Friday, May 25, 2018

Teething symptoms and remedies/ Dos and Don'ts 2018

Topic of the Week:
Teething management/ Dos and Don'ts

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

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

It is rare for teeth to actually make an appearance before 4 months. Once in awhile parents will notice a smooth round white bud on a baby’s gum. This is a little benign cyst called an Epstein Pearl. It is not a tooth and it usually goes away without causing any bother.

Many parents think of teething as something they are only dealing with for their young infants. Think again. If your 6 year old is going through an extremely grumpy phase, or has a mysterious bout of mild, clear congestion that has been hanging on for a few weeks, take a feel in the back of the mouth and see if those first permanent molars are starting to pop through. By age 21, all 32 of the permanent teeth have usually erupted.

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


Let's talk about the symptoms:

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


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


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


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

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

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

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

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

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

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

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

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

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

Cool teething rings: make sure they are made out of a safe material. Do not tie any teething rings around your baby's neck. Strangulation has occurred.

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

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

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

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


Brandy/ alcohol:
Ask great grandma what she used to do for teething and she may tell you that she used to put whiskey or brandy on the baby’s gums. Obviously giving our babies alcohol is not something that most doctors would suggest today, but I actually wouldn’t worry if you caught grandma rubbing some directly on the gums. It probably does help. Some folks also say that rubbing pure vanilla extract on the gums is an effective home remedy. That may be from the alcohol content. (I am referring to a tiny amount applied topically, no swigging booze!)

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



I have had multiple parents tell me that these beads seemed to help but recent (12/18) concerns have surfaced about these being a potential choking hazard

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

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


DO NOT USE
Oragel or any product that contains benzocaine. They are no longer recommended due to safety concerns:

Hylands teething tablets were recalled several years ago. Even if you can find them somewhere they are no longer considered a safe option: https://www.cnn.com/2016/10/12/health/hylands-teething-tablets-discontinued-fda-warning/index.html


Once your child has teeth it is especially important to keep bottles out of the crib. Milk has sugar and can cause tooth decay if a baby sleeps with a bottle in their mouth. It is never too early to start brushing the teeth. Let's get your baby in good dental habits. It is important to use a soft toothbrush and non abrasive toothpaste. The current recommendation is to use fluoride toothpaste; just a teeny bit the size of a grain of rice.

Once they have a mouthful of teeth it makes sense to start shopping for a pediatric dentist that you can establish a relationship with. This will come in handy if you have any tooth questions or mouth injuries..

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

Wishing you easy teething!!

Friday, May 18, 2018

Mosquito and insect bites/prevention



Prevention is the key when it comes to dealing with mosquitoes. The news reports are predicting that this season is looking to be a nasty one for mosquito and ticks

  • Make sure that you have intact screens on all windows. This seems like a no brainer but if you are getting bites, check for holes or cracks where the insects might be getting in.

  • Get rid of any standing water that is around your house; do a double check to make sure there are no pots, bird baths...etc. that are places where mosquitoes can breed. The larvae are dependent on water for breeding. Unfortunately just dumping out the water might not be good enough because it won’t dislodge the larvae that might be attached to the side. You really need to give a good scrub. Nurse Lainey taught me about Mosquito bits and mosquito dunks. You can add these to any water features to keep the mosquitoes from breeding.


  • There tends to be increased mosquito activity during dusk and dawn so that is when most of the biting happens. (For the travelers out there, pay heed: the mosquitoes that carry Zika don’t have a time preference.)

  • Try to wear (keep your child covered with) long pants/ long sleeves etc. Light colored clothing is recommended.

  • If you are going into a heavy mosquito area use bug spray on exposed skin and clothing. Mosquito repellent works only on the surface to which it is applied directly. They will actually bite skin only four centimeters away from where the repellent is applied, so the wristbands or just spraying clothing does not offer full protection.

  • As for the traditional electric bug zappers, some bug experts would rather that you don't use them. The violet light may be irresistible to some flying insects, (and that zap is such a satisfying noise), but mosquitoes are actually not attracted to the light. Some of the innocent and beneficial insects are the ones getting fried.

