Friday, March 31, 2017

Vitamin D/ Do you need to supplement? 2017

Vitamin D/ Is your baby getting enough? Are you???
Food superstars come and go. One minute something is going to cure all of your ills and the next minute it might be considered poison. (Who agrees with me that as long as chocolate and wine are considered to have some health benefits, they should stop doing further studies?)
One of the current favorite good guys is vitamin D. At the same time that scientists were stressing the importance of this vitamin, they were also discovering that many folks are surprisingly quite vitamin D deficient without being aware of it. There are 2 forms of vitamin D: D2 and D3. Most experts are in favor of focusing on D3, which is the more natural form.

Years ago, vitamin D deficiency was most associated with Rickets (a disease that causes very soft bones.) More and more recent studies are finding that vitamin D levels are also very important well beyond good bone health. Deficiencies are linked to multiple illnesses including diabetes, cancer, heart disease and even mood disorders. There are also current studies underway to see if there is a link between low Vitamin D levels and increased allergies. Other studies are linking D deficiency to insomnia and ADHD. There have been studies linking Vitamin D and cognitive health in older folks.
Just recently a large-scale meta-analysis using more than 10,000 participants concluded that vitamin D supplementation may help to prevent acute respiratory tract infections. Let’s make sure our babies are getting enough.
For several years now, the American Academy of Pediatrics has recommended that all breastfed babies start getting 400 IU of a vitamin D supplement within the first few days of life. (IU stands for international units, which is a common way that vitamin D is measured.) Quality infant formulas have vitamin D in them. Babies who get 32 ounces of formula per day have their needs covered.
But what about the majority of our babies who are partially or completely breast fed? I instinctively like to believe that breast milk is  a "complete source" for all of your baby's needs. In the case of vitamin D this is not necessarily the case. It comes down to the mom.
The only way a baby is getting enough D through the breast milk is if mom has a good level. Unfortunately, the segment of the population who test the lowest for vitamin D are pregnant and breastfeeding women.  If you are a nursing mom and you are deficient, your baby is simply not getting the amount that they need. There are some studies that claim that a nursing mom might need to take 4,000 IU/daily to be sure the baby is getting the suggested amount of 400 IU through her milk. Giving vitamin D drops directly to the baby can take the guesswork out of this. If you do end up giving your baby vitamin D supplements, one of the most common brands is the Enfamil D-Vi-SOL. One dropperful is 1 ml. This gives the daily dose of 400 IU.
Babies seem to tolerate this well. There are some other forms out there that give 400 IU in each drop! That is quite a difference. It is very important that you pay attention to the form that you are giving.
If you are giving your baby a multi vitamin supplement like Poly-Vi-Sol, that already has the D in it. Be a label reader! While vitamin D is one of the fat soluble vitamins, you cannot get "too much" from sun or diet. But as with any supplement, you don’t want to overdo it. Most studies suggest that the upper limit for safe supplementation is 1,000 IU/day for babies or 4,000 IU for adults. There are some current studies taking place that may in fact raise that level, but as of now I wouldn’t recommend going beyond that upper limit unless you are working closely your personal physician.
Children over the age of one, and all adults, should make sure they are at the very least getting 600 IU daily.  Milk and orange juice that have D added, some fatty fish, and cod liver oil are on the short list of good dietary sources for vitamin D, but a person would have to drink ten tall glasses of vitamin D fortified milk each day just to get minimum levels of vitamin D into their diet.
Other foods like some mushrooms and eggs will get you a bit, but not enough to begin to make a dent in the daily requirement.
Historically much of our vitamin D is/ was from sun exposure. Folks who live in sunny climates generally have higher levels. Darker pigmented skin has a harder time absorbing it. Being out in the sun, unprotected for 30 minutes 2 or 3 times a week would probably give most people the amount they need. But wait!! Do we really want to expose ourselves and our children to the risks associated with sunburn? To compound things, the rays of natural sunlight that produce vitamin D in your skin cannot penetrate glass. This means you can’t get vitamin D from indirect sunlight in your car or at home,
In fact, our recent healthier sunscreen practices are quite possibly the cause of our lower vitamin D levels. Weak sunscreens (such as SPF 8) can block Vitamin D by up to 95%. It is hard to find a balance. Some exposure is healthy, but overdoing it is problematic, Sunburn and an elevated risk of skin cancer don’t seem like a sensible answer.
If you are a nursing mom and are one of the many folks out there who has a low level, it is very important that your baby get the vitamin D that they need (and yourself as well !!) In our office we are not wedded to babies receiving a daily supplement as long as you are sure that they are getting enough through their milk intake. In any case, giving your baby a daily vitamin D supplement is certainly harmless if giving the proper dose. If you choose to skip the vitamin D recommendation, please consider getting a blood test to see what your level is. The recommended test usually ordered is a 25-hydroxy vitamin D level. There is some debate about what the proper level should actually be, but everyone seems to agree that:
  • < 12ng/ml is severely deficient.
  • 12-20 ng/ml is still not adequate
  • 20-50ng/ml  is a reasonable range of normal
40% of folks tested in this country are low!! Please make sure that you and your baby are not one of those. Daddies, you need it too!!! My husband found out at his last physical that he was deficient. The first visits to the office with your new baby are loaded with various things to consider. If the vitamin D discussion didn't make the list and your baby is several months old before you  are hearing about this for the first time, don't stress. This is not just a recommendation for newborns,it  is a life long health issue. Now you know and can make a vitamin D plan for your family.

Friday, March 24, 2017

Poison Oak


For all of my blogging over the years, poison oak has been one of the subjects that I have had on my “to do” list but haven’t sat down and pounded it out until now.
This week I have gotten multiple calls about poor little patients with probable poison oak. Several of them most likely got it from Glen Park.
The symptoms start with a small itchy rash that then spreads over the next several days into weepy, nasty blisters. The rash can begin within a few hours of contact, but keep in mind that it might not actually show up for several days. It usually takes about 2 weeks to clear up. At least three out of four  people coming into contact with the plant will end up with a problem, but some folks are much more sensitive than others. As with most allergies, the reaction tends to get worse with each exposure.
The substance that the skin is reacting to is an oil called urushiol (ooh-roo-she-all). Urushiol is found in all parts of the poison ivy, oak and sumac plants. When urushiol gets on the skin it binds to the skin within 10-20 minutes. At that point the urushiol becomes extremely difficult, if not impossible, to get off the skin with soap and water.
The oil can linger under the fingernails. The rash itself is NOT contagious, but if you still have oil under the nails, it can be spread from the scratching.
The key is to wash any possible areas that came in contact with the plant immediately after any possible contact. If you are spending time outdoors please keep a product called Tecnu in your backpack.
Simply apply Tecnu to dry skin, rub vigorously for two minutes, and rinse with cool water or wipe off with a cloth. When used within 2-8 hours after exposure to poison oak, ivy or sumac, Tecnu can remove urushiol oil before the rash begins. Once a poison plant rash has started, washing with Tecnu is still somewhat useful because it helps remove any free oil on the skin allowing the natural healing process to begin without the possible spreading of poison ivy or oak (re-contamination).
If you don’t have that, you can use rubbing alcohol. Some folks use dishwashing detergent. Dawn is especially good at removing oil. Avoid using warm water because that will enhance the penetration of the oil
Poison ivy and oak oil can also spread from contaminated clothing, shoes (don't ignore the laces), gloves, tools and pets. Since urushiol oil does not evaporate, it can remain on these items for months or even years at a time. Gardening tools, sports equipment, clothes and pets are all possible sources. Get in the habit of washing any suspicious objects before storing them so that they don’t cause trouble later on.
All exposed clothes should be removed and soaked in a pan with Tecnu prior to being washed.
Pets are actually a pretty common culprit for spreading poison oak. If you have a dog, try to keep them on the paths if you are out hiking; dogs can get the oil on their fur and it will transfer to humans when you snuggle them. Pets can be wiped off with tecnu prior to being washed off with a pet shampoo.
If it is too late and you or your child has poison oak, it usually takes a couple of weeks until it clears.
For a mild case, taking Zyrtec or Benedryl, oatmeal baths and topical steroid creams can give some relief. There is also a good product  called Domeboro gel.
Dr Schwanke strongly prefers Zyrtec to Benedryl as an oral antihistamine because it lasts longer and won't "turn your kid into a zombie". Of course if you are looking for a little Zombie at night, you might do Zyrtec in the morning and Benedryl for the night time dose.
If the rash has spread to the face or genitals (with boys, that is pretty much a given) you may need a course of steroids.
Dr. Fast, my go to allergist, strongly recommends hitting any poison oak  hard and fast with oral steroids. Dr. Hurd has a more cautious  approach with the steroids. Some kids get a bit hyper from them, so if the rash is mild enough, she would rather stick with the topical symptomatic relief remedies. My daughter Alana was on a course of steroids once and that week she ended up sewing several pairs of pajamas because she didn't seem to know what else to do with her body. Steroids can make you feel weird but a short term course is not dangerous. A less than 10 day course does not need to be weaned down although several doctors in our office all have different ways of prescribing the steroids.
It is a good idea to learn how to recognize poison oak even though the plant can spread the oil when there are no leaves, so nature isn’t making it all that easy to avoid.
Most of the time there are three leaves. At some points there may be little flowers and berries. During some seasons the leaves turn red.
If there are thorns it isn’t poison oak (of course now you will be calling me about thorn issues. Stay on the path!)
It is rampant all over the Bay Area, but if you are heading up to the mountains you can take some comfort in in knowing that poison oak does not grow above 4300 feet.
If you are in the vicinity where  Poison oak is being burned, be careful, burning can cause irritated airways, eyes...etc.
Know your area. Many places will have warning signs posted that there is poison oak in the area.
Be prepared. Stay on the paths. Wash of any areas of skin that have had potential exposure. Most importantly, make sure to scrub your hands especially under the nails, when coming in from a hike.

Friday, March 17, 2017

Flat heads/physical therapy/chiropractor resources


FLAT HEADS
In 1992, the American Academy of Pediatrics initiated the "back to sleep" program in order to try to combat Sudden Infant Death Syndrome. Since this program began, the rate of SIDS has decreased by over 40% .
An unintended consequence though was the number of babies who have flat heads from spending so much time on their backs. Nice round heads are becoming a real rarity.
Newborn’s skulls have a lot of plasticity, so they are pretty susceptible to external pressure. Up until about six months of life, the skull is naturally thin and flexible. It can easily change shape. It turns out that if you drop a cell phone on your baby’s head it will actually leave a little dent! (Don’t worry he’s fine.)
Babies  don’t have a lot of motor control during their early months, so they can’t always easily re position.
This flat head condition is called plagiocephaly. It occurs about once in 300 births.  Interestingly, little boys are twice as likely to have issues with this, and right side flattening is more common than left.
Positional plagiocephaly does NOT affect brain growth or development, and by ages 4-6 months, most heads have developed a normal shape. But early intervention and recognition can speed up the rounding process
Let's start tummy time early and often. It doesn’t need to be hazing. Even one minute at a time can count.
The first tummy time can be within their first couple of days, having your baby simply laying on you. Don’t worry about the cord (you most likely aren’t that firm of a surface.) Tummy time is an excellent way for them to develop muscles and work on their head control.
Infants lack head control, but they should be able to turn their heads to either side at rest. There are little steps that you can start early to try to avoid letting them have one favorite side.
  • Try to  give each side equal attention.
  • Make sure you swap feeding positions.
  • Offer objects from either side.
  • Alternate directions on the changing table.
  • Consider changing the position of the crib or the orientation of the baby in the crib to reduce the baby’s tendency to look in the same direction.
  • When awake and supervised, prop the baby onto one side with a foam wedge or a towel rolled lengthwise along the baby’s back.
  • Change positions when feeding, carrying, and holding the baby.
  • Provide supervised upright play as soon as the baby has upright head control.
  • During quiet alert times, also encourage mid-line control. Place their hands together and have them look straight at you.
Pay attention to  places other than the crib where their little head is up against a hard surface. Anytime that the baby doesn’t have their heads in contact with a firm surface is a bonus!
It is not recommended that babies have a pillow for night sleeping, but I am fine with one of the memory foam infant pillows for changing tables. There are quite a few options for this available on Amazon.
Janet Green Babb, one of the PT’s listed below, says that one product that her clients have found helpful is a pillow called Mimos Baby Pillow.
Some babies, particularly those with shortened neck muscles may develop a more serious kind of flattening. You may hear this condition referred to as torticollis.  If you find that they don’t easily move their head from side to side easily I would suggest a visit to a Physical Therapist or Chiropractor. It is never too early for an evaluation. I have some resources listed below.
If all of your tummy time and intervention have not been as successful as we like, the next referral will be to the cranio facial or neurosurgery team for an evaluation. Either of those specialists  might end up sending you along to the  pediatric orthotist team. The orthotists do some scanning (no radiation) and become part of the team that is monitoring your child’s head shape. In some cases, the kids may end up with helmets. Insurance companies vary greatly with their coverage of helmet therapy. The orthotist team at UCSF is top notch.
Although helmet therapy is usually not started prior to 5 months of age, there is little downside to having a referral sooner. For those of you interested in further details about the cranial helmet remolding process, see the information at the very bottom of this post. Although we sure do see a lot of kids with flat heads, very few of them end up needing a helmet.

