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 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)

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.”


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:
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, December 11, 2015

Essential equipment to make parents life easier

How old are my kids? They are so old that they slept on their tummies in cushy little cribs surrounded by tons of stuffed animals. They survived their early years without owning a cell phone or ipad.

The  baby swing that we owned was wound up with a crank. If you are a grandparent reading this, you are nodding as you remember the model that I am talking about. The babies loved it and would be lulled into a contented relaxed state for several minutes of clickety click, clickety clack. Then alas it would wind down and need to be cranked up again. This was a noisy process that more likely than not would wake the sleeping baby who had just nodded off.

Parents of young children have a much wider variety of “parenting hacks” to choose from. There are plenty of new things constantly coming onto the market that parents will refer to as “game changers”. These are the item that really make things feel more manageable. The following products are not personal endorsements; I am simply sharing wisdom from others that may be useful to my patients and readers.
Having a safe place where where your baby can comfortably hang out is essential.
Having them on a comfy 45 degree angle is a bonus.
Dr Anne likes the Boppy newborn lounger
Some of Dr Hurd’s favorites are

the Mamaroo
and the Snuggabunny
Khaley, one of the folks who works in our office loved the Fisher Price rocker for her crew:

You can rock it with your foot (never run out of batteries.) One of the nice things about this is that it is reasonably priced and can transition to be used as your kids grow.

For kids over 4 months, my husband Sandy says I can’t leave the doorway jumpers off the list. Our daughter Lauren absolutely loved hers and would bounce and twirl in that thing in rhythm to music.These of course only work if you have sturdy door jambs. With any carrier or swing, use your common sense and don’t keep the babies in there for ridiculous stretches of time.

Please never leave kids unattended.
Just this week I had a call involving a baby not fully strapped into a little bouncer who managed to flop himself forward and bonk his head (he’s fine.)

Don’t put carriers up on a high surface. Trust me, they manage to fall. You don’t want to be the person calling me about that. This is more dangerous if there is a toddler or large dog that can 'help' the baby get knocked over.
Wherever they are hanging out, Dr Anne also suggests checking out the
Summer Infant Snuzzler Infant Support for Car Seats and Strollers- this is terrific for small newborns or babies having a having a hard time transitioning to bassinet in first month.
If you are carrying your baby around with you check out the Nesting Days carrier. These are invented by  San Francisco’s postpartum doula Julie Arvan
Once the babies are over 4 months old, Noe Valley Pediatrics' Lily loved her infantino flip advanced convertible baby carrier  
For the Crib:
Dr Hurd suggests that all of her patients get invest in a simple crib wedge.
One of our patients Amy (mama of twins) told me about wonder bumpers
These are one of those “why didn’t I think of that” products
Many parents and Dr Anne all really like the Merlin Sleepsuit to help with the transition out of the swaddle around 3 months
Random Tips:
When asked for his favorite item, Dr. Schwanke put Sophie the Giraffe on the list.

This is a classic favorite of his that has been much loved by generations of  patients.
One more of Dr Anne favorite items are the
Amy also recommends Dr Brown's mixing pitcher
This is especially helpful for a family with twins who are mixing larger quantities of formula at a time.

My niece Lena says that the swaddle blankets with velcro were really useful. These give the option of snugging the arms tight while leaving the feet free to be strapped into a bouncer.

My lovely patients Rita and Ricardo spend a recent date night trying to brainstorm for me. They reminisced and thought about the most essential baby equipment (especially the first time around). Here's their list:
For the tall parents out there -- the Uppa Baby stroller line is great.They  have the Uppa Baby Vista and the Uppa Baby G-Lite strollers and both are great for Riccardo (who is 6'8').
The book "Baby Bargains" - - was a great resource to help them find general baby equipment (strollers, car seats, cribs, etc).  It's not just about bargains - it's about quality, and they test and know about all the latest products.
The Frenchie Mother towel - - this is a towel that velcros around mom or dad's neck and makes it easier for you to take the baby out of the bathtub (and keep you dry at the same time.)  So simple but such a good invention!
Mama Regan let me know about the Oogie bear, little scoop for removing little boogies