  • If you are seeing mosquitoes around your house, San Francisco's Environmental Health Department will send an inspector to investigate (415-252-3805.) They will check the area around your home (including sewers) to see if they can find any breeding areas.



Alas, longs sleeves alone aren’t going to do the trick if you are out in a buggy area.

There are plenty of natural products on the market that claim to be repellents, ranging from Vitamin B to catnip. Most of these are generally safe, but unfortunately the scientific studies show that they are mostly ineffective. We have the luxury in the Bay Area of not having some of the more notorious mosquitoes, so the bites are mostly an aggravation rather than a health risk. If you are local to the Bay Area, it is not a big deal to give something a try to see how it works on your family. However, If you are traveling to an area where there are more dangerous mosquitoes, I would stick with the strong stuff. No kidding around.

The EPA has five registered insect repellents.


DEET is likely the most well known option. It is the only product labeled safe for infants as young as 2 months old. It comes is different concentrations. The concentration of DEET in a product indicates how long the product will be effective. A higher concentration does not mean that the product will work better; It means that it will be effective for a longer period of time. Therefore, products containing lower concentrations of DEET may need to be reapplied, depending on the length of time a person is outdoors.

Oil of Lemon Eucalyptus is considered one of the least toxic options but interestingly, the age recommendation for it is for 3 years and older.(Natural lemon eucalyptus oil is not the same as Oil of Lemon Eucalyptus) Some people are sensitive to the smell of this, it is worth sniffing it before you buy it.

Picaridin  is odorless and is approved for children 6 months (recently lowered from 2 years) and older.



Avon Skin so Soft Bug Guard PLUS IR3535 Insect Repellent has been around for years but seems to be more commercially available than it used to be (also for over 6 months of age.) It comes in a highly rated product that combines Avon Skin So Soft and an SPF 30 sunscreen


Bite Blocker is a botanical formula that claims to provide protection for up to 8 hours. The reviews mention a strong odor, but otherwise it gets high rating.


Before applying anything topical to the skin for the first time, do a little test patch on the skin to make sure there is no sensitivity before you widely spritz or wipe on any of these products. You will need to read the labels to see how often you need to reapply. Avoid contact with eyes and keep all of these safely away from kids.

I would also be cautious about getting any insect repellents on the hands especially if your child is young enough that those hands are going into the mouth a lot.

If you are also using sunscreen, apply sunscreen first and insect repellent second.

All of the EPA recommendations are considered safe, and they are clearly better than getting bitten, but at the same time, let’s use them wisely. The EPA has created the following tool to help you find the proper product for you needs


Some products are more effective than others for certain types of mosquitoes, so the product you choose might depend on where you are going and what you might be most at risk for.

It is always good to check in at cdc.gov/travel prior to any travel.

Mosquitoes don’t like fans! The nasty insects are lightweight enough that a good breeze may make it hard for them to zoom in on their target. The Off! Clip on  gets some folks who swear by it. If you are looking for an alternative to the DEET, it might be worth giving it a try (perhaps it is the fan aspect that makes it work…)

If you are interested, Here is some current info on some of the mosquito borne illnesses that have been in the headlines the most in the past year or so.

West Nile Virus is the one most likely to be circulating here in the Bay area

If you see any dead birds, give them a wide berth and report them to 1-877-968-2473 (WNV -BIRD) or online at westnile.ca.gov. That website also will give you the up to date numbers on how many West Nile virus cases there are in California, county by county. It is updated weekly.




DEALING WITH A BITE

If the prevention has failed,treat the itching. Scratching at a bite will make it worse. There is a fairly new product called a mosquito zapper that I just learned about from Nurse Heidi. Some patients are startled from the noise, but others claim that it is great for minimizing the reaction.

Over the counter hydrocortisone cream probably works the best, but other topical treatments can include calamine lotion, or mixing up a paste of baking soda with a bit of water. A cold black tea bag compress can also be very soothing. Black tea contains tannins, which seem to help.

Some kids can have enormous reactions. Eyes and ears can be remarkably swollen. Topical treatment won’t be enough for these. Give a dose of Zyrtec or Benedryl right away. Scroll to the bottom for dosing info

If the antihistamine doesn’t make a difference or if there is fever or severe discomfort, those kids need to be seen.

If your little one is getting bitten, check the bedroom carefully. Look at the mattress and all the corners of the room; bites could be from spiders, fleas or other culprits.


Here are some bonus facts about mosquitoes:

  • Both males and females make that awful whining noise, but only the females bite humans.
  • Mosquitoes are especially attracted to people who drink beer.
  • Mosquitoes love the smell of sweaty feet.
  • Mosquitoes can sense CO2 from up to 75 feet away.
  • Mosquitoes only fly as fast as 1-1½ miles per hour.
  • Some blood types may be tastier than others. O seems to be the favorite, A the least. B lands somewhere in the middle.
  • Mosquitoes love pregnant women (regardless of their blood type) possibly because they emit a little extra CO2.


Zyrtec Dosage Chart
The dose of cetirizine depends on age:

  • 6 - 12 months of age: 2.5 mg given once daily (maximum dose 5 mg daily)

  • 12 - 24 months of age: 2.5 given once or twice daily (maximum dose 5 mg daily)

  • 2 - 6 years of age: 2.5 - 5 mg given once daily (maximum dose 5 mg daily)

  • Over 6 years of age: 5 - 10 mg given once daily (maximum dose 10 mg daily)

Zyrtec comes in a 1mg/ml solution (so 2.5 mg = 2.5 ml). There is also a 10mg/ml oral drops preparation (so 5 mg is 1/2 ml). Make sure you check the strength of the solution.

Benedryl dosage will be the same volume as your tylenol dose. The liquid says for children 4 and over; we still use it for our younger patients who need it. Benedryl makes most kids sleepy but can have the opposite effect.

Friday, May 11, 2018

Lessons from my mom



My mom was a teacher. She was that favorite teacher that people never forget. After she died, ex students reached out to say how my mother was the one who steadied them, gave them a sense of what they could do and sent them off, better able to cope with the path ahead. Teaching was not only her career, but one of the main aspects of who she was.

I would like to honor her memory this Mother’s Day week to pass along some of the life lessons that she taught her children, grandchildren, friends, and students.


Reach past the grumpy countenance to find the person behind it.
My mom had a private little game. How long would it take to get on, as she called it “kissing terms” with people she met. She was pretty hard to resist and even the most sullen security guard at the bank would break out into a sunny smile when they saw her.

Take the time to reach out to people.
Mom was a letter writer. She stayed in steady contact with older relatives and friends who were otherwise alone. If someone was ill, they would get a card or a call.

Take a moment to give positive feedback.
My mom had cancer the last years of her life. I remember going with her to her chemo appointment once when I was visiting home in Pittsburgh. She was hugged by everyone we encountered. She knew everyone by name. She brought seeds from her garden.

We were called back to get her blood drawn. The phlebotomist reached into her drawer to show me a letter that my mom had written to the facility, telling them what a good job this woman did. She still had the letter, many years later. The valet parker pulled out a similar letter when we went down to get the car.


Wonder about things
Mom was known far and wide for her story telling ability. She could have a roomful of energetic kids quiet and hanging onto her words within a moment. If she saw something odd, like a pair of shoes left at the playground, it would be fodder for a story. How did those shoes get there? Who left in such a hurry and why?

You don’t have to follow a script
Her stories would take random and unexpected turns. No story was ever the same. There was always an underlying theme of kindness.

You CAN teach an old dog new tricks.
My younger sister is a National Park Ranger. My parents took full advantage and turned all vacations into opportunities to visit the parks where Amy was working. Mom was exceedingly proud that for her 60th birthday she got her first pair of hiking boots.

Stay active
When she could no longer go for walks, she did chair yoga or got on her stationary bike.

Find a way to relax
She was a reader and read an assortment of genres, but she unashamedly plowed through the harlequin romances. You know the ones with the shirtless, muscled, long haired Fabio types on the cover? Yep. Those. She always had one in her purse. I bought her a couple from her favorite author and Amazon has never let me forget it. (if you ordered this, you also might like…..)

Having a sense of humor is imperative

Be self aware and recognize your own needs
Mom was very social, but in her mid adult years she realized that she needed to carve out some alone time. She became a morning person. She used to say that the dawn belonged to those who chose it. She relished her quiet time while the rest of us were still asleep.

Get involved
Mom was the block watch captain. It is also no surprise that she was the girl scout and Brownie troop leader. She also became the accompanist, playing piano for all sorts of school shows.

Give your kids the opportunity to learn an instrument
Both of my parents were amateur musicians. I confess that I took it for granted that there was often chamber music going on in my living room. My mom thought that it was a special gift to learn an instrument that could be part of an orchestra. I only learned piano. My older sister Marjie played all sorts of things and sat next to my mom in the cello section for the local Gilbert and Sullivan troupe. (My dad sat right in front of them playing the violin.)

Have a family pet (say yes to the stray that finds you)
Unless there are horrible allergies, let your children grow up with the love of a pet. My childhood house had cats, birds, fish and gerbils. Marjie attracted strays like magnets (still does), and somehow they were allowed to stay.

Don’t be a pushover, if you see an issue, say something or do something about it. Yours might be the voice that ultimately makes the change happen. Potholes? Speed bumps? Mom wasn’t shy about taking her letter writing to her congressman or newspapers,and oh by the way, the congressman and the mayor?... Kissing terms!

Vote
It was ingrained in me early that you should never skip an election, regardless of how insignificant the issues might be. Our right to vote is sacrosanct. Some of my earliest memories are accompanying my parents to the voting booth. When she was no longer able to get out of the house, she had an absentee ballot.

Be kind to the earth
Mom was an avid gardener. Her favorite plants were her “silver dollar” money plants. She would pass out the seeds to anyone with a garden. If there are any gardeners out there who want some, let me know. Her seeds live on. I think they can grow just about anywhere.

She also hated waste, She could spot potential treasure or art projects in the most mundane articles. My parents were recycling many years before it came into fashion.

“Don’t be too hard on yourself”
She was never too worried about perfection. Giving a good effort, rather than a successful outcome, was what mattered.
“It is what it is, and you do the best you can” is a motto that I continue to live by.

In that vein, mom herself was of course, not perfect. She could hold a grudge like nobody’s business. I can still hear her saying “When I turn off, I turn off.” No more kissing terms for THEM.
In an interesting twist, this was just as important of a lesson as all of the others. From it, I learned the importance of forgiveness. Releasing all the negative energy is something I find essential.

Here is a lesson from me...Turn the mad into sad, turn the anger into disappointment, bank any wisdom earned from the interaction, communicate as needed (or not), and then move on.

It is my pleasure to forward her ripples of positive energy. The world is in dire need.

I asked my sisters, daughters and nieces to take a peek at this list to see if there was anything glaringly missing.

Alana laughed out loud when she thought about the list she would have to make if she was creating her own “lessons from mom.”

I did have a very specific list of “strong suggestions” for my girls that had a very different flavor than the list above. My list included:

  • No getting on a reality tv show
  • No taking a job that requires the wearing of a humiliating hat
  • Don’t eat french onion soup on a first date
  • Check your blind spot
  • Floss

And a few other easily R (X?) rated suggestions that are not suitable for sharing in this venue!

Friday, May 4, 2018

Diaper Changing tips




Mama Jennifer was dealing with a baby who was doing a lot of fussing during diaper changes. I LOVE that she searched my blog to see if there was a post that dealt with that. This was not, in fact a subject I had even considered covering in the past. I am always happy to to get topic suggestions and the more I gave it some thought, the more there was to write about. Thanks to Jennifer for the topic suggestion and to the contributors who shared their wisdom on the subject.

There is so much new stuff to get used to when you have a new baby. One of the first things to get comfortable with is that you are going to come in intimate contact with an array of bodily fluids (that are not yours) and you will learn not to think twice about it. In my baby boot camp I sometimes tell one of my favorite pee stories.

Prior to moving out to San Francisco, my husband and I spent a few years in New York City. Anyone who has experience with hot sticky summers (the reason I can’t ever leave my city by the bay) knows how miserable that weather can be. Our upstairs neighbors had a fairly new baby. This was August and it was sweltering. The little baby boy was in his infant seat, completely naked, getting a little air. The exhausted couple needed to go shopping, but that evening they were making the very last bit of food that they had on hand (Grub Hub was but a future dream.) The pasta was being strained when the baby peed an arcing stream of urine that went several feet across the room and landed directly into the colander of spaghetti. The parents looked at each out in shock and awe, and then said at the same time, “rinse and eat?” which they proceeded to do. The next morning when they told us what happened, we laughed, gave a big yuck, and told them they were nuts; they should have called us, we would have gone out and gotten them food.
Here is the thing. We didn’t have kids yet. Every one of their friends who were parents, went over to the “rinse and eat” team immediately. Most of you will get there.

Of course, the goal of diaper changing is to keep the pee and poop safely contained and disposed of without getting it all over the place.

It has been thirty years, but I still recall the Poopageddon event of Sandy’s first attempt at changing Lauren. In a rookie move, he opened the diaper and didn’t take the step of carefully folding the front over to cover and contain the poop before starting the cleanup. With the soiled diaper open, Lauren managed to get her kicking feet right in there. Her feet, now smeared like a nasty paintbrush, managed to get poop on the walls and just about everywhere else. That was the night of her very first bath in the big tub. Sandy ultimately became much better at the mechanics of diaper changing and swaddling than I ever was.


When babies are young, most parents manage to get pretty adept at changing the diapers without too much ado because even though they may fuss, the babies don’t have the motor skills to do anything but put up with it. If your baby really seems to hate it, see if you can make some adjustments.

Make sure the room is warm and that the wipes are not freezing cold. There are wipe warmers available on Amazon that are not terribly expensive. Please make sure that the wipes are free of unnecessary ingredients such as scents or alcohol that might cause stinging. Make sure you have everything within reach and ready to use before you start the process (don’t forget the box of tissues for blotting the area dry after using the wipes.) Nurse Heather's tip is to put the clean diaper down first. When all the wiping up is done, you just slide the old one out. Have a washcloth or something right at the ready to protect yourself from getting peed on. Babies love to pee within a moment or two of when the diaper comes off.

See if you can put the changing area on a bit of a slant, This might help for those babies who just hate to be completely flat.

Dr Schwanke reminded me that there are some changing pads that have an indentation that makes it harder to wriggle around but make the babies feel secure and comfortable.


Preventing diaper rash is so important:


Once diaper changes become uncomfortable it is tough to remove the “negative association” associated with the diaper change.

My friend Sari, a Cranial Sacral therapist in Arizona, says that parents should consider slowing down the pace dramatically. Our instinct is to hurry up and get it over with, but many babies actually react better to a slow and quiet pace. While you are at it, she loves the upside-down U movement. Gently stroke from the top of the right hip, up to the ribs, across the ribs and down to the left hip. Lift up and start again at the right hip and repeat. This stimulates the direction of the colon and is often relaxing to babies. Have some interesting things nearby for them to look at. Mobiles, and other toys or rattles are good options. Make sure that anything in the changing area is completely washable.



And then the babies start to roll... Of course try everything you can to distract them, sing a song and let them hold a toy. How you handle this will have an impact on future diaper changes. You need to be the alpha here. It is okay to be firm and get down to business; the wet or dirty diaper needs to be changed. Your baby won’t be psychologically scarred if they aren’t getting their way. Sometimes if you are firm and matter of fact, they will stop struggling when they realize that fighting and squirming doesn’t get them very far.

