The Back to work transition

Please see the updated post March 2018

The first couple of weeks home with your baby is a tumultuous time to say the least. It is full of so much amazement, sleep deprivation, joy, learning, and love. You might be in such a haze that you may or may not even remember this period very clearly. It is the minority of families in our practice who have the luxury of having one parent stay home with the baby full time. Most families are faced with the huge transition that hits when one or both parents need to return to work. The luckiest families have flexible, understanding jobs and a local grandparent who can’t wait to baby sit. If you can work part time, that is often the perfect balance. The rest of you are left trying to figure out the best option. One of the biggest issues that many of the breastfeeding moms face is how to successfully continue to nurse. If your baby has never taken a bottle, try to give yourselves enough time for them to get used to one. Babies may refuse to take the bottle from mom. They know that breast is right there! They can smell it! It is best to have the other parent or caregiver be the one to offer  the bottle. Ideally offer fresh breast milk, so that there aren’t too many changes at once. Try the bottle a bit before the baby is genuinely hungry. Some babies are remarkably easy and go back and forth between breast and bottle with ease. Others like my daughter Alana, can make it much more stressful. Alana screamed for an entire day. Luckily she was with a very patient and experienced caregiver who eventually had success. Local lactation guru Nurse Charity shared some successful pumping tips. She suggests that you start pumping 7-10 days prior to going back to work. Nurse Charity's Wisdom about various pumps Yes, this will bump up your supply, but going back to work usually does tend to decrease the supply over time, so starting at a higher level is good. Prior to pumping do an all over breast massage. Bring a photo of the baby or an outfit with that wonderful baby smell. Hopefully your job will be supportive of your need to pump and you will have a comfortable area. Frequent short pumps are just as good as trying to carve out one or two long sessions. Nurse Kenlee suggests making a “nursing play list” or having some strong association with nursing that you can take with you when you are pumping away from the baby. In general in order to protect your supply, make sure you drink plenty of fluids. Eat a healthy diet and make sure you get adequate rest. (I know, I know, but I had to add that) Do lots of skin to skin contact when you are with your baby. It takes some effort but many moms are able to successfully produce enough milk that supplementing is not needed. KellyMom is an excellent source for guidelines on storing the milk. If you have fresh milk, use it prior to defrosting your frozen stores. I always suggest putting a baggy full of ice cubes in the freezer. As long as they stay frozen as cubes, you are assured that the freezer has maintained the correct temperature. If the ice cubes refreeze into one clump, the milk can no longer be trusted. Make sure that all the milk is dated. Make sure that your milk freezes well. Some moms have an excessive amount of the enzyme lipase in their milk. The milk remains safe but has a nasty smell. Scalding the milk prior to freezing it will eliminate this issue. You don’t want to be the one who discovers this after you have a freezer full. The lipase has some health benefits, so if it isn't causing problems, don't bother scalding the milk. While many moms have no trouble keeping up with their supply, others are not so lucky. Please don’t spend even a minute beating yourself up. Do not be the parent who limits the amount of milk the baby is allowed to have due to supply. Do not be the parent who is incredibly stressed out if they are an hour late home from work because the baby will starve. Simply do the best you can and take advantage of the fact that there are many excellent formula supplements out there. Being a good parent is not only about the breast milk. Be careful that your child doesn’t swap their days and nights. If moms aren’t careful, some babies refuse the milk during the day, but wake up every couple of hours to nurse during the night. Sure, the baby is getting the milk they need, but mom will lose her mind from sleep deprivation. Let me repeat myself. An intact mom is more important than breast milk. Beyond the issue of feeding is the huge question of finding a loving caregiver in your home or a safe place to send the baby while you are at work. Many of our parents have success with small family day cares or nanny shares. Once kids are away from the safe relative quarantine of your home, they are going to start getting all of the little childhood colds and viral syndromes that are a rite of passage for most kids. Having a solid conversation with the daycare, other parents and/or nanny is essential so that everyone is on the same page regarding which symptoms necessitate staying home.  Do your kids still have cooties? Take a moment to click on one of my all time favorite blog posts. It is all about striving to find balance between all the various aspects of your life. It is never more relevant than during this transition. Nurse Judy's Pie Theory

Vicks VapoRub on the feet (update)

I saw an interview recently where a well respected pediatrician completely dismissed the value of any natural remedies. He didn't believe in doing anything for his patients that wasn't completely "science based". In his practice, coughs just have to run their course.

He and I wouldn't get on very well. I love science too, but in my  years of practice I have seen many people feel quite a bit better from reaching for some alternative solutions. As long as they are benign and not taking the place of necessary prescribed medication, I love to see what relief can be achieved without standard medication. This post is all about one of the odder things I have tried. It seems to help!

Seasons come and go. Occasionally I find something that seems to work well for patients, but then the illnesses quiet down and I don’t think about it much. With all the never ending coughs plaguing my patients and families, I recently added a link in the “what’s going around section”. The link was to one of my earliest posts about the benefits of putting Vicks Vaporub on the feet. Several dozen folks clicked through and followed up with feedback that this seemed to be the difference maker. The kids had much quieter nights without nearly as much coughing. With cold season in full force, it seems like it is worth updating and re-posting.

The internet is a minefield. It is a goldmine of valuable information. Unfortunately, it also has the power to terrify unwitting folks who go online to look up symptoms or whatnot.

Most wise folks know enough to realize that the good information is muddled up with loads of crap. It is hard to know what is real. Therefore, when I got an email several years ago touting the magic of applying Vicks VapoRub to the feet to stop a cough, I promptly dumped it into my spam. Frankly anything that tells you that it works 100% of the time is 100% false (have fun with that statement!) But then a variation of the same email came to me again and I thought it might be fun to see if there was any merit to it.

The claim is that covering the soles of the feet with the VapoRub and then putting socks on is very helpful for coughs. I am always looking for safe, natural remedies to help relieve symptoms of colds and coughs for my patients without loading them with systemic medications. So, several winters ago I set out to do a completely unscientific study.

While talking to the hundreds of my Noe Valley Pediatric parents who were trying to relieve the coughs that were keeping their kids up at night I enlisted them to give the "Vicks on the feet" a try. I asked them to report back.

To my surprise, well more than 50% of the folks who tried this seemed to find that it was quite helpful; imagine that! Even Snopes doesn't completely debunk it; just labels it as unproven. No one who tried it had any ill effects. I occasionally completely forget about this, but someone asked me about it the other day. With the colds and coughs out there in full swing, this might be something you want to try.

Before applying anything topical, it is important to make sure you or your child do not have a reaction. Place a small dab on the leg and rub it in. If there is no irritation within 30 minutes or so, you should be fine. (I do this same test with a new sunscreen.)

 Folks ask about the difference between the adult and the baby Vicks. I think that either is safe for the feet. If you happen to have only the regular Vicks in the house, feel free to use it. If you are going out to the store and you have options, go ahead and get the baby version.That is especially preferable if you are going to put in on the chest as well as the feet.

Along with the Vicks, don't forget about steam, sinus irrigation and keeping heads of beds/cribs on a slant.

If you have an infant who is under 4 months of age with a cough that is keeping them up or interfering with their eating, they need to be seen.

If the cough is lasting more that a couple of weeks it is probably worth a listen.

Any significant shortness of breath needs to be evaluated.

Tis the season and we are seeing loads of coughs and colds out there, so if you or your family members are hacking away, unfortunately you are running with the pack.

I still do love getting feedback, so if the Vicks works magic, let me know!!

One of my mom readers who is also a physician shared the following warning from a physician reference called Up To Date and it is certainly worth adding to this post.

Approximately 11,000 pediatric camphor exposures are reported to United States poison control centers annually [2]. Exploratory ingestion of camphor-containing products by children younger than six years of age is most common, accounting for about 80 percent of exposures. Toxicity from topical absorption of camphor is less common than from ingestion but has been described after application of unlabeled camphor oil in a four month old infant [4] and copious application of a labeled topical ointment hourly for 10 hours in a three year old child

With anything, please use common sense child proofing precautions and don't leave your kids alone with  anything that they can ingest.

I remain confident that the ingredients in Vicks, when applied topically are quite safe.

Nurse Judy

Talking to your kids about "the birds and the bees"

This post was updated 2/19


While the majority of the calls we deal with are about little acute illnesses, we also field queries  about all aspects of growth and development. Recently I have had several folks ask me my two cents about answering the "Where do babies come from" question:so here goes.

Comes the time in every family when it is time to have the talk about sex, but how and when? It varies with every child.

There is a story about a young boy visiting his grandparents’ house one summer. He came rushing in from outside where he had been playing with some new friends from the neighborhood. “Grandma, what’s it called when two people are in bed, but one is on top of the other one?”

Grandma was taken aback for a moment but sat him down and gave him a matter of fact talk about the birds and the bees, so to speak. The little boy listened carefully with his eyes open wide and then ran back out to join his friends. It wasn’t long before he ran back into the house saying, “Grandma, it’s called BUNK BEDS and Mrs. Wilson wants to talk to you!"

The all important moral of this story is to make sure that when your child presents you with a question, that you understand what they are actually asking before you launch into any complex explanations. You could start with a statement such as “ I am so glad that you asked me. I am always happy to help you find answers to things. Tell me more about what you are wondering about”

Get yourself as comfortable as you can with the discussion. What do you call body parts? Does your family use a nickname (perfectly fine) or is your child able to rattle of the anatomical names for all of their “parts"? Of course having discussions about bodies usually comes long before discussions about sex.

Many parents are a little shocked and uncomfortable when infant boys have erections or they notice young boys and girls masturbating. This is incredibly common (the human race is quite fortunate that masturbation doesn’t actually cause blindness.) While it is usually quite normal, if you notice that your child is constantly touching themselves to excess, I want to make sure there is no irritation or external cause. Maybe their underwear is too tight. It could even be something like pin worms! If there is no obvious underlying issue, consider having a discussion about that fact that, yes it feels good, but our bodies are delicate and it is important not to touch so much that things can get sore. Some families have a talk about family rules and theirs might be that gentle touching is a private activity. Beware, a true story - One of my families who made a point of having accurate vocabulary was caught off guard one night when their 4 year old son made an announcement at a fairly formal dinner party with mom’s boss. “ I am going to go into my room now so that I can touch my penis in private.”

This is also an important time to have a discussion about body ownership. No one should be able to touch any part of your child’s body without permission. Exceptions are parents and doctors (with parent present)  and that should never be a secret! Empowering your child about their body early is important.

And then they get a little bit older….

I remember driving a van loaded with carpool kids to school many many years ago. I caught a piece of the conversation that was going on in the back seat and my ears perked up a bit as I tuned in.

“Yours have done it at least twice." “Yours have done it at least once” "Ours have done it at least twice...Oooh/Yuck”

As soon as you feel that your child is curious and is possibly going to be picking up odd or skewed information from their friends or classmates, it is important that you make an opportunity to have a chat. It is essential that your child sees you as the trusted source of correct information and is comfortable asking you questions. Unfortunately in this high tech world, it is becoming increasingly easy to kids to be exposed to all sorts of things with very adult content at a very young age.

You may want the help of a book. Amazon and libraries have an enormous amount of books that you can use as a resource. There are so many good ones out there. I would suggest that you read several until you find one that feels like it is the right comfort level for you. You may want to do this research a little ahead of time.

Liesel Harris-Boundy from the West Portal Branch of the San Francisco Public Library was kind enough to come up with a list of good books on the subject that she is familiar with. Liesel shared that an ObGyn friend recounted that her 7-year old son asked her, "Mom, what's a vagina?" and though she talks about vaginas all day, she was unprepared to tell her son and excused herself from answering!  That reserved part of her upbringing came through in spite of all her medical training!

The following books should all available through the library. Perhaps go in and leaf through a few until you pick one that you like.

Talk to Me First: Everything You Need to Know to Become Your Kids' "Go-To" Person about Sex by Deborah Roffman

Talking to Your Kids About Sex: turning "the talk" into a conversation for life by Laura Berman

Asking About Sex & Growing Up: A Question-and-Answer Book for Kids by Joanna Cole

Everything You Never Wanted Your Kids to Know about Sex, (but Were Afraid They'd Ask): The Secrets to Surviving Your Child's Sexual Development from Birth to the Teens by Justin Richardson and Mark A. Schuster

Talking to Your Kids About Sex: From Toddlers to Preteens by Lauri Berkenkamp, Steven C. Atkins, Charlie Woglom

Sex Is a Funny Word: A Book about Bodies, Relationships, and YOU by Cory Silverberg

It's Perfectly Normal: Changing Bodies, Growing Up, Sex, and Sexual Health (20th Anniv. Edition) by Robie H. Harris

You want to make sure that the books are geared to the correct age. Some are guides for the parents and some are meant as a resource for the child.

