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: https://www.amazon.com/Annie-Stories-Special-Kind-Storytelling/dp/0894805282 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: http://well.blogs.nytimes.com/2015/08/17/bedtime-stories-for-young-brains 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......

When can you take your baby out into this germy world ( 2016)

The discussion with new parents about when it is safe to take the baby out and about and risk exposure to crowds comes up quite a bit. This is one of those questions that gets a lot of differing opinions from anyone you ask. The only opinion that really matters in the end is that of you and your partner. All the well meaning friends, family and healthcare professionals can only advise. It is up to you to pick a path that feels right for you.  It is an especially popular question this time of year with the holiday season looming. Many folks have celebrations and gatherings ahead. Lots of folks are considering traveling.

It is often not a black and white case and we end up trying to identify all the considerations specific to your situation. There is a vast difference between a single parent taking the baby with them to get provisions, and the choice to take a newborn out to a crowded concert.

Travel questions come up a lot. I would rather avoid having a very young baby on a full airplane but some travel is worth the risk. I would likely say "go for it"  to a baby going to see aging great-grandparents, or to a once in a lifetime family event like a wedding. I would say "are you absolutely nuts???" to a family taking an infant to a beach vacation in Mexico.

What time of year is it? Are there any active viruses circulating? We are just coming into the winter cold and flu season. I am going to be stricter in my recommendations this month. RSV is actively going around. I posted about it a few weeks ago and since that post we have had positive tests in the office. I want my newborns safe.

I have a very different standard when dispensing advice about the under two month crowd. That two month old check up and first set of vaccines is a significant milestone. If you know that you have upcoming travel, bring that up at your early doctor appointments. In our office we can accelerate some of the first vaccinations.

Any fever in a young infant gets my attention. Babies are the most vulnerable the first 6-8 weeks of life. If one of these young babies gets a fever, it is going to be taken very seriously by any doctor that they encounter. In an emergency room, a fever in a young baby will most likely trigger diagnostic testing such as blood work, a urine catheter, x-rays and even a spinal tap. If in fact that baby has a serious infection, early intervention can be life saving, so the doctors aren't kidding around. No one wants their baby to have to  go through that.

I know that many new parents get cabin fever, but whenever possible, keep your newborn away from any circumstance that may expose them to anyone who is sick. In general, crowds should be avoided. If someone is coming to the house to visit make sure they are healthy before they come in. If they feel like they may be coming down with something, they are not doing you any favors by exposing you and your newborn. If you have family staying with you I prefer that anyone who is planning on spending time with your baby be vaccinated.  Ideally they have gotten the TDaP and Flu vaccines already. It takes a week or so for immunity to take effect. Plan ahead and make sure that family members get the shot now if they haven’t yet. Send them over to a pharmacy for the shots as soon as possible if they haven't gotten around to it. As long as visitors appear healthy and are more help than hindrance, don't hesitate to take advantage of your support network even if they haven't gotten the shots yet. Good hand washing is essential. We haven’t started seeing true influenza, but it is coming.

First time parents have the luxury of protecting and isolating the baby and should take advantage. That being said, in my opinion, a walk outside on a lovely day is usually perfectly fine for even the most conservative family.

Second kids are a different story by necessity.  They are often born into the situation where they have a loving, snotty nosed older sibling that wants to kiss and handle them from the start. These babies generally get exposed to things much earlier. Anyone who has multiple kids can tell you that it is really sad watching the young babies struggling with their first illness. As I mentioned in my sibling post, tell your older child or any children who will be in close contact with the baby, that they are in charge of the “germ patrol.” It is their job to make sure that anyone who is going to touch the baby washes their hands first or uses a hand sanitizer. Good hand washing is essential but quarantining your kids from each other is not reasonable. Common sense also dictates that kids are likely contagious before you realized they were getting sick, and by the time you realize that something is up, it is already too late.

When making decisions about how much contact your infant is going to have with the outside world, it is nice to have choices. Unfortunately situations will come up when it’s not so simple. When faced with these types of decisions, recognize that things are usually not clear cut so explore your options. Sometimes they are limited so do the best you can and use your best judgement!

