Thursday, February 19, 2015

Finding balance/ an update of one of my top ten favorite posts



Time is funny. It seems like just days ago my first born Lauren was in her crib having long discussions with her Winnie the Pooh crib bumpers (yes she survived having bumpers in her crib). Suddenly she was in kindergarten, then Lowell and then off to UCSB.

I looked up from typing and said to my husband, “ I need help finding a word.” Without missing a beat he responded, “ Opossum.” Hmmph; never mind. The word was bittersweet. I continue writing…

Having your first child successfully fly out of  the nest leaves most parents (I was no exception) with a bittersweet mix of emotions, but pride and love rise to the top. Once Lauren left for college, our first visit with her wasn’t until mid October when the family did what would become a familiar trek down 101. Her campus was exactly 350 miles away. This two months was the longest we had ever been apart. As we got close to Santa Barbara I realized that I had a visceral longing to grab hold of her and take in big sniffs. I felt like a mother lion on the Serengeti. I imagine a lot of moms reading this can relate. I called Lauren and warned her what to expect. She was very tolerant “It’s okay mom, you can smell me as much as you like.”

Time raced forward and soon both babies were out of the nest. Both my daughters now know to expect a giant hug, some tears and some surreptitious sniffing when I haven’t seen them in a while.  Lauren is spending the year overseas and this current separation is  the longest ever for me. I haven’t seen her since August. My younger daughter Alana, who is in grad school back east, is able to join us as well. Having the family together for a little stretch of time is something that I plan to cherish. I am getting ready for a really big sniff!

This week I am reposting one of my favorite topics
~ Nurse Judy

The "pie theory" got its inception many years ago. For a number of years I was the Parent Association President at my daughters' elementary school. It took an inordinate amount of my spare time, including meetings several times a week. On many levels it was rewarding being so involved but I assure you, I was delighted to pass the reins when my stint was over. Though I was really genuinely relieved to have my time back, I felt off balance by all the sudden free time in my schedule, and at first I couldn't figure out why I was so unsettled. I finally realized that although the new empty hours were welcome, they had created a bit of a vacuum. I filled it quickly (started taking up karate a few evenings a week), but it was right around that transition period that the "pie theory" helped me make sense of things.

Imagine your identity is a circle (or whole pie). Who you are is divided into many pieces; some pieces are large, some small, some temporary. Some are constants that are with you life long, some are optional, some are good for your soul, while still others are energy sappers that give you little in return.

Are you:
Daughter?
Son?
Sibling?
Friend?
Spouse?
Ex spouse?
Grandparent?
Student?
Volunteer?
Pet owner?
In a job/occupation or seeking one?
Doing a hobby that takes time and energy?
Member of a book club or any club for that matter?
Churchgoer?
Exerciser?
House cleaner?
Carpool driver?
Event planner?
Adventure seeker?
and of course last but not least....
Parent?

The list goes on and on. What activities make up your day, your week, your month, your year? What pieces make up your pie? Take a few moments to figure it out.

It's interesting to think how you can be identified in different ways by the various pieces of pie. Many folks recognize me as Nurse Judy. More than once I have actually looked at a rash, or given advice from a restaurant table (as my patient husband rolls his eyes.) There was a time years ago when I came to work one day and saw a construction worker on the roof of a neighboring building. He looked awfully familiar and I was struggling to place him; was he a parent from the practice? Someone from school? I could see that he recognized me as well; we kept looking at each other and a moment passed. I could see that he had figured it out first. He gave a big grin and called out " Ahoy there Java's mom!" Of course! I ran into him several times a week with his pack of dogs when I walked my dog Java. Not only did being a dog owner dictate my daily schedule and get me out walking rain or shine, it also included me as a member of a distinct social network in the neighborhood for many years. All the dog owners knew each other by sight and all the dogs by name. Being "Java's mom" was a wonderful piece of my "pie" for 12 years. If you are a pet owner, that piece has a very special place allotted to it.

Your pie is finite. You can only do and be so much, as there are only so many hours in the day. Some folks have too many things competing for time and attention, and figuring out which pieces can be compressed can be quite stressful. Sometimes we make poor choices

For busy working parents this might be a foreign concept, but some folks don't actually have enough pieces to begin to fill the shell. A big empty pie can be just as unsettling as a full one.

