Friday, October 28, 2016

Halloween Safety tips 2016

Halloween can be such a fun holiday, but as you can imagine, as advice nurses we tend to hear about some of the misfortunes that can along as part of the festivities.

Carving a pumpkin can be a very fun tradition. Please make sure that your child's level of participation is consistent with their age and ability. Watch out for the sharp implements and make sure you assign your younger child to the safer tasks (young kids can draw on the pumpkin rather than carving.)
Clean up the mess. Pumpkin flesh is slippery and can cause falls and injuries when dropped on the floor. Layer newspaper or old cloths under your carving work space and clean up spills right away so no one slips or trips. Skip the candles, which may cause fires. A burning candle in a pumpkin may become a blazing fire if left unattended. Instead, use a glow stick (available in many colors) or flame-less candle to safely illuminate your jack-o'-lantern.

Choosing a costume
Children are more than twice as likely to be hit by a car on Halloween than on any other day of the year!

  • Decorate costumes and bags with reflective tape or stickers and, if possible, choose light colors.
  • Have kids use glow sticks or flashlights to help them see and be seen by drivers. Is your dog going along with the trick or treaters? Have them wear a glow in the dark collar!
  • When selecting a costume make sure it is the right size to prevent trips and falls.
  • Be sure to wear flame-resistant costumes. Remind your child that they need to pay very close attention to their surroundings and avoid walking near any candles or flames, especially if they have loose flowy costumes.
  • If a sword, cane, or stick is a part of the costume, make sure it is not sharp or too long. A child may be easily hurt by these accessories if he or she stumbles or trips.
  • make sure that no part of the costume is covering their ears solidly enough that their hearing might be impacted.
  • Since masks can sometimes obstruct a child's vision, try non-toxic face paint and makeup as another option. Face paints have been in the news lately. Some of them have some toxic ingredients like lead. Be familiar with the ingredients before you apply anything to your child’s skin.
  • Always test the makeup in a small area first.  Always completely remove it before bedtime to prevent possible skin and eye irritation.
  • Make sure that your child doesn't have any latex sensitivity before you do too heavy of an exposure. Many masks are made of latex. We actually had a patient who had an allergic reaction to the hair tinsel. You may want to do a test run of the costume and make up a couple of days ahead of time to rule out any allergies.

Trick or treat rules
Children under the age of 12 should not be alone at night without adult supervision. If kids are mature enough to be out without supervision, remind them to stick to familiar areas that are well lit and trick-or-treat in groups. Never go into a strangers house without supervision.

Popular trick-or-treating hours are 5:30 p.m. to 9:30 p.m. so be especially alert for kids during that time if you are out driving.

A good meal prior to parties and trick-or-treating may discourage youngsters from filling up on Halloween treats.

Bring plenty of water along when you go trick or treating. Just trust me on this one.

Make sure that your children know that after trick or treating, the grown up needs to pick through trick or treat bag and toss anything that looks suspicious. There is a warning out in Colorado this year about "pot laced" treats. That could happen here just as easily. Anything that looks like it has been tampered with should get tossed. Some candies are real choking hazards. If you have a younger child in the house, make sure they don't have access to the stash.
If you have a child with nut allergies (I am sure this is NOT your favorite holiday) make sure that they turn over ALL the candy so that you can separate out anything that might cause trouble. My favorite allergist adds another piece of advice. Most of the time nuts may be just one of the ingredients, but as a general rule, kids who are allergic to nuts should also be able to identify the nuts that they are allergic to. If it is peanuts, make sure they know what an actual peanut looks like.

Expecting trick-or-treaters or party guests?
Consider purchasing non-food treats for those who visit your home, such as coloring books, stickers or tattoos. Provide healthier treats for trick-or-treaters such as low-calorie treats and drinks.(Okay, fine...maybe you don't want to be "that" house, but I had to put it on the list.) Be sure walking areas and stairs are well-lit and free of obstacles that could result in falls. Keep candle-lit jack o'lanterns and luminaries away from doorsteps, walkways, landings, and curtains. Place them on sturdy tables, keep them out of the reach of pets and small children, and never leave them unattended.