Antibiotic considerations

Fortunately  the majority of my patients understand that antibiotics need to be used with care. Antibiotic resistance is a reality and it is essential that we don’t exacerbate the problem by giving these important medications unless they are really needed. Antibiotics should not be given for viral illness. Of course, sometimes a viral syndrome does morph into something bacterial. Fluid in the sinus cavities, ears, or lungs can become infected. To be certain that we are dealing with a bacterial infection, the best practice would be to do a culture prior to starting treatment. Reality sets in and considerations such as cost and invasive testing are complicating factors. In our office the doctors use their best clinical judgement when deciding whether or not antibiotic treatment is appropriate. If a bacterial infection is suspected and treatment is started, here are some factors to consider: UNDERSTAND THE DOSE Many antibiotics come in different concentrations. Some conditions will warrant higher dosing and longer courses. Some doctors also will also have individual dosing habits and practices. Dr Schwanke has his own favorite way of using Zithromax. When he first started ordering it his way, it was routine for me to get calls from the pharmacies saying ??????     Parents, please don’t hesitate to check with your doctor/nurse if you have any question about the dosage. Read the directions on the bottle to see if refrigeration is necessary. I suggest keeping a checklist with the bottle. Check off each dose when you give it. This will help you keep track of the doses. It is not unusual for me to get  calls about double dosing when both parents realize that they had each given the scheduled dose. (Usually not a big deal, aside from possible GI upset, but keeping track is a worthwhile habit.) Some antibiotics like Septra can make you more sensitive to the sun. It is a good idea to be especially cautious about exposure if you or your child is on any medication. Antibiotics usually are better absorbed on an empty stomach, but medications like Augmentin can be tough on the tummy and taking them with food helps make them easier to tolerate. Ask the pharmacist if there are any food interactions to pay attention to. Some antibiotics don’t interact well with very acidic foods such as grapefruit juice. Some naturopathic doctors suggest that green tea is a positive thing to drink when taking medications. Warning to women on birth control pills - while this is not universal, some antibiotics do interact with, and minimize the effectiveness of, the pill. Unplanned pregnancies have happened. Sometimes parents report a miraculous improvement after the first dose, but that isn’t typical. Although folks are considered to no longer be contagious after 24 hours of treatment, It can take several days before the patient starts feeling better. If 3 or 4 days has passed with no change, it is worth checking in with your doctor to make sure you are on the right medication. DON’T PARTIALLY TREAT The goal of the treatment is to knock out the bacteria. Stopping the medicine mid course may allow the hardier bacteria to develop resistance to future treatment. http://www.cdc.gov/getsmart/community/about/antibiotic-resistance-faqs.html If you start the treatment and can’t complete the course, confirm with the doctor that the infection you are treating has cleared up prior to stopping. PROBIOTICS The job of the antibiotic is to kill bacteria. Our body has a host of necessary good bacteria that might be caught in the crossfire. If this balance gets out of whack, issues like indigestion and yeast can occur. I think that taking a good probiotic while taking antibiotics is a good move. Do not take them at the same time as the antibiotic, but space them out.  If the antibiotic is twice daily, give the probiotic mid day. BRUSH TEETH Most antibiotic liquids are loaded with sweetener to make them more palatable (I wish that the sweetness was magic, many are still pretty nasty.) You can also ask the pharmacy to add a flavoring to help with compliance. It is essential to brush teeth after every dose. I have seen teeth get discolored when this isn’t done. ALLERGIC REACTIONS As my favorite allergist says, “not all drug rashes are created equal.” Anything that seems drug related and involves blisters should be seen immediately. These can indicators of serious complications. If the patient gets hives, that is a sign  of a classic drug allergy. With hives or blisters no further doses of that medication should be given. Less serious rashes are more common, but are still worthy of attention. Some patients develop a rash once they have been on the medication for several days (8 seems to be the magic number for some reasonand Amoxicilin seems like a frequent culprit for this.) This might be a T-cell mediated hypersensitivity. Some physicians feel comfortable completing the treatment as long as the patient seems comfortable, but anytime a patient develops a rash when they are on medication it is worth having them seen. Remember, they were on medications for a reason. We don’t want to simply stop a partially treated infection.The doctor can make the decision if the condition still needs treatment, in which case we will likely swap to a different medication. If you child has any type of rash, their chart should be flagged with an allergy alert. If this was a hive reaction, that medication should not be given again. If it was a non hive rash, it is possible that it can be tried again cautiously in the future. There does seem to be some family tendencies toward allergies but no firm rules.  It is important that parents keep track of allergies, and don’t count on a notation in their child's records. With multiple children in the family, many parents actually have a hard time keeping track of who is allergic to what. If you are traveling, you should know what your child should not be treated with. The travel doctor most likely won’t have access to your child’s history.

