Friday, July 22, 2016

Car seat guide 2016


Car seats are an essential part of keeping your child safe.
I get  calls all the time from parents hoping for my blessing to give them the go ahead to finally turn their kids into a forward facing seat.
The thought is appealing and they are counting the days and keeping on eye on their babies size waiting and waiting. I need to inform you that you will need to be waiting a little longer. Repeat after me, " The bottom line is safety."
I completely get it that this is not what you think you want to hear, but according to manufacturer's recommendation, infants should be rear facing in the back seat until they are at least two years of age. If you haven't heard, Governor Jerry Brown recently signed a new law that will go into effect in 2017. This law requires children be rear facing to a minimum of 2 years old.  It is recommended that they remain rear facing until as close to age 4 as possible!  More and more studies are showing that rear facing is the safest place and position in the car. In fact, it is 5 times safer than forward facing.
In the case of an accident, a child's head and spine are better protected  if their car seat is rear facing. One study shows that children ages two and under are 75 percent less likely to die or be severely injured in a collision if they face the back. I know they might appear to be squished, but I wouldn’t recommend turning them unless they absolutely can’t fit. Children who are 40 pounds or 40 inches are exempt from the law and can face forward, but while they may be exempt from the law, they are not exempt from the laws of physics. Rear facing is safer. Please take a moment to click this link.

This video is a good illustration about why rear facing is so important

Kira Beer, Co-Founder of The Mama Coalition and a local car seat expert, shares the following

For taller kids (we see that the majority of toddlers hit the height limits before the weight limits), we recommend convertible seats that allow for up to 49" of standing height. Graco, Britax, among other seat manufacturers  are making some wonderful convertible seats that allow for up to 49" of standing height (Most Graco Convertibles have high height limits, as do the Britax Boulevard and Advocate seats).  In terms of squished legs-- we're finding this is more of a perception issue for parents than children. Safety wise, we've not yet seen any leg injuries from a rear facing child, whereas we've seen leg injuries in forward facing children.  We also find that children are quite comfortable sitting criss-cross, or with their legs up the seat. The children in the studies have preferred their legs propped up, rather than dangling down forward. It's counter-intuitive to adults, but children are very flexible little beings and are very rarely uncomfortable sitting rear facing.  For those parents/caregivers who are concerned about leg room, Graco has released the Extend2Fit, a new seat which allows for Extended Rear facing, and includes a foot that when extended, provides children an extra 5" of legroom.
Check out her coalition’s website

Toddlers who have outgrown the rear facing weight or height limit for their car seat should use a forward facing car seat with a harness for as long as possible, up to the highest weight or height allowed by the car seat manufacturer.
The current California Law also requires a car seat or booster seat until your child is 8 years or 4 ft 9 inches. Previously the requirement was  6 years or 60 pounds. Height parameters make more sense than the previous weight ones. For a child to safely transition into a booster,  we look beyond the child's age/height/weight. There's another set of criteria to help determine if your child is ready to transition to a booster.
There is a '4 Step Test', in which all criteria should be met, and to be completely honest, Step 4 is the single most important part of the list, and the one most often disregarded by parents -- with dire results. Developmentally, most children don't meet all of these steps until somewhere between 5-7 years old, and generally closer to 6 or 7 than 5. A lot of this has to do not only with physical maturity, but emotional maturity.
The criteria is as follows:

1. Child is an absolute minimum of 40 lbs
2. Minimum of 4 yrs old
3. There is a lap & shoulder belt in child's seating position
4. The Child can be trusted to sit properly for the entire trip, every trip - even while asleep. This means no slouching (back straight up against seat), no leaning to either side, no playing with the belt, etc... Even unsupervised.

We like to tell parents that this is one of those times in your parenting life where your child NOT graduating is actually a good thing. The longer your child is harnessed, the safer and more protected they'll be.You child needs to be tall enough so that the seat belt goes across the chest, not across the neck.  The purpose of a booster is to properly position a child in the adult-intended seat belt. What you’re looking for is proper belt fit across the lap and shoulders - the belt should be low and tight on the hip bones (not on the belly), and should be hitting the shoulder bone, not the child’s neck.

When children are old enough and large enough to use the vehicle seat belt alone, they should always use Lap and Shoulder Seat Belts for optimal protection. To determine if your child is ready to sit unassisted, they must pass the 5-Step test:

The 5-Step Test.
1. Does the child sit all the way back against the auto seat?
2. Do the child's knees bend comfortably at the edge of the auto seat?
3. Does the belt cross the shoulder between the neck and arm?
4. Is the lap belt as low as possible, touching the thighs?
5. Can the child stay seated like this for the whole trip?

*If you’ve answered NO to any of the above, your child should remain safely boostered.

If your children complain about this rule, show them photos of race car drivers all bucked up in their restraint system. Be matter of fact about it and explain that there is no compromise for safety (there is also a mighty large fine if you are caught breaking this law.)

