Parapertussis/Whooping cough's milder cousin

What is parapertussis? It is annoying for sure, but it isn't quite as scary as it sounds.

Bordetella is a bacterium best known for whooping cough in humans (B.pertussis) and kennel cough in dogs (B.bronchiseptica). B. parapertussis is a lesser known member of the family. It is estimated that 1%-35% of known Bordetella infections are caused by B. parapertussis. Because only a small percentage of patients actually ever get tested, these are tough statistics to get accurate. To compound the challenge of data gathering, parapertussis is not one of the diseases that mandates reporting it to the public health department, so it really is tough to have a real sense of numbers.

The nastier cousin, B.Pertussis is making the rounds. Because it is currently active at some local San Francisco schools and daycares, several of our coughing  patients have asked to be tested. A number of those results came back negative for pertussis (fortunately), but  positive for parapertussis. The PCR test done to rule out pertussis tests for both. (It is actually possible for folks to have both illnesses at the same time, how unfair is that?!)  Parapertussis has some distinct differences. It is very similar to regular pertussis but not nearly as severe or long lasting. One main difference is that parapertussis does not produce the pertussis toxin which is responsible for some of  the more severe symptoms.

With parapertussis, patients can still have the prolonged cough, (with characteristic coughing fits) and vomiting but we are talking about 3 weeks instead of 3 months. This is a fairly variable illness; up to 40% of patients with it can be almost symptom free.

Just as with Pertussis, we are more concerned about infants younger than 6 months, or someone with an underlying health condition or compromised immune system.

This month our patients who tested positive were all fully vaccinated, and that makes sense. While the whooping cough vaccine gives about 80-90 % protection against pertussis to folks who get it, it does NOT protect against parapertussis.

Just like pertussis (and the common cold), parapertussis  is transmitted from coming in contact with respiratory secretions.

The incubation period is also similar to that of pertussis. This is measured from the time someone was exposed until they come down with the illness. Most commonly it is 7-10 days, but it can be as short as 5 days and you can’t really count yourself as out of the woods until at least 21 days have past since the exposure and no symptoms have presented.

A patient is infectious (they can spread the illness and make someone else sick) from a day or so before showing the first symptom until up to about 3 weeks after the beginning of the illness. If treated, a person is still considered  contagious until they have finished a 5 day treatment.

There are not really any official guidelines for managing the illness. Basic symptomatic treatment measures such as steam, fluids and rest will help get you through. Certainly if the patient is less that 6 months old, or in close contact with a young baby or someone high risk, they should get treatment as soon as possible. The standard treatment is five days of Azithromycin. Remember that patients are considered contagious until they have completed the course.

For the older, lower risk patients, should we treat? The limited studies that are out there suggest that treatment that is initiated within the first 6 days of the onset of the symptoms may possibly help get the patient better faster. Another benefit of early treatment is that it can minimize the spread.

Prophylactic treatment, to prevent the disease in someone who was exposed but isn’t sick yet, is worth considering for high risk contacts, if started within 2-3 weeks of the exposure. Most experts agree that starting prophylaxis more then 3 weeks after the exposure is probably of no benefit.

But in most cases, it isn’t that simple. We don’t tend to bother seeing patients unless they have a cough that is really troublesome or lingering; we couldn’t possibly bring everyone in the minute they start to cough. The other issue of course is that nobody wants to overuse antibiotics. With pertussis and parapertussis, the illness often starts for a week or so with a mild cold before the coughing begins.By the time we recognize that we are dealing with parapertussis, the reasonable window for treating may already be passed.

I do have my antenna up for any illness that has coughing spasms. Many of these patients seem fairly well, until a coughing fit hits. Often there will be vomiting from coughing so hard. There may or may not be a characteristic whoop.

Here is the question many of you are asking: Can they go to school? Officially parapertussis is considered a mild but irritating illness. It is not a reason to keep them home. Keep in mind that people are contagious a bit before they have flagrant symptoms, so we have to exercise a bit of common sense here. Someone who was at school on Monday and starts coughing on Tuesday has already exposed all of the classmates. They also likely picked it up from a fellow student. Keeping them home if they feel fine and have no fever makes no sense. If you have a child who is miserable, feverish, poor appetite, poor sleeping, with labored breathing, that child should not be at school. Likely they need to be seen by the doctor!