Achieving a healthy weight

Helping your child maintain a healthy weight is a goal that we all share.

In my solid foods class, one of the things I talk about is how important it is for you to help your child establish a healthy relationship with food. It is never too early to start.  

Don't push food. When you baby indicates that they are "all done", don't coax them to take that last bite or fuss over a clean plate. In order not to waste food, only give them a small amount at a time. Add more on request. Of course give them as much as they want (unless they routinely eat until they barf!)

Offer a wide assortment of healthy meals and snacks. Pinterest is a fabulous resource for creative ways to make food interesting and appealing. Most young children will eat what they want/need. If you have concerns about health or adequate weight gain, it is reasonable to check in with your doctor's office and see where they are tracking on the growth chart. We like to see the height and the weight increasing at a reasonably parallel rate. If your child seems happy, healthy and is growing well, please trust them.

Give positive feedback for trying new foods. (Click here to review my past post on picky eaters) I generally suggest allowing a reasonable amount of sweets (the definition of what constitutes reasonable will vary from family to family.)  I have found that kids completely banned from sugar love it all the more when they have an opportunity to get a hold of anything sweet.

That being said, Dr Kaplan thinks that every family should check out the online documentary called FED UP, which gives some disturbing information about how bad sugar is for all of us.

In our family we tried to stress "growing food first". Anything with some nutritional merit could fall into that category. Once your body had enough growing food, if there was room for something extra, that was fine. I would rather not to consistently set dessert aside as a reward.

In spite of our best efforts it is sadly typical in our society to have folks on either end of the healthy weight spectrum. On one end are the kids who are way too thin. While some completely healthy kids are genetically predisposed to be very thin, Anorexia and Bulimia are a real concern. It is real. It is rampant. It isn't limited to girls. If you have a child (teens and preteens are most at risk) who is losing weight and/or has any food aversions, it is easy to be in denial but please keep your antenna up and check in with your doctor's office.

In San Francisco, one resource The Lotus collaborative

offers free support groups every Sunday to patients and families who are dealing with  eating disorders.

On the other end of the spectrum are kids who are heavier than they should be. As much as we recognize the importance of healthy eating and getting more exercise, putting these things into practice can be a challenge.

Keep in mind that it is not unusual for kids to have a bit of "pre-puberty pudginess"

I generally don't like to focus on numbers. It also may feel like a veritable minefield opening up the weight discussion with your preteen or adolescent. I would make the focus on health for the entire family. Everyone would benefit from more exercise. The entire family will benefit from eating a healthy nutritious diet.

We are always on the lookout for local programs to support young children and families through this process. The ones that exist are expensive, have fairly long wait lists and require a significant time commitment. Therefore we were delighted when several years ago we found out about fabulous resource called Kurbo. This is an app that helps get the kids engaged in a healthy eating/exercise plan. The folks behind it started out with the Stanford weight loss program. They know what they are doing. The app is free, but to get the most out of this, you can sign up for some coaching. It is significantly less expensive than comparable programs. Even one month of the coaching can get you started on the right track.

The Kurbo folks wanted to share some articles on Kurbo kids & families. The first is about a family in Los Angeles whose young son was told by his doctor that he had to lose weight, and he has lost over 17 pounds on Kurbo.  The second is by the Editor of Parents Magazine who did Kurbo with his daughter.  The results: she lost weight, looks and feels better.  It is great seeing results experienced by these Kurbo Kids!

http://www.laparent.com/unique-health-program-appeals-to-digital-kids/

http://www.parents.com/blogs/parents-perspective/2015/03/11/news/my-daughter-eats-better-by-following-the-traffic-lightshttp://www.mercurynews.com/business/ci_30074298/palo-alto-based-kurbo-health-tackles-childhood-obesity

https://kurbo.com/blog/

   

If you are interested in checking it out, We have a promo code that will give you some savings: NoeValley (no space, capital N, capital V).

Here in the city, The Community Health Resource center offers nutritional counseling for all ages.
They are at 2100 Webster Street by the CPMC Pacific campus.
415-923-3155
This service is covered for Brown and Toland HMO patients.
For all others, they have a sliding scale fee schedule.
http://chrcsf.org/

If you don't mind traveling down to the peninsula, Stanford Weight control Program has some openings

http://www.stanfordchildrens.org/content-public/pdf/ppwcp-flyer.pdf

Vision Health/ when does your child need to see an eye doctor?

