Basic Butt Care/Diaper Rash

Basic Butt Care/Diaper Rash

There is nothing quite as cute as a baby’s little butt and nothing quite as sad as when that cute little tush is covered with a rash. With any rash, it is worth playing detective to see if there is an obvious source. A new diaper brand, a diaper that is too tight, a new soap or detergent can all be culprits. Believe it or not, once your little one is old enough to be eating solids, acidic foods such as citrus and/or berries seem to be connected with diaper rash flare ups.  But the fact is, most diaper irritations are simply caused by your baby's delicate skin being in contact with irritating stool and urine. Even with the most careful parents, rashes happen. It is much easier to prevent a rash than to treat it, so it is worth some effort to avoid rashes in the first place. The basics of prevention include: Change the diaper frequently. Use alcohol free wipes that don’t have added scents. https://www.babylist.com/hello-baby/best-baby-wipes After the wiping, I like to blot the damp skin with a tissue, this helps make sure that the area is completely dry. That simple tissue can also find leftover pieces of poop that were hiding in the creases. You would be amazed what is lurking in all the little crevices. You will see that the tissue will actually stick to the skin when it is still tacky from being wiped. Keep gently tapping the tissue until it no longer sticks. Some people use a warm hair dryer to get the skin dry. Both methods work well. Having some ‘diaper off time’ and letting the tush get some air is key. Give your little one some time with no diaper for several sessions a day. Babies are less likely to fuss for this if they are kept warm, so try to have a cozy place for this to happen. Lauren and Adam actually blew some warm air from the hair dryer on baby Elliot the other day during some ‘air time’ and he seemed to love it. The combination of the noise and the warm air kept him pretty happy. A short session of indirect sunshine through a window is also beneficial if you have the opportunity. Of course your little one is going to take this opportunity to pee and poop all over the place. Using the blue absorbent pads (you can actually get them from a pet store) or a towel can help contain any mess. Have a washcloth or a pee-pee teepee handy. Don’t underestimate the ability of poop to squirt impressive distances. Boys of course are the most likely sprayers, but don’t count out your little daughters in their ability to make a mess. Another good preventive measure is to add a splash of apple cider vinegar to the bath water. I don't have an exact amount because tubs vary greatly, but somewhere around a ¼ cup for a normal tub full of water. Keep your baby well hydrated; concentrated urine is more irritating. You may hear diaper creams also referred to as a barrier cream; this is simply because they are creating a barrier between the skin and the irritating pee or poop. Once your baby is giving you a longer stretch at night, I would suggest that it is now time to start automatically applying a barrier cream. For preventive care I don't have a favorite, there are lots of wonderful brands. The Environmental Working Group, EWG, is always a good source of information. They have rated some of their favorites. They do a deep dive into every ingredient and rank them accordingly: https://www.ewg.org/skindeep/browse/category/diaper_cream/?sort=score#! Dr. Den’s  favorite is one called Emily Diaper Soother. If you are local, you can get it directly from her. My daughter Lauren really likes Tubby Todd. It is a bit pricey, but it works really well for Elliot If you already are dealing with a rash and the cream that you are using isn’t doing the trick, here are some options that I especially like: Bag Balm is a standout, with a good rating from EWG. Originally used by farmers to soothe cows irritated udders, I have seen it clear up some stubborn rashes with remarkable success. Another favorite of mine that is not quite as highly rated by EWG, but is still fine to use is Calmoseptine. This is a cream originally used for ostomy care. I have found it very effective for some of the more raw skin situations. You can also make your own concoction by mixing together an assortment of ingredients. I learned about this from an old baby nurse that I worked with in a NICU back in NY. This is especially helpful for rashes that appear to be associated with food sensitivity or teething. Take a clean container and add equal parts: Thick white paste of your choice (Desitin/ Zinc/ butt paste) Clear stuff of your choice (Aquaphor/ A%D ointment/ shea butter) A squirt of a liquid antacid such as Maalox or Mylanta You may have heard of a prescription cream called APNO (all purpose nipple cream.) This is a combo of antifungal/ antibiotic and a steroid cream. When I was working at Noe Valley Pediatrics we would have our local Walgreen’s compound this for the most severe rashes. A rash that is severe enough to require this, also likely needs an appointment to evaluate it first. Beyond the common diaper dermatitis, there are some other potential causes. Once in a while a rash can be caused by yeast. Yeast thrives in warm, dark moist areas. It is no surprise that a diaper area (and nursing bra) is the perfect breeding ground.  Yeasty rashes can look very spotty or very red with distinct borders. They also like the creases and can spread outside of the diaper area. The prevention and treatment are similar to the ways we would treat a standard diaper rash. The air and apple cider vinegar are even more important but usually not quite enough to get rid of it. For suspected yeast I am going to add an antifungal cream to the mix. Over the counter creams such as Lotrimin (used to treat athlete’s foot and jock itch) is fine. There is not a baby version.  After the air time, add a thin layer of the antifungal cream and follow with whatever protective cream you prefer. Do this three times a day. It takes a week or so to get rid of it completely, but you should start to see a difference within a day or so if you are on the right track. Some rashes get so raw that the poor little bottoms bleed. I would put a thin layer of Neosporin on any open, sore areas, also three times a day (sometimes it feels like a little paint by numbers kit...a little of this here, and a little of that there.) If there is absolutely no improvement after a couple of days, it is worth having an evaluation. Your doctor will most likely always want to see any diaper rash that is pimply or oozy. Some very red diaper rashes are caused by bacteria. Strep is the biggest culprit for this. One more thing to consider. Evivo is a probiotic that is given to the baby. They have some impressive clinical data that shows that Evivo reduces bad gut bacteria by 80% and restores the baby’s natural fecal PH. 72% of mom’s using it report a decrease in diaper rash. Okay, get that tushy out for some air ( sorry about your carpet!) If you need some more diaper changing tips. Check out this previous post. Diaper changing tips post The photo on top is courtesy of Jake and Shachar's baby Noam's epic poop episode that actually got the walls and the lamp. Don't say you haven't been warned.

No matter how much help you have, no matter how perfect your baby is, being a new parent is HARD!

No matter how much help you have, no matter how perfect your baby is, being a new parent is HARD!

 Little black bug, little black bug where have you been? I’ve been under the rug, said the little black bug… Lauren and I were sitting together as she nursed her newborn. My first grandchild.

 She was telling me that she had been singing the songs that my mom used to sing to her and that it made her cry. As she told me that, tears were welling up in her eyes. So, I also got weepy and we sat there letting the feelings in and crying together about the people that we were missing. 

 Lauren is a lucky mom. She has a wonderful supportive husband who takes initiative and doesn’t wait to be asked. She has two sets of grandparents, and other close family who are in her COVID bubble and have been all hands on deck. Everyone is happy to hold the baby and give her and Adam a break whenever they need it. 

She has more support than most, especially during COVID. What’s remarkable is that, even with all these resources... IT IS STILL HARD! 

 She has the “Nurse Judy Network”, where her baby has been treated like royalty and guess what? IT IS STILL HARD! 

 She has plenty of milk and her baby got back to birth weight the first week. IT IS STILL HARD

 Nursing is challenging. It is not intuitive. Getting the baby to latch works well one moment, but is tricky the next. 

 Not being able to sleep longer than a 3 hour stretch is exhausting. Hormones are a force to be reckoned with.

 All new parents need support. That is where Oath comes in https://www.oathcare.com/

 I can’t sit by you in your nursery, but I can be right there when you have a question about spit up, poop, purple feet, hiccups ... you get the idea. 

 The Oath community is a place where small, facilitated groups of parents can share their wisdom as well as the ups and downs of parenting. 

It is a place to cheer each other on as well as a safe place to be messy and vulnerable when things are feeling a bit overwhelming. 

 Beyond the collective wisdom and experience of your fellow parents, we have a team of providers to assist you. Starting when you are pregnant, there is an OB, a nurse midwife, doula, pelvic floor specialist, traditional Chinese Medicine practitioner, and a mental health therapist available to you.

 Once the baby is born, our Oath parents can tap into a provider network that includes a pediatrician, lactation specialist, sleep expert, physical therapist and speech therapist. 

We are continually adding to our panel of experts. Oh, yes...then there is me, the advice nurse, helping you figure out when to worry and when things are perfectly normal. 

 We furnish you on the way with stage appropriate educational content that is empathetic, data based, and draws from decades of experience caring for kids just like yours.. Your pediatrician is sure to be grateful that your source of information is a trusted one, as opposed to the minefield of disinformation that you may find when searching the internet for answers. 

 If you are pregnant or know of someone who is expecting, I think you will find joining Oath incredibly valuable. This also makes a great baby shower gift! If you already have young children (our current groups are for 3 years and younger) please click the link to join the waitlist, so that we can match you with the perfect group. A value of $500, the Oath membership is only $19.50/month. Such a deal. Enter the promo code NURSEJUDY for a free month I would love to see you in one of the Oath circles.

Car seat guide 2021

Car Seat Guide 2021 

 Make sure you little ones are strapped in properly! It is important to check the fit as they grow! 

 The Rules

 Car seats are an essential part of keeping your child safe. Countless children’s lives are saved annually by being properly installed in a car seat during a crash. Governor Jerry Brown signed a law that went into effect on January 1st, 2017. 

This law requires children be rear facing to a minimum of 2 years old: https://csftl.org/updated-car-seat-law-california/ 

 Even though the law is until they are 2, it is recommended that they remain rear facing until as close to age 4 as possible! 

More and more studies are showing that rear facing is the safest place and position in the car. In fact, it is 5 times safer than forward facing. 

 In the case of an accident, a child's head and spine are better protected if the car seat is rear facing. 

One study shows that children ages two and under are 75 percent less likely to die or be severely injured in a collision if they face the back. 

I know kids might appear to be squished but most children are actually quite comfortable sitting criss-cross, or with their legs up the seat. 

For those parents/caregivers who are concerned about leg room, Graco has released the Extend2Fit, a new seat which has a 4-position extension panel that provides 5" of additional leg room. 

 Children who are 40 pounds or 40 inches are exempt from the law and can face forward, but while they may be exempt from the law, they are not exempt from the laws of physics.

 Rear facing is safer. Please take a moment to click the link 

Here is another one.

This video is a good illustration about why rear facing is so important: 

 Rear facing versus forward facing Toddlers who have outgrown the rear facing weight or height limit for their car seat should use a forward facing car seat with a harness for as long as possible, up to the highest weight or height allowed by the car seat manufacturer. 

 The current California law also requires a car seat or booster seat until your child is 8 years or 4 feet 9 inches tall.

 Height parameters make more sense than the previous weight ones. 

For a child to safely transition into a booster, we look beyond the child's age/height/weight. There's another set of criteria to help determine if your child is ready to transition to a booster. 

There is a "4 Step Test", in which all criteria should be met; don’t dismiss the importance of Step 4! 

 1. Child is an absolute minimum of 40 pounds 

 2. Minimum of 4 yrs old 

 3. There is a lap & shoulder belt in child's seating position 

 4. The Child can be trusted to sit properly for the entire trip, every trip - even while asleep. 

This means no slouching (back straight up against seat), no leaning to either side, no playing with the belt, etc...even unsupervised. Developmentally, most children don't meet all of these steps until somewhere between 5-7 years old, and generally closer to 6 or 7 than 5. 

A lot of this has to do not only with physical maturity, but emotional maturity. 

 This is one of those times in your parenting life where your child NOT graduating is actually a good thing. The longer your child is harnessed, the safer and more protected they'll be. 

Your child needs to be tall enough so that the seat belt goes across the chest, not across the neck. The purpose of a booster is to properly position a child in the adult-intended seat belt. 

What you’re looking for is a proper belt fit across the lap and shoulders - the belt should be low and tight on the hip bones (not on the belly), and should be hitting the shoulder bone, not the child’s neck.

 Be aware that most newer car and car seat models use the LATCH system (Lower Anchors and Tethers for Children). 

The Latch system attaches the car seat to the vehicle through anchor points that are installed in the car and connectors on the car seat. 

This is supposed to make the installation easier as well as eliminating potential errors that can result from installing a car seat with a seat belt. 

The LATCH system has a 65 pound weight limit. 

What many parents are surprised to find out is that this limit includes the weight of your child as well as the weight of the car seat (some can weigh up to 25 pounds!) 

 When children are old enough and large enough to use the vehicle seat belt alone, they should always use Lap and Shoulder seat belts for optimal protection. 

To determine if your child is ready to sit unassisted, they must pass the 5-Step test: The 5-Step Test: Does the child sit all the way back against the auto seat? 

Do the child's knees bend comfortably at the edge of the auto seat? 

Does the belt cross the shoulder between the neck and arm? 

Is the lap belt as low as possible, touching the thighs? 

Can the child stay seated like this for the whole trip? 

 If you’ve answered NO to any of the above, your child should remain safely in a booster seat! 

 If your children complain about this rule, show them photos of race car drivers all bucked up in their restraint system. 

Be matter of fact about it and explain that there is no compromise for safety (there is also a mighty large fine if you are caught breaking this law.) 

 All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection. Airbags can actually be quite dangerous to a child so it is worth making sure that this isn't an issue with your car and the placement of your child's safety seat. 

 Picking the right car seat

 If you are looking to buy a new car seat, check out these helpful links:

 https://carseatblog.com/safest-recommended-car-seats/ 

https://www.babylist.com/hello-baby/best-convertible-car-seats 

If you are someone who doesn’t own a car and is popping the car seat in and out of car services, finding one of the cars that is easier to install in becomes even more important. 

 Making sure it is installed correctly! The AAA states that 75% of car seats are installed or used improperly. 

As your child grows, there are services offered here in the San Francisco Bay Area that will check out your car seat or booster seat and make sure it is properly installed. 

Have the infant car seat checked before the baby is born and then again with each transition to a larger seat. 

 Below are some local resources for making sure that not only is your car seat properly installed but that it is the right fit for your child's size and age. 

They can make sure that all the straps are where they need to be and that you pass the "pinch test", making sure that the seat's harness is tight enough. 

 To be super safe, consider having the car seat fit and installation checked every 6 months. 

The reality is unless you are a certified child passenger safety technician, you’re not aware of some of the nuances of different kinds of seat belt systems, or the different features on different car seats. 

 When you go to get help with your car seat make sure you go to a certified car seat technician. Then you will know you are getting the best information available.

 I have updated this information to reflect the changes during the pandemic. If you are reading this and we are fortunate enough to be in the clear, call the numbers below for current guidelines and info

 AAA https://calstate.aaa.com/automotive/car-seat-inspections 

Appointments need to be made ahead of time. You do not need to be a AAA member to take advantage of this free service. 

During COVID, they are offering virtual appointments only 

 CHP (California Highway Patrol) 415-557-1094 

This is very popular, and by appointment only. Please make an appointment as far in advance as possible. 

The inspections are done at 455 8th Street in San Francisco. They are NOT doing inspections during COVID 

 SFPD 415-575-6363 They try to have an officer at all of the local police stations who is trained to do the car seat safety inspections. Call the number above for more info.

 They are NOT currently offering inspections during covid 

 Willing to pay to have someone come to you? 

 http://www.buckledbaby.com/services/ Bryan is continuing to offer his services during the pandemic.

 ON-LINE RESOURCES 

The following links can you assist you in finding the right car seat: 

 The National Highway Traffic Safety Administration website has a place to click to find updated local car seat inspection stations for those of you who are not in the Bay Area. 

 NHTSA/Get Your Car Seat Inspected has a page where you can plug in your child's age and size and they will tell you what type of seat they should be in. 

 Car Seats for the Littles - Car Seats for the Littles gives lots of great info about the specific brands of car seats on the market https://csftl.org/ 

 The Car Seat Lady The Car Seat Lady video

 Other considerations 

 Car safety doesn't end with being safely buckled. I know it is hard to avoid distraction with a baby fussing in the back seat. 

Consider getting one of the specially made mirrors so that you can keep an eye on your rear facing baby. 

Make certain that they can't reach anything that is a choking hazard. Don't let them hold the keys; they can lock you out!! 

 If your child is asleep in the car seat and you have arrived at your destination, leaving them snooze for a few minutes is fine as long as they are supervised, but keep them tightly buckled. Having a baby in a car seat without being tightly strapped in not safe. The loose straps can be a safety hazard. 

 WINTER CAR SEAT TIP: The straps need to be tight up against your baby; puffy coats or blankets need to be OVER the straps! 

 Never leave your child unattended in a vehicle. Children can die from prolonged exposure to excessive temperatures in a hot car. 

 Most accidents happen within a few miles of your house. Even a short trip down the block requires the full "buckle up". 

Hey parents, model good behavior and always make sure you fasten your own seat-belt! 

 Did you know that car seats expire? Most of them have a 6-9 year life span. This date can usually be found underneath or behind the seat. 

Buckles and straps can wear out. Prolonged exposure to sunshine can weaken the plastic. Also, the technology is always changing and this ensures that nothing gets too out of date.

 Save the instructions/registration in a safe place. I know most of us never register the products we buy but make sure you register your car seat! If there is ever a recall, this will ensure that you are notified, and this is one of those products where you must know if there is an issue! 

 Let me close by confessing that I am NOT a car seat expert. The seats that my children grew up with were much simpler (but not nearly as safe!) When I see new parents struggling with all the straps and trying to figure things out, I am often as clueless as they are. Here is the takeaway message. Putting your baby or older child in a car seat is an essential skill that you need to learn in order to travel with them safely. Find an expert to help you master this and make sure that you are using the car seat restraint properly. Safe travels!

I am a grandma

I am a grandma!

 I was all set to update my car seat guide this week. I planned to check in on the local resources to see what is available for people who want to get the car seats inspected during COVID. 

Making sure that the seats are installed properly is important. I didn’t get to all of the calls, but I have a very good excuse. Instead I will tell a story that involves a car seat. 

 I am a grandma! Lauren was due on January 18th, but in the early hours of Monday morning her water broke. Coincidentally, she had an appointment already scheduled with her OB later that morning. They confirmed that her water had broken, she was sent home for the day with orders to return to the hospital that evening. 

 Another lucky coincidence was that afternoon her doula was already scheduled to do a home visit. I went over and watched Jen help Lauren and Adam get prepped for labor. 

Sadly with Covid, the doula support would be virtual. Even though the due date was two weeks off, Lauren and Adam had been all ready to go. The nursery was ready, the go bag was packed, they had a cooler with meals and snacks all set. The only thing missing was causing some stress. The car seat had been ordered more than a month earlier but was on backorder. 

Without a car seat, a baby won’t be allowed to leave the hospital. We were figuring out a plan B of either buying or borrowing, but just in the nick of time, ding dong, UPS was at the door with the car seat. 

Fortunately, Jen the doula used to be certified to install car seats, and she was still at the house. Timing and serendipity, my grandson is part of my family for sure. 

 Labor was the hardest thing Lauren had ever done (take that Kilimanjaro and Everest Base Camp!) Not being with her was one of the hardest things I have ever done. But, Now I am a grandma of a beautiful 6 pound 8 ounce grandson. 

Mother and baby are doing well. This boy will be welcomed into a village of family and friends with so much love. He couldn’t have picked better parents, that’s for sure. 

Next week I will make those calls and update the car seat information for you. As I call, I fully intend to have a baby snuggled in my arms.

Give your kids the gift of music

Both of my parents were amateur musicians and I grew up surrounded by music. 

My mom had played piano all of her life, but when she met my dad she learned the cello so that they could play together. 

They were members of the International Chamber Music Society, so visiting musicians from all over the world would connect and play together when they were in town. 

At the time, I completely took it for granted. String quartets in my living room were routine. 

The first time my poor husband Sandy crossed the threshold of my childhood home at the age of 18, my father placed a violin in his hands to see if he knew how to hold one properly. 

My mom promptly rescued him, “Robert, leave him alone!” 

 It was expected that my sisters and I would learn to read music at the same time that we learned to read letters. 

I have such powerful and positive memories of playing violin and piano duets with my dad. Those are the ones closest to my heart. 

I of course also have memories of grumbling about being nagged to practice and being less than polite when dad would appear the moment I sat at the piano to turn on the metronome. 

 It seems to me that most adults who took music lessons as a kid, even if they were in the group that complained about them, are grateful for that opportunity when they look back. 

At the same time, most adults who did not have music as part of their childhood, wish that they had. It is not hard to find the takeaway here. Give your kids the opportunity to learn an instrument. 

When they are all grown up, they won't regret it. 

 I didn’t even consider that there were any other options. In my opinion, music should be a basic part of everyday life! 

My kids started piano lessons at an early age. I played piano duets with both of the girls, as I did with my mom, and she did with hers. 

Part of their nightly bedtime routine was daddy on the guitar making sure that both of his girls were well versed in all things Beatles and rock 'n roll. 

 My mom always encouraged the family to learn to play an instrument that could be part of an ensemble. She thought that being part of the collective sound was the stuff that magic was made of. We were therefore delighted when our daughters' school started a music program. 

In 5th grade, each child was given a choice between several instruments. The choices varied a bit from year to year. When it was Lauren’s turn, she chose the flute. When Alana was in 5th grade, she was excited that one of the choices was the saxophone. 

This was Lisa Simpson's instrument and therefor Alana's first choice.

 At some point during the year there was a performance where they could show off what they had been learning.

 Although there would be many future opportunities to watch Lauren up on a stage, I don’t actually remember her 5th grade concert. Alana’s, however, lives on in my memory banks; indeed, in the memory banks of all who attended! 

 First came the flutes...toot toot toot. We all politely applauded. 

Next came the guitars, strum strum strum...more applause. 

Now it was time for the group who had chosen the saxophone. 

 To be fair, Alana had come a long way and to my ear, had a fairly nice tone. 

It was no longer torture listening to her practice, but adding in 10 extra novice players who all were playing in their own distinct key is something that is hard to quite capture. 

 That first blast of sound that came charging out into the audience is something I will never forget. It was a palpable energy. If you were watching an animated cartoon, you would have been able to see it leave the stage. 

Words can’t really capture it. No two saxophones had the same sound coming from them. 

The audience took a collective deep breath and I believe we all had just one goal. Don’t laugh! 

These were our earnest children up there doing their best, but oh heavens, the shoulders were shaking. Most of us were managing to hold ourselves together, until one of the players made that feat even more difficult; a young boy named Max, with a round expressive face and a loud, infectious laugh. 

 After that first blast, Max, who clearly had heard what the rest of had, simply put his instrument down and started to laugh. 

The laugh very quickly turned into a full howl. While the others kept playing, Max just sat there on stage and guffawed for the rest of the performance! 

How the other students managed to keep playing at this point was somewhat astonishing. We were all near tears of repressed laughter until that last cacophonous note was finally silent. 

More than 20 years later, all who were there still have vivid memories of that evening! 

 So, yes, you might have to endure some recitals, but the benefits of having music in your life are enormous. 

I am not going to dive deeply into the studies, but they are bountiful. 

Music instruction appears to accelerate brain development in young children, particularly in the areas of the brain that are responsible for processing sound, language development, speech perception and reading skills.

 It isn’t just for kids. Older folks, including people with dementia are able to recall tunes long after they have forgotten so much else. (There is an amazing documentary about this, called Alive Inside.) 

 Singing to your kids can instantly ‘change the climate’. You don’t need to be able to carry a tune. I have seen many a temper tantrum thwarted with a song. 

 Break out of your comfort zone and expose yourself and the kids to as many genres of music as you can. 

When Alana was in high school, one of her Lowell teachers had the routine of playing a random piece of music as the students entered the classroom. These ranged from classical, classic rock, big band... Whoever could ‘name that tune’ would get a point. 

He was never able to stump Alana and as the semester went on, it became more and more of a personal challenge. 

He finally gave up when she was even able to identify a song from one of the more obscure Gilbert and Sullivan operettas. When she told me this story I felt absolutely victorious! 

 Of course I recommend that you try to go a step beyond singing and listening to music. Give your kids some hands on experience actually playing an instrument. It doesn’t need to break the bank. There are now inexpensive keyboard options as well as many apps for learning some basics.

 Making sure that music is part of your life is an excellent New Years resolution.