Friday, July 31, 2015

Cord care




As many of you in our practice know, some of the most common questions that the advice nurse team field on a regular basis have been addressed in past blog posts.

When we get a call, we will often send a link to a past blog post that addresses the topic. It saves us from repeating the same information over and over again. Of course we encourage follow up calls if you still have unresolved questions.

Recently for some reason we have been getting lots of calls about cord care. It often goes that way; things tend to occur in bunches. It was pointed out that this is one of the topics that I haven’t written up, so this week’s post is for the new kids on the block. I will do a more broadly based post next week.

Before birth, the umbilical cord is the connection between the baby and the mom through which the baby receives nourishment and oxygen. After birth it becomes useless.

One cord trend that comes in and out of fashion is the discussion about cord banking. 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. Very few of our patients opt to do this.


The optimal timing for clamping the umbilical cord after birth has 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 that the baby is tended to. If everything is lovely, 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 check. We occasionally  get newborns in our office for their first visit 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 who is changing the diaper when it comes off.

The newborn diapers that have the little cut outs are very useful. You want to avoid having it 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 sponge baths are recommended until it is off. 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 smelly (trust me, you will know if it is smelly or not) call the office to get it  checked out. This can 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 we will want to take a look if things are not healing up. A persistent granuloma will need attention.

Once the cord is off, it is normal for it 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 area, 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 we get lots of calls 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 it’s 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 your 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, July 24, 2015

Make a bedtime book

The Bed time book

This post is a little different. I had intended to share it a few months ago as part of the sleep series, but it got pushed to the side. It is time for a family project. Come on moms and dads, get your creative juices flowing. Make a bedtime book!

Children love ritual and will enjoy reading their special book night after night (you will tire of it long before they do.) Here is a step by step guide to making your own. Many children love helping you make the book by posing for the appropriate pictures.

Get a binder. Make sure that it is one that has an insert on the front so you can slide in a photo. This should not be too hard to find. Put the pages into clear page protectors for a waterproof book that you can tweak over time by adding or subtracting pages. You may want to update it yearly with current photos and rituals.

Call it what you want; MY BEDTIME BOOK or add your child's name and age.

Start the book with photos of important people and introduce them.
Text:    Here is (parent) and if there are two of you, here is (parent),
Here is (sibling)
Here is (pet)
and end with This is Me (or us if sharing)

For young kids I would keep it to your immediate family members and pets, but you can be as inclusive as you want. Keep in mind that you don't want it too long.

Next add a Picture of your house with street sign and address:
This is where my family lives (great way for kids to learn their address)
Picture of bed.
Picture of special blanket
This is the safe comfy place where I sleep
These are my special stuffed animals

If your child has two homes you can take a picture of each room and make 2 copies of the book so there is one at each house. It is nice to have a ritual that is a consistent in both places.

Take pictures of your nighttime rituals such as:

I get into Pajamas
Picture of toothy smile - Before I go to sleep I brush my teeth. It is important to have clean and healthy teeth.
We get into bed and the lights get a little darker (picture of snuggling)

You can add some open-ended pages that allow the story to vary each night. Options include things like:
We have read our (number that you have agreed on) stories/books
We have sung our (number that you have agreed on) songs

Let's tell about something I did today that I am proud of
Let's tell about something I did today that was kind
Lets tell about something I learned today
Let's talk about something special that we can look forward to tomorrow
We send special goodnight "thought kisses" to people that we love

Finally, end with pages appropriate to winding down the good night process:

Getting good sleep is important. My body does a lot of growing when I am asleep.
My family is very proud of me when I stay in bed all night. If I get up too much they might get grumpy ( photo of silly grumpy faces)

Now it is time to say good night and to turn off the light; maybe I will get a special massage (optional but what a nice way to end the day)

Good night!! See you tomorrow!!
*************************************************************
I would LOVE to see your finished projects.
    

Friday, July 17, 2015

Calcium requirements/ The milk transition



The Milk transition!

Calls about the transition from breast milk or formula over to whole milk rank up there in the "frequently asked questions" category.
   