Please see the updated Post March 2018

Doing an eye exam on a young child can be challenging but more entertaining than you might think. I used to get a kick out of the creativity of some of the kids when I would point to a picture on the eye chart. A circle could be anything from a simple circle, to a zero, a bagel or a donut (my kind of kid), The crescent could be a moon or a banana. I fondly remember a little 4 year old who had just finished testing his first eye. He stood there with his hand over his right eye waiting for directions. “ Okay, great job, now cover your other eye” Without removing his right hand from his right eye, He quickly raised his left handup. He stood there for a moment with both eyes now covered before I figured out what was going on. Early intervention for eye abnormalities is very important. Parents are often the first to note if there is something abnormal going on. There are always individual variations with developmental milestones,  but many babies eyes don’t track too well until they are about 3 months. Once they are old enough, watch to see if they can follow an object with both eyes. If one eye wanders , that is something we want to get checked out. Check the pupil size. Are both the same? There are some kids with normal variations, but it is worth noting this ahead of time. I have had parents frantic after a mild head injury when the pupils were noted to be of mildly different sizes. It turned out that this was just the baseline. Noting it in advance would have saved some stress! If you take a photo with flash and there is “red eye” make sure the reflection seems to be equal in both eyes. Are the eyes watery or gooey? This could be a blocked tear duct. That usually resolves in a few months, without any intervention http://nursejudynvp.blogspot.com/2013/06/blocked-tear-ducts.html In our office we actually start doing eye screenings for our patients as early as 6.months. We can screen for a variety of abnormalities with our iscreen machine.http://www.iscreenvision.com/ Dr Good, one of our favorite pediatric ophthalmologists says he has been pretty impressed so far with issues that have been discovered early. While some of the conditions don’t actually require any intervention, having the patients identified so young is very valuable, because we can now know to monitor them closely Once the kids are four or five years of age and old enough to cooperate, we do the Snellen eye test. This screening for nearsightedness is usually  done in conjunction with the routine annual well child check up. The operative word here is screening. Farsightedness or astigmatism are usually not picked up without a full eye doctor exam. The gold standard recommendation  is a complete eye exam by an eye doctor at 3 and 5 years. At that point, the decision for how often routine exams are needed may depend on your child. Obviously if your child seems to be squinting it is worth getting them in sooner. There is a genetic component to eye issues, but kids should be checked even if the parents have perfect vision. What is difference/ need between ophthalmologist or optometrist for basic child eye health? Ophthalmologists are specialists that deal with the full range of eye care, but they are also surgeons who can deal with any eye abnormality or condition. Optometrists might be your best bet for any simple vision issues. Finding someone who regularly works with kids is pretty important. If there is a medical diagnosis some insurance companies will cover the cost of an eye exam. It is worth checking in advance with the eye doctor's office as well as your insurance or vision plan  to see if there is an advantage to seeing one or the other. I don’t think people necessarily need to add vision and dental plans for the kids the first year, but after that, especially if they come bundled, it is probably worthwhile. There are some common sense things you can do promote good eye health. Get outside! Of course, get in the habit of wearing sunglasses when outside during the day. Ideally they should be made out of a strong poly-carbonate plastic that is shatterproof. Floppy hats or visors are also a good idea. Recent studies show a 30-40% decrease in myopia (nearsightedness)  with daily time outdoors. Try to minimize the “blue lights” that we are surrounded with by screens in our world. The American Academy of Pediatrics recommends no more than 2 hours of recreational screen time/day. Eat well! Carrots and foods with Vitamin A are good, but the dark green leafy vegetables are the real super helpers of the eye because they have lutein and zeaxanthin (go ahead and impress people at your next cocktail party with that one) These two eye nutrients help replenish the pigment in the retina and can prevent diseases of the eye. Peppers turnips and paprika are also a good part of an eye healthy diet. Avoid smoking or exposure to secondhand smoke. If your child does need glasses, make sure they get their vision checked yearly (or more frequently as needed)  to make sure the prescription is correct. If the myopia is getting progressively worse, believe it or not multi-focal contacts may help slow things down. They can be started with some cooperative children as young as 5! You might not make an obvious connection but headaches, dizziness, motion sickness and ADD can all be associated with eye problems. I have sent more than one patient who were having trouble concentrating in the classroom to my favorite optometrist Dr Vincent Penza. The difference that he was able to make for them was astounding. http://www.city-optometry.com/team/vincent-penza-o-d/ Josie takes her son down to Dr Kim Cooper and loves the care she receives there Dr Cooper shares that her most important eye tip is the need for quality safety goggles. If your child is playing any sport where there is danger of getting hit in the eye by a ball or body part, they should be wearing eye protection. Not a week goes by that she isn't dealing with a sports related eye injury. Most are minor, but the serious ones are devastating. Her office happens to be great resource for getting quality goggles. In fact, they are having a trunk sale on August 1st. http://mypedeyedr.com/ Dr Cooper also told me about another good office. Dr David Grisham and Dr Jeremy Shumaker at Vision Academy and Rising Star Optometry are terrific and do see pediatric patients. http://risingstaroptometry.com/ Dr Good and Dr Martin are another office where we send a lot of our patients http://www.cpmc.org/dr-william-v-good.html Berkeley Eye Institute is a great resource. It tends to be lower cost because it is associated with the school. 510-642-2020 Fun Facts: You may not be able to know your child's ultimate eye color until they are a year! Your baby might be crying, but they usually don’t develop actual tears until they are between 4-13 weeks The eyes are the fastest muscle in the body and blink an average of 17 times/minute

