Friday, March 30, 2018

Vision Health/ eye doctor resources

Topic of the Week:
Vision Health/ Eye Doctor resources

Early intervention for eye abnormalities is very important.
Parents are often the first to note if there is something going on that doesn’t seem quite right.
Are the eyes watery or gooey? This could be a blocked tear duct.
That usually resolves in a few months, without any intervention.

There are always individual variations with developmental milestones, but many babies' eyes don’t track too well until they are about 3 months. Once they are old enough, parents should pay attention and see if the baby can follow an object with both eyes. If one eye wanders, that is something we want to get checked out.
Check the pupil size. Are both about the same size? There are some kids with normal variations, but it is worth noting this ahead of time. I have had parents frantic after a mild head injury when the pupils were noted to be a bit unequal. It turned out that this was just the baseline. Noting it in advance would have saved some stress!

If you take a photo with flash and there is “red eye,” look to see if the reflection seems to be hitting both eyes in the same general area.

In our office we actually start doing eye screenings for our patients as early as 6 months. We can screen for a variety of abnormalities with our iscreen machine.

Several years ago when I did this post for the first time, Dr. Good, a popular pediatric ophthalmologist, said he has been fairly impressed so far with issues that have been discovered early. While most of the conditions don’t actually require any intervention, having the patients identified so young is very valuable, because we can now know to monitor them closely

Once the kids are four or five years of age and old enough to cooperate, we do the Snellen eye test. This screening for nearsightedness is usually done in conjunction with the routine annual well child check up. The operative word here is screening. Farsightedness or astigmatism are usually not picked up without a full eye doctor exam.

The gold standard recommendation is a complete eye exam by an eye doctor at 3 and 5 years. At that point, the decision for how often routine exams are needed may depend on your child. Obviously if your child seems to be squinting it is worth getting them in sooner.
There is a genetic component to eye issues, but kids should be checked even if the parents have perfect vision.

What is difference/ need between ophthalmologist or optometrist for basic child eye health?

Ophthalmologists are specialists that deal with the full range of eye care, but they are also surgeons who can deal with any eye abnormality or condition. Optometrists might be your best bet for any simple vision issues. Finding someone who regularly works with kids is pretty important.

If there is a medical diagnosis some insurance companies will cover the cost of an eye exam.

It is worth checking in advance with the eye doctor's office as well as your insurance or vision plan to see if there is an advantage to seeing one or the other.

I don’t think people necessarily need to add vision and dental plans for the kids during the first year, but after that, especially if they come bundled, it is probably worthwhile.

If your child does need glasses, make sure they get their vision checked yearly (or more frequently as needed) to make sure the prescription is correct. If the myopia is getting progressively worse, believe it or not multi-focal contact lenses may help slow things down. They can be started with some cooperative children as young as 5!

You might not make an obvious connection, but headaches, dizziness, motion sickness, and ADD can all be associated with eye problems. Even anxiety can be related!

There are likely plenty of good eye doctors in the Bay Area,
The folks on my list are ones that I am familiar with. If you are aware of someone excellent who should be on this list, please let me know.


  • Dr. David Grisham and Dr. Jeremy Shumaker at Vision Academy and Rising Star Optometry are top notch and do see pediatric patients.


  • Both UCSF and DR Good have a fairly long wait time for an appointment so planning ahead is a good idea. Both offices will require a referral from your primary pediatrician before they will make an appointment. Be aware that when we send the referral it might take a week or so before they make contact with you to schedule an appointment

  • Kim Cooper Check out her website. It is more fun than most! Dr Cooper is down on the Peninsula but many folks feel that it is worth the drive to see her. She shares that her most important eye tip is the need for quality safety goggles. If your child is playing any sport where there is danger of getting hit in the eye by a ball or body part, they should be wearing eye protection. Not a week goes by that she isn't dealing with a sports related eye injury. Most are minor, but the serious ones are devastating.Her office happens to be great resource for getting quality goggles.