Even though school and normal activities are fine, please be cautious about letting your coughing child be around any vulnerable newborns. I recognize that siblings present a uniquely complex issue. It is usually not reasonable or even possible to try to quarantine them for weeks.

Check out the links below for help with symptomatic treatment

Pertussis review

vicks vapo rub on the feet?

humidifier vs vaporizer

colds/coughs review

Cord care

Cord care

 

 

Before birth, the umbilical cord is the connection between the baby and the mother through which the baby receives nourishment and oxygen. After birth it becomes useless. By the time the baby is several weeks old, this is something you will likely never think about again, but right after birth it deserves a bit of attention.

 

You may have heard of cord banking. Cord banking is a trend that comes in and out of fashion. The idea is to save your baby’s stem cells as an insurance policy in case there is a future medical need. In theory it is great. Unfortunately it is very expensive and it is hard to predict if the bank you choose will still be around in the future should you need it. At the time of this post, very few of my patients opt to do this, but it is worth checking to see if there are any updates.

 

The optimal timing for clamping the umbilical cord after birth has also been a subject of controversy and debate. There is a current trend to delay clamping for a few minutes after birth.  It is best to discuss this with your OB ahead of time. The important thing is simple that the baby is tended to. If everything is stable, by all means, delay the clamping for a moment or two. If for some reason the baby needs attention, the clamping is done immediately, and you don’t get that extra time, please don’t focus on this as something to fret about. I imagine your baby's chances of becoming president one day won’t hinge too closely on how quickly they got their cord clamped!

 

Whenever it occurs, the umbilical cord is clamped and cut close to the baby's body. There are no nerves in the cord, so this is a painless procedure.

The cord clamp should be removed prior to leaving the hospital. It is a good idea to double check. I have occasionally seen newborns discharged with the clamp still on. Once the clamp is off, an umbilical stump remains attached to your baby's navel.

 

There is not much you need to do to care for it. Often, the less you fuss with it, the sooner it will fall off. It tends to fall off between 7-17 days (not everyone follows those rules.) At some point it will be hanging by a thread and you will see who the lucky person is on diaper duty when it finally comes off.

 

There are newborn diapers that have the little cutouts that are very useful. This helps you avoid having the cord rubbed and irritated. Hopefully you won’t need more than a few boxes of those. If you have a larger baby who is too big for size one, just roll down the diaper to avoid rubbing.

 

We want to keep the area dry so no actual submerging the baby in a tub until it falls off.  Sponge baths can get the job done. Yes, babies get some pee and poop on there, don’t freak out. Just clean it as best as you can. If the cord gets a foul odor (trust me, you will know if it is smelly or not) call your pediatrician to get it  checked out. A stinky cord can be a signal that the baby has an infection (called omphalitis.) The docs will do a good cleaning and get in there in a way that the parents often aren’t comfortable doing. If needed, the doctor may apply silver nitrate. This is a chemical that cauterizes the area. That will leave a grayish/black discoloration around the area that may take a few weeks to fade. It may take more than one application for the cord to be healed.

 

Once in a while a small piece of the cord stays in place. This is called a granuloma. If the baby is acting perfectly fine in every other respect, there is no need to rush in, but your doctor will want to take a look if things are not healing up. A persistent granuloma will usually need attention.

 

Once the cord is off, it is normal for the area to continue to ooze a bit for another week or so. It is quite common to have a bit of green or yellow stain on the diaper or shirt. Sometimes there is also what looks like blood. Unless there are actual drops of blood coming from the cord, I am not concerned about little staining. At this point you can clear around the area with a bit of alcohol and a dab of Neosporin.

 

Another thing that parents might call  about are umbilical hernias. An umbilical hernia occurs when part of the intestine protrudes through the umbilical opening in the abdominal muscles. Umbilical hernias are common and typically harmless. They are most common in infants, but they can affect adults as well. In an infant, an umbilical hernia may be especially evident when the infant cries or strains causing the baby's belly button to protrude. This is a classic sign. Some of these are as big as golf balls. Usually this resolves on its own. As long as you can gently push the belly button back in, it is not a concern. If you have an inconsolable baby and the area seems to be stuck on the outside, that would need an immediate evaluation.

