Friday, August 23, 2019

Sleep tips through the ages/Insomina

This week's topic
Sleep tips through the ages/Insomina
Sleep deprivation is used as a torture device. A good night's sleep is essential for our health and happiness. I brushed up and updated my earlier sleep series.
The links are below.

For all of you new parents starting out, the above link has some essential tips to get you started out with good habits

The above link review some nap and bedtime strategies

The name of the post speaks for itself, Here are some strategies for keeping your kids to adjust to the new bed and the freedom that comes along with it

Now it is time for the post for the big kids and adults.

I had promised this post over the years, but somehow never got around to doing it.

If you or your child are having sleep issues, start playing detective to see if you can figure out an obvious source.

Here are some things to consider:

  • Is the insomnia every night or just once in a while?
  • Are there obvious triggers, such as anxiety? Starting school can certainly be a trigger. Are there any changes going on in the family?
  • Is the environment conducive to sleep?
  • Is it dark enough? Consider black out shades.
  • Are there noises around? Consider a white noise machine. Most folks have easier sleep in a cooler room, perhaps invest in a fan.
  • Are they snoring? It might be worth checking in with the Ear Nose and Throat specialist to see if their could be tonsils or adenoids getting in the way.

The basic sleep routine matters a lot. Sleep specialists often focus on something called sleep hygiene. This means getting to sleep and waking up at the same time every day. Yes, this means weekends.

Some teenagers get themselves sliding down the slippery slope by staying up late on the weekend nights and sleeping late on the weekend mornings. On Sunday evenings when it is bedtime, no one is particularly tired if they just woke up at noon. A week or so of rigid bedtime and wake up can make a huge difference.

Avoid screen time for several hours prior to going to sleep. I know this is hard for folks who are trying to finish up homework, but all the specialists are emphatic about this. Try to get your child to do any computer focused homework out of the way first. At the very least, try using a program such as f.lux or nightmode that adjusts the blue light, which is one of the issues shown to impact sleep.

Make sure there is no caffeine or too much sugar in the evening. This includes chocolate! Chamomile tea with a splash of warm milk has the combo of the tryptophan from the milk and chamomile in a nice soothing nightcap.

For the older kids, teens or adults that are having a tough night, don’t stay in bed tossing and turning any longer than thirty minutes or so. Instead, get out of bed and go sit in a chair or desk and do something boring. This is not the time to read Harry Potter or any book that is a page turner. After fifteen minutes get back in bed and try again. One way to ensure a teen gets back in bed is to limit their reading options to their textbooks (good luck!)

Consider meditation, acupuncture/ acupressure and or hypnosis. I have had many patients respond well to those.

Did you know that insomnia has a strong connection to anemia and vitamin D level? If you or your child are having chronic sleep issues, consider having your iron and vitamin D levels checked. There is no downside to making sure your diet is getting adequate iron, and that you are getting enough vitamin D, even if you don’t want to go to the lab.

While gentle yoga stretching can probably be relaxing, strenuous and heart-pumping exercise should be avoided at least two hours before bedtime. 

If none of the above remedies have helped you, occasional use of melatonin is fine. Especially if it is to get over jet lag or to help you get a good night's sleep before an important test or event.


CBD is very helpful for occasional sleepless adults. It is essential that you have these stashed carefully away so that your younger kids don’t have access.

Friday, August 16, 2019

When your child plays favorites

When your child plays favorites
I know that we are supposed to be the adults, but when your child seems to show a strong preference for the other parent, feelings get hurt.

You can be the head of a multi million dollar company or a world renowned heart surgeon, but when you become a parent, you had better protect that ego of yours. When a 2 year old says “Go away, I only want the other parent..” it feels rotten.

