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...... |
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Friday, November 27, 2015
The Power of story telling
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:
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:
chapstick
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.
Beef...160
Chicken ( white meat/ dark meat)...170/180
Fish......160
Eggs....not runny
Chicken ( white meat/ dark meat)...170/180
Fish......160
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: 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.
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.
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.
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:
www.foodsafety.gov (this site keeps track of any food recalls)
www.Stilltasty.com (great site for seeing how long food will last)
www.fightbac.org (this site has loads of kid friendly activities)
http://kellymom.com/category/bf/pumpingmoms/milkstorage/ (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.
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
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