Friday, November 28, 2014

Problem solving skills

Strange stuff happens to my daughter Alana all the time. Folks that know her refer to her life as "Alana Land". Aspects of this range from winning an incomprehensible percentage of raffles to creating lasting friendships with random people that she meets on public transportation. Once, as she walked to Muni after her late night shift working at the suicide hot-line, an odd procession of old men playing Dixieland jazz music followed her for several blocks on the otherwise empty streets When she got to the station, they tipped their hats and veered away. So, when I got a text from her earlier this week telling me that she had the "weirdest evening ever" I couldn't wait to hear the tale.

Alana is currently living in Ann Arbor working on her Masters in Social Work. She shares a house with 5 other grad students. The other night the doorbell rang and one of her housemates opened the door to find an "old woman" there having trouble breathing. His idea of problem solving was to holler for Alana who appeared and took over.

Among the things this stranger was saying was that although she was not a religious person, God had told her to come to this house where she would get help. She also talked about wanting to kill herself. Alana managed to calm her down, get contact info for family members, contact the social work department at the hospital, and ultimately get this woman to an emergency room. There are a lot of adults who would have found this overwhelming.

Since we all can work on our problem solving skills, in honor of her handling that situation so well, I am updating and rerunning this post from last year.

What  would you do if?
I have been doing these little weekly emails for just about 2 years now. Some posts are clearly more relevant to parents with young children while others are much more applicable to older children. Some are more global and your child's age doesn't matter so much. This is the latter.

Today's topic is a about an important activity that you can do with your child that teaches them to be "problem solvers".

Although at first glance it may seem targeted to parents with older children, in fact everyone could learn from it. Adults need to learn to be problem solvers also. Some are much better at this than others. For instance, if you got in a fender bender, what would you do? Many folks would just freeze and panic. What should you do?

*Assess for injury' call 911 if needed
*Know where your insurance info is
*Take a photo of any damage
*Take a photo of the other driver's insurance card and drivers license...etc.
*Always have a charger in your car for your cell phone so that a low battery is never an issue.

Having a plan in advance could help you stay calm. That is the main theme of this post.

Years ago, the concept that everyone would carry around an individual cell phone seemed as futuristic as the communicators on Star Trek. Now, of course it is hard to imagine how we got along without them. It was, however, the lack of the cell phone that prompted me to create a game that became a favorite in our family.

It must have been 1994 and I was on my way to pick up Alana from preschool. She was about 4 years old at the time. It was one of those days. I was uncharacteristically running late. Then, I got stuck in terrible traffic. To compound things, I took some random turns to try to work around the congestion and ended up utterly lost. (Remember that this was also before Google maps or GPS)  My stomach was in a knot and I wondered what my younger daughter would do when mommy was late picking her up.

It turned out that she was calmly waiting for me in the office, but that was the day that the "what would you do if" game was created.

It went something like this:
I would ask a question such as, "What should you do if mommy is late picking you up? What are some of the choices? Which is the best one?"

Getting a teacher or trusted grown up to wait with her or take her to the office was clearly the right answer and I praised her for figuring that out on her own.

Alana loved this game. We created all sorts of situations

" What if we were at a store and you couldn't find me?
Alana.." I would go to the check out and ask them to page you"
We never made it too simple...
Mommy :"What if they refused?"
Alana :"I would demand to talk to the manager"

Our scenarios covered any number of little emergencies including earthquakes, fires, and getting lost or separated. We didn't cover the "what would you do if a strange, suicidal old woman shows up at your door?"  It turns out that the better you are at problem solving, the easier it gets to improvise.

This game came in handy more than once. The shining example that comes to mind happened after years of playing this game. Alana and I were walking the dog on the beach one day. I had donated blood earlier that morning and didn't realize how foolish I was for doing anything strenuous. I got very light headed and ended up down on the sand trying hard not to completely pass out. Alana was ten at the time and she went right into problem solving mode. We did have cell phones at this point. She got the dog on the leash, patted some water on my forehead and calmly called daddy. I could vaguely hear her talking. "Mommy fainted...I think she is okay"

The game was such a success that my sister taught it to her kids. Hers had an interesting spin because they lived in Alaska at the time:

"What would you do if you saw a bear?"
"What would you do if a Moose wanders into the yard?"