Then they start to crawl and pulling themselves up on things. I have vivid memories of chasing little naked butts across the room and learning how to do a diaper with them in a standing position, but is there a better way? Once they are crawling they can start playing games. Perhaps play a game where everyone does a silly dance and when you say “stay still” everyone freezes. Count to a number (your choice, high or low, slowly or quickly) and people can move again. If they learn the ‘stay still game’... just maybe you can play it when you are changing diapers. Counting to ten, if you do it slowly enough, should be enough time to do a quick change. Not that I am equating your little one to a dog, but the stay still command is one that might have other future uses.

Nurse Lainey makes an excellent point. Teaching your child to cooperate during a diaper change becomes even more important when you are away from home. Having a child lay still rather than touching nasty surfaces on a rickety changing table in a public bathroom drastically reduces the risk of injury and cooties.

NEVER EVER leave the baby on the changing table to step away even for a moment, even if they are strapped in.

Make sure you wash your hands AND the baby's hands after each change.

Since one of the goals of these posts is to address questions that we get frequent calls about, it is worth mentioning the following:
When the diaper is off, it is completely natural for babies to explore the areas of their body that they don’t usually have access to. Make sure that nails are trimmed so that they don’t scratch themselves. If there are any signs of rash or infection, there may be some irritation that is worth the doctor seeing. If their hands are getting in the way of the changing, give them something interesting to hold on to (although, nothing is really quite as interesting as genitalia, but do the best you can.)

There are times in the office when the advice nurse team doesn’t have the time to have long chats with parents about issues such as diaper changes. We often refer non medical questions to the folks over at the Parentline. This is a valuable, and currently free, service. I reached out to the very wise Dhara Meghani for her feedback about this topic and she had some worthwhile things to add.

Developmentally, for babies 9-15 months or so who are getting to be quite mobile, adding a mirror against the wall where the changing table is can help distract them. They may want to touch/poke the “baby in the mirror,” not recognizing that it’s themselves until about 15 months or so, which can be a fun game to further engage them with something else while you’re changing them. You can ask them to point to baby’s nose, eyes, etc. A similar ‘game’ can be done with other pictures or art on the wall. Some parents may also feel less anxious about potential injuries or falls if they have an especially active baby at this stage by moving the changing area lower or to the floor, as long as this is comfortable for the caregiver. You can still store the changing supplies at a higher level or in a childproof container.

Slightly older toddlers thrive on predictability and feel proud when they can help or do something themselves. In this case, letting them know what’s coming up (‘e.g., it’s going to be diaper changing time after we finish coloring’) or walking them through what you are doing during the change can help them get that ‘this is the drill’ and that it’s easier to go and play again when they help by being very still and patient.

I also like to remind parents that it’s essential to “catch your child being good” - toddlers especially love being praised even for things that we expect them to do. So with a diaper change, I’d let your little one know it right away when she did a great job laying down, not wriggling around, staying still, handing you the diaper, etc. (it’s important to be specific in your praise so that they are reinforced to do it again!).

Thanks to all the readers who shared their tips.

Susan says "diaper changes have been among Milo's least favorite things for about a year now, so I'm really looking forward to what you hear from other parents and what you advise as well! That said, I finally struck upon something in the last few months - from when he was about 14 months, or so: enlisting his help. I have him help unfold the diaper, place the fresh diaper where it needs to go, help by remembering/showing me how the fresh diaper goes under his bottom (I like to have the fresh one in place under the dirty one before I open that one up). For Milo, the objections I believe are mostly to do with his strong desire for autonomy and for figuring out how things work and participating in them. I'm actually looking forward to potty training because I think he'll be really into being able to take care of something that's so fundamental and frequently occurring himself."

Rachel S. says "When my guy is squirmy and being changed, we sometimes pick a toy or stuffed animal to hold before going on the changing table, or we start a song to sing, or count in either Spanish or English. Sometimes I talk with him and tell him we do it all the time and it’s quick, and if he’s still (sometimes I use the word cooperative) then it goes faster."

Amanda and Randall - "Best idea we have for diaper squirm - Randall put a collection of books on the shelf next to the changing table so we do a book rotation. I can't believe it works, but it does. She looks at the pictures and each one buys me about 45 seconds which is sufficient if I move quickly. Plan B - we sing ABCs, but far less effective. Dad's book plan is a better one."