Friday, July 27, 2018

Drowning Prevention: Appoint a Water Guardian!

This is the time of year that many of my families are traveling. Anytime you are away from home, there are a range of safety issues that can arise. When you get to your vacation destination, do a basic assessment as soon as you arrive. Are there smoke and carbon monoxide detectors? Do you know where the fire extinguisher is? If you are visiting older relatives, are any of their medications safety out of reach? Are any unfamiliar pets comfortable with children?

Think like a toddler. What type of trouble can they get into? Can they open the doors on their own?

Water danger is one of the more essential considerations. If you are going anywhere that has a pool or is near water of any sort, you need to be aware that drowning can happen in just a few inches of water and it can happen quickly!!! According to the CDC drowning is now the most common cause of death in children under the age of four (excluding congenital issues)

We had a scare with one of our families a few summers ago. Several adults and children were enjoying a day at a friend's pool in the East Bay. They got out of the pool to have some lunch. Some of the oldest kids started to bicker. While the adults turned their attention to the squabble, a one year old got back into the pool unnoticed and submerged. Thank goodness another of the adults looked up, noticed, and was able to get her out and perform CPR. The little girl is perfectly fine, but this was terrifying for everyone. Dr. Karen Makely, one of the wonderful urgent care physicians over at St. Lukes, says that sometimes having a lot of adults around lends a false sense of security. Consider having each adult take turns being on a shift as the designated lifeguard.

It is so important to be aware that a person who is drowning usually does not thrash about and call attention to the fact that they are having trouble. They can slip silently under the water without being noticed until it is too late. Even if your child has proven themselves to be solid swimmers, you need to stay actively focused and engaged on watching them like a hawk while they are in the water.

Nurse Lainey sent me this link last week Levi's Legacy and I am going to do my part to spread the word. Many parents are on high alert when they are actively at a poolside but the danger doesn’t end when you are inside.

Levi's Legacy tells a heartbreaking story of a child who slipped out of the vacation home, made it out to the pool and drowned as the parents were busy doing some preparation for a family evening outing.

The important message here is that the lifeguard shift does NOT end when you go inside.

If you are staying anywhere with a pool, make certain that your child has absolutely no access to the pool area when there is no adult present. Hotels or apartments with fountains need to be treated with caution as well. If you do have pool access, there are a variety of pool alarms and safety monitors on the market. Some devices are little gadgets that your child wears around their wrist. Alarms and monitors may add a layer of safety but I would warn you not to have a false sense of security. Someone needs to be on duty. Take turns. Appoint a water guardian. On duty mean no distractions (that means your cell phone. Put it down, you can do it.)

I am linking some of my past posts that are swimming related.

Monday, July 23, 2018

A pet safety tip: Java and the Bologna

Java and the Bologna

Last week I got a call from a parent of a fairly young child who was bitten by a friend’s dog. The toddler was feeding the dog and a finger got in the way. Anytime there is food, a young person, and an animal, I am worried that inadvertent nibbles might happen. In this case, there was nothing malicious and the doggy was current on it’s shots. Anytime a bite breaks the skin, we want to keep an eye on it, but you might be surprised to know that human bites are more of a concern for causing infection than a dog bite.

This made me recall the tale of my old girl Java. The sweet golden wearing the nurses cap who decorates my blog was my family’s beloved dog. We had her for twelve wonderful years. Time zooms along; she would have been 19 years old this July. I still miss her deeply. The pet owners out there understand.

Towards the end of her life, she was a happy girl, but was moving pretty slowly. Instead of bounding across the grass to chase her favorite ball, we would toss the ball a paltry few feet and she would be satisfied with that. One day, she and I were playing the “old dog” version of fetch at the end of the grassy part of Midtown terrace playground.

All of a sudden her nose gave a twitch and my old girl absolutely flew across the park to the children’s play area where two women were giving a group of young children a snack. The kids were lined up on a bench about to eat what turned out to be bologna sandwiches. No one was more surprised than I was that Java could run so fast. I might add her that in her 12 years, although we were misguided dog owners who let her eat way too much “people food” (she loved pizza) bologna was uncharted territory for her.

