Friday, December 25, 2015

The best Present is your presence


I saw a bumper sticker a while ago that said:

Good parenting requires Twice as much time and half as much money.
So true!

This is the season for gift giving, but we all actually could do with a lot less stuff!! The best present I think that families can give to each other is the gift of self ( 
otherwise known as time and attention)

For kids who are old enough to understand, give a certificate that promises a special activity that you might do some time in the future.

It is great for families to do outings all together, but one on one time is so important if you can manage it. Mix and match so that you make sure that everyone gets special time with one other family member. This includes one on one time for you parents as well.

The list below has some old and new ideas.

Nurse Judy's Inexpensive and creative activities

Collect and decorate rocks with colorful paints and glitter for a rock garden.
This is a great one to use as a reward for good behavior. When they see the pretty rocks, they will remember that they earned them.

Make a collage. Old magazines and old photos are great for this activity.

Make a musical instrument... Use your imagination: a shoe box with rubber bands can be a guitar; Glasses filled with different levels of water make different tones; Tapping different surfaces with chopsticks makes different sounds.

Go on a 'use all your senses' walk. What do they see, smell, hear, and feel?

Make a personalized place mats. Take some family photos, glue onto cardboard and cover with clear contact paper. Kids will love to use these with meals.
Create a scavenger hunt walk. Plan a list ahead of time of thing to find...like a dog, an airplane, or even a girl with purple hair.

Go on an ABC walk. Find things that start with all the different letters...or find the actual letters on signs and license plates. This is a great game in a supermarket.

Download Free coloring pages from the internet. With a little searching, you can get a picture of just about anything.

Draw with chalk. Make a hopscotch board.

Make your own play dough. You can find the recipe on line

Make a fort using the couch cushions,

For a really special occasion, set up the tent and have a backyard camp out

Write a story and illustrate it together.

Decide on a recipe and bake or cook something. Kids will often try foods more eagerly if they helped with the cooking. Let them help sprinkle in different spices and be the taste-tester.

Have a Tea party. Invite the dolls, and get out the good china that you never use.

Trace your hands and feet and color them in.

Have some down time while watching a video or a special TV program. There are some lovely educational TV programs and videos out there.

Play a computer game. Don't be afraid of controlled use. Children that don't learn how to be comfortable on computers at a young age are at a distinct disadvantage in this high tech culture.

Blow bubbles

Playing board games with the family is the stuff that great memories are made of

There is little out there that is as much fun as a giant box to get inside of . If you buy a new appliance or see a neighbor buying one, ask for the box.

let’s be optimistic: Make a rain gauge!

Play dress up. In my opinion, every house needs a good dress up box, (after Halloween is a great time to pick up costumes and things on sale)

Read!
If you can manage to make it work, try hard to have at least one meal of the day sitting down with the entire family. Have everyone say a little about their day.

Take advantage of where we live, there are always fairs, festivals and museums that are so close. SFKIDS.ORG   and Parenthoods are great resources for all of the happenings that are going on  


Make a scrapbook with keepsakes and photos of all the fun activities
Unless you are using the phone or tablet as part of the activity make sure you put them down and be fully engaged in what you are doing  
(emails can wait)

For Those lucky enough to live in or near the Bay Area, here is my list of quirky, only in SF things to do.
Fort Funston: Bring some dog treats and take a walk. You are pretty much guaranteed to see lots of fuzzy friends to pet.  If you are lucky you will see hang gliders. (Free)

Turrell Sky dome: For this you need an admission to the De Young museum. Many folks have no idea that this magical place exists. Go out to the garden by the cafe and follow the path and signs down to the sky dome. Once you are in there, make sure you sing and listen to the acoustics

The camera below the cliff house: Lots of folks don’t bother stepping in there, but it is worth it. The Camera Obscura gives a real time 360 view of the surrounding. It is only open when the weather is clear. It isn’t free, but it is reasonably inexpensive
The Wave Organ: This is an old exploratorium exhibit that remains out at the end of a jetty behind the St Francis Yacht club. When the tide is right (good luck, I have rarely been there are the right time) pipes will play music. It is an enchanting place regardless, especially if you are there when no one else is out there.  It is free

The Gingerbread house in the lobby of the Fairmont Hotel is worth a trip. It is only there until the New Year. This is free unless you opt to splurge on the very expensive tea.

