Managing the Tylenol and Motrin shortages/Winter 2022

 

Tylenol and Motrin shortages

My grandson Elliot isn’t feeling well. It turns out that he has croup. He flew with his family during the holidays and came down with a fever the day after they got home. Lauren asked me to pick up some children’s Motrin for him. I had seen the news stories about the shortage of children's pain and fever relievers, but I still wasn’t quite prepared for the impact that the empty shelves had on me. Fortunately, as a planner, I had snared a bottle of children's Motrin several weeks ago when I first heard about the shortage. We couldn't find any liquid, but had been able to get the chewable, but that was fine. He turns two next week, so he is old enough that this wasn't an issue. No one who knows me will be at all surprised that Elliot is familiar with chewables. He has been taking the Sambucol lozenges for quite a while. Having a child who is sick with a fever is stressful. I imagine that not being able to get medication is adding to anxiety. The lack of these medications is not dangerous! While I am quick to suggest the use of acetaminophen and Ibuprofen as needed, they are mostly about comfort. In fact, it is important to keep in mind that fevers are doing an important job. Fevers turn on the body immune system. They are one of our body's protective mechanisms   Many fevers can actually help the body fight infection.   Fevers that are associated with most viral syndromes and infections don't cause brain damage. Our normal brain's thermostat will not allow a fever to go over 105 or 106.   Only body temperatures higher than 108°F (42.2°C) can cause brain damage. Fevers only go this high with high environmental temperatures (e.g., confined to a closed car.) As Dr. Ted shares in the fever post, He doesn’t actually worry about a fever unless it is higher than 105. But we still would like to have the medication on hand. The big chains may be out, but some parents have success at small health food grocery stores or convenience stores. The ‘natural’ or generic brands are fine. If you aren't finding what you want, consider getting suppositories if those are available A Compounding pharmacy may be another option. Check in with your local one to see if they have access to what you need. Laws vary by state, but in California they can only ship to addresses here in CA. My favorite compounder Eddie Lau from Feel Good Pharmacy says: The taste is probably not the best as the commercial item uses many syrups, sweeteners, etc. to make it palatable. But generally speaking, this is exactly the situation where a compounder can step in to help address drug shortages of commercially available products. If your child is young and you can get your hands on the chewable version, you can try your own hand at compounding. Take the chewable, grind it up and sprinkle on applesauce or yogurt. When Elliot decided he was too tired to cooperate with the chewable last night, my son-in-law Adam ground it to a powder and added it to a little fizzy water with a bit of simple syrup. The fizzy ‘medicine soda’ was a big hit. Turning it into a little game got every drop down (dilute it in as small an amount as possible). For older kids, it might be worth seeing if you can get them to actually learn how to swallow pills. Start with a little piece of candy. A Tic Tac works well for this. See if they can swallow one either with water, or by putting it in a spoonful of yogurt or jelly. If they have success, you can then try with a small caplet of the appropriate dose of medicine Even if you are able to procure medication, that doesn’t necessarily need to be plan A. Here are some natural ways to reduce fevers. Tepid baths cool compresses - back of neck, forehead, inside of elbows Popsicles. Keep hydrated. Pedialyte is better than plain water, but sips are sips so any fluids can be considered a win. Dress lightly; don’t over bundle Dr. Den has some more excellent tips in this link: https://theacupunctureden.com/index.php/2020/10/09/fever-tips-from-den/ Preparation for future situations This supply shortage will likely pass before too long. If you got caught without some basics on hand, don’t beat yourself up. Just try to do some basic planning so that it doesn’t happen again. A fine New Year's Resolution is to stock up. Here is a post on stocking your medicine chest . And don’t hoard!

