Friday, August 31, 2018

Anaphylaxis/Epipen options

Anaphylaxis/Do you need to carry injectable epinephrine?
Anaphylaxis is a very severe allergic reaction that can occur within moments of exposure to an allergen. People can die from this if it isn't treated. It can be triggered by an allergy to a particular food (peanuts or shellfish are among the most common), biting or stinging insects (like bees), medication (like antibiotics), latex (the type of rubber many balloons are made from) or a variety of other allergic triggers. Allergic reactions occur when the body mistakenly identifies something as harmful and overreacts. With anaphylaxis, this reaction can be life threatening. Symptoms usually start within seconds or minutes of the exposure, but there are exceptions. Once in awhile, a reaction can be delayed by several hours. This of course makes it much harder to figure out the culprit.

In an anaphylactic reaction there may be different parts of the body involved.

  • Mouth: itching or swollen lips or tongue
  • Lungs: cough, wheezing, shortness of breath
  • Heart: weak pulse, dizziness, fainting
  • Skin: hives, itching, redness, swelling
  • Face: flushed, swollen (eyes and ears common)
  • Throat: itching, tight feeling, swelling
  • GI system: vomiting, diarrhea, cramps, nausea

The first time that someone has a severe allergic reaction is very frightening. Unfortunately subsequent reactions can be even more severe. It is essential to recognize symptoms that need immediate attention.

Several years ago, a patient in our practice had been given yogurt for the first time.The child’s face began to swell and she started to have labored breathing. Mom’s first instinct was to call me; I redirected her to call 911 immediately. If it feels like an emergency situation, 911 beats the advice nurse. Of course, we want to be kept in the loop and help with any follow up. This child turned out to be severely allergic to milk. Interestingly she had no trouble with breast-milk. It is very important that folks figure out what the trigger is so that the you can try to avoid future reactions, although there are cases that remain a mystery.

Knowing that your child is at risk for anaphylaxis is very unnerving to say the least. It is very important to educate your child (age appropriate) and all teachers and caregivers about how critical it is to keep your child from being exposed to the allergen.

One case comes to mind of a school aged patient who was at Costco with some friends. The child was allergic to nuts. The friends parents allowed him to taste something from one of the samples. They had done a cursory check of the ingredients and thought it was safe. It turned out the the knife used to cut the samples had also been used to cut something with nuts, and the child ended up in the ER. Some kids are so sensitive that cross contamination (in this case, the knife) can cause a full reaction.

Here is another story of one of our patients with an anaphylactic reaction:

This little 9 month old was already teething and fussy, which complicated things. She also is prone to eczema, so rashes are not unusual. The family had had a recent checkup and had come home motivated to increase solids and calories to fatten up their slender child. Dinner that evening was some Chinese take out. Our little patient was offered bits of foods from the various containers. They didn’t offer any foods that struck the parents as obviously new, but one of the containers was a shrimp dish. Although the baby didn’t actually eat any shrimp, she started to get very fussy and swiping at her face and ears.

After several moments of excessive fussing from no overt cause, mom and dad opted to give her a bath and start the bedtime process. When they removed her clothing they saw that she was covered with hives. At that point they wisely opted to go into the ER. It had been about 20 minutes since the food. The baby was fairly inconsolable and her face and ears were swelling. Luckily she did not appear to be having labored breathing (that would be a reason for a 911 call.) Once in the ER she vomited. She was given epinephrine and kept overnight for observation. She was singing and happy the next morning with no seeming ill effects. The current plan is to avoid any mystery foods and follow up with an allergist within a few weeks. The family will have an epipen on hand just in case.

As a caution, I recommend to try all first time foods when there is time to observe for a little while to make sure there is no reaction. Giving something brand new and then putting a baby straight to bed is not a good plan. This is especially important with high risk foods like nuts, milk, eggs, shellfish, and any medication. It is also a good idea for every household to own Zyrtec liquid (scroll down for dosage chart.)

If your child is old enough,talk to them about the fact that just about everyone has a little something special going on, and it their case they need to be careful about whatever their trigger is. Check out this book, available on Amazon. Perhaps pick one up for the class and make sure the teacher reads it out loud. No Nuts for Me

Make certain that any babysitters or friends caring for your child know what allergens are potential hazards so that they can be certain to avoid them They should also have an injector handy just in case.

If you go to a restaurant, ask to speak to the chef so that you know the restaurant understands the importance of avoiding the ingredient in question. In serious cases, you might want to call ahead to make sure they are willing and able to accommodate you.