I love the Stairway walks of SF book. If you child is old enough that they don't start asking to be carried half way through the walk, these are a great family activity.



Happy Holidays...go out and make some wonderful memories!

Friday, December 18, 2015

Dealing with loss/helping your child cope

Laughter/Crying/Happiness/Sadness. Life is such a balance.


Assuming you are lucky enough to have people, pets, or even objects that you care about, then dealing with loss is inevitable.


If you have a child, you need to be prepared to know how to approach the subject.
Parents, it may be helpful to ask yourselves the following questions:

  • How do you, yourself deal with loss?
  • What do you believe? Some folks have a deep faith that there is  “More to it than this,”  and others think that “this is it.”
  • Are you comfortable sharing your belief system with your children?
  • How do you find comfort?
  • What can your friends and family do for you when you are grieving? Do you need hugs or space??

There is not one simple approach for every person, child, or family. My mother-in-law liked to say that there is no right or wrong way to grieve. There are no rules. It is important to be supportive of the different paths that people take. There are also many cultural factors that may impact the situation.


If your family is hit with a loss, sudden or anticipated, unless we are talking about a goldfish, likely the death is hitting you just as hard, if not harder, than it is impacting your child ,though don’t minimize the loss of that goldfish as a valuable opportunity for ritual and conversation.( My husband managed to delay the "goldfish conversation" several times with a visit to the "24 fish store" where Goldie was replaced several time with no one the wiser)


The routine losses that the families in my practice deal with most often are the passing of a grandparent or beloved family pet. Those are the lucky ones. An anticipated loss is no less devastating, but this is the cycle of life that is sad but not shocking. Others are flattened by the loss of a partner, friend, sibling, child.


Parents don’t usually have the luxury of collapse. How do you help your child when you yourself are dealing with all the grief?


There are factors to keep in mind for each age that you are dealing with.
  • ages 2-4 generally don’t grasp the concept of death as permanent
  • ages 4-7 may feel responsible for the death because of their thoughts, actions, or lack of action
  • age 7-11 just starting to see death as something irreversible
  • over 11 has a better understanding about the loss


Not to make light of the subject, but here is a classic family anecdote:


When Lauren was between 3 or 4, she went through a phase of obsessing over several musicals and movies that were centered around orphans. Annie and Disney's The Rescuers are ones that comes to mind, but I know there were others. One day she asked, “what is an orphan?”

We discussed that an orphan was someone who didn’t have any parents. We immediately went on to say that she was very lucky that she had both mommy and daddy, but if in the very unlikely event that anything ever happened to both of us, her aunt and uncle, Barbara and Richard, would be her guardians. She was quiet for a moment and then said, “ I had better have their phone number.”

Hmmmm.


Do's and Don't s


Do NOT say that an animal was “put to sleep” or use any phrase that can confuse your child. The words “passed away” are also fairly passive and confusing. They might wonder if that could happen to them at any time. Do NOT lie. Find a way to convey truth that you are comfortable with. Your child will know that you are very upset. Shielding them from honesty and communication is not doing them a favor. It is okay to be sad. It is okay to cry.


Find a ritual that you feel comfortable embracing. Take comfort in happy memories. Celebrate the life of the one you lost! Tell wonderful stories. Don’t be afraid to laugh.
Honor the memories with kind gestures.


Finding a good therapist to help you or your child give you coping tools is often a good idea. Check to make sure that the therapist has experience dealing with bereavement issues.