Free E-Book Helps Kids Get Ready For An Eye Exam

Howard the Hedgehog visits the eye doctor for the first time. Initially he's doubtful, but he ends up having a great time and seeing much better thanks to his new glasses! During show-and-tell, he shares with his classmates what he learned about vision tests.
That's the plot of an e-book you can download for free and share with your children. Not only is Howard and the Amazing Eye Examfun to read, it's very educational and reassuring for kids who may be worried about visiting the eye doctor.
The e-book has cute illustrations and was created by Alcon's The Eye Solution team and Dr. Catherine McDaniel, an optometrist who teaches and practices at The Ohio State University. You can download the e-book for tablets and computers on Amazon  andGoogle Play .

There are some common sense things you can do promote good eye health.

  • Get outside! Get in the habit of wearing sunglasses when outside during the day. Ideally they should be made out of a strong poly-carbonate plastic that is shatterproof. Floppy hats or visors are also a good idea.

  • Recent studies show a 30-40% decrease in myopia (nearsightedness) with daily time outdoors.

  • Try to minimize the “blue lights” that we are surrounded with by screens in our world.

  • The American Academy of Pediatrics recommends no more than 2 hours of recreational screen time/day.

  • Eat well!

  • Carrots and foods with Vitamin A are good, but the dark green leafy vegetables are the real super helpers of the eye because they have lutein and zeaxanthin (go ahead and impress people at your next cocktail party with that one)

  • These two eye nutrients help replenish the pigment in the retina and can prevent diseases of the eye. Peppers turnips and paprika are also a good part of an eye healthy diet.

  • Avoid smoking or exposure to secondhand smoke.

Fun Facts:

  • You may not be able to know your child's ultimate eye color until they are a year!

  • Your baby might be crying, but they usually don’t develop actual tears until they are between 4-13 weeks

  • The eyes are the fastest muscle in the body and blink an average of 17 times/minute

Friday, March 23, 2018


If you got my recent post about altitude and were momentarily disappointed when you realized it was about going up to the high country as opposed to your teenager giving you the stink eye or your toddler being a pill, you were not alone. Somehow, even though actions speak louder than words, attitude, in its silence, speaks the loudest of all.

We tend to have such a knee jerk reaction to attitude. We are human after all. If someone is saying and doing the right things but is sullen or rude, it is upsetting. It is also frustrating that it is hard to make a concrete accusation that doesn't sound just a wee bit weak.

“Your honor, they rolled their eyes at me and then slammed the door….”

To take it a step further, the nuance and meaning of a sentence can be completely changed depending on which word gets stressed

“You would like ME to clean my room tonight?”
(why would I do do it)

“You would like me to clean MY room tonight?
( have you seen the mess that YOURS is?)

You would like me to clean my room TONIGHT?
(tonight is so inconvenient)

Tone matters. The tone we use or hear can completely change the interpretation. Absence of tone can have an equal impact.
People can also get into all sorts of trouble from a text conversation when there is no inflection.

So we can agree that attitude is silent but powerful, but here is the most important thing to keep in mind. We can try to influence others, but the only real power we have is over ourselves.

Reacting to attitude

Can you calmly be aware of how you are affected by someone else’s non verbal cues? Realize that someone else's negative energy might not actually be directed at you. If someone is tired or grouchy, you might just be in the path.

If this is a casual interaction, you might opt to simply walk away and not take it personally. This is a good example of how not to ‘sweat the small stuff’. Our measured response to someone’s attitude could possible diffuse a situation rather than escalating it. “You seem like you are having a rough day, can I help?”

If this is a Groundhog day situation that you live over and over again with a child or partner, then it is worth addressing.
‘Toddlertude’ and ‘Teentude’ (Thanks BK for those monikers) are not the same thing.

Toddlers can’t really be accused of ‘giving attitude’. They don’t usually have the verbal skills to communicate what they are feeling. If you are able to identify the cause of the frustration, it is on you as the grown up to problem solve the situation and see what fixes you can come up with. Remember that everything is worse when they are tired or hungry.
Even from a young age though, kids can be made aware that they have a choice about whether to be sunny or difficult. During a recent phone conversation, Nurse Lainey overheard Daddy Adam ask his daughter Millie," Do you want to take the rainbow road or the rocky road? You get to decide." I love it.

'Teentude' is different. When you are on the receiving end of “attitude”, but they have done what you asked, validate the appropriate words and actions but then point to the unspoken.

"Thank you for following my directions (cleaning your room, doing your homework, getting out of the house on time)
Thank you for agreeing to…….
My instinct is telling me that you are upset by this situation. "

Don’t get into an escalating attitude battle. My father was the king of letting things roll off his back. I can hear him now saying," I am going into the garden to eat worms"

Teens have a lot on their plate. A little stomping when they have to put their phone down to do some homework shouldn’t be taken personally.
Many teens are wonderful citizens to their teachers and other people that they interact with in the world outside of the family circle. They save all the pent up angst for parents because you guys are a safe place. Find the right moment to see if they are open to a team problem solving session. Writing down all of the stressors and identifying ways that the family can support them are really positive activities. You are taking the unspoken and putting a name to it.

Emitting attitude

It is typical for most people to silently broadcast our anger or frustration. We start early, telling our children to use their words, but the truth is most adults don’t always do such a good job at that.

Think about whether better communication would be preferable to stomping, eye rolling and/or stewing. Can you be self aware enough to turn your eye roll, or huffy sigh into words?

Sometimes we are faced with a choice where it is best to suck it up and not say anything.

Let's make the example that your partner wants you to go out to dinner with friends. You are really tired and would rather stay home. If that is the case, imagine that the choice is a scale.
You may weigh all the pros and cons. You choose to go out because your partner is looking forward to it. We say yes but once in a while we can’t help it, here come the tired martyr. It as if we have written all the reasons we don't want to go on little post it notes and stuck them all over ourselves. Don't be that person. Wad them up and throw them out. Once you have made a choice, own it. Leave the attitude at home.

I wish I could wave a wand and make everyone in our surrounding have a sunny and positive attitude. Alas I am not that powerful.

Friday, March 16, 2018

Travel tips 2018

Our all time most common travel related question is probably, "When is my baby old enough to fly?" There are many different factors to consider, so there is no one simple answer. Adopted babies might fly within the first few days on their way to their new home. Other folks make the valid choice to fly earlier than we are really comfortable with in order to see an aging relative or deal with a family crisis.

In ordinary circumstances, I would prefer to have the babies wait until they are over 2 to 3 months of age and have had their first set of immunizations (keep in mind that the first shot does NOT give full protection against some serious illnesses, but it is a start.) The size of the baby as well as the time of year are also factors. If there is some kind of crazy flu epidemic, I would think long and hard before taking a young baby on a plane. It isn't unusual for there to be some type of health alert circulating, so keeping current on the news is important. A couple of years ago there was a measles outbreak here in the states. Measles is still a potential issue if you are going to Europe. When I ran this post in 2016, Zika was all over the news. As of this month (March 2018) there aren't any major scares. The flu may finally be winding down. The bottom line is that my recommendations might change depending on what is going around and where you are heading. It does make planning a trip well in advance a bit more challenging.

Regardless of how old your child is, if you are planning a trip here are some tips and things to keep in mind.

Before you leave
I get calls from all over planet from parents who are dealing with a sick child during their trip. Prior to the trip, check with your insurance company to see what the best method is for having out of state or international doctor visits covered. Some plans are much easier to deal with than others. Whether the visit is covered or paid for out of pocket, you also need to figure out what your actual options are. Is there an urgent care facility near by? Do you have a friend or relative with a pediatrician who is willing to see patients who are not in their practice? Does your insurance only cover an emergency room visit?

Hopefully you won't need to use this info, but if you are dealing with a sick child away from home it is nice to have a "Plan B" in place. If your child has a history of wheezing, it is wise to bring all medications along even if they haven't needed them in a while.
Keep in mind that infrequently used asthma inhalers need to be primed before use.

If you are traveling someplace exotic it is worth checking with a travel clinic to see if there are special travel vaccines or malaria precautions necessary. The only vaccine that we routinely give here in our office that might be considered a travel vaccine is Hepatitis A. Most other special travel vaccines need to be gotten at a travel clinic. A travel clinic keeps current with all the ever changing recommendations and consideration for each country and season. Plan in advance. Lauren and Sandy actually had to get rabies vaccinations for their trip to Nepal. is a good starting point to figure out what you might need. The is one good option for getting any necessary shots. Depending on your insurance, CPMC Travel clinic is another good choice.

One of my wise readers suggests that if you are traveling out of the country it is worthwhile to register your journey with the state department . Great idea!

Surviving the flight.
Keep in mind that a car seat is the safest place for your child.
It is worth checking with your carrier to see if you can get a discounted rate.

A few years ago I sat next to a mom with a very young baby. She was so worried about the possibility of getting evil looks from the other passengers that she had actually brought ear plugs to hand out to the people sitting around her. What she didn't have was anything to soothe her baby. Please always make sure that you have Tylenol or Motrin with you on the plane (not packed away in your suitcase). It is okay to bring small bottles through security. They need to be smaller than 3 ounces. I don't tend to give it ahead of time, but I am quick to medicate during the first sign of fussiness. Does your child suffer from motion sickness? Click to review my post on that topic.

I often get questions about the use of Benadryl. This is an option for a child who is over 8 months with a long flight ahead. It helps dry up any congestion and makes 90% of kids who take it deliciously sleepy. Aha, but what about the other 10% you might ask? It turns those little darlings into hyperactive, wild hooligans. You do not want to find out on the plane that you are the parent of the 10%. There is no such thing as infant Benadryl; we use the children's liquid generic diphenhydramine.

Many labels will warn not to give to children under 4. We routinely ignore that. You may want to give a test dose a few days prior to the trip to make sure it is a viable option for you. I want parents to have the tools with them to deal with an unhappy child. Don't give any medication unless it is necessary. While I would usually err on the side of less medication, Benadryl and Tylenol/Motrin can be given at the same time.

Many babies and children may have trouble with their ears . For the younger ones, try to nurse or have them feeding during takeoff and landing. Sucking on a pacifier may be helpful as well. Have a lollipop or chewing gum for older kids. Ayr saline gel is a nice thing to have along. A dab at the base of the nostrils can moisturize the dry air and make the breathing easier (use it for yourselves as well.)

If you have a child with a history of ear trouble, have some of the little gel heat packs in your bag. You can activate them as needed and the warmth feels great to a sore ear. For adults and older kids, you can equalize the pressure by holding the nose and gently blowing until the ears pop.

Take WAY more diapers with you than you think you need for the trip. I was on another flight not too long ago when we sat on the tarmac for three hours. There was an unfortunate family behind me who had planned on a short little trip and was out of diapers long before we took off. It wasn't pretty. Plan accordingly.

Many folks automatically bring a change of clothes for their baby. It is also worth bringing an extra outfit for yourself. If you have a long flight ahead of you with a child on your lap, it may come in handy (I learned that one the hard way and sat for several hours covered with poop.)

Changing your baby on the plane can be a challenge. It is helpful to have little changing packs, with a diaper and some wipes, in individual zip lock bags. This will prevent you from having to take the entire bulky diaper bag with you into the tiny bathroom.

Bring some disinfectant wipes along and give the tray table and any surfaces a nice wipe down before you use them.

You can't count on airlines giving you any reasonable snacks, so it is important to bring along enough provisions in case of delays.
Kari, one of my mom readers added this tip. "-remember being surprised that airlines didn't have a way to heat up bottles either. Trying to heat a bottle in a tiny airline cup full of "tea" temperature water was rough. After the first flight, we took a large, insulated plastic Jamba Juice mug that would easily hold a bottle and water."

My daughter Lauren says that a hydroflask is another good option for keeping a bottle warm for hours.

Download some activities or shows ahead of time for your laptop or tablet. None of us want to overdo screen time, but if you have managed to keep it special, a long flight is the perfect time to make use of this tool.

Don't forget about the old fashioned low tech options! If you are visiting family, print out a bunch of photos of the people you are going to see. You can use these for all sorts of art projects on the plane. Make a paper doll family! This can help your kids recognize folks that they don't see too much of. Wikki sticks are also a great activity to bring along. They are lightweight and not too messy. Reusable stickers will stick on the window. Don't bring anything that will make you sad if you loose it in between the seats.

Once you get to where you are going, make sure the place is adequately child proofed (this is also a discussion that it is worth having with your hosts before you get there.) I had one situation where a 3 year old opened a drawer and got into grandma and grandpa's medications.

Is there a pet where you are going? Make sure that any dogs are safe with children.

If you are staying in a vacation home, do a quick safety check. Do they have working smoke detectors? A fire extinguisher?

Time zones are tricky. My best suggestion is eat when you are hungry, sleep when you are tired and just do your best. Staying hydrated and getting fresh air are essential. Sunshine is a bonus.

The link above has wonderful information for dealing with jet lag. Even the best sleepers may have a period of needing a sleep training tune up when you get home.

You can have lots of fun while you are away and it is wonderful to see family. But, in my opinion, if you are traveling with children under the age of seven, don't call it a vacation. It's not. It is a TRIP (we used to call our visits to the various grandparents the "bad bed tour.")

A little preparation goes a long way and remember that some of the more challenging moments make for the best stories!

Here is one of mine...

Many years ago when my daughter Lauren was two, I got creative as I was planning for an upcoming flight as a solo parent. I had seen a craft in a magazine (long before Pinterest existed) where a necklace had been made of cereal and I thought that this seemed like a fabulous thing for an airplane trip. Unfortunately, not all ideas turn out to be good ones. Lauren and I strung some Cheerios onto elastic and she proudly wore her new necklace onto the plane. Soon after take-off Lauren decided to eat some of the Cheerios. I noticed with some dismay that as she bit off a Cheerio, some would go into her mouth while other parts would shoot off like little spitty projectiles. They were landing (unnoticed by anyone but me) on just about everyone within three rows of us. As soon as I realized what was happening, I tried to see if there was a way for her to nibble them off without making a mess. When that didn't work, I tried to take the necklace off to make it easier or to have her stop eating them at all. But as mentioned, she was two. My choices were clear... tantrum on the plane or unsuspecting fellow passengers having little pieces of spitty Cheerios in their hair.

I opted for peace (besides, ignorance is bliss, right?)

Have safe travels and make great memories!

Friday, March 9, 2018

Dealing with Altitude 2018

This is the time of year when we get a lot of calls from folks wanting to take a road trip up to the mountains and asking about whether or not altitude is a problem for the baby. Keep in mind that many babies are born in places quite a bit above sea level and live their lives in high altitude year round.

Some folks in general are more sensitive to altitude issues than others, but there is no real difference between adults and children.Most people can tolerate altitudes below 2500 meters/8200 feet with only mild discomfort. If your child has significant heart or lung issues if is worth checking in with your specialist prior to travel. For the majority of my patients, Tahoe is generally okay for any age.

Mild symptoms can still have an impact. Folks may have headaches, tire easily and be a bit short of breath. Dr. Kaplan adds that tummies can get upset because the gas in your gut expands. Make sure your bring gas-X or simethicone along to help deal with this.

It is essential to make sure that you and your kids stay hydrated. Breastfeeding moms should take extra care that they are drinking enough.

Sunburn can happen easily in the high altitude. This is even more of an issue when there is snow or water to reflect the sun. Make sure you have appropriate sun protection for skin and eyes.

In the winter time, the air tends to be drier. The need to use heat in your accommodations can exacerbate that. It is worth bringing along your humidifier. (If you are flying, consider purchasing an inexpensive one when you get there.)

The biggest difference between adults and young children is that the adults can communicate what they are feeling. Babies can’t. If your baby appears pale, fussy or has labored breathing, get them to a travel clinic to be assessed. Make sure they have the oxygen level checked. On the other hand, young babies aren’t generally hiking around or doing anything strenuous so in some cases, they may have an easier time.

If you are traveling to a place that is higher than 8,200 feet, see if you can get there in stages so that your body has a little bit of time to acclimate. Know ahead of time what medical services are available should any family members run into trouble. Dr. Kaplan has had some patients, traveling to Colorado high country, who needed supplemental oxygen.

I personally am an altitude wimp. I like my oxygen and have trouble if I am anywhere over 5,000 feet. I will NOT be accompanying my husband and oldest daughter on their next adventure this, month when they go to Everest Base camp. They successfully summited Mt. Kilimanjaro… just a bit under 20,000 feet in 2016. Base camp is only a measly 18,192...piece of cake.

Friday, March 2, 2018

The Back to work transition 2018

The first couple of weeks home with your baby is a tumultuous time to say the least. It is full of so much amazement, sleep deprivation, joy, learning, and love. You might be in such a haze that you may or may not even remember this period very clearly.

It is the minority of families in our practice who have the luxury of having one parent stay home with the baby full time. Most families are faced with the huge transition that hits when one or both parents need to return to work. The luckiest families have flexible, understanding jobs and a local grandparent who can’t wait to babysit. If you can work part time, that is often the perfect balance. The rest of you are left trying to figure out the best option.

One of the biggest issues that many of the breastfeeding moms face is how to successfully continue to nurse. If your baby has never taken a bottle, try to give yourselves enough time for them to get used to one. Babies may simply refuse to take the bottle from mom. They know that breast is right there! They can smell it! It is best to have the other parent or caregiver be the one to offer the bottle. Ideally offer fresh breast milk, so that there aren’t too many changes at once. Try the bottle a bit before the baby is genuinely hungry. Some babies are remarkably easy and go back and forth between breast and bottle with ease. Others like my daughter Alana, can make it much more stressful. Alana screamed for an entire day. Luckily she was with a very patient and experienced caregiver who eventually had success. They all figure it out when they get hungry enough. I know that this battle of wills is a tough one.

If you are planning on pumping and keeping the baby on as much breast milk as possible, local lactation guru Nurse Charity shared some successful pumping tips. She suggests that you start pumping 7-10 days prior to going back to work.

Yes, this will bump up your supply, but going back to work usually does tend to decrease the supply over time, so starting at a higher level is good. Prior to pumping do an all over breast massage. Bring a photo of the baby or an outfit with that wonderful baby smell. Hopefully your job will be supportive of your need to pump and you will have a comfortable area. Frequent short pumps are just as good as trying to carve out one or two long sessions. Nurse Kenlee suggests making a “nursing playlist” or having some strong association with nursing that you can take with you when you are pumping away from the baby.

In general in order to protect your supply, make sure you drink plenty of fluids. Eat a healthy diet and make sure you get adequate rest. (I know, I know, but I had to add that)
Do lots of skin to skin contact when you are with your baby. It takes some effort but many moms are able to successfully produce enough milk that supplementing is not needed.

KellyMom is an excellent source for guidelines on storing the milk. If you have fresh milk, use it prior to defrosting your frozen stores. I always suggest putting a baggy full of ice cubes in the freezer. As long as they stay frozen as cubes, you are assured that the freezer has maintained the correct temperature. If the ice cubes refreeze into one clump, the milk can no longer be trusted.
Get in the habit of clearly dating all the milk and rotating the stock. Use up the oldest stores first.

Make sure that your milk freezes well. Some moms have an excessive amount of the enzyme lipase in their milk. The milk remains safe but has a nasty smell. Scalding the milk prior to freezing it will eliminate this issue. You don’t want to be the one who discovers this after you have a freezer full. The lipase has some health benefits, so if it isn't causing problems, don't bother scalding the milk.

While many moms have no trouble keeping up with their supply, others are not so lucky. Please don’t spend even a minute beating yourself up. Do not be the parent who limits the amount of milk the baby is allowed to have due to supply. Do not be the parent who is incredibly stressed out if they are an hour late home from work because the baby will starve. Simply do the best you can and take advantage of the fact that there are many excellent formula supplements out there. Being a good parent is not only about the breast milk.

Be careful that your child doesn’t swap their days and nights. If moms aren’t careful, some babies refuse the milk from the caregiver during the day, but wake up every couple of hours to nurse during the night. Sure, the baby is getting the milk they need, but mom will lose her mind from sleep deprivation. Let me repeat myself. An intact mom is more important than breast milk.

Beyond the issue of feeding is the huge question of finding a loving caregiver in your home or a safe place to send the baby while you are at work.

Many of our parents have success with small family day cares or nanny shares. Once kids are away from the safe relative quarantine of your home, they are going to start getting all of the little childhood colds and viral syndromes that are a rite of passage for most kids. Having a solid conversation with the daycare, other parents and/or nanny is essential so that everyone is on the same page regarding which symptoms necessitate staying home.

Take a moment to click on one of my all time favorite blog posts. It is all about striving to find balance between all the various aspects of your life. It is never more relevant than during this transition.