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

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

Did you know that car seats expire? Most of them have a 6-9 year life span. This date can usually be found underneath or behind the seat. I questioned this when I first found out about it. The explanations made sense to me. First of all buckles and straps can wear out. Prolonged exposure to sunshine can weaken the plastic. Also, the technology is always changing and this ensures that nothing gets too out of date. Save the instructions/registration in a safe place. Make sure you register your car seat. If there is ever a recall this will ensure that you are notified.

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

The AAA states that 75% of car seats are installed or used improperly. As your child grows, there are services offered here in the San Francisco Bay Area that will check out your car seat or booster seat and make sure it properly installed. Have the infant car seat checked before the baby is born and then again with each transition to a larger seat. 
Below are some local resources for making sure that not only is your car seat properly installed but that it is the right fit for your child's size and age. They can make sure that all the straps are where they need to be and that you pass the "pinch test", making sure that the seat's harness is tight enough

To be super safe, consider having the car seat fit and installation checked every 6 months.
Fortunately there are lots of places to help.

553-7208          2300 16th St suite 280
The contact person is Ingrid. Appointments need to be made ahead of time. You do not need to be a AAA member to take advantage of this free service.
If you want to take the trek up to Mill Valley. The AAA office there is at 750 Redwood highway.The technicians there are Wayne 415-380-6031 and Travis 415) 488-2905.They do the inspections on Wednesdays and Fridays, but they also say you will do best to plan in advance. You can probably get it taken care of within the month.

CHP (California Highway Patrol)                  415-557-1094
This is very popular and is by appointment only. Please make an appointment as far in advance as possible. The woman on the phone there said that her preference is for people to call as soon as that pregnancy test comes back positive! ( I assume she was partially joking, but you get the gist.) When I called this week to make sure all my info is up to date, the woman on the phone told me that the current wait time is almost 2 months.

SFPD                415-575-6363
They try to have an officer at all of the local police stations who is trained to do the car seat safety inspections. Call the number above for more info.
The Colma police department will do a car seat inspection for free (650-997-8321)
By appointment only. Same day appointments are sometimes available.

Baby World
has a technician at both of their existing locations
4400 Telegraph Ave, Oakland,510-547-7040  Mon-Sat(10-5:30) Sun(12-5)
556 San Mateo Ave, San Bruno, 650-588-7644
Appointments are needed but reasonable. You may be able to get same day service mid week. Weekends are trickier.  Inspection and installation are free if you purchased the seat through them. If you got a seat from somewhere else, they will still do a free inspection, but any adjustment or installation will be $40.00.

The Mama Coalition - Kira Beer, CPST
Serving Marin County
Free of Charge, Appointments required

If you are not inclined to schlep, Bryan will  come to you. It is not free, but the convenience is worth a lot to some families.

 This info is current for July 2016


-NHTSA website has a place to click to find updated local car seat inspection stations for those of you who are not in the Bay Area.
(national highway traffic safety association)
They also have a page where you can plug in your child's age and size and they will tell you what type of seat they should be in. - Car Seats for the Littles gives lots of great info about the specific brands of car seats on the market (Keyword :car seat ) has a very comprehensive guide to safe installation as well as a list of current care seats on the market for 2016

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

If your child is asleep in the car seat and you have arrived at your destination, leaving them snooze for a few minutes is fine, but keep them tightly buckled. Having a baby in a car seat without being tightly strapped in not safe. The loose straps can be a safety hazard.

Never leave your child unattended in a vehicle. Children can die from prolonged exposure to excessive temperatures in a hot car.
Thanks to one of my patients who read the post last year and then shared this link

Special thanks to Kira Beer for her assistance with this post!

One of the wise Mamas out there shared additional tips. (Thanks Jackie!!!)
Your toddlers weight is an important factor when making the switch from the latch system to the car belt.

Also, although the middle of the back might be the safest place in the car. Some cars don't have adequate space

So much to keep track of!!

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

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.
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

Berkeley Eye Institute is a great resource. It tends to be lower cost because it is associated with the school.

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.  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 with the state department...Great idea!

Friday, July 1, 2016

July 4th safety list 2016

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

Since some of the holiday festivities may involve large crowds, I have some recommendations for dealing with situations where you might find yourself in a throng of people. Dress your child in bright clothes that stand out from the pack. Take a photo of them before you set out, so if heaven forbid you get separated, you have a current picture to pass around that shows exactly what they are wearing.
The Clovis Police department suggests writing your phone number on your child's wrist and covering it with liquid band-aid, to make sure it doesn't wash off.
Make a solid plan with your older children. What should they do if they lose sight of you? Where should you meet up? This is a good time for the "what would you do if...? Activity:

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

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

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

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

For those of you escaping the city make sure you stay well hydrated and protected from sun:

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

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

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

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

If your picnic/meal is outside and you will be spending time in grassy, wooded places, make sure you do a head to toe check for ticks once back inside:
Ticks are rampant right now. Finding them early before they have been attached for a couple of hours will vastly decrease any concern about disease transmission.

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