What's the deal with Santa? Having the 'talk' with your child

 

Talking to your kids about Santa

Let me preface this post by saying that I think it is essential to be honest with people in your lives. You don’t need to knock them over the head with the truth, but if they ask a question and press for an answer, please don’t lie. Over the years several parents have asked me to weigh in on the ‘Santa discussion.’ What is the best way to keep the magic alive while not endangering the trust that is so important in any relationship? Covid has added an extra layer to the conversation. Some kids are worried that he will either have issues with social distancing or have trouble taking the time to wash his hands in between the houses that he visits. For this general discussion about Santa, we can put him into the fine company of the Tooth Fairy and the Easter Bunny, but it is safe to say that Santa is usually the member of this trio that has the most emotional connection. For the young kids who ask if the mythical creature is real, you might deflect the questions fairly easily without telling a falsehood if you want to extend the magic for another year. A simple,“What do you think?” works pretty well. Or, “It is fun to believe in magic sometimes and Santa is part of the holiday magic.” Keep in mind that once your child gets to kindergarten, believing that Santa is actually going to try to fit down your chimney, rather than the ‘spirit of the holiday magic,' may result in a shocking disappointment for them when they learn the truth. There are lots of kids at school, even virtually, who are eager to share the cold hard facts with your innocent child. It is much better if this discussion comes from you before your kids find out a harder way. I spoke to several people who recounted that they believed in Santa with all of their hearts and were completely devastated when they learned the truth.They felt deceived. One person told me that finding the truth was the moment they stopped believing in all magic. How sad! Letting them know the truth gently doesn’t have to be a negative experience. For older kids, I love a good story. Perhaps this one has an element of historical truth: “Once upon a time in a far off country there was a man named Nicholas. He loved to do good things for other people. What was special about him is that when he gave people presents or did nice things, he didn’t do it because he wanted something in return. He simply wanted to do good things. Lots of times he did it in secret and no one even knew who did something nice for them. Maybe this Nicholas was big and jolly and had a white beard. He became known as Santa Claus. Santa is a symbol of love and magic and hope and happiness. He teaches children how to believe in something that they can’t see or touch. I am on his holiday kindness team and now you can be too. Really little children might believe that there is one Santa who manages to be everywhere at once. Big kids like you get to know the secret. Team Santa is all the big kids and grown ups who want to help make other people happy. “ Perhaps take the opportunity to help your child be an active member of this awesome team; an initiation of sorts. Is there someone in your life that seems like they need a little kindness? What could you do for them? Is there a little gift that might make a difference? Plotting a secret kindness is the thing that wonderful lasting holiday memories are made of. Every kid and family are unique. There are families that make the choice to protect the ‘Santa is real’ narrative as long as it is possible. Make whatever choices feel right for you, but if your child asks a direct question, my advice is to find a gentle way to be honest. One more piece of Santa advice. The photo on Santa's Lap should be voluntary. If your child isn't eager to go sit on a stranger's lap, please don't force them.

EAR INFECTIONS 2022

 

