Friday, April 28, 2017

The poop series chapter two/ Along comes solids

Topic of the Week: chapter two of the Poop Series

Baby Poop: Along comes solids
Baby poop is a fairly benign substance. Once you start feeding your little one solids, everything is about to change.
I remember an email that I got one Sunday morning. I should have known better then to open it when I was sitting down to eat breakfast. The subject line was “undigested carrots, is this normal?”
The answer was yes, but there needed to be a much stronger warning for the attached photo.
As your child learns to digest substances other than milk, the consistency of the stool will change. As I tell the parents who come to my solid foods class, "You are the Conductor of the Poop Orchestra."
What I mean by this is that you are in charge of how much milk, how much solid food and how much extra fluid goes into your baby. You should pay attention to the outcome and make adjustments as needed. You don't want watery stools and you certainly don't want formed little pellets.
The goal is for the stools to remain soft. At at the risk of ruining your appetite or changing your dinner plans,( if I haven’t done so already),  think hummus.
Unless you are in a very hot climate, until your baby starts solids, it is unlikely that they need extra water in their diet. Once they start eating food,it is time to get in the habit of offering water throughout the day. If the stool is getting thicker, the first thing to do is add a little extra fluid to the diet. Plain water or very diluted prune juice are good options.
Most foods are fairly neutral but some  will help keep the stools soft.  Many fruits and veggies fall into this category. Prunes, pears and peas are some of my favorites. A little molasses can also get things moving.
On the other hand, some  foods tend to make the poops more solid. Keep in mind that if your older child ever has diarrhea, we will suggest the BRAT diet. This is a diet with bland starchy foods such as bananas, rice, or applesauce (the apples have pectin with tends to be binding) and toast.
Those foods are certainly fine for your beginning eater, but if the stool is getting thick, there are better choices for first foods.
Some organic formulas seem to bind up my patients, so keep an eye on that. 
With the addition of new foods, the poops can be quite fascinating. Different colored foods can give you a rainbow of different poop shades. My daughter Alana once unbeknownst to me ate a pint of blueberries and had a bright blue load in her diaper that caught me by surprise to say the least. Anything with red color can stain it red. Beets are the obvious culprits, but watermelon can least to an interesting shade.
Bananas can cause little brown thread-like substances to be in there; imagine a piece of banana cake. When I get the frantic “there are little brown worms in my babies poop” call, the first question is whether or not they had bananas.
Most babies start the solid food journey with pureed food. As soon as they are able, I like to do a combination of feeding styles and introduce some “Baby led weaning”. With this method, babies can simply pick up soft pieces of food and feed themselves.  Once they start eating little pieces be prepared to see some of those same pieces pass through without being digested. This is normal.
Constipated kids are really miserable. Please be proactive with diet, fluids and fiber and make sure it doesn't happen on your watch. If you know there is a bunch of hard stool in there, all the prunes in the world aren't going to help you. You may need to go in from the bottom and help get the plug out (see the earlier postregarding the glycerin options.) Once the hard piece comes out, focus on finding your balance with fluids and solids so that you aren't dependent on a suppository; I have no problem with occasional use.
If you ever see blood in the stool at this age, it can be caused by poop at either end of the consistency spectrum. A very hard stool can cause a little tear near the anus. Lots of diarrhea can cause irritation that can bleed. If you are seeing blood with no obvious cause, or very mucousy stools, check in with your doctor.