Travel tips 2016

Many years ago, (prekids) my husband Sandy and I were hiking in Waimea Canyon on the Island of Kauai. After a few miles, we were almost at our destination and could hear the tantalizing sound of a waterfall right around the bend. The issue at hand was that that path was getting narrower and steeper. On my left was a wall of rock, to my right was a sheer drop of thousands of feet (death). I was pushing myself along until I just couldn't take another step. I didn't usually have trouble with heights but this was extreme. I told Sandy that I couldn't keep going. His initial response was to do a little jig on the path to illustrate how safe it was.

"That isn't helping!"

Sandy accepted that there was no waterfall in the cards that day but as we turned around he grumbled,"When we have kids, I am going to take them hiking with me and you can stay at the hotel." "Fine with me" I shot back. "I hereby bequeath to you our first born for any hiking you want to do!"

That offer has now caught up to me.

Tomorrow Sandy and Lauren (the first born) are leaving on a grand adventure. They will be hiking up Mt. Kilimanjaro, the highest free standing mountain in the world. In honor of that, and for all of the travelers out there, I am updating my annual Travel Tips post.

Our all time most common travel related question is probably, "When is my baby old enough to fly?"  There are  many different factors to consider, so there is no one simple answer. Adopted babies might fly within the first few days on their way to their new home. Other folks make the valid choice to fly earlier than we are really comfortable with in order to see an aging relative or deal with a family crisis. In ordinary circumstances, I would prefer to have the babies wait until they are over 2 to 3 months of age and have had their first set of immunizations (keep in mind that the first shot does NOT give full protection against some serious illnesses, but it is a start.) The size of the baby as well as the time of year are also factors. If there is some kind of crazy flu epidemic, I would think long and hard before taking a young baby on a plane. It isn't unusual for there to be some type of health alert circulating, so keeping current on the news is important.  A couple of years ago there was a measles outbreak. A year before that we had the Enterovirus D68 which likely no one even remembers now. As of this month (July 2016) the biggest concerns are probably Zika related. The bottom line is that my recommendations might change depending on what is going around and where you are heading. It does make planning a trip well in advance a bit more challenging. Regardless of how old your child is, if you are planning a trip here are some tips and things to keep in mind. Before you leave I get calls from all over planet from parents who are dealing with a sick child during their trip. Prior to the trip, check with your insurance company to see what the best method is for having out of state or international doctor visits covered. Some plans are much easier to deal with than others. Whether the visit is covered or paid for out of pocket, you also need to figure out what your actual options are. Is there an urgent care facility near by? Do you have a friend or relative with a pediatrician who is willing to see patients who are not in their practice? Does your insurance only cover an emergency room visit? Hopefully you won't need to use this info, but if you are dealing with a sick child away from home it is nice to have a "Plan B" in place. If your child has a history of wheezing, it is wise to bring all medications along even if they haven't needed them in a while. Keep in mind that infrequently used asthma inhalers need to be primed before use. If you are traveling some place exotic it is worth checking with a travel clinic to see if there are special travel vaccines or malaria precautions necessary. The only vaccine that we routinely give here in our office that might be considered a travel vaccine is Hepatitis A. Most other special travel vaccines need to gotten at a travel clinic. A travel clinic keeps current with all the ever changing recommendations and consideration for each country and season. Plan in advance. http://wwwnc.cdc.gov/travel  is a good starting point to figure out what you might need. The SF health Department adult immunization clinic is one good option for getting any necessary shots. Depending on your insurance. CPMC Travel clinic is another good choice. Surviving the flight. Keep in mind that a car seat is the safest place for your child. It is worth checking with your carrier to see if you can get a discounted rate. http://www.faa.gov/passengers/fly_children/media/child-safety-tips.pdf A few years ago I sat next to a mom with a very young baby. She was so worried about the possibility of getting evil looks from the other passengers that she had actually brought ear plugs to hand out to the people sitting around her. What she didn't have was anything to soothe her baby. Please always make sure that you have Tylenol or Motrin with you on the plane (not packed away in your suitcase). It is okay to bring small bottles through security. They need to be smaller than 3.5 ounces. I don't tend to give it ahead of time, but I am quick to medicate during the first sign of fussiness. Does your child suffer from motion sickness? Click to review my recent post. I often get questions about the use of Benadryl. This is an option for a child who is over 8 months with a long flight ahead. It helps dry up any congestion and makes 90% of kids who take it deliciously sleepy. Aha, but what about the other 10% you might ask? It turns those little darlings into hyperactive, wild hooligans. You do not want to find out on the plane that you are the parent of the 10%. There is no such thing as infant Benadryl, We use the children's liquid generic name diphenhydramine. Many labels will warn not to give to children under 4. We routinely ignore that. You may want to give a test dose a few days prior to the trip to make sure it is a viable option for you. I want parents to have the tools with them to deal with an unhappy child. Don't give any medication unless it is necessary. While I would usually err on the side of less medication, Benadryl and Tylenol/Motrin can be given at the same time. Many babies and children may have trouble with their ears . For the younger ones, try to nurse or have them feeding during takeoff and landing. Sucking on a pacifier may be helpful as well. Have a lollipop or chewing gum for older kids. Ayr saline gel is a nice thing to have along. A dab at the base of the nostrils can moisturize the dry air and make the breathing easier (use it for yourselves as well.) If you have a child with a history of ear trouble, have some of the little gel heat packs in your bag. You can activate them as needed and the warmth feels great to a sore ear. For adults and older kids, you can  equalize the pressure by holding the nose and gently blowing until the ears pop. Take WAY more diapers with you than you think you need for the trip. I was on another flight not too long ago when we sat on the tarmac for three hours. There was an unfortunate family behind me who had planned on a short little trip and was out of diapers long before we took off. It wasn't pretty. Plan accordingly. Many folks automatically bring a change of clothes for their baby. It is also worth bringing an extra outfit for yourself. If you have a long flight ahead of you with a child on your lap, it may come in handy (I learned that one the hard way and sat for several hours covered with poop.) Changing your baby on the plane can be a challenge. It is helpful to have little changing packs, with a diaper and some wipes, in individual zip lock bags. This will prevent you from having to take the entire bulky diaper bag with you into the tiny bathroom. Bring some disinfectant wipes along and give the tray table and any surfaces a nice wipe down before you use them. You can't count on airlines giving you any reasonable snacks, so it is important to bring along enough provisions in case of delays. Download some activities or shows ahead of time for your laptop or tablet. None of us want to overdo screen time, but if you have managed to keep it special a long flight is the perfect time to make use of this tool. Don't forget about the old fashioned low tech options! If you are visiting family, print out a bunch of photos of the people you are going to see. You can use these for all sorts of art projects on the plane. Make a paper doll family! This can help your kids recognize folks that they don't see too much of. Wikki sticks are also a great activity to bring along. They are lightweight and not too messy. Reusable stickers will stick on the window. Don't bring anything that will make you sad if you loose it in between the seats. Once you get to where you are going, make sure the place is adequately child proofed (this is also a discussion that it is worth having with your hosts before you get there.) I had one situation where a 3 year old opened a drawer and got into grandma and grandpa's medications. Is there a pet where you are going? Make sure that any dogs are safe with children. If you are staying in a vacation home, do a quick safety check. Do they have working smoke detectors? A fire extinguisher? Time zones are tricky. My best suggestion is eat when you are hungry, sleep when you are tired and just do your best. Staying hydrated and getting fresh air are essential. Sunshine is a bonus. http://www.reflexandmore.com/en/articles-heb/25-english/articles/21-jetlag The link above has wonderful information for dealing with jet lag. Even the best sleepers may have a period of needing a sleep training tune up when you get home. You can have lots of fun while you are away and it is wonderful to see family. But, in my opinion, if you are traveling with children under the age of seven, don't call it a vacation. It's not. It is a TRIP (we used to call our visits to the various grandparents the "bad bed tour.") A little preparation goes a long way and remember that some of the more challenging moments make for the best stories! Here is one of mine.. Many years ago when my daughter Lauren was two, I got creative as I was planning for an upcoming flight as a solo parent. I had seen a craft in a magazine (long before Pinterest existed) where a necklace had been made of cereal and I thought that this seemed like a fabulous thing for an airplane trip. Unfortunately, not all ideas turn out to be good ones. Lauren and I strung some Cheerios onto elastic and she proudly wore her new necklace onto the plane. Soon after take-off Lauren decided to eat some of the Cheerios. I noticed with some dismay that as she bit off a Cheerio, some would go into her mouth while other parts would shoot off like little spitty projectiles. They were landing (unnoticed by anyone but me) on just about everyone within three rows of us. As soon as I realized what was happening, I tried to see if there was a way for her to nibble them off without making a mess. When that didn't work, I tried to take the necklace off to make it easier or to have her stop eating them at all. But as mentioned, she was two. My choices were clear... tantrum on the plane or unsuspecting fellow passengers having little pieces of spitty Cheerios in their hair. I opted for peace (besides, ignorance is bliss, right?) Have safe travels and make great memories One of my wise readers suggests that if you are traveling out of the country it is worthwhile to register https://step.state.gov/step/ with the state department...Great idea!

