Friday, February 23, 2018

We could all use a little dose of Mr Rogers

A couple of headlines intersected this week. First of all was the horrible school shooting in Florida. That put me in a mind to rerun my “horrible headline” post from a year ago when some similarly terrible event happened.  But in a smaller headline was the reminder that Mr. Rogers aired his show 50 years ago. In my post about talking to our children about scary situations, I actually quote Mr. Rogers. He shared a lesson that he learned from his own mother, “look for the helpers”. Those might be a person in uniform, or another parent with children. That remains great advice and is one of his more well known pearls of wisdom.

Since I have some extra time on my one hand this week, I decided to give my own shout out to Mr Rogers. Most of you may not know this, but I was fortunate enough to interact with him several times while I was working at my first job as a nurse at The Children's Hospital of Pittsburgh. Mr Rogers routinely visited my little patients there. He also created several movies there that we would use for patient education. He was the real deal. There was nothing fake about that man. A generation of children grew up better people because of the lessons he taught. Here are some of my favorite pieces of Mr Roger's wisdom:

  • "There are three ways to ultimate success: The first way is to be kind. The second way is to be kind. The third way is to be kind."

  • “There is only one thing evil cannot stand, and that is forgiveness.'"

  • "There's a part of all of us that longs to know that even what's weakest about us can ultimately count for something good." It is okay not to be perfect!

  • “Solitude is different from loneliness, and it doesn't have to be a lonely kind of thing.”

  • Accept people as they are

  • Look and listen carefully
  • We all have feelings.” Talking and acknowledging them is the first step towards finding ways to deal with them that don’t hurt anyone

  • Anything that's human is mention-able, and anything that's mention-able can be more manageable. When we can talk about our feelings, they become less overwhelming, less upsetting, and less scary. The people we trust with that important talk can help us know that we're not alone.

  • Wonder about things

  • “You can’t go down the drain in the bathtub” Don’t be shy about sharing things that might be scary

  • “Be yourself.” It is not how you look, what you wear or what toys you have that make you special

  • What can you grow in the garden of your mind? Use your imagination.

  • You rarely have time for everything you want in this life, so you need to make choices. And hopefully your choices can come from a deep sense of who you are.

  • One of the most important things a person can learn to do is to make something out of whatever he or she happens to have at the moment.

Mr. Rogers was a gift to generations of kids but I wonder if any of my patients know who he is? I believe that Daniel Tiger is making sure that the whisper of his gentle message lives on!

Friday, February 16, 2018

The misadventure of Nurse Judy/Managing Stress

The misadventure of Nurse Judy

Last Sunday I was taking a hike along Land’s End. I tripped and fell forward. My right wrist took the brunt of the fall. The triage nurse part of my brain knew that bones were broken. What an impact one little misstep can make!

  • I didn't fall off a cliff, break a leg or sustain a head injury.
  • I was with sensible people who helped hike the mile back to the car.
  • One person had a large scarf that we were able to fashion into a sling.
  • All of the passing hikers stopped and offered to help. Humanity put on it’s best face.

  • I had no id or insurance cards with me.
  • It’s time to update the first aid kit in the car and make sure it has arnica and instant cold packs.

I spent a few hours in the Davies ER. It's OK to call ERs to see how long the wait is for non-critical care. UCSF was 3 hours. Davies was none! That is a gem of a resource for adult patients. I was able to get an early Monday appointment with an orthopedist. Both of the bones in my right forearm are broken. Yes OUCH

  • I have a wonderful support system (thank you Sandy), family, friends, good insurance, and access to good health care (way to meet the deductible early in the year!)
  • Noe Valley Pediatrics is a very supportive work environment and is trying to muddle along the best they can with the office manager mostly out of commission.

  • Ongoing trying to figure out how to manage for 6 weeks without use of right hand.
  • Trying to Learn how to say yes to the friends who have reached out with offers to help

Impact on the office
Nurses will be short staffed. Every effort will be made to return calls in a timely manner, but please understand we won’t have the luxury of time for longer conversations. The turn around for emails may be as long as a week. Please call if you need to speak to a nurse.

I have cancelled February classes. I will update this after my next ortho appointment. I may end up requiring surgery, so it is difficult to plan.

Don’t count on weekly emails, but I will try to keep them coming. 
This post is short and simple, but hopefully it can give you a new awareness or way of looking at things.

  Topic of the week: Managing Stress
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. Breaking your wrist - half a cup!

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.

Friday, February 9, 2018

When is your child contagious? 2018

Some of the most common questions the come to the advice nurses revolve around when kids are contagious and at what point are they ready to go back to nanny-share, daycare or school.
The answer is almost never clear cut. In a black and white world, this is my 50 shades of gray.  In order to logically best make these decisions there are many issues that we need to consider.
Of course we want to be a responsible parents and not expose others to our sick child. We also want to protect our own recovering child from going back into the 'germ pool' too quickly. If they are just getting over something, their immune system may a bit diminished and they are vulnerable to coming down with something new.

For older kids,sometimes they have an important test that they are reluctant to miss. Some are reluctant to miss school. (others not so much.....)

Another consideration is that some parents have an easy time taking time off to stay home with their little sick child and others simply can't afford to. It is naive to think that these aren't real factors.

What makes it all so tricky  is that most viral syndromes can be spread a day or two before the kids show clear signs that they are ill. Many kids may be a little fussier than usual. Perhaps they don't eat quite as much. Most savvy parents know enough to be suspicious when their 5 year old who fights naps with a vengeance announces that they are going up to have a daytime snooze. Your antenna might be up that something is brewing, but are those reasons to miss work and keep your child at home??? Of course not!

The fact is, if you child comes home from school in the afternoon and is sick that evening, most likely everyone they were with earlier that day has already been exposed and I am going to take that into consideration when we try to come up with the most sensible plan on when they can return.
It is nearly impossible to isolate siblings. Of course be scrupulous with your hand washing, avoid sharing utensils and sloppy wet kisses, but it is likely that they will catch each other’s cooties. Breastfeeding moms, sorry to say that by the time you realize you are ill, it is too late to prevent an exposure. Hopefully the magic of breast milk will protect your baby, but it is rare that we would suggest that you avoid nursing. Most of the time we will recommend that you keep on with the feedings. (Make sure that you are getting plenty of fluid. If you are given medication, check with your nurse or doctor’s office to see if it is compatible with breastfeeding.)

If you are in a small share care situation, it is essential to have a talk with the nanny and the other families involved to make sure you are all on the same page.
I would suggest that you agree that the kids will have  a "sibling" relationship. This simply means that you all accept that the kids are most likely going to get each other’s mild illnesses.

As far as common colds go, the average child under 2 years of age has EIGHT colds a year. Frankly, if you plan on keeping your child at home until your little toddler is free from a runny nose, you will be waiting a very long time before you leave the house.
Remember that some clear runny noses are not contagious. Teething as well as some allergies can be the cause. (There is debate about whether or not teething is associated with congestion. Nurse Judy votes yes.)

While I would strive to keep my youngest and most vulnerable patients free from viral syndromes and colds as long as possible, exposure to these common viruses is in fact developing the immune system. At some point they are going to have to deal with the myriad of  illnesses that make the rounds. Think of it as a rite of passage. It is actually better to get some of the childhood illnesses out of the way. Unfortunate adults that lack immunity and catch these illnesses are pretty miserable.

Typically if I have a child with a fever over 101, a  new case of diarrhea, or a brand new cold that has them spewing green mucus it is worth keeping them home for at least a day or so to see what  is coming next.

If your child has an infection that is being treated with antibiotics, we generally consider them no longer contagious after they have been on the medication for at least 24 hours.

Bacterial conjunctivitis is also usually given the all clear after 24 hours of eye drops (of course you need to finish the course.)

Hand Foot Mouth issues come up a lot. I respect that schools want to keep this yucky virus from getting spread around. Patients can shed that virus in their stool for several weeks. I would suspect that there is a reasonable chance that the infected kids likely got it from school in the first place and/or were contagious before they were identified and segregated.Since I don’t think schools are able to genuinely keep them out until they are completely clear, I suggest common sense guidelines. If they have a fever keep them home. If they are fussy and miserable, they will be much happier home with mom or dad. If they seem to be feeling okay and are fever free, for the above reasons, I don’t think it is reasonable to exclude them from daycare/school until all the blisters are gone. Kids are going to get this.

If you are questioning whether or not to go on an upcoming play date, explain your situation to the other parents. They may be perfectly fine hanging out with you and your snotty nosed child, or perhaps they have an important event or vacation coming up and want to be more cautious. Let them decide. Full disclosure ahead of time is the best practice.

We wish there were a magic light that signaled the "all clear." Alas, there isn't.
I wouldn't even completely trust the rapid tests that we do for strep, RSV or Flu. If the test says negative, but the child looks sick we have to remember that the tests aren't 100% accurate.
There is never any complete assurance that can be given that your little one is "not contagious".
Use your best common sense. When in doubt avoid contact with anyone who is vulnerable. This would include newborns, or someone with a compromised immune system.

Friday, February 2, 2018

When should your child start seeing the dentist? 2018

Topic of the Week:
When should your baby start seeing a dentist?
SF Dentist guide 2018 and Tooth Brushing tips

Scroll down for the list of dental practices

Parents often ask us when they should start taking their kids to the dentist. Believe it or not, the current official recommendation now is that your child should have his or her first dental visit by age one. In California, about one third of preschoolers have dental decay. It is much easier to prevent decay in toddlers' teeth than to fill a cavity in a young child. Tooth decay is the most common chronic childhood disease and it can be prevented.

As parents, we may think, "baby teeth fall out, so we don't need to worry about them." This sounds logical, but unfortunately is not true. Luckily, dental science has found out many new facts about how to prevent dental decay. We now know that bacteria causes tooth decay. This "bad" bacteria can find its way into your babies mouths in many ways. Eating foods high in sugar is one of the most obvious offenders. In order to prevent decay in our adult teeth, baby teeth have to be kept healthy as well.
What can you do to keep your child's teeth healthy right from the start? For the youngest babies with brand new teeth you can wipe them off with a soft piece of gauze or a wet washcloth. Not only are you cleaning off the teeth, (breast milk does have sugar) but you are getting the baby used to a routine. Training your child from the start that teeth get brushed is a good way to create good dental habits that will last a lifetime.

There are other options besides the standard hand held toothbrush. For very young babies there are little flavored towelettes specially formulated for wiping baby teeth. Spiffies was the first of these that I was familiar with. Now there are several brands available. You could also consider using a soft finger brush. These fit over your finger and if your baby will let you, this option allows you to get in there and do a nice thorough job.

If you use a regular toothbrush, make sure it has soft bristles. Replace the brush when it looks like the bristles are getting worn. It is also a good idea to run all the family toothbrushes through the dishwasher every once in awhile. One extra perk about routine dental care is that you might walk out of the dentist's office with a new toothbrush! Younger children will have an easier time handling a toothbrush with a thicker handle. Perhaps you can let your child be in charge for one brushing a day and the parent be in charge of the other; that way you know you are doing a more thorough job at least once a day. Some people use a two toothbrush approach. Toddler gets to hold one, but so do you. Both of you can be in there at the same time.
Consider putting a little tune on while you brush. This can act as a timer. Brushing is ideally supposed to last 2 minutes. Do the best you can. A full two minutes might be a goal that is a little unrealistic for many of my patients.

Daddy Adam sent me this tip: He used a kids bluetooth sonicare toothbrush, which has a corresponding app on the iPad. It gives you a little creature that you need to take care of, and you not only clean the critter's teeth when you brush yours, but you also get food and treats to feed it. His daughter Millie loved it, and it made brushing super easy. They no longer use the app very frequently anymore, but the brushing routine is ingrained. 

You can sing...but don’t dance!!
I just had a patient who got a fairly serious mouth injury from doing a little rough housing while brushing his teeth. Make sure your child isn’t running around with a toothbrush in the mouth.

The old recommendation was to use non fluoride toothpaste for kids younger than two years. The new suggestion is to actually use a tiny amount (just a little dab) of fluoride toothpaste. It is important to note that too much can be harmful so keep the amount tiny. Once kids get to be over two and can spit it out after brushing, you can use a pea sized amount. Xylitol is another recommended ingredient for dental health. It is found in some toothpastes. This natural sweetener is found to help reduce bacteria and strengthen tooth enamel.

It is important to use a toothpaste that is non abrasive. Most kids brands are specially formulated to be gentle. Some adult ones are fine. Most toothpastes will have the abrasive rating noted on the package. Ideally try to brush twice a day and floss once a day (for teeth that are touching.)

Pay attention to habits that may or may not be good for your teeth. Children who are “grazers” tend to have more cavities than the those who eat less frequently. Saliva neutralizes the acids in the mouth and actually ‘washes’ the teeth, but it needs about 2 hours in between meals to work. If someone is constantly eating, the saliva isn’t getting a chance to do its job.

Foods that are high in carbohydrates and sugar are not healthy for our teeth or general health. A daily intake of 60 grams of carbs or higher more than doubles your chance of getting caries (and all that sugar can lead to type II diabetes in kids!)


Find a dentist that treats very young children and bring your child to his or her first appointment when the first teeth erupt - no later than by age one. During the visit, the dentist will check your child for dental decay and talk to you about cleaning your baby's teeth. They might also talk to you about proper nutrition for keeping baby teeth healthy.
If you have any concerns about the manner in which the teeth are erupting, having a dentist who is familiar with your child will be very useful.

Another important thing to think about is that having a dentist can come in very handy if you happen to have any dental emergencies. Kids have accidents! It is not unusual for me to get calls about chipped or loose teeth after a fall. I usually suggest that they contact their dentist on those occasions, and the folks that already have one are way ahead of the game. If there is a dental emergency, early intervention can be the difference between saving the tooth or losing it.

Some parents avoid taking children to the dentist to save money, yet studies show that the dental costs for children who have their first dental visit before the age of one are 40 percent lower in the first five years of life than for those who do not see a dentist before their first birthday. Consider this when deciding whether or not to add your child to your dental plan (if you are lucky enough to have one.)

We are fortunate to have lots of excellent choices in our city. Below is a partial list of dentists who we send patients to. If someone is conveniently located or is on your insurance plan that is certainly worth consideration.
If you have a favorite dentist who you think should be included on my list, let me know!

David Rothman 415-333-6811 is over on Ocean avenue near Stonestown. He was my kids' dentist and they loved him. He is an excellent dentist with a wonderful sense of humor. His office is able to do procedures under general anesthesiology in the office if needed.He remains my "go to" guy if I have any tooth related questions.

Bergen James, Doris Lin-Song and Jennifer Yu 415-668-3500 They are located on Parker Street near Laurel Village. Love dogs? They have a couple in the office! Dr. Kaplan uses this office for her son and gives them two thumbs way up.

Claudia Masouredis 415-753-2777 is fairly close to our office, just up the hill on Portola. Nurse Jen brings her kids here and they adore her. Dr. Masouredis can also do procedures in her office that require sedation.

Dorothy Pang 415-681-8500 is on Taraval and 18th in the Sunset. Dr. Pang is affiliated with the UCSF dental school. If someone needs a dental procedure under anesthesiology she can do this at UCSF rather than in the office.

Raymond Katz 415-751-7900 This practice is at 5233 Geary. We have plenty of patients who have been using these folks and only have nice things to say about them. Dr. Schwanke used to take his girls over there when they were young.

Han Pediatric Dentistry 415-681-3220 Dr. James Han’s office is at 1530 Noriega Street. Dr Han is also on staff at CPMC and attends any dental emergencies at the ER there. He can perform general anesthesia cases in the OR there as well.

Dr. Charles Spitz and Dr. Tyler Davis 650-375-8300
Peninsula Pediatric Dentistry and Orthodontics. If you are looking for a practice down on the peninsula, this great practice is located in San Mateo. Dr. Davis works with Dr. Spitz, who used to have a practice in the Mission. They are located in the Mills Medical Arts building on the corner of South San Mateo Drive and 2nd Avenue in downtown San Mateo.
"We are a preventative practice first and foremost. We believe the best dental care is personalized to meet the individual needs and preferences of each child we see. We work hard to get to know our patients and their families. We're always willing to listen, to discuss options and to answer your questions."

Anne Lee DDS 650-873-5212

Dr Retailleau is the newest member of the Noe Valley Pediatrics team. This is the dental office where she takes her own kids. She has had good experience with them. They are located in South San Francisco

Kid Smiles 415-681-5437

I don’t know much about this office, but some of my patients go there and give them a thumbs up

These folks are right down the street from the office. Their pediatric dentist is not in every day, so check their schedule when you call. Patients have found them lovely and convenient for basic care, but have been referred out for dental emergencies.

There are some low cost options available as well.

If you need assistance in finding a dentist, or low-cost children's health insurance in San Francisco, please call the Women and Children's Health Referral Line @ 1-800-300-9950.

In honor of Dental health month San Francisco Give Kids a Smile Day 2018 is hosting several free dental check ups

Saturday February 10th

February 24th

RECAP: Tips for Healthy Teeth
Take your child to a dentist twice a year; starting by age one. Brush your child's teeth everyday; as soon as they come in. Make that snacks are healthy ones. Take care of your own teeth; adults can spread cavity-causing bacteria to children. Cups and/or bottles in bed are not a good idea in general, but, if you must, have them filled with water only.2018