It should never be a competition. Ultimately your child will have a unique relationship with each parent. During the first couple of months, accept that if one of the partners is producing breast milk, it is developmentally appropriate for a baby to focus on her. It makes perfect sense. Even if mommy is pumping and the baby is fed from a bottle, mommy smells like milk. She is the sustenance. Being a nursing mom has its highs and lows. One of the benefits is the closeness that ensues. We need to give her this one. Mom has earned it from 9 months of pregnancy and then labor. It is not at all easy to be the primary supplier of your baby’s milk. 

Once the infant’s world expands beyond eating and sleeping, it is very common for babies to now make room for the other parents and caregivers in their hearts. It is normal for parents to come in and out of favor as the preferred parent as your child grows. While I hope that you can delight in the fact that your partner and your child have a solid bond, don’t minimize the input that you have over the relationship that you are forging with each child.

Do not allow your child to be the one in charge of how much time they spend with you. If your goal is a positive, deep and lasting relationship, then it is essential that each parent gets a slice of quality time with the kids. I know that many of us have busy lives. Make this happen if you can. Family time is great. The more the better, but it isn’t a substitute for one on one time. Take turns with reading, baths, bedtime.

Does this sound familiar?

“ I want daddy to read” 
“Tonight it is my turn”.

For kids that are old enough, get a calendar and show them. If something is stated as a rule it is sometimes more readily accepted.

"See today it is August 21.There is a big P for papa. That means it is my turn to do bedtime. Tomorrow is the D for daddy."

If they are old enough to articulate their demands, they are old enough to understand the concept of rules.

Acknowledge their displeasure.

“No..I only want daddy to put me to bed”

“I see that you are mad/sad that daddy isn’t doing bedtime tonight. How many ‘Phooeys’ are you feeling. Five? Okay, PHOOEY PHOOEY PHOOEY PHOOEY PHOOEY. Lets do an extra loud one together PHOOEY!!

Okay, Now, which story or song should we pick”

My husband brought his guitar in for some bedtime singing each night and earned the spot as the preferred parent for the final tucking in. Make an effort, figure out your gimmick and get that pendulum swinging back towards the center.

Truthfully, a 60/40 favorite parent is probably more normal than not. This tends to go in waves. If you feel like you are moving into a 70/30 then I think action is needed. Don’t get caught in the trap of spending less time with your child because they are playing favorites. Make an effort to adjust the balance. The answer is usually finding quality time. Even if you are a busy working parent, make the time that you have together count (put your phone away)! Find the common interests. Figure out a hobby that you can do together.

Many parents get caught in the trap of good cop/bad cop. If that is happening to you, it is time to step away and look hard at what is going on.

We often come from different upbringings and discipline style. It is imperative for the two parents to agree on common standards. Figure out the rules and then enforce them equally. 
If you are having trouble coming to agreement on the family rules, see if both parents can agree to have a third party to work with to help you find a compromise.

Even if you think you are on the same page as your partner it is a good habit that if older kids get into trouble, delay handing down a consequence until you have discussed the situation: 

Both of the parents will discuss this privately and will tell you what the consequence will be.”

This might avoid the out of proportion ridiculous punishment that you want to hand out simply because you are frustrated. “No play-dates or television for a month!” While that might be satisfying for a moment, giving a consequence that you know you can’t follow through with will just weaken your position.

Aside from discipline issues, some personalities are naturally easier together while some people clash. There is no reason to think this doesn’t happen with a parent/child relationship. Careful management now will reflect in the relationship that you carry over with your adult child. Learn how to communicate with each other. That can take work but it is worth the investment.

My bottom line suggestion is that time management is the key to solving a lot of issues. Kids playing favorites is just one of them.

  • Schedule family together time: Outings, game night, family meals...etc.

  • Make opportunities for one on one time with each kid: find a hobby that you enjoy working on together. My dad and I played piano and violin duets. Every time I hear one of the pieces we played I get full of positive emotions. For younger kids, put the bedtime routine on the calendar. Parents are in charge of this, not the kids.

  • Make opportunities for one on one time with your partner. Having an intact relationship with your partner is one of the best gifts you can give your kids. See if you can find another couple to swap babysitting with if it gets too pricey to have an evening out.

