Friday, September 25, 2020

Talking to your child about loss

I wrote my first post about loss back in 2015. I updated it in 2017 when I was dealing with the loss of my mom Ruth Ann. The same week that my mom died, I was still working at Noe Valley Pediatrics. We lost a young patient one day and a young mother the next. Both were sudden and unexpected. Those were tragedies. An 86 year old woman, who was able to peacefully pass away in her own bed with her family around her is not. As I noted in the intro to my post: My mom was pretty amazing. She was a force of good. She routinely wrote thank you letters to strangers who were kind and good at their jobs. She actively reached out to lonely friends, family, and acquaintances to let them know that someone was thinking of them. She was the second mom to all of my childhood friends. She was the kindergarten teacher who remained beloved by all of her students. She was incredibly charitable. I was incredibly blessed with both of my parents. A wise friend once shared a theory with me that the world is like a scale that is a precarious balance between good and evil. The smallest act of kindness might be the essential spark that is making the difference in tipping the scale in the right direction. It is going to take a lot of kindness and good deeds to make up for her loss. This week we lost another Ruth. My Oath team was on a zoom meeting together when the news came through. We sat in stunned silence as the emotions slammed through us. Children all over the world watched their parents weep and mourn. Talk to them. Teach them. May her memory be a blessing and may all people recognize and embrace her legacy that all people should be treated with equal rights and respect. This week's topic Dealing with loss/helping your child cope Laughter/Crying/Happiness/Sadness. Life is such a balance. Assuming you are lucky enough to have people, pets, or even objects that you care about, then dealing with loss is inevitable. If you have a child, you need to be prepared to know how to approach the subject. Parents, it may be helpful to ask yourselves the following questions: How do you, yourself deal with loss? What do you believe? Some folks have a deep faith that there is “More to it than this,” and others think that “this is it.” Are you comfortable sharing your belief system with your children? How do you find comfort? What can your friends and family do for you when you are grieving? Do you need hugs or space?? There is not one simple approach for every person, child, or family. My mother-in-law liked to say that there is no right or wrong way to grieve. There are no rules. It is important to be supportive of the different paths that people take. There are also many cultural factors that may impact the situation. The routine losses that the families deal with most often are the passing of a grandparent or beloved family pet. Those are the lucky ones. An anticipated loss is no less devastating, but this is the cycle of life that is sad but not shocking. Others are flattened by the loss of a partner, friend, sibling, child. If your family is hit with a loss, sudden or anticipated, unless we are talking about a goldfish, likely the death is hitting you just as hard, if not harder, than it is impacting your child, though don’t minimize the loss of that goldfish as a valuable opportunity for ritual and conversation. (My husband managed to delay the "goldfish conversation" several times with a visit to the "open till midnight fish store" where Goldie was replaced several times with no one the wiser!) Parents don’t usually have the luxury of collapse. How do you help your child when you yourself are dealing with all the grief? There are factors to keep in mind for each age that you are dealing with. ages 2-4 generally don’t grasp the concept of death as permanent ages 4-7 may feel responsible for the death because of their thoughts, actions, or lack of action age 7-11 just starting to see death as something irreversible over 11 has a better understanding about the loss Not to make light of the subject, but here is a classic family anecdote: When Lauren was between 3 or 4, she went through a phase of obsessing over several musicals and movies that were centered around orphans. Annie and Disney's The Rescuers are ones that come to mind, but I know there were others. One day she asked, “what is an orphan?” We discussed that an orphan was someone who didn’t have any parents. We immediately went on to say that she was very lucky that she had both mommy and daddy, but if in the very unlikely event that anything ever happened to both of us, her aunt and uncle, Barbara and Richard, would be her