Intentional Communication/A Parenting Pearl

 

I No one ever said that being a parent was easy. I am not talking about the lack of sleep. I am referring to all the decisions that you need to make as a team. People come from different backgrounds, cultures and parenting styles. It is not always easy to merge approaches and points of view. Navigating the barrage of vastly differing opinions from grandparents, friends and online sources doesn’t necessarily make it any easier. As an advice nurse for so many years, I have been fortunate enough to forge authentic relationships with many of my patients and their families.  At some point,I  found myself expanding beyond the standard health topics and spending a lot of time discussing behavior challenges. Parenting styles and responses to behavioral issues are so personal.  It became common for parents to trust me to be a sounding board for their disagreements. They wanted ‘Judge Judy’ to be the arbiter, but I was always clear from the start that the only side I would be on was that of the child. My biggest piece of advice was “love your child more than your need to be right” Most couples have some common themes that they disagree about and tend to have the same arguments over and over. Feel familiar? These aren’t limited to parenting. (I think that the knives in the dishwasher should be pointed down!) Even if there isn’t agreement, the sense that you are being heard can be enormously important. As many parents have discovered, when toddlers are having a tantrum, they often will calm much sooner when the caregiver confirms what they are observing.   “You are mad that you have to leave the sandbox right now.”  “I know you don’t want to lie still right now, but you have a giant, stinky poop and I would rather not get it all over the walls.” “I know you don’t want to put shoes on, but that is the rule when we walk outside.” In the above instances, you are not letting them have their way, yet validating their feelings still makes a difference. That need to be ‘seen’ doesn't go away as we get older. You might be surprised how an argument loses its steam when the other person simply feels heard. It is also important to accept the possibility that rules can be amended and there isn’t always a clear ‘right or ‘wrong’. Optical illusions are the perfect example of the fact that there is often more than one right way to look at things. One  classic one pictured here is either a white goblet or two profiles in black. Both images exist. Some people can see both. Telling someone that there is only the image of the goblet is not going to do anything to change the mind of the person who sees the profiles. They see what they see. Many people actually feel threatened when deep beliefs are challenged. Take a few moments to watch the link below.  https://theoatmeal.com/comics/believe So often squabbles involve people going back and forth or talking in circles. You may even agree with many of the core issues, but get so caught up in making your next point that no one stops to see or evaluate what is actually being said or heard. If bickering is something that you actually get a charge out of, then by all means continue in your old patterns. (You might do your partner the courtesy to see if they enjoy it as much as you do.) But if you both are willing to break that cycle of bickering, not surprisingly, the magic ingredient is real communication. This deep communication that I am referring to, is the genuine attempt to hear and understand what the other person sees and feels. It relies on active listening There is a big difference between casual conversation, political debate and actual deep listening. A casual conversation can be effortless. It can bump along without a clear agenda and touch on a variety of topics. Do you always remember what you talked about? Not likely. On the other extreme, real communication in political debates these days is almost nonexistent. Usually the end goal of a discussion is not to try to hear the other person's point of view but rather to pontificate the same talking points over and over again. I  am guilty as charged and with some of the hot button topics, It would be a lot of deep work for me to try to get beyond my sense of what ‘should be’ to delve into what someone on the other side is thinking. If world leaders are interested in sitting down with me, that would be lovely, but until then, let’s focus on your micro world, where you actually have some power to affect change. Intentional Communication, step by step.... Start with something simple, like how you both want to handle your mother-in-law allowing your child more screen time than you are comfortable with, before working up to why assault rifles should not be legal for anyone who wants one.  Step one: Agree that you are willing to listen fully Step two : Find a time of day when no one is exhausted, hungry or in pain, try to have a long enough stretch that you won’t feel rushed or get interrupted. (I know, good luck with that.) Step three: agree on the ground rules Pick one focused topic. The speaker holds an item that ‘gives them the floor’. This can be a teddy bear, bottle of wine, or wearing a silly hat. Bonus points if you can keep your sense of humor throughout. Whoever possesses the item gets to talk with no interruptions; you will get your turn. Set a timer for 5 minutes, not as a limit, but for awareness. If they have more to say, reset for another 5. The first speaker hands over the item and it is time to swap roles. The first listener starts by repeating a short summation of what they ‘heard’ from  the other person's narrative. If there is something you don’t understand ask for clarification. If there is a part that you agree with, highlight that. (This is not the time for you to tell them why you think they are wrong.) Switch sides. One important ground rule is that no one just walks out on the conversation when things get heated.  Either person can ask for a ten minute break, and then the conversation continues. I asked Oath’s wonderful therapist for her input on this Brittany’s offerings: Asking for verbal consent before starting the conversation can be helpful for those deep, emotionally charged topics. An example, “I am ready to initiate repair from our last argument and discuss what that experience was like for both of us. Are you in a space mentally and emotionally right now to have this conversation with me?”  There are always two streams of communication occurring simultaneously, the report (verbal, the content of what we are communicating) and the command (nonverbal communication, rate of speech, tone, body language). When you’re the communicator, it’s important to make sure both pieces of your communication are flowing in the same direction. As the listener you want to make sure your nonverbal communication is reflective of what the speaker is saying. This is essential to the communicator feeling seen at a neuronal level (think satisfying those mirror neurons).  Once you have both had a chance to share your point of view, the real problem solving can begin. Naming the issues often makes them much easier to work on Review the things you agree on. Come on, there must be something…. You can decide how you will make this decision. Do you both need to come to a full agreement? Are there compromises that you can both feel comfortable with? It may be that even though there is some doubt, there is a willingness to try one person’s approach and see the results. If you can’t find common ground right after this conversation, that doesn’t mean you won’t. You each may need some time to absorb and let your perspective adapt to new information.  Revisiting the topic a day or a week later may soften the rougher emotional edges and make a shared solution more evident.  It isn’t always easy.There are some really tricky issues where it is clear there is fundamental disagreement and no real middle ground. These are the tough ones. It still helps to be able to identify, name them and calmly discuss where you are coming from. If it still feels incendiary, would a therapist or a 3rd party be of help? Going through this exercise is not just healthy for your relationship. Modeling good communication for your kids can be a valuable gift. Beyond that, the end result of hopefully having parents who find a way to act as a unit, is such a positive thing for the entire family.  And if you can’t be in complete agreement, you can still be united as you try one person’s approach. This also models mutual respect and a spirit of cooperation. On the other hand, if you don’t figure out how to work as a team, I promise you that your older kids will certainly figure out a way to divide and conquer. Barbara Kivowitz, my sister-in-law and coauthor of Love in the Time of Chronic Illness: How to Fight the Sickness, Not Each Other (a guide for ill partners and their family caregivers) offers this final thought:  Once you have come to your combined decision about how to address the behavioral issue, agree to observe the results over the next few weeks (or months) and assess how you both think it's working and consider any tweaks you might want to make.  Addressing your child’s behavior is a never ending process. They grow and change, and so do you. If you approach this with the tools of Intentional Communication and an attitude of try/observe/adapt, you’ll all learn, together.

