dosage is listed here because some HCP use the one time vaginal yeast protocol (which does not work) Diflucan (generic is just fine) 400mg loading dose on day 1, then 200 mg day 2-day 14 until you are PAIN FREE, can be repeated. We sometimes use this in conjunction with gentian violet or nystatin for the baby.  

For those moms who are yeasty people
Sometimes women with stubborn yeast are just really, really good yeast growers.  They tend to get oral thrush, and vaginal thrush at the drop of a hat, or with any antibiotics.  You know who you are.  I am one of this group; It really, really sucks.  For these folks, we go heavy hitting early (gentian violet, and APNO and diflucan) and we also recommend some stuff to cut down on yeast in your home environment.  It is labor intensive, so not every mom with a yeast problem needs to do these things!  Use your towel once, and only once.  Wear a new nightgown or pajamas, sleep bra etc every night, change your sheets every 5 days. Add vinegar to every rinse of your laundry.  Cut down on simple carbohydrates, and sugars.  

So that's it!
THRUSH, may you never have to do battle,
but if you do-  Go prepared! 

Friday, July 18, 2014

Make sure your child is in the right Car Seat


Please see updated post July 2015


car seat guidelines

Car seats are an essential part of keeping your child safe. California law as of 2012 requires:

Infants should be rear facing in the back seat until they are at least 1 year or 20 pounds. This is the safest place and position in the car.The current recommendation is that they stay there until they are two.
They can sit facing backwards until they reach the highest weight or height allowed by the car seat manufacturer. Size is a more realistic factor than age.

Toddlers who have outgrown the rear facing weight or height limit for their car seat should use a forward facing car seat with a harness for as long as possible, up to the highest weight or height allowed by the car seat manufacturer. This applies to children younger than 2 years who have outgrown the rear facing seat.

The current California Law also requires a car seat or booster seat until your child is 8 years or 4 ft 9 inches. Previously the requirement was  6 years or 60 pounds. Height parameters make more sense than the previous weight ones. You child needs to be tall enough so that the seat belt goes across the chest, not across the neck.

When children are old enough and large enough to use the vehicle seat belt alone, they should always use Lap and Shoulder Seat Belts for optimal protection. If your children complain about this rule, show them photos of race car drivers all bucked up in their restraint system. Be matter of fact about it and explain that there is no compromise for safety (there is also a mighty large fine if you are caught breaking this law.)

All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection. Airbags can actually be quite dangerous to a small child so it is worth making sure that this isn't an issue with your car and the placement of your child's safety seat.

Most accidents happen within a few miles of your house. Even a short trip down the block requires the full "buckle up". Hey parents, model good behavior and always make sure you fasten your own seat-belt!

Did you know that car seats expire? Most of them have a 6 year life span. This date can usually be found underneath or behind the seat. I questioned this when I first found out about it. The explanations made sense to me. First of all buckles and straps can wear out. Prolonged exposure to sunshine can weaken the plastic. Also, the technology is always changing and this ensures that nothing gets too out of date. Save the instructions/registration in a safe place. Do make sure you register your car seat. If there is ever a recall this will ensure that you are notified.

The AAA states that 75% of car seats are installed or used improperly. As your child grows, there are services offered here in the San Francisco Bay Area that will check out your car seat or booster seat and make sure it properly installed. Have the infant car seat checked before the baby is born and then again with each transition to a larger seat.

AAA 553-7203
2300 16th St suite 280
Contact is Dee Rivera. Appointments need to be made  at least 6-8 weeks ahead of time. Dee is the only current SF AAA car seat person and she only does it on Wednesdays. She says that email is a good way to arrange things: Dee.zapata@GOAAA.COM . You do not need to be a AAA member to take advantage of this free service. AAA also offers a fun interactive safety related website, , which is appropriate for kids 4-7.
(one of my mom's says that she had easier access through the AAA in Mill Valley)

CHP (California Highway Patrol)                  415-557-1094  
This is very popular and is by appointment only. Please make an appointment as far in advance as possible. The woman on the phone there said that her preference is for people to call as soon as that pregnancy test comes back positive! ( I assume she was partially joking, but you get the gist.) 

