Friday, September 30, 2016

Colic/standard,alternative and something new!


I think the most common calls I get are about fussy, gassy babies (although I sure do talk about poop a lot; perhaps it's a tie.) Often these colicky kids have wretched periods during the late afternoon and early evening when it seems to be especially hard to settle them (I refer to this as the witching hours.)



With most of my patients this usually seems to improve at least a little once you hit the 3 month mark (keep your fingers crossed.) If one of those gassy babies is yours and you are breastfeeding, the first thing I will ask about is your diet. I know that not everyone agrees that there is a connection, but in my case I swear to you that if I even looked at cabbage my kids cried for a week. The biggest culprits in my opinion are:


coffee
caffeine (in tea and chocolate among other things)
dairy
gassy foods (like cabbage, onions, broccoli)
spicy foods


What I suggest you do is see if you can establish a connection between an extra fussy day and something that you recently ate. Yes, I have some moms that know perfectly well that coffee is a problem but drink it anyway because they can't face the day without it. As always, it is a balance. It is worth finding out if there is a connection between your diet and your baby's gassiness, but then make whatever choice works best for you.


The other thing that breastfeeding moms should pay attention to is hind-milk. The milk that the babies get as they empty a breast is helpful with digestion. Sometimes greenish stools (not necessarily something that I worry about) and increased gas issues are because they are switching breasts too soon and never getting to the hind-milk.


If you haven't found any magic cures from a diet elimination, it is perfectly fine to experiment with some different colic remedies. Simethicone is the ingredient found in most of the OTC gas drops that you can get at a drug store. Some of the name brands are Mylicon or Little Tummies. Simethicone drops are very safe and helpful in about 70% of my patients. They are certainly worth a try.


Homeopathic colic remedies come in a few products. I am most familiar with Coccyntal drops (made by the Boiron company) and colic tablets by Hylands. These seem to help about 60% of the time. I consider them fairly harmless if used properly. They too are worth having in your arsenal. Grippe Water is an herbal remedy that can be found in many health food stores or Whole Foods. I find this helps about half of the time. Stools might get a touch green with this (not to worry.)


Soothe probiotics drops: These claim to cut crying time by 50% after a week of use. They should be given daily.


Brew some chamomile tea, add a few grains of sugar and give a dropperful or two to your baby. This also helps about half of the time. Probiotics may be helpful with digestion in general. This is especially true for babies who were born via c-section.


Colief is a fairly new product specifically for babies who may have a lactose intolerance. Regardless of the directions on the box, it is fine to administer directly to the baby without mixing with breast milk. If you are going to give this a try, you need to make sure you give it with each feeding for a few days to see if it is helping. (You may have a couple of months of colic ahead of you; you will have plenty of time to try all of these.) Dr. Schwanke thinks that the reason any of the above remedies work is because they have sugar in them. I think there is probably more to it than that.


The new product that I mentioned at the top is a Chinese medicine patch. We were fortunate enough to meet the inventor Dr Loo and do some beta testing on some of our patients.
Check out the website for a full description of this exciting new option.
For convenience sake, we will be carrying these in our office for purchase as soon as they are available.


Don't forget about massage! Go on line and check out baby massage techniques on You-tube or take an infant massage class. Make gentle clockwise circles on the baby’s palm with your thumb. Bicycle their little legs. Get up and dance. Hold your baby over your shoulder with their knees tucked up in fetal position. Give firm pats on the back. Sway, bounce and sing. (I teach the "shuffle" at my baby boot camp class.) Warm (not too hot of course) baths are very soothing for some babies.


Ready to think outside the box? Advanced Allergy Solutions (http://aasclinics.com ) treats babies as young as 2 weeks old and has success with colic. Their services identify possible foods your baby is reacting to through breast milk or formula and then helps resolve these sensitivities naturally to relieve symptoms.