Swimming 2022/An advice nurse's guide

 

I blinked and it is mid Summer already. I have gotten several questions lately about babies and swimming, prompting me to update my swimming post. Participation in formal swimming lessons is absolutely associated with a huge reduction in the risk of drowning, but all the lessons in the world cannot take the place of having a designated adult keep a constant, watchful eye on anyone in, or around water. That being said, I don’t usually recommend lessons until your child is at least 6 months old. Swimming lessons for children under 3 years are mostly about getting them comfortable in the water. Water play is also a fun and healthy form of exercise for the entire family. As a bonus it may improve strength and motor skills. I give swimming with your kids a big thumbs up. Recent AAP (American Academy of Pediatrics) guidelines actually suggest that all children over the age of one take swimming lessons. At the bottom of this post is a list of swimming options for families in the SF Bay area Even if you aren’t looking for local pools or classes, many families might have some opportunities to swim during summer travels, or even a visit a friend's pool. One of the most common questions I routinely get is the one asking how old a baby needs to be before it is safe for them to go into the water. I am assuming that you are sensible enough that you aren’t planning on taking your one month old on a tropical vacation. If your baby isn’t brand new, then generally my answer about getting into the pool is “sure!”, but there are several factors to consider.   For young babies, a little splashing is okay, but I wouldn’t let them submerge their heads until they are old enough to keep their mouths closed. There are claims that very young infants are natural swimmers and don’t take in a lot of water; I prefer not to test that out. A big gulp of chemical filled water is yucky at any age.   Is the pool outdoors? We all need to be careful with the sun, but a baby's thin skin is especially vulnerable. Young children need to have a big floppy hat and perhaps sunglasses and sunscreen. Remember that sunscreen needs to be reapplied even more often if the kids are getting wet. Get in the habit of doing a sun assessment at least every 15 minutes. If they are getting pink, it is time to get out of the sun. Don’t wait until they are bright red. While it is true that my fairest patients are the most at risk for a sunburn, all skin pigments should be protected. Shade is best!    https://nursejudynvp.blogspot.com/2021/06/sun-protection-2021.html   There are some cute little umbrella baby floats that offer quite a bit of shady protection if you are in a pool. But be aware that the reflection from the water can add to the risk of burning.   The next factor is the water temperature. Young babies don’t regulate their body temperatures very well, so make sure that any pool water is nice and warm and that the outside temp isn’t too chilly for them.    As an advice nurse I have all sorts of swimming related issues to share that go beyond safety. Here are some other considerations:   Hot tubs Most hot tubs and jacuzzis are too hot for kids under 5 years old because they are at greater risk for overheating. For kids over 5, if the temp is 104 degrees, a child should be in for five minutes or less. If the temp is between 98 and 102 you can let them hang in there for 15 minutes at a time. Be warned, if the hot tub isn’t clean, people can get a pimply rash called folliculitis. Most of the time this is self resolving, but it is worth checking with your doctor if it isn’t resolving.   Foot fungus Anytime you are hanging out at a pool please wear flip flops when wandering around poolside or in the locker room. Fungal infections and athlete's foot are fairly common from public locker rooms.! A spray bottle with some diluted vinegar solution to spritz on the feet, followed by making sure that the feet are very dry before putting shoes and socks on, are good preventive measures.   Yeast/irritations Little girls that spend a lot of time wearing a wet bathing suit can also get irritations. It is a good practice to get the kids out of the wet suits as soon as possible. Do a good rinse off as soon as you can and then apply a nice moisturizer to avoid exacerbating dry skin.   Ear issues If your child has had a recent ear infection, it is okay for them to swim as long as the tympanic membrane is intact. If your child has had ear tubes or a recent ruptured eardrum, they should NOT be submerging their ears in the water (or the bathtub for that matter) without having protective ear plugs.  Sound Speech and Hearing makes custom ones with sparkly color options that may help with compliance.   If your child has been doing a lot of water play, they may be prone to otitis externa (better known as swimmer's ear.)  