Have you ever noticed that when you are super busy you can manage to get through an entire to-do list very efficiently? On the other hand, on a quiet day you may have only one or two things on the list but somehow nothing gets done.

A healthy pie has plenty of interesting pieces that can grow and shrink according to your needs. The more forgiving and elastic the pieces, the easier time you will have finding a good balance.

Your pie will naturally change from year to year, but some changes are enormous. Some people are quite comfortable having a very crowded pie, while others are quite fine and happy doing nothing at all. Part of this is figuring out what your ideal is, and work towards that.

Any large sudden changes to your pie will make you feel unsettled, way less so if you have a glimmer of what is going on; hence this theory. Both of my daughters have taken this to heart. In fact Alana has permitted me to share her own blog post on the Pie Theory that she wrote several years ago:


(Blogging runs in the family I guess)

When there is a large shift in your pieces my girls and I refer to this as "pie disequilibrium"

Common culprits might include:

Event planner:
Folks planning a wedding or large event can spend months dealing with all the fun details. When the event is over, that planner piece is gone, your pie has a gap.


Sports Fan:
My daughter Alana has a twinge of "Pie Disequilibrium" every October when baseball season is over

Actor:
My daughter Lauren had to learn how to deal with the extra time that appears after a show run is over.

Caregiver:
Folks that spend much of their time and energy tending to someone else’s needs might find themselves suddenly with a large vacuum when that person is gone or no longer needs them.

Parent:
As your children grow up and don't need you in quite the same capacity it can be a tough adjustment (don't worry, they still love you.) Luckily this happens in stages. Kindergarten...a full day of school...college. Parents who have the "parent piece" taking up the entire pie may suffer.  

Huge life changes will create seismic shifts. Nothing will ever match the huge transitions that take place when you add the parent piece to your pie. My best advice to you as you shuffle all your pie pieces and see how things fit comfortably is to identify pieces that need to be protected so that they don't get too small.

DO NOT IGNORE YOUR PARTNER!
Protect that piece. Get creative and make sure that you have time for the two of you  have some moments being a couple

DO NOT IGNORE YOUR OWN NEEDS!
Being the best parent that you can be includes living by example. Let your kids have parents that are multifaceted and not consumed by any one thing (be that parenting or a job.)

Best of luck finding a balanced, interesting, and fulfilling pie!

Friday, February 13, 2015

Nurse Charity to the rescue/ Care for Open Nipple Wounds


Care for Open Nipple Wounds
(nipples that are excoriated, scabbed, bleeding, or have pus)

OUCH!   A great latch fixes most problems, so the first step is to find expert help ASAP. (Your IBCLC needs to watch a latch or two, and check the baby's mouth for unusual anatomy).   But while you and your new cutie are learning, sometimes you get a painful latch, and within minutes those tender nips are in need of some serious TLC.  Or you got a little aggressive with the pump suction, and there are blisters or cracks at the nipple base.

Pro-tip:   Pumping should be comfortable, not just tolerable- if it is pinchy at all turn down the suction, even at the lowest setting, the pump will still work. Don't fall into the trap of suction beyond comfort will move more milk.  Pain interferes with letdown.

Once you have an open wound, there is greater risk for infection so nipple care is very important- we aim to lower your risk of infection, and support moist wound healing.  I have tried many things over the past years- this is what seems to work best.


Saline Soaks twice a day (minimum) for 3-5 minutes-  Saline helps flush the wound, promote healing, and feels great.  Just make your own.  ¼ teaspoon of SEA SALT (not table salt) in 1 cup therapeutically hot  water (not asking you to boil your nipples, that would be a bad idea- but the water should not be tepid either- good hot bath water temperature).  Make it in a small coffee cup (two if you have damage on both sides), and then lower your breast into the cup.  Some gentle pressure with your hand will allow you to seal the cup to your breast, and you can sit comfortably upright (or walk around).  Sometimes the cup becomes unsealed, a towel on hand to clean up any water spills is wise.  Twice a day is great, but you can do it more if you love it.