Horrible headlines/ How to talk to your kids/ What would you do if?

 

 

Last week, civilized caring people everywhere were horrified with the senseless shootings in Orlando. If that wasn’t enough, the bizarre death of the toddler by a crocodile made any person watching the news want to curl up and weep. It is all too frequent that we turn on the TV to find out about sad and scary events. Several parents have asked me to write a blog addressing how to talk about these incidents with our children.

Obviously the first step is to protect them from the media as much as you can, but even if they are not watching TV, if parents are devastated by an incident, your kids may well pick up on the fact that something is “not right.” Talking about things out in the open makes future conversation possible and keeps things from feeling like a bad secret that needs to be avoided at all cost. Unfortunately simply avoiding tough conversations won’t make the issue go away. You may decide to ask your kids if they heard that something sad or bad had happened. Allow them to tell you what they have heard or seen. I wish I had the perfect way to make sense of the inexplicable evil. I have to believe that there is more good than bad; the bad folks just make so much noise.

We need to feel like we have some tools for dealing with emergencies if they happen closer to home. I am rerunning my problem solving post (one of my favorites) but I have added some new thoughts at the bottom.

What  would you do if?

I have been doing these little weekly emails for just about 3 years now. Some posts are clearly more relevant to parents with young children while others are much more applicable to older children. Some are more global and your child's age doesn't matter so much. This is the latter.

Today's topic is a about an important activity that you can do with your child that teaches them to be "problem solvers".

Although at first glance it may seem targeted to parents with older children, in fact everyone could learn from it. Adults need to learn to be problem solvers also. Some are much better at this than others. For instance, if you got in a fender bender, what would you do? Many folks would just freeze and panic. What should you do?

*Assess for injury;  call 911 if needed

*If you are on a highway, wait for assistance. Getting out of the car might be more dangerous

*Know where your insurance info is

*Take a photo of any damage

*Take a photo of the other driver's insurance card and driver's license...etc.

*Always have a charger in your car for your cell phone so that a low battery is never an issue.

But I do I want to add one more benign  tidbit here. What if you lost your cell phone or it ran out of batteries and you don't happen to have a charger? Do you know important phone numbers, or do you count on speed dial? Having a list of important numbers in an accessible place is a good idea for everyone.

Having a plan in advance could help you stay calm.

Years ago, the concept that everyone would carry around an individual cell phone seemed as futuristic as the communicators on Star Trek. Now, of course it is hard to imagine how we got along without them. It was, however, the lack of the cell phone that prompted me to create a game that became a favorite in our family.