Thursday, April 20, 2017

The Poop Series/ Chapter one/ Baby Poop

Most folks don't realize when they sign up for this "parenthood" gig that poop is going to be the frequent subject of many conversations. I am not kidding when I tell you that I have poop related phone calls every single day. It helps to know what is normal so that you don't worry.
I remember as if it were yesterday, my husband Sandy's first real experience changing a poop laden diaper. He soon became an expert, but that first one was a disaster. Lauren's little feet managed to get covered in poop, and before he knew it there was poop all over the place, including most of the baby and part of the walls. 
When babies are first born the stools are very dark and tarry. This is called meconium.
The meconium is very sticky and can be a bit challenging to clean. Vaseline, Aquaphor or Cerave ointment can help you gently remove the meconium from your child’s delicate skin.
Once babies start to successfully feed, the stools will gradually transition to a lighter color.
Normal colors range from yellow, orange, green or brown. I rarely pay much attention to color unless it is accompanied by a fussy baby or other symptoms that are telling us that something is off.
Those first bowel movements help signal us that the system is working and that the baby is actually getting milk. We certainly want to encourage breast feeding, but I understand that it is not an option for everyone. If you can make nursing work, there are a lot of benefits. If it feels overwhelming, try to give it at least 2 weeks before you give up. Take advantage of the excellent lactation assistance that is out there.
One of the real challenges for a nursing mom, is that It is harder to track the milk intake for the breast fed babies. It can be hard for new parents to be certain that the baby is successfully nursing. The baby might be hanging out on the breast for hours, but not reliably transferring adequate milk. The not-being-able-to-know-for-sure how much the baby was getting drove me nuts with my firstborn. Listening for swallowing and watching mom's breasts to see that the milk is coming in will give important clues, but when we see those first yellow stools I always want to give mom a big congratulatory hug. Yellow stools are proof that the baby is getting milk. If a baby is fed from a bottle, then of course we can track how much they are eating fairly easily.
Normal breast milk stools are very squirty and yellowish. Some may have little seeds. Think Mustard. (You may want to change your plans for having lunch at the deli today)
It seems that almost every new parent gives me a call to make sure it is okay for the stools to be so runny. Yes it is. Diarrhea would be clear watery stools with only flecks. Baby poop is routinely very liquidy. Remember, they are not eating any solid food, liquid in/liquid out!  Some babies seem to have loud squirty poops every time they eat (or as soon as you have put a fresh diaper on them). As long as it has a color, it is likely fine.
There are many factors that can impact the color. Stools from a formula fed baby tend to be a bit greener than the yellow ones we get from breast milk. Grippe water can also make stools greenish, as can the lack of hind milk. (see the colic post)
If blood is noted in the stool, we certainly want to be notified, but most of the time it is not something I am alarmed about as long as the baby looks good...(Is their color fine? The belly nice and soft? Are they eating well?)
Red blood is usually fresh and comes from near the anus. It can be caused by the gentle skin down there getting irritated.
Darker blood is not as fresh and comes from higher up in the digestive tract. My first question will be about mom's nipples. If they are very sore, it is likely that there was some bleeding and the blood we are seeing in the stool is mom's blood. (I know, yuck.)
If stools are mucousy with some fresh blood it can also be connected to mom’s diet. Often removing dairy completely will alleviate the issue.
Once we see that the baby is gaining weight and having a regular pooping pattern we are no longer concerned about monitoring the frequency.
It is quite common for babies who used to have frequent poops, to suddenly shift to way less frequent stools.
As long as the stools remain soft it is not something that concerns us. Some babies go as infrequently as once a week.
It is also quite normal for babies to grunt, groan and turn bright red as they work on a bowel movement.
It is considered constipation when the actual stool is hard, formed and pellet-like. If that is the case, check in with your doctor's office. This is very unusual for a breastfed baby. I have found some organic formulas to be the culprit.