Now to protect from infection!

Antibiotic Ointment-  I like to use a small amount of antibiotic ointment after each feed or pump. Not picky what kind, but should be ointment, not cream (bacitracin and neosporin are what most people have at home- check the expiration date, throw away anything that looks old).  Just a little dab, and then do not wash it off.  New skin needs to be left alone, washing the nipples before each feeding can do more damage than good.  The very small amount of residual ointment will not hurt anyone.   If you have a prescription for mupirocin ointment (Bactroban), or APNO (All purpose Nipple Ointment- a combination antibacterial, antifungal, plus steroid potion) that can be used instead of the OTC options.

Gentle Cleansing- if signs of active infection are present- If you have any kind of ooze or pus (sometimes looks like yellow/greenish crust), you need to add another step.  A once to twice a day wash with mild antibacterial soap, very gently, and then pat dry.  NOTE: If the nipples are open and scabbed but do not have any oozing, you can skip this step.  Soap is very drying and can create irritation if over used.

Help!  My nipples keep getting stuck to everything and are rubbing against my clothes!

Open to Air- best course of action is to leave them open to the air as much as possible, Yay for topless parenting!  

Pro-tip: Here is the litmus test for helpful postpartum care- anyone in your home for longer than 15-20 minutes should be able to watch you breastfeed (which includes seeing your bare breasts for extended amounts of time), be cheerful and willing to scrub your toilet (or fold laundry, or run the vacuum- anything you need), and be able to provide a meal (they can cook it, they can order in, but they must provide sustenance).   Everyone else should ring the bell, leave the casserole at the door, and blow you air kisses from the sidewalk.  No exceptions. People who just want to admire/hold/coo the baby and cannot do the above need to go in a hurry.    

If that is not practical for you here are some other suggestions-

Food grade Oil-
Some coconut oil or olive oil can promote moist wound healing, and help the skin from sticking to things, go ahead and be liberal.  Do not wash it off.  The fancy things you got as shower presents also work (nipple butter, mother love etc etc etc), but I find food grade oils to be just as good, and less expensive.

Medical Grade Lanolin- same directions as above.  I sometimes get people who are allergic, and unfortunately no one sells just pure lanolin any more- they have all added emollients so it is easier to spread, but it is tried and true.

Hydrogel Dressing-   If you are using the antibacterial ointment, you can use a product call hydrogel dressing (Soothies or Hydrogel) to soothe, protect and promote moist wound healing without having the wounds stick to your breast pads or bra.  It is what we use for burns in the hospital setting.  Because it is a warm moist environment, a little dab of antibacterial ointment will help keep the bacterial levels modest (do not skip this step, studies show that hydrogels used incorrectly can increase your risk for mastitis- do not let this be you!).  The directions will tell you to wash your breast before each feeding- OVERKILL- again over washing is bad for healing wounds, so skip that step unless you see that the hydrogel dressing is crumbly, and you have some hunks on the breast.  Then of course you would rinse those bits off, and throw away the hydrogel (it has outlived it's usefulness). The pad itself is sticky and attracts lint, so do rinse the pad with water before each use. Some moms love storing them in the fridge so they can have something cool to soothe their nipples.  



Using the above methods, and a stellar latch, your nipples should look significantly better in 3 days, and be healed in 7-10 (maybe even faster).  So check in if you are struggling at the 3-5 day mark.   

*Any potion, gel pad, disposable breast pad or soap has the potential to* *cause an allergic reaction or aggravate sensitive skin*
If anything you try for 24-48 hours seems to be making things worse, please discontinue and give us a call to check in.


If you think you have YEAST, please see my guest blog about Thrush.



Friday, February 6, 2015

More about the measles. Is your child protected?

A lot of our families are understandably quite worried about this current measles outbreak. It is not a surprise that our phones are ringing off the hook with questions about our patients' vaccine status. Here is the scoop.

If your child is under 6 months, it is too early to give them the shot. Luckily these babies do have some maternal antibodies protecting them (based on the assumption that most moms are actually immune.) Of course it is a good idea to avoid crowds when given the choice, but do keep in mind that your baby has a bigger risk of getting the Flu or RSV than they do of contracting the measles. Either way, crowds this season are best avoided if you have a young, vulnerable infant.