SFPD                415-575-6363
They try to have an officer at all of the local police stations who is trained to do the car seat safety inspections. Call the number above for more info.

The Colma police department will do a car seat inspection for free (650-997-8321) and they currently do NOT have a long wait for appointments.

Baby World Has a technician at all of the stores:

4400 Telegraph Ave, Oakland,510-547-7040 Mon-Sat(10-5:30) Sun(12-5)

556 San Mateo Ave, San Bruno, 650-588-7644 Mon-Sat(10:30-6) Sun(12-5)

514 4th St, San Rafael, 415-456-5533 Mon-Sat(10-5:30) Sun(12-5)

Appointments are needed but reasonable (within a week.) Inspection and installation are free if you purchased the seat through them. If you got a seat from somewhere else, they will still do a free inspection, but any adjustment or installation will be $40.00.

All of the above resources have changed so often during the past couple of years that it makes my head spin.
This info is current for July 2014

If you are not inclined to schlep, click below for info on an inspection that comes to you. It is not free, but it is certainly worth knowing about and some of my patients have used Bryan and raved about the service: 


-NHTSA website has a place to click to find updated local car seat inspection stations for those of you who are not in the Bay Area.
(national highway traffic safety association) (Keyword :car seat ) has a very comprehensive guide to safe installation.

 Car safety doesn't end with being safely buckled. I know it is hard to avoid distraction with a baby fussing in the back seat. Consider getting one of the specially made mirrors so that you can keep on eye on your rear facing baby. Make certain that they can't reach anything that is a choking hazard. Don't let them hold the keys; they can lock you out!! This happened to one of our little patients in the Noe Valley Pediatrics parking lot last year. Mommy parked and handed the fussing 15 month old the keys in order to distract her. Mom exited the car and as she walked around to open the back door, her child clicked the lock button on the key. Mom was locked out. Luckily it was a cool San Francisco day. Dad had an extra key, but of course he worked on the peninsula. He was on his way to the rescue when the little girl clicked the "unlock" and we were able to get into the car. Of course if it was an emergency we would have called the police or AAA to break in right away. In this case, our little patient had been as happy as can be, hitting lock over and over again and grinning at us through the window.  

Never leave your child unattended in a vehicle. Children can die from prolonged exposure to excessive temperatures in a hot car.
Thanks to one of my patients who read the post and then shared this link

Friday, July 11, 2014

Travel tidbits

This is a very popular time of year for folks to be traveling. Therefore, it is time to dust off, tweak and rerun the travel post.

"When is my baby old enough to fly?" is a question that we advice nurses hear all the time. There are  many different factors to consider, so there is no one simple answer. Adopted babies might fly within the first few days on their way to their new home. Other folks make the valid choice to fly way earlier than we are really comfortable with in order to see an aging relative or deal with a family crisis.

In ordinary circumstances, I would prefer to have the babies wait until they are over 2 months of age and have had their first set of immunizations. (Keep in mind that the first shot does NOT give full protection against some serious illnesses, but it is a start.) The size of the baby as well as the time of year are also factors. If there is some kind of crazy flu epidemic, I would think long and hard before taking a young baby on a plane. Regardless of how old your child is, if you are planning a trip here are some tips and things to keep in mind.

I get calls from all over planet from parents who are dealing with a sick child during their travels. Prior to the trip, check with your insurance company to see what the best method is for having out of state or international doctor visits covered. Some plans are much easier to deal with than others.  Whether the visit is covered or paid for out of pocket, you will need to figure out what your actual options are. Is there an urgent care facility near by? Do you have a friend or relative with a pediatrician who is willing to see patients who are not in their practice? Does your insurance only cover an emergency room visit?   

Hopefully you won't need to use this info, but if you are dealing with a sick child away from home it is nice to have a "Plan B" in place.

A few years ago I sat next to a mom with a very young baby. She was so worried about the possibility of getting evil looks from the other passengers that she had actually brought ear plugs to hand out to the people sitting around her. What she didn't have was anything to soothe her baby. Please always make sure that you have Tylenol or Motrin with you on the plane (not packed away in your suitcase). It is okay to bring small bottles through security. They need to be smaller than 3.4 ounces. Unless there is a glaring reason, I don't tend to premedicate, but I am quick to treat during the first sign of fussiness.