Annie, one of my mom’s whose baby ended up requiring a helmet shared her story and wisdom. Her little guy is a second child with a mellow temperament so she wonders if that led to a bit more time hanging out in his infant seat.
Her doctor repeated the need for tummy time at each visit, but Annie thinks that with a bit of hindsight, if she had seen a helmet in her future she would have been more aggressive with it. At 2 months she did end up at the chiropractor who loosened up the neck muscles.
These treatments made a big difference in his favoring one side over the other, but this little guys head was seriously flat and keeping him off of it did not seem to be helping as much as we needed it to. Annie adds a healthy dose of perspective:  “There are worse things, We are fortunate to live in a place where this can be fixed.”

Physical Therapists
Pinnacle Kidz is a terrific pediatric physical therapy resource in our neighborhood. The owner Bethany, has been making a big difference for quite a few of my patients.
1772 Church Street
www.pinnaclekidz.com
415-654-5324
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The UCSF physical therapy is still over at 500 Parnassus, Room MU-09. At some point they will likely move over to Mission Bay, but not in the near future.
Ph: 415-353-4972
Fx: 415-353-4974
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Janet Green Babb is a physical therapist that we have been working with for years. Her office is out in the avenues, but many folks find it worth the “schlep.”
4200 Irving Street San Francisco, CA 949122
415-664-6061
Babb.devprog@gmail.com
Janet notes that It is interesting how many babies are experiencing flat heads and preferential head turning. Early intervention seems to be so effective in preventing further asymmetry and for promoting midline and symmetrical orientation.
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Starfish Therapies is a pediatric physical therapy provider with several locations in the Bay Area.
They have one of their clinics right in the wonderful KidSpace at 2401 Mission St. here in SF
To inquire about services call 650-638-9142 or email admin@starfishtherapies.com

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Michelle Foosaner Diamond, PT at Children's Therapy Associates
Children's Therapy Associates
They will do home visits in SF with a prescription from your pediatrician. Michelle says that  as few as 1-3 physical therapy visits can teach parents how to prevent the progression of, or correct, positional plagiocephaly when initiated early enough in development.
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Laurel Condro at the Feldenkrais center is another excellent option for physical therapy.
She does group classes as well as individual therapy
415-271-2683
www.feldenkraissf.com

Chiropractors
Claudia Kindler, a local chiropractor in Noe Valley, shared the following statement:"I love working with all of my patients but I hold a special place in my heart for infants.  Their transition into the world is impressive but not always smooth.  I love holding them and feeling their spine and all of their joints and muscles. Because they are so “new”, they are an open book.  As I investigate their spine and come across a subluxation, or a point of interest to me, the infant frequently pauses and makes eye contact.  They are telling me, “Yes, that spot is the problem”.
In working with torticollis in an infant, I am curious how the baby is transitioning- do they prefer to nurse on one side to the other?  Do they only look to one direction?  Do they detest tummy time?   These patterns provide me skeletal clues that should be addressed.  When I feel their neck, upper back and shoulder girdle, I note skeletal challenges that are limiting symmetrical development.  With simple, small and gentle adjustments to the spine and shoulders the skeletal system can relax and return to optimum functioning."
Two other chiropractic options are Sandra Roddy Adams and Laura Sheehan.
They both work out of an office in the inner sunset at 915 Irving Street
Laura Sheehan R.N., D.C.
415-681-1031 or  sheehanchiropractic@gmail.com
laurasheehan.com
Laura says that she has helped many a flat head round out and sometimes with only one visit if it's due to upper cervical strains.
Sandra Roddy Adams happens to be my chiropractor, but she works with all ages. She can be reached at 415-566-1900.

Dr. Austin Davis works on infants and the whole families. One of my readers contacted me to get him added to this list because she has found him enormously helpful
Life Chiropractic


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The following information is provided by the UCSF Orthotic and Prosthetic Center

How The Helmet Works

Approximately 85% of head growth occurs within the first 12 months of life.
During this time the head is moldable and responds to light contact/pressures over extended periods of time. Static positioning (laying in one position for long periods of time) on the back or one side of the head often contribute to the development of plagiocephaly. In a similar fashion, the helmet places contact over the areas that are more prominent and allows space over flattened areas. This encourages the head to grow in the “path of least resistance”. The helmet does not push in areas of the head; it directs growth of the flattened areas of the head.

Depending on the severity of the flatness and the child’s age will determine the treatment options. Under the age of 4 months we typically observe and have parents actively reposition the baby throughout the day, nights and naptime. Babies this young with a mild flat spot can be fully corrected with repositioning alone.

Around the age of 5 months the effectiveness of repositioning is reduced and most health care providers will recommend the initiation of a helmet if the flatness is significant. Ideally if a baby needs a helmet we are starting the treatment between the ages of 5 and 8 months of age.

Insurance

As with all areas of medical care, health insurance is complicated and specific to each individual plan. The authorization staff at UCSF will perform a check with your insurance around the time of your first appointment with an orthotist.

Craniofacial Evaluation

After your pediatrician/family physician has placed a referral for a cranial remolding helmet evaluation. First you must see a Craniofacial specialist to confirm the baby’s presentation is plagiocephaly and not something else called cranial synostosis. This appointment is a requirement prior to making a helmet and is much better if this is done before your first appointment with the orthotic team.

The Helmet Process

Beginning the process for cranial remolding helmets can be daunting for families. The practitioners at UCSF are here for you as you go through this journey. Below is an explanation of the helmet process at UCSF.

 First Appointment – Evaluation

o The first appointment you have with an orthotist (person that is
educated and trained in cranial remolding helmets) to assess your
baby’s head shape, size and gather relevant information. Now is a
good time to ask questions you have about the treatment and what
your expectations should be.

o Measurements: regardless of how the orthotist chooses to capture to
shape of your baby’s head (by hand vs scanning) measurements will
be taken to use as a way to track changes over time. These
measurements will be referred to throughout the helmet treatment to
ensure progress is being made

o Impressions: In order to make a helmet the orthotist must capture
the shape of your baby’s head. The two primary ways are with a cast
and with a laser scanner. The most important piece is that the shape is
well captured and matches the shape of your baby’s head; this will
make the helmet fitting process (we will discuss later) much easier. It
is common for babies to become fussy during this point in the
appointment.

 Casting: Plaster of paris will be used to lay over the baby’s head
to capture the shape of his/her head. This process is messy and
takes about 15 minutes.

 Scanning: The baby will have a laser scan taken to create a
virtual 3-D image of his/her head. The scan itself can take as
few as 3 seconds, but the baby must be extremely still
(typically multiple attempts are made).

 Fitting Appointment

o The helmet has been made and is ready to fit to your baby. The
appointment will take 1-2 hours, so bring diapers and food just to be
safe. The orthotist will put the helmet on the baby’s head and mark
the helmet in areas that are too long and need to be removed. The
orthotist will take the helmet off and on the baby’s head multiple
times throughout this appointment to ensure it is fitting properly. It is
common for babies to be upset/fussy throughout this appointment.

o The helmet should not be immobile on the baby’s head. A small
amount of shifting and rotation on the baby’s head is acceptable, so
long as the helmet is not: coming in front of the baby’s eyes, touching
the baby’s ears, or squishing the forehead.

o You will be given a break-in schedule to slowly increase the amount of
time your baby wears the helmet. Even after she/he has built up to
wearing the helmet full-time you will need to monitor the skin for
excessive redness every time you take the helmet off. Red marks
lasting more than an hour or skin irritation require the helmet to be
removed and your orthotist should be contacted for an adjustment.

 One week follow-up appointment

o Over the first week of having the helmet you and the baby slowly
increase to wearing the helmet full-time (23 hours/day). This
appointment is to check the fit of the helmet now that they are able to
wear the helmet full-time. Minor adjustments are expected at this
appointment.

o Typically, redness that lasts less than an hour is okay. If you are
concerned about the redness on your child’s head make sure to
discuss this with the orthotist at your appointment.

 One month follow-up appointment

o These appointments should occur every 3-5 weeks to assess the
progress being made with the helmet and to accommodate for any
growth that has happened in the last month. Typically the orthotist
will take measurements and/or a scan to evaluate the changes in your
baby’s head shape.

o In general, a change in your baby’s head shape happens if there has
been growth over the last month. It is common for babies to have
large growth spurts followed by smaller growth spurts. There may be
some appointments where you see a large change in your baby’s head
shape, and some appointments where you see very little change in
your baby’s head shape. For this reason we are measuring and
checking the baby’s head shape every 3-5 weeks to ensure the helmet
is doing what it should be.

 Adjustments

o Despite trying to accommodate for growth on a regular basis (by
having an appointment every 3-5 weeks), sometimes the babies go
through large growth spurts and need adjustments sooner than
planned. This is okay.

o When to call the orthotist for an adjustment:

  • Redness lasts for more than 1 hour and is still very red
  • The helmet seems too tight
  • The baby is suddenly resistant to wearing the helmet when
  • previously they tolerated it well
  • Determining the end of treatment
o The typical length of treatment is 3-5 months, this will depend on the
age when the baby begins wearing the helmet and how severe of a
flattened spot is to begin with. With older babies we expect to have a
longer treatment time because their heads do not grow as quickly.
They can wear the helmet up to 15 months of age, beyond this age
there is limited evidence to support the effectiveness of the helmet.

o Clinical markers are used to numerically compare your baby’s head
shape to “normal”. These markers are helpful in determining a
slowing of growth and provide an objective assessment of the changes
in the head shape over time.

o Satisfaction with head shape and appearance is the ultimate goal. This
is used in addition to the clinical markers to decide the end of the
treatment.

Friday, March 10, 2017

Finding Balance/ The pie theory of life

Finding balance/
an update of one of my top ten favorite posts

The "pie theory" got its inception many years ago. For a number of years I was the Parent Association President at my daughters' elementary school. It took an inordinate amount of my spare time, including meetings several times a week. On many levels it was rewarding being so involved but I assure you, I was delighted to pass the reins when my stint was over. Though I was really genuinely relieved to have my time back, I felt off balance by all the sudden free time in my schedule, and at first I couldn't figure out why I was so unsettled. I finally realized that although the new empty hours were welcome, they had created a bit of a vacuum. I filled it quickly (started taking up karate a few evenings a week), but it was right around that transition period that the "pie theory" helped me make sense of things.
Imagine that your identity is a circle (or whole pie). Who you are is divided into many pieces; some pieces are large, some small, some temporary. Some are constants that are with you life long, some are optional, some are good for your soul, while still others are energy sappers that give you little in return.