Now what do we do with all this candy!!!
Make a plan about how much candy they can eat at one time. It is okay to be a little more liberal than usual for a day or two, but come to an agreement about a reasonable candy intake over the next few weeks. Some dentists and orthodontists have buy back programs, where they will give your child a reward for turning in their candy. Click the link for a partial list:

Bibi, one of our mom's, doesn't bother with the dentist and has instituted her own buyback program. Her kids can exchange candy of new lego pieces.

You may need to be extra vigilant with teeth brushing this season.

Remember that candy freezes (and some of it is actually better that way; frozen snickers bars, yum!) My daughter Lauren was about 6 when she caught on that mom and dad were pilfering through her trick or trick bag and stealing all the good stuff. After that she guarded her stash more carefully.

Here are some tips that some wise mamas have added to this post over the years:

"Once Cleo was out of the stroller and walking, we put glow stick bracelets and necklaces on her so we could see her more easily when out and about in crowded spaces in the dark (we do this at things like the Dia de Los Muertos parade, too.) Cliff's sells them in a big 100-stick bulk container. Not terribly eco, but gives a little extra "eyes on" help when navigating the crowds."

My little patient Franny, bent a glow stick in order to activate it and it broke.
Some squirted in her mouth. While, you do want to avoid unnecessary contact with the insides of a glowstick, they are non toxic

What a crazy world we are living in that we might actually have to have a conversation about creepy clowns, but here is some wisdom on the topic from Kidspower:

I can't end this post on a creepy clown note. Halloween is supposed to be fun.
Here is a link on all sorts of events this weekend:


Thursday, October 20, 2016


I get a lot of calls about habits.  Nail biting and  thumb sucking are probably the two most common, but you can’t begin to imagine what some kids come up with. Are you ready to tackle your child’s habit? Here is a truth - nagging doesn’t work. In fact, giving a lot of negative attention to a habit might even make it worse.

The most effective way to address a habit is to work on it as a team, which means that your child has to be involved and motivated to make a change. Maneuvering so that you can even have this discussion with your child taking an active role at problem solving and brainstorming  is easier said than done. You need to find the magic opportunity.

I like to share the “supermarket analogy” for this. Many of the parents who have picked my brain about parenting issues have heard this one before. Imagine your child is the checkout clerk at a supermarket. You are putting the items on the conveyor belt and they are systematically scanning them. But then… aren’t sure quite what, but something you placed on the conveyor triggered something, and the clerk decided to just close the line mid transaction. It doesn’t matter that you are not finished, you haven’t payed, and that you have ice cream melting  in the cart. There will be no more shopping at this moment.

In spite of this, many of us still stand there, putting more and more items on the belt. We are wasting our time of course. This lane is closed.There will be no transaction completed right now.
Whenever you want to have a conversation that has an agenda or a teaching moment, you need to find the right moment. Make sure the “line is open”. You might need to use the express lane (or pick one short topic.) If this is a pattern, try to figure out if you recognize what triggers the line to abruptly close and approach that subject delicately.

It is tricky, but it can be done. When is your child most likely open for a ‘transaction’?  Maybe broach the subject when you are in the car, taking a walk, or sitting on the side of the bed during bed time. One-on-one time is usually best if you can manage to carve some out of your schedule. Allow your child to be involved in the choice to invite other family members or wise friends to the brainstorming.

Before you even start the 'habit discussion' consider reading a general book about habits. Berenstain Bears and the Bad Habit,  is a good one.

In this classic, Mama Bear explains what a habit is by comparing it to her pushing the wheelbarrow back and forth between the shed and the garden, Over time the wheels have made a deep rut. It is easy enough to wheel the barrow on that well worn track. It would take some effort to push it in any other way. As Mama and Sister walk along to the garden, they talk about the habit in question. Sister Bear nibbles her nails. They brainstorm together about a solution. Reading a book or telling a story about habits is a great launching point for the discussion.
Identify the habit that you want to address. Point out other folks you know with different habits so your child doesn’t feel singled out.

What are some of the consequences of the habit? Downsides of nail biting or thumb sucking could include broken and irritated skin, germs, teasing from other children...

We don’t want to end up with Lady Macbeth on our hands by scaring kids about germs too much. Find a middle ground. There are indeed germs in the environment. More and more studies show that having children exposed to a certain amount of germs is actually healthy (bring on the dog kisses.) One way to bring this up with your kids might be, “when we are healthy our body has germ fighters inside. Dirty hands in the mouth might add so many extra germs that our body can’t keep up." (Or you can really freak them out and teach them about pin worms)

What is the benefit of breaking the habit? Pretty nails, no broken skin, no teasing, less risk of germs.

What is a good reward to work towards if they succeed? A special outing or a coveted toy perhaps.

What are some ideas that you might come up with to help break the habit?

In the Berenstain Bear book, they start the day giving Sister Bear 10 pennies that she will need to give back through the day every time she is caught nibbling. Sometimes the act of having to give something back is indeed  more effective than the promise of earning it.

There are some products you can apply to make the fingers take nasty, but I only like to use those when the child has agreed that they are motivated to stop the hand to mouth habit. A jingly bracelet might serve as a reminder. Having lots of healthy crunchy snacks available to chomp on can help too. A sticker chart might be useful to show progress. When you first start out, small goals might be easier to attain. Maybe a sticker can be earned every hour that they succeed in remembering to keep their hands out of their mouth (or whatever the habit is that you are working on.) See if you can think of a good habit that they can substitute.

Make an agreement about how your child would like you to be their cheerleader. Do they want you to verbally remind you?  They might be relieved to have the power to take that off the table. How about a finger snap,a quick whistle or a tap on your nose if you see them doing the habit?

Not all habits are bad ones of course.
I just got a fitbit, so I am trying to start the good habit of walking more. If you see me walking aimlessly back and forth in the office, I am trying to get my steps in!

Friday, October 14, 2016

Managing stress

This post is short and simple, but hopefully it can give you a new awareness or way of looking at things.

My kids grew up having to deal with all of mom’s theories. One of the classics is the “stress theory”. My daughter Alana, who is now a therapist at a community mental health center in Michigan, finds herself referring to some of these with her clients.

She let me know that she used this one the other day and I realized that I had never put this one in a post. So here goes.

Is there a water bottle near by? Take a look at it, Imagine that you are that bottle. There is a thick label. You can not easily see how much liquid is inside. Elements of your life are varying amounts of fluid. Every aspect of your life adds liquid to the bottle.
Some things may add a few ounces, others only a tiny drop (drops can add up!) Being a sleep deprived parent is easily a couple of ounces. A new job? An illness in the family? Moving? Ounces! Large changes or stresses are of course equated to larger amounts.

We generally don’t pay too much attention to how full our bottle is until it is near the top.
The smallest drop of water, something that normally you could handle with no problem, may make the entire bottle overflow.

This is the proverbial straw that broke the camel's back. Are you crying because you burnt your toast? Take a moment to figure out what is going on that has your bottle so full that the littlest thing can set you off.

One of Alana’s clients found that this way of looking at things really resonated with him.
He coined the term “dump the cup,” which in turn resonated with me.

What can you do to dump out your bottle a bit? Arrange a little time for yourself? Take a walk? Have the perfect cup of tea? Sometimes making a list of all the things you feel like you need to do helps quite a bit.

With your young kids, they can’t hold as much. Simply being tired or hungry will fill their little ‘bottle’ right up to the top. That’s when the temper tantrums and meltdowns happen.

Everyone who you interact with has their own stress level. It is good to keep that in mind if someone seems to be ‘overreacting’.

Are you past the sleep deprivation hell? Do you have a friend with a new baby? If you are thinking about giving a gift, consider skipping the outfit that the baby will grow out of in a minute. Give them a certificate or two that can be redeemed for a 2 hour nap while you watch the baby.

Helping your friends "dump their cup" feels pretty good.

Thursday, October 6, 2016

Teething/ tooth charts

Please see the updated post May 2018

Normal infants have 20 primary (baby) teeth which have started to develop in the womb.
The teeth start to erupt through the gums around 6 months of age. The baby teeth are then shed at various times throughout childhood. Below you will find a chart with the normal range of ages when most teeth start to come and go.

