Friday, July 15, 2016

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.

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.
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.


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

Friday, July 8, 2016

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.

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.

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!