Books and stories can be an excellent launching off point for discussions. If you can’t come to terms with how you feel about death, you might be able to turn the spotlight  away from you with lines like:

“Some people believe…”
“Other people think……”

In my search for further local resources I reached out to my old friend Dr. Nancy Iverson.

Nancy has not only written several published articles about the grieving process, but has been involved in facilitating various support groups for many years. She pointed me towards Josie’s Place. (It was a bit of a treasure hunt.)

This is a small but wonderful center here in San Francisco that offers support groups and other services for families and children who have experienced loss.

Josie’s Place:
415-513-6343
Groups meet in the Inner Sunset

If you scroll down to the bottom of the home page on their website in the "Articles on Grief/Grief Resources" tab, Pat Murphy, the director has cobbled together a list of other local resources that might be useful.


Janet Jaskula, RN, MS, A pediatric hospice nurse, also shared her list of resources:


This is a great book about what loss and grief can do if one does not deal with it.  Kids and adults.


"Fall of Freddie the Leaf" by Leo Buscaglia  


"Velveteen Rabbit" by Margery Williams


"There is a Rainbow Behind Every Dark Cloud"  written by a group of children with leukemia who attended The Center for Attitudinal Healing.

A Lion in the House Movie that follows several children and teens and their families through illness and loss, grief and death. Though not all of the kids in the film die, they are certainly affected by their illnesses and loss of their "normal" childhood and teen years.

The Giving Tree Shel Silverstein. 


For parents, check out the the website of Barbara Karnes. Barbara Karnes is the author of  "Gone From My Sight."  She has some excellent combo coloring/story books about loss for kids.


Dr Nancy Iverson recommends the book:
"Never Too Young to Know" by Phyllis Rolfe Silverman


The very helpful children's librarian Liesel Harris-Boundy at the San Francisco Public Library West Portal Branch did some research for me and came up with some good choices for kids. Scroll down to the end of the post for her list.

*****************************************************************************************

I saw the following gem circulating around the internet and it resonated with me. I thought it worth sharing.

Someone put out a post asking for help dealing with grief. This answer was the response from a fellow in his late 70s:


I'm old. What that means is that I've survived (so far) and a lot of people I've known and loved did not.


I've lost friends, best friends, acquaintances, co-workers, grandparents, mom, relatives, teachers, mentors, students, neighbors, and a host of other folks. I have no children, and I can't imagine the pain it must be to lose a child. But here's my two cents...


I wish I could say you get used to people dying. But I never did. I don't want to. It tears a hole through me whenever somebody I love dies, no matter the circumstances. But I don't want it to "not matter". I don't want it to be something that just passes. My scars are a testament to the love and the relationship that I had for and with that person. And if the scar is deep, so was the love. So be it.


Scars are a testament to life. Scars are a testament that I can love deeply and live deeply and be cut, or even gouged, and that I can heal and continue to live and continue to love. And the scar tissue is stronger than the original flesh ever was. Scars are a testament to life. Scars are only ugly to people who can't see.


As for grief, you'll find it comes in waves. When the ship is first wrecked, you're drowning, with wreckage all around you. Everything floating around you reminds you of the beauty and the magnificence of the ship that was, and is no more. And all you can do is float. You find some piece of the wreckage and you hang on for a while. Maybe it's some physical thing. Maybe it's a happy memory or a photograph. Maybe it's a person who is also floating. For a while, all you can do is float. Stay alive.


In the beginning, the waves are 100 feet tall and crash over you without mercy. They come 10 seconds apart and don't even give you time to catch your breath. All you can do is hang on and float. After a while, maybe weeks, maybe months, you'll find the waves are still 100 feet tall, but they come further apart. When they come, they still crash all over you and wipe you out. But in between, you can breathe, you can function. You never know what's going to trigger the grief. It might be a song, a picture, a street intersection, the smell of a cup of coffee. It can be just about anything...and the wave comes crashing. But in between waves, there is life.