Ear Infections

The basic medical term for an ear infection is otitis. But ear infections come in different varieties and complexities. Although ear infections are a common occurrence, there is nothing simple about them. In 2015, the World Health Organization came up with a system to track every possible diagnosis. These are called ICD10 codes. To be clear, they erred on the side of leaving absolutely nothing out. There is a code for being bitten by a dolphin and another for getting sucked into a jet engine. I am not kidding. When it comes to ear infections, there are hundreds and hundreds of codes, Which ear? Is there fluid? Is it ruptured? Is it chronic or the first time? The list goes on and on. I am going to focus on the basics.   The most common types of ear infections are: Otitis media, which is a middle ear infection. Serous otitis, which is fluid behind the eardrum Otitis externa, which is also known as swimmer's ear   Kids are so much more vulnerable to ear infections than adults. This is because the middle ear is connected to the upper respiratory tract by a tiny channel known as the eustachian tube. Children’s eustachian tubes are smaller and more level than those of an adult. This means it is harder for them to drain well and easier to get blocked up even with mild swelling. Germs that are growing in the nose can climb up the eustachian tube and enter the middle ear. Because of these drainage issues, when kids are congested, they also may have fluid in their ear (serous otitis). This is why I am more suspicious about a possible ear infection in a child who has a cold. What may start out as a virus can turn into something bacterial. That fluid is the perfect medium for bacteria to grow. I compare it to a stagnant pond just waiting for the mosquitoes to breed.   Check out Dr. Ted’s video on TikTok to learn more about eustachian tubes.     Common symptoms and associated factors with ear infections:    Most of the time, an infection in the middle ear is associated with congestion, the flu, or other types of respiratory infections including RSV If they are still young and nonverbal, they often have extra fussiness, fever, or are tugging at their ear.  Many kids wake up more than usual at night.  Vomiting can be associated with ear infections.  Some kids complain bitterly when you lay them down but seem more comfortable when they are upright. Some kids seem like their balance is off.  Others seem like they are having trouble hearing. Of course we all know that all of our kids can seem deaf when we are telling them something they don’t care to hear!   Just because your child is tugging at their ear does not mean they have an infection. Some kids do it as a habit. My grandson Elliot holds onto his left ear whenever he is tired. Others do it when they are teething, especially upper teeth. Nevertheless, frequent pulling at the ear can be a clue that is worth paying attention to, especially if it accompanies any other symptoms.    I realized after the fact that I had ignored my daughter Lauren’s first ear infection for more than a week when she was fairly young. Looking back at videos you can see the poor kid simply grabbing at her ear constantly. This was back when I was working at UCSF with complicated surgical cases. Thoughts of an ear infection didn’t even cross my mind.   What makes it tricky? A good number of kids don’t show any symptoms at all. I have seen patients go in for a well child exam be caught by surprise when a routine ear check revealed a raging infection. I have also seen ear infections go from ‘zero to sixty’ in no time flat. No, your doctor didn’t miss it. A child with a perfectly normal ear exam one day can have a horrible ear infection the next. Some stoic kids don’t make a noise about a severe infection while others complain bitterly about a little fluid in the ear that is not actually infected.    Diagnosis To make an accurate diagnosis, for otitis media or serous otitis there is a lighted tool called an otoscope. Checking ears is a real skill that often takes practice to do well.   What makes it tricky? Factors like lots of ear wax, or an uncooperative patient can add a level of complexity to the exam. If a patient is screaming bloody murder from the simple exam, that can make the eardrum appear redder than normal. Not only is there not one standard treatment, but many times no treatment is even needed. If people blindly treated every complaint about an earache, antibiotics would end up being wildly over prescribed. This is an issue for various reasons. Not only does nobody want their kids taking medication unnecessarily, but antibiotic resistance is a potential problem for everyone. In some locations there are actual shortages right now (December 2022), so it is even more important that they are only prescribed for the people who actually need them.   Treating Otitis Media If your child is diagnosed with a middle ear infection, you may get a prescription for antibiotics.    If the eardrum is bulging and looks like it might rupture, the doctor will advise you that you should absolutely go ahead with the medication regardless of how your child is acting. Another reason to treat it is if your child is miserable and feverish.   On the other hand, if it is not a severe infection and your child seems consolable, some wise doctors agree that it is perfectly fine to watch and see for a few days.  Many ear infections can indeed clear up on their own and of course we all would like to avoid the use of antibiotics if we can.    A Note about ruptured eardrums: My main agenda, aside from making the kids more comfortable, is preventing an eardrum from rupturing. An eardrum that ruptures frequently can become scarred and this can lead to hearing loss. Something to keep in mind is that a miserable screaming child might actually seem more comfortable after the eardrum finally bursts.    They will also likely have lots of yellow/orange stuff draining out of the ear.  The good news is that the pain of the pressure in there is gone, but the tympanic membrane (an important protective barrier) is no longer intact.    Therefore, if your child does have a ruptured membrane, they need to be seen and treated even though they are no longer quite as fussy. After a rupture it is worthwhile getting the hearing tested to make sure there is no lingering hearing loss after the eardrum heals. This is even more important if it has happened more than once.   Antibiotics Most pharmacists will take a moment when you pick up the prescription to go over the directions. Don’t treat this opportunity the way most of us do when the flight attendants are telling us how to buckle a seat belt. Pay attention and please make sure you are clear with the dosing instructions.  