Craniosacral therapy has been helpful for some of our fussy babies. Two of my favorites are Sandra Roddy Adams 4150566-1900 and Laura Sheehan 415-681-1031

Some folks have found that homeopathy makes a difference.
http://www.homeopathyamerica.com/
Dr Pearlyn Goodman-Herrick is a naturopathic  Doctor who is currently having office hours every Wednesday in San Francisco at the Getzwell pediatrics Union Street office.

Acupuncture is another option.
Den Bloome Bremond sees patients as young as newborns
www.theacupunctureden.com

Amy Gelfand, a pediatric neurologist at UCSF, looks at the connection between colic and a family history of migraines. Interestingly, recent evidence suggests there may be a relationship between infant colic and migraines. Mothers with migraine are more likely to have a colicky infant, and colicky infants are more likely to grow up to have migraines as adolescents.


Given this connection between infant colic and migraine, the UCSF Pediatric Headache program is now starting a program for management of infant colic. Their goal is to use what they know about helping children with migraines to also help babies with colic.  
Here is a snippet of info from Dr. Gelfand:


What will happen at my baby’s visit with the UCSF pediatric headache neurologist?
Your baby’s pediatrician has referred you to see a pediatric neurologist who specializes in managing migraine in children.  At the visit, the neurologist will go over your baby’s health history and the details of your baby’s crying pattern.  She or he will also review your family history of migraine. It may help to ask your family members about their headache history in advance of the visit as only about half of adult migraineurs in the U.S. have ever been diagnosed by a physician.  The neurologist will also perform a neurologic examination of your baby.  


If there is a family history of migraine, it is possible that migraine could be playing a role in your baby’s colic.  Given the young age of infants with colic, our approach in the UCSF infant colic program focuses mainly on behavioral interventions to help manage crying. We also want to ensure you have adequate support, as taking care of an inconsolably crying infant can be tiring and stressful. We only recommend medications that are safe for babies, and we work closely with your pediatrician to ensure that medication choices—if they are needed—are safe for your baby.
Dr Gelfand also adds that if there is a family history of colic, think about things like how to limit light and sound stimuli etc during the evening "witching hours".  


There are lots of experts who are convinced that the worst of the colic cases slowly build up to the 6 week peak and then slowly subside. As mentioned earlier, by the time three months comes around, most of our families can see the light at the end of the tunnel. One study that I read years ago postulated that kids with lots of colic symptoms ended up with higher IQ's. Hold that thought....


As with everything, this stage will pass. Enjoy the calm moments.

Here is a bonus from Mama Val

Yesterday I went on a hunt to buy all things that could help as suggested in your blog.  However, I stumbled upon a new product that was nothing short of AMAZING.  It is from the same company that makes the nose frida.  It is called Windi.  Basically, it is a little gas passer for their bottoms.  You insert the tip into their rectum (same as a rectal thermometer) and all the trapped gas blows out.  OK, I was totally freaked out about buying/using this weird product.  I didn't try it till this morning, and oh boy the amount of gas I got out in 2 seconds!  He immediately went slack and went to sleep.  I am using it when he looks uncomfortable and every time I get a huge wind of gas out.  I was terrified to try this and now can't wait to give him comfort in just a second.

Yay!  Check it out and pass it on.   




Thanks Val for the reminder. I had samples of Windi several years ago and I couldn't convince anyone to take them off my hands.
This is very popular in Europe....Listen to Val and don't be scared off!!

Here are a few suggestions for overwhelmed parents from the folks at the Parentline
*Allow yourself emotional space: Cry, vent to friends/family/partner or professionals. It is okay to be honest
*Avoid anything that makes your feel ineffective as a parent, including advice from people, books and the web that do not apply to your or your baby.
*Find the helpful help: Who can relieve you for a bit to give you time to sleep, eat, take a bath or do anything else you like-no strings attached?
*Acknowledge that this will pass. Being with your baby during the trying times is just as important as sharing in the joyful moments.
*Call the Parentline: The is a free service  sponsored by University of San francisco.
They are there to listen and support you. 1-844-415-2229

Friday, September 23, 2016

Anaphylaxis/Do you need an epipen?

