Friday, July 26, 2019

Lead exposure and prevention 2019

Lead exposure and prevention 2019

Unfortunately in our current world, many of us live in environments where our kids are not completely safe from getting some lead exposure. Lead does not break down or fade away with time. It remains in the environment and we are stuck dealing with bad habits past and current.

In 1979 lead based paint was banned from use in house paint. The 2015 census claimed that 83% of houses in San Francisco were built before that law went into effect. It is possible that that statistic has changed with all the new neighborhoods popping up, but the fact is, the majority of our kids are growing up in older homes.

Knowledge is power. It is worth getting your child tested. In our office we usually suggest a blood test at either the 9 month, 12 month or 15 month exam depending on the circumstances. If there are obvious hazards we order the test at the earlier visit. I suggest coupling the lead test with a routine CBC (complete blood count) that also measures the iron level.

Once in awhile things can get sidetracked at some of the well child exams. There are so many things to talk about and sometimes the kids are kicking up a bit of a ruckus towards the end of the visit. If the doctor doesn't bring up the subject of getting a blood test, feel free to remind them. We don't do the test in the office. You should find out which laboratories are preferred by your specific insurance plan. Although they are not always in network, the hospital labs facilities are often more adept and drawing blood from our younger patients.

When we get the lead results, the best news is <2 or undetectable. No measurable level is considered okay. If there is some lead showing up, we want to figure out where it is coming from and keep that level from getting higher. If your child in San Francisco has any elevated lead level, the city will send out a public health nurse to help you explore your environment and see if they can figure out the source. A lab that finds an elevated level is legally required to report all positive tests for environmental and communicable issues. The most common results that we see in our patients population are 1 or 2. I almost never see 0. It is often simply reported as less than 3 and I consider that fine.

Just recently we had some siblings with the level of 9. The family was caught by surprise. That is what is prompting me to update this post!

For reference, a level over 45 is an urgent situation that needs treatment.

If an elevated level is found, repeat testing will be required to make sure it is subsiding.

Young children are much more likely to be exposed to lead hazards by touching lead-contaminated surfaces and then putting their hands in their mouths. In addition, children's bodies absorb more lead than adult bodies do because they are still growing; but lead is a problem for all of us. Pregnant women need to be especially careful because any exposure can harm their unborn babies.
Lead poisoning affects learning and behavior, damages organs, causes dental cavities, decreases hearing and decreases intelligence.

Lead in the water can be a concern. It is worth finding out if your water sources are safe!

According to the very helpful Childhood Lead Prevention Program here in SF, new brass fixtures can actually be as much of a problem as the old pipes because they can give someone a false sense of security. Even if the new fixtures claim to be lead free, it is still possible for some lead to get into the water from the pipes. Only use cold water for cooking, drinking or making baby formula because hot water is more likely to contain higher lead levels. If you haven't used a faucet in the last six hours, flush it out for one to two minutes before drinking or cooking with it. The longer water has been sitting in the pipes, the more lead it can absorb. You can use the initial water for watering plants.

The following links are terrific resources:

If you want to go the extra mile and get your water tested, in San Francisco, it is free for anyone on the WIC program. Contact the lead program for a voucher. For everyone else it is $25/tap. Click the link for directions :

There are also some products for testing water available from Amazon, but as is the case with most things, they have mixed reviews.

If you are not lucky enough to live in a place with safe water, consider getting a filter that is tested to remove contaminants. Boiling water will NOT remove lead. Make sure that if your child is getting only filtered water that they are getting necessary fluoride.

Common Sources of Lead:

Pipes and water are only one of the many ways in which kids can get exposed. Most of the lead gets into your child from the hand to mouth route. They either chew on something directly, or put hands that have been in contact with lead dust into their mouths.

Paint chips.

Keys - don't let your child chew on them

Brightly painted pottery or toys.

Beware of things imported from different countries The brighter the color, the more apt they are to have lead. It's hard to be absolutely sure if a toy has lead in it or not. Start by or to see if a specific toy has been recalled.

Be wary of cheaper toys -- like those from vending machines or street fairs -- and especially plastic jewelry. If you notice that your child is putting a toy in her mouth frequently and you're not absolutely sure it's lead-free, take it away. To lower the risks of poisoning, make sure that your child is playing with age-appropriate toys that they are not at risk of swallowing.
There was a recent article claiming that some toys bought online had higher lead levels than are considered safe. Make sure you are buying things directly from a trusted source.

Children arts and craft products - some products have been recalled due to the violation of paint standards. Look for the label Meets ASTM D-4236 to make sure they are safe

Coatings, jewelry and decals on some imported children's clothing

Antique furniture varnish

Varnish on bathtubs

Some lipstick brands

Some candies imported from other countries Fruit is always a better choice

some computer cables - of course chewing on cables is not a good idea no matter what

Dirt and sand that get tracked in from outdoors

Urban gardening increases contact with possibly contaminated soil Always grow vegetables and fruit in raised beds with OMRI(organic material review institute) certified Lead Free soil available at the hardware stores. 

Ayurvedic medicine

Imported beads or necklace 

Pre 1997 imported vinyl blinds

Prevention is the best defense!