If your child is between 6 months and 12 months, then we are in a bit of a gray area. If you feel strongly that you want it, call for an appointment and we will give the MMR to any of our patients who are requesting it. But here are some things to consider. This will likely NOT be covered by insurance. It also does NOT count towards the two MMR doses that must be given after the age of one year. Every case is a little different. I am not currently advocating automatically doing the shot early. There haven't been studies done for this age group. I have no hesitation about the safety of the shot, but am reluctant to give an extra dose of anything unless I am convinced it is really necessary.

It takes about 10-14 days to get any significant protection from the first MMR. For instance, getting an MMR for a 7 month old to protect them from a travel situation the same week is not going to do much of anything. If you are planning well in advance it might be worthwhile prior to airplane travel.

The Measles outbreak is a bit like fire. There are embers out in the community. It is NOT a wildfire yet. Don't panic! A few hundred cases is a few hundred too many, but that does NOT mean there is a child with measles standing on every street corner. The next couple of weeks will be very telling. It is possible that the numbers of infected patients will spread dramatically. It is also possible that the infected individuals have been identified and quarantined and we can all breath a little easier.
If we start getting cases in San Francisco, or continuing to see a rapid spread, then  I am going to become more aggressive in protecting the 6-12 month olds.

If they are over 12 months old let's get them protected now. All Noe Valley Pediatrics families can feel free to call and schedule an appointment to get the first MMR ASAP if your child is over 12 months and they haven't gotten it yet. Prior to this recent outbreak, It was fairly common to wait until the 15 month exam for the MMR, so your one year old may not have gotten it at the one year checkup. Call the office to ask about  the vaccine status if you aren't sure.

The second dose is routinely given after the age of four. This dose is thought to bump up the protection from 95% to 99%. It is safe to give a second dose any time, as long as it is at least 1 month following the first dose. We are pretty comfortable with the protection from that first dose and are not spending much energy trying to get the second dose early.
If you do opt to do it on the early side, and they have had the first dose after a year, the second dose will count regardless of how early it is given and the series will be considered complete. It is possible that some insurance companies may give trouble to folks giving it outside of the routine schedule recommendations. I went through the motions of trying to get a pre-authorization done for one of my families who wanted to get it done early. I did 10 minutes of automated hell, 20 minutes of holding; when I finally got the human voice I was told to submit a letter. The response to the letter was essentially they may pay, they may not. Ugh.

We are going to do our best to make sure that we don't have a measles patient walk into our office. If your child is over 12 months and has not been vaccinated, we will need to take extra precautions if they have any fever over 102 along with a cough. You will need to speak with the nursing staff before being given an appointment.

My mom is one of my loyal readers. When I updated the post about measles a few weeks ago she told me that it vividly reminded her about how frightening measles was when I was a young child. In the early 60's my family had traveled and she had seen a child with measles encephalitis. She was terrified that we might have been exposed. We were the first in line as soon as the measles vaccination became available. These diseases were very real to the parents back then and they couldn't wait to protect their children. Everyone knew someone who had died or became disabled from this illness. Parents in this country today are fortunate that the reality of these diseases has not really impacted them on a daily basis.

It is never my intent to shame parents who make the choice not to vaccinate. Some parents hold off because their child can not get the shot for a variety of valid medical reasons. Other well educated parents are opting to not get it, citing other reasons that they firmly believe to be valid. Over the past decades, the refusal to vaccinate did not put their kids at too much risk because the numbers of actual cases were down. That is now no longer the case. Unvaccinated kids are at risk. I hope that parents who are still reluctant to vaccinate will reconsider. Some parents of vulnerable children don't have the option.

One of my adult friends said to me the other day,  "we all got measles and survived, what is the big deal" My response was, "It is true enough that the vast majority of folks who get measles will recover intact and have lifelong immunity. However, one to two kids out of 1000 will die, more than that will be permanently damaged. That is too many when we are talking about something that can be prevented. That 1 child out of 1000 matters."