This is an update of an old post from several years ago. Since I last wrote about this topic there have been changes in the treatment option availability. Unfortunately the epipen has also gone up in cost significantly. I have been actively keeping my eye out on the various options. At the time of this post, I don’t have great cost saving alternatives to suggest but if something comes along I will add any new info to this post on the blog.


Anaphylaxis is a very severe allergic reaction that can occur within moments of exposure to an allergen.  It can be triggered by an allergy to a particular food (peanuts or shellfish, are among the most common), biting or stinging insects (like bees), medication (like  antibiotics), latex (the type of rubber many balloons are made from) or a variety of other allergic triggers. Allergic reactions occur when the body mistakenly identifies something as harmful and overreacts. With anaphylaxis, this reaction can be life threatening. Symptoms usually start within seconds or minutes of the exposure, but there are exceptions. Once in awhile, a reaction can be delayed by several hours. This of course makes it much harder to figure out the culprit.


In an anaphylactic reaction there may be different parts of the body involved

  • Mouth: Itching or swollen lips or tongue
  • Lungs: cough, wheezing, shortness of breath
  • Heart: weak pulse, dizziness, fainting
  • Skin:Hives, itching, redness, swelling
  • Face:flushed, swollen (eyes and ears common)
  • Throat:itching, tight feeling, swelling
  • GI system: vomiting, diarrhea, cramps, nausea

The first time that someone has a severe allergic reaction is very frightening. Unfortunately subsequent reactions can be even more severe. It is essential to recognize symptoms that need immediate attention.

Several years ago, a patient in our practice had been given yogurt for the first time.The child’s face began to swell and she started to have labored breathing. Mom’s  first instinct was to call me; I redirected her to call 911 immediately. If it feels like an emergency situation, 911 trumps the advice nurse. Of course, we want to be kept in the loop and help with any follow up. This child turned out to be severely allergic to milk. Interestingly she had no trouble with breast-milk. It is very important that folks figure out what the trigger is so that the you can try to avoid future reactions, although there are cases that remain a mystery.


Knowing that your child is at risk for anaphylaxis is very unnerving to say the least. It is very important to educate your child (age appropriate) and all teachers and caregivers about how critical it is to keep your child from being exposed to the allergen.
One case comes to mind of a school aged patient who was at Costco with some friends. The child was allergic to nuts. The friends parents allowed him to taste something from one of the samples. They had done a cursory check of the ingredients and thought it was safe. It turned out the the knife used to cut the samples had also been used to cut something with nuts, and the child ended up in the ER. Some kids are so sensitive that cross contamination (in this case, the knife) can cause a full reaction.


Here is another story  of one of our patients with a fairly recent anaphylactic reaction.
This little 9 month old was already teething and fussy, which complicated things. She also is prone to eczema, so rashes are not unusual. The family had had a recent checkup and had come home motivated  to increase solids and calories to fatten up their slender child. Dinner that evening was some Chinese take out. Our little patient was offered bits of foods from the various containers. They didn’t offer any foods that struck the parents as obviously new, but one of the containers was a shrimp dish. Although the baby didn’t actually eat any shrimp, she started to get very fussy and swiping at her face and ears.

After several moments of excessive fussing from no overt cause,  mom and dad opted to give her a bath and start the bedtime process. When they removed her clothing they saw that she was covered with hives. At that point they wisely opted to go into the ER. It had been about 20 minutes since the food.  The baby was fairly inconsolable and her face and ears were swelling. Luckily she did not appear to be having labored breathing (that would be a reason for a 911 call.) Once in the ER she vomited. She was given Epinephrine and kept overnight for observation. She was singing and happy the next morning with no seeming ill effects. The current plan is for to avoid any mystery foods and follow up with an allergist within a few weeks. The family will have an epipen on hand just in case.

As a caution,  I recommend that all first time foods are always tried when there is time to observe for a little while to make sure there is no reaction. Giving something brand new and then putting a baby straight to bed is not a good plan. This is especially important with high risk foods like nuts, milk, eggs, shellfish, and any medication. It is also a good idea for every household to own Zyrtec liquid.

If your child is old enough,talk to them about the fact that just about everyone has a little something special going on, and it their case they need to be careful about whatever their trigger is. Check out this book, available on Amazon. Perhaps pick one up for the class and make sure the teacher reads it out loud.


Make certain that any babysitters or friends caring for your child, know what allergens are potential hazards so that they can be certain to avoid them They should also have an injector handy just in case.

If you go to a restaurant, ask to speak to the chef so that you know the restaurant understands the import of avoiding the ingredient in question. In serious cases, you might want to call ahead to make sure they are willing and able to accommodate you.


Mild allergic reactions can be treated with a dose of Zyrtec (My favorite go to  allergist Dr Fast counsels against using Benedryl. Benedryl might make some kids sleepy and it might muddle things) , but epinephrine is the only first line treatment for an anaphylactic reaction. It relaxes the muscles in the lungs to improve breathing. To quote  Dr. Fast, “Epinephrine is what saves lives. It is never wrong to give epinephrine."

The easiest way to give it is via the Epipen. This  is a pre-dosed epinephrine injection. It comes in 2 strengths. The junior (.15mg)  is for anyone under 66 pounds. Anyone over 66 pounds gets the full adult strength (.30 mg)


In the case of a severe allergic reaction, give the immediate dose of epinephrine but then head over to the ER for some observation. It is possible for the symptoms to rebound. This is called a biphasic reaction. Hours after a patient seems stable, the symptoms can flare up again. Since it is always better safe than sorry, keeping a close eye on the patient  is essential for the next 24 hours



The auto-injector should be administered into the upper outer thigh. It can be given through thin clothing. New studies suggest that holding for 5 seconds is adequate. The leg should be restrained and the injector should be held against the thigh and then compressed, rather than jabbing it.


Epipens have trainers available. Please ask your nurse or doctor's office to give you a demo and make sure you are comfortable using it.  The auto-injector takes the ‘need to think’ out of the equation, which is a big advantage during a crisis situation.

Epipens are fairly temperature sensitive and should not be left in a hot car (keep in mind,they shouldn’t be left in the car anyway, they should be with you at all times.) The increased cost has been all over the news lately. Epinephrine by itself is actually a  fairly inexpensive drug. It is frustrating that the auto injector is so expensive
If you have a high deductible and you are close to meeting it towards the end of the year, this is an excellent time to get a refill.

Also check out this link:  www.goodrx.com   They shop around and let you know where you can get the best deal. Our friends at Script dash have competitive pricing and will deliver for free. They will also automatically apply any applicable coupons.

Children with reactive airway disease and/or eczema are more at risk for allergic reactions, but they can happen to anyone.


No, of course not everyone needs to carry around epinephrine, but it is SO important to recognize the symptoms and act quickly if you are concerned about the possibility of an anaphylactic reaction.


There is a  law SB 1266, effective January 1, 2015, that mandates all schools keep an epinephrine auto-injector on hand and that someone on site has been trained. Check with your child’s school to make sure that they are complying. I just put a call in to the wellness center at Lowell high school and they confirmed that they have epi-pens available.



1/12/2017
generic epipen now available!!! 

2/13/2017
AUVI Q is back!!!

4/1/2017  nope, not an April fools joke
EPIPEN recall!!

http://www.cbsnews.com/news/mylan-announces-nationwide-epipen-recall-over-potential-defect/

Friday, September 16, 2016

Carbon Monoxide

Carbon monoxide (hereafter referred by its chemical symbol CO)
This post could save your life. How many of you own a Carbon Monoxide alarm? If you do, good for you. Make sure that it is in good working order. The units do not last  forever. Batteries need to be changed annually (at least) and some units suggest that you vacuum the cover monthly to remove accumulated dust. If you are one of the many who do not yet own one, please remedy that immediately. As of January, 2013, with few exceptions, it is the law.

Homes with a  fireplace, attached, garage, any gas appliances are at higher risk but there are many different factors that can cause an elevated level. A friend of mine is a lawyer who was involved in a heartbreaking case where a guest at a Bay Area hotel sustained long term health impairment from an exposure. The victim’s room was above the hotel pool and a faulty boiler used to heat the pool vented carbon monoxide into his room. When he didn't show up for dinner, his friends found him unresponsive. It was a very alert physician in the emergency room who figured out the cause. It was only at that point that the hotel was evacuated. This is not an isolated incident.
As a result, my lawyer friend takes a portable detector along with him on all of his travels!

Because heaters and fireplaces are often involved, exposure is usually higher during the winter months.

Carbon monoxide is a colorless, odorless and tasteless poison gas that can be fatal when inhaled. CO binds to hemoglobin with much greater affinity than oxygen, forming carboxyhemoglobin (COHb). It is hundreds of times more efficient than oxygen at attaching to the cells, so even small amounts can deprive our bodies of vital oxygen. In severe cases, for folks who survive an exposure, it can cause irreversible brain damage by starving the brain of oxygen.

Normally if someone is deprived of oxygen they may look pale or cyanotic (bluish); in the case of CO poisoning, the color will remain nice and pink. A standard pulse oximeter may not be an accurate indicator of where or not there is a problem. If carbon monoxide exposure is suspected a blood test can be done to check the carboxyhemoglobin level.
One of our local ER docs who allowed me to pick his brain added that one of the tricky things about CO poisoning is that the symptoms are very vague and nonspecific. A faster than normal heart rate (tachycardia) is the only really reliable physical exam finding.

Mild exposure  might cause slight headache, nausea, vomiting and fatigue. This can easily be mistaken for flu or viral syndrome. Medium exposure  symptoms would be a throbbing headache, drowsiness, confusion and a rapid heart rate. Extreme exposure will lead to unconsciousness, seizures, and cardio-respiratory failure that usually is fatal.
The effects of exposure can vary greatly from person to person depending on age, overall health, and the concentration and length of exposure. Young children and pets are thought to be especially vulnerable. Pregnant women should also be especially careful because the fetus can be seriously  impacted.

A carbon monoxide alarm is similar to a smoke detector because it monitors the air in your home and sounds a loud alarm to alert you of trouble. However, the way you respond to a CO alarm is very different than a smoke detector. When a smoke detector goes off, it is pretty easy to to judge the level of danger. You can see or smell the smoke.
On the other hand, because CO is completely undetectable to your senses, you are dependent on the alarm to let you know there is a problem. If the alarm sounds:

  • Operate the test/reset button
  • Call 911
  • Immediately move to fresh air. (make sure that everyone in the household is     accounted for)
  • Do not go back in until  you have the all clear from the emergency responders.

Concentrations of CO between 1 and 30 ppm can often occur in normal, everyday conditions. See the chart below for CO levels and corresponding symptoms.

If your unit is coming to the end of it’s life it may give off multiple chirps to notify you that you need to replace the device or change the batteries. Newer alarms might be good for as long as 10 years.  Ours has a digital display that will signal when it is time to replace it.

Just last month my daughter Alana had her CO alarm go off in her apartment in Michigan. She knew enough to get outside and call 911 immediately. After the fact she recounted her conversation with the fireman who had responded:

“I am worried about my cats, can you help get them out?”
“What do they look like?
“They are CATS, they are furry, have 4 feet and tails!”

Happily the kitties were all safety brought out of the apartment.

The best guess for what set off the alarm was something faulty with the air conditioning system. You may not think that your home is at risk, but there is NO downside for investing in an alarm (plus you are complying with the law.) They are inexpensive. If you are renting and there is not a unit in your apartment, call your landlord immediately and get that remedied.

Friday, September 9, 2016

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!


