Friday, September 26, 2014

Nurse Jen blogs about Keeping Play Dates Safe

A few years ago, my daughter (then 7) declined an invitation to play at her friend's house; a neighbor she had played with many, many times. In fact, they had just spent the day before together. I thought she was being moody, but she dug in her heels and refused to go. What I later found out was the friend had led a game of doctor the day before, complete with physical exams and my daughter as the patient. My daughter did not like it and I was proud of her for standing her ground and not returning the next day (although the true reason why didn't come out until much later.) When I spoke to the mom about the incident she respected my daughter's feelings but I got the sense that being naked was not such a big deal in their household. In fact, she confided that her younger son was often taking his clothes off in public places because he was so used to being naked at home. While my daughter was fine being naked in our home, she was less than pleased about nakedness at someone else's home!
This got me thinking about how we may think we know our friends and neighbors well, but we really don't know the intricacies of how they parent until we are faced with a real life situation....involving our own children.

Providing enough supervision to keep kids safe while also letting them have the chance to make mistakes and grow is one of our many jobs as parents. It's not an easy one. Local non-profit Kidpower offers some advice about setting up safe playdates for our kids, I've forwarded their recent newsletter below.

The fact of the matter is, your parenting style will never be exactly the same as your friends - even your best friend. I was reminded of this just last week when my best friend visited with her three kids. While I refused to allow my kids to ride in their camper van because there were no seatbelts, she refused to let the group of kids out of sight at a small town street festival. We explained to the kids that different families have different rules. I worry about car accidents, she frets about stranger abduction. Hopefully the "It takes a village" mindset will help keep all of our kids safe, I think the advice below is a great start.

From Kidpower (
When setting up playdates with kids who we think will enjoy spending time together, we usually think of logistics such as what time and which house. Assuming that other parents will have the same standards about safety and respect that we do because they are nice people and have great kids is normal. At Kidpower, we call these assumptions: "The Illusion of Safety," because they can lull us into believing that everything is fine - until something suddenly goes wrong.
For each situation, make a realistic assessment of your child's ability to speak up or refuse if someone does something against your safety rules - and to get help if anything makes them uncomfortable. Make sure that your child knows how to reach you or another adult caregiver at all times.
Have a frank conversation with the other parents about your expectations and, before you accept responsibility for their child, insist that they do the same with you. These conversations might be uncomfortable - but, as we teach in Kidpower, your children's safety is more important than anyone's discomfort.
Here are 8 questions to ask yourself and other parents as you are setting up a playdate in someone else's home:
1. What is and is NOT okay with you? Sometimes there can be an issue due to a difference in culture. For example, families with young children might have very different ideas about kids playing naked in the water on a hot day - or seeing each other's private areas.  Sometimes there may be a difference in values - families have very different beliefs about teasing, for example, or what kinds of videos kids are allowed to watch. Sometimes there may be an issue due to a lack of understanding. For example, people who don't have allergies might have a hard time believing that one little bite of something your child is allergic to could cause a problem. Having a clear agreement about what is and is not okay ahead of time can prevent a great deal of unpleasantness.
2. Will my child spend any time around older children or other adults? Visiting children are sometimes harmed by their friend's older siblings, friends of those siblings, or neighbors -  who may tease them or who do something unsafe, such as locking them in the closet, taking them out of the yard without permission, or molesting them.
3. Will you be there and available the whole time? Some people think nothing of leaving their and your kids with someone else for "just a few minutes" while they go to the store - and you want to know who is going to be in charge of your children.
4. Are there places you let children go without you with them? Kids going alone to the park down the street might seem normal to this family - but you want to know and decide yourself if your child is ready to handle this kind of independence and be aware of the potential hazards.
5. Are there guns in your home? If so, what kinds of safeguards do you have so that children do not get hold of them? Too many tragic accidents have happened with kids playing with guns, so we want to be aware of this hazard.
6. Do you supervise all use of smart phones, computers and television so that you know what children are seeing? Letting kids go unsupervised with technology can be as dangerous as leaving them alone in any public area without adequate preparation.
7. Will you be taking the children anywhere? You want to know where your children are, who is with them, how they will get there, and what they are doing.
8. Is there a pool, hot tub or other water feature nearby?During summertime especially, many playdates involve playing in the pool, or even in cooler weather, sometimes a hot tub. Knowing if the children will be in or near a private or open body of water, and how they will be supervised around it, is important in order to avoid tragic accidents. Even children who are good swimmers can get injured or surprised and find themselves in trouble in the water - and therefore need close supervision.
A parent's response to your questions will help you to make the decision about whether or not playdates with this family will be in the best interests of your child.  Finally, check in with your child before and after each playdate to review the safety rules and find out what went well, what didn't, and how can you make things better.

Friday, September 19, 2014

Tech Time/ How much is too much?

See updated post on this topic February 2019

Dr. Schwanke is an avid reader who often sends me copies of articles that catch his eye. The other day, he sent me one about Steve Jobs being a low tech parent. Many of you may have seen it:

I realize that this is a topic that affects most of us.

There is no disputing that we live in an ever changing world. Those who try to ignore all the technology won't be able to keep up. As much as we may be tempted to wrap the Luddite cloak around our households, is that really fair to our kids?

On the other hand, I want kids outside playing, not inside glued to a screen (for the purpose of this post I am referring to screen time as anything computer, tv or video related.) I want my patients to know what it feels like to turn the pages of a real book, not just to swipe their fingers across an Ipad. I want them to know how to get messy with fingerpaints, not just how to create virtual art. I want them to interact with friends in person, not with avatars online. How can we find a balance?

You are still in charge of how much screen time your child gets.
I think that there is absolute value in getting some. Technology offers a vast array of education and entertainment. We can learn so much from computers. The games are fun. Television has some nice programs. Having some down time while you get something else done and your child is happily engaged can be very helpful. How many of you have been in the position when you want to strangle your partner because they voiced the "no computer or videos for you ALL week!" as a consequence for some errant behavior. Some of you need that down time more than the kids!

The key is figuring out how much is too much. This is a plan that each family should discuss and create. Some families will allow more than others. Your own family should be the only one to make rules that make sense to you, but please, set some sensible limits that apply to all of you. Don't sabotage each other. If you have a partner, figure out the rules that you both feel comfortable with. Make a plan and be consistent. If your kids figure out that the rules are meaningless, you have significantly weakened your credibility.

At my solid foods class when I discuss "safe eating" I tell parents that they need to set a good example. If you shovel food in your mouth and talk with your mouth full, why would your child learn to eat any other way? Put in a small piece of food, chew and swallow. Set the standard.

When it comes to being a role model, technology is no different.
If you are always looking at a screen, if your forms of relaxation are all technology related, consider making some small changes.

My goal is for your child to have a healthy relationship with technology. Learning how to use it at a young age will keep them on the level playing field with others. Let them enjoy their allotment of tech time, but focus on opportunities where they can have just as much fun reading a book, or doing other things that don't have a screen involved. There are so many options:

Having a no TV/ no computer environment is not something that I recommend. When your child emerges from that protective bubble, they may feel a bit like Alice in Wonderland. Back in the "olden days" when my kids were young, our screen was simply the TV. They had friends come for play dates who were not allowed any television at home. If I allowed it, the only thing those kids wanted to do was watch tv because it was such a treat for them. They had no balance.

Extra screen time (still with limits) can be a commodity that can be earned for good behavior. But because I don't want it elevated to the most important thing in their lives, I would rather make the rewards that they work towards be special non-tech activities with you.

Make sure you put some child control limits on your device:

There are lots of apps out there, with more being developed all the time. Some can help you make sure that all the sites that your child can access are safe and appropriate, others can help you limit the time allowed.

As your child gets older, it becomes much trickier. It is reasonable for rules to be renegotiated with each age. Have your child be part of the discussion and verbalize understanding of the family rules. Until they are a certain age, many experts agree that all computing should be done in a common room.
May the force be with you...this is a tough one. 

Friday, September 12, 2014

Pacifiers - Friend of Foe

There are plenty of differing opinions out there when the subject is pacifiers. My thoughts are as follows. If used with a few common sense rules, a pacifier can be a useful tool, and what parent doesn't need all the tools they can get?

The main benefit is that it satisfies the baby's need to suck. Sure, a finger works, but a pacifier can offer a little peace and free up your hands so you can get something else done while the baby is content. If your baby is fussing and you are fairly certain they are not hungry, a pacifier may help them calm right down. Trust me, if they are looking for milk and you offer a pacifier instead of a meal, they will NOT simply happily suck. I also want to protect mom's tender nipples. It is not so good for a baby to linger on mom's nipple long after the feeding is done just because they are enjoying the sucking. A little extra sucking is fine, of course, but some kids will never sign off.

If I have my way though, I would counsel that you keep the pacifier out of the crib. Certainly it is fine if your baby drifts off to sleep occasionally when they have a pacifier in their mouth, but make it the exception, not the rule. Take it out before you put them in the bed. The cornerstone of my sleep advice is that you let your baby learn to fall asleep without too much assistance from you. Don't PUT them to sleep. Don't SNEAK them into their beds. If they learn that a pacifier is an essential part of their sleep routine, then they are dependant on you to replace it every time it falls out. I have plenty of families who are ruing the fact that they didn't heed that advice. Some of my patients now go to sleep with a dozen pacifiers scattered around the crib in the hopes that they will be able to find one and replace it themselves rather than waking up mom or dad every few hours.

Other disadvantages of a pacifier if you don't set limits is that you could end up with a Maggie Simpson on your hands. For the few of you who may not get that reference, Maggie is a cartoon character who is actively sucking on a pacifier 100% of the time. Pacifiers are also potential germ minefields. It is important to clean them well, especially after any illness. The dishwasher is fine for this.

Pacifiers can also be safety issues if they are worn down. If you have a brand that your baby is attached to, make sure you have several, and throw away any damaged ones immediately.

Typically the oral stage should be ending around 12 months. This is also an age when the mouth is about to go through some major growth changes. Ideally try to lose the pacifier habit well before that.

Dr David Rothman, who was my children's dentist says that he is often  able to guess the brand of the pacifier by the shape of the roof of the mouth. They do have an impact! Some forceful frequent sucking on a pacifier can generate more force than an orthodontic appliance. When I asked him his opinion about which is the least heinous type, he told me the better ones are probably the Playtex natural nurser and the evenflo. He says the worst offenders are the NUK and "orthodontic" type pacifiers.

Dr Claudia Masouredis, another popular local pediatric dentist says that she doesn't have any strong opinions on pacifiers. She admits to having had a daughter who used one and feels they provide comfort to some children, so she is not militant about forbidding their use. She adds that they can cause bite issues if used frequently. These malocclusions may self-correct when the habit stops.

Nurse Charity says that pacifiers can be  linked to early weaning. She prefers that folks use round ones for the least impact. She is fine with limited use.  As she says, "use them for a purpose, don't just shove them in!"

One of Dr Anne's twins enjoyed the pacifier while the other rejected them right off the bat. Every baby is different. She stopped offering the pacifier around 4 months.

My older daughter Lauren loved her pacifier. I don't even know what brand it was. It was pink and plastic and luckily she seems to have survived having that habit without any long term repercussions. She referred to it as her "powell" which was probably the garbled way she would have said "pacifier" if she didn't have it in her mouth. At the time, I didn't know enough to set any pacifier limits and it became clear that if we didn't intervene, this was a habit she was in no hurry to break. When she was older than two, we ultimately made the rule that she could only have it when she was at home and she had to deposit it in a little bowl when we were leaving the house. Eventually we staged an intervention and "gave them away" to a new baby that a friend had just had. She plaintively asked for her powell for about a week before she moved on.

Dr Kaplan sent her little guy's pacifier up to the pacifier fairy by tying it to the end of some helium balloons. "Bye bye pacifier"

Bottom line, if your baby likes it, use a pacifier for occasional sucking needs during the day and for the first year only (but try to get rid of it before 6 months unless it is essential to your peace of mind.) If you follow these guidelines, you shouldn't have to worry about breaking a difficult habit later.

Friday, September 5, 2014

Cold/Congestion review

Please see the updated post February 2017

With school back in session we often see an increase in colds and congestion, so I am brushing off an earlier post with some updates. It is important to have some guidelines to help you figure out when a trip to the doctor's office is indicated. On the other hand, often there is nothing to do but wait it out, so below are some tips to help you and your child get through the illness as comfortably as possible.

Colds and coughs are a common issue for all of us with or without kids. Studies say that most children will have an average of EIGHT colds within the first 18 months of life. Most of the time the congestion is caused by a viral syndrome. Allergies and teething* can also be culprits causing you to be congested. All that mucous is the perfect breeding ground for bacteria, which is why something that starts as a virus can turn into an ear infection, sinus infection, or lower respiratory infection fairly quickly. Be warned,  
we can see a patient one day with clear lungs and no ear issues, and the very next day they can seem a lot worse and have a raging infection.

When to come in:  
If you are dealing with a congested family member, here are the questions to consider:

*Do they seem to be having any labored breathing?  Babies with labored breathing will look like their little tummies are going in and out more than usual. Respiration will be more rapid (I am more concerned with the lungs than a stuffy nose.) Noisy breathing alone is not a very good indicator as it may be caused by upper airway issues that we aren't too worried about.

*How is their mood?

*Do they have a fever?

*How is the appetite? If your baby is nursing well, that is very reassuring

*Are they sleeping well at night?

* What color is the mucous?

*How long has this been going on?

Many colds and coughs can last between 7-10 days. Some coughs can linger for a few weeks.  

we have a reasonable consolable child with clear mucous who is eating and sleeping  well, whose breathing isn't alarming and who has no significant fever,  

THEN I am okay playing the "wait and see" game. Of course if the symptoms show no signs of improvement, please check in with your doctor's office.
you have any labored breathing, wheezing, a child who is much grumpier or fussier than usual, and/or a fever that is hard to control or has lasted more than 3 days with  mucous that is getting thicker and greener,  

THEN that person needs to be seen. Green mucous does not automatically signal a problem. It is just one more clue.

Try sticking your ear up to their lungs and see if you can hear anything. If you can hear nice clear air noises, that is great. If you hear whistles or squeaky noises, that may mean the lungs are involved. More than half the time this won't work and you won't be able to hear anything, but once in a while parents are able to get some important clues from the "ear to chest" evaluation.

Any baby less then 2 months old is probably worth a visit to the office with their first cold, unless they are eating really well and seem completely happy. It is certainly at least worth a call to the nurse.

Management tips:

The best way to manage congestion at home is to make sure your little patient is getting plenty of fluids (this will help to keep the mucous thinner.) Breast milk is perfect if you are lucky enough to have it.

With some older kids, cows milk may not be the best choice because it can increase the amount of mucous (it doesn't impact everyone the same way.)

Steam is great. Hang out in the bathroom when anyone takes a shower. Running a humidifier or vaporizer at night is a good idea. Turn it off during the day and give the room a chance to dry out so that you don't grow mold. Make sure you change the water daily. As long as you follow those rules, I don't have a preference between warm or cool mist.

Keeping the head elevated makes a huge difference. Some of the younger babies will do best sleeping in their car seats, bouncy seat or swing (make sure it is safe.) Otherwise try a crib wedge or place a towel underneath the mattress to raise it up a bit.

You can put saline drops or breast milk into the nose (and then suck it out with a Nose Frida or snot sucker). This is the most natural way to clear the nose. Your baby will no doubt hate this, but if you can manage to do it about ten minutes before a feeding, it may clear the nose up enough to make eating much easier. Do not torture your baby with the nasal irrigation if they are managing just fine.

For patients over 6 months of age, ask your doctor about Windbreaker (a Chinese herb that we use to dry up congestion) Many of our families swear by it. It is sold at the Chinese medicine works on 25th and Noe. For convenience our office tries to also keep it in stock.

For older kids don't minimize the value of chicken soup!

For night coughs try a bit of  Vicks Vaporub on the feet!

For parents and big kids I really like Sambucol and zinc lozenges. This may be placebo, but in my case I say " bring it on" because they seem to work. Remember that I work in the germ factory and (knock wood) I manage to avoid many of the things I tend to be exposed to. The second I feel that little tickle in my throat or any tell tale signs of an illness I take a zinc cold therapy lozenge (Walgreen's generic taste better and are cheaper) and a Sambucol lozenge twice a day.

Another very good thing to do for folks who are old enough is to use a Neti Pot or sinus irrigation

11/15 new tip!!! One of my moms swears by the Oogiebear nose and ear cleaners. These are safe, soft little plastic scoops that allow you to remove stubborn little boogies

Good hand washing is of course essential.

Wishing you a back to school season that is kind and gentle.
*Most medical literature disputes whether or not teething is connected to any symptoms, but I have been at my job for many years, and I see what I see