It must have been 1994 and I was on my way to pick up Alana from preschool. She was about 4 years old at the time. It was one of those days. I was uncharacteristically running late. Then, I got stuck in terrible traffic. To compound things, I took some random turns to try to work around the congestion and ended up utterly lost. (Remember that this was also before Google maps or GPS.)  My stomach was in a knot and I wondered what my younger daughter would do when mommy was late picking her up.

It turned out that she was calmly waiting for me in the office, but that was the day that the "what would you do if" game was created.

It went something like this:

I would ask a question such as, "What should you do if mommy is late picking you up? What are some of the choices? Which is the best one?"

Getting a teacher or trusted grown up to wait with her or take her to the office was clearly the right answer and I praised her for figuring that out on her own.

Alana loved this game. We created all sorts of situations

" What if we were at a store and you couldn't find me?

Alana.." I would go to the check out and ask them to page you"

We never made it too simple...

Mommy :"What if they refused?"

Alana :"I would demand to talk to the manager"

Our scenarios covered any number of little emergencies including earthquakes, fires, and getting lost or separated. The better you are at problem solving, the easier it gets to improvise.

This game came in handy more than once. The shining example that comes to mind happened after years of playing this game. Alana and I were walking the dog on the beach one day. I had donated blood earlier that morning and didn't realize how foolish I was for doing anything strenuous. I got very light headed and ended up down on the sand trying hard not to completely pass out. Alana was ten at the time and she went right into problem solving mode. We did have cell phones at this point. She got the dog on the leash, patted some water on my forehead and calmly called daddy. I could vaguely hear her talking. "Mommy fainted...I think she is okay."

The game was such a success that my sister taught it to her kids. Hers had an interesting spin because they lived in Alaska at the time:

"What would you do if you saw a bear?"

"What would you do if a moose wanders into the yard?"

There were actually times when these things happened, and my nephews were able to act calmly and appropriately!

Topics can range from handling a bully to getting separated on Muni. Being prepared for unexpected situations can be invaluable.

 If your child finds themselves without you and in need of assistance, finding a grown up wearing a uniform is often a valid option for some of the difficult situations. Finding a parent who has a child with them and asking them for help, might be another safe option.

This game is meant to empower. It is wonderful for some kids, but could be terrifying for others. You need to assess your child's temperament before playing. Either way, identify a problem or situation. Start with simple, less scary ones. Discuss all the possible solutions and then agree what the best plan should be for any given situation.

Stressful situations happen. Teaching your child to take a deep breath and use their problem solving skills is one of those things you can do now that can have lasting implications for them when they grow up.

Even teaching a very young child to dial 911 in an emergency can be life saving!

You have to figure out if this will be empowering for your child as it was for Alana. My daughter Lauren never liked to play it. In fact, I remember one day when Lauren and I were taking a walk, I tripped on something, stumbled and fell. I was perfectly fine, but Lauren's reaction was to start screaming. I think she was ten at the time. As she says, "mommies aren't allowed to fall". Every kid is different. As your child grows, the situations that you might want to bring up will increase in scope.

Preparation is power.

It saddens me we have to be prepared for things other than losing track of our kids on Muni, but that is the world we live in.

Have a family plan in place in case of emergency.   If someone other than one of the regular people is going to pick up your child, have a family “safe word” so that they know they were sent by you.

Do you have your earthquake/emergency kit ready? Does it include adequate diapers, medications, pet food? Where will everyone meet up if home is not a safe option? Find out from your schools what kind of emergency plans they have in place.

Teach your kids to get in the habit of looking for emergency exits, especially for your olds kids who are at a concert, theater or a club.

I think that the "what would you do" exercise is actually something that you might want to do with a nanny or caretaker. Training to keep calm in any type of emergency situation is essential.

If there is a crisis or loss that is closer to home

http://nursejudynvp.blogspot.com/2015/12/dealing-with-losshelping-your-child-cope.html

Kidspower is another fabulous resource. I reached out to the director Irene, and she shared the following valuable links.

Helping Children Regain Their Emotional Safety After a Tragedy

Tragic Shootings: How Can We Protect Our Loved Ones and Ourselves From Violent Attacks?

Safety Comes From Inside Ourselves: Protecting Emotional Safety After A Terrorist Attack

Fears about School Shootings and Lockdown Drills – Kidpower Recommendations and Resources