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In our practice we are fortunate to have many different kinds of families, It isn’t always mommy plus daddy equals baby. I was happy to find out about the book below.

http://corysilverberg.com/what-makes-a-baby/

What Makes a Baby is a children’s picture book about where babies come from that is written and illustrated to include all kinds of kids, adults, and families. 

Geared to readers from preschool to about 8 years old, it teaches curious kids about conception, gestation, and birth in a way that works regardless of whether or not the child in question was adopted, conceived using reproductive technologies at home or in a clinic, through surrogacy, or the old fashioned way; and regardless of how many people were involved, their orientation, gender and other identity, or family composition. Just as important, the story doesn’t gender identify people or body parts, so most parents and families will find that it leaves room for them to educate their child without having to erase their own experience.

Once  you do pick your book that you feel comfortable using as a resource,go ahead and buy a copy so that there isn’t a time limit.

If your child is embarking on puberty and you are looking for something more interactive than a book, I recently learned about the Heart to Heart seminars hosted by Stanford. They hold these in multiple locations. The San Francisco class is held at CPMC on California street.     www.hearttoheart.stanfordchildrens.org

A list of other classes they offer are here:  http://www.stanfordchildrens.org/en/classes

One mom in our practice who went to the session thought it was very worthwhile, but she wished she had taken it earlier. She thought ten or eleven would have been perfect.

Bottom line, honesty and communication are essential. As awkward as this conversation may feel to some of you, you really don’t want your kids to be getting their sex education from the neighborhood kids (or even worse, the internet!) Don't force too much information on a younger child who isn't interested. Letting them know that you are always open and willing to talk about "grown up" stuff with them is a great start.

Happy Valentines day.

Head Injuries (update)

Please see the updated post February 2019

I can safely say that not a week goes by at work when I don't get the call. The mom or dad is in tears as they recount in horror that their baby just fell. Sometimes they left the baby on an unprotected surface for a moment, not imagining that the infant could manage to roll off. That thud is an awful sound. Sometimes they are right there watching it happen, but can't move fast enough to catch them. Once in awhile a baby is accidentally dropped (watch out for wet, squirmy babies right out of the tub.) Sometimes a parent falls when holding the baby and they both get injured. Recently I have even seen a new cause: Selfie accidents! Mom or dad holding the phone way out for a photo op, and not having a good grip on the baby. Head plops backwards...

There are so many scenarios.

My husband came pretty close to dropping Lauren, our first born when she was very young. He just barely caught her by grabbing the bottom of the sleep sack that she was wearing. He had nightmares about that one for awhile.

I actually remember in my own case, what I describe as the definition of absolute ambivalence. My four year old Alana had a friend over and they were playing upstairs. I heard the unmistakable sound of someone tumbling down the steps. As I ran to the scene I recall thinking, "who do I want that to be? My child or the friend?" It turned out that it was my kid. They had been playing dress-up and she was wearing a pair of high heels (Satan's shoes.) She stood up with a giggle and brushed herself off, but it took me a moment before I could take a breath and then we made a new rule about dress up shoes and steps.

The fact is that most of the time that kids are indeed fine following a mild to moderate fall.

I think that younger children are like cats. Instead of tensing up when they fall, they remain relaxed until they make contact and for that reason they avoid getting more injured.

Of course it isn't just babies who fall. Children and adults have accidents and sports injuries all the time.   

If your baby just fell or you are the first responder at any kind of accident, take a deep breath. You need to remain calm. You can have a glass of wine later.  

If there is a loss of conscience or any possible neck injury, CALL 911.

Most of the time your child will be crying after a moment or two of stunned silence.

Do a quick head to toe assessment. Is there any obvious bleeding, bruising, sprains or fractures that need to be tended to? Check the mouth and make sure there are no loose teeth (this is the reason that you already have a relationship with a pediatric dentist...(Dental blog post)

If your child will let you, get a cold pack on any bruises. If you are out of the house, a cold can from a vending machine is a good option. If you are home, a bag of frozen peas makes a nice ice pack. For toddlers and preschoolers, playing doctor before anything happens and letting them know that after a bump we put on the cold pack may help them be more willing to let you put anything on there after an injury.There are some cute little pediatric friendly cold packs available that might elicit cooperation.

I also have had good results with the use of Arnica. Arnica is a homeopathic treatment that comes as a topical ointment or little pellets that are taken by mouth. Many parents swear that it significantly decreases bruises (roll  your eyes if you must, but I have seen it work.) It is worth having some around.

Be aware that head wounds can create a huge amount of blood if there is even a tiny little break in the skin. If the skin remains intact, all of that blood can collect into an enormous goose egg. These can get big, fast! These can look fairly alarming and can turn all sorts of lovely colors, but they do resolve. Bruises and bumps by themselves are not typically a concern.

But, now comes the scary part. We are much more focused on any bleeding that might be happening beneath the skull. If there is bleeding under the skull, there is little room for any swelling. This could cause potential pressure on the brain. Typically we would be alerted to the fact that this is happening by your child's behavior. We want to pay attention to any vomiting, sleepiness, fussiness or dizziness.

I actually give the kids "one free vomit". Often they have cried hard enough that they might spit up a little. Let's not worry about that first emesis. If they vomit a second time, they need to be seen. Note that Murphy's Law pays close attention to these scenarios and your child could be coming down with a tummy bug that has no relation to the fall.

You may have heard the adage that following a head injury you should not let someone fall asleep. This comes from the fear that someone with a significant head trauma could go into a coma and if not monitored would simply not wake up. Granted, in the rare, worst case scenarios this is indeed true, but I have never had that happen to any of our patients (and remember this is a very frequent call!) If your child calms down and seems to be acting okay, let them take their normal nap. Face it, without a nap, your little one will be cranky and falling asleep and may be near impossible to assess. Don't let them take a 'super nap'. Wake them up after two hours. Depending on how far and hard they fell, I would check on them every couple of hours during the night. You can set your clock to make sure you get up to do this.

With an infant you can offer them a dream feed. They don't need to be fully roused.

With an older child, let them know you will be asking them for a "magic word" during the night and when you come to them they simply need to say whatever predetermined word or phrase such as "I love you" and then then can go back to sleep. You are simply establishing consciousness; you often don't need to wake them completely up.

Keep in mind that if your child is in a deep sleep stage, a gentle whisper might not be enough to wake them up. For older kids, if they know ahead of time that you will be coming in, they are easier to wake up.

Pupil changes would be of immense concern but would happen only with a serious injury and would NOT be the only symptom. Some folks, as their baseline, have pupils that are not exactly the same size. They were born this way but no one noticed. I would suggest checking your child's eyes before they fall so that you don't get freaked out if they seem off to you after a fall if you are noticing that for the first time.  

After a solid knock to the head you are not out of the woods the next day. Any dizziness or headaches that occur within a week or two following the head trauma need to be paid attention to.

If your child has a concussion, it is critically important to avoid another head trauma within the next couple of weeks. There is a something called Secondary Impact Syndrome that can occur when this happens . In this case one plus one does NOT equal two.

Please exercise common sense precautions to avoid being the person who has to call about a fall, but remember that most of the time it is harder on the traumatized parent than it is for the patient. Accidents happen to even the most vigilant care giver.

If you call, we will want to know:

• How far do you think they fell?
• What kind of surface did they fall onto?
• What was the immediate reaction?
• How long did it take until they stopped crying?

A basic neurological exam might include the following (of course some of these are age dependent):

• can they answer simple questions?
• Is there any complaint of blurry vision
• Do the pupils react to light at the same speed (generally if a penlight is shined into the eyes, the pupil will get smaller)
• Can they touch their finger to their nose? Do this with each hand.
• Is there any clear drainage from the nose or ears? (Murphy's Law again. What toddler doesn't have a runny nose?)

If they are assessed and there is concern, the next step is generally an imaging study (CT scan.) This is a valuable option when it is genuinely needed, but if your child looks good, I would hesitate to put your child through the stress, expense and radiation.

Stay safe!