I often get questions about the use of Benadryl. This is an option for a child who is over 8 months with a long flight ahead. It helps dry up any congestion and makes 90% of kids who take it deliciously sleepy.
Aha, but what about the other 10% you might ask? It turns those little darlings into hyperactive, wild hooligans. You do NOT want to find out on the plane that you are the parent of the 10%.

You may want to give a test dose a few days prior to the trip to make sure it is a viable option for you. I like parents to have the tools with them to deal with an unhappy child. Don't give any medication unless it is necessary. While I would usually err on the side of less medication, Benadryl and Tylenol can be given at the same time.

Many babies and children can have trouble with their ears. For the younger ones, try to nurse or have them feeding during takeoff and landing. Sucking on a pacifier may be helpful as well. Have a lollipop or chewing gum for older kids. Ayr saline gel is a nice thing to have along. A dab at the base of the nostrils can moisturize the dry air and make the breathing easier (use it for yourselves as well)

If you have a child with a history of ear trouble, have some of the little gel heat packs in your bag. You can activate them as needed and the warmth feels great to a sore ear.

Take WAY more diapers with you than you think you need for the trip. I was on another flight not too long ago when we sat on the tarmac for three hours. There was an unfortunate family behind me who had planned on a short little trip and was out of diapers long before we took off. It wasn't pretty. Plan accordingly.

Many folks automatically bring a change of clothes for their baby. It is also worth bringing an extra outfit for yourself. If you have a long flight ahead of you with a child on your lap, it may come in handy. (I learned that one the hard way and sat for several hours covered with poop.)

Changing your baby on the plane can be a challenge. It is helpful to have little changing packs, with a diaper and some wipes, in individual zip lock bags. This will prevent you from having to take the entire bulky diaper bag with you into the tiny bathroom.

You can't count on airlines giving you any reasonable snacks, so it is important to bring along enough provisions in case of delays.

For older kids make sure you have little activities to keep them busy. If you are visiting family, print out a bunch of photos of the people you are going to see. You can use these for all sorts of art projects on the plane. Make a paper doll family! This can help your kids recognize folks that they don't see too much of. Wikki sticks are also a great activity to bring along. They are lightweight and not too messy.

Once you get to where you are going, make sure the place is adequately child proofed (this is also a discussion that it is worth having with your hosts before you get there). I had one situation just last year, where a 3 year old opened a drawer and got into grandma and grandpa's medications. Is there a pet where you are going? Make sure that any dogs are safe with children.

If you are staying in a vacation home, do a quick safety check. Do they have working smoke detectors? A fire extinguisher?

Time zones are tricky.

My best suggestion is eat when you are hungry, sleep when you are tired and just do your best. Staying hydrated and getting fresh air are essential.

The link above has wonderful information for dealing with Jet Lag.

Even the best sleepers may have a period of needing a sleep training tune up when you get home.

You can have lots of fun while you are away and it is wonderful to see family. But, in my opinion, if you are traveling with children under the age of seven, don't call it a vacation. It's not. It is a TRIP. (We used to call our visits to the various grandparents the "bad bed tour.")

A little preparation goes a long way and remember that some of the more challenging moments make for the best stories! Here is one of mine..

Many years ago when my daughter Lauren was two, I got creative as I was planning for an upcoming flight as a solo parent. I had seen a craft in a magazine (long before pinterest existed) where a necklace had been made of cereal and I thought that that seemed like a fabulous thing for an airplane trip. Unfortunately, not all ideas turn out to be good ones. Lauren and I strung some Cheerios onto elastic and she proudly wore her new necklace onto the plane. Soon after take-off Lauren decided to eat some of the Cheerios. I noticed with some dismay that as she bit off a Cheerio, some would go into her mouth while other parts would shoot off like little spitty projectiles. They were landing (unnoticed by anyone but me) on just about everyone within three rows of us. As soon as I realized what was happening, I tried to see if there was a way for her to nibble them off without making a mess. When that didn't work, I tried to take the necklace off to make it easier or to have her stop eating them at all. But if you recall, she was two. My choices were clear...tantrum on the plane or unsuspecting fellow passengers having little pieces of spitty Cheerios in their hair.