Java had reached the picnic before I even figured out what was going on. By the time I had gotten to her, she had already stolen the first sandwich, wolfed it in one happy gulp and was about to get a second. There was total mayhem. The group had every reason to be seriously annoyed, but let me make it clear, these were not dog lovers under any circumstances.

I arrived just as one of the women grabbed her little girl’s hands holding the sandwich as Java was trying to snatch it. A finger got scratched and there was a drop of blood. More panic ensued. I got Java on her leash and profusely apologized. Java was as waggy as could be, She could smell another full bag full of sandwiches and was hoping for more. She was ‘bologna delirious’ and I just needed to get her out of there.

I assured the adult women that Java’s shots were up to date. I showed them her license, gave my phone number and suggested that I remove her from the scene, take her home (we lived across the street) and I would come back with band aids, Neosporin (and some lollipops). I told them I was a nurse. I would be right back.

I said to the kids, “The silly dog was not being a good girl. She wanted to steal your sandwich, which is a bad thing to do, but she certainly didn’t want to hurt anyone or scare you.I am sorry that that happened”

I dragged my reluctant dog home, grumbling at her the entire time, “I can’t believe you did that!!” I threw together some first aid stuff and rushed back to the park as quickly as I could.I was gone for no longer than five minutes.

Are you kidding me? As I got there, I could see red lights flashing from an ambulance and several fire trucks. They had called 911. The park happens to be across the street from a firehouse, so firetrucks hadn’t had to travel very far.
In fact, the firemen mostly all knew Java and me from years hanging out at the park. I arrived as one fireman was convincing the still distraught women that they probably didn’t need to go to the ER. He looked at me and rolled his eyes. The family ended up accepting my cuter band aids (although there was almost nothing to see on the little finger and no more bleeding.)

I thought that was the end of the story, but the Oscar Meyer gang also reported the incident to animal care and control. Poor Java was under house arrest for several weeks...Oh the indignity. We all took to calling her Kujo!

Even though a 911 call was wildly out of proportion, I really was horrified that this happened. Java was a gentle dog who loved all people, but especially loved kids. As is my way, I looked for the lessons. Should I have had her on a leash? Perhaps, but that wasn’t the lesson I came away with. Instead I started teaching the “Java Rule” at my safety classes
As you are teaching your kids about safe interaction with pets, keep these guidelines in mind.

  • Java's rule: Teach your child and practice this. If they are holding food, and a dog tries to get the food, they should drop it, rather that trying to keep it from the dog. This would be especially true if you are at a park and you don’t know the dog. Just open your hand and let it go. You can always replace the food.

  • If you are at home, make sure that your child can eat safely with no pets able to grab food away from them (droppings on the floor are a different issue.) If your dog is a food grabber, they need to be out of the room when your kid is eating. (Dogs should also be given the the same respect and should be entitled to the luxury of eating without a toddler in the room.)

  • Children shouldn’t be allowed to feed animals until they are old enough to be deliberate and hold the food out in a flat hand with a thumb safely tucked away.

Friday, July 13, 2018

The milk transition/calcium requirements

The milk transition/calcium requirements

Calls about the transition from breast milk or formula over to whole milk rank up there in the "frequently asked questions" category.
If you are breastfeeding and it works for you to continue to nurse beyond the first birthday, good for you! Don't be in a rush to stop. The length of time that you choose to nurse is a very individual and personal decision. For those moms who continue to breastfeed beyond the first year, that magical breast milk feels like a godsend if your child doesn't feel well. Not only is nursing a comfort, but breast milk is great for tummy bugs, eye issues and all sorts of stuff. One parent was poking a bit of fun at me and said "if you call Nurse Judy, she will just tell you to put breast milk on it."

On the other end of the spectrum, many moms (myself included) end up weaning sooner for any number of reasons. In our practice, the first birthday is probably the average age that the milk transition occurs. Keep in mind that if your baby is on formula and tolerating it well, there is no hurry to get off (except for the expense and the hassle). If you have a case of formula left over, by all means use it up.

While it is fine to carefully introduce milk-based products such as cheese or yogurt to your children once they are over 6 months, plain cow's milk is not an appropriate substitute for formula or breast milk in the first year, as it lacks some important nutrients. 

The first birthday is also usually when we recommend a blood test that checks the iron level. Formula has more iron than cow's milk, so if your child is a fussy eater it is important to make sure the iron levels are adequate before we switch over to plain milk. At our office, we usually send the patients to a local lab to have both the iron and lead levels done with one poke. If there are obvious concerns about diet or lead exposure, your doctor may end up doing the labs sooner.

Once you move along to cow's milk, I prefer that you use whole (full fat) milk. If possible, and you can afford it, go ahead and buy organic. I know there are folks out there that tout the benefits of raw milk, but I have a strong opinion that milk should be pasteurized. I have had parents asking me about vat pasteurization, and that does seem adequate.

Most kids who were on a milk-based formula have no trouble moving on to cow's milk. It is fine to do it gradually so that they get used to the taste (add a few ounces to the formula and see how they do). Intolerance will likely show up as tummy aches, poop changes or rashes. My older daughter got a terrible flare up of eczema when we first got her on milk (Eczema post). I put her back on her formula for a couple of months and when we retried the milk she was just fine with it.

But if you thought that the main choices about cow's milk were organic or fat content, think again. Along comes the choice between A1 and A2. Huh??? It turns out that there are indeed two kinds of cows out there (don't worry there won't be a test on the following paragraph).

A1 and A2 beta-casein are genetic variants of the beta-casein milk protein that differ by one amino acid. The A1 beta-casein type is the most common type found in cow's milk in Europe (excluding France), the USA, Australia and New Zealand. This is what most of us have grown up drinking. African and Asian cows are predominantly A2 cows. Milk from goats and humans contains only the A2 beta-casein.

There was a lot of buzz about this when I first wrote this post several years ago. The claim is that folks who have trouble with our common (A1) milk may in fact be able to tolerate A2 milk without any issues.
I rolled my eye when it first came around, but I confess that I have had some patients with milk intolerance who seem to do better on the A2 milk. In the past year, A2 milk has become more widely available at many grocery stores and doesn’t seem to be all that more expensive. For those of you with milk issues, it is worth checking out.

Milk is a great source of calcium, protein, vitamin D and the fat that your child needs for brain development. Not all proteins are the same. For those who can tolerate it, dairy milk is a complete source. It contains essential amino acids – the “building blocks” of protein – that our bodies need. The protein in most nut or plant-based milk substitutes is incomplete, meaning it's lacking in these essential amino acids. Since your body can’t produce essential amino acids on its own, it has to come from the choices you make in your daily diet - like dairy milk.

If you have a hard time getting your child(ren) to drink milk, it is important to make sure they are meeting those nutritional needs through other sources. If you choose to use a milk alternative such as goat, soy, rice, almond, coconut (seriously, there is a wide array of choices) the labels and see how they compare. In general:

Cow's milk and soy milk are both going to be the more complete sources of protein and calcium. Goat's milk is also good for protein and calcium, but doesn't have as much vitamin B-12. Almond milk and coconut milk have significantly less protein but are good sources of calcium.
It is important to be looking at the entire diet to make sure your kids don’t have any nutritional gaps

We want our toddlers to be getting at least 700 mg of calcium per day.
With a little planning, getting enough calcium should be reasonably easy if they are eating cheese and yogurt.
Table 1 and Table 2 at the bottom of the post will give you the calcium requirements through the ages and a list of calcium amounts in a variety of foods.

Interestingly, breast milk doesn't have quite as much calcium per ounce as cows milk, but the calcium it does have has twice the bio-availability. 


I personally don't feel the need to be completely off of the bottle at 12 months. I am perfectly fine with a snuggle bottle when first waking up or going to sleep for an extra couple of months. NEVER leave a bottle of anything other than water in bed. If a child falls asleep and keeps the bottle in their mouth it will cause tooth decay.

Try to transition most of the fluid intake to a cup. Once you start moving away from the bottle and transitioning to a cup, many kids significantly decrease their milk intake. Kids just don't like to drink as much milk from a cup. I couldn't tell you why. Some parents feel a little better assuring at least some milk intake by giving it in the bottle.

If you are trying to encourage your child to drink the milk from a cup, try adding a few drops of vanilla or a dash of cinnamon. Some kids might like it better warm. You can also try frothing it. I am not in favor of adding unnecessary sugar into your kids lives, so I would not suggest adding chocolate or strawberry flavor to the milk on a regular basis. Consider making smoothies with milk as the base. Kids like adding things into and turning on the blender. You can get a special cup that they have helped pick out. If you are using any alternative milks, watch out to make sure you aren't getting a sweetened version that is adding all sorts of extra sugar.

As is the way of things, There are those kids where getting enough milk in is always a challenge. One the other hand, there are those kids who drink too much milk are often anemic because they fill up on milk and don't eat enough solids. Those are the 'milkaholics'.
Once your little one is over a year, 12-24 ounces a day is a fine range.  

Friday, July 6, 2018

Speech milestones/Local speech therapy resources 2018

My older daughter Lauren reached her verbal milestones at a young age. It turned out that she was stringing together sentences quite a while before we could actually understand what she was saying. The fact that she was actually using real words to communicate became apparent to me one day when she and I were wandering around the zoo. She may have been as young as 15 months at the time. Lauren started to tug on my arm saying “shoofaloff”

It sounded like typical babble; I tried to figure out what she was attempting to communicate as we walked. Was it an animal perhaps? Did she want a snack?

“SHOOFALOFF” She kept repeating. She was getting upset that I clearly wasn’t understanding what she was insistent on telling me. “SHOOFALOFF”

I paused for a moment, happened to look behind us and saw that her shoe had fallen off and was about 10 feet behind us. Shoofaloff was “shoe fell off!” Duh! At that moment I realized that her fairly incessant cute little gibberish was actually speaking. As the weeks passed, Lauren became more and more articulate and I completely took it for granted that we lived with a little talking wonder.

When Alana came along, I expected nothing less. Alana (no need to fret about her, she graduated top of her Master's program and is currently working as a therapist) didn’t care about reaching milestones (any of them!) She had no trouble at all with comprehension, but her speech was incredibly garbled. By the time she was two, we could still barely make out a dozen words. Fortunately we had Lauren, who translated for her without any problem.

GUGUGUGGODH might mean “I would like more popcorn please”. Lauren was puzzled as to why we couldn’t understand her sister. This just goes to show that often siblings have magic communication skills with each other at a very young age. Eventually Alana had plenty of words, but there were still a few letters that were hard for her to pronounce until she was quite a bit older.

There is a huge range of normal, so when do we need to have our antenna up? There are a few basics to keep an eye on. By 4 months your baby should be cooing and making sounds. If this is not happening, one of the first things we would want to make sure is that your child doesn’t have an issue with their hearing. Babies born in California are given a hearing screen at birth, but it is still something to check out if you have concerns. Does your baby react to your voice? Do they look in the direction of a loud noise? As they get older, can they follow simple commands? If you are looking at a picture book, can they point to the appropriate picture with your prompt?

By 15 months they should be able to speak at least a few recognizable words.These don’t even need to be valid words. Alana couldn’t pronounce Lauren, but she could say Yaya and it was clear that Yaya meant Lauren. To this day, it still does! Perhaps "da" means dog. As long as they are consistent and communicating, those sounds count as a word. If your child knows some signs, those are counted among their words. If you know for sure what they are saying, repeat after them and expand on their utterance. When they see the dog and say “da!” you should say “Yes. DOG!” (repeat) “look at the big dog” (expand.) If they are using a sign, say the word. For instance if they are signing “more” during a meal, say “more” (repeat) and then expand, “would you like more peas?
By repeating and expanding , not only are you reinforcing correct production of their words, but you are supporting their language development

Michelle Geffen, a speech therapist at Jennifer Katz, Inc., advises not to pressure your kids by always asking them to say the specific word. Instead, let them hear you use the word and wait for a response. Waiting can do wonders!

If your child reaches 18 months and there isn’t any understandable language, this is an appropriate time to get a baseline evaluation from a speech and language therapist. Sure, it is okay to wait a bit longer if you like, but early intervention is always a good thing. I like to be proactive. Often the evaluation is covered by insurance.
By the end of the 2nd year, children should be able to speak roughly 100 words, understand 300, and have some word combos. They should be understood by close family members 50% of the time.