A nutritious diet is VERY important and should be considered a first line of defense. Lead in the body is distributed to, and absorbed by, the brain, liver, kidneys and bones. A healthy, low-fat diet rich in iron, vitamin C and calcium reduces the body’s ability to absorb lead. Lead actually binds to these critical nutrients and is eliminated instead of being absorbed by the body’s organs and bones. Regular meals are also important since lead can have more opportunity to absorb on an empty stomach.

Iron deficiency increases absorption of lead from the stomach and intestines. Good sources of iron are:
· Iron-fortified cereals
· Green leafy vegetables
· Pureed meats
· Lean red meats
· Tuna, salmon, fish
· Raisins, dates, and prunes
· Dried beans and peas
· Skinless poultry
· Nuts or sunflower seeds

Vitamin C
Vitamin C and iron rich foods work together to reduce lead absorption. Good sources of vitamin C include:
· Oranges and tangerines
· Grapefruit
· Limes and lemons
· Strawberries
· Cantaloupe
· Kiwi
· Potatoes and sweet potatoes
· Tomatoes
· Broccoli
· Bell peppers

Calcium reduces lead absorption and also helps to build strong bones and teeth. Foods that are good sources of calcium are:
· Milk and milk products
· Cheese and yogurt
· Green leafy vegetables
· Calcium-enriched orange juice
· Tofu
· Salmon
· Peanuts

If you notice that your child is not growing out of the "everything in the mouth" phase and is constantly putting non food items in the mouth, it is worth bringing this up to the doctor. This can be the sign of an elevated lead level.

Consider having a 'shoes off' policy to avoid tracking lead dust inside. This is especially important if someone in the household has routine lead exposure during their job; make sure they clean off well before having close contact with other family members.

Make sure your kids get in the habit of frequent hand washing,especially before meals and snacks

Do the best you can to make sure there are no obvious lead sources inside your home. Remember that any home built prior to 1979 is at greater risk. If you do have an older house with any peeling paint, make sure that cribs and highchairs are moved away from walls.

There are some home testing kits that check paint for lead, but they are often misused. The easiest way to test paint is to check the paint that is on wood or varnish. In order to get an accurate result, you need to scratch the surface and mix the test liquid with more powdery paint. I don't have a favorite brand.

Never disturb paint in old buildings yourself. Always hire a professional for Lead jobs. A list of Lead certified professionalsis available by calling 1-800-597-5323 or visiting the link.

If you have any concerns about your home, regardless of whether or not your child has been tested for lead, call the SF lead program to arrange a public health nurse visit or speak with the Public Health nurse. Call 311 or visit

Thank you to the very helpful folks at the Children's Environmental Health Promotion Program at the San Francisco Department of Public Health for their input on this post

Friday, July 19, 2019

Siblings 2019

This week's topic
Siblings - nothing is ever quite the same!
Imagine your partner says to you, "Honey, I really love you. You are one of the most important people in my life. Please don't be concerned that a younger, very adorable person will be spending a lot of time with me. They will possibly be sleeping with me in my bed for a while. There may be some sucking on my breast."


The oldest child was the center of the world for a time. Moving over to make room for a new member of the family isn't always easy.

Some big brothers and sisters are actually eagerly expecting the baby's arrival. Others are too young to really understand what is going on. Regardless, there is a big adjustment to be made. Many parents report that the older siblings are quite sweet to the baby, but act out horribly to the parents. Once in a while, but less often they will also act out towards the baby. One of the nurses who used to work with me remembers the time that her oldest daughter dropped a medicine ball on her new sister. Others have no malice but don't have a sense of how to be gentle.

Below are some suggestions that may help ease the transition.

Do some gentle preparation by including books about new babies among your reading choices. Please keep reading other favorites that have nothing to do with a new baby as well.

Once the baby has arrived give your older child plenty of opportunity to talk about what if feels like to have a baby in the house. Children might feel guilty for having some negative feelings. Validate that it is very normal for the big sister/brothers to sometimes feel mad, sad or aggravated. Some children might actually need to be told that the new brother or sister is here to stay as a part of the family. Sending the baby back in not an option.

Bestow a gift for the big sibling that is “from the baby”. I am not sure what the age cut off for getting away with this is. Lauren was a remarkably clever, almost 3 year old, when Alana came along. Nevertheless, when we gave her a little present from her baby sister, she accepted it without question. She was delighted and was quite pleased with the very thoughtful baby. I don’t recall what it was….

Some big siblings feel very important if you let them be "helpers". Find some safe baby related tasks for them to assist you with. This shouldn’t be hard to do. Even pulling out a diaper or wipe qualifies.

The most important tip of all is to make sure that you carve out one on one time with the older child. Often they are craving birth mom right now. If mommy is breast feeding, make sure that in between feedings she hands the baby off to the other parent or support system for burping, diaper changes, etc. and make a fuss about having "special big boy/girl time." Nurse Jen says that lots of people gave her this advice but she didn't realize that having a sleeping baby in a sling doesn't count. She wanted me to make sure to add that if you are holding the baby, it simply isn’t the special "one on one" time.