If you are breast feeding and it works for you to continue to nurse beyond the first birthday, good for you! Don't be in a rush to stop. It is a very individual and personal decision. For those moms who choose to nurse beyond the first year, that breast milk feels like a godsend if your child doesn't feel well. Not only is nursing a comfort, but breast milk is great for tummy bugs, eye issues and all sorts of stuff. One parent was poking a bit of fun at me and said "if you call Nurse Judy, she will just tell you to put breast milk on it."

On the other end of the spectrum, many moms (myself included) end up weaning sooner for any number of reasons. In our practice, the first birthday is probably the average age that the milk transition occurs. Keep in mind that if your baby is on formula and tolerating it well, there is no hurry to get off (except for the expense and the hassle). If you have a case of formula left over, by all means use it up.

While it is fine to carefully introduce milk-based products such as cheese or yogurt to your children once they are over 6 months, plain cow's milk is not an appropriate substitute for formula or breast milk in the first year, as it lacks some important nutrients.  

The first birthday is also usually when we  recommend a blood test that checks the iron level. Formula has more iron than cow's milk, so if your child is a fussy eater it is important to make sure the iron levels are adequate before we switch over to plain milk. At our office, we usually send the patients to a local lab to have both the iron and lead levels done with one poke. If there are obvious concerns about diet or lead exposure, your doctor may end up doing the labs sooner.

Once you move along to cow's milk, I prefer that you use whole (full fat) milk. If possible, and you can afford it, go ahead and buy organic. I know there are folks out there that tout the benefits of raw milk, but I have a strong opinion that milk should be pasteurized. I have had parents asking me about vat pasteurization, and that does seem adequate.

Most kids who were on a milk-based formula have no trouble moving on to cow's milk. It is fine to do it gradually so that they get used to the taste (add a few ounces to the formula and see how they do). Intolerance will likely show up as tummy aches, poop changes or rashes. My older daughter got a terrible flare up of eczema when we first got her on milk (Eczema post). I put her back on her formula for a couple of months and when we retried the milk she was just fine with it.

But if you thought that the main choices about cow's milk were organic or fat content, think again. Along comes the choice between A1 and A2. Huh??? It turns out that there are indeed two kinds of cows out there (don't worry there won't be a test on the following paragraph).

A1 and A2 beta-casein are genetic variants of the beta-casein milk protein that differ by one amino acid. The A1 beta-casein type is the most common type found in cow's milk in Europe (excluding France), the USA, Australia and New Zealand. This is what most of us have grown up drinking. African and Asian cows are predominantly A2 cows. Milk from goats and humans contains only the A2 beta-casein.

There is a lot of buzz about this (especially in Noe Valley perhaps?). The claim is that folks who have trouble with our common (A1) milk may in fact be able to tolerate A2 milk without any issues. The jury is still out. As you can imagine, there is passion on both sides. If you want to spend the money, I am sure that the A2 milk is healthy and delicious, but at this point I don't know if it is all hype or if there is any real validity to the claim.

Milk is a great source of calcium, protein, vitamin D and the fat that your child needs for brain development. If you have a hard time getting your child(ren) to drink milk, it is important to make sure they are meeting those nutritional needs through other sources. If you choose to use a milk alternative such as goat, soy, rice, almond, coconut (seriously, there is a wide array of choices)...read the labels and see how they compare. In general:

Cow's milk and soy milk are both great sources of protein and calcium. Goat's milk is also good for protein and calcium, but doesn't have as much vitamin B-12. Almond milk and coconut milk have significantly less protein but are good sources of calcium.

We want kids at this age to be getting at least 700 mg of calcium per day. You can see from the chart below that this should be reasonably easy if they are eating cheese and yogurt.

Yogurt1 cup400 mg
Milk1 cup300 mg
Cheddar cheese3 ounces325 mg
Tofu1/2 cup200 mg
Mozzarella cheese1.5 ounces275 mg
Fortified OJ6 ounces200 mg
Kale1 cup cooked95 mg
Ice cream1/2 cup85 mg
Almonds1 ounce75 mg
Broccoli1/2 cup21 mg
Corn tortilla1 small42 mg




 Interestingly, breast milk doesn't have quite as much calcium per ounce as cows milk, but the calcium it does have has twice the bio-availability.  