The earliest sounds for kids are usually Pa Ba Ma Na Wa Ka Ga. By the age of 3, kids should have most speech sounds. Ruth White, a local speech therapist, counsels that if the majority of folks can’t understand most of what your three year old is saying, an evaluation is advised. On the other hand, it is not uncommon for many otherwise articulate kids to distort some of the more difficult sounds such as l, r, s, sh,ch, v, z, th. These sounds may actually not be fully mastered until age 7 or 8. Ruth reminds parents that there is a wide range of normal.

Even though we know that some sounds aren’t perfected until later, 4 or 5 is a reasonable age to check in about articulation issues.
Bailey Levis, owner of San Francisco Speech and Fluency Center, receives many calls from parents who are concerned that their pre-school child might be stuttering. Many children will have some amount of disfluencies, (e.g. “Um um um, I want...I want...I want some ice cream”) in their speech, but only some of them will show signs of stuttering.  Some red flags for early signs of stuttering include tension or frustration if/when words get stuck, more than 2 repetitions (e.g. “cuh-cuh-cuh-cookie”), or if there are other family members who stutter. Whether or not you observe any of these red flags in your child’s speech, if you have any concerns, Bailey recommends seeking out a speech therapist who is comfortable working with stuttering. With early intervention, the likelihood of complete recovery is very high.

Frequent ear infections or fluid in the ear can impact your child’s early language skills so it is important to work closely with the doctor if this is an issue. We may send you along to an audiologist or ENT to be part of the team.

Of course, keep in mind that there is a huge difference between hearing and listening. I can’t tell you how many young child failed to follow the directions with our in-office hearing test, but when I quietly whispered “ would you like a sticker?” they heard me just fine.

One of my favorite in-home hearing tests is an active listening game. Tell your child to whisper a word to you (perhaps the name of an animal.) Then you quietly whisper a word back to them. Make sure they can’t see your face so that there is no lip reading. If you have any concerns that the hearing isn’t as sharp as you think it should be, get them checked.

Jodi Vaynshtok from Sound Speech and Hearing Clinic shared her explanation of the different aspects of communication skills that a speech language pathologist addresses:

Listening: In order to use the correct speech sounds, and understand/use language, a child must build upon their listening skills. This includes detection, identification and comprehension of spoken words. Listening therapy helps children learn to detect and interpret sounds, allowing their learning system to develop speech and language skills appropriately. 

Speech: This is often what people think all speech therapy sessions consist of – the production of sounds that make up our words and sentences. Speech involves the coordination of articulators (i.e. jaw, lips, tongue, vocal folds, vocal tract and respiration), divided into three areas: articulation, voice and fluency.

Language: A child’s language can be split into two domains. The information they understand (receptive language) and the language they use (expressive). Language therapy can concentrate on spoken, written or non-verbal communication. Goals can target vocabulary, grammar, formulation of sentences, following directions, and reading comprehension, just to name a few! A child’s ability to correctly understand and use language can affect their behavior, academic and social success.

Jodi also shares some tips for enhancing communication and language. Your child learns from every interaction you have together. Let’s learn some ways to enhance those communication opportunities to help your child learn the power of social interactions. Let’s O.W.L:

Observe: Body language – action, gestures, facial expressions – learn what is motivating and interesting to your child.

Wait: Stop talking, lean forward, look at your child expectantly – your child will take the lead. By waiting you can respond to your child’s signals, play, imitate, interpret and comment.

Listen: Pay close attention to all words and sounds – no interruptions, even if you know what they are trying to say.

Turn Taking: From body language, cooing, and words, use these tips for turn taking - match the length of your child’s turn. Try to match how much your child says or does by keeping your turns short and simple too. If your child uses one word, use no more than two! Match your child’s pace; let your child set the pace for the conversation. Slow down and wait longer if necessary. This allows your child time to explore, understand, and respond. Match your child’s interest; focus on what your child is interested in. When following their lead, they’ll interact longer.

Four S’s
  • Say less: Use short, simple, but grammatical sentences when you talk to your child.

  • Stress: Make important words stand out.

  • Go slow: Slow down your speech giving your child time to understand what you’re saying.

  • Show: Children learn best when they can see what you’re talking about – visuals help show what the words mean.

I am grateful to the speech therapists who took the time to share their wisdom with me about this post!