My super adorable neighbor and patient Sean loves his Zo li sippy cup. His mom Sara says she tried a bunch before they found this winner and that it helped them transition away from the bottle.
I couldn’t do a post like this without checking in with Jennifer of Hint Mama.
She send along the following tips
1.) Glow-in-the-dark pacifiers:
2.) Sleep sacks with loveys attached
3.) These lunch boxes:
Clive’s mom Kylie says favorite toy as infant and now great distracter in car seat is baby Einstein take along tunes.
(Bells and whistles are fine and entertaining. But there is nothing as great as a cabinet full of food storage containers and lids!)
Beyond equipment, there are now all sorts of apps
Robert, the new daddy of baby Noah says that they find the baby tracker app  really useful
Parenthoods is another great resource. It is available on i phones, but the general website is available to anyone
If your favorite life changer is missing from the list, let me know. All of my posts end up as resources on my blog. I will be happy to keep this one updated.

Thanks to Pediatric Dentist David Rothman for chiming in with a bit of wisdom. His says that his kids favorite was the different colored stacking blocks that kept them happily playing for hours.

Thanks to Nurse Lainey for telling me about the DockaTot

This product has been getting some rave reviews for helping out with the all important sleep issues.

Thanks to Tiila for sharing about the sleeper hero

Friday, December 4, 2015

Holiday safety check list/ Have you thought of everything?

This coming week, the winter holidays begin (although the radio station that wakes me up on work mornings has been playing Christmas Carols for a while already; what's that about!?)

Hanukkah (since it is based on a lunar calendar) doesn’t fall on the same date every year. Many folks laughingly refer to it as coming either “early or late” This year it is on the early side and begins on the evening of December  6th. That is my signal to update the holiday safety post.

For most people, holidays are a time for celebration. That means more cooking, home decorating, entertaining, and an increased risk of fire and accidents.

Call me a Debbie Downer if you must, but the mind of an advice nurse is a skewed one. For every aspect of holiday celebrations, I can tell you the story of a patient who called with a related accident. It is not my intent to scare folks with my tales. As I tell parents who attend my safety class, if you know ahead of time what accidents can happen, you have a way better chance of avoiding them.

Baking cookies is just one example. A patient's mom called to tell me that her 10 month old had sustained a burn on his hand. She was holding him in the crook of one arm as she removed the cookie sheets  from the oven. As she recounted, he turned into a cartoon character with a telescoping reach and he was able to stretch across her body and grab a hold of the piping hot tray. Simple solution: don't hold your child when you are working with hot stuff in the kitchen. Their arms are longer than you think. If even one accident has been prevented, this post was worth it.

Candles are another biggie. It was a winter evening several years ago in a cabin at Lake Tahoe. Dr Jessica and family lit some holiday candles and went to sleep. Somehow one of the candles ended up burning a hole through a plastic mat that was on the table. Luckily the smell of burning plastic woke them up before any real damage was done, but it was a frightening lesson. This was a vacation rental. In this instance there seemed to be no working smoke detector. She had no idea if and where there was a fire extinguisher. There are several obvious lessons here. Never to go to sleep leaving candles or a fireplace still burning. Get acquainted with the safety features of any place your family is staying.
Below are some safety checklists for dealing with the holiday season ahead. Some of these may seem like common sense but there might be a few tidbits in here that you haven't thought about.

For instance, button batteries. They are everywhere nowadays in all sorts of small electronics (and musical cards) and can be quite hazardous if swallowed. Take time in advance to do a mental inventory of items that you have around that may be powered by these. Put a piece of duct tape over the battery compartments to make sure they can't fall out.

Certain holiday plants like poinsettias can be mildly toxic (especially to someone with a latex allergy). You may not have them in your own house, but if you are visiting a friend or even a supermarket make sure little hands don't grab the pretty red leaves and put them in their mouths.

Be very careful transporting hot food to a holiday potluck. I have patients who have been burned from hot food spilling on them in a car.

Since Hanukkah comes first this year:

  •   Make sure that all candles are safely out of harms way
  •   the menorah should be on a glass tray or aluminum foil
  •   Make sure candles are not close to wrapping paper
  •   Don't go to sleep with candles still burning
  •   Don't leave the matches or lighters hanging around
  •   If you are frying latkes (fried potato pancakes that are a holiday tradition, yum) make sure that no one gets spattered by oil
  •  Never leave the hot oil unattended
  •  Remember that  adding water to a grease fire will make it worse! Baking soda is okay, but a fire extinguisher is best. Make sure you know how to use it.

Christmas tree checklist:

  • When purchasing a live tree, check for freshness. A fresh tree is less of a fire hazard
  • Cut 1-2 inches from the base of the trunk immediately before placing the tree in the stand and filling with water to ensure absorption
  • check the water level daily to avoid the tree drying out
  • When purchasing an artificial tree, look for the label "Fire Resistant"
  • Never use electric lights on a metallic tree. The tree can become charged with electricity from faulty lights and a person touching a branch could be electrocuted
  • Place your tree at least 3 feet away from all heat sources, including fireplaces, radiators and space heaters
  • Make sure the tree is steady enough that it can't be pulled over by a toddler
  • Trim your tree with non-combustible or flame resistant materials
  • Before using lights outdoors, check labels to make sure they have been certified for outdoor use
  • Make sure all bulbs work and that there are no frayed wires, broken sockets or loose connections
  • Plug all outdoor electric decorations into circuits with ground-fault circuit interrupters to avoid potential shocks.
  • Strings of lights and garlands are a staple of holiday decorating, but they can also pose a strangulation hazard.
  • Avoid trimming the tree with things that look like candy which may pose a temptation to the kids.
  • Keep sharp, glass or breakable ornaments out of reach of small children
  • Holly berries and other small decorations can be choking hazards
  • Don't overload extension cords; make sure that your extension cords are high quality
  • If you are going to use your fireplace, make sure that you have the chimney checked and cleaned if it has been awhile since you built your last fire.

Kwanzaa may be the safest of the holidays, (no hot oil or stressing the electrical outlets) but there are still candles involved, so make sure they are placed in a safe place and toddlers don't have access.

This is a great time to test your smoke alarms!!!
Stay safe and have a wonderful holiday season.

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 20, 2015

Food safety/storage guidelines

Thanksgiving is a holiday associated with lots of yummy leftovers so it's usually my signal to update my food safety post. If you ever watch the news you know that food contamination issues can happen all year round. This post will give you some safe guidelines for foods that you buy and cook. If you do a lot of eating out, restaurants are supposed to have their cleanliness rating publicly displayed. Check the bottom of the article for some great links on food storage guidelines; everything from egg safety and turkey leftovers to breast milk storage.

It is certainly not a sterile world. As soon as they are able, your baby will start putting anything that they can reach into their mouths. You can't even begin to imagine the phone calls we get about the more disgusting items that some of our little patients have managed to get their hands..and mouths on. Just this week we talked to parents of various kids who had possibly had a nibble or taste of the following things:
essential oils
particles from an exploded cold/hot pack
kitty litter

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

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

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

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

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

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

  • Don't  put baby food back in the refrigerator if your child doesn't finish it and you used the "used" spoon to take the food directly from the jar. Your best bet - simply don't feed your baby directly from the jar. Instead, put a small serving of food on a clean dish. Add more as needed with a clean spoon. Remember that once saliva has come into contact with the food it is no longer sterile and some bacteria can grow quickly.

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

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

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

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

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

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

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

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

Some excellent resources for food safety tips can be found at:  (this site keeps track of any food recalls)   (great site for seeing how long food will last)   (this site has loads of kid friendly activities) (Kellymom is a worthy site for all sorts of breastfeeding info)

Enjoy your Thanksgiving!

Friday, November 13, 2015

RSV (update)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Friday, November 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 30, 2015

Halloween Safety checklist 2015

Halloween can be such a fun holiday, but as you can imagine, as advice nurses we tend to hear about some of the misfortunes that can along as part of the festivities.
Carving a pumpkin can be a very fun tradition. Please make sure that your child's level of participation is consistent with their age and ability.
  • Watch out for the sharp implements and make sure you assign your younger child to the safer tasks (young kids can draw on the pumpkin rather than carving.)
  • Clean up the mess. Pumpkin flesh is slippery and can cause falls and injuries when dropped on the floor. Layer newspaper or old cloths under your carving work space and clean up spills right away so no one slips or trips.
  • Skip the candles, which may cause fires. A burning candle in a pumpkin may become a blazing fire if left unattended. Instead, use a glow stick (available in many colors) or flame-less candle to safely illuminate your jack-o'-lantern.

Choosing a costume
Want to hear a terrifying statistic? Children are more than twice as likely to be hit by a car on Halloween than on any other day of the year.
  • Decorate costumes and bags with reflective tape or stickers and, if possible, choose light colors.
  • Have kids use glow sticks or flashlights to help them see and be seen by drivers. Is your dog going along with the trick or treaters? Have them wear a glow in the dark collar!
  • When selecting a costume make sure it is the right size to prevent trips and falls.
  • Be sure to wear flame-resistant costumes. Remind your child that they need to pay very close attention to their surroundings and avoid walking near any candles or flames, especially if they have loose flowy costumes.
  • If a sword, cane, or stick is a part of the costume, make sure it is not sharp or too long. A child may be easily hurt by these accessories if he or she stumbles or trips.
  • Since masks can sometimes obstruct a child's vision, try non-toxic face paint and makeup as another option.
  • Always test the makeup in a small area first.  Always completely remove it before bedtime to prevent possible skin and eye irritation.
  • Make sure that your child doesn't have any latex sensitivity before you do too heavy of an exposure. Many masks are made of latex. We actually  had a patient who had an allergic reaction to the hair tinsel. You may want to do a test run of the costume and make up a couple of days ahead of time to rule out any allergies.

Trick or treat rules

  • Children under the age of 12 should not be alone at night without adult supervision. If kids are mature enough to be out without supervision, remind them to stick to familiar areas that are well lit and trick-or-treat in groups.
  • Popular trick-or-treating hours are 5:30 p.m. to 9:30 p.m. so be especially alert for kids during that time if you are out driving.
  • A good meal prior to parties and trick-or-treating may discourage youngsters from filling up on Halloween treats.
  • Bring plenty of water along when you go trick or treating. Just trust me on this one.
  • Make sure that your children know that after trick or treating, the grown up needs to pick through trick or treat bag and toss anything that looks suspicious. There is a warning out in Colorado this year about "pot laced" treats. That could happen here just as easily. Anything that looks like it has been tampered with should get tossed.
  • Some candies are real choking hazards. If you have a younger child in the house, make sure they don't have access to the stash.
  • If you have a child with nut allergies (I am sure this is NOT your favorite holiday) make sure that they turn over ALL the candy so that you can separate out anything that might cause trouble.

Expecting trick-or-treaters or party guests?
  • Consider purchasing non-food treats for those who visit your home, such as coloring books, stickers or tattoos.
  • Provide healthier treats for trick-or-treaters such as low-calorie treats and drinks.(Okay, fine...maybe you don't want to be "that" house, but I had to put it on the list)
  • Be sure walking areas and stairs are well-lit and free of obstacles that could result in falls.
  • Keep candle-lit jack o'lanterns and luminaries away from doorsteps, walkways, landings, and curtains. Place them on sturdy tables, keep them out of the reach of pets and small children, and never leave them unattended.

Now what do we do with all this candy!!!

Make a plan about how much candy they can eat at one time. It is okay to be a little more liberal than usual for a day or two, but come to an agreement about a reasonable candy intake over the next few weeks. Some dentists and orthodontists have buy back programs, where they will give your child a reward for turning in their candy. Click the link for a partial list:

You may need to be extra vigilant with teeth brushing this season.

Remember that candy freezes (and some of it is actually better that way; frozen snickers bars, yum!) My daughter Lauren was about 6 when she caught on that mom and dad were pilfering through her trick or trick bag and stealing all the good stuff. After that she guarded her stash more carefully.

Bonus tip from Cleo's mom:

"Once Cleo was out of the stroller and walking, we put glow stick bracelets and necklaces on her so we could see her more easily when out and about in crowded spaces in the dark (we do this at things like the Dia de Los Muertos parade, too.) Cliff's sells them in a big 100-stick bulk container. Not terribly eco, but gives a little extra "eyes on" help when navigating the crowds."

Post Halloween tip:
My little patient Franny, bent a glow stick in order to activate it and it broke.
Some squirted in her mouth. While, you do want to avoid un necessary contact with the insides of a glowstick, they are non toxic