Should it be taken with or without food? Does it need to be stored in the refrigerator? Do you need to be more cautious with sun exposure? Are there other medication interactions? Are the foods that should be avoided? What are common side effects? Are you clear about the dosage and timing?   Liquid antibiotics tend to be sticky and sweetened in order to make them more palatable. Please don’t forget to brush those teeth! In case you have a compliance issue, Here are some tips for giving the meds. Unfortunately even with the added sweetness, some are pretty nasty.   Make sure that you finish the medication as directed. Don’t stop as soon as they are feeling better. That behavior can lead to antibiotic resistance.   Antibiotics are not an instant magic wand. It may take the medication at least a couple of days before you notice a significant improvement. If your child is still super fussy or feverish after a full three days, have your doctor take another look in there to make sure the meds are working.    Some kids who are having a really difficult time may end up getting an antibiotic injection. These hurt a bit, but they are usually quite effective.   Chinese Medicine I asked local acupuncturist Dr. Den for her input on managing ear infections. She confirmed that Traditional Chinese Medicine (TCM) is a great and effective way to address ear pain and infections in your little ones. Acutherapy treatments (non-needle methods are available!) help the body to reduce inflammation and mucus, relieve pain and increase the necessary drainage. Early treatment is your best shot at avoiding antibiotics! Acutherapy treatments can also help prevent future infections, so they’re especially good for kids who tend to get an ear infection with every cold. There are also safe pediatric Chinese herbal tinctures available and easy to use. For kids prone to ear infections, Dr. Den recommends keeping them on hand, so you can start giving them to your child at the very first signs of ear discomfort or infection. Reach out to your local pediatric TCM practitioner for specific products or advice. If you’re in San Francisco, Dr. Den is happy to help! Dealing with Serous otitis Fluid in the ear can be really bothersome to some people and can absolutely have an impact on their hearing. Many doctors will suggest antihistamines and decongestants. The Chinese herbs can help with this as well. There is some anecdotal evidence that gentle chiropractic adjustments/craniosacral therapy can help with drainage. Thanks to my chiropractor Sandra Roddy Adams for sharing some articles. Kids with chronic serous otitis who get one infection after another will usually end up at the ENT doc who may put some tubes in the ear to help them drain.    Melissa Wilson, Doctor of Audiology at Sound Speech and Hearing, adds that tubes are also put in to address the hearing loss that often accompanies middle ear fluid. Fluid build-up often causes a hearing loss on the order of 30-40 decibels. Average speech is about 60 decibels, so having fluid is like listening with your fingers plugging up your ears. Everything your child hears is muffled and over time, this can impact their speech and language development, and for the school-aged children this can cause issues with listening in the classroom and academics.     Otitis externa (also known as swimmer’s ear) With otitis externa the outside of the ear is usually red and sore. The ears may be tender and will look inflamed. They may smell funky. These can be associated with time in water or pools but not always. This condition may be treated with ear drops rather than oral medications, depending on the severity. As opposed to the other forms of otitis, this one impacts plenty of adults as well   Comfort measures/symptomatic treatment With or without the use of antibiotics there are several things you can do to ease the discomfort of a painful ear.  Tylenol and/ or Ibuprofen are useful. Here is a dosage post .   Warmth usually feels good and can promote drainage. Some folks swear by a warm hair dryer held about a foot away from the ear.  Warm compresses are another option. Try a warm wet washcloth against the ear.  Little microwavable heat packs are great for this. If you don’t have one on hand you can make your own. Pour enough water into a clean diaper to get it nice and wet. Heat it up in a microwave for a quick heat pad that will stay warm for a while.  Dr. Den recommends putting some uncooked rice in a sock, and then tie the sock off (if it’s long enough), or close it with an elastic band. Unless it becomes soiled, the same sock can be reheated many times, making this an easy, no mess method. Warm it briefly in the microwave.  Whichever kind of heat pack you choose, warm it up in 30 second increments to make sure it doesn't get too hot. Always test the temperature carefully before placing it against your child’s ear. It should be a comfortable warm/slightly hot temperature.    Believe it or not, my favorite remedy is garlic oil. Check the ear to make sure there is no reason to suspect a rupture; I don’t like to add any home remedy drops if there is any suspicion that the eardrum may not be intact. If there is no odor or drainage (a little wax doesn’t count) garlic oil may be a good option.  Here’s how to do it: Saute some cloves of garlic in some olive oil. Let the oil cool until it is warm/not hot. Take a cosmetic square or cotton ball. Dip into the warm oil and stick it in the ear. Do this as often as your child will allow.    Dr. Den likes garlic mullein oil drops. These are soothing and will help fight the infection. (and you don’t need to fuss). Roll the bottle between your hands to warm it slightly, and then place 1 drop in the affected ear, up to three times per day.    If it is the middle of the night and your child is screaming, you can try any of these pain relief options until you have an opportunity to have your child checked. Persistent unrelenting misery may warrant a trip to the ER.   I feel a pang for stressed out, busy parents who would love to avoid dragging their sick kids out into this germy world for an in person office visit, but virtual care is usually not adequate for an ear check.  An important thing to note is that when kids have goopy eyes, many times they also have otitis, which is why a visit to your pediatrician may be needed in order to check out the eyes and the ears rather than just giving eye drops over the phone.     And because pediatrics is never boring: It is also not unusual for pediatricians to find a little surprise when the ears are checked. Back when I was working at the pediatricians office, we found an assortment of little treasures in there, including little beads, unpopped popcorn kernels, and even the occasional insect.