I personally don't feel the need to be completely off of the bottle at 12 months, but I NEVER want a bottle in bed (if they fall asleep and keep the bottle in their mouth it can rot their teeth.) I am perfectly fine with a snuggle bottle when first waking up or going to sleep for an extra couple of months.

Try to transition most of the fluid intake to a cup. However, many kids significantly decrease their milk intake once you start moving away from the bottle and transitioning to a sippy cup. Kids just don't like to drink as much milk from a cup. I couldn't tell you why. Some parents feel a little better assuring at least some milk by giving it in the bottle.

If you are trying to encourage your child to drink the milk from a cup, try adding a few drops of vanilla or a dash of cinnamon. Some kids might like it better warm. You can also try frothing it. I am not in favor of adding unnecessary sugar into your kids lives, so I would not suggest adding chocolate or strawberry flavor to the milk on a regular basis. Consider making smoothies with milk as the base. Kids like adding things into and turning on the blender. You can get a special cup that they pick out. If you are using any alternative milks, watch out to make sure you aren't getting a sweetened version that is adding all sorts of sugar.

 Kids who drink too much milk are often anemic because  they fill up on milk and don't eat enough solids. Those are the 'milkaholics'.
Once your little one is over a year, 12-24 ounces a day is a fine range. Try to find the balance.  

  





 Interestingly, breast milk doesn't have quite as much calcium per ounce as cows milk, but the calcium it does have has twice the bio-availability.  

I personally don't feel the need to be completely off of the bottle at 12 months, but I NEVER want a bottle in bed (if they fall asleep and keep the bottle in their mouth it can rot their teeth.) I am perfectly fine with a snuggle bottle when first waking up or going to sleep for an extra couple of months.

Try to transition most of the fluid intake to a cup. However, many kids significantly decrease their milk intake once you start moving away from the bottle and transitioning to a sippy cup. Kids just don't like to drink as much milk from a cup. I couldn't tell you why. Some parents feel a little better assuring at least some milk by giving it in the bottle.

If you are trying to encourage your child to drink the milk from a cup, try adding a few drops of vanilla or a dash of cinnamon. Some kids might like it better warm. You can also try frothing it. I am not in favor of adding unnecessary sugar into your kids lives, so I would not suggest adding chocolate or strawberry flavor to the milk on a regular basis. Consider making smoothies with milk as the base. Kids like adding things into and turning on the blender. You can get a special cup that they pick out. If you are using any alternative milks, watch out to make sure you aren't getting a sweetened version that is adding all sorts of sugar.

 Kids who drink too much milk are often anemic because  they fill up on milk and don't eat enough solids. Those are the 'milkaholics'.
Once your little one is over a year, 12-24 ounces a day is a fine range. Try to find the balance.  

 

Friday, July 10, 2015

Car Seat guide 2015

PLEASE SEE UPDATED POST 7/2017



Make sure your child is in the right Car Seat



Car seats are an essential part of keeping your child safe. California law in 2015 requires:


Infants should be rear facing in the back seat until they are at least 1 year or 20 pounds. Keep them facing backwards until they can no longer fit in that direction.This is the safest place and position in the car.The current recommendation is that they stay there until they are two.

They can sit facing backwards until they reach the highest weight or height allowed by the car seat manufacturer. Size is a more realistic factor than age.


Toddlers who have outgrown the rear facing weight or height limit for their car seat should use a forward facing car seat with a harness for as long as possible, up to the highest weight or height allowed by the car seat manufacturer. This applies to children younger than 2 years who have outgrown the rear facing seat.


The current California Law also requires a car seat or booster seat until your child is 8 years or 4 ft 9 inches. Previously the requirement was  6 years or 60 pounds. Height parameters make more sense than the previous weight ones. You child needs to be tall enough so that the seat belt goes across the chest, not across the neck.