Somewhere down the line, and it's different for everybody, you find that the waves are only 80 feet tall. Or 50 feet tall. And while they still come, they come further apart. You can see them coming. An anniversary, a birthday, or Christmas, or landing at O'Hare. You can see it coming, for the most part, and prepare yourself. And when it washes over you, you know that somehow you will, again, come out the other side. Soaking wet, sputtering, still hanging on to some tiny piece of the wreckage, but you'll come out.


Take it from an old guy. The waves never stop coming, and somehow you don't really want them to. But you learn that you'll survive them. And other waves will come. And you'll survive them too.


If you're lucky, you'll have lots of scars from lots of loves. And lots of shipwrecks.

*****************************************************************************************

Liesel Harris-Boundy's recommended reading list:

Life Is Like the Wind by Shona Innes - 2014 Written by a clinical child psychologist, Barron's "A Big Hug" series offers a gentle and direct approach to the emotional issues that children face. This book introduces the concept of death to young readers by likening life to the ever-moving wind.






Missing Mommy by Rebecca Cobb - 2013


Ben's Flying Flowers by Inger M. Maier - 2012 Emily introduces her younger brother, Ben, to butterflies, which he calls "flying flowers," and when his illness makes him too weak to go see them she draws him pictures, but after his death she no longer wants to draw happy things. Includes note to parents.


Harry & Hopper by Margaret Wild  - 2011 Harry is devastated when he returns home from school to find that his beloved dog, Hopper, will no longer be there to greet him.


The Blue House Dog by Deborah Blumenthal - 2010 A boy whose beloved dog has died, and a dog whose owner also died, find each other and slowly begin to trust one another.


Always by My Side by Susan Kerner - 2013 A rhyming story written to help children understand that a dad's love is forever. Even if they grow up without his presence in their lives.

Rabbityness by Jo Empson - 2012 Rabbit enjoys doing rabbity things, but he also loves un-rabbity things! When Rabbit suddenly disappears, no one knows where he has gone. His friends are desolate. But, as it turns out, Rabbit has left behind some very special gifts for them, to help them discover their own unrabbity talents! Rabbityness celebrates individuality, encourages the creativity in everyone and positively introduces children to dealing with loss of any kind.


The Scar by Charlotte Moundlic. When his mother dies, a little boy is angry at his loss but does everything he can to hold onto the memory of her scent, her voice, and the special things she did for him, even as he tries to help his father and grandmother cope.


Remembering Crystal by Sebastian Loth - 2010 Zelda the goose learns about death and loss when her turtle friend Crystal disappears from the garden one day.


A Path of Stars By Anne Sibley O'Brien - 2012 A refugee from Cambodia, Dara's beloved grandmother is grief-stricken when she learns her brother has died, and it is up to Dara to try and heal her.


I Remember Miss Perry by Pat Brisson - 2006 When his teacher, Miss Perry, is killed in a car accident, Stevie and his elementary school classmates take turns sharing memories of her, especially her fondest wish for each day.

Friday, November 27, 2015

The Power of story telling


My mom could go into a room full of chaos. “Once upon a time..” she would start in a steady calm voice.

It wouldn’t be long before everyone in the room was hanging on her every word; whatever they had been in a snit about a moment ago was forgotten.
She would then take her audience on a magical journey with a story that she often made up as she went. If it were a classic tale, you could count on her to take dramatic liberties. I don’t believe she told any story quite the same way twice. In her kindergarten classroom she would have her students shut their eyes as she told her tales.
"Use your imagination", she would tell them. "I am thinking of a big black dog, he has 2 floppy ears. He also has 2 tails and 3 eyes!"

One distinct recollection of a time when mom’s storytelling saved the day comes to mind. My younger daughter Alana had several friends spending the night. In one of my bigger lapses in good “mommy judgement” I had rented a movie that I thought they would all enjoy. It turned out to be fairly dark and scary (always pre-screen, don’t rely on faulty memory of what may or may not be appropriate.) One of the girls started to cry and some of the other girls started to get sad and upset. A few of them wanted to stop the movie, but of course most of the others wanted to keep watching. The situation seemed like it could go downhill quickly. Fortunately my mom was visiting. She took control, turned off the movie and started to tell stories. These weren’t toddlers; they must have been about ten. They sat raptly listening to story after story. The evening was saved.

Books are wonderful too, but in truth, they also are not quite the same as a story. A story is yours to tweak as you please. Stories are powerful mediums for working through issues. Folks who have asked me for parenting advice over the years know that using stories is a favorite tool. For as long as I can remember I have been counseling parents to create a fictional child with a similar name. Talk about what that parallel child has been going through. This tends to be a very non threatening way to talk about all sorts of issues. Once upon a time there was a little girl who had an “owie” ear. The doctor had given her some medicine to make it better, but when she tried the medicine it tasted yucky.”....

Once upon a time there was a little boy who didn’t like to stay in bed……

Once upon a time there was a little girl who didn’t want to go to school...

Once upon a time there was a little boy who liked to put pieces of cheese in his nose….

These stories are great ways to launch into a dialogue about all sorts of positive and/or negative ways that the protagonist can deal with  a variety of situations. This is an excellent problem solving technique.

When I was working on this post, I mentioned the storytelling theme to one of the wise mamas in my life. She immediately referred to these as “Annie Stories”. It turns out that back in 1988 this was quite the thing, and there was a book about how to use this method:


I use storytelling at work on a regular basis. Many of our savvy parents who know that they have a “shot phobic” patient on their hands, will make sure that they schedule the visit when Josie and I are both there. Josie is my amazing medical assistant who has been my ‘right hand’ at the office for many years.
I can’t even count how many times I have been called into an exam room where a crying, or cowering child is terrified of a “dreaded shot”.... I start my story:

“Once upon a time there was a patient who was so big. He played football for his high school. He was bigger than me, he was probably bigger than the grown up in your house, he was really big...and he was really scared of getting shots." At this point 90% of the kids are now still and listening to me talk. Yes,  they might be huddled on their parents lap, or on the floor under the chair. They are probably not making eye contact, but I have their attention.

“He wasn’t afraid of getting bumped around on the football field but he hated shots. He was so scared of them that he would try to hide. He tried to hide inside the garbage can, but he wouldn't fit..”   Now 99% are listening and some are almost laughing.

From here I am able to start a dialogue with them about why we are giving the shot. “It is magic protection so that if certain germs get inside of your body, you won’t get sick.” We talk about the fact that we wish there was a less yucky way to get the protection and that it is really normal for lots of people to be scared of shots. We talk about the fact that being brave is trying hard to hold still and it is still really okay to cry and yell if they need to. As soon as they are ready, Josie (the best shot giver in the country) has already gotten it done.

It all starts by engaging them with a story.

Not everything has to have a purpose. Sometimes stories are just for fun

If I happen to be taking a  walk outside and see something unusual such as  a pair of shoes sitting by themselves on a street corner, I can’t help to think to myself. Here is a story. How did those shoes get there? Take turns telling the same story. Families can have a wonderful time creating a collaborative tale.
Another wise Mama tells me that she used to have her kids give her three things that they wanted the story to include; perhaps a special name or a certain feeling.

Our kids these days are both blessed and cursed with the enormous choices of digital wonders. I am not opposed to limited use of regulated tech time, but it should not be in place of plain old imagination.

Recent studies show that books and stories started young have a real impact on brain development:


This Black Friday, as people run around to shop for all kinds of new technological marvels, don’t forget to “power down” and be thankful for the magic moments that you capture as you snuggle with your kids and simply tell a story. "Once upon a time......

Friday, November 6, 2015

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




Friday, October 16, 2015

Hepatitis A: Are you protected?


Please see the updated recommendation February 2019
Parents have you gotten your Hepatitis A vaccine?