If your child has any mystery reaction to something, it is worth having a visit with the doctor so that we can help pinpoint the cause. In some cases we will refer you to see an allergist. Mild allergic reactions can be treated with a dose of Zyrtec or Benadryl. Keep in mind that Benadryl might make some kids sleepy and it could muddle your assessment. For an anaphylactic reaction epinephrine is the only first line treatment. It relaxes the muscles in the lungs to improve breathing. To quote Dr. Fast, a local allergist, “Epinephrine is what saves lives. It is never wrong to give epinephrine."

One of my mom readers shared her story with me after this post first went out. She recently spent five days in the hospital due to an allergic reaction. She had 4 of the 7 symptoms (including full body hives), but was NOT given epinephrine early because she wasn't having respiratory distress. It took several days to get the allergic reaction under control.
Not only does epinephrine help with the respiratory distress, but it lessens the release of the chemicals that are causing the reaction in the first place. The world health organization  would agree with Dr Fast that using epi early is a "no Brainer"

Auto injector options

Epipen comes in 2 strengths. The junior (0.15mg) is for anyone under 66 pounds. Anyone over 66 pounds gets the full adult strength (0.30 mg) .Epipens have been in the news due to high cost and recent shortages. If you have an epipen, check out the lot numbers, some of them have extended their expiration date
 May 2019 update
The avilailability of the epi pen junior has been very spotty.  Auvi Q is available directly from the website.

Auvi Q is a competing product that I always preferred. I liked it because it is flat and easy to stick in a pocket. It also actually talks you through the steps. When you are in the midst of a patient having a reaction, that can be more helpful than you would imagine. It was recalled several years ago due to trouble with the needles. I was thrilled to find out that AuviQ is available again, and believe it or not...drum roll please…. It has a ZERO copay to anyone with commercial insurance or a household with income less than $100,00.00.

Auvi Q comes in 3 strengths:

  • 0.1 for infants from 16.5-33 pounds
  • 0.15 children 33-66 pounds
  • 0.30 for anyone over 66 pounds

 You have several options.
 You can go to the Auvi Q website and download the prescription. Have your doctor sign and fax it over to them and they will deliver it directly to your door:

The customer service phone number is on the website and I found them extremely helpful.

Of you can now get the Auvi Q at your local walgreens. They signed an agreement just this week (July 2019)
Regardless of which one you use, the auto-injector should be administered into the upper outer thigh. It can be given through thin clothing. The leg should be restrained and the injector should be held against the thigh and then compressed, rather than jabbing it.

In the case of a severe allergic reaction, give the immediate dose of epinephrine but then head over to the ER for some observation. It is possible for the symptoms to rebound. This is called a biphasic reaction. Hours after a patient seems stable, the symptoms can flare up again. Since it is always better safe than sorry, keeping a close eye on the patient is essential for the next 24 hours

Children with reactive airway disease and/or eczema are more at risk for allergic reactions, but they can happen to anyone.

No, of course not everyone needs to carry around epinephrine, but it is SO important to recognize the symptoms and act quickly if you are concerned about the possibility of an anaphylactic reaction.

There is a law, SB 1266, effective January 1, 2015, that mandates all schools keep an epinephrine auto-injector on hand and that someone on site has been trained. Check with your child’s school to make sure that they are complying.

Zyrtec Dosage Chart

The dose of cetirizine depends on age as below:

  • 6 - 12 months of age2.5 mg given once daily (maximum dose 5 mg daily)

  • 12 - 24 months of age2.5 given once or twice daily (maximum dose 5 mg daily)

  • 2 - 6 years of age2.5 - 5 mg given once daily (maximum dose 5 mg daily)

  • Over 6 years of age5 - 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.

Friday, August 24, 2018

2018/19 flu season and vaccination information

Here is information about the flu vaccine for the upcoming 2018/19 season:

Some flu seasons are worse than others. It is important to keep in mind that influenza is one of the deadliest vaccine-preventable childhood diseases. Each year, influenza kills more children in the United States than meningococcal infection and whooping cough combined.

The 2017/18 season was a nasty one. According to statistics from the CDC, last years season set the record for the highest number of flu-related deaths in children reported during a single flu season (excluding pandemics). Approximately 80% of these deaths occurred in children who had not received a flu vaccination for that season. One hundred and seventy two children died.Thank goodness I don’t know of any local children dying, but in our office at Noe Valley Pediatrics, we had a fairly large number of kids who ended up with pneumonia as a consequence from the flu. Kids were SICK! So were the parents.

It is recommended that all children over the age of 6 months get the flu protection. Infants can’t get the shot until they are 6 months old. If you have a baby at home who is too young to get vaccinated for the flu, please take extra care to make sure that all the household contacts are protected so that you don’t bring the virus home. Children, especially those younger than 5 years, are at higher risk for serious flu-related complications. Folks of any age with chronic health problems like asthma, diabetes and disorders of the brain or nervous system also are at higher risk of serious flu complications.

Children under the age of nine, who are getting the flu vaccine for the very first time, need to receive two doses of the vaccine in order to be considered fully protected. The first dose “primes” the immune system; the second dose provides immune protection.The two doses need to be separated by at least four weeks. Over the years I have seen patients who have had only their first shot come down with the flu. One dose will not fully protect them.

If your child has ever had more than two previous doses of any flu vaccine, they only need one this year. It takes about 2 weeks for the shot to take effect. Children under the age of three get half of the adult dose. The nasal flu mist is still not being recommended because studies show that it doesn’t protect as well for the H1N1 which is once again expected to be one of the strains going around this year.

Every year the disease trackers do the best they can to predict which strains of the virus will circulate and try to match the flu vaccine to the anticipated strain. Typically the vaccine changes from year to year. This year's vaccine is not the same as last seasons. Some years have better matches than others.

Last season we saw plenty of people get the flu and have a miserable week. The media was claiming that the shot was not terribly effective. There were indeed some vaccine failures but the folks who had the flu shot did not seem to be nearly as ill as an unvaccinated person. In our office almost no one got the late season B strains if they had received the shot. It didn’t seem to be as much as a barrier for the A strains. We actually had a few folks who got the flu twice with different strains. I don’t remember that happening in the past. Starting Tamiflu quickly seemed to help.

Let's keep our fingers crossed that this year has the magic combination. Our office will again be supplied with the quadrivalent vaccine that covers two A strains and two B strains. All of the flu vaccine in our office is preservative free. For any of you interested, the strains in the quadrivalent vaccine for the 2018/19 season are:

- A/Michigan/45/2015 (H1N1)pdm09-like virus
- A/Singapore/INFIMH-16-0019/2016 (H3N2)-like virusa
- B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage)a
- B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage)
aIndicates a strain change

Since we never really know when the flu season will start with a vengeance, getting your child vaccinated early in the season is your best bet. The manufacturers claim that the protection is supposed to last through the entire season. My personal sense is that it does seems to lose it's oomph after 7 months or so. As soon as a baby turns 6 months old we can get them started with their first dose. Because we don’t have experience with this particular flu vaccine, I don’t have a sense of what kinds of reactions to expect. We don’t generally see any major reactions but every year it is different. Last year some of our patients had low grade fevers for a day or two, but for the most part the vaccine was tolerated very well. A day or two of fever is still better than a full-blown case of the flu.

If your child has a sensitivity to egg, it is okay to give the shot, but we want to be cautious. I would recommend that you keep the patient in the office for at least half an hour or so to make sure they aren’t having any issues. Please advise the nursing staff if you have any concerns. I have been giving flu shots for almost 30 years and in that time I have only seen ONE patient with an allergic reaction to the vaccine (and that patient has no history of egg intolerance, so you just never know.) This happened several years ago. The patient left the office and started complaining about an itchy feeling throat. Mom brought him right back in and he got a dose of epinephrine. I am sharing that as a reminder that it is important to keep a close eye on your child for at least 30 minutes after the shot. If they seem to be having any breathing issues or exceptional fussiness they should get checked out immediately (an emergency room is the best choice.)

The safest way to prevent having an issue with a potential shortage is to get the shot on the early side. Fortunately we had plenty of vaccine right up until the end this past season. That isn’t always the case and it is impossible to predict. In some years there have been delays and shortages with the supply, but so far everything seems like it will be smooth this season. We have already received our first shipment of the vaccines. For Noe Valley Pediatrics patients we will be booking flu shot appointments starting September 5th. The appointments will be available on Tuesday, Wednesday and Thursday from 10:00 until 11:30 am and then from 2:00-4:00 pm. Call the same day for an appointment. Please understand we can only manage a set number of patients on any given day. Flu shot appointments are for shots only. If you have a reason to see the doctor, it is important to have an appointment on the main doctor schedule. I tell parents that “we can add a shot to any doctor appointment, but we can’t add a doctor to a shot appointment.” If your child is especially fearful of shots, let us know in advance and we can schedule a longer visit for them during office hours.

If your child isn’t feeling well, ideally we would wait until they are better before giving them the shot. That is another reason to plan to get it done early. Last winter when we were late in the season with a scary flu circulating, we did end up giving the shot to kids who were already a little sick. They were just fine, but it isn’t my first choice.

We will be holding several evening flu shot clinics throughout the season. I will post about the dates as soon as they are firm. The first evening clinic will likely be mid September.

When you come for a shot appointment, it is helpful if your child is wearing short sleeves or clothes that will allow us easy access. We can offer ice packs by request. Give yourself a bit more time for some icing in advance. The shot usually doesn’t hurt too much but an ice pack gives some kids a little boost of confidence.

We will not be offering immunizations to parents during normal business hours because the staff is usually too busy. You may be able to get the shot from your place of business or from Walgreens and save a few dollars, but for your convenience, we are happy to immunize parents during the evening clinics. Parents will be charged $45 at the time of service. We will not be billing your insurance. We are happy to give you a bill that you can submit on your own.

I will update vaccine supply and any info about the clinic dates in my weekly emails and also on our Facebook page. I will also let you know what type of reactions I am seeing, and what the actual flu looks like when it starts knocking on the door this season.

Click below for the 2018 Flu Vaccine information statements from the CDC. This is the same statement that has been active since 2015. They did not feel that there were any significant changes to report.

Friday, August 17, 2018

Dealing with Motion Sickness/Something new on the horizon

It is not unusual for us to get calls from folks who have a child or family member that suffers from motion sickness. Females are more likely affected than males. People who suffer from migraines tend to be especially susceptible. While the majority of people who have the most issues with this are between 2-12, some younger babies seem to have trouble as well. We have some unfortunate moms who have babies that vomit every time they go out in the car.

If you know in advance that motion sickness is an issue, here are a few natural remedies that you may want to try. If you are someone who deals with this a lot, you will have plenty of car rides ahead to do your experiments and see what works for you.

Getting fresh air by having a window open is the first course of action. Do some distraction by playing a game that has your child looking out the window. Experts say to specifically look at the horizon. For those kids who are not super sensitive, you can play some 'I Spy' games. See if you can find interesting license plates or different colors or letters on signs. Don't sabotage your trip by bringing along trip activities that have your child focusing on things inside the car. Even the best passengers might be fine until they start reading or looking at a phone or map.

Most kids do best when their tummies are not too full or too empty. Little crackers to snack on might be useful.

There are wristbands that provide pressure to some acupressure points that seem to give relief. You can find these on Amazon. There are several brands. A popular one is called sea-bands. They come in multiple sizes and colors. Otherwise simply massage the wrist and lower arm area. The magic spot is located on the inner arm about 1.5 inches above the crease of the wrist, between the two tendons there.

Ginger seems to be very helpful. For older kids, there is a ginger gum specifically made for nausea (also available on Amazon). Find your favorite ginger cookie or candy. Trader Joe's has a wide assortment. Of course don't give anything to a young child that might be a choking hazard. Check out ginger lollipops (often marketed towards pregnant women.)

Motion Eaze is a topical aromatherapy that some folks swear by. You just dab a drop behind the ears and it provides relief within a few moments. Don't do this one for the first time before you embark on a long car ride. The smell is fairly pungent and other folks in the car might have a hard time with it. If you prefer not to apply a scent directly, there are several essential oils that have been found to help with nausea. Peppermint, spearmint, ginger and lemon are all on the list. Consider letting your child chose the favorite scent. You can apply a few drops to a cotton ball and put it in a baggy. The kids can take sniffs whenever they feel the need.

Hylands and Boiron both make a homeopathic motion sickness remedy. As with many homeopathic remedies they gets mixed reviews. Homeopathy does seem to be the ticket for some folks, and is unlikely to cause trouble as long as it is used as directed. It might be worth a try. My husband likes to cry "placebo"
I say, "Bring it on, whatever works!"

If you are going on a long car ride, plane ride or boat trip and you have struck out with the natural remedies there are some medication options. Benedryl is an antihistamine that often works quite well for motion sickness. It comes as a liquid. The bottle says for children over the age of 6, but in our office we do use it for younger kids. The dose usually agrees with the tylenol dose volume. Kids over 22 pounds would get 5 ml or one teaspoon. Always check with your own doctor's office to see what their policy is. Benedryl makes most kids sleepy, but don't count on that. It gets some kids hyper. You probably don't want to find that out on a cross country flight.

Dramamine is another choice. It is an over the counter medication specific for motion sickness. Children 2-6 years of age can take ½-1 tab; children 6-12 years of age can take 1-2 tabs. These chewable tablets can be repeated every 6 hours, no more than 3 doses in a 24 hour period. Start with the smaller dose first to see if it works. Giving the dose 30-60 minutes before travel is recommended. For kids over 6, Bonine is another reasonable choice. This medication can be given at the first sign of nausea and is less sedating.

For patients over the age of 12, if all else has failed some people use a scopolamine patch. This is a much stronger prescription medication that I would never use as a first line drug. Some of my motion sensitive older patients have found these valuable for cruises.

Luckily, kids do tend to grow out of it...except for an unfortunate few. If you or your child have chronic motion sickness issues, it can be eye related. Cover one eye for several moments to see if the symptoms ease. If this works, you may have something called vertical heterophoria. It is worth having a consult with an eye doctor. My favorite eye expert in this is Dr. Vincent Penza

Some people with chronic motion sickness have also gotten relief from chiropractic treatment.

There is a new product on the horizon that got my attention. The media is abuzz about special glasses that have been reported to be real game changers for folks who have tried them.

Unfortunately, I haven’t been able to find out how to get them in this country quite yet. If you are interested, it seems that pre ordering a pair is possible if you have connections in Europe who are able to send them to you.
In the meanwhile, if you or a family member suffers from this very annoying ailment, See if any of these other methods will help you out until those magical glasses become available

If you are on a car ride, assuming the kids are old enough to comply, have them try very hard to give you as much warning as they can. Ideally they should try to get in the habit of warning the driver at the first twinge. The initial signs are usually paleness, yawning and restlessness. They may feel a little sweaty. This is quickly followed by the nausea and vomiting. With enough warning you might have time to pull over and get them out of the car for a couple of moments until the motion sickness eases. Being stoic is not a good plan; it usually backfires.

In my car, I actually kept barf bags in the glove compartment. I used to collect unused ones from my airplane travels.They may come in handy. If you don't have an actual barf bag, have a container or plastic bag that you can whisk out at a moment's notice.

Your trunk should be prepared:

A change of clothes (don’t forget socks)
A clean towel
A plastic bag for putting the soiled clothes in
Some wet wipes
A lollipop to get the yucky taste away
Febreze for cleaning off the seats (you will bless me)

While kids are usually the ones most apt to barf in your car, motion sickness can afflict any of us at different times. I hope that some of these tips can help you out.

I remember my days as a carpool driver.
One of my little passengers had Emetophobia ( fear of vomiting) and would quite literally open the car door and leap out if anyone so much as made a gagging noise. It kept things interesting!

Friday, August 10, 2018

Back to school adjustment tips for you and your child

My regular readers have heard me repeat this analogy often.
Being a parent is like being the coach of a sports team. The real work is the preparation before the game when you learn and practice the plays. More work can be done after the game when you review how your team fared and work on any changes that need to be made.

During the actual game, you might be able to chime in to make little adjustments, but for the most part you simply get to watch. This is not the time to effect any real teaching or change. Recognizing the difference between “game time” and effective coaching opportunities is critical.

Having your child march off to a new daycare or preschool or school is game time. Doing some preparation ahead of time can be very valuable and can smooth the way.

Some kids go off with a smile and wave. You win. Others weep and you need pull them off your body as they clutch at you in desperation. You end up leaving them in their new situation feeling like you have somehow failed. Welcome to being a parent. You lost this round but there are many rounds ahead that will be more successful. Keep in mind that many of the kids are putting on a big show, and are feeling stressed and sad for the moment. Most of them calm down shortly after you are out of sight and end up having a fine day. You on the other hand, will feel like you have a fist clenched inside your gut.

Check in with the teachers for a reality check. They can tell you how your little one fared once you are out of the picture. Or do what Sandy did when he took Lauren to her first day of pre-school. He left her crying with her new teachers and then went to the side of the building, hid in the bushes, and watched through the window. Lauren was fine in about 5 minutes but those were among the toughest 5 minutes of his life.

The teachers should be an essential part of the team helping with this adjustment period.If you feel like your child might need a little extra help separating, talk to the staff about what options they can come up with. Sometimes having a hand to hold, or a loving lap to sit on can be very helpful

One friend or familiar face can make a huge difference. See if you can get a roster of the other children in the class before school starts. If you don’t know anyone, go ahead and cold call some families to see if they want to meet in a playground for an hour and let the kids play together for a bit.

Once school begins, ask your child to identify a few other children who seem nice. Reach out to those families and try to arrange some playdates outside of school hours

Communication is so important.

Create an arena where you and your child can have safe discussion about feelings and actions. This is a basic problem solving skill.

Make a list of some of the more common feelings that people might be feeling when they start a new school:

  • Happy
  • Sad
  • Nervous
  • Excited
  • Tired
  • Hungry
  • Lonely
  • Missing home
  • Confused
  • Bored
  • proud

I am feeling______________. You don’t need to limit it to one emotion.

Identify some things, good and bad, that might be triggering  the emotion:

  • I learned something new
  • I made a friend
  • I helped someone
  • Someone made a face at me
  • Someone wouldn’t hold my hand
  • Someone wouldn’t share
  • I didn’t like my lunch
  • I am scared of the toilet
  • I am having trouble with a skill that others seem to be able to do with ease

I am feeling ______________ because_______________

If the feeling expressed is a negative one - mad, sad, nervous, and you were able to identify a source, now is the time to make a list of possible things that might help.

Telling stories and teaching through play are really good methods for talking about the feelings and coming up with solutions.

Make up a pretend child who also happens to be going to a new school situation (what are the odds?) For this post we will call the pretend child Pat (the ultimate non gender identifying name). Pat can be the main character in many stories.
Sometimes the right moment presents itself and your child might be able to chime in and talk about what they think might be making Pat happy or sad. For some children this feels much easier than telling about themselves.

Practice saying goodbye. Do it several times.

Try some play sessions with a couple of dolls or stuffed animals; one is bravely heading off to school and proudly tells all about it after they are home. The other is having a much harder time. Talk about some things that may be tools that the brave bear is using or might help the scared bear.

Perhaps bringing something like a scarf that smells like home.
Maybe wear a necklace with a photo. Maybe find a little smooth round stone that you both rub some energy into and they can keep in in their pocket. Maybe write a little heart or doodle on their arm and cover it with liquid band-aid

"How was your day, dear?"

Avoid the “How was your day? Fine” trap. Get in the habit of doing a little checklist.

  • Tell me something you learned
  • Tell me something that surprised you
  • What was the silliest thing that happened?
  • What did you do that was kind?

Teach your kids the concept of a mitzvah. This is the Jewish term for doing a good deed or act of kindness. Getting in the habit of at least one “mitzvah” a day is something to strive for.
Beyond simple acts of kindness, consider giving them 3 small goals to achieve each day. They can tell you how they did.

If you are able to do a family dinner, that is the perfect time for conversations. Otherwise it is fine to do this at bedtime, but try to carve out a time where you can talk about the day.

This is a great opportunity to review tomorrow’s schedule and list any special things that are coming up that the family might be looking forward to.

Alana learned to debrief her day in excruciating detail, but it was a habit that endured for years. As my faithful readers know, she continues to share this with Sandy every day on her drive home from work.

Other considerations.... Dr. Elizabeth shared a story from one of her friends. They had made quite the big deal of the first day of kindergarten and the child went in without a hitch. The trouble occurred that evening when the little 5 year old realized that this school business wasn't an isolated event and she had to go back the following day.

It is essential that you make sure you are able to pick up your child on time, especially those first couple of weeks. If you are going to be late, have an alternate trusted adult who can be there. Make sure that the school has all of the current cell phone and emergency contact numbers.

Lots of studies show that eating a healthy breakfast makes a big difference. Have a breakfast plan and clothes picked out the evening before to avoid stressful confrontations.

Make sure your child is not overtired. Start bedtime early enough that they are getting the sleep they need.

You never know when your child will decide to make transition to school a “thing”. Some children who never had issues will decide that this is the year to challenge you. My daughter Lauren was reasonably well adjusted in school so I was caught by surprise when suddenly she was in third grade and a new problem reared its head. Alana was now in kindergarten at the same school. The kindergarten kids got picked up about 90 minutes earlier than the rest of the school and Lauren was simply not okay with that. The injustice of her younger sibling going to spend some private time with mom, while Lauren had to stay in class was more than she could stand. If she saw me anywhere on the campus during the early pick up time, she would get quite upset. I would like to say that this eased after a week or two, but if memory serves, I spend most her third grade year scurrying past the window of her classroom in a low crouch . If they were outside at recess it made things even more complicated. I believe I toyed with wearing camouflage in my efforts to make certain that she didn’t catch a glimpse of me during the early pick up.

Even if you are one of the lucky parents whose intrepid child marches into their new situation without a backwards glance, it is perfectly normal for you to be deeply impacted by these milestones that signal the passage of time and that your child is growing older.

Lauren reminded me of a cartoon that I used to have taped on the wall above my desk. It was a sketch of a doctor, nurse  mom and a baby. The baby was about to get a shot. The caption was. “you had better hold her close, she might cry."
The next frame was the nurse hugging the crying mom as the baby got the shot. Yes, this is likely to be just as tough on you as it is for your child!

Friday, August 3, 2018

Car Seat and Booster seat guide 2018

Car Seat and Booster seat Guide 2018
Please see updated post November 2019
Kids grow! Make sure they are strapped in properly!

The Rules

Car seats are an essential part of keeping your child safe. Countless children’s lives are saved annually by being properly installed in a carseat during a crash. Governor Jerry Brown signed a law that went into effect on January 1st, 2017. This law requires children be rear facing to a minimum of 2 years old:

It is recommended that they remain rear facing until as close to age 4 as possible! More and more studies are showing that rear facing is the safest place and position in the car. In fact, it is 5 times safer than forward facing.

In the case of an accident, a child's head and spine are better protected if the car seat is rear facing. One study shows that children ages two and under are 75 percent less likely to die or be severely injured in a collision if they face the back. I know kids might appear to be squished but most children are actually quite comfortable sitting criss-cross, or with their legs up the seat. For those parents/caregivers who are concerned about leg room, Graco has released the Extend2Fit, a new seat which has a 4-position extension panel that provides 5" of additional leg room.

Children who are 40 pounds or 40 inches are exempt from the law and can face forward, but while they may be exempt from the law, they are not exempt from the laws of physics. Rear facing is safer. Please take a moment to click the link below. This video is a good illustration about why rear facing is so important:

Toddlers who have outgrown the rear facing weight or height limit for their car seat should use a forward facing car seat with a harness for as long as possible, up to the highest weight or height allowed by the car seat manufacturer.

The current California Law also requires a car seat or booster seat until your child is 8 years or 4 ft 9 inches. Height parameters make more sense than the previous weight ones. For a child to safely transition into a booster, we look beyond the child's age/height/weight. There's another set of criteria to help determine if your child is ready to transition to a booster. There is a '4 Step Test', in which all criteria should be met; don’t dismiss the importance of Step 4!

1. Child is an absolute minimum of 40 lbs
2. Minimum of 4 yrs old
3. There is a lap & shoulder belt in child's seating position
4. The Child can be trusted to sit properly for the entire trip, every trip - even while asleep. This means no slouching (back straight up against seat), no leaning to either side, no playing with the belt, etc... even unsupervised.

Developmentally, most children don't meet all of these steps until somewhere between 5-7 years old, and generally closer to 6 or 7 than 5. A lot of this has to do not only with physical maturity, but emotional maturity.

This is one of those times in your parenting life where your child NOT graduating is actually a good thing. The longer your child is harnessed, the safer and more protected they'll be.Your child needs to be tall enough so that the seat belt goes across the chest, not across the neck. The purpose of a booster is to properly position a child in the adult-intended seat belt. What you’re looking for is proper belt fit across the lap and shoulders - the belt should be low and tight on the hip bones (not on the belly), and should be hitting the shoulder bone, not the child’s neck.

Be aware that most newer car and car seat models use the LATCH system ( Lower Anchors and Tethers for Children). The Latch system attaches the car seat to the vehicle through anchor points that are installed in the car and connectors on the car seat. This is supposed to make the installation easier as well as eliminating potential errors that can result from installing a car seat with a seat belt. The LATCH system has a 65 pound weight limit. What many parents are surprised to find out is that this limit includes the weight of your child as well as the weight of the car seat (some can weigh up to 25 pounds!).

When children are old enough and large enough to use the vehicle seat belt alone, they should always use Lap and Shoulder Seat Belts for optimal protection. To determine if your child is ready to sit unassisted, they must pass the 5-Step test:

The 5-Step Test:

1. Does the child sit all the way back against the auto seat?
2. Do the child's knees bend comfortably at the edge of the auto seat?
3. Does the belt cross the shoulder between the neck and arm?
4. Is the lap belt as low as possible, touching the thighs?
5. Can the child stay seated like this for the whole trip?

If you’ve answered NO to any of the above, your child should remain safely boostered!

If your children complain about this rule, show them photos of race car drivers all bucked up in their restraint system. Be matter of fact about it and explain that there is no compromise for safety (there is also a mighty large fine if you are caught breaking this law.)

All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection. Airbags can actually be quite dangerous to a child so it is worth making sure that this isn't an issue with your car and the placement of your child's safety seat.

Picking the right car seat

If you are looking to buy a new car seat, check out these helpful links:

If you are someone who doesn’t own a car and is popping the car seat in and out of car services, finding one of the cars that is easier to install in becomes even more important

Making sure it is installed correctly

The AAA states that 75% of car seats are installed or used improperly. As your child grows, there are services offered here in the San Francisco Bay Area that will check out your car seat or booster seat and make sure it properly installed. Have the infant car seat checked before the baby is born and then again with each transition to a larger seat.

Below are some local resources for making sure that not only is your car seat properly installed but that it is the right fit for your child's size and age. They can make sure that all the straps are where they need to be and that you pass the "pinch test", making sure that the seat's harness is tight enough

To be super safe, consider having the car seat fit and installation checked every 6 months. Fortunately there are lots of places to help.

  • AAA 553-7208         2300 16th St suite 280. The contact person is Ingrid. Appointments need to be made ahead of time. You do not need to be a AAA member to take advantage of this free service

  • CHP (California Highway Patrol) 415-557-1094  This is a very popular and is by appointment only. Please make an appointment as far in advance as possible. The current wait when I called to update this post was pretty short, but it varies and sometimes can be longer than a month. The inspections are done at 455 8th Street in San Francisco

  • SFPD    415-575-6363 They try to have an officer at all of the local police stations who is trained to do the car seat safety inspections. Call the number above for more info.

  • The Colma police department 650-997-8321 Does a car seat inspection for free. As with the other options, this is by appointment only.

Willing to pay to have someone come to you?


The following links can you assist you in finding the right car seat:

  • Car Seats for the Littles - Car Seats for the Littles gives lots of great info about the specific brands of car seats on the market

  • The folks from sent me the following resource guides: We recognize how difficult it can be to find the right information on car seats, so we evaluated both infant and convertible styles to help inform parents. To find the best, we consulted with child safety experts, dove into federal ease-of-use ratings, surveyed hundreds of parents, and then took a closer look at the top options. You can see our guides here:

Other considerations

  • Car safety doesn't end with being safely buckled. I know it is hard to avoid distraction with a baby fussing in the back seat. Consider getting one of the specially made mirrors so that you can keep on eye on your rear facing baby. Make certain that they can't reach anything that is a choking hazard.

  • Don't let them hold the keys; they can lock you out!!

  • If your child is asleep in the car seat and you have arrived at your destination, leaving them snooze for a few minutes is fine, but keep them tightly buckled. Having a baby in a car seat without being tightly strapped in not safe. The loose straps can be a safety hazard.

  • WINTER CAR SEAT TIP: The straps need to be tight up against your baby; puffy coats or blankets need to be OVER the straps!

  • Never leave your child unattended in a vehicle. Children can die from prolonged exposure to excessive temperatures in a hot car.

  • Most accidents happen within a few miles of your house. Even a short trip down the block requires the full "buckle up". Hey parents, model good behavior and always make sure you fasten your own seat-belt!

  • Did you know that car seats expire? Most of them have a 6-9 year life span. This date can usually be found underneath or behind the seat. Buckles and straps can wear out. Prolonged exposure to sunshine can weaken the plastic. Also, the technology is always changing and this ensures that nothing gets too out of date. Save the instructions/registration in a safe place. Make sure you register your car seat. If there is ever a recall this will ensure that you are notified.

  • If you have an old car seat that you want to get rid of, Alioto's Garage has been offering a Recycled Car Seat Program. Anyone, not just regular customers, can drop a car seat off at any Alioto's location during regular business hours. They will recycle the usable parts and keep it out of our landfill:

Let me close by confessing that I am NOT a car seat expert. The seats that my children grew up with were much simpler (but not nearly as safe). When I see new parents struggling with all the straps and trying to figure things out, I am often as clueless as they are.

Here is the takeaway message. Putting your baby or older child in a car seat is an essential skill that you need to learn in order to travel with them safely. Find an expert to help you master this and make sure that you are using the car seat restraint properly. Safe travels