When children are old enough and large enough to use the vehicle seat belt alone, they should always use Lap and Shoulder Seat Belts for optimal protection. If your children complain about this rule, show them photos of race car drivers all bucked up in their restraint system. Be matter of fact about it and explain that there is no compromise for safety (there is also a mighty large fine if you are caught breaking this law.)


All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection. Airbags can actually be quite dangerous to a small child so it is worth making sure that this isn't an issue with your car and the placement of your child's safety seat.


Most accidents happen within a few miles of your house. Even a short trip down the block requires the full "buckle up". Hey parents, model good behavior and always make sure you fasten your own seat-belt!


Did you know that car seats expire? Most of them have a 6 year life span. This date can usually be found underneath or behind the seat. I questioned this when I first found out about it. The explanations made sense to me. First of all buckles and straps can wear out. Prolonged exposure to sunshine can weaken the plastic. Also, the technology is always changing and this ensures that nothing gets too out of date. Save the instructions/registration in a safe place. Do make sure you register your car seat. If there is ever a recall this will ensure that you are notified.


*If you have an old car seat that you want to get rid of, Alioto's Garage has been offering  a Recycled Car Seat Program. Anyone, not just regular customers, can drop a car seat off at any  Alioto's location during regular business hours. They
will recycle the usable parts and keep it out of our landfill

The AAA states that 75% of car seats are installed or used improperly. As your child grows, there are services offered here in the San Francisco Bay Area that will check out your car seat or booster seat and make sure it properly installed. Have the infant car seat checked before the baby is born and then again with each transition to a larger seat.


AAA 553-7208

2300 16th St suite 280

Contact is Ingrid. Appointments need to be made ahead of time. You do not need to be a AAA member to take advantage of this free service.

If you want to take the trek up to Mill Valley. The AAA office there is at 750 Redwood highway.

The technicians there are LJ 415-380-6036 and Wayne 415-380-6031.
They do the inspections on Wednesdays and Fridays, but they also say you will do best to plan in advance. You can probably get it taken care of within the month.

AAA also offers a fun interactive safety related website, www.ottoclub.org, which is appropriate for kids 4-7.



CHP (California Highway Patrol)                  415-557-1094  

This is very popular and is by appointment only. Please make an appointment as far in advance as possible. The woman on the phone there said that her preference is for people to call as soon as that pregnancy test comes back positive! ( I assume she was partially joking, but you get the gist.)

When I called this week to make sure all my info is up to date, the woman on the phone told me that the current wait time is almost 2 months.

SFPD                415-575-6363

They try to have an officer at all of the local police stations who is trained to do the car seat safety inspections. Call the number above for more info.


The Colma police department will do a car seat inspection for free (650-997-8321

*Update 12/2015 they do not currently have someone to do the inspections 


Baby World
has a technician at both of their existing locations 

4400 Telegraph Ave, Oakland,510-547-7040  Mon-Sat(10-5:30) Sun(12-5)

556 San Mateo Ave, San Bruno, 650-588-7644 currently Saturday only

Appointments are needed but reasonable. You may be able to get same day service mid week. Weekends are trickier.  Inspection and installation are free if you purchased the seat through them. If you got a seat from somewhere else, they will still do a free inspection, but any adjustment or installation will be $40.00.


All of the above resources have changed so often during the past couple of years that it makes my head spin.

This info is current for July 2015


If you are not inclined to schlep, click below for info on an inspection that comes to you. It is not free, but it is certainly worth knowing about and some of my patients have used Bryan and raved about the service:  www.buckledbaby.com


ON-LINE RESOURCES


-NHTSA website has a place to click to find updated local car seat inspection stations for those of you who are not in the Bay Area.

(national highway traffic safety association)

They also have a page where you can plug in your child's age and size and they will tell you what type of seat they should be in.

-Healthychildren.org (Keyword :car seat ) has a very comprehensive guide to safe installation.