Occasionally I have a patient that doesn’t seem to like to follow rules, ignores the charts and does things their own way. I know of one baby who was born with teeth! Another started out with the upper canines and looked like a little vampire. As you can imagine, those parents were so happy when the rest of the teeth popped through. There is some heredity involved. If one of the parents was very early or late it is possible for the baby to follow suit. Check with grandma to see if she remembers anything special about your teething pattern!

It is rare for teeth to actually make an appearance before 4 months. Once in awhile parents will notice a smooth round white bud on a baby’s gum. This is a little benign cyst called an Epstein Pearl. It is not a tooth and it usually goes away without causing any bother.Many parents think of teething as something they are only dealing with for their young infants.  Think again. If your 6 year old is going through an extremely grumpy phase, or has a mysterious bout of mild, clear congestion that has been hanging on for a few weeks, take a feel in the back of the mouth and see if those first permanent molars are starting to pop through. By age 21, all 32 of the permanent teeth have usually erupted.

Just like the timing varies, the symptoms may also vary greatly from child to child and even from tooth to tooth. By far and away the most common first teeth are the ones in the bottom middle (and they are so cute once they come through.) Take your clean finger and run it along your baby’s gum. If the tooth is imminent  you may feel that the area of the affected gum feels soft and boggy

Let's talk about the symptoms:
Many healthcare providers and dentists dispute that there is any real relationship between teething and any of the symptoms below, but I have been at this job for a long long (long) time and I maintain that I see a connection.

Fussiness: Teething is uncomfortable. Most parents report that the babies seem fussier than usual right before a tooth pops through. Do what you can to relieve symptoms, but if your baby is inconsolable ( screaming with NO break) for more than 30 minutes and there is nothing you can do to calm them down then please call to have them checked. That would be an extreme reaction and we want to see if there is something else going on.

Drooling: Drooling starts weeks and weeks before you actually see a tooth pop through. Many kids will get a drool rash on their chins and cheeks. There are several products that I find quite useful for this. Clean of the area with Cetaphil Cleanser . (No water needed, apply with a cotton ball and wipe off.) Follow it up with aquaphor or cerave ointment (which you can use multiple times throughout the day.)

Gnawing/biting: Biting on things will feel great to the baby. Not so good to your nipples if you are nursing. If your baby starts biting you during feedings I recommend a loud “ouch!!” and immediately remove them from the breast. Most babies can be trained to stop this. Remember that you want to make the association mildly unpleasant so that they will stop the habit quickly. Biting = loud yell and loss of breast! If you are too gentle some babies will think it is quite amusing and will continue to bite at will.

Poor Sleeping: If your little one is miserable, this is not the time for sleep training. I would go in and quietly and try one of the teething remedies listed below. If you are going through a rough patch remember that parents should take shifts. Give yourselves each a few hours where you are off duty. There is no reason for both of you to be up all night. If you have the option, it is often best for the NON breastfeeding parent to go in, unless it is time for a feeding. This is a slippery slope, I would try not to feed for comfort throughout the night.

Bleeding/ bruised gums: It is not unusual to have a little bit of bleeding on the gums. Once in awhile you may also see a purple/ bluish bruise on the gums right before a tooth breaks through. This will usually resolve without any intervention although something cold will feel good on there.

Low grade temp :  Not everyone agrees that teething can cause fevers, but I see it all the time. If a fever goes higher than 100.5 I am not likely to blame it on teething. Any fever that is lasting more than three days is worth a call to the doctor's office to check in.

Loose stools: You will likely get differing opinions on whether or not teething can be the cause of loose stools and again; I will state here that I see it all the time.  Some folks speculate that swallowing all that saliva and drool might be the reason. Regardless, I do think there is a link. If you have a baby with loose stools you want to go with the bland, starchy diet and make sure they are on probiotics.

Rashes: If your child has sensitive skin and/or eczema sometimes, you might notice that the general rashiness flares up during active teething.

Congestion:  This clear runny nose and congestion can last for weeks and weeks. Sometimes it causes a post nasal drip that in turn causes a little hacky cough.  

Ear tugging: When  kids are working on some of the upper teeth they do tend to poke and play with their ears.

Uh oh, many of these symptoms are the same thing we look out for if we suspect an ear infection. Even though teething may well be the cause, if I have a patient who is very fussy , feverish and is having trouble sleeping, I am likely going to want to have someone take a peek in those ears.