Hepatitis A is an inflammatory disease of the liver that is caused by a virus. Some people consider the Hep A shot a travel vaccine because it  is the most common vaccine-preventable illness that folks get infected with when traveling. We think that everyone over a year old should get it even if you aren't going anywhere. Hepatitis A is certainly more common in countries with lower standards of sanitation, but this virus doesn’t care about borders. There are plenty of cases right here in this country.

Transmission occurs  through direct person-to-person contact (fecal-oral transmission); contaminated water, ice, or shellfish harvested from sewage-contaminated water. You can also get it from contaminated raw, inadequately cooked, frozen fruits, vegetables, or other foods. Hepatitis A is quite hardy and can live outside the body for quite a while. It can  survive being frozen. This is a nasty virus. Hand washing is important and can stop you from spreading it, but won't protect you from catching it. It makes no sense not to get the vaccine if eligible.

Poor hand washing and then handling food is a common mode of transmission, but so is changing a diaper. Thus diaper age children, infected with the virus, are a large reservoir for spreading it. People are most infectious 1–2 weeks before the onset of clinical signs and symptoms, and can shed the virus in the stool for months and months. Dr. Schwanke had read somewhere that in some cases poop can remain contagious for up to a year!

The incubation period averages 28 days (range 15–50 days). Infection can be asymptomatic or range in severity from a mild illness lasting 1–2 weeks to a severely disabling disease lasting several months. Most common symptoms include the abrupt onset of fever, malaise, poor appetite, nausea, and abdominal discomfort, followed within a few days by jaundice. Urine may be very dark colored and stool is often clay colored or freakishly light. The likelihood of having symptoms with a Hep-A infection is related to the age of the infected person. Fortunately, although it is rarely fatal, adults with this can become quite SICK!

Here is one of the most important facts worth emphasizing: In children aged <6 years, most (70%) infections are asymptomatic. In the young children who are actually acting ill, jaundice is not a common symptom, so it might be awhile until someone figures out that they are dealing with a form of Hepatitis. Most of the time,young children don’t usually exhibit many symptoms at all, or appear too ill, but they pass the virus along to their caregivers who get walloped. We have seen it sweep through a daycare, with many of the caregivers and parents catching it.

The vaccine first became available in Europe back in 1993 and started getting phased in to our vaccine schedule in 1996. Interestingly, although it is recommended, it is not one of the vaccines that are required for school entry. It can be given as soon as a child reaches their first birthday and should be followed by a booster six to twelve months later. Protection against hepatitis A begins approximately two to four weeks after the initial vaccination. Protection is proven to last at least 15 years and is estimated to last at least 25 years if the full course is administered. There is currently no follow up booster suggested, but if the immunity looks like it is waning, I imagine that will get revisited. The vaccine comes only in preservative free form (no thimerosal concerns). I rarely see any side effects at all. Once in awhile a baby post vaccine might be extra fussy, but that is rare and not necessarily shot related.

This one requires little thought. You should make sure that Hepatitis A vaccine is included in your child’s immunization schedule. Our office routinely starts the series within the first 15 months. Parents, also please check your own health records and make sure that you are protected. Adults are often quite clueless about their own vaccination status!

Friday, July 31, 2015

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!)




Friday, June 26, 2015

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

Friday, June 19, 2015

Chickenpox/Shingles exposure guide



The Varivax (chickenpox vaccine) came out in 1995. Frankly our office was a little slow to adopt it. We did an about face one season when we had hordes of chickenpox patients who were absolutely miserable, and there didn't seem to be a sensible answer as to why we shouldn't simply give the shot to prevent it. The answer that "we had them and survived" seemed a little weak. While it is true that most chicken pox sufferers simply have a very unhappy week, complications do occur. Even the moderate cases can have painful lesions in the genitals and mouth. Some folks get them in the eyes and need round the clock eye drops. Some of the lesions end up leaving scars. At the very least you have a sleepless, itchy week and will need to take time off of work.