Car safety doesn't end with being safely buckled. I know it is hard to avoid distraction with a baby fussing in the back seat. Consider getting one of the specially made mirrors so that you can keep on eye on your rear facing baby. Make certain that they can't reach anything that is a choking hazard. Don't let them hold the keys; they can lock you out!! This happened to one of our little patients in the Noe Valley Pediatrics parking lot a couple of years ago. Mommy parked and handed the fussing 15 month old the keys in order to distract her. Mom exited the car and as she walked around to open the back door, her child clicked the lock button on the key. Mom was locked out. Luckily it was a cool San Francisco day. Dad had an extra key, but of course he worked on the peninsula. He was on his way to the rescue when the little girl clicked the "unlock" and we were able to get into the car. Of course if it was an emergency we would have called the police

or AAA to break in right away. In this case, our little patient had been as happy as can be, hitting lock over and over again and grinning at us through the window.  

 

WINTER CAR SEAT TIP: The straps need to be tight up against your baby. puffy coats or blankets need to be OVER the straps!


Never leave your child unattended in a vehicle. Children can die from prolonged exposure to excessive temperatures in a hot car.

****

Thanks to one of my patients who read the post and then shared this link


the car seat lady You tube video

Friday, July 3, 2015

4th of July safety guide


The phone calls that we get following the July 4th holiday are fairly predictable so here are some tips that can help you all have a safe & healthy holiday weekend.

Since some of the holiday festivities may involve large crowds, here are some recommendations for dealing with situations where you might find yourself in a throng of people. Dress your child in bright clothes that stand out from the pack. Take a photo of them before you set out, so if heaven forbid you get separated, you have a current picture to pass around that shows exactly what they are wearing. Make a solid plan with your older children. What should they do if they lose sight of you? Where should you meet up? This is a good time for the "what would you do if...? Activity:

Will it be loud? Loud music and fireworks can be damaging to your child's sensitive ears. Consider getting some ear protection if you are going to be someplace that can put hearing at risk:

Please be very careful of fireworks. If you are skipping the organized shows and planning on setting them off yourself, make sure your kids don't have any access to the fireworks or matches ahead of time. Do an inventory and know exactly what you have on hand.
Keep the kids at a safe distance during the actual fireworks. Have a bucket of water or a hose nearby.

I have NEVER had a morning-after-July 4th without a call or two about fireworks injuries. Don't let this be you making that call. I will be kind, and I will help you out, but I may make you squirm! 

If you are in San Francisco chances are you don't have to worry about the heat. When my kids were growing up, our July 4th fireworks watching usually included warm blankets, hot chocolate and lots of thick fog. I remember one year when Lauren was 3 or 4 and we were driving to a vantage point, she saw a traffic light through the fog. "Is that a firework? It's beautiful!" Ah, our San Francisco babies.

For those of you escaping the city make sure you stay well hydrated and protected from sun: http://nursejudynvp.blogspot.com/2014/06/sunscreen-update.html 

Get in the habit of doing a skin check at least every 30 minutes (more frequently for fairer kids) to see if it is time to reapply the sunscreen. Be very wary about applying any of the aerosol sunscreens around a heat source (like a grill.) These are flammable and there are horror stories out there about terrible burns that have occurred.

Let's move our discussion over to grills. I was watching the news the other night and a story came on about the hazards of metal bristles coming loose from utensils that are used to clean your grill. These metal strands may get lodged into pieces of food. People have been reporting mouth injuries and worse. Happily, that is one call that I have never gotten,  but it seemed like a caution worth sharing. Check your utensil brushes to make sure there is nothing loose. While you are at it, check the grill surfaces to make sure there are no pieces of any foreign objects that can get stuck in the food.

Make sure your child can't get anywhere near any type of grill. The danger begins from the moment you light it and are waiting for it to be ready, until long after the cooking is done and you are certain it is completely cool.

If you are cooking meat, make sure that it is thoroughly and safely cooked. Food borne illnesses don't just love undercooked meat; pay attention to any picnic foods that will be out of refrigeration for several hours:

If your picnic/meal is outside and you will be spending time in grassy, wooded places, make sure you do a head to toe check for ticks once back inside:

No, it is not okay to keep your child in bubble wrap; that isn't my intent. Go forth and have a festive, fun and safe holiday. Happy 4th of July!