  • Carve out some sanctioned (no guilt) alone time. Everyone needs to put their own oxygen mask on first. It will make you function better. Maybe this is something as simple as going for a run, or taking a nap. Some people need this more than others. Identify your needs with your partner and see what can be done to allow you a bit of time.

Not everyone has the capacity to arrange these quality time opportunities as regularly as you like, but get your calendar out and see what you can figure out.

Friday, August 9, 2019

Flu season 2019/2020

Flu season 2019/20
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.

According to statistics from the CDC the death toll for children in the past four seasons from influenza and/or related causes was:
  • 2018/19 111
  • 2017/18 187
  • 2016/17 110
  • 2015/16 95

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. 

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. The decision of which strains to put in the shot was made later than usual because the World Health Organization recommended a last minute switch.
This might cause a mild delay in when the vaccine will become available. I don’t believe we will get any of our supply until September. Last year we already had it by mid August.

This year the flu mist is once again available but in limited supply. It is approved for kids over the age of 2.

Noe Valley Pediatrics was able to procure a handful of these. If you have a shot phobic kid on your hand, check in early in the season to see if you can get one of those doses.

Let's keep our fingers crossed that this year has the magic combination. For any of you interested, the strains in the quadrivalent vaccine for the 2019/20 season are:

  • A/Brisbane/02/2018 (H1N1)pdm09-like virus (updated)
  • A/Kansas/14/2017 (H3N2)-like virus (updated)
  • B/Colorado/06/2017-like (Victoria lineage) virus
  • B/Phuket/3073/2013-like (Yamagata lineage) virus.

Some offices offer the trivalent that is missing protection from that last B strain. In my mind it makes no sense to not get the Quadivalent.

All of the flu vaccine in our office is preservative free.

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. Starting Tamiflu quickly seemed to help.

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. My daughter's boyfriend had a case of influenza this July, and he was vaccinated early last season.

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 can't have a sense of what kinds of side-effects 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 over 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 quite a few 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. For Noe Valley Pediatrics patients we will start booking flu shot appointments when we get our first shipment. 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 nasty flu circulating, we did end up giving the shot to kids who were already a little sick. That isn’t my first choice.

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.You might also order something called a Shot Blocker from Amazon and bring it with you. These little gizmos have helped a few of my ‘shot haters’ have an easier experience.

This season, I won’t be doing the weekly emails, so the office will try to keep folks updated with flu info on the Noe Valley Pediatrics website. They will update vaccine supply and any info about the clinic dates. Click below for the 2019 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 2, 2019

Kids and Pets

Kids and pets

Personally I think that most families are enriched by having a pet. Of course, as an advice nurse I have a bit of an unusual take on things. I get plenty of animal related calls. A little knowledge and planning can help keep the relationship between your pet and your child happy and safe, and can help avoid incidents with animals who don’t belong to you.

For those of you who already have pets living with you, I understand that animals are essential and much loved members of the family. In some cases they may actually feel like your first child, but here are a few things to consider:

Many cats are quite happy to welcome a baby to the family, but cats are cats. Once your child has the ability to chase after them, the cat will usually establish dominance once or twice with a good swipe if someone is invading their space when they aren’t in the mood. Kids (and new puppies figuring out how to get along with the family cat) learn pretty quickly what the rules are. Watch out for cat scratches, they can get infected fairly easily. It is essential to clean them well and apply an antibiotic ointment. (Don't use peroxide, current thinking says to avoid it because it causes tissue irritation). If there is any increasing redness or red streaking appearing around the scratch site, that might be a sign that it is infected and it should be evaluated.
If your crawling child starts getting little red spots, consider that they might be flea bites. Fleas are rampant here in San Francisco year round. When not on your pet, fleas tend to hang out in the carpets and while they might not bother you, your child is spending more time on the rug and presents a tasty treat.
Please do your best to keep your kitties out of your baby's crib or bed. I know I sound like an old grandmother, but it is a safety hazard for a cat to snuggle around an infant's face.
Meow mix generally doesn't hurt anyone, but you want to make sure that the cat food is not left out where your toddler can get into it.
Now, getting a little more disgusting, make sure the litter box is somewhere where the child has no access. You don't want to be the parent who calls me horrified that their baby just had a snack of cat poop.
If any family members seem to be plagued with allergies, consider checking out Advanced Allergy Solutions. I have seen them make a huge difference for some people with allergies to cats and/or dogs
Make sure you closely supervise any interactions with your dog and your new baby to make sure the dog is not exhibiting any behaviors that you need to worry about. If the dog is at all growly, as heart wrenching as it may be, they might need to be placed in a home with no kids. 
Earlier signs of doggie stress can include:

  • Licking lips
  • Panting
  • Yawning when they are not tired
  • Pacing

By the time the dog is growling, it is possible that these other signs weren’t noticed.

There are some apps out there that can help you and your older children learn how to have appropriate interactions with dogs.

Puppy Prep’s Steph Miller, owner of Recess With Steph,shared the following excellent tips:

Dogs, Babies, and Expectations – Getting YouReady!
Here are some suggestions to help you prepare your dog for Baby’s arrival:
1. Practice basic manners and tricks so that your dog has plenty of cues he knows well and you can direct him to do. Examples: sit, touch, place, out, down, leave it, settle, target.
2. Socialize your dog around children in a positive and controlled environment. Observing kids while you give your dog treats or enjoy a game of fetch is a wonderful way to build a positive association. Short exposure is perfect!
3. Replace unwanted attention seeking behaviors with desired behaviors.
Example: sit to be petted instead of pawing you on the couch.

4. Practice short times of separation with a “success station” while you are home! Crates, gates, indoor tethers, or a doggie room are all great success station options.
5. Know your dog’s sensitivities. Research his breed or mixture of breeds. Observe whether the dog startles with fast motion, noises, or other sudden events.
6. Begin a “baby flexible schedule” vs. a rigid schedule. For example, if your dog always eats at 6 am, you may want to vary this time so that your dog gets used to changes and won’t wake you up early for breakfast!
7. Allow your dog to become familiar with the baby equipment. Focus on teaching him how you would like him to behave near this equipment. Doing this ahead makes a world of difference!
8. Place a baby doll or teddy bear in the baby’s carrier and move through the house and yard with it. Practice helps you to get the idea of what it will be like to use this equipment around your dog.
9. Walk your dog with an empty stroller, or put a heavy doll or a 10 lb weight in it for a more realistic feel, in order to learn more about the skills your dog needs to learn before a walk with a real baby.
10. Use a CD of baby noises to introduce new sounds and create a positive experience prior to the baby’s arrival. You can purchase dog expert Terry Ryan’s baby sounds as a CD or digital download by visiting
11. Have partner bring home a blanket with the baby’s scent on it (partner will smell like the baby, too). Let the dog become accustomed to the scent in positive ways.
12. If your dog is due for his yearly check-up and vaccinations, schedule your visit well ahead of time, and be sure to stock up on all necessary medications and supplies.
13. Familiarize your dog with the person that may care for them while you are away.
14. Find a good, safe spot for your diaper pail.
15. Find a licensed Family Paws Parent Education presenter in your local area: or contact me directly at
16. Have fun and enjoy your family!

Most dogs are perfectly wonderful with the children but even with the most loving dogs please make it a rule that your baby or toddler is not allowed near them at meal time. The innocuous infant might become more of a threat when they start getting more mobile. Let your doggy have a baby free zone where they can eat in peace. By far most of the bites that I get called about are food related.
I recall one situation where we had a toddler who got bitten by the family dog. One of those "treat balls" was unearthed under the sofa where it had been hiding for months. The dog got very territorial when the toddler tried to get it and the baby took the brunt of it.