 

Before you know it, that cord will be off and most likely you won’t be giving much thought about your kid’s navel until they are teenagers and begging for permission to get it pierced. (It is also quite possible that when they turn that C in geometry into an A you will reluctantly give your blessing, as we did with our daughter Lauren!)

Travel Tips updated

It's that time of the year again when many of my patients and families are  traveling.

Therefore, it is time to dust off, tweak and rerun the travel post. Fully half of the calls I took this week were from folks who were calling from a trip. After listening to the list of symptoms and concerns, I would be all set to say "Gee, it sound like you need to be seen for that" and the caller would answer "but I am in Delaware/ Minnesota/ Timbuktu"

 

TRAVEL TIPS

"When is my baby old enough to fly?" is a question that we 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 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 to 3 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. A few months ago we had that crazy measles outbreak. Last fall we has the Enterovirus D68. Right now, (June 2015) unless you are heading to South Korea, things seem reasonably quiet (knocking on wood as I type this.) Regardless of how old your child is, if you are planning a trip here are some tips and things to keep in mind.

Before you leave

I get calls from all over planet from parents who are dealing with a sick child during their trip.

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 also 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. If your child has a history of wheezing, it is wise to bring the meds along even if they haven't needed them in a while.

Surviving the flight

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 3.5 ounces.I don't tend to give it ahead of time, but I am quick to medicate 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%. There is no such thing as infant Benadryl, We use the children's liquid generic name diphenhydramine.

Many labels will warn not to give to children under 4. We routinely ignore that. 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 want 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/Motrin 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.

Bring some disinfectant wipes along and give the tray table and any surfaces a nice wipe down before you use them.

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

Download some activities or shows ahead of time for your laptop or tablet. While I am dreading the day when cell phone use is okay in flight, technology has certainly made it much easier to keep your child entertained during the journey. Don't forget about the old fashioned low tech options!

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. Reusable stickers will stick on the window.

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. Sunshine is a bonus.

http://www.reflexandmore.com/en/articles-heb/25-english/articles/21-jetlag 

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 as mentioned, 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

Headaches/Migraines

Headaches are very common in children and adolescents. In one study, 56% of boys and 74% of girls between the ages of 12 and 17 reported having had a headache within the past month. By age 15, 5% of all children and adolescents have had migraines and 15% have had tension headaches. Does your child tend to head off to a quiet, dark room when there is too much going on? It could be migraines.

While headaches are more common in children once they reach 9 or 10, some children as young as 2-3 can articulate that their head hurts.

Migraines, tension and cluster are called primary headaches because they are neurological disorders not caused by an underlying medical condition. There is no specific medical test for migraines, so diagnosis is usually based on symptoms. Some of the classic symptoms include:

*A moderate to severe throbbing pain for 24-72 hours. Often this is on one side of the head. (for those of you who enjoy knowing its etymology,  the word migraine comes from the Greek hemicranios, meaning half a head.)

*nausea (they may or may not actually vomit)

*Sensitivity to light, noise or odor

Roughly 15-20% of migraine sufferers experience visual disturbances about 15 minutes before the headache sets in. This is known as an aura.

The drawing up at the bottom was drawn by one of my favorite people, Rachel, when she was seven years old  in an attempt to describe to her doctor what an aura felt like.

Migraines don't always manifest as headaches. Some children also have abdominal migraines. If your child is having frequent tummy aches and or complaints about nausea, ask them if they have any visual symptoms.

Migraines have a big genetic component. There is often a strong family history. A pediatric neurologist at UCSF says, "If you're having trouble finding the family history, the paternal grandmother is often the link.  Because migraine genes are expressed more often in women than in men, dad might pass on the genes to a child without knowing it."

There are also current studies to see if there is a connection between colic in a baby and migraines later on.  

  

Secondary headaches result from another medical condition. These conditions can range from a relatively harmless illness like sinusitis or the flu to more serious conditions. Strep throat is often accompanied by a headache. Simple cold/allergies are also common culprits. As miserable as these headaches are, most parents and practitioners are less concerned if there is an obvious cause like a virus.

Mystery headaches are somewhat more alarming. A red flag that you should contact a doctor about a headache would be one:

*    that wakes the patient out of a deep sleep

*    appears suddenly and is more severe and different from past headaches

*    comes along with weakness or numbness or tingling

*    makes it difficult to think or remember things

*    follows  a recent head injury (within 2 weeks)

Headaches that are associated with vomiting are also worth checking out (if the entire family has the flu and is having similar symptoms, I am much less concerned.)

If there is a headache that is coming more than once a week or with any kind of frequency that has you alarmed,  it is worth getting checked out. It is always worth starting with  your primary doctor, but they may want to do a referral to a headache specialist.

The first step is for the  neurologist to make sure that there isn't something serious going on. Once the scary stuff has been ruled out, they can be an essential part of your team helping to manage chronic headaches moving forward. Headache specialists can help you identify the triggers and explore many non-medical options. The folks at UCSF are on the cutting edge of managing migraines. They are exploring things like CoQ10 and Riboflavin rather than jumping to medication options (you need to see them to discuss dosages.) In fact they are currently looking for teens for a study seeing if melatonin might play an important role in treatment. If you have a teen 12-17 who might be interested in taking part in this check out this link:

 http://brain-m.ucsf.edu/  

The patient will need to only go in for one visit. The rest of the data will be gathered remotely. The participants will also be given a Fitbit that they get to keep!

 

If your child is having headaches, start keeping a journal to see if you can identify the causes. The information that will be most useful to the doctor is the frequency of the headaches and the tracking of the treatment. What did you try? Did it help?

As you think of other things to add to the journal look at this list of some common triggers and see if any obvious one come to mind:

*Irregular sleep habits

*Dehydration

*Skipping breakfast

*Not getting regular exercise

*Change in weather

*Foods with additives/nitrates

*Red wine (hey this info is for you grown ups too)

*Hormone fluctuations

*Recent stress

*Lighting changes e.g., bright fluorescent

*screaming baby? 

My daughter Lauren had very frequent headaches. Our cousin Avi lovingly nagged and nagged her to see if a gluten free diet would help. He was relentless. She finally gave in and agreed to give it a shot. To her delight (and horror) it made a huge difference. She has been gluten free (and headache free) for years. When she gets an accidental exposure to gluten the headaches come roaring back. There is no ignoring the connection.

I get migraines when I drink a certain type of red wines. A glass of Syrah will trigger a headache that knocks me flat. Every step ricochets from my feet up through my head. Not fun. My learning curve on this was almost comical. I couldn't imagine that I was really reacting to only one type of wine and it took about 3 or 4 miserable experiences until I stopped all experiments and simply don't drink any Syrah.

If you or your child are suffering from headaches be a sleuth!

There was a recent study that showed in some cases regular exercise was just as effective as medication in preventing and reducing headaches.  

Some people have also had success with alternative therapies such as gentle chiropractics and or acupuncture.  

  

I will close with some last words of wisdom from the wonderful Dr Gelfand

*    Get regular sleep

*    Stay well hydrated with non caffeinated beverages

*    DON'T skip breakfast

*    Get regular exercise.

*    Chocolate is innocent!! It is no longer on the list of frequent triggers,  

I was very fortunate that Dr Amy Gelfand allowed me to "pick her brain" so to speak about this important topic. Dr. Gelfand is a child neurologist at the UCSF Headache Center. She specializes in diagnosing and treating children who suffer from a variety of headache disorders, as well as children with childhood periodic syndromes such as abdominal migraine that are felt to be precursors to migraine headache later in life.

September 2015 check out this blog from Dr Gelfand
bit.ly/migrainebacktoschool

Night Terrors

Night terrors rank up there with things that are pretty horrible for parents, but ultimately usually not dangerous. If you want to practice your latin, they are also known as Pavor Nocturnus. These are not your typical nightmares. Your child might wake up screaming and thrashing. They may be sweating, wide eyed and terrified. Their hearts are racing. They seem frantic but you can't calm them down. No one is going to sleep through this. Except your child. They seem awake, but they won't remember a bit of this.

Your job is simple. Keep them safe until this passes. If your child is small, I have found that it is helpful to try to swaddle them with a big sheet. Think straight jacket! Hold the sheet wide and try to wrap around the thrashing arms until they are snuggled tightly. Sing quietly until they are calm. If you can't manage that, just make sure they don't hurt themselves until it is over. These rarely last longer than 20 minutes. Bigger kids might get even wilder if they feel restrained so see if you can put a comforting hand on them, but mostly you are just being present. If your child is toilet trained, see if you can manage to walk them to the bathroom and have them pee. Believe it or not, that might settle them down.

Pediatric night terrors happen to between 1-6% of kids. The typical age range is 3-12 years of age. There seems to be a genetic component. If you put your parents through this yourself, it is payback time. I think I may have had a few younger patients over the years that had bouts of these, but with really young infants, a sudden wake up is more likely from gas pains or something illness related.

These tend to happen in intervals and you may have days or weeks with frequent episodes and then they go away. It is worth trying to figure out if there is some extra stress or changes going on. Are they on any new medications? Any change in their diet? Lots of extra sugar perhaps? Are they overtired? Have they been watching any over-stimulating videos, movies or games (if they are in the room when an adult is playing or watching something, that counts)? If night terrors are happening on a routine basis and there is no obvious cause it is worth having them checked out by their physician. Some kids who are plagued with these for an extended period might have sleep apnea at the root of the problem.

Unlike dreams or nightmares, night terrors do not occur during the REM sleep. They usually occur during a phase of the sleep cycle that comes about 2-3 hours after falling asleep. If you are going through a stretch where you dealing with them nightly, some experts suggest breaking the cycle by waking your child about 15 minutes before they routinely occur (this would be a fine time to walk them to the bathroom for a "dream pee.") This assumes that you are on a regular bedtime routine and the terrors are happening roughly at the same time nightly.

Take comfort in knowing that extensive studies have found absolutely no correlation between

kids with night terrors and an increase in occurrence of psychiatric disorders.

Sleep part 3/ leaving the crib behind

Part 3

Sleep part 3/ leaving the crib behind

You are sound asleep but suddenly sense that something is amiss. Sure enough you look over to the side of your bed to see one of your children inches away quietly staring at you. Sound familiar? Once your little one is no longer confined to the crib, nocturnal visits can be a nightly affair if you don’t nip this habit in the bud.

There are a variety of signals that will alert you that it is time to move the kids out of their crib. At some point every parent is going to have to deal with this transition. My daughter Lauren learned to climb out of hers at a fairly young age. The day she proudly called me into her room to show me how she could balance on the crib rails was my signal that her crib days were gone. She wasn’t even two. Alana would have stayed in her crib forever, but she eventually got big enough that it was just silly.

It is important that the new bed be low and safe. There are all sorts of toddler rail options that can keep kids from falling out. Some folks keep the mattress on the floor for the first couple of weeks. A pool noodle placed under the sheet makes a nice little edge to keep them from rolling off.

Once your kids are out of the confines of the crib there is always a bit of an adjustment. The main issue, though, is not falling out of bed, it is a new found freedom to wander out of the bedroom. Even if they used to be a good sleeper, many kids may need a little help learning to stay put. If your child discovers that they need to show up in your bedroom several times a night, it can get exhausting.

Once you have the marvelous luxury of getting an uninterrupted night’s sleep, it doesn’t take long to see  how disruptive it can be to be woken frequently throughout the night. If you make a plan and stick to it, you can get through this transition with minimal disruption.  As noted earlier, both of my kids had the unnerving habit of silently entering  my room, coming to my side of the bed and just staring at me until I woke up. It didn't take long until I was jolted out of a deep sleep. Interestingly, my dog would do the same thing if she needed a middle of the night pee. Children  have a myriad of reasons for getting out of bed...scary shadows, strange sounds, they are thirsty, they can’t sleep and so on and so forth. Let them know right from the start that except for an emergency, they need to stay in bed. Be consistent with your expectations. As mentioned in a previous post, a video monitor can be a great tool. Keeping an eye on your not-yet-asleep toddler and saying, “back to bed” into the microphone can often keep them in place. If they do get out of bed, just keep taking them back and say, “shhh it’s bedtime. SHHHH, bedtime! For the first week you may find yourself doing this dozens of times. Say nothing else. “Shhh bedtime.” Keep physical and eye contact to a minimum. 

Night time is not the best time to reinvent your bedtime routine. Creating an improvement plan with your child as a key member of the team has to take place earlier in the day when they have your attention. Talk about how important sleep is. Read bedtime books. The library is full of great ones. Tell stories about other children who are learning to have good sleep habits. I like telling stories about the “cooperative” and the “not so cooperative” child. The troublesome child gets into all sorts of trouble and everyone is grumpy. The positive role model figures out a way to stay in bed. Everyone is proud. yada yada yada….. Make the stories nice and silly to keep them engaged. Problem solve with them ahead of time for ways to manage their issue without leaving their bed.

Let’s evaluate any possible issues before bedtime. Once the lights are out, we want to keep our engagements to a minimum. Thirsty? Let’s have a little sippy cup of water next to the bed. Lonely? This is the perfect time for a special new stuffed animal or favorite blanket. Alana not only had several special blankets, but she started sleeping with one of my old soft green sweaters. That sweater stayed in her bed for years. Scary shadow? Let's turn on and off the light and figure out exactly what it is that is making that shape. Creaking noise? Let’s identify what is making that sound. Is it a bird? Maybe it is a branch scratching against the window. Thinking about monsters? Do NOT look under the bed to make sure the coast is clear,  that would lead them to believe that a monster lurking in the room is a possibility. Tell them that really smart kids have amazing brains and good imaginations. Try to do some exercises using that power. Draw the scariest monster that you can think of, then add a pair of polka dotted underwear on the scary monsters head. Now put a lollipop in their hands; there, they turned them from scary to silly.

For kids 3 and older who are going through a phase of getting out of bed a lot you might consider doing a one week exercise. Once again, find the moment when they are receptive (not bedtime) and talk about the fact that bedtime routines needs to be better. Have them help you pick out 14 little, inexpensive, age appropriate toys or treats. Wrap them up like presents. Every night your child has 2 passes. If they need you for anything, they need to turn in one of the passes every time they get out of bed. Any unused pass can be redeemed in the morning for one of the prizes. Of course, for older kids, a trip to the bathroom that does not require your assistance doesn’t use a pass. At the end of the week, any unclaimed prizes are given to another child who needs a treat, or put away for a later time.  It is important to know that in the immediate time frame they are missing out on any prizes that they didn’t earn. I have seen this work well for kids who are old enough to reason. Be clear that the earning prizes for staying in bed has a firm expiration date. One week only.

If you don’t want to fuss with prizes and passes, that is fine. Focus on appropriate rewards and consequences.

Reward: if you get a good night's sleep, plan a special activity. Make sure you give lots of positive attention. “You let me sleep and only got out of bed once. I am proud of you. We are all rested, let's do something fun.”

Consequence: You kept waking me up during the night. I am tired and grumpy. I don’t want to do a special activity.

As I mentioned in a previous post, there are some very creative toddler clocks that will help your child know when it is okay to get up and when they need to stay in bed. Just google “toddler clocks” to see some of the varieties.

Also, as noted in last week’s post, you may want to have a chime on the door that alerts you that you have a wanderer.

Sleep tidbits part two/ Shifting nap times and bedtime routines

   

Part 2

Sleep tidbits part two/ Shifting nap times and bedtime routines

    

Here is a quick reference for the average sleep needs by age group per day:

Birth - 2 months: 14 to 18 hours (cat naps)

2 - 4 months: 13 to 14 hours (starting to shift to 3-naps per day)

5 - 6 months: 12 to 14 hours (3 naps)

7 - 12 months: 12 to 14 hours (2 to 3 naps)

1 - 2 years:      12 to 14 hours (includes 1 or 2 naps)

2 - 4 years:      12 to 13 hours (1 nap)

5 years:      11-12 hours (hopefully 1 nap)

Sleep requirements vary from person to person. 

 Hopefully by the time your baby is routinely eating solids foods you are all getting to sleep through the night. Doing a dream feed before you go to sleep yourself works well for some families.

Kids need naps. If they don't get them, they get overtired and actually don't end up sleeping as well at night. Generally a good napper is a good sleeper. Someone who is overtired from missing naps has an even harder time with bedtime. I know it is counter intuitive, but sleep begets sleep.

Many babies and toddlers will begin to fight their naps but this does not mean they are ready to drop them. Sleep is necessary for healthy brain development and your sanity! Having a shifting nap schedule is always challenging, as they grow from needing three naps a day down to two and finally down to just the one. When your nap schedule no longer feels like it is working, don’t panic, take a few days to observe your baby’s new patterns, and adjust the schedule. No doubt you have made many appointments that will no longer work. 

If you are looking for some schedules. This blog is a great reference

https://takingcarababies.com/nap-schedules/

 Do your best to avoid the late afternoon crash that wreaks havoc with bedtime. Try to be firm about at least one nap a day in their crib/bed. More is always better. I realize that if you have more than one child, the baby might be doing more naps while out and about. It is what it is; do the best you can.

Assuming you have the luxury of a schedule that allows for a firm nap time, be consistent. Have a brief routine leading up to the nap, make the room dim, consider having a little quiet music playlist that you can set for a certain amount of time. There are great bedtime playlists that you can find online.

For the kids old enough to get it, they can be taught that it is nap time/quiet time in bed until the music stops. Toddler clocks can also be set so they know when they are allowed to get out of bed. A video monitor with a microphone that allows you to talk to your child can be a huge asset. In other words, “get your asset back in bed!” Be consistent and don’t wait until they are out of the room. If they do make it out, bring them right back to bed. Either say nothing or a short phrase such as, “nap time.” When they are older and claim not to be tired, continue to insist on the quiet time even if they don't fall asleep. It is really common for some kids to nap much better for a nanny or at daycare than they do with the more inconsistent parents. Kids can follow rules fairly well as long as they know what they are.

With any sleep training, including naps, your job is to be very clear and follow through. First step is to enforce that your child will be in be in their bed/crib for naptime for a certain amount of time on a reasonably regular schedule. If your child is really resisting, it may be that initially you need to sit there, gradually move your chair further and further away until you don't need to be in the room. Do a quiet activity to keep yourself occupied while you are in there.

For the record, I would like to think that I have a lot more knowledge and experience now than I did then, but I personally failed 'Naps 101'. My first time around I somehow couldn't allow myself to simply place my daughter in her crib and have a little "down time" for myself. My older daughter Lauren made the rules. Naps would be in my bed with me.  She had a tight hold of my hair, and as part of this routine, I had hold of her foot. I wasn't going anywhere. If you are able to take a nap with your child, enjoy. I actually loved it. The important thing is that you figure out what works for you. Just don't ignore the importance of naps.

*Safety tip: If you are both sleeping and your child is not in a crib, make sure you have a bell or alarm on door so you will be woken if your child gets up and starts to wander.

For night time our ultimate goal is to have your child be able to drift off with minimal intervention and sleep well until the morning. If possible, start winding down at least 30 minutes before the nighttime ritual starts. Don't give anything with sugar or caffeine. Avoid roughhousing, or stimulating screen time. It is important to find a bedtime that works for your family and accounts for your child's sleep needs. I know it can be challenging with working parents. Many folks want to spend precious time with their kids at the end of the day, but it is important to start the routine before your child is already overtired. Forty five minutes is a good length of time from the start of the bedtime ritual until sleep. Keep this time consistent except for special occasion exceptions.

My husband was the bedtime enforcer. One night when he was out of town, even though it was a school night, I kept the girls out late at some friends' house. They started getting crabby as our evening was wrapping up. I said, "Hey look, I let you stay up late as a special treat, so you need to stop being grouchy." They both essentially responded, "we are grumpy because we are tired and you should have made us go home. Mommy should know better."  Betrayed!!!

Create a ritual that your child will look forward to. This might include reading books or telling a story. Have a set number of books you will read, or a set limit to story time and STICK TO IT! One option is to have one book at the start of the bedtime ritual and if, and only if, your child cooperates while getting ready (toothbrushing, going to the bathroom, getting into pajamas, etc.), do they get a second book right before bed. Once you go down the slippery slope of "just one more" you are stuck.

Perhaps talk a little about the day or a pleasant upcoming event  that you are anticipating. A few minutes of massage are a lovely way to end the day. Hands, feet and earlobes have relaxation points (find the reflexology maps online.) Make sure the environment is a safe and soothing one. Use light to your advantage and get the room dimmer and dimmer throughout the bedtime activities. Some families like white noise in the room, such as a HEPA filter or fan. It may create a habit, but so what. It is not something that I have issue with. Just as I suggest for naps, there are also a lot of lovely lullaby CD's available that set a nice ambiance for the bedtime ritual that you are creating.

Some children sleep better with a special blanket or stuffed animal. Once they are over a year I am fine with these, although I would still avoid things that are super cushy until they are two.