The Magic of a Great Big Box

 

The Magic of a Great Big Box

We are heading into the holiday season. Lots of people are busy making lists of what to buy for their friends and family. It’s time to think outside of the box. Or actually IN the box! For young kids, a great big box can be magical. If you have any large purchases that come in a box, pause before breaking it down and automatically putting it in the recycle bin. Any large box can be hours of entertainment, but a really giant box, like the one from an appliance, is a treasure. (If you spot any neighbors getting anything huge delivered, ask them if you can have the box.) These can be turned into a clubhouse or a rocket ship. The possibilities are limitless. There are great ideas all over the internet with just a little bit of searching. https://www.pinterest.com/ClassroomDirect/cardboard-box-ideas-for-kids/ But even a moderately big box can be a way to foster creativity and imagination. You can make it a unique art project. Do this in a garage or someplace where you are not afraid of mess. Cover it with stickers or painted hand prints. Cut out pictures from a magazine and glue them on. Cover it with a layer of mod podge which will seal it. Make sure everything is dry before moving back into your living space. I would avoid anything with glitter (my niece Rose calls glitter ‘the herpes of the art world’!) A mid sized box is just big enough to sit in there with grandma and pretend it’s a car. Take turns driving of course. Or add a blanket and a stuffed animal and make a sweet little nest. You could also flip it over and make it the perfect table for a pretend tea party. Or a hiding place for the toddler! Get the imaginations in gear.  “I am inviting the zebra queen. She has purple stripes and is wearing a giant hat that is covered in strawberries. Who are you going to invite?” Smaller boxes can be turned into instruments. Rubber bands wrapped around them can be plucked. Tapping on the box with a spoon can make it a drum. Is it a box with a lid? Those are great for storing little toys. Take a picture of the items that will live there, print it and stick it on along with any other fun decorations. The task of cleaning up after playing is much easier if it is clear where things belong. Have fun!

Pinworms/ updated treatment options

 