It is worth having an arsenal of tools at the ready for dealing with the months of teething that you have ahead of you.

Cool teething rings: make sure they are made out of a safe material. Do not tie any teething rings around your baby's neck. This could cause strangulation.

Frozen wash cloth: Wet half of a wash cloth and put it in the freezer. The baby will be able to hold the dry half and chomp happily on the frozen side.

Distraction: There is nothing as nice as a body massage and a warm bath by a calm singing parent.

Teething tablets:  there has been a recent media buzz regarding  homeopathic teething tablets.

This link shows the FDA concern and the response from Hylands

Teething gels (homeopathic):  There are several brands.  If you aren’t scared off by the news, you might want to try both the tablets and the gel and see if one works better than the other for your child.

Homeopathic drops: The ones I am familiar with are Camilia by the Boiron company. Click the Boiron link for a coupon.

Boiron was NOT impacted by the recall and their product is perfectly fine to use!

Oragel:  Oragel and other commercial teething remedies work by numbing the gums.
I keep this on the list because when used properly it is safe and can be quite effective. It is nice to be able to get relief by applying something topically and not relying so much on systemic medications like Tylenol. Before I suggest it, I usually tell parents this little anecdote:

Many years ago I had a toothache and saw that I had a tube of Oragel in my medicine cabinet. I took a pea sized glob and rubbed it on my gum. Within moments it felt like my entire mouth was numb. It is nice to know that this stuff really works, but the sensation was almost frightening. If you decide to use this on your baby I want you to put a TINY bit on your own gums first so that you can see how numb the area gets.

Currently Oragel comes with a little Q-tip applicator so that it is much easier to put really small amounts exactly where they are needed. If care is taken, I am fine when this stuff is used appropriately. As I said, it seems to give relief to some patients. I also need to mention that the ingredient Benzocaine has been linked to something called Methemoglobinemia  that can be quite serious. It is exceedingly rare. I have certainly never seen it. (If you read the fine print on any medication you won’t want to give your child anything. Try to find a balance)

Brandy/ alcohol:
Ask great grandma what she used to do for teething and she may tell you that she used to put whiskey or brandy on the baby’s gums.
Obviously giving our babies alcohol is not something that most doctors would suggest today, but I actually wouldn’t worry if you caught grandma rubbing some directly on the gums. It probably does help. Some folks also say that rubbing pure vanilla extract on the gums is an effective home remedy. That may be from the alcohol content.

Feeding bags:   (baby safe feeder, or sassy teething feeder).
If your baby has had some solid foods introduced these feeding bags are great for teething relief, Add a cold hunk of fruit or veggie (pick a food that they have been introduced to already so that you don’t need to worry about any odd reactions) and let them gnaw away happily. With the mesh bag you don’t need to worry about them breaking off a piece that could be a choking hazard. You can find these bags online pretty easily.

I have had multiple parents tell me that these beads seemed to help.

Acetaminophen (Tylenol) and Advil  (Ibuprofen) are useful but I prefer not to overuse them. Make sure you are using the proper dose.

Start with the other approaches first. If possible, I would prefer to keep these as remedies for night time use only. Tylenol and Advil are quite safe but if they are used for a long period of time they can be stressful to the liver and kidneys. If you find that you have gone more than 5 nights where you are depending on these meds to keep your child comfortable, give your doctor's office a call to see if you need to make sure that nothing else is going on.

Once your child has teeth it is especially important to keep bottles out of the crib. Milk has sugar and can cause tooth decay if a baby sleeps with a bottle in their mouth.
It is never too early to start brushing the teeth. Let's get your baby in good dental habits. It is important to use a soft toothbrush and non abrasive toothpaste. The current recommendation is to use fluoride toothpaste, just a teeny bit the size of a grain of rice.
Once they have a mouthful of teeth it makes sense to start shopping for a pediatric dentist that you can establish a relationship with. This will come in handy if you have any tooth questions or mouth injuries..

Your next task is to figure out what the going rate for the tooth fairy is!!  I can’t help you there.

Wishing you easy teething!!

To add to the mire, Here is another caution about teething tablets: