- Head lice/ Sklice co-pay coupon
- Should you give tylenol before the shots? / vaccine reaction discussion
- Skin fold irritations
- HAND FOOT MOUTH (and butt) VIRUS
- Tips for giving medication
- Strep Throat
- The Poop series: Chapter #1 Baby poop
- Nurse Judy' Blog
- Anaphylaxis/Do you need an epipen?
- Pinworms (ugh)
Friday, October 30, 2020
Halloween 2020 style Sometimes circumstances demand flexibility. For folks who love to do a festive Halloween, this year you may need to be a bit more creative. https://sf.gov/celebrate-safer-halloween-during-pandemic I am going to tell a quick story. It is actually about July 4th, not Halloween, but bear with me. For those of you who live in San Francisco, you know that our 4th of July is a bit different. People all over the country are out in their shorts, sandals and tank tops watching fireworks. Invariably here in SF, we are huddled under blankets, drinking hot chocolate, sitting on a peak somewhere and looking carefully to see if we can see a glimmer of the fireworks through the fog. In the 35 years that I have lived here, I can recall only a handful when the weather was clear. In any event, when Lauren was 3 or so, I bundled her and some neighbors into my car and decided to drive to see if there was any place in the city clear enough to see the light show. The fog was so thick that it was getting hard to drive. Through the fog, there was a traffic light that just turned red. Three year old Lauren got excited “Is that a firework? It’s beautiful!” It was becoming apparent that it was NOT going to be clear enough to see anything, so we pulled to the side and watched several traffic light changes through the fog. The kids oohed and aahed every time they went from red to green. And then we returned home. If my kid can get excited about a traffic light, with the right attitude your kids can still have special memories of Halloween 2020. There is nothing about the quarantine to stop us from having fun with costumes. Think about having a zoom costume party with friends and family. At the very least have your own photo shoot. Maybe take all the photos and turn them into a book, or some mugs that you can bring out next year when Halloween rolls around again. The SF Chronicle is still doing their costume and decoration contest this year. Submit photos of your decorations and/ or costumes, by midnight tonight and maybe you will be published! Not having to deal with enormous bags of candy is not such a bad thing. Of course, your kids (and you too; who are we kidding?) can still have some candy. Make them work for it and perhaps do a treasure hunt around your house or yard. I heard of one family who is planning to trick or treat in their own house. The kids will knock on all of the doors inside the house and get to say “trick or treat”. The internet is full of amazingly creative ideas for spooky foods that you can concoct together. they don’t all need to be loaded with sugar! Here is one list, but there are tons of them out there. Covid is no reason that we also can't enjoy the fun activity of carving a pumpkin, but keep these safety tips in mind Be careful of sharp implements! Make sure that any carving is age appropriate. Younger kids can decorate them with paint instead of carving them. Pumpkin innards are slippery! Make sure you do a thorough clean up so that no one slips on slime and gets hurt. Since many of you are going to make the safe choice to stay in, perhaps cuddle together and watch a Halloween movie. The goal is not to have something so scary that your kids will end up with nightmares. Here is a good list of options. I am not in the habit of wishing time away, but 2020 might be an exception to that. I hope that someday years in the future, when you look back at photos of years that have passed, you look at pictures of your pandemic Halloween and you remember only sweet and special memories. Stay safe and make good choices!
Posted by Nurse Judy at 10:47 AM
Friday, October 23, 2020
Adjusting to the time shift I am quite certain that it will happen. Forty eight hours or so before the official directive to set our clocks back, I will glance at a clock somewhere in my house and do a double take, “What? It is only 9 o'clock? It feels so much later!” Sandy will laugh and we will know that he ‘got me yet again’. There are so many clocks to adjust in our houses these days between the clocks in the cars, microwaves, coffee makers, etc. Some adjust automatically, but for the others, in our family it is Sandy’s job to make the changes, and for all of the years that we have been together, it has been his habit to start the process several days ahead of time. Even though I should know better, invariably there will be the moment I look at a clock and get confused and caught off guard. Indeed, twice a year the powers that be have decided that we need to adjust our times either one hour backwards or forwards. Some people love it and others hate it, but unless the law changes, or you live in Hawaii or Arizona, it is something most of us need to deal with. In general, for most adults, other than a tiny bit of lag, a one hour time shift is a no big deal. However it is quite the thing when you have a baby who is already waking up at 6 am. If you don’t make a bit of effort in advance, the ‘Fall Back’ means the babies are now awake at 5am (shudder!) With a little bit of planning, the following tips should make it a bit easier for you. Before we tackle the time shift, let's review some sleep basics. There are many different approaches to helping your kids sleep well, but here are the cornerstones. Getting enough sleep is essential, not only for the health of your child, but for the sake of your own sanity. If your child has the ability to do some self soothing, everything will be easier on you. It is never too early to start paying attention to this. Even if they are only able to doze off without having a nipple in their mouth or by having you actively rocking them once a day, consider that a win. Create a routine and strong sleep association, such as a special song, massage or snuggle. Make the environment conducive to good sleep. People tend to sleep better in cool dark rooms. Babies are no exception. A perfect temp is somewhere around the 68 degree range. See what you can do to keep the room dark. Consider the use of a Hepa filter or white noise machine. Hopefully once your little one weighs more than 14 pounds, they are giving you a good stretch at night and are on somewhat of a regular schedule. This is not something I count on for babies who are younger than 4 or 5 months. For you newer parents, take a deep breath, you need to be patient for just a bit longer. Babies still need to be feeding at night for the first several months. This phase will pass. Even though the young ones don’t usually have a real schedule in place yet, and it is normal for them to be feeding during the night, self soothing, sleep associations and a good environment are still very important, trust me! If you start good habits early, you will tilt the odds in your favor for getting a good nights sleep sooner than later. Once your baby is routinely sleeping through the night, the sleep goal should be that they stay in bed roughly 11 hours after bedtime. If bedtime is 7:30pm, the ideal wake up time would be 6:30 am (I see some of you rolling your eyes at the concept of 6:30 am being considered ideal. Someday you will be able to sleep in again, just not right now.) The simplest way to adjust to the new time zone is to do it gradually. I would suggest starting a week or so earlier and every night, move the bedtime 10 minutes earlier. This fall, the official time to change the clocks is 2am, Sunday, November 1st, but most people (except Sandy) change the clocks on Saturday night. For toddlers and preschool kids, many parents end up purchasing a toddler clock or someway that the kids can see so they know when they are allowed out of bed in the morning. If they get up earlier, for the big kids, calmly walk them back to their room, but with the infants, you can do the check in and pat them. Pam from Sweet Dreams suggests not switching your clocks until you actually wake up on Sunday morning. I tend to agree with her, but I would add that being conscious of the “extra hour” can be a fun thing to do with your kids. For the grown ups, make sure you each get an hour of being off duty. Spend it doing something just for yourself, maybe a bubble bath, or some meditation or go for a run. It is your hour. Your partner gets one as well. For the kids, ask them how they would like to spend their hour. I want to make one more point about the early waking. When my sisters and I were young, my mom was the first one up. She loved the dawn. Sometimes it was because it was the only time she could claim quiet time before the rest of us woke up, but there was something about it that called to her. The reason that this lifestyle worked for her was because whenever she could, she also went to sleep early. Many of us get a second wind in the evenings and enjoy some adult time once the kids are in bed, but if you are routinely exhausted in the morning, it might be worth the effort to put your kids schedule on the back burner for the moment and take a look at your own. Sleep needs vary. How much do you tend to get? How much do you think you need? If you are running at a steady deficit, this is going to start taking a toll on every aspect of your life. Much of the time it is simply about making better choices. Yes, I am saying that perhaps you should stop binge watching whatever series you are following, or put down candy crush and get into bed! If you have trouble falling asleep, make sure your iron and vitamin D levels are within normal limits. When your kids have grown and you are retired, you can sleep in as late as you wish. The years with young kids in the house are fleeting. Most kids are early birds. See if you can train yourself to embrace this, or at least not look at it as torture. If life offered the option of going back in time, I wouldn’t rule out a 6 am encounter with my babies Enjoy your extra hour! I hope your kids behave. You are on your own with your pets......
Posted by Nurse Judy at 1:48 PM
Friday, October 16, 2020
Happy Birthday to Frida the Lamp As many of you know, Sandy and I spent 2 months last year wandering around Europe by train and by foot. Knowing what we now know, I am so grateful that we traveled while we could. We packed extremely sparingly. We each had one small rolling suitcase and shared one smalI backpack that we took turns wearing (meaning I had it 5% of the time and Sandy had it the other 95%) I found that packing cubes were essential (Sandy found them useless). My suitcase was like an intricate puzzle. Things just fit exactly. There wasn’t a spare micro inch for anything else. We didn’t do much shopping, because we simply couldn’t fit anything extra. I joked that every time I used a Q-Tip there was a tiny bit more room in my suitcase. Because we were doing so much walking, we were grateful that we were able to manage traveling so lightly. Typically we would simply have to manage our stuff from the train station to whatever lodging we had chosen. Finding lodging that was walking distance to the train station location was always a consideration when selecting our hotel, or AirBnB. It was amazing how much walking we did. We ended up taking a total of 3 cabs/ubers the entire 2 months! A bit over the midway point in our trip we were in the lovely city of Florence. Our daughter Lauren and her husband Adam had been in Italy several months earlier. She had a favor to ask. While they were there she had fallen in love with a lamp that she saw in a cute little store. It wasn’t cheap. She wavered for several days and couldn’t stop thinking about it. Adam strongly encouraged her to just buy it, and finally Lauren agreed. On their last day, they returned to the store and to their great dismay found that it was closed. How many of you have had the item that “got away”, you were in a store eyeing something, but decided for whatever reason not to buy it and the moment was lost? For Sandy and me, it was a clock. If you live in the Bay Area, you might have seen it. Many years ago, a quirky store in Sausalito had several amazing clocks in their window. These were large clocks with gold wire mechanical figures climbing and moving about throughout. We were both enthralled. It wasn’t so much that they were expensive, but they were also big, and we weren’t even sure where we could put it. One day we were over in Sausalito and saw that the store was going out of business. The one clock left was on sale; should we finally get it? We gave ourselves a night to think about it. When we went back the next day it was gone. The store was shuttered. Of course now that we had lost our chance, we really wanted it even more. We did an internet search putting in all the keywords that might help us, but we never saw anything quite like it. We were out of luck. We still look for it! Whenever we pass an antique shop we pop in to see if ‘Our Clock” is there. So, when Lauren told us about the lamp, we understood. She insisted that she would want to reimburse us, but could we go by and purchase one of the lamps for her? She remembered exactly where the store was. We went to the store and immediately understood why she was charmed. It turns out that there were dozens of these wonderful lamps. They were figures holding umbrella lamp shades. Each one was wearing something different and was holding a different colored umbrella. They all had names. They were all unique. We connected with Lauren over WhatsApp, explained to the puzzled shop owners what we were doing, and wandered through the store showing her all of the options. It is easy to take for granted how easy it is to communicate these days. When I traveled as a teenager my poor mom had to wait weeks for the airmail letters to get through. Lauren ended up choosing the lamp named Frida. We started the process of buying it but when we got to the shipping option we were shocked to find that the shipping cost was almost as high as the cost of the lamp. We did some searching around to see what all the options were. The lamps were NOT available for purchase in the US and there was no way to ship it without paying exorbitant costs. We updated Lauren and she sighed and told us to never mind. Sandy and I thought about it overnight and both of us came to the same conclusion. We would get it and just carry it with us. The store did a magnificent job creating a little handle on the large box and we were on our way. Did I mention “large box’? The lamp was taller than my suitcase. So, as mommies and daddies will do for their kids, we schlepped this large lamp with us for the rest of our travels. If this lamp had her own passport, it would be an impressive one, When we were lucky, Frida got her own seat on the train. During our last night in Amsterdam, for some reason we were upgraded to a 4 bedroom suite (the benefit of traveling off season); Frida the lamp got her own room! On our flight home, she was too large to take on as a carryon, but we were amused that she was literally the first thing to appear on the baggage carousel. Friday now lives happily shedding some light on Lauren’s piano. It is hard to fathom that it was almost exactly a year ago that we got her. It feels like just moments have past, while at the same time it could be a century ago. Many of my posts and stories have a lesson to be gleaned. Hmmmm, not sure what the lesson from this one is. Maybe.. When you see something super special, if you can afford it, don’t let it get away. There are usually more regrets from passing it by, then buying it. OR A bit of short term schlepping is absolutely worth the long term pleasure. OR When we are all are able to travel once again, packing cubes are great! (except for Sandy, but I think more people agree with me!)
Posted by Nurse Judy at 9:26 AM
Friday, October 9, 2020
Teething symptoms and remedies: Dos and Don'ts Normal infants have 20 primary (baby) teeth which have started to develop in the womb. The teeth start to erupt through the gums around 6 months of age. The baby teeth are then shed at various times throughout childhood. At the end of this post, you will find a chart with the normal range of ages when most teeth start to come and go. Occasionally, I have a patient that doesn’t seem to like to follow rules, ignores the charts and does things their own way. I know of one baby who was born with teeth! Another started out with the upper canines and looked like a little vampire. As you can imagine, those parents were so happy when the rest of the teeth popped through. There is some heredity involved. If one of the parents was very early or late it is possible for the baby to follow suit. If you are lucky enough to have the option, check with grandma to see if she remembers anything special about your teething pattern! It is rare for teeth to actually make an appearance before 4 months. Once in a while parents will notice a smooth round white bud on a baby’s gum. This is a little benign cyst called an Epstein Pearl. It is not a tooth and it usually goes away without causing any bother. Many parents think of teething as something they are only dealing with for their young infants. Think again. If your 6 year old is going through an extremely grumpy phase, or has a mysterious bout of mild, clear congestion that has been hanging on for a few weeks, take a feel in the back of the mouth and see if those first permanent molars are starting to pop through. Once your child reached the age of 21, all 32 of the permanent teeth have usually erupted and they can no longer blame their grumpiness on teething. Just like the timing varies, the symptoms may also vary greatly from child to child and even from tooth to tooth. By far, the most common first teeth are the ones in the bottom middle (and they are so cute once they come through). Take your clean finger and run it along your baby’s gum. If the tooth is imminent you may feel that the area of the affected gum feels soft and boggy. Let's talk about the symptoms. Many healthcare providers and dentists dispute that there is any real relationship between teething and any of the symptoms below, but I have been an advice nurse for a long, long (long) time. I speak to parents of teething babies all of the time, and I maintain that I see a connection. Fussiness: Teething is uncomfortable. Most parents report that the babies seem fussier than usual right before a tooth pops through. Do what you can to relieve symptoms, but if your baby is inconsolable (screaming with NO break) for more than 30 minutes and there is nothing you can do to calm them down, please call to have them checked. That would be an extreme reaction and we want to see if there is something else going on. Drooling: Drooling starts weeks and weeks before you actually see a tooth pop through. Many kids will get a drool rash on their chins and cheeks. There are several products that I find quite useful for this. Clean off the area with Cetaphil cleanser (no water needed, apply with a cotton ball and wipe off). Follow it up with aquaphor or cerave ointment (which you can use multiple times throughout the day). Gnawing/biting: Biting on things will feel great to the baby; not so good to your nipples if you are nursing. If your baby starts biting you during feedings I recommend a loud “ouch!!” and immediately remove them from the breast. Most babies can be trained to stop this. Remember that you want to make the association mildly unpleasant so that they will stop the habit quickly. Biting = loud yell and loss of breast! If you are too gentle some babies will think it is quite amusing and will continue to bite at will. Poor Sleeping: If your little one is miserable, this is not the time for sleep training. I would go in quietly and try one of the teething remedies listed below. If you are going through a rough patch remember that parents should take shifts. Give yourselves each a few hours where you are off duty. There is no reason for both of you to be up all night. If you have the option, it is often best for the NON-breastfeeding parent to go in, unless it is time for a feeding. This is a slippery slope; I would try not to feed for comfort throughout the night. Bleeding/bruised gums: It is not unusual to have a little bit of bleeding on the gums. Once in a while you may also see a purple/bluish bruise on the gums right before a tooth breaks through. This will usually resolve without any intervention although something cold will feel soothing. Mildly elevated body temperature: Most dentists will remind you that teething does not cause an actual fever, but I commonly see it associated with an elevated temperature. If a fever goes higher than 100.5 I am not likely to blame it on teething. Any fever that is lasting more than three days is worth a call to the doctor's office to check in. Loose stools: You will likely get differing opinions on whether or not teething can be the cause of loose stools and again; I will state here that I see it all the time. Some folks speculate that swallowing all that saliva and drool might be the reason. Regardless, I do think there is a link. If you have a baby with loose stools, you want to go with the bland, starchy diet and make sure they are on probiotics. Breast milk is safe, but other milk-based products may aggravate the situation. Rashes: If your child has sensitive skin and/or eczema sometimes, you might notice that the general rashiness flares up during active teething. Congestion: Many young teething kids seem to have a clear runny nose and congestion. This can last for weeks and weeks. Sometimes it causes a post nasal drip that in turn causes a little hacking cough. Ear tugging: When kids are working on some of the upper teeth they tend to poke and play with their ears. Uh oh, many of these symptoms are the same thing we look out for if we suspect an ear infection. Even though teething may well be the cause, if I have a patient who is very fussy, feverish, and is having trouble sleeping, I am likely going to want to have someone take a peek in those ears. It is worth having an arsenal of tools at the ready for dealing with the months of teething that you have ahead of you. Chinese herbs: These are a great place to start. A very safe pediatric herbal tincture called Tender Teeth can be obtained at The Acupuncture Den, a family practice located in Noe Valley. Please contact Dr. Den to arrange a pick-up or mail delivery if you’re not in San Francisco. Beyond just the herbs, our local acupuncturist can offer relief with acupuncture and/or non-needle techniques. Many parents report babies taking a long and deep nap after a treatment! Cool teething rings: make sure they are made out of a safe material. Do not tie any teething rings around your baby's neck. Strangulation is a real risk! Frozen washcloth: Wet half of a washcloth and put it in the fridge or freezer. The baby will be able to hold the dry half and chomp happily on the frozen side. For an interesting twist, consider soaking the washcloth in chamomile tea before chilling it. Distraction: There is nothing as nice as a body massage and a warm bath by a calm singing parent. Homeopathic drops: The ones I am most familiar with are Camilia by the Boiron company. Click the Boiron link for a coupon. Orajel’s new formula is also safe. https://www.orajel.com/en/products/child-oral-care/orajel-non-medicated-cooling-gels-for-teething. The older formula which actually numbed the gums was recalled years ago due to safety issues. Make sure you read the labels carefully to make sure that it is Benzocaine free Feeding bags (baby safe feeder, or sassy teething feeder): If your baby has had some solid foods introduced, these feeding bags are great for teething relief. Add a cold hunk of fruit or veggie (pick a food that they have been introduced to already so that you don’t need to worry about any odd reactions) and let them gnaw away happily. With the mesh bag you don’t need to worry about them breaking off a piece that could be a choking hazard. You can find these bags online pretty easily. You can also fill one of the bags with a frozen ‘Milksicle'.Take 3 or 4 ounces of breastmilk, or formula, and combine it with some fruit, like banana, pear or mango. Puree until very smooth and stick it into an ice cube container. Pop out a frozen cube and add to the mesh feeding bag. Spa in your mouth - cool cucumbers of course! This is for kids who have proven themselves to be able to handle actual pieces of food, but for your toddlers who are cutting teeth, these might be a hit. Peel the cucumber, slice into circles, get rid of the seeds. Put the cucumber circles in a bowl in the fridge to keep cool. Teething Tube I actually just learned about these little gizmos from Pam of Sweetdreams infant care. She tells me that her grandson loves this, and it was very helpful getting him through the teething process Chew beads: I have had multiple parents tell me that these beads seemed to help but there is valid concern about these being a potential choking hazard. If Grandma feels strongly about using these, I have no objection as long as you have checked carefully for safety (nothing that can get loose) and are actively watching the baby while they chew on them. These should never be in a crib. I worry about strangulation with any necklace. Brandy/alcohol: Ask great grandma what she used to do for teething and she may tell you that she used to put whiskey or brandy on the baby’s gums. Obviously giving our babies alcohol is not something that most doctors would suggest today, but I actually wouldn’t worry if you caught grandma rubbing some directly on the gums. It probably does help. Some folks also say that rubbing pure vanilla extract on the gums is an effective home remedy. That may be from the alcohol content (I am referring to a tiny amount applied topically, no swigging booze!) Acetaminophen (Tylenol) and Advil (Ibuprofen) are useful but I prefer not to overuse them. Make sure you are using the proper dose. Start with the other approaches first. If possible, I would prefer to keep these as remedies for night time use only. Tylenol and Advil are quite safe but if they are used for a long period of time they can be stressful to the liver and kidneys. If you find that you have gone more than 5 nights where you are depending on these meds to keep your child comfortable, give your doctor's office a call to see if you need to make sure that nothing else is going on. DO NOT USE Any product that contains Benzocaine or Belladonna!! Once your child has teeth, it is especially important to keep bottles out of the crib. Milk has sugar and can cause tooth decay if a baby sleeps with a bottle in their mouth. It is never too early to start brushing the teeth. Let's get your baby in good dental habits. It is important to use a soft toothbrush and non abrasive toothpaste. The current recommendation is to use fluoride toothpaste; just a teeny bit the size of a grain of rice. Once they have a mouthful of teeth it makes sense to start shopping for a pediatric dentist that you can establish a relationship with. This will come in handy if you have any tooth questions or mouth injuries. Your next task is to figure out what the going rate for the tooth fairy is! I can’t help you there. Wishing you easy teething!
Posted by Nurse Judy at 9:55 AM
Friday, October 2, 2020
This week's topic Your Family Tree/ How far back can you trace? When Lauren was in 4th grade, her class was given an assignment. Pick a grandparent or great grandparent who immigrated to this country. Where did they come from? What was their story? Lauren ended up picking one of her great grandmothers, Mollie Kivowitz, but the project got me thinking. I was curious to trace all of the branches to highlight each of the ancestors who made the courageous journey to a new life in America. Sandy and the girls bought me a family tree program for Chanukah that year and I went to work. As part of my search I sent letters to relatives and talked to older aunts and uncles trying to get as much information as I could. I was very fortunate to find relatives from different branches who had already done a lot of family tree legwork and were willing to share. In the process I made wonderful connections with long lost relatives. Some branches are easier to find information on than others. For one thing, a name like Smith is going to be a lot tougher than one like Kivowitz. There are other factors. My paternal grandfather, Asher Isaacs, came from a family that had the distinction of being the only family in America at that time that could claim having 8 members (including my grandfather) who were members of the Phi Beta Kappa honor society. That branch was almost too easy, since there are actually multiple books written about them. Other branches take quite a bit more digging and the information is going to be based on a combination of stories that were passed down along with census searches. It is easier than it used to be. A lot of this stuff is online. Here is an assignment to all of you. If you are blessed enough to have people to ask, capture this information while you can. See what you can find out! On my mom’s side I have a second cousin who is a popular comedian/late night talk show host. Mom would tell stories about sitting on the porch with her first cousin and doing the routine catching up on kids. “Lauren got the starring role in her high school play” "Seth is hosting the Whitehouse Correspondents' Dinner" Um. My father's side is peppered with people that were known to have the 'second sight' and includes his first cousin Dr. Brian Weiss, MD, an author who has written extensively about past life regression therapy ( brianweiss.com/ ) (No, I don’t have a familiar relationship with either of my famous relatives.) Simply writing the names down in a family tree program doesn’t necessarily bring their stories to life. During my search, I was able to capture a lot, but so much has been lost to time. I am grateful for whatever stories have been captured and sad at all of those that are beyond my reach. After my mom died, when we were at the family house sorting through old letters, I came across a pile of correspondence between my mom’s parents. These were love letters, filled with personality and pet names; sweet and funny treasures, but they left me thinking. I wonder how Flora and Asher met? How is it that I didn’t know that story? The loss of my mom pierced through me with the realization that there was no one left to ask. Some little piece of my brain nudged me to do an internet search. Amazing, there it was! Back in 1987, the Pittsburgh chapter of the National Council of Jewish Women did an oral history project. My grandmother was interviewed! She was 86 at the time. There are 4 sections of the interview, each 30 minutes, that are online. In the first section she gives me the answer I was seeking. She tells the story of how she met my grandfather! I felt like the universe had given me a gift. I just listened to these again this week as I was getting my daily steps. The first sounds of her voice still get me choked up, but then I get swept up in her stories. Make this effort for your children and their legacy. How far can you go back? Some families can’t trace back too far, others can go back many generations. Celebrate the remarkable mix of cultures and DNA that have combined to create you and any offspring that you might have. Don’t be afraid of the moonshiners or the proverbial black sheep that are on your tree. They all led to this moment in time. Time passes and opportunities are fleeting. Talk to your older relatives! They will likely love telling you their tales!
Posted by Nurse Judy at 10:55 AM