Itchy butt at night? Uh oh. It might be pinworms. This post will review What are they? How they spread? How to Diagnose Treatment options Clean up tips All things considered, in the big scheme of things there are a lot of worse things that can happen, but you are certainly entitled to give a big groan if this is happening to you or one of your family members. Who Gets Pinworms The Pinworm (Enterobius vermicularis if you want to impress folks the next time it comes up in conversation) is the most common worm infection in the USA. The target age range for the primary infection is children between the ages of 5 and 10. It is fairly uncommon under age 2. These preschool and school age kids are usually the culprits bringing it home, but it is really easy for the pinworms to spread among family members if you live in close quarters and spend any snuggle time in the same bed. Animals do NOT get pinworms, but they can carry them around on their fur and spread them that way. How Pinworms Spread The most common way for a person to get infected is by ingesting the eggs. They can also be inhaled through the nose. The eggs can live out of the body for up to 3 weeks, although they lose infectivity after 1 to 2 days in hot dry climates. These eggs are way too small to be seen by the naked eye, but can be seen under a microscope. If you happen to touch a surface that is contaminated and then put your fingers in your mouth or handle food...tag you're it. It takes between one and two months after the exposure for the symptoms to appear. The eggs mature into the worms.. They live in the intestine and gradually make their way down the GI tract until they are close to the anus. The actual worms are very small, white and threadlike. There is no microscope needed to see them. The male worms die fairly quickly, but the female worms make their way out of the body and lay the eggs on the anus. They tend to do this at night.  Why is that? One theory is that the body temperature is a little higher when you are sleeping and this drives them out. When they emerge from the body, this might cause some itching. It is common for some children with pinworms to wake at night. Children that are old enough to use their words may tell you that they are itchy or that their butt hurts. Little girls might have itchy vaginas or vaginal discharge. Some kids just have mysterious tummy aches. Not everyone will be aware of them. In fact, many people with pinworms have no symptoms Diagnosis In some cases you can actually see little wiggling thread-like worms in the poop. You can just imagine the calls I get when that happens. But more often than not, diagnosing this condition won’t be quite as simple as glancing into the toilet. Some folks recommend putting a piece of scotch tape across the anus and looking in the morning to see if there is anything stuck on it. I prefer the actual ‘look and see’ method. I suggest that a parent go check in the middle of the night. Make sure that your child goes to sleep with a very clean butt, perhaps after a good bath. Once they have been asleep for several hours, take a flashlight and spread the butt cheeks far enough that you can actually visualize the anus. Unless your kiddo is a remarkably sound sleeper, I would tell them ahead of time that you are planning on doing a butt inspection. With a little advanced warning, if they wake up with a flashlight shining at the tush, they are not going to be startled. Pinworms will look like little white threads. They will likely be moving. If your sleeping angel has slept through this far, and you do see wriggling worms, try not to shriek and wake them up. Treatment Once the diagnosis is made, many folks opt to treat, even though most cases are asymptomatic. The medications do not kill the eggs, just the worms, so they should be taken initially and then repeated in one to two weeks. There is an over the counter medication called Reese pinworm (generic pyrantel pamoate), which has a rebate, making it even more affordable. They also have some very handy wipes to deal with the itching. If over the counter fails, there is a prescription medication called albendazole (Albenza) which can also be quite pricey. This also only comes in a tablet so it is a bit challenging for younger kids. This one is still over $400 but at least gives the 2 dose course. Check with your insurance to see if it’s covered, and if it’s not you can get the price down to ~$40-$70 on GoodRX. Singlecare is another option for getting it cheaper. Because most people do not have symptoms but can still spread it, the entire family should be treated if you want to really get rid of pinworms as quickly as possible. None of the medications have been rigorously tested for pregnant, breastfeeding (it does transfer into the milk) or children under two. While there have been no adverse reactions reported, if you are dealing with an infant, I am going to give you the unwelcome suggestion to ‘check with your doctor’. Natural Remedies Natural remedies include eating a diet high in garlic and/or believe it or not, enjoying some pumpkin seeds. Worms love carbohydrates. Limiting sugar and white flour (which is a good idea anyway) may keep them from thriving. Probiotics, which stimulate the healthy bacteria in the gut will also make the environment one where they can't flourish as well.  Vaseline around the anus at night will make it harder for the eggs to be laid. If you like natural remedies, try crushing up garlic and making a paste with the Vaseline and putting that around the butt every night. The fact is that if there were absolutely no further ingesting of the eggs, pinworms could resolve untreated after about 14 weeks (two life cycles), but the problem is most folks just keep on ingesting the eggs which gets them reinfected, and so the cycle continues. Preventing Spread It is gross, I know, but the most common issue is fingers scratching an itchy butt and then making their way to the mouth.  This might be why diaper-age kids don’t get impacted as often. They simply don’t have ‘butt access’. We must do our best to eliminate the eggs and prevent the egg to mouth circuit. Scrub under the fingernails and make sure that they are cut short. Focus on frequent and effective good hand washing. Do a nightly bath with particular attention to the butt. Add some apple cider vinegar to the bath water. If you are worried about dry skin, just make sure you apply a good all over lotion after the bath. Clean up As mentioned earlier, the eggs can live on a surface outside of the body for up to 3 weeks. They survive longer in moist environments. High heat will kill them. They can be easily dispersed into the air. Pay attention to this when changing the sheets. Avoid shaking the sheets out into the air as much as possible. Wash all sheets, towels, pajamas and underwear in HOT water. You want to vacuum or mop, NOT sweep. Scrub the bathroom and any surfaces. Clean your toothbrushes. Putting them through the dishwasher works.  Remind yourself that there are worse things. But this is indeed the proverbial pain in the butt.