Are you:
Daughter?
Son?
Sibling?
Friend?
Spouse?
Ex spouse?
Grandparent?
Student?
Volunteer?
Pet owner?
In a job/occupation or seeking one?
Doing a hobby that takes time and energy?
Member of a book club or any club for that matter?
Churchgoer?
Exerciser?
House cleaner?
Carpool driver?
Event planner?
Adventure seeker?
and of course last but not least....
Parent?
The list goes on and on. What activities make up your day, your week, your month, your year? What pieces make up your pie? Take a few moments to figure it out. Get a piece of paper and a working pen (if you can find one) and create your pie.
It's interesting to think how you can be identified in different ways by the various pieces of pie. Many folks recognize me as Nurse Judy. More than once I have actually looked at a rash, or given advice from a restaurant table (as my patient husband rolls his eyes.) There was a time years ago when I came to work one day and saw a construction worker on the roof of a neighboring building. He looked awfully familiar and I was struggling to place him; was he a parent from the practice? Someone from school? I could see that he recognized me as well; we kept looking at each other and a moment passed. I could see that he had figured it out first. He gave a big grin and called out "Ahoy there Java's mom!" Of course! I ran into him several times a week with his pack of dogs when I walked my dog Java. Not only did being a dog owner dictate my daily schedule and get me out walking rain or shine, it also included me as a member of a distinct social network in the neighborhood for many years. All the dog owners knew each other by sight and all the dogs by name. Being "Java's mom" was a wonderful piece of my "pie" for 12 years. If you are a pet owner, that piece has a very special place allotted to it.
Your pie is finite. You can only do and be so much, as there are only so many hours in the day. Some folks have too many things competing for time and attention, and figuring out which pieces can be compressed can be quite stressful. Sometimes we make poor choices
For busy working parents this might be a foreign concept, but some folks don't actually have enough pieces to begin to fill the shell. A big empty pie can be just as unsettling as a full one.
Have you ever noticed that when you are super busy you can manage to get through an entire to-do list very efficiently? On the other hand, on a quiet day you may have only one or two things on the list but somehow nothing gets done.
A healthy pie has plenty of interesting pieces that can grow and shrink according to your needs. The more forgiving and elastic the pieces, the easier time you will have finding a good balance.
Your pie will naturally change from year to year, but some changes are enormous. Some people are quite comfortable having a very crowded pie, while others are quite fine and happy doing nothing at all. Part of this is figuring out what your ideal is, and work towards that.
Any large sudden changes to your pie will make you feel unsettled, way less so if you have a glimmer of what is going on; hence this theory. Both of my daughters have taken this to heart. In fact Alana has permitted me to share her own blog post on the Pie Theory that she wrote several years ago:
(Blogging runs in the family I guess)
When there is a large shift in your pieces my girls and I refer to this as "pie disequilibrium."  Common culprits might include:
Event planner:
Folks planning a wedding or large event can spend months dealing with all the fun details. When the event is over, that planner piece is gone, your pie has a gap.
Sports Fan:
My daughter Alana has a twinge of "Pie Disequilibrium" every October when baseball season is over
Actor:
My daughter Lauren had to learn how to deal with the extra time that appears after a show run is over.
Caregiver:
Folks that spend much of their time and energy tending to someone else’s needs might find themselves suddenly with a large vacuum when that person is gone or no longer needs them.
Parent:
As your children grow up and don't need you in quite the same capacity it can be a tough adjustment (don't worry, they still love you.) Luckily this happens in stages. Kindergarten...a full day of school...college. Parents who have the "parent piece" taking up the entire pie may suffer.  
Huge life changes will create seismic shifts. Nothing will ever match the huge transitions that take place when you add the parent piece to your pie. My best advice to you as you shuffle all your pie pieces and see how things fit comfortably is to identify pieces that need to be protected so that they don't get too small.
DO NOT IGNORE YOUR PARTNER!
Protect that piece. Get creative and make sure that you have time for the two of you; have some moments being a couple.
DO NOT IGNORE YOUR OWN NEEDS!
Being the best parent that you can be includes living by example. Let your kids have parents that are multifaceted and not consumed by any one thing (be that parenting or a job.)
Best of luck finding a balanced, interesting, and fulfilling pie!

Monday, March 6, 2017

Dealing with Loss


 I lost my mom this week.
Earlier in the week our office lost a patient one day and a mom the next. Those were tragedies. An 86 year old woman, who was able to peacefully pass away in her own bed with her family around her is not.
Not a tragedy, but oh so sad. No one is ever really ready.
My mom was pretty amazing. She was a force of good. She routinely wrote letters to strangers who were kind and good at their jobs. She actively reached out to lonely friends, family, and acquaintances to let them know that someone was thinking of them. She was the second mom to all of my childhood friends. She was the kindergarten teacher who remained beloved by all of her students. She was incredibly charitable. I was incredibly blessed with both of my parents.
A wise friend once shared a theory with me that the world is like a scale that is a precarious balance between good and evil.  The smallest act of kindness might be the essential spark that is making the difference in tipping the scale in the right direction.
It is going to take a lot of kindness and good deeds to make up for her loss.
In her memory I am rerunning this post about loss:

Dealing with loss/helping your child cope
 
Laughter/Crying/Happiness/Sadness. Life is such a balance.


Assuming you are lucky enough to have people, pets, or even objects that you care about, then dealing with loss is inevitable.


If you have a child, you need to be prepared to know how to approach the subject.
Parents, it may be helpful to ask yourselves the following questions:

  • How do you, yourself deal with loss?
  • What do you believe? Some folks have a deep faith that there is  “More to it than this,”  and others think that “this is it.”
  • Are you comfortable sharing your belief system with your children?
  • How do you find comfort?
  • What can your friends and family do for you when you are grieving? Do you need hugs or space??

There is not one simple approach for every person, child, or family. My mother-in-law liked to say that there is no right or wrong way to grieve. There are no rules. It is important to be supportive of the different paths that people take. There are also many cultural factors that may impact the situation.


If your family is hit with a loss, sudden or anticipated, unless we are talking about a goldfish, likely the death is hitting you just as hard, if not harder, than it is impacting your child ,though don’t minimize the loss of that goldfish as a valuable opportunity for ritual and conversation.( My husband managed to delay the "goldfish conversation" several times with a visit to the "24 fish store" where Goldie was replaced several time with no one the wiser)


The routine losses that the families in my practice deal with most often are the passing of a grandparent or beloved family pet. Those are the lucky ones. An anticipated loss is no less devastating, but this is the cycle of life that is sad but not shocking. Others are flattened by the loss of a partner, friend, sibling, child.


Parents don’t usually have the luxury of collapse. How do you help your child when you yourself are dealing with all the grief?