There were actually times when these things happened, and my nephews were able to act calmly and appropriately!

Topics can range from handling a bully to getting separated on Muni. Being prepared for unexpected situations can be invaluable.

If your child finds themselves without you and in need of assistance, finding a grown up wearing a uniform is often a valid option for some of the difficult situations. Finding a parent who has a child with them and asking them for help, might be another safe option.

This game is meant to empower. It is wonderful for some kids, but could be terrifying for others. You need to assess your child's temperament before playing. Either way, identify a problem or situation. Start with simple, less scary ones. Discuss all the possible solutions and then agree what the best plan should be for any given situation.

Stressful situations happen. Teaching your child to take a deep breath and use their problem solving skills is one of those things you can do now that can have lasting implications for them when they grow up.

Even teaching a very young child to dial 911 in an emergency can be life saving!

You have to figure out if this will be empowering for your child as it was for Alana. My daughter Lauren never liked to play it. In fact, I remember one day when Lauren and I were taking a walk, I tripped on something, stumbled and fell. I was perfectly fine, but Lauren's reaction was to start screaming. I think she was ten at the time. As she says, "mommies aren't allowed to fall". Every kid is different.
As your child grows, the situations that you might want to bring up will increase in scope.
Just this month a child right in Noe Valley avoided a potential kidnapping situation by making good choices in that terrifying situation.

I think that the "what would you do" exercise is actually something that you might want to do with a nanny or caretaker. Having them be able to manage a crisis with a clear head is essential.

I want to add one more tidbit here. What if you lost your cell phone or it ran out of batteries and you don't have a charger? Do you know important phone numbers, or do you count on speed dial. Having a list of important numbers in an accessible place is a good idea for everyone.

Preparation is power.

Friday, November 21, 2014

Food safety considerations

Thanksgiving is a holiday associated with lots of yummy leftovers so it seems like a good time to brush off and update this post about food safety. 
Check the bottom of the article for some great links on food storage guidelines
Everything from egg safety and turkey leftovers to breast milk storage


It is certainly not a sterile world. As soon as they are able your baby will start putting anything that they can reach into their mouths. You can't even begin to imagine the phone calls we get about the more disgusting items that some of our little patients have managed to get their hands..and mouths on.

So yes, the world is full of germs, and while I don't generally get too concerned about a little dirt here or a big sloppy dog kiss there, food-borne bacteria are especially nasty and we need to minimize any exposure.

Infants and young children are particularly vulnerable to food-borne illness because their immune systems are not developed enough to fight off infections. This is especially important for infants under 6 months of age  Extra care should be taken when handling and preparing their food and formula.

Here are some basic food safety guidelines:

*Wash hands for at least 20 seconds before food preparation. Soap is best. Hand sanitizer will do. Re wash as needed after handling food that might carry germs (poultry, meat, raw eggs)

*Make sure kitchen towels and sponged are changed and cleaned frequently (sponges can go through the dishwasher)

*Keep your refrigerator temperature at 40 degrees or colder and your freezer below 0 degrees.
(One way to make sure that the Freezer has continued to have safe temps is to freeze a baggie filled with ice cubes....If they remain cubes, you are in good shape, if they melt and refreeze as a block of ice that means that at some point your freezer was not cold enough)
Label things in your freezer and rotate so that you are using up older stuff first.

*Check the dates of baby food jars and make sure the lid pops when you open them.

*Don't "double dip" with baby food: Never put baby food back in the refrigerator if your child doesn't finish it.
Your best bet: Don't feed your baby directly from the jar. Instead, put a small serving of food on a clean dish. Add more as needed with a clean spoon. Remember that once saliva has come into contact with the food it is no longer sterile and some bacteria can grow quickly.

*Don't leave open containers of liquid or pureed baby food out at room temperature for more than two hours.
Bacteria thrive in temperatures between 40-140 degrees

*Don't store opened baby food in refrigerator for more than three days.
If you are not sure that the food is still safe, remember this saying: "If in doubt, throw it out"
(see links below for guidelines on how long food stays safe)

*Make sure that foods are properly cooked. A food thermometer is the best tool for this.
Chicken ( white meat/ dark meat)...170/180
Eggs....not runny

For all of you "older kids" who will be baking this holiday season.
Watch out for  batter. (I am a notorious offender), but
even one lick from raw food containing a contaminated egg can get you ill.

Myth: Freezing food kills harmful bacteria that can cause food poisoning
Fact: bacteria can survive freezing temperatures. When food is thawed, bacteria can still be present and can begin to multiply.
Cooking food to the proper internal temperature is the best way to make sure any bacteria is killed.

Myth: vegetarians don't need to worry about food poisoning
Fact: Fruits and vegetables are an important part of a healthy diet, but like other foods they may carry a  risk of food-borne illness.
Always rinse produce well under running tap water.
Never eat the pre-washed 'ready to eat' greens if they are past their freshness date or if they appear slimy

Myth:  Plastic or glass cutting boards don't hold harmful bacteria on their surfaces like wooden cutting boards do.
Fact:  Any type of cutting board can hold harmful bacteria on its surface.  Regardless of the type of cutting board you use, it should be washed and sanitized after each use.  Solid plastic, tempered glass, sealed granite, and hardwood cutting boards are dishwasher safe. However, wood laminates don't hold up well in the dishwasher.  Once cutting boards of any type become excessively worn or develop hard-to-clean grooves, they should be discarded.

Myth:  Locally-grown, organic foods will never give you  food poisoning.
Fact: Any food, whether organic or conventional, could become unsafe with illness-causing food-borne bacteria at any point during the chain from the farm to the table.  Consumers in their homes can take action to keep their families safe.  That is why it is important to reduce your risk of food-borne illness by practicing the four steps: Clean, Separate, Cook, and Chill.

Some excellent resources for food safety tips are  (this site keeps track of any food recalls)   (great site for seeing how long food will last)   (this site has loads of kid friendly activities)

 breast milk storage/ pumping guidelines (Kelly mom is a worthy site for all sorts of breast feeding info) (Self eggs..planitory) 

Tuesday, November 18, 2014

RSV season

Post updated 11/2015
November is often considered the start of RSV season. Sure enough we have already seen it in the office and confirmed our suspicions with our in-office test.

Here is the RSV post, updated for the 2015/16 season.

What is severe RSV disease?
Respiratory syncytial (sin-SI-shul) virus, or RSV, is a common, seasonal, and easily spread virus. In fact, nearly all children will get their first RSV infection by age 2.
Like most viruses it ranges in its severity from case to case.

Severe RSV disease is the number one reason babies under 12 months old have to be admitted to hospitals in the US. You know the wretched colds that knock you flat and stand out in your memory? These are the colds that come with runny noses, sniffling and sneezing, harsh cough and fever. That illness might well be RSV. I actually can almost diagnose it over the phone when I hear the patients coughing. The cough sounds like it hurts.

There is a test that we can do in the office (a swab to the nose) to see if it is RSV or not, but unless your child is looking really sick we might not bother. It doesn't necessarily change the approach. We often do nebulizer treatments for our wheezers, but with RSV they don't always help all that much.

Time usually fixes this and all that we can offer is often the same symptomatic treatment and supportive care that we would do for any bad cold and cough. Treat the fever as needed   

To clear the nose, squirt some saline or breast milk in each nostril and then suck it back out with either a  Nose Frida/ aspirator or the Neil Med Naspira I think those are much easier to use than the standard bulb aspirators.
I also just learned about a brand new product. The Oogie bear is a safe little scoop that can safely get into the nostril and removed the more stubborn boogies.

If your child is having trouble eating because of all the congestion, try doing some clearing about ten minutes before a feeding.
It is also helpful to keep their heads elevated. They may need to spend the night in a safe infant seat or you can try to raise the mattress a bit. For older kids, add an extra pillow. Let them sit in a steamy bathroom, and use a humidifier at night. Increase fluids during the day.

RSV can cause ear infections and pneumonia. Severe RSV disease symptoms include:
  • Coughing or wheezing that does not stop
  • Fast or troubled breathing
  • A bluish color around the mouth or fingernails
  • Spread-out nostrils and/or a caved-in chest when trying to breathe
  • Gasping for breath

If your child is having trouble breathing, or significant trouble feeding, they may need to be hospitalized for a night or two for fluids, oxygen and observation. I would say that we have several kids routinely hospitalized for this every year (not just young babies.) There is no other real treatment for RSV other that close observation, but for certain high risk patients, there is a medication that is given monthly that significantly protects them. This medication is called Synagis.

If your child was premature, or has cardiac or pulmonary issues they may qualify. Talk to your doctor's office ASAP to find out if your child fits into the guidelines. Alas the guidelines are quite restrictive. Much to the dismay of most sensible practitioners, they became even tougher last year. We used to be able to get it for preemies who were born before 35 weeks. The new rules moved that to 30 weeks. So far I don’t have any candidates this season. I hope it stays that way. In California the official RSV season starts on November 1st. (I don't think that RSV knows that it has a season, but that is when the insurance companies will start shipping the medication.)

Since most of our children can not get protected with Synagis, please take precautions to prevent the spread of this nasty virus, especially for the youngest most vulnerable babies.

Wash your hands before touching your child. Make sure others wash up, too. Clean toys, crib rails, and any other surfaces your baby might touch. Try to keep your baby away from crowds. Avoid anyone with a cold or fever. Don't let anyone smoke near your baby. Tobacco smoke exposure can increase the risk of severe RSV disease.

Sadly it takes multiple exposures before you develop immunity. Most folks get RSV about 8 times until they finally seem to be not as vulnerable! It spikes again in older folks when the immunity tends to wane and it can sweep through retirement communities, so be cautious for the older adults in your life as well.

If your child is unfortunate enough to get a nasty case of RSV during the season it takes a long time for the lungs to calm down. In my experience it is not uncommon for these kids to have a tough winter. Every new cold seems to retrigger the wheeze. This does NOT necessarily mean they have asthma. For repeat wheezers, if the nebulized medications bring relief it might be worth owning a machine. We rent them out of the office for $5/ day, but you can purchase them for less than $100 from Walgreen's. Having a nebulizer safely tucked away in the bottom of the closet may save you from a night time or weekend trip to the emergency room.

Friday, November 7, 2014

Temper Tantrums

It is  the rare parent who hasn't had to deal with the occasional tantrum.
Here are a few tips for managing them.

When you are a parent, imagine that you are the coach of a football team. Keep in mind that most of the coaching takes place before and after the games. Your team may win big or they might completely screw up. During the game you are mostly just a spectator. Leading up to the game you strive to prepare your players the best you can. After the game you can be the Monday morning quarterback and identify ways to improve.

I have found it very  helpful for parents if they can recognize the difference between "game time" and "coaching opportunities." If we follow my theory, transition times, mealtimes, getting out of the house in the mornings and bedtimes are considered game time. You can't do any effective coaching or teaching during these moments. Hopefully you have created  a "game plan" so that generally things go smoothly. When you encounter a situation that sets off a tantrum, do your best to just get through it as calmly and creatively as you can. If you notice that you are stuck in a rut and you can identify routine behavioral issues, you need to work on creating a new plan.