guardians. She was quiet for a moment and then said, “ I better get their phone number.” Hmmmm. Do's and Don't s Do NOT say that an animal was “put to sleep” or use any phrase that can confuse your child. The words “passed away” are also fairly passive and confusing. They might wonder if that could happen to them at any time. Do NOT lie. Find a way to convey truth that you are comfortable with. Your child will know that you are very upset. Shielding them from honesty and communication is not doing them a favor. It is okay to be sad. It is okay to cry. Find a ritual that you feel comfortable embracing. Take comfort in happy memories. Celebrate the life of the one you lost! Tell wonderful stories. Don’t be afraid to laugh. Honor the memories with kind gestures. Finding a good therapist to help you or your child give you coping tools is often a good idea. Check to make sure that the therapist has experience dealing with bereavement issues. Books and stories can be an excellent launching off point for discussions. If you can’t come to terms with how you feel about death, you might be able to turn the spotlight away from you with lines like: “Some people believe…” “Other people think……” In my search for further local resources I reached out to my old friend Dr. Nancy Iverson. Nancy has not only written several published articles about the grieving process, but has been involved in facilitating various support groups for many years. She pointed me towards Josie’s Place. (It was a bit of a treasure hunt.) This is a small but wonderful center here in San Francisco that offers support groups and other services for families and children who have experienced loss. Josie’s Place: 415-513-6343 Groups meet in the Inner Sunset For children over the age of 7 If you scroll down to the bottom of the home page on their website in the "Articles on Grief/Grief Resources" tab, Pat Murphy, the director has cobbled together a list of other local resources that might be useful. Janet Jaskula, RN, MS, A pediatric hospice nurse, also shared her list of resources: The Heart and the Bottle This is a great book about what loss and grief can do if one does not deal with it. Kids and adults. "Fall of Freddie the Leaf" by Leo Buscaglia "Velveteen Rabbit" by Margery Williams "There is a Rainbow Behind Every Dark Cloud" written by a group of children with leukemia who attended The Center for Attitudinal Healing. A Lion in the House Movie that follows several children and teens and their families through illness and loss, grief and death. Though not all of the kids in the film die, they are certainly affected by their illnesses and loss of their "normal" childhood and teen years. The Giving Tree Shel Silverstein. Or check out this newer version that I quite prefer! For parents, check out the the website of Barbara Karnes. Barbara Karnes is the author of "Gone From My Sight." She has some excellent combo coloring/story books about loss for kids. Dr. Nancy Iverson recommends the book: "Never Too Young to Know" by Phyllis Rolfe Silverman The very helpful children's librarian Liesel Harris-Boundy at the San Francisco Public Library West Portal Branch did some research for me and came up with some good choices for kids. Scroll down to the end of the post for her list. ****************************************************************** I saw the following gem circulating around the internet and it resonated with me. I thought it worth sharing. Someone put out a post asking for help dealing with grief. This answer was the response from a fellow in his late 70s: I'm old. What that means is that I've survived (so far) and a lot of people I've known and loved did not. I've lost friends, best friends, acquaintances, co-workers, grandparents, mom, relatives, teachers, mentors, students, neighbors, and a host of other folks. I have no children, and I can't imagine the pain it must be to lose a child. But here's my two cents... I wish I could say you get used to people dying. But I never did. I don't want to. It tears a hole through me whenever somebody I love dies, no matter the circumstances. But I don't want it to "not matter". I don't want it to be something that just passes. My scars are a testament to the love and the relationship that I had for and with that person. And if the scar is deep, so was the love. So be it. Scars are a testament to life. Scars are a testament that I can love deeply and live deeply and be cut, or even gouged, and that I can heal and continue to live and continue to love. And the scar tissue is stronger than the original flesh ever was. Scars are a testament to life. Scars are only ugly to people who can't see. As for grief, you'll