I opted for peace. (Besides, ignorance is bliss, right?)

Have safe travels and make great memories
Don't forget to snatch your unused barf bag for the glove compartment.

Friday, July 4, 2014

Motion Sickness

It is not unusual for us to get calls from folks who have a child or family member that suffers from motion sickness. Some younger babies seem to have trouble, but the majority of people who have the most issues with this are between 2-12.  Luckily, kids do tend to grow out of it...except for an unfortunate few.

All babies should stay rear facing as long as possible, BUT if your child vomits every time they are in the car, I would try to turn them around and see if facing forward makes a difference. It isn't ideal, but having a vomiting child has it's own safety issues.

If you know in advance that motion sickness is an issue, here are a few natural remedies that you may want to try. If you are someone who deals with this a lot, you will have plenty of car rides ahead to do your experiments and see what works for you. 
 Getting fresh air by having a window open is the first course of action. Do some distraction by playing a game that has your child looking out the window. I SPY is a good one. See if you can find interesting license plates or different colors or letters on signs. Don't sabotage your trip by bringing along trip activities that have your child focusing on things inside the car. Even the best passengers might be fine until they start reading or looking a phone or map.

Most kids do best when their tummies are not too full or too empty. Little crackers to snack on might be useful.

There are wrist bands that provide pressure to some acupressure points that seem to give relief.
You can find these on Amazon. There are several brands. A popular one is called sea-bands. They come in multiple sizes and colors.

Ginger seems to be very helpful. For older kids, there is a ginger gum specifically made for nausea (also available on Amazon). Find your favorite ginger cookie or candy. Trader Joe's has a wide assortment. Of course don't give anything to a young child that might be a choking hazard.

Motion Eaze is a topical aroma therapy that some folks swear by. You just dab a drop behind the ears and it provides relief within a few moments. Don't do this one for the first time before you embark on a long car ride. The smell is fairly pungent and other folks in the car might have a hard time with it.

Hylands makes a homeopathic motion sickness remedy. As with many homeopathic remedies it gets mixed reviews. It does seem to be the ticket for some folks, and is unlikely to cause trouble as long as it is used as directed. It might be worth a try.

For the older kids, have them try very hard to give you as much warning as they can. Ideally they should try to get in the habit of warning the driver at the first twinge of nausea, so that you might have time to pull over and get them out of the car for a couple of moments until the motion sickness eases. Being stoic is not a good plan, it usually backfires.

In my car, I actually kept barf bags in the glove compartment. When you fly, assuming yours remains unused, take it home with you.They may come in handy. If you don't have an actual barf bag, have a container or plastic bag that you can whisk out at a moments notice.

If you are going on a long car ride, plane ride or boat trip and you have struck out with the natural remedies there are some medication options. Benedryl  is an antihistamine that often works quite well for motion sickness. It comes as a liquid. The bottle says for children over the age of 6, but in our office we do use it for younger kids. The dose usually agrees with the tylenol dose volume. Kids over 22 pounds would get 5 ml or one teaspoon. Always check with your own doctor's office to see what their policy is. Benedryl makes most kids sleepy, but don't count on that. It gets some kids hyper. You probably don't want to find that out on a cross country flight.

Dramamine is another choice. It is an over the counter medication specific for motion sickness. Children 2-6 years of age can take ½-1 tab; children 6-12  years of age can take 1-2 tabs. These chewable tablets can be repeated every 6 hours, no more than 3 doses in a 24 hour period. Start with the smaller dose first to see if it works. Giving the dose 30-60 minutes before travel is recommended. For kids over 6, Bonine is another reasonable choice. This medication can be given at the first sign of nausea and is less sedating.

Your trunk should be prepared:
a change of clothes
a plastic bag for putting the soiled clothes in
some wet wipes
a lollipop to get the yucky taste away
Fabreeze for cleaning off the seats

While kids are usually the ones most apt to barf  in your car, motion sickness can afflict any of us at different times. I hope that some of these tips can help you out.