   
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

Friday, September 2, 2016

Nail care/cutting your infant's nails

I have had multiple parents actually offer me bribes to cut their infant's sharp little nails.
Sorry folks. Guess what? I hate it just as much as anyone else. Nail clipping (as well as splinter removal) are not among my many talents.

I will tell you a secret. In my family the task of nail clipping belonged completely to my husband Sandy. Our kids referred to it as "snip snip." Daddy cut  their nails when they were babies and continued his job as they got older, clipping nails and applying polish on request to his daughters' fingers and toes. If he accidentally cut them and drew blood at any point, I have blocked that out of my memory and in any case, they survived.

Babies have sharp nails that grow quickly. It is not uncommon for them leave scratch marks on themselves if you don't keep those nails short. Some babies actually manage to scratch their eyes, leaving little red marks in the sclera. I know some parents who put little mittens on the hands, but really, as tempting as it  is to keep those on, it is not a realistic long term solution. Here are a few tips related to nail cutting. Keep in mind that babies nails tend to be much thinner than adult nails.

Use special tools for the job; there are baby nail clippers and nail scissors available. Some clippers even come with a magnifying glass attached. The special kid scissors have rounded tips that can help avoid injury if your baby moves suddenly. Dr Anne liked the Piyo brand for her twins. She says that she is still using them.
If you can get away with just a file, good for you, but most of the time the nails need some more trimming than that. Adult clippers and scissors are often quite a bit sharper and therefore not as safe.  

Some folks do the nails right after a bath when they tend to be softer. Some people actually nibble the nails down. Most medical sources will warn you that this is tremendously unhygienic. True enough, but grandmothers have done that for generations and I haven't ever heard any issues.

Many  folks cut the baby’s nails when the infants are in a deep sleep cycle. You can identify this sleep stage because the baby is completely limp and relaxed, the hands are usually unclenched. If you choose this option consider keeping a little pair of nail clippers with you in your diaper bag as you go on outings. If your baby is asleep in the car seat, you can seize the moment. Doctor Schwanke says that the most important thing to do with any nail clipping is to push down on the finger pad to make sure you get a little space between the nail and the finger.

At some point, as your child gets a bit older, it is reasonable to  simply want and expect cooperation. You may have to work towards this goal.

When we got our puppy many years ago, we were advised to handle her all over so that she didn't have any areas that were "off limits". I would do that with your baby. Get in the habit of doing a gentle, relaxing little hand and foot massage that includes all the fingers and toes so that they get used to you handling the nails. Do a little rhyme or song as you do it. Think "my little piggy". Of course you are only clipping the nails some of the time, but they may stay more relaxed when it is actually nail clipping time. Who doesn't enjoy a little hand or foot rub!

If you do accidentally cut a finger or toe, just hold pressure for a few minutes. You can apply a dab of Neosporin if it seems like more than just a superficial little nick. Hopefully the little cut doesn't need more than a few minutes of pressure but if you need to apply pressure for a bit longer, you can put a band aid on a finger or toe and then put a sock over the hand or foot so that your baby doesn't pull  it off. Band Aids can be choking hazards so you need to be wary.

Toe nails should be cut straight across, fingernails can be rounded a bit. If your child does develop an ingrown nail, try to soak it or apply a warm compress. Apply Neosporin a few times a day. Infections on fingers and toes can actually get pretty nasty, so if it doesn't look like it is improving or there are any red streaks running down the finger or toe, it needs same day medical attention.

For your older children it is lovely to have the treat of a manicure or pedicure at a local salon, but do your due diligence and make sure the you use a place that sterilizes the equipment. Fungal infections acquired from a dirty salon can be a nightmare to get rid of.  It is also worth checking online for a list of non toxic nail polish brands. Three very common ingredients found in many nail polishes are Toluene, Dibutly Phthalate ( DBP) and Formaldehyde. These are carcinogenic and should be avoided. Formaldehyde Resin and Camphor are two other ingredients to avoid. It is worth checking online for a list of non toxic nail polish brands. With more awareness these days, safer nail polish is becoming more widely available.