A pooping baby tends to be a happy baby. If you have one of those infrequent poopers it is hard to watch them struggle.
Massage their tummy. Go on youtube and search out some Infant Massage techniques. A good belly massage can help stimulate peristalsis (which is the movement within the intestines that moves the poop along.)
The tummy may be the most important area, but doing an entire body massage will help them relax. 
Don't forget their little hands! Take your thumb and make firm little circles on their palms. This is a reflexology technique that grandmas have been practicing for generations.
You can also bicycle their legs. Let gravity help them out. Hold them in an upright position and pull their little legs up to a squat position. Nobody poops as easily in a reclining position.
Sometimes a little rectal massage will also help. To do this you can put a dab of KY jelly or Vaseline on a Q-Tip and stick it a tiny bit of the way (just the cotton tip worth) into the butt. In the office when we take a rectal temp, more than half of the time this will make the baby poop right on the thermometer.
The Windi is another gentle way to stimulate pooping and help relieve gas at the same time.
There is no intervention needed for infrequent stools as long as you have a happy baby.
If it has been many days in between poops, your baby seems quite uncomfortable and massage has not helped, our next step will be glycerin. With the glycerin you have 2 options.
Glycerin suppositories are little sticks of glycerin (over the counter in most drugstores.) You break off a piece and stick it into the butt (KY jelly helps.) This stimulates the babies to poop fairly soon.
The other option is a product called Pedialax. These are little bulbs full of liquid glycerin. You pull off the cap and insert the pre-lubricated tip into your baby's butt and squeeze the liquid in. These works really well. The box says that these are for babies 2 and over, but I have found them safe and quite effective for younger folks.
Often just going out and buying glycerin will make your kid poop. It is a useful product to have on hand. Someday within the next couple of years it will come in handy.
Baby poop is a fairly benign substance. This will change.....
Next week’s post will address the changing stools as solids are introduced. )

Friday, April 14, 2017

Siblings (2017)


Imagine your partner says to you:
“Honey, I really love you. You are one of the most important people in my life. Please don’t be concerned that a younger, very cute person will be spending a lot of time with me. They will possibly be sleeping with me in my bed for a while. There may be some sucking on my breast.”
The oldest child was the center of the world for a time. Moving over to make room for a new member of the family isn’t always easy.
Some big brothers and sisters are actually eagerly expecting the baby’s arrival. Others are too young to really understand what is going on. Regardless, there is a big adjustment to be made.
Many parents report that the big siblings are quite sweet to the baby, but act out horribly to the parents. Once in a while, but less often they will also act out towards the baby. Nurse Jen remembers the time that her oldest daughter dropped a medicine ball on her new  sister.
Others have no malice but don’t have a sense of how to be gentle.
Below are some suggestions that may help ease the transition.
Do some gentle preparation by including some books about new babies among your reading choices. Please keep reading other favorites that have nothing to do with a new baby as well.
Once the baby arrives give your older child plenty of opportunity to talk about what if feels like to have a baby in the house. Validate that it is very normal for the big sister/brothers to feel mad, sad or aggravated sometimes (some kids might feel guilty about the way they feel.)
Many kids need to be told that the baby is here to stay as a new part of the family. Sending them back in not an option.
Have the new baby bestow a gift on the big sibling; I am not sure what the age cut off for getting away with this is, but you might be surprised.  Lauren was a remarkably clever almost 3 year old when Alana came along. Never the less when we gave her a little present from her baby sister, she accepted it without question. She was delighted and was quite pleased with the very thoughtful baby.
Some big siblings feel very important if you let them be “helpers”. Find some safe baby related tasks for them.
The most  important tip of all is to make sure that you carve out one on one time with the older child. Often they are craving mom right now. If mommy is breast feeding, make sure that in between feedings she hands the baby off to the other parent or other support system for burping, diaper changes... etc. and make a fuss about having “special big boy/girl time”
Nurse Jen says that lots of people gave her this advice but she didn’t realize that having a sleeping baby in a sling isn't the same. She wanted me to make sure to add that If you are holding the baby, it doesn't count as the “one on one” time.
As your kids get older, the oldest child will always feel a bit entitled to some solo time. If you can manage it, take just one child with you on routine errands and turn them into adventures.
Perhaps you can have only one child at a time allowed to “help” with a meal.
Even a walk around the block or some special time at bedtime makes a difference.
Try to make sure that each parent should make sure that they get special time with each kid.
My husband made it a tradition to take Lauren out for breakfast every Sunday morning.  Eventually Alana was old enough that she went along too, and mommy got to sleep in (heaven!)
Once the second child comes along you will feel like simple math no longer adds up. One plus one must surely equal five. You will manage to find the balance, but those first few months are challenging to say the least.
With the first child you had the luxury of focusing on schedules and nap time as if they were set in stone. Unless you are remarkably lucky or hire someone, a true schedule doesn’t really exist with this second child. Naps? Maybe while you are driving from here to there (they survive.)
Do your remember how careful you were with the first one? You avoided crowds and made sure that no one came around if they weren’t completely healthy. The new baby will simply be developing that immune system a bit earlier. There is almost no avoiding it, unless you never go out and you quarantine your older child to an unreasonable degree. Second kids get exposed to things quite a bit sooner (they survive.)
I do like to make the big siblings the deputies of the 'Hand Washing Patrol'. Have Purell around (you can also get the kind that is alcohol free.) Call it magic soap. Tell your deputy that they are in charge of making sure that anyone who is going to touch the baby washes their hands first. This may help make sure that they don’t feel like they are constantly being nagged at.
Keep in mind that all of your kids will reach their milestones on their own timeline. It doesn’t pay to compare them to each other or to the other kids in the play group.
My baby Alana, for the record, doesn’t mind when I use her as an example. She is now a licensed social worker and is an amazing super star all around, but goodness was she slow starting out.
Talking: Lauren was singing Rogers and Hammerstein musicals at a remarkably young age. She not only knew the lyrics, but she sang them in tune. (I have video proof of this.)
Alana barely had ten articulate words before she was two. Lauren would translate for her and act surprised that we didn’t know that  “gbabp[ps[p” meant, “I want popcorn please”
Walking: Lauren took her first steps at a year. Alana waited until she was about 16 months and then carried a chair across the room within a day of mastering walking.
Toilet training: Lauren was an early 15 months. Alana had no interest until she was 3. I thought we were going to have to buy depends.
They will all get there.
Siblings will have days when they are best friends and days when they torture each other. Mine interspersed periods of intense closeness with periods of mild bickering.

 Fast forward 20 years...
My family was on a cruise, savoring time together. We were in Cozumel. My husband Sandy was off on a real dive, while the girls and I went Snuba diving. Snuba is a combination of Scuba and snorkeling. With Snuba you breathe through a 30 foot tube that is connected to an oxygen source that floats along the surface.
My daughters were swimming along the ocean floor. I was about 10 yards above them watching them animatedly communicate with each other through hand gestures and some signing. I remember proudly thinking...Look at my daughters. They are both intelligent, funny, kind and lovely. I love them so much. I am so glad they have each other and that they have gotten so close as they have gotten older.
Our time was up and the guide gestured to all of us that it was time to go up to the surface.
They removed the mouth pieces and…….the fight continued:
“You were getting tangled in my hose”
“You were kicking too hard and making too many bubbles”  and so on.
Oh well, a mom can dream.

Fast forward 25 years -  I think that my daughters could now enjoy an excursion without bickering. Of course no more silly 'Snuba' for Lauren. She has since gotten certified to do real diving.
And  we each got a kid to keep us company on our travels.  Alana loves to come with me shopping or sipping a beverage in a small cafe while Lauren climbs mountains with her dad (they're planning their next climb now!)

Friday, April 7, 2017

Urgent care/ After hours options 2017

Please see the updated post April 2018

After hours/Urgent care options
Murphy's Law generally seems to make certain that the fever spikes or the vomiting starts right at 5:01 pm when the average doctor's office turns their phones off. It is important to be familiar with your after hours/urgent care options.
Waiting until you or your child is ill is not the best time to start learning about what choices exist in your area. Does your insurance plan have a preferred option that won’t cost as much? Are there after hours advice nurses available? Where is the closest emergency room? Is it staffed with pediatricians?
If you are traveling, plan ahead and figure out local options for care before the trip.
For Noe Valley Pediatrics patients who need help after hours, we ask you to start with the pediatric after hours clinic/triage nurse line: 415-387-9293
If the nurse is NOT able to help, you will be directed to our answering service where the Noe Valley Pediatrics physician who is on call that night will be paged. The answering service number is 415-753-4697
Here in the San Francisco Bay Area we are lucky to have very good options for after hours care.

The UCSF Benioff Children’s Physicians Pediatric After Hours Clinics and Advice Service
  • In San Francisco 3490 California Street, Suite 200                          415-387-9293
  • In Berkeley 3000 Colby St Suite 301  (New Location 7/2017)           510-486-8344   
Patients are seen by  appointment:
Monday through Friday 6:00 pm - 9:30 pm,
SaturdaySunday and holidays 8:30 am -9:30 pm

Weeknight pediatricians are made up of participating private pediatricians, including several of our doctors who work an occasional shift in the clinic there. Weekend doctors are fully trained and board certified pediatricians.
On weekdays the phone lines turn on at 5 pm. The advice nurse triage team is available through the night, even after the clinic is closed. The availability of the triage nurse makes this our number one choice.
The Pediatrics After Hours Care at St Luke’s Hospital is affiliated with Sutter/ CPMC and is located at 1580 Valencia Street, 7th Floor #701 This clinic has been open for about a year now.
Pediatrics After Care at St. Luke's
It is now open 7 days a week.
Monday-Friday 5:00pm-10:00pm
Saturday-Sunday 8:30am-10:00pm
Phone: 866-961-8588
This service does not currently have an advice nurse team, but the person answering the phone can help do some basic triage when making the appointment and help redirect you to an emergency room if that seems necessary. This clinic has some advantages besides the convenient location. They start the scheduling process as early as 2 pm, which may make it easier to make a plan if we are already solidly booked here in our office and can’t get you in to see us that same day. They also offer weekend weight and bilirubin checks for our newborns. As a bonus, there is a special waiting area so that the healthy newborns aren’t exposed to the other sick kids.

The two options listed above are the only urgent care facilities with which our office has a close relationship. 
When things are going as they should, both of the above after hours options send a report to the primary doctor's office. In our office, the nurse team reviews the reports and follows up to see how you are doing to maintain a sense of continuity.

I am listing the others below as a convenience.

If you are not in San Francisco, on the Peninsula you have several good options. is a  pediatric urgent care facility. There is no appointment needed.
210 Baldwin Ave in San Mateo. Telephone 650-579-6581

The Palo Alto Medical Foundation has several pediatric urgent care options:
Palo Alto Medical Foundation
They have a choice of appointment or drop in. The website gives info about the various locations and current wait times.

In Marin
Greenbrae Pediatric After hours clinic
1260 S Eliseo Drive Floor 2
Greenbrae CA
6:30 pm-9:30 pm Monday through Friday
9:00 am-9:00 pm Weekends and Holidays

There are plenty of general urgent care places popping up all over the place as well. Keep in mind that with most urgent cares, there is no such thing as an appointment and folks just show up and get seen in the order that they come in. There is risk for a much longer wait. They are also not usually staffed with pediatricians. For a teen, this is usually not much of an issue, but for my younger kids, I would try to stick with one of the pediatric after hours clinics. If you do end up at another urgent care, please ask them to send over a report so that we stay in the loop.
Emergency Rooms
In a true emergency of course call 911. If it is less urgent, but you are certain that you child needs immediate medical attention we are lucky to have excellent options here in SF.
When given the choice I will generally opt for one of the true pediatric emergency rooms. You are not competing for care with the elderly heart attack and stroke victims that may be populating the waiting room and getting ranked higher on the triage scale. You will also be assured of seeing a pediatrician and having appropriate pediatric equipment. If an admission is needed, my preference would be either CPMC California campus or UCSF Mission Bay, so there also won’t be any transport needed if you are already at one of those ERs. I think it is worth the extra ten minute drive across town and may save you time in the long run.
The UCSF Pediatric ER in Mission Bay is located at 1975 Fourth Street:
UCSF Pediatric ER
This emergency room has scored very high in a nationwide ranking for getting patients seen in a timely manner.

CPMC pediatric emergency room is located at 3700 California Street/ at Cherry:
CPMC Pediatric Emergency Room
This ER generally gets high marks from our patients.
Some of the common calls that folks need help with after hours are dosage questions. Here is the link to a post with that info: