Friday, January 25, 2019

Gun Safety

Gun Safety
I don’t pretend that I am neutral when it comes to discussions about guns. I am a pediatric nurse who lives in San Francisco, California; it's easy to figure out which side of the aisle I am standing on. But if you are a gun lover, please keep reading. I am really hoping that we can find something here that we can stand together on. It is inexplicable to me how so many issues these days have become partisan, but there MUST be some common ground. If you are a parent, regardless of how you feel about firearms, I am hoping that we can all agree that we want to keep our children safe.

I was recently approached by Krystal, a mom in our practice who is involved in a program called Be Smart For Kids. This group is tackling the gun safety issue.

I was startled by the statistics. The Centers for Disease Control has stated that firearm-related deaths from homicide, suicide or unintentional injury remain one of the top three causes of death for American children. Every year, hundreds of children in this country gain access to a firearm and unintentionally shoot themselves or someone else. This happens every 34 hours! The vast majority of these shootings happened with a gun that the child found in their own home or car. These accidents are tragic.

What is also sadly happening is that every day, at least one child takes their own life with a gun. Almost 500 American children die by gun suicide every year and the rate is climbing. More than 80% of the children who commit suicide use a gun that they found at home. Suicide attempts are often spur of the moment, feeling overwhelmed with despair situations, but those who attempt suicide with a gun more often than not, don’t get a second chance. Most of the gun suicide attempts end in death.

Be SMART's goal is to prevent children's access to firearms.

Secure guns in homes and vehicles.
Model responsible behavior.
Ask about unsecured guns in other homes.
Recognize the risks of teen suicide.
Tell your peers to be SMART.

I am including some of the Be Smart strategies along with other information that I gathered while researching for this post.

Secure the guns
Research shows that nearly 4.6 million children live in homes with guns that are not properly stored.

The American Academy of Pediatrics defines responsible gun storage as locked, unloaded and stored separate from the ammunition. Hiding a gun is not a good solution. Kids find things. They know how to poke around in closets and drawers. Guns simply must be locked up.

If your gun is used for hunting, this should be a no brainer. If the gun is used for protection, I can understand the concern with anything that limits quick access. There is a solution! If Nurse Judy and the NRA are both in agreement with something, it must be good.

There are biometric safe options. You can access the guns within several seconds with a fingerprint. They can be programmed to open with more than one person’s fingerprints for the adults in the family. Sentry Safe - Quick Access Pistol Safe has videos on their website showing access in as little as 2-3 seconds. Barska Mini Biometric Safe also claims 2.5 second access.

Perfect would be a biometric box, but don’t let perfect get in the way of good. At the very least ammunition should be locked away in a different location.

Model responsible behavior
If you own a gun, of course teach your children all of the safety rules. Don't be lulled into a false sense of security because you think your child knows what to do if they come across a gun. The thing to remember is that kids will be kids. Study after study has found that even though kids had been taught never to touch a gun that they found and that they should instead to run to tell a grown up, most are unable to resist the temptation to handle it. Trusting your kids to do the right thing in this case is not the answer. The responsibility rests 100% on the grown ups. 20/20 has done some stories on this. 20/20 Gun Safety Clip

As one wise person says in the above clip, “You can’t educate the curiosity out of the child.”

It doesn’t help that so many of our kids are exposed to guns on television, movies and video games where people almost seem to be bulletproof.

Ask about guns
I have to confess that this never occurred to me before meeting with Krystal. I have taught a safety class for years. The topics are numerous - how to deal with a strange dog on the sidewalk, how to avoid burns, how to remove an edamame from a nostril, how to rescue your child if they are choking; discussion about guns wasn’t on the agenda. It will be from now on.

When you allow your child to leave your protective orbit and entrust them into the care of someone else, it is quite reasonable to have a routine safety list.

  • Is there a pool?
  • Are any pets safe with kids?
  • Is there a safe car and appropriate car seats for any driving?
  • Are medications childproofed?
  • Does anybody smoke?
  • Are the guns in the house? If so, can they be safely locked away, separate from ammunition while your child is visiting?

This is not only for a short play date. It is also an important checklist if your family is traveling and staying with relatives.
You might be surprised at the answer to the gun question. Many people might even have guns that they inherited, or used to collect and don’t think much about it. Some households don’t have young children so this isn’t an issue until you point it out.

If this conversation feels awkward, perhaps do it via email or text. Free free to blame me. ”Nurse Judy asks all of her parents to go through this safety list”….

If someone is entrusting their child to your care for a visit, feel free to front load your own safety info. They will likely appreciate it. “Just so you our house there is no smoking. We do have a cat, but she will likely make herself scarce and has always been gentle. There are no guns.
Are there any food allergies that I should know about?”

Recognize the risk of teen suicide
It is essential for family members and friends of teens be on the lookout for change in mood and behavior or increased aggression. Any talk about killing themselves or statements such as “you would be better off without me” need to be taken very seriously. Contact the Suicide Prevention center for more guidance.

In children under 16 the presence of a gun in the house is a more significant risk factor than psychiatric illness. This is likely because suicidal behavior in children and adolescents of this age can be a spur of the moment choice.

We don’t always know. Some of the kids who on the outside seem to have it all together are quite troubled. Knowing the impulsiveness of teens, let’s get the gun option off the table. When children and teens can’t get access to a gun in their moment of crisis, they are much less likely to die, even if they attempt suicide by another method. In the US, children are 11 times more likely than their peers in other nations to die by gun suicide, while they are no more likely to die by other suicide method.

Tell your friends and family to be smart
Many people, like me hadn't really thought about this. I never recall asking anyone if they had a firearm before sending my children into someone's home. Sharing this info with your friends can help get this message out there. For readers in San Francisco, the Be SMART campaign has trained volunteers who can give presentations to parents' groups, PTAs/school groups, and any other interested community groups about simple strategies to help keep children safe from the risk of unsecured firearms. Please contact if you would like to schedule a presentation or invite Be SMART to be part of your community safety fair or other events.

In December I was in Vietnam where there are NO guns. Even the law enforcement doesn’t carry weapons with live ammunition. There are limited situations when a special swat team has access to them, but that’s it. I know that is never going to happen here. I dream of a day when sensible, common sense conversations can take place to figure out a way to slow down the relentless violence here in our nation.
Some issues feel so big and impossible to tackle. The inability to have calm discussion about guns in this country is one of them. The Be SMART program shows that there is something measurable that YOU can do. It won’t get rid of gun violence, but it can tilt the odds for your child

We need to start somewhere. Let’s keep all of our kids safe from OUR guns.

Friday, January 18, 2019

The Four Month Sleep Regression/Nap tips

The four month sleep regression

Ah, the dreaded 4 month sleep regression. I get calls about it all of the time. Noe Valley Pediatrics Dr. Elizabeth doesn’t like to call it a regression and she makes a good point. Think of it as moving into a new phase. Similarly, Parentline founder and clinical psychologist Dhara Meghani says, we tend to encourage parents to think about the 4 month sleep regression as a time of reorganization, rather than a setback. An (imperfect) analogy is to compare it to when you are cleaning and reorganizing your closet or kitchen cabinets. Often times we have to pull everything out, may have to shuffle things around, discard what no longer fits, and even install some new hardware to make the storage more efficient. The brain does exactly this every few months during infancy, and even years into development -- it goes through what we refer to as phases of "synaptic pruning" in the service of increasing efficiency and speed of important neural connections. So while there is all this work occurring underneath the surface, what may temporarily go by the wayside are the infant's developing skills of falling and staying asleep, feeding fully without being distracted, and being consolable when overtired, cranky, hungry, or bored.

While your baby's brain is going through this enormous growth spurt, they are more aware of everything around them. You might find that they pop off the breast or bottle more frequently to pay attention to their surroundings. There are lots of developmental changes going on. Babies are trying their best to roll over, but usually can only flop over from tummy to back. Daily tummy time exercises are even more important now so that they can work on mastering the roll in both directions.

In the first few months of life there is usually no real set schedule. Babies eat, they snooze, they are awake for a bit, maybe another snack and then some more sleep. Ideally you have made a clear distinction between daytime and nighttime feedings and have encouraged longer stretches at night.

But here you are, your baby seemed to be doing pretty well. You were getting a nice enough stretch at night that you couldn’t tell your other friends with young kids without sounding like you were boasting. Now, just when you thought you were about to see the light after this stretch of new parent sleep deprivation, suddenly horrors, your previously good sleeper is back to waking up at night. This phase will vary from baby to baby. Sometimes it is only a night or two, and for the more unfortunate, it can last a few weeks. The not knowing how long it might last adds a degree of frustration.

Let’s consider some of the more obvious causes of what could be stopping them from going back to sleep when they have those middle of the night wake ups .

Step one is making sure that they have some self soothing skills!
The sleep cycles are becoming a bit more like those of an adult, with the light sleep, deep sleep and REM. When babies hit those light cycles they may wake up. It is essential that they have the ability to get themselves back to sleep without relying on you.

If you put your baby to sleep with help, nursing and rocking rather than letting them drift off to sleep on their own, then when they become aware of their surroundings and you are no longer present, they are going to object. Shooshing and quiet singing with a hand on their chest may be a nice compromise. Your message is, “you are fed, your are changed, I am right here. You need to sleep.”

Right from the beginning (brand new parents, I hope you are paying attention) it is essential that you allow them to do some self soothing. Of course they will fall asleep when they are feeding; that’s fine. But, when you transfer them to their crib and they stir a bit, that’s okay! Don’t return them to the breast; simply give them some little pats, and see if they can settle back down. Every single time that your drowsy baby is able to drift off to sleep on their own it should be considered a win.

My mother in law tried to gently give me that wisdom which I soundly rejected. What did she know? My baby wasn’t going to allow me to simply put her down! I nursed and vigorously rocked Lauren to sleep for at least 4 months at which point we (who am I kidding, it was all on my husband!) had to do a phase of tough sleep training to teach her some sleeping skills.

Once they are finally asleep, tiptoeing around in utter silence to avoid waking the sleeping baby gets pretty old. Some parents find that turning on a white noise machine for the sleeping period helps. A Hepa filter works well for this and serves a purpose at the same time. Soft music playing is another option. If you have Alexa she can play some nice lullabies for a set period of time. If they can learn to sleep with some background noise you won’t have to worry so much about them waking from a sudden sound.

Baby might be hungry. My sleep advice doesn’t get terribly strict until they are getting some extra calories during the day with the addition of some solid food. Until they seem ready for that, I would consider offering a dream feed before you go to sleep. If your superstar was giving you 9-10 hours without a meal before this unwelcome change in their sleep pattern, do not go down the slippery slope of offering extra meals at night aside from that dream feed. If you offer them more frequent nursing, I would imagine they will be happy to accept it. That doesn’t mean they need it. At this age, the body benefits from a break from digesting at night so that it can concentrate on other growing tasks.

Is it dark enough?
Try to make the sleeping room as dark as possible. Making sure that you have blackout shades or thick curtains can extend your mornings and help out at nap time.

Make sure they are not over tired!
This is also when you can start establishing a more regular nap schedule. A 4 month old should be getting a total of 13 -16 hours of sleep in a 24 hour period.This ideally includes 3 naps a day. More often than not, 2 of the naps tend to be shorter and there is one longer one. Some babies absolutely don’t seem to need quite as much sleep as others, but if you have a cranky kid on your hand, I am going to suggest you make sure that their sleep schedule is adequate. You might think that a baby who didn’t nap well will catch up with a great night sleep, but you would be wrong. When a baby is overtired you are trapped in a nasty cycle.

The first nap is usually about 2 hours after their morning wake up. The second nap is about 2 & 1/2 hours after they wake up from nap number 1. The third nap is 2 & 1/2 hours after nap number 2, but it is essential that the 3rd nap is over before 5 pm or it will interfere with bedtime.

If you are lucky you can get into a grove with this for a couple of months. At some point between 6-9 months they usually get rid of the third nap and go down to 2.

Naps don’t need to be written in stone. I don’t think you need to be pinned to the house because of a nap schedule. Second babies don’t have that luxury and nap on the go. If you are lucky enough to have a baby who snoozes in a stroller or carrier, that can count as a nap as you go about your day and get some errands done or go for a walk with a friend.

I would try to have at least one nap that is in the crib. That nap is great practice for letting them drift off on their own. Make it dark, turn on the Hepa filter, sing a song while you do a little massage and then leave them be. Some babies need to fuss a bit as they go down. If they are absolutely screeching when you leave, go back and soothe them. Starting good habits from the start will make everything much easier.

Trust me on this. Sleep begets sleep. If your baby still doesn’t seem to be getting enough sleep, you might need to start your bedtime earlier. I understand that this isn’t always easy to do. Working parents want to have time with their babies for a bit in the evening and it can be a challenge.

Have a bedtime routine that signals that the day is winding down. Make sure it is calm, this is not the time for jumping around. Having a special song and massage routine right before bed is also a nice way to wind down. Hands, ears, feet are especially relaxing.

I am fine if they use a pacifier to fall asleep. DO NOT get into the habit of replacing it every time it falls out. That is akin to a dog with a ball, it never stops.

Room Temperature/sleep suit options
Keep the baby’s room somewhat cool and use a sleep suit when swaddling is no longer an option.

Because this is the age when babies are growing out of the swaddle, many of my families have found the Baby Merlin's Magic Sleepsuit will help you out of this transition. Dhara sent a few other links to share that look like they are worth checking out.

2. Zipadee Zip: zipadee-zip

3. Puck-A-Baby: puckababy

The Puck-A-Baby has a higher price but can follow your child through their early toddler years and through seasons.

Try to be as consistent as you can.
Remember, any time that your baby has an extended period of tough nights, it could also be an ear infection or something else going on. It is worth calling about a fussy baby if you aren’t able to get things under control.

Dhara reminds you:
--Get support. If baby's not sleeping, chances are you aren't either. Can you find a neighbor, family member, or friend to come by and help with the dishes or the laundry? Can they take the baby for 15 minutes so you can get a shower in? If you have a partner to split up the shifts at night that can also reduce the burden on any one person.

Don’t forget that Parentline is one more terrific resource for parents who are trying to figure things out. It is a free service hosted by the University of San Francisco. More info down in the bulletin board section

Thanks so much to Dhara Meghani from the University of San Francisco Parentline for her valuable input and feedback on this post!

Friday, January 11, 2019

Whooping Cough/Pertussis 2019

Whooping Cough/Pertussis
Pertussis has been a steady presence since the early 2000’s, but it has been back in the news recently with a rise in numbers since the fall of 2018. If you watch the news you have heard that there are quite a few cases currently in Marin County.

Commonly known as whooping cough, pertussis is a very contagious respiratory illness caused by a type of bacteria calledBordetella pertussis. These bacteria attach to the cilia (tiny, hair-like extensions) that line part of the upper respiratory system. The bacteria release toxins, which damage the cilia and cause inflammation.

Despite generally high coverage with childhood pertussis vaccines, pertussis is one of the leading causes of vaccine-preventable deaths worldwide. It is estimated that there are 16 million pertussis cases, and about 195,000 pertussis deaths in children per year. By far, most of the deaths occur in young infants who are either unvaccinated or haven't had at least 2 shots in the series.

Historically there is a cycle associated with whooping cough. It seems to peak every 3-5 years. In 2010, here in California there were more than 9,100 reported cases and at least 10 infant deaths. In 2014, 11,209 cases were reported which included two infant deaths and hundreds of hospitalizations. The Public Health department was expecting another peak to happen last summer when in July, California had its first infant death from pertussis since 2016, but no surge of illnesses occurred as anticipated. We may be at the beginning of the next cycle this coming year, as the timing fits.

For the most up to date info from the public health department click this link:

This illness usually starts with a week or two of a runny nose and cough. There may or may not be a low grade fever. Those patients with their little runny nose and not much fever are quite contagious. This is why every effort should be made to keep kids with colds away from young infants. We never know if it is going to turn into something worse. At week two, the cough becomes much more troublesome. The patient will often have coughing fits...and I mean FITS!! This is spasms of coughing for minutes at time that make even the hardiest person feel like they can't catch their breath. Newborns often do not have the intercostal muscles to cough so their symptoms could be cyanosis (lips turning blue) due to lack of oxygen. Patients may or may not have a high pitched "Whooping" sound with the cough (hence the name). Some folks will vomit after these coughing fits. Sweating, gagging and choking episodes are common. Some people cough so hard from this that they can break ribs.

This cough lasts and lasts...and then lasts some more.
In Chinese medicine this is referred as the "Hundred day cough" and they aren't kidding. This is a miserable illness for anyone, but for young infants pertussis can be deadly. Babies routinely get their first vaccination for this around 2 months of age. The primary series is given at 2, 4, 6, months and at 12-18 months, and again before kindergarten entry. Significant protection isn't achieved until the 4th shot at the 12-18 month visit. The four doses gets them up to 75% protected. This goes up to ~90% after the 5th dose (known as the booster.) Thankfully, ever since the state law passed requiring vaccination for school entry, we don’t have many patients trying to avoid getting this immunization.

Because babies are so vulnerable to this illness, current practice recommends giving all pregnant moms
a Tdap (Tetanus/Diphtheria/Pertussis) with every pregnancy. The Tdap vaccine was licensed in the US in 2005. This immunization should be done in the third trimester between 27-36 weeks. Studies have found that since this program began there has been a whopping 75 percent reduction of infant pertussis hospitalization and a 46 percent reduction of any infant pertussis cases.

For folks who will have a newborn in their lives,If it has been more than 2- 3 years since you had the shot OR the actual illness you should get another booster. The immunity wanes. Researchers claim that three out of four babies who get pertussis get it directly from family members or caregivers. It is essential that all the family contacts have current vaccine protection. This means partners, grandparents, caregivers and siblings or anyone who anticipates spending any time with your new baby. This way everyone will be able to remember the date of their most recent tetanus shot; it will be right around your baby's birthday!

People who have been exposed to whooping cough will usually start showing symptoms 7-10 days after the exposure and are contagious by the time they give that first sneeze. If someone is diagnosed, a course of antibiotics will help limit the spread and may minimize the symptoms. It won't make your cough go away, but the illness won't be quite as severe and you won't be contagious.

Testing for Pertussis is far from perfect. We usually send a culture obtained by a swab stuck up the nose. (as pleasant as it sounds.) The results may take more than a week, depending on the lab, so the decision about whether or not to treat often needs to be made based on the clinical history and symptoms rather than a lab result. If you do test positive, the Department of Public Health will be involved to make sure they get all of the contacts treated.

If you have pertussis, symptomatic treatment includes a cool mist humidifier and drinking plenty of fluids. Smaller more frequent meals may help make vomiting less of an issue.
Smoke exposure will make things much worse. Cough medicines don't seem to be of much use alas, although honey might be soothing (no honey for babies less than a year old.)

As I noted earlier the vaccine is not 100% effective, but folks who are vaccinated tend to get a much milder case than those who have no protection. The studies are actually fairly discouraging and see a big drop in protection after the first year or two, but aside from being around an infant, there is currently no plan for requiring a booster dose. There is no current call for routine TDaP boosters if you don't have a newborn in your life, But since everyone should get a Tetanus shot every 10 years, there is no good reason not to make that the Tdap.

A big Thank you to Sheila Zarate from the SF Public Health Department for her input and oversight to make sure I am passing along information that is accurate.

Friday, January 4, 2019

Vaporizers/Humidifiers: What's the difference? Do you need one?

Vaporizer vs humidifier

A lot of folks who live in San Francisco keep their homes fairly cool. My husband actually prefers the cold and our own house is usually pretty chilly. Our out of town guests and my daughters are likely rolling their eyes at that blatant understatement. Having visitors is a fairly regular occurrence and I confess that they tend to keep their coats on as they shiver on our couch while wrapped in a blanket. East Coast folks aren't used to cool houses in the winter time; they keep the furnaces are on steadily for the colder months making making the indoors actually warmer and dryer than I like.

Recently the weather got chilly enough that even the most stubborn of us cranked up the heat. When the heat goes on, I know that I will be getting more calls about nosebleeds, snoring, night coughing and even worsening eczema. If you have sparks and static electricity in your house or apartment, I am talking to you. Getting out the Humidifier/ Vaporizer will make sleeping much more comfortable.

Humidifying the air is also one of the first things I recommend for patients who have colds/cough and congestion. Added moisture will usually ease irritated airways. I find it essential for kids with croup and RSV (both of which are going around). As a bonus, some researchers have found that humidity levels above 40 percent might help deactivate virus particles, making them less infectious

It’s important to match the humidifier to the room size. A small room is roughly considered 26-299 square feet and a medium room is 300-499. Do a quick measure of the rooms that you are shopping for. The ideal indoor humidity should be 30 to 50 percent. If you want to be a real science nerd, invest in a hygrometer. They are available for less that $15 on Amazon and they can help you fine tune the humidity level in your house.

Even without the hygrometer, if the air in your house or apartment feels dry, it is time to invest in a machine.

Using a humidifier that’s too small won’t be as effective, and using one that’s too big can cause indoor allergies. Dust mites are the number one indoor allergen and they thrive on moisture from any source. It is a fine balance. We really don't want to keep the rooms overly damp. In San Francisco you can grow mold very quickly, which is another allergy trigger for many people. My suggestion would be that you don't run the machines 24/7. Make sure you turn them off during the day and dry up any dampness on walls or around windows.

Many of the machines will recommend using distilled water instead of tap. Unfiltered tap water usually contains higher levels of minerals and other particles. The humidifier can push these particles into the air. They will either get inhaled or settle around the room as dust. Neither is ideal. The harder the water, the bigger the issue but using distilled or purified water is always the better option.
Aside from the health issues, the minerals from hard tap water will build up in the machine and cause it to wear down much faster.

Vaporizers and Humidifiers essentially do the same job, but they have a few differences that you should be aware of. The world has changed a bit since I last updated this article in 2013. Now when you look for vaporizer ratings, it is more likely that they are cannabis related. (calm down, it is legal here!)You may have to scroll down a bit in the google search to find the type that I am referring to.

Vaporizers heat the water to make steam. The downside for them is the potential for getting burned (and it does happen, trust me, I get the calls.) On the plus side, Vaporizers have LESS chance for growing bacteria (still change the water please.) On a cold night, I find the warm mist more comforting but if you opt to use a vaporizer it is essential that you have it placed so that kids and pets can’t get close enough to knock it over or even get burned by getting too close to the steam. Make sure you place the machine on a level surface that can’t get knocked over. It should be at least 4 feet away for a crib or bed.

Humidifiers use a cold mist. A humidifier has a greater chance of growing bacteria if not cleaned properly. The technology is always improving and you can get machines that claim to kill the bacteria.
There are a lot of great machines out there with huge price ranges. I have seen some for under $30. If you are just going to bring out the machine for the occasional cold symptoms, you should be fine with an inexpensive machine. In a recent Consumer Reports ratings, one of their favorites, and best buys, is a $30 unit from CVS. You don’t have to spend a lot.

There are tons of sites out there that rate different machines. I do not have a favorite and you should have no trouble finding a list of the most highly recommended units.

A few features that I would pay attention to would be the ease of cleaning and an auto shut off. Some machines also give you the choice of hot or cold mist.

Many of my patients travel with theirs, especially if driving up to the mountains where the air is even dryer, so you might also consider how portable it is when choosing a machine.

Some machines give you the option of pairing with Vicks or other inhalants. When you are doing your shopping, you might want to pay attention to that. You should not add anything to a vaporizer or humidifier unless it specifies that you can. I find that Vicks smell quite soothing, but I wouldn’t use if for babies under 3 months.

Don't be lazy! When you use a humidifier, you need to at least change the water every day no matter what type it is. Not all manufacturers make that recommendation, but Consumer Reports does. They have done quite a bit of testing to lead them to that conclusion. Here’s a good routine to follow:

  • Every day: Empty, rinse, and dry the base tray or reservoir before refilling.
  • Every week: Remove water scaling with vinegar, and disinfect the unit with a bleach solution following the manufacturer's instructions.
  • Before storing: Clean to remove scaling, disinfect with a bleach solution, and dry thoroughly.
  • After storing: Before using again, clean to remove scaling, disinfect with a bleach solution, and dry thoroughly. Don’t fill it before you need to.

Every year we get calls from people taking the old machine out from the bottom of the closet, finding it covered in mold and freaking out. Alas, we don’t have a magic wand to remedy that. It is easily avoided if you follow the directions above.