Below is a partial list of some excellent resources that we have in the SF area. For some folks finding someone in their insurance network is of primary importance. For others it is location and availability. You won’t go wrong with any of the folks on this list.

Sound Speech and Hearing 415-364-8774
Sound is one of the wonderful resources here in SF. They are the one stop shop that can combine the hearing and speech assessment in one visit. They also have the option of having Mavis, the animal therapy pup at the visits ( it doesn’t get better than that.)
Check out their blog. Below is a recent article about children's headphones

Bailey Levis 415-496-6757
Bailey does all sorts of general speech therapy for all ages but is top notch for stuttering issues. He offers a free 30 minute consultation.

Jennifer Katz Inc415-550-8255
This popular practice has several locations and has been taking care of my patients' speech therapy needs for many years. They have expanded to several locations. They also work with many insurance plans, which is a bonus. Their team includes feeding therapists.

In addition to their individual speech-language sessions they have a wonderful small group program called TheraPlay. TheraPlay is a language-based therapy group that is highly structured with an array of carefully planned activities targeting social skills, speech and language development, pre-academic, fine and gross motor skills. The groups are lead by a speech language pathologist and an aide with a maximum capacity of four children per group.   

Jennifer Katz, Inc. is happy to let you know that they will be doing their More than Words program . More Than Words® is a parent training program for children with social communication and language delays that provides parents with practical tools on how to support their child’s communication and social development during everyday routines.  More Than Words® was developed by expert speech-language pathologists and is grounded in extensive research and evidence-based practices. More Than Words® is an amazing program that will complement the services you are already providing to families. Some of the valuable things parents will learn when they attend the More Than Words® Program
•      What motivates your child to communicate
•      How to use your knowledge about your child to set appropriate and realistic goals
•      How to make interactions with your child last longer
•      Tips for using pictures and print to help your child’s understanding
•      Strategies for how to talk so that your child understands you
•      Strategies for developing your child’s play skills
•      Ways to help your child make friends
*Registration is due August 30th

Ruth White 415-225-6152
Ruth has a private practice but is also an instructor at SFSU in the communicative disorder clinic and currently run graduate clinics there.

SF Speech Therapy 415-404- 8343
SF Speech Therapy is a small, family centered private practice in Diamond Heights. It provides speech, language, and feeding therapy to people of all ages, with a particular emphasis on early intervention for the very youngest San Franciscans. Therapists at SF Speech Therapy have specialized training in a number of areas, including infant and toddler language, articulation, stuttering, voice disorders, and the Sequential Oral Sensory (S.O.S.) approach to feeding. There are both English and Russian speaking therapists on staff, and home visits are offered. To get a feel for the practice, check out the blog and website below. Appointments can be made by calling Teresa Newmark at 415-404- 8343 or by emailing,

Northern California Speech and Hearing 415 -921-7658

Shannon Kong and Sara Spencer 415-469-4988

Shannon Kong, MS, CCC has been renamed to Seven Bridges Therapy ( and they now have offices in SF, San Mateo, and Oakland. They specialize in working with children 5 and under as well as children with autism but see children of all ages!

Sara Spencer, continues to see children ages 6 and up under her company name, Sara Spencer and Associates. Same addresses in SF and San Mateo. They continue to work hand in hand as they always have (since 2000).

Tulips Speech 415-567-8133
tuLIPS Speech Therapy has exciting news. After 7 years on Union Street in Cow Hollow, they have opened a 2nd location on Castro Street in the heart of Noe Valley! tuLIPS Speech Therapy offers speech and language therapy, social skills groups and their very popular Talking tuLIPS program. They have an amazing neuropsychologist on staff who offers neuropsychological testing and they work closely with a wonderful occupational therapist. tuLIPS Speech Therapy is now accepting new patients. Call them today and ask about their complimentary speech and language screening!

Lauren Van Burkleo 415-633-6648

UCSF Audiology 415-353-2101
For our patients using any of the UCSF pediatric specialty clinics, including audiology, a referral is needed before they will make an appointment. If you are interested in meeting with them, let your doctor or nurse know. We can send a referral over and they will contact you to get something scheduled.

Talking time/Speech and language therapy
Devra Posner 415-326-6199