All of that being said, some parents opt out and this is not one of the vaccinations that will elicit a strong armed argument from us. For those still on the fence, keep in mind that children generally have an easier time with this virus than adults. It isn't quite as simple to catch as it used to be because there is so much less of it going around. If your unvaccinated child doesn't come down with it, consider getting them the vaccine before they are all grown up and out of the house.  

There are also some studies that indicate that future occurrence of shingles may be less likely in a patient who had the Varivax than someone who had the actual chicken pox. In all honesty that question probably won't be answered for another 40 years or so, when the first wave of kids who got the vaccine become middle aged. In our office we used to see the occasional young patient with shingles and so far since starting the Varivax program we have seen little or no shingles cases in vaccinated kids. I realize that this small sample is statistically useless but one can hope.

Similar to the MMR, infants have some maternal protection that starts to wane when they are about 7 months. The protection is probably gone by a year. The first dose of the shot is usually given between 12-15 months. Unlike the MMR, Varivax is not recommended before the age of a year even if traveling or your child has been exposed. A booster is given between 4-6 years. For children age 13 years or older who are getting the Varivax for the first time, the minimum interval between doses is 4 weeks.

Because most of our patients get immunized, actual cases of chickenpox are getting more and more unusual, but they still are occurring. At our office, we ask that If someone suspects that their child might have chickenpox they alert us ahead of time. One of the nurses will go out and see if it is okay for them to come in. We do our best to try to avoid exposing our other patients. Most of the time it is a false alert. We go out, take a look at the rash and end up bringing them directly into an exam room.

Therefore last week when I went out to check someone, I was surprised to see what looked like a classic case of chickenpox.  Luckily it was a nice sunny day because that family was not welcomed in. That particular patient was NOT vaccinated. It turns out that there is a small spike in cases out there right now.

We get many calls  about the incubation and contagion period of chickenpox and shingles. Here is the scoop.

Kids are contagious a day or two before they get any lesions. They may have a low grade fever and be cranky. It is very likely that they are out and about in school, daycare or activities during this period spreading this virus to anyone who is not immune. It is what it is. No reasonable person expects you to keep your child home every time they are cranky. They remain contagious until all of the lesions have crusted over. That usually takes about a week.

So there you were in the park, playing with patient X. You get a call on day 2 from patient X's parent that they have come down with chickenpox. If they were having close interaction with each other, it is likely that your child was indeed exposed. The chickenpox virus is very contagious. It is airborne and can live on some surfaces. If your child is vaccinated or already had the illness, you likely don't need to worry too much. The vaccine is about 85% effective. The other 15% of folks tend to get much lighter cases. If your child in not immune you are now on alert.

From the first moment of exposure, the incubation period is usually 2 weeks but can range from 10-21 days. If 3 weeks go by with no sign of anything you are likely in the clear. Just because your child has been exposed is not a reason for you to keep them home from school or daycare and for you to miss work. They may or may not catch it.
Do be on the lookout for any signs that your child might be succumbing. The words "I want to go take a nap now" may be a red flag. If they get a fever you may want to issue a warning to any friends or caregivers as you wait to see if vesicles appear. If your child does come down with it they are now patient X and were likely contagious a day or so before the first sign of a rash.

After you recover from chickenpox, the virus can enter your nervous system and lie dormant for years. Eventually, it may reactivate and travel along nerve pathways to your skin - producing shingles. It is most common in folks when they are older adults. It may be stress related. One easy diagnostic trick is that the blistery rash will usually not cross the midline of the body.

Shingles can be spread only if someone comes into direct contact with the lesion. A healthy person who has immunity to chickenpox is generally not considered to be at risk. Someone with a compromised immune system or someone who has never had the chickenpox needs to be a little more cautious. If infected, they would catch chickenpox, not shingles, from the infected person. Over the years we have had a couple of patients who came down with cases of chickenpox that we traced back to a shingles exposure, but again, that is most unusual. It is NOT airborne. If the shingles patient keeps the lesions covered you can still go visit grandma.