There are factors to keep in mind for each age that you are dealing with.
  • ages 2-4 generally don’t grasp the concept of death as permanent
  • ages 4-7 may feel responsible for the death because of their thoughts, actions, or lack of action
  • age 7-11 just starting to see death as something irreversible
  • over 11 has a better understanding about the loss


Not to make light of the subject, but here is a classic family anecdote:


When Lauren was between 3 or 4, she went through a phase of obsessing over several musicals and movies that were centered around orphans. Annie and Disney's The Rescuers are ones that comes to mind, but I know there were others. One day she asked, “what is an orphan?”

We discussed that an orphan was someone who didn’t have any parents. We immediately went on to say that she was very lucky that she had both mommy and daddy, but if in the very unlikely event that anything ever happened to both of us, her aunt and uncle, Barbara and Richard, would be her guardians. She was quiet for a moment and then said, “ I had better have their phone number.”

Hmmmm.


Do's and Don't s


Do NOT say that an animal was “put to sleep” or use any phrase that can confuse your child. The words “passed away” are also fairly passive and confusing. They might wonder if that could happen to them at any time. Do NOT lie. Find a way to convey truth that you are comfortable with. Your child will know that you are very upset. Shielding them from honesty and communication is not doing them a favor. It is okay to be sad. It is okay to cry.


Find a ritual that you feel comfortable embracing. Take comfort in happy memories. Celebrate the life of the one you lost! Tell wonderful stories. Don’t be afraid to laugh.
Honor the memories with kind gestures.


Finding a good therapist to help you or your child give you coping tools is often a good idea. Check to make sure that the therapist has experience dealing with bereavement issues.


Books and stories can be an excellent launching off point for discussions. If you can’t come to terms with how you feel about death, you might be able to turn the spotlight  away from you with lines like:

“Some people believe…”
“Other people think……”

In my search for further local resources I reached out to my old friend Dr. Nancy Iverson.
Nancy has not only written several published articles about the grieving process, but has been involved in facilitating various support groups for many years. She pointed me towards Josie’s Place. (It was a bit of a treasure hunt.)

This is a small but wonderful center here in San Francisco that offers support groups and other services for families and children who have experienced loss.

Josie’s Place:
415-513-6343
Groups meet in the Inner Sunset

If you scroll down to the bottom of the home page on their website in the "Articles on Grief/Grief Resources" tab, Pat Murphy, the director has cobbled together a list of other local resources that might be useful.


Janet Jaskula, RN, MS, A pediatric hospice nurse, also shared her list of resources:


This is a great book about what loss and grief can do if one does not deal with it.  Kids and adults.


"Fall of Freddie the Leaf" by Leo Buscaglia  


"Velveteen Rabbit" by Margery Williams


"There is a Rainbow Behind Every Dark Cloud"  written by a group of children with leukemia who attended The Center for Attitudinal Healing.

A Lion in the House Movie that follows several children and teens and their families through illness and loss, grief and death. Though not all of the kids in the film die, they are certainly affected by their illnesses and loss of their "normal" childhood and teen years.

The Giving Tree Shel Silverstein. 


For parents, check out the the website of Barbara Karnes. Barbara Karnes is the author of  "Gone From My Sight."  She has some excellent combo coloring/story books about loss for kids.


Dr Nancy Iverson recommends the book:
"Never Too Young to Know" by Phyllis Rolfe Silverman


The very helpful children's librarian Liesel Harris-Boundy at the San Francisco Public Library West Portal Branch did some research for me and came up with some good choices for kids. Scroll down to the end of the post for her list.

*****************************************************************************************

I saw the following gem circulating around the internet and it resonated with me. I thought it worth sharing.

Someone put out a post asking for help dealing with grief. This answer was the response from a fellow in his late 70s:


I'm old. What that means is that I've survived (so far) and a lot of people I've known and loved did not.


I've lost friends, best friends, acquaintances, co-workers, grandparents, mom, relatives, teachers, mentors, students, neighbors, and a host of other folks. I have no children, and I can't imagine the pain it must be to lose a child. But here's my two cents...


I wish I could say you get used to people dying. But I never did. I don't want to. It tears a hole through me whenever somebody I love dies, no matter the circumstances. But I don't want it to "not matter". I don't want it to be something that just passes. My scars are a testament to the love and the relationship that I had for and with that person. And if the scar is deep, so was the love. So be it.


Scars are a testament to life. Scars are a testament that I can love deeply and live deeply and be cut, or even gouged, and that I can heal and continue to live and continue to love. And the scar tissue is stronger than the original flesh ever was. Scars are a testament to life. Scars are only ugly to people who can't see.


As for grief, you'll find it comes in waves. When the ship is first wrecked, you're drowning, with wreckage all around you. Everything floating around you reminds you of the beauty and the magnificence of the ship that was, and is no more. And all you can do is float. You find some piece of the wreckage and you hang on for a while. Maybe it's some physical thing. Maybe it's a happy memory or a photograph. Maybe it's a person who is also floating. For a while, all you can do is float. Stay alive.


In the beginning, the waves are 100 feet tall and crash over you without mercy. They come 10 seconds apart and don't even give you time to catch your breath. All you can do is hang on and float. After a while, maybe weeks, maybe months, you'll find the waves are still 100 feet tall, but they come further apart. When they come, they still crash all over you and wipe you out. But in between, you can breathe, you can function. You never know what's going to trigger the grief. It might be a song, a picture, a street intersection, the smell of a cup of coffee. It can be just about anything...and the wave comes crashing. But in between waves, there is life.


Somewhere down the line, and it's different for everybody, you find that the waves are only 80 feet tall. Or 50 feet tall. And while they still come, they come further apart. You can see them coming. An anniversary, a birthday, or Christmas, or landing at O'Hare. You can see it coming, for the most part, and prepare yourself. And when it washes over you, you know that somehow you will, again, come out the other side. Soaking wet, sputtering, still hanging on to some tiny piece of the wreckage, but you'll come out.


Take it from an old guy. The waves never stop coming, and somehow you don't really want them to. But you learn that you'll survive them. And other waves will come. And you'll survive them too.


If you're lucky, you'll have lots of scars from lots of loves. And lots of shipwrecks.

*****************************************************************************************

Liesel Harris-Boundy's recommended reading list:

Life Is Like the Wind by Shona Innes - 2014 Written by a clinical child psychologist, Barron's "A Big Hug" series offers a gentle and direct approach to the emotional issues that children face. This book introduces the concept of death to young readers by likening life to the ever-moving wind.






Missing Mommy by Rebecca Cobb - 2013


Ben's Flying Flowers by Inger M. Maier - 2012 Emily introduces her younger brother, Ben, to butterflies, which he calls "flying flowers," and when his illness makes him too weak to go see them she draws him pictures, but after his death she no longer wants to draw happy things. Includes note to parents.


Harry & Hopper by Margaret Wild  - 2011 Harry is devastated when he returns home from school to find that his beloved dog, Hopper, will no longer be there to greet him.


The Blue House Dog by Deborah Blumenthal - 2010 A boy whose beloved dog has died, and a dog whose owner also died, find each other and slowly begin to trust one another.


Always by My Side by Susan Kerner - 2013 A rhyming story written to help children understand that a dad's love is forever. Even if they grow up without his presence in their lives.

Rabbityness by Jo Empson - 2012 Rabbit enjoys doing rabbity things, but he also loves un-rabbity things! When Rabbit suddenly disappears, no one knows where he has gone. His friends are desolate. But, as it turns out, Rabbit has left behind some very special gifts for them, to help them discover their own unrabbity talents! Rabbityness celebrates individuality, encourages the creativity in everyone and positively introduces children to dealing with loss of any kind.


The Scar by Charlotte Moundlic. When his mother dies, a little boy is angry at his loss but does everything he can to hold onto the memory of her scent, her voice, and the special things she did for him, even as he tries to help his father and grandmother cope.


Remembering Crystal by Sebastian Loth - 2010 Zelda the goose learns about death and loss when her turtle friend Crystal disappears from the garden one day.


A Path of Stars By Anne Sibley O'Brien - 2012 A refugee from Cambodia, Dara's beloved grandmother is grief-stricken when she learns her brother has died, and it is up to Dara to try and heal her.


I Remember Miss Perry by Pat Brisson - 2006 When his teacher, Miss Perry, is killed in a car accident, Stevie and his elementary school classmates take turns sharing memories of her, especially her fondest wish for each day.
Dealing with loss/helping your child cope

Laughter/Crying/Happiness/Sadness. Life is such a balance.


Assuming you are lucky enough to have people, pets, or even objects that you care about, then dealing with loss is inevitable.


If you have a child, you need to be prepared to know how to approach the subject.
Parents, it may be helpful to ask yourselves the following questions:

  • How do you, yourself deal with loss?
  • What do you believe? Some folks have a deep faith that there is  “More to it than this,”  and others think that “this is it.”
  • Are you comfortable sharing your belief system with your children?
  • How do you find comfort?
  • What can your friends and family do for you when you are grieving? Do you need hugs or space??

There is not one simple approach for every person, child, or family. My mother-in-law liked to say that there is no right or wrong way to grieve. There are no rules. It is important to be supportive of the different paths that people take. There are also many cultural factors that may impact the situation.


If your family is hit with a loss, sudden or anticipated, unless we are talking about a goldfish, likely the death is hitting you just as hard, if not harder, than it is impacting your child ,though don’t minimize the loss of that goldfish as a valuable opportunity for ritual and conversation.( My husband managed to delay the "goldfish conversation" several times with a visit to the "24 fish store" where Goldie was replaced several time with no one the wiser)


The routine losses that the families in my practice deal with most often are the passing of a grandparent or beloved family pet. Those are the lucky ones. An anticipated loss is no less devastating, but this is the cycle of life that is sad but not shocking. Others are flattened by the loss of a partner, friend, sibling, child.


Parents don’t usually have the luxury of collapse. How do you help your child when you yourself are dealing with all the grief?


There are factors to keep in mind for each age that you are dealing with.
  • ages 2-4 generally don’t grasp the concept of death as permanent
  • ages 4-7 may feel responsible for the death because of their thoughts, actions, or lack of action
  • age 7-11 just starting to see death as something irreversible
  • over 11 has a better understanding about the loss


Not to make light of the subject, but here is a classic family anecdote:


When Lauren was between 3 or 4, she went through a phase of obsessing over several musicals and movies that were centered around orphans. Annie and Disney's The Rescuers are ones that comes to mind, but I know there were others. One day she asked, “what is an orphan?”

We discussed that an orphan was someone who didn’t have any parents. We immediately went on to say that she was very lucky that she had both mommy and daddy, but if in the very unlikely event that anything ever happened to both of us, her aunt and uncle, Barbara and Richard, would be her guardians. She was quiet for a moment and then said, “ I had better have their phone number.”

Hmmmm.


Do's and Don't s


Do NOT say that an animal was “put to sleep” or use any phrase that can confuse your child. The words “passed away” are also fairly passive and confusing. They might wonder if that could happen to them at any time. Do NOT lie. Find a way to convey truth that you are comfortable with. Your child will know that you are very upset. Shielding them from honesty and communication is not doing them a favor. It is okay to be sad. It is okay to cry.


Find a ritual that you feel comfortable embracing. Take comfort in happy memories. Celebrate the life of the one you lost! Tell wonderful stories. Don’t be afraid to laugh.
Honor the memories with kind gestures.


Finding a good therapist to help you or your child give you coping tools is often a good idea. Check to make sure that the therapist has experience dealing with bereavement issues.


Books and stories can be an excellent launching off point for discussions. If you can’t come to terms with how you feel about death, you might be able to turn the spotlight  away from you with lines like:

“Some people believe…”
“Other people think……”

In my search for further local resources I reached out to my old friend Dr. Nancy Iverson.
Nancy has not only written several published articles about the grieving process, but has been involved in facilitating various support groups for many years. She pointed me towards Josie’s Place. (It was a bit of a treasure hunt.)

This is a small but wonderful center here in San Francisco that offers support groups and other services for families and children who have experienced loss.

Josie’s Place:
415-513-6343
Groups meet in the Inner Sunset

If you scroll down to the bottom of the home page on their website in the "Articles on Grief/Grief Resources" tab, Pat Murphy, the director has cobbled together a list of other local resources that might be useful.


Janet Jaskula, RN, MS, A pediatric hospice nurse, also shared her list of resources:


This is a great book about what loss and grief can do if one does not deal with it.  Kids and adults.


"Fall of Freddie the Leaf" by Leo Buscaglia  


"Velveteen Rabbit" by Margery Williams


"There is a Rainbow Behind Every Dark Cloud"  written by a group of children with leukemia who attended The Center for Attitudinal Healing.

A Lion in the House Movie that follows several children and teens and their families through illness and loss, grief and death. Though not all of the kids in the film die, they are certainly affected by their illnesses and loss of their "normal" childhood and teen years.

The Giving Tree Shel Silverstein. 


For parents, check out the the website of Barbara Karnes. Barbara Karnes is the author of  "Gone From My Sight."  She has some excellent combo coloring/story books about loss for kids.


Dr Nancy Iverson recommends the book:
"Never Too Young to Know" by Phyllis Rolfe Silverman


The very helpful children's librarian Liesel Harris-Boundy at the San Francisco Public Library West Portal Branch did some research for me and came up with some good choices for kids. Scroll down to the end of the post for her list.

*****************************************************************************************

I saw the following gem circulating around the internet and it resonated with me. I thought it worth sharing.

Someone put out a post asking for help dealing with grief. This answer was the response from a fellow in his late 70s:


I'm old. What that means is that I've survived (so far) and a lot of people I've known and loved did not.


I've lost friends, best friends, acquaintances, co-workers, grandparents, mom, relatives, teachers, mentors, students, neighbors, and a host of other folks. I have no children, and I can't imagine the pain it must be to lose a child. But here's my two cents...


I wish I could say you get used to people dying. But I never did. I don't want to. It tears a hole through me whenever somebody I love dies, no matter the circumstances. But I don't want it to "not matter". I don't want it to be something that just passes. My scars are a testament to the love and the relationship that I had for and with that person. And if the scar is deep, so was the love. So be it.


Scars are a testament to life. Scars are a testament that I can love deeply and live deeply and be cut, or even gouged, and that I can heal and continue to live and continue to love. And the scar tissue is stronger than the original flesh ever was. Scars are a testament to life. Scars are only ugly to people who can't see.


As for grief, you'll find it comes in waves. When the ship is first wrecked, you're drowning, with wreckage all around you. Everything floating around you reminds you of the beauty and the magnificence of the ship that was, and is no more. And all you can do is float. You find some piece of the wreckage and you hang on for a while. Maybe it's some physical thing. Maybe it's a happy memory or a photograph. Maybe it's a person who is also floating. For a while, all you can do is float. Stay alive.


In the beginning, the waves are 100 feet tall and crash over you without mercy. They come 10 seconds apart and don't even give you time to catch your breath. All you can do is hang on and float. After a while, maybe weeks, maybe months, you'll find the waves are still 100 feet tall, but they come further apart. When they come, they still crash all over you and wipe you out. But in between, you can breathe, you can function. You never know what's going to trigger the grief. It might be a song, a picture, a street intersection, the smell of a cup of coffee. It can be just about anything...and the wave comes crashing. But in between waves, there is life.


Somewhere down the line, and it's different for everybody, you find that the waves are only 80 feet tall. Or 50 feet tall. And while they still come, they come further apart. You can see them coming. An anniversary, a birthday, or Christmas, or landing at O'Hare. You can see it coming, for the most part, and prepare yourself. And when it washes over you, you know that somehow you will, again, come out the other side. Soaking wet, sputtering, still hanging on to some tiny piece of the wreckage, but you'll come out.


Take it from an old guy. The waves never stop coming, and somehow you don't really want them to. But you learn that you'll survive them. And other waves will come. And you'll survive them too.


If you're lucky, you'll have lots of scars from lots of loves. And lots of shipwrecks.

*****************************************************************************************

Liesel Harris-Boundy's recommended reading list:

Life Is Like the Wind by Shona Innes - 2014 Written by a clinical child psychologist, Barron's "A Big Hug" series offers a gentle and direct approach to the emotional issues that children face. This book introduces the concept of death to young readers by likening life to the ever-moving wind.






Missing Mommy by Rebecca Cobb - 2013


Ben's Flying Flowers by Inger M. Maier - 2012 Emily introduces her younger brother, Ben, to butterflies, which he calls "flying flowers," and when his illness makes him too weak to go see them she draws him pictures, but after his death she no longer wants to draw happy things. Includes note to parents.


Harry & Hopper by Margaret Wild  - 2011 Harry is devastated when he returns home from school to find that his beloved dog, Hopper, will no longer be there to greet him.


The Blue House Dog by Deborah Blumenthal - 2010 A boy whose beloved dog has died, and a dog whose owner also died, find each other and slowly begin to trust one another.


Always by My Side by Susan Kerner - 2013 A rhyming story written to help children understand that a dad's love is forever. Even if they grow up without his presence in their lives.

Rabbityness by Jo Empson - 2012 Rabbit enjoys doing rabbity things, but he also loves un-rabbity things! When Rabbit suddenly disappears, no one knows where he has gone. His friends are desolate. But, as it turns out, Rabbit has left behind some very special gifts for them, to help them discover their own unrabbity talents! Rabbityness celebrates individuality, encourages the creativity in everyone and positively introduces children to dealing with loss of any kind.


The Scar by Charlotte Moundlic. When his mother dies, a little boy is angry at his loss but does everything he can to hold onto the memory of her scent, her voice, and the special things she did for him, even as he tries to help his father and grandmother cope.


Remembering Crystal by Sebastian Loth - 2010 Zelda the goose learns about death and loss when her turtle friend Crystal disappears from the garden one day.


A Path of Stars By Anne Sibley O'Brien - 2012 A refugee from Cambodia, Dara's beloved grandmother is grief-stricken when she learns her brother has died, and it is up to Dara to try and heal her.


I Remember Miss Perry by Pat Brisson - 2006 When his teacher, Miss Perry, is killed in a car accident, Stevie and his elementary school classmates take turns sharing memories of her, especially her fondest wish for each day.