Thanksgiving 2022

 

Like my mother before me, I have always loved Thanksgiving.    For more than 30 years, several close families have joined with ours to create wonderful holiday traditions. Our typical celebration includes deep fried turkey, boozy cranberry sauce, my grandmother's award winning apple chocolate chip cake. After dinner, if we aren't in a food coma, we play games. Everyone insists that none of it counts if my husband Sandy doesn’t wear his special 'uglier than you can imagine' Thanksgiving pants.   Covid messed things up for a few years, but this year we are gathering again. Now the kids have significant others and babies in the mix.    One fond memory from one of our earliest gatherings comes to mind. My daughters were probably 6 and 3 years old. We were taking turns sharing what we were thankful for. This was long before something like this would simply bring on heavy eye rolling from Lauren, but at the age of six, she embraced this activity with a gusto.   She was thankful for rainbows and sparkles, family and love...she went on for several minutes with a fairly classic list of things that made a 6 year old girl feel happy. The other kids at the table followed her lead and the lists of things to be grateful for were getting longer and longer. Then it was 3 year old Alana’s turn.    “Lani, what are you thankful for?”   There was a moment's pause and the one word answer.   “Soda”   Not everyone is able to gather in person and I understand how hard it is to be away from friends and family during the holiday season. I also know how lucky I am. That beats soda any day.   In honor of Thanksgiving, I am reposting my food safety guidelines. There are some useful links in here that you might want to bookmark for later. Food contamination issues can happen all year round. This post will give you some safe guidelines for foods that you buy and cook. Check the bottom of the article for some great links on food storage guidelines; everything from egg safety and turkey leftovers to breastmilk storage.  If you do a lot of eating out, restaurants are supposed to have their cleanliness rating publicly displayed. It is certainly not a sterile world. As soon as they are able, your baby will start putting anything that they can reach into their mouths. You can't even begin to imagine the phone calls I have gotten about icky things that some of my little patients have managed to get their hands and mouths on. Chap-stick, particles from an exploded hot pack, kitty litter, the little packet in shoe boxes that says do not eat. You name it, they lick it. So yes, the world is full of germs, and while I don't generally get too concerned about a little dirt here or a big sloppy dog kiss there, foodborne bacteria can be nasty, and we need to minimize any exposure. There were more than 300,000 reports of children under the age of five being impacted by tainted food last year alone. Infants and young children are particularly vulnerable to foodborne illness because their immune systems are not developed enough to fight off infections. This is especially important for infants under 6 months of age. Extra care should be taken when handling and preparing their food and formula. Here are some basic food safety guidelines. Wash hands for at least 20 seconds before food preparation. Soap is best. Hand sanitizer will do. Re-wash as needed after handling food that might carry germs. The most common offenders are poultry, meat, and raw eggs. Make sure kitchen towels and sponges are changed and cleaned frequently. Sponges can go through the dishwasher. Cloth can get easily contaminated and then spread germs. Watch out for potholders or other cloth items that come into contact with raw food. Wash your reusable grocery bags especially after they are used for milk or chicken. Keep your refrigerator temperature at 40 degrees or colder. It is worth investing in an appliance thermometer so that you can keep track. All the science says that the 40 degree number is essential for keeping the bacteria from multiplying. Your freezer should be below 0 degrees. To ensure the safety of your frozen food, you need to be sure that it has been actually kept constantly frozen. One clever trick to make sure of this is to keep a baggie filled with ice cubes in the freezer. If they remain cubes, you are in good shape; if they melt and refreeze as a block of ice that means that at some point your freezer was not cold enough. This can happen in a power outage or even if the door wasn't kept tightly closed. I am sad to say that if there was stored breast milk in there that has thawed and refrozen, I would no longer consider it safe. Label things in your freezer and rotate so that you are using up older stuff first. Check the dates of baby food jars and make sure the lid pops when you open them. Don't put baby food back in the refrigerator if your child doesn't finish it and you used the "used" spoon to take the food directly from the jar. Your best bet - simply don't feed your baby directly from the jar. Instead, put a small serving of food on a clean dish. Add more as needed with a clean spoon. Remember that once saliva