In another instance, Grandma’s cosseted little dog didn’t like the fact that a visiting grandchild got on the bed. The child got a severe bite on the face. It wasn’t the first time that dog had bitten someone. Grandma should have been more wary of the interaction.

Just an FYI, A study of dog bites in Calgary finds no breed group can be singled out for serious bites. It has much more to do with the training, or lack thereof.

The Family Dog cites the chilling statistic from a study that was done of Philadelphia emergency room visits that found that 77% of dog bites are actually from a dog that belongs to a family or friend.

Always make sure your dog has a safe, kid free zone that they can retreat to if they need a break. If they have a crate, make sure that it is off limits for the kids.

If you are visiting a friend or relative's house and they have a pet ask them explicitly if the animal has any history at all of aggressive behavior with children. Some folks have a blind spot where their beloved pets are concerned and lose their common sense. If there is any doubt please ask that the pet be kept away from your child.

Never reach through a fence or into a car to pet a strange dog.
If you are walking down the street, teach your child that before you pet any unfamiliar animal you ask the owner for permission. Alisha Ardiana
who is a local dog trainer (she works with my grand dog Bowie) says that she believes that dogs deserve access to public spaces without being put in the position of having to interact with strangers. Some animals, walking on leash or tied up outside a store may be stressed and don't feel comfortable being approached. Don’t take it personally if the owner prefers that their dog be left alone.
If you do get the 'all clear' to say hello, demonstrate the safest and best way to meet any new animal. Show them how to hold out their hand first. Tuck the thumb inside the fist so that there are no fingers sticking out. Respect the animal’s personal bubble. Let the animal come to them to give them a sniff. Even if the owner says its fine, but the doggie isn’t interested, move on. 

Here is a good article worth reading.

After that initial sniff, for younger kids who are learning how to do gentle petting, consider teaching them the one finger petting technique - have them make a fist except for the pointer finger. Alternatively they can pet with the back of the hand. These methods can keep the kids from grabbing hunks of fur.

Even with the best training and intentions, my youngest Alana kept me on my toes. From the minute she could crawl, she was scampering across the park to say hello to anything with fur.

If you don't have a pet and are considering getting one:
I am a total animal lover and I think that having a pet is a wonderful thing. In our case, our family was adopted by a semi-stray Siamese cat when Lauren was still a baby. George (we didn’t name him) lived a very long life and I am sure never regretted choosing us as his family. A cat who comes to seek out ‘toddler love’ is indeed a cat starved for affection.
We also wanted a dog.

My mother-in-law had plenty of strong opinions. Among them were some pearls of wisdom that resonated with me. Her theory was:

All children need a dog, teenagers especially so. There is nothing quite like the unconditional love of a dog to get you through tough times. The last thing an adolescent needs is to lose their dog during those tumultuous years. Barring an unforeseen tragedy, the lifespan of a dog is roughly predictable, so plan accordingly.
When she first mentioned this to me I was actually a little horrified. It felt so callous and calculating, but I thought about it a little further and it made perfect sense. We ended up getting our beautiful golden Java when my girls were 9 and 12. We were blessed to have her with us for 12 wonderful years. Our family was much richer for it.

For an extra pet safety tip and a story, click this link to an old post:

Please accept ahead of time that as much as you bargain with your child and make agreements about how the dog responsibility will be shared, just give up right from the start. The dog is yours. You (in my case it was my husband) will be the one remembering to feed them, doing all the walks in the rain and probably 100% of the poop scooping. Trust me on this. Luckily the value of getting a family pet goes way beyond teaching your child responsibility.
Keep in mind that a dog bite impacts everyone involved. Let's do everything in our power to prevent them!

No offense to the fish, birds, snakes and other more unusual animals out there since most of the focus of this post was on the more popular furry cats and dogs.
Pets regardless of species, give us many life lessons. They teach us how to deal with loss, but also about unconditional love.

Big thank you to Stephanie Miller and Alisha Ardiana (Dog trainer extraordinaire) for their valuable input on this post