Here's an example of a "game time" situation. Many years ago I was a solo parent on a flight, returning home from grandparent visit/family visit. My sister Marjie had bestowed each of my daughters with a "my little pony" gift to entertain themselves on the flight. Alana the two year old had chosen the pink one, and Lauren the five year old was happy with the blue one. Mid way through the long flight, Alana wanted to make a trade. Lauren, wasn't interested and quite within her rights she soundly refused. Alana was usually a fairly mild mannered child, but I could see the tantrum brewing and she was about to cause a serious disruption. I did a quick negotiation with Lauren: "Hand over the blue pony now, and we get home they are both yours." Lauren took only a second or two to recognize the value of this and gave Alana the blue pony. Crisis averted. This wasn't the moment to teach about sharing, or fairness. This was game time. Get off that plane intact. If we had been at home I may have handled it quite differently.  It is absurd to think that you will handle a tantrum in the middle of a crowded public area the same way you would in your home. Home field advantage???

Watch for clues and do your best to ward off an impending tantrum if the warning signs are clear, but once your child has already entered the meltdown zone, it is time to change tactics. There is a popular parenting book that counsels parents to get down on the child's level and loudly evoke their inner caveman by chanting "You are mad, you are mad,  you are mad mad mad!" When that book first came out, I would routinely hear parents out in our waiting room making more of a racket than the fussing kids. I must confess, that when I still hear the occasional parent grunting "you are mad" I do roll my eyes a little bit, but the premise is actually a solid one. When your kid is having a tantrum, acknowledging that you are trying to understand what is going on in the first step.
"You seem mad, sad, frustrated etc"  are often exactly what your child needs to hear.
If you told me that you have a headache and I responded by discussing the weather, it would not be very satisfying. Distraction is all well and good, but not until they get it that you are trying to understand what has them so upset. Validating a feeling is not the same thing as giving in to an unreasonable request. Try to hold them close, get them on your lap and wrap your arms around them so that they can't thrash around. Make shushing noises. Keep it simple. This is not the time for lots of words. Those come later.

If your child has frequent tantrums, see if you can figure out what is setting them off. Look for patterns. Many parents realize that kids get more fragile when they are getting hungry. Try having little snacks on hand and pay attention to any cues that might be leading up to a melt down. Are they tired? If tantrums are routine, you need to examine your child's nap/sleep schedule. Are they frustrated by something? In a calm moment, if your child is old enough, help them work on their problem solving skills.

Problem solving activities work very well after a situation has happened. Talk about what went wrong. See if they can help plan a better way to deal with it the next time.
Step one is always identifying the problem. Break it down to a small but manageable issue. Rather than the diffuse "fighting with sister" get down to a very specific issue, such as "sister won't share yellow crayon."

Step Two is talking  about some choices one might have in that situation:
Some are good choices, others not so much. They all make it to the list. Adding a silly one is just fine and makes this feel more like a game. Choices could include:
Using a different color; Using words and asking sister nicely to share (may need to wait a minute for her to finish coloring her own yellow parts.) Asking  a grown up for help; start screaming; drabbing the crayon; draw a frowning face on your hand with a black crayon; use your "walking away power" and take some deep breaths. Hopefully with some gentle guidance they can identify the more positive choices.

Problem solving exercises are very empowering for your child. The age range for when kids are able to take part in these is fairly variable, but they will all get there.

For kids over 3, see if they can recognize their own warning signs before losing control. This is a tool that will serve them so well for their entire life. Perhaps create a song together that they can sing when they are approaching tantrum stage:

"I am mad mad mad
I want to stamp my foot
I want to clench my fists
but I am going to shake out my hands
I am going to take 3 deep breaths
I am going to use my words"

Any time that you see your child get calm without losing control give them loads of positive feedback.

Kids can also get a lot out of a well told story. Create two little children that you can tell tales about. They are the same age as yours, with very similar family circumstances. One tends to make good choices and the other also gets into trouble often. Allow your child to chime in and talk about why these other children had a tantrum and what they ended up doing about it. Kids do much better talking about these very relatable characters than they do about their own actions. Once they come up with a plan for the made up child, you can bring it back around; "Maybe you could try that also."

Even the best kids have occasional meltdowns.
All tantrums can be turned into learning experiences for you and your child. Stay calm and be consistent.