has come into contact with the food it is no longer sterile and some bacteria can grow quickly. Powdered formula is NOT sterile. Don't mix up more than you need in advance. If the infant is less than 4 months, I would mix it with boiling water and let it cool. Don't leave open containers of liquid or pureed baby food out at room temperature for more than two hours. Bacteria thrive in temperatures between 40-140 degrees Don't store opened baby food in the refrigerator for more than three days. If you are not sure that the food is still safe, remember this saying: "If in doubt, throw it out." See links below for guidelines on how long food stays safe. Make sure that foods are properly cooked. A food thermometer is the best tool for this. Cook beef, pork, veal, and lamb (steaks, roasts and chops) to 145°F and allow to rest for 3 minutes. Hamburgers made of ground beef, pork, veal, and lamb should reach 160°F. All poultry (including ground) should reach a minimum of 165 °F. NEVER partially grill meat or poultry and finish cooking later. Eggs should not be runny For all of you "older kids" who will be baking this holiday season, watch out for the batter (I am a notorious offender.), Even one lick from raw food containing a contaminated egg can get you ill. ____________________________________________ Myth: Freezing food kills harmful bacteria that can cause food poisoning. Fact: bacteria can survive freezing temperatures. When food is thawed, bacteria can still be present and can begin to multiply. Cooking food to the proper internal temperature is the best way to make sure any bacteria is killed. Myth: vegetarians don't need to worry about food poisoning. Fact: Fruits and vegetables are an important part of a healthy diet, but like other foods they may carry a risk of foodborne illness. Always rinse produce well under running tap water. Never eat the pre-washed 'ready to eat' greens if they are past their freshness date or if they appear slimy. Myth: Plastic or glass cutting boards don't hold harmful bacteria on their surfaces like wooden cutting boards do . Fact: Any type of cutting board can hold harmful bacteria on its surface. Regardless of the type of cutting board you use, it should be washed and sanitized after each use. Solid plastic, tempered glass, sealed granite, and hardwood cutting boards are dishwasher safe. However, wood laminates don't hold up well in the dishwasher. Once cutting boards of any type become excessively worn or develop hard-to-clean grooves, they should be discarded. Myth: Locally-grown, organic foods will never give you food poisoning. Fact: Any food, whether organic or conventional, could become unsafe with illness-causing foodborne bacteria at any point during the chain from the farm to the table. Consumers in their homes can take action to keep their families safe. That is why it is important to reduce your risk of foodborne illness by practicing the four steps: Clean, Separate, Cook, and Chill. Some excellent resources for food safety tips can be found at: www.foodsafety.gov  This site keeps track of any food recalls www.Stilltasty.com This is as great site for seeing how long food will last. I used it just this week to figure out if an open can of chickpeas was still good. (After a week, the answer was no) www.fightbac.org   This site has loads of kid friendly activities Breastmilk storage guide http://www.eggsafety.org Enjoy your Thanksgiving! Grandma Fuffy’s apple chocolate chip cake Beat together 3 eggs 1 3/4 cups sugar 1 cup oil (can make some of it apple sauce) sift together 2 ¼ cups flour (can substitute cup for cup Gluten free flour) ½ teaspoon salt 1 teaspoon baking soda                             ¼ teaspoon baking powder Mix together wet and dry ingredients Add ½ cup of chopped nuts ( optional) ½ cup chocolate chips ( sometimes more seem to find their way into the bowl) 4 cups peeled and diced apples ( about 4 apples) this is the only pain in the butt part of this recipe, otherwise it is so easy cook in ungreased 9X13 pan in 350 oven if you use only oil it is about an hour, if you use some applesauce it is done more quickly, use a toothpick to check the center ******************************************************************* Cranberry Puree (8 servings) 1 pound of fresh cranberries 2 cups of sugar 3/8 cup of Marsala wine ½ cup of Grand Marnier 1/8 cup of Angostura Bitters Cook cranberries and sugar in heavy medium saucepan over medium heat until cranberries are very soft, stirring frequently, about 20 minutes. Puree mixture in blender with half of Marsala wine. (The original recipe says that you should strain this mixture into a medium bowl, pressing to extract as much fruit as possible, although I don’t bother with this step as I think the texture with the seed and fruit bits is more interesting.) Whisk in remaining Marsala wine, Grand Marnier, & bitters. Cover and refrigerate overnight. (Can be prepared up to 5 days ahead.) Serve well chilled. (The amounts of alcohol can be decreased but not by more than ½ of what is called for; the less liquids added, the more jelly-like the puree.)   Don't eat this cranberry sauce and drive!!