find it comes in waves. When the ship is first wrecked, you're drowning, with wreckage all around you. Everything floating around you reminds you of the beauty and the magnificence of the ship that was, and is no more. And all you can do is float. You find some piece of the wreckage and you hang on for a while. Maybe it's some physical thing. Maybe it's a happy memory or a photograph. Maybe it's a person who is also floating. For a while, all you can do is float. Stay alive. In the beginning, the waves are 100 feet tall and crash over you without mercy. They come 10 seconds apart and don't even give you time to catch your breath. All you can do is hang on and float. After a while, maybe weeks, maybe months, you'll find the waves are still 100 feet tall, but they come further apart. When they come, they still crash all over you and wipe you out. But in between, you can breathe, you can function. You never know what's going to trigger the grief. It might be a song, a picture, a street intersection, the smell of a cup of coffee. It can be just about anything...and the wave comes crashing. But in between waves, there is life. Somewhere down the line, and it's different for everybody, you find that the waves are only 80 feet tall. Or 50 feet tall. And while they still come, they come further apart. You can see them coming. An anniversary, a birthday, or Christmas, or landing at O'Hare. You can see it coming, for the most part, and prepare yourself. And when it washes over you, you know that somehow you will, again, come out the other side. Soaking wet, sputtering, still hanging on to some tiny piece of the wreckage, but you'll come out. Take it from an old guy. The waves never stop coming, and somehow you don't really want them to. But you learn that you'll survive them. And other waves will come. And you'll survive them too. If you're lucky, you'll have lots of scars from lots of loves. And lots of shipwrecks. ******************************************************************** Liesel Harris-Boundy's recommended reading list: Life Is Like the Wind by Shona Innes - 2014 Written by a clinical child psychologist, Barron's "A Big Hug" series offers a gentle and direct approach to the emotional issues that children face. This book introduces the concept of death to young readers by likening life to the ever-moving wind. My Life Changed A Journal for Coping With Loss & Grief by Amy Dennison - 2003 Parenting Through Crisis Helping Kids in Times of Loss, Grief, and Change by Barbara Coloroso - 2001 Missing Mommy by Rebecca Cobb - 2013 Ben's Flying Flowers by Inger M. Maier - 2012 Emily introduces her younger brother, Ben, to butterflies, which he calls "flying flowers," and when his illness makes him too weak to go see them she draws him pictures, but after his death she no longer wants to draw happy things. Includes note to parents. Harry & Hopper by Margaret Wild - 2011 Harry is devastated when he returns home from school to find that his beloved dog, Hopper, will no longer be there to greet him. The Blue House Dog by Deborah Blumenthal - 2010 A boy whose beloved dog has died, and a dog whose owner also died, find each other and slowly begin to trust one another. Always by My Side by Susan Kerner - 2013 A rhyming story written to help children understand that a dad's love is forever. Even if they grow up without his presence in their lives. Rabbityness by Jo Empson - 2012 Rabbit enjoys doing rabbity things, but he also loves un-rabbity things! When Rabbit suddenly disappears, no one knows where he has gone. His friends are desolate. But, as it turns out, Rabbit has left behind some very special gifts for them, to help them discover their own unrabbity talents! Rabbityness celebrates individuality, encourages the creativity in everyone and positively introduces children to dealing with loss of any kind. The Scar by Charlotte Moundlic. When his mother dies, a little boy is angry at his loss but does everything he can to hold onto the memory of her scent, her voice, and the special things she did for him, even as he tries to help his father and grandmother cope. Remembering Crystal by Sebastian Loth - 2010 Zelda the goose learns about death and loss when her turtle friend Crystal disappears from the garden one day. A Path of Stars By Anne Sibley O'Brien - 2012 A refugee from Cambodia, Dara's beloved grandmother is grief-stricken when she learns her brother has died, and it is up to Dara to try and heal her. I Remember Miss Perry by Pat Brisson - 2006 When his teacher, Miss Perry, is killed in a car accident, Stevie and his elementary school classmates take turns sharing memories of her, especially her fondest wish for each day.

Friday, September 18, 2020

A Mysterious story about a pair of socks

This evening ushers in the holiday Rosh Hashana, which is the Jewish New Year. I think everyone is ready for a fresh start! There is so much going on around us! I am taking a break from things like poor air quality and viruses and simply telling a story this week. This week's topic A strange but true story about a pair of socks Serendipity? Coincidence? All I can tell you is that odd things happen more than you would think to me and my family. My husband for years tried to find explanations that made sense, but he finally gave up. Here is one such tale. The mysterious socks Social media is a mixed bag. I try to avoid the political spats and focus more on the sweet updates from family and friends (admittedly I don’t always succeed.) One of the more enjoyable aspects of Facebook is the memories that surface. Just this week a memory popped up from 2013 about a pair of socks. I had forgotten all about it. It was such a strange story that I have no way of explaining it. I can only promise you that Sandy the skeptic bore witness to it. When we moved out to San Francisco back in 1985, I made it clear that moving to the west coast was contingent on me going back to visit my family in Pittsburgh several times a year. Sandy was very supportive of this. The big brick house where I grew up in the actual Mister Rogers Neighborhood of Squirrel Hill became a second home to my kids as they regularly came back with me to visit family. As the kids got older, they still made it their business to get back there, but they no longer were able to come with me on every visit. On that August visit seven years ago, I had gone solo. The house had several stories and somehow, much to my mom’s dismay, was a magnet for “stuff”. My childhood home and it’s various collections are featured in many of my posts over the years. Aside from the generations of letters, photos and treasures, new and odd things had a way of appearing. My mom had taken the term barnacle and used it to describe things that somehow took root in a place where they had no business being. That empty container of hand sanitizer in your house that has been sitting on it’s side, on the coffee table for several weeks, and somehow looks like it belongs there...that’s a barnacle. During this particular visit, my mom had asked a favor. Somehow the set of steps going from the second floor up to the attic had amassed a collection of stuff. Would we be kind enough to go through it and clear the area? She had someone coming to do some work on the third floor and has been asking for people to get the steps clear. My visits were often her catalyst to getting things done. My sister, my niece (who lived up on the third floor) and I started our sorting. Here was a copy of the Pittsburgh Post Gazette with Lauren and I on the cover, the day after the Loma Prieta earthquake. Here were piles of clothes to go to the thrift store; here were some books. Piles were made. Keep it, toss it, donate it. We were making good progress. At the bottom of a bunch of clothes was one sock. It had a distinct embroidered pattern and I recognized it as mine. “Hey that sock is one of mine.” This was August, sandal weather in Pittsburgh. My best guess is that this sock got separated from its mate (as socks do) during a laundry during my last visit, which in this case was December. That is a good definition of a barnacle. The sock had somehow taken root on the steps and folks just stepped around it. But for now, I stuck it in my suitcase. I spent a week in Pittsburgh and then stopped for a few days in Denver to visit one of my best friends. The day before I was heading home I spoke to Sandy for what was a fairly routine call. “I miss you very much and can’t wait to have you home. There are fresh sheets on the bed, and I cleaned the house from top to would be nice if the house could stay neat for at least a day once you are home.” (As an side, there is of course a reason why he had to ask me that; I am not the neat one in our relationship!) “Yes dear.” I got home to a truly spick and span house. I brought my suitcase up to our bedroom, and plopped it on the bed. Before I even opened it, I turned around and saw that on my dresser was a single sock. Yes. It was the mate of the lone sock in my suitcase. I picked it up in a bit of shock and yelled “Why is this sock here?” Sandy looked puzzled. “I have no idea, I didn’t put it there, I straightened up everywhere, maybe Alana put it there." As soon as Alana came home that afternoon I waved the sock in her face. ”Where did this sock come from?” “Gee Mom, it is nice to see you too!, I have no idea where that sock came from. It has been hot out and I haven’t worn socks for awhile." I opened up the suitcase and pulled out the matching sock to show them. This sock had been sitting on a step in Pittsburgh for months and months and somehow its mate was waiting for it. If you are waiting for me to follow up with an explanation, I have none. I will say that if I knew I had one wish, it likely would not have been to find a missing sock. There is a follow up. The socks were clearly special. On my next trip to Vegas I brought them along. Yes I got a straight flush at the poker table and the slot machines smiled at me a bit more than they usually do. When we came home and did the laundry, only one of the socks came out. Somehow I think it will turn up again. Is this my strangest story? Probably not.  What is yours?

Friday, September 4, 2020

Mosquito bites/West Nile Virus

West Nile Virus/ Mosquito Information West Nile Virus has been detected in the Bay Area. It is 2020; this should not be a surprise to anyone. What else is coming our way? Oh yes, that asteroid right around election day... Even if they weren’t carrying any diseases, I hate mosquitoes. Yes I am aware that they are part of nature's vast food chain but that doesn't stop my loathing. For the record, it is a mutual dislike and fortunately I rarely get bitten. The rest of my family, both of my daughters in particular, are tasty targets, and are feasted on when given the opportunity. Of all the mosquito-borne illnesses, the West Nile virus is the one that has gotten the most local media coverage lately. It is thought to have originated in Africa (hence the name.) It has spread throughout the world and it was first detected in this country in 1999. Unfortunately we now have it in most states, including California. Mosquitoes get this virus from feeding on infected birds and then transmit it to humans. Humans are referred to as "dead end hosts"; they get the virus from being bitten by the infected insect, but then can not spread it to each other. It is possible that it can be transmitted from blood transfusions, pregnancy or breastfeeding but there are no known cases of infants who have gotten seriously ill from these transmissions. The good news is that most of the time it is actually not such a big deal. Children under 5 seem to be at relatively low risk for getting terribly ill, and folks over 50 seem to get hit the hardest. It can be found year round but seems to peak in late summer/early fall. 80% of folks who get WNV have no idea that they are infected and feel perfectly fine. There are probably thousands of cases that go under the radar since we would never consider testing if someone is only showing mild symptoms of a mystery illness. The unfortunate other 20% of infected folks may have fever, joint pain, muscle weakness, stiff neck, diarrhea, vomiting, swollen glands, photo-phobia rash on the trunk. Not everyone will have every symptom. Most people showing these mild to moderate symptoms will recover completely, although there are reports that some of these folks can remain fatigued and achy for several weeks. 1% of infected people can get more serious neurological complications including encephalitis and meningitis. It can be fatal for those with serious cases. People with troubled immune systems are at the greatest risk. The incubation period is usually between 2-14 days after the bite from an infected mosquito (most commonly 2-6 days.) There is, alas, no treatment beyond supportive care. It is thought that most people who have fought off the illness end up with some level of immunity. Keep in mind that any severe headache-fever-stiff neck combination always needs to be evaluated right away. If West Nile virus is suspected there are blood tests that can help with the diagnosis. Since there is no vaccination at this point, and no treatment, the key is prevention. Of course right now with Covid circulating, any fever is something that we pay attention to, but if there have been recent mosquito bites, make sure you report those as part of the relevant history. Prevention is the key when it comes to dealing with mosquitoes. Make sure that you have intact screens on all windows. If you are getting bites, check for holes or cracks where the insects might be getting in. Get rid of any standing water that is around your house; do a double check to make sure there are no pots, bird baths...etc. that are places where mosquitoes can breed. The larvae are dependent on water for breeding. Unfortunately just dumping out the water might not be good enough because it won’t dislodge the larvae that might be attached to the side. You really need to give a good scrub. Check out Mosquito bits and mosquito dunks. You can add these to any water features to keep the mosquitoes from breeding. There tends to be increased mosquito activity during dusk and dawn so that is when most of the biting happens. This seems to be true for the mosquitoes who carry West Nile Virus, not as much for Zika. Try to wear (keep your child covered with) long pants/ long sleeves etc. Light colored clothing is recommended. If you are going into a heavy mosquito area use bug spray on exposed skin and clothing. Mosquito repellent works only on the surface to which it is applied directly. Experiments have shown that they will actually bite skin only four centimeters away from where the repellent is applied, so wristbands or just spraying clothing does not offer full protection. Some bug experts would rather that you avoid the traditional electric bug zappers. The violet light may be irresistible to some flying insects, (and that zap is such a satisfying noise), but mosquitoes are actually not attracted to the light. Some of the innocent and beneficial insects are the ones getting fried. Mosquitoes don’t like fans! The nasty insects are lightweight enough that a good breeze may make it hard for them to zoom in on their target. The Off! Clip on has some folks who swear by it. If you are looking for an alternative to the DEET, it might be worth giving it a try (perhaps it is the fan aspect that makes it work…) If you are seeing mosquitoes around your house, San Francisco's Environmental Health Department will send an inspector to investigate (415-252-3805.) They will check the area around your home (including sewers) to see if they can find any breeding areas. Alas, long sleeves alone aren’t going to do the trick if you are out in a buggy area. There are plenty of natural products on the market that claim to be repellents, ranging from Vitamin B to catnip. Most of these are generally safe, but unfortunately the scientific studies show that they are mostly ineffective. We have the luxury in the Bay Area of not having some of the more notorious mosquitoes, so the bites are mostly an aggravation rather than a health risk. If you are in San Francisco, it is not a big deal to give something a try to see how it works on your family members. However, If you are traveling to an area where there are more dangerous mosquitoes, I would stick with the strong stuff. No kidding around. The EPA has five registered insect repellents. DEET is likely the most well known option. It is the only product labeled safe for infants as young as 2 months old. It comes in different concentrations. The concentration of DEET in a product indicates how long the product will be effective. A higher concentration does not mean that the product will work better; It means that it will be effective for a longer period of time. Therefore, products containing lower concentrations of DEET may need to be reapplied, depending on the length of time a person is outdoors.  Oil of Lemon Eucalyptus is considered one of the least toxic options but interestingly, the age recommendation for it is for 3 years and older.(Natural lemon eucalyptus oil is not the same as Oil of Lemon Eucalyptus) Some people are sensitive to the smell of this, it is worth sniffing it before you buy it. Picaridin is odorless and is approved for children 6 months (recently lowered from 2 years) and older. Dr. Anne especially likes the Sawyer product. Avon Skin so Soft Bug Guard PLUS IR3535 Insect Repellent has been around for years but seems to be more commercially available than it used to be (also for over 6 months of age.) It comes in a highly rated product that combines Avon Skin So Soft and an SPF 30 sunscreen Bite Blocker is a botanical formula that claims to provide protection for up to 8 hours. The reviews mention a strong odor, but otherwise it gets a high rating. Before applying anything topical to the skin for the first time, do a little test patch on the skin to make sure there is no sensitivity before you widely spritz or wipe on any of these products. You will need to read the labels to see how often you need to reapply. Avoid contact with eyes and keep all of these safely away from kids. I would also be cautious about getting any insect repellents on the hands, especially if your child is young enough that those hands are going into the mouth a lot. If you are also using sunscreen, apply sunscreen first and insect repellent second. All of the EPA recommendations are considered safe, and they are clearly better than getting bitten, but at the same time, let’s use them wisely. The EPA has created the following tool to help you find the proper product for you needs EPA guide to finding the right repellent Some products are more effective than others for certain types of mosquitoes, so the product you choose might depend on where you are going and what you might be most at risk for. Trusting that someday we will be able to move around the globe again, it is always good to check in at prior to any travel. DEALING WITH A BITE If the prevention has failed the most important thing is to treat the itching. Scratching at a bite will make it worse. There is a product called a mosquito zapper that some folks find useful. Young kids might be startled from the noise, but others claim that it is great for minimizing the reaction if you use it quickly. Over the counter hydrocortisone cream probably works the best, but other topical treatments can include calamine lotion, or mixing up a paste of baking soda with a bit of water. A cold black tea bag compress can also be very soothing. Black tea contains tannins, which seem to help. Some kids can have enormous reactions. Eyes and ears can be remarkably swollen. Topical treatment won’t be enough for these. Give a dose of Zyrtec or Benadryl right away. Scroll to the bottom for dosing info. If the antihistamine doesn’t make a difference or if there is fever or severe discomfort, those kids need to be evaluated by a doctor. If your little one is getting bitten, check the bedroom carefully. Look at the mattress and all the corners of the room; bites could be from spiders, fleas or other culprits. Zyrtec Dosage Chart The dose of cetirizine depends on age: · 6 - 12 months of age: 2.5 mg given once daily (maximum dose 5 mg daily) · 12 - 24 months of age: 2.5 given once or twice daily (maximum dose 5 mg daily) · 2 - 6 years of age: 2.5 - 5 mg given once daily (maximum dose 5 mg daily) · Over 6 years of age: 5 - 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. Benadryl dosage will be the same volume as your Tylenol dose. The liquid says for children 4 and over; we still use it for our younger patients who need it. Benadryl makes most kids sleepy but can have the opposite effect. If you are interested, Here is some current info on some of the mosquito borne illnesses that have been in the headlines the most in the past year or so. West Nile Virus If you see any dead birds, give them a wide berth and report them to 1-877-968-2473 (WNV -BIRD) or online at That website also will give you the up to date numbers on how many West Nile virus cases there are in California, county by county. It is updated weekly. Zika Chikungunya Here are some bonus facts about mosquitoes: Both males and females make that awful whining noise, but only the females bite humans. Mosquitoes are especially attracted to people who drink beer. Mosquitoes love the smell of sweaty feet. Mosquitoes can sense CO2 from up to 75 feet away. Mosquitoes only fly as fast as 1-1½ miles per hour. Some blood types may be tastier than others. O seems to be the favorite, A the least. B lands somewhere in the middle. Mosquitoes love pregnant women (regardless of their blood type) possibly because they emit a little extra CO2.