As your kids get older, the oldest child may always feel a bit entitled to some solo time.

If you can manage it, take just one child with you on routine errands and turn the outing into an adventure. Perhaps you can have only one child at a time allowed to "help" with a meal. Even a walk around the block or some special time at bedtime makes a difference. Try to make sure that each parent gets special time with each kid.

Be creative. Even if you are on the toilet, let the big one in with you and tell a story. Point out that this is “special big boy or big girl time” Hey, sometimes we need to be creative carving out our moments.

Once the second child comes along you will feel like simple math no longer adds up. One plus one must surely equal five. You will manage to find the balance, but those first few months are challenging to say the least.

With the first child you had the luxury of focusing on schedules and nap time as if they were set in stone. Unless you are remarkably lucky or hire someone, a true schedule doesn't really exist with this second child. Naps? Maybe while you are driving from here to there. Somehow these non firstborn children muddle through.

Do your remember how careful you were with the first one? You avoided crowds and made sure that no one came around if they weren't completely healthy. The new baby will simply be developing that immune system a bit earlier. There is almost no avoiding it, unless you never go out and you quarantine your older child to an unreasonable degree. Second kids get exposed to things quite a bit sooner. They survive.

I like to make the big siblings the deputies of the Hand Washing Patrol. Have hand sanitizer such as Purell around. If your toddler is prone to putting things in their mouth,you can also get the hand sanitizer that is alcohol free. Call it magic soap. Tell your ‘deputy’ that they are in charge of making sure that anyone who is going to touch the baby cleans their hands first. This may help make sure that they don't feel like they are constantly being nagged at.

One more important thing to keep in mind is that all of your kids will reach their milestones on their own timeline. It doesn't pay to compare them to each other or to the other kids in the play group. My baby Alana, for the record, doesn't mind when I use her as an example. She has her MSW from the University of Michigan and is currently working as a therapist here in San Francisco. She is a super star all around, but goodness was she slow starting out.

Talking: Lauren was singing Rogers and Hammerstein musicals at a remarkably young age. She not only knew the lyrics, but she sang them in tune. I have video proof of this. Alana barely had ten articulate words before she was two. Lauren would translate for her and act surprised that we didn't know that "gbabpgpsmp" meant, "I want popcorn please."

Walking: Lauren took her first steps at a year. Alana waited until she was about 16 months and then carried a chair across the room within a day of mastering walking.

Toilet training: Lauren was an early 15 months. Alana had no interest until she was 3. I thought we were going to have to buy depends.

They will all reach the milestones in their own time.

Siblings will have days when they are best friends and days when they torture each other. My older sister and I were fast friends until 4:00 pm like clockwork every day when she started to pull my hair while saying "Jeep Jeep". My husband was tortured by his older sister until his early teens! My daughters interspersed periods of intense closeness with periods of mild bickering.

If you can avoid it, try not to be the judge and jury. See if you can let them work out mild skirmishes. Observational statements can be fairly effective. " I see two girls who are having a hard time sharing."
Teach your children the very important tool called 'walking away power'. If they are having trouble with a sibling, leaving the room is a better choice than whacking them.

Fast forward 20 years:

My family was on a cruise, savoring time together. We were in Cozumel. My husband Sandy was off on a real dive, while the girls and I went Snuba diving. Snuba is a combination of Scuba and snorkeling. With Snuba you breathe through a 30 foot tube that is connected to an oxygen source that floats along the surface. My daughters were swimming along the ocean floor. I was about 10 yards above them watching them animatedly communicate with each other through hand gestures and some signing. I remember proudly thinking...look at my daughters. They are both intelligent, funny, kind and lovely. See how well they can communicate in that secret language that siblings share. I love them so much. I am so glad they have each other and that they have gotten so close as they have gotten older. Our time was up and the guide gestured to all of us that it was time to go up to the surface. They removed the mouth pieces and.......the fight continued:

"You were getting tangled in my hose"
"You were kicking too hard and making too many bubbles" and so on.

A mom can dream......

This post has been updated from one that I ran several years ago. I think that we could possibly get through a snuba excursion in peace, although Lauren has since gotten her actual scuba certification. 

I still marvel over how different they are.

Lauren and her dad summited Mt. Kilimanjaro and then several years later made it to Everest Base Camp. I had used my rare veto power and forbid them from trying to go beyond base camp or approach the death zone (it is called the death zone for a reason!) Fortunately they heeded. Alana had zero desire to join them on these expeditions. She is my pedicure and shopping buddy. The sisters are incredibly close and relish time together. For the first time in many years they live in the same city. I mentioned that Alana is a mental health therapist. Lauren has started her own company called Inclusive Arts, whose mission is to create opportunities for individuals of all abilities to experience and participate in creative and performing arts.

With all the differences, they have important similarities. Both are wise and kind. I am a very fortunate mom.

* Bonus sibling tip from supermom Dee-Dee:
Make a kindness jar. Have a bowl of marbles (this is for families where choking hazards are no longer a concern.) Every time a sibling says or does something kind to one another, every witness gets to put one of the marbles in the jar. As soon as the jar is full, the family rewards itself with a special outing.