As opposed to an inner ear infection that requires an otoscope to make a diagnosis, an outer infection is often visible to the naked eye. The ear looks red and sore and may have some drainage. If that is happening, it is worth a visit to your pediatrician so that they can see what’s happening and prescribe some antibiotic ear drops if warranted. Keeping the ear canal as dry as possible may help prevent this condition. There is a simple proactive measure that can be cheaply and easily made by mixing equal parts of rubbing alcohol and white vinegar (50:50 mixture). This solution will increase the rate of evaporation of water in the ear canal and has antibacterial properties. Using this solution to rinse the ear before and after water exposure can help protect against infection.   Hazardous Algae Blooms If you are planning on swimming in open water (lake, river etc) make sure you check ahead of time to make sure there are no advisories. There are some local lakes and rivers that occasionally have some toxic algae blooms that I would not want any of my patients to get near.  The EWG has a good article on how to recognize this hazard . I mentioned that drinking pool water is not ideal, but I am going to double down on the yuck factor in some lakes and rivers. These are the kids that end up with giardia. Try hard to make sure they aren’t getting any water near their mouths.  Basic water common sense Most of my local families know to be very wary of our local Ocean Beach, but if you are traveling to a place with a warmer and more inviting ocean, never turn your back on the water and beware of currents and strong waves. When you are near water, it is important to make sure that one adult is the appointed water Guardian.   If you are looking for swim lessons, here are some of the great options here in SF. Here are some of the more popular options   La Petite Baleen Swim School . They have several different sites. The one in SF is in the Presidio at 933 Mason St.  https://www.swimlpb.com/ 866-896-3603   Jewish Community Center of San Francisco https://www.jccsf.org/fitness/aquatics/ 3200 California St San Francisco, CA 94118 Phone number (415) 292-1200   Bakar Fitness & Recreation Center https://campuslifeserviceshome.ucsf.edu/fitnessrecreation/aquatics Mission Bay 1675 Owens St Phone number (415) 514-4545   There is an indoor and outdoor pool here with all sorts of options for just swimming with your baby or doing classes.   YMCA http://www.ymcasf.org/ There are several branches in SF that offer swim classes. sessions are likely full already, but if you plan ahead you may be able to join some July classes.   Stonestown 415-242-7100 Presidio 415-447-9622 Embarcadero 415-957-9622   The city pools also have some classes available but they also fill up fast. Register at www.sfreconline.org  https://apm.activecommunities.com/sfrecpark/Home  to sign up for swim lessons (and other great classes). This website will also give info about the city pool hours if you are interested in just having some pool time with your kids and skipping the expensive lessons. You may want to go by yourself first to scope out the water temperature.   My kids grew up going to the Janet Pomeroy Center. This is out by the zoo at 207 Skyline Blvd. It used to be called the Recreation Center for the Handicapped. The lovely thing about it is that the pool is very warm. They have several slots every week where you can go and play in the pool with your child. It is reasonably priced, but you need to call to enroll in advance, They don’t have any drop in sessions. The phone number is 415-665-4241   https://www.prrcsf.org/swimming   Do you have a pool that should make the list? Please share the info and I will add it to the post.   If your child is enrolled in swimming classes and they have a mild runny nose, they can probably still go swimming if they are feeling up to it. If they are vomiting, have diarrhea or a fever, do everyone a favor and keep them out of the pool!   Swim classes are NOT a reason to take your eyes off of your child in the pool; no one should ever have a false sense of security!  -----------------------------------------------------------------   Dr. Ted’s Tidbits:   It always bums me out to talk about summer pool safety. I don’t like feeling like I’m ruining your ability to relax by telling you your kid might die on vacation. But I couldn’t agree more with Nurse Judy’s advice above. The most important part is the designated water guardian. Every time I take care of a young near-drowning child in the hospital (it happens at least annually), I hear the same refrain “I just went inside for one minute.” When liquids enter the lungs, seconds matter. The longer liquid is in there, the more reactive the lungs become. After children inhale water, they need to be monitored in a hospital setting for a number of hours, as their blood oxygen concentration can change hours after being rescued. It’s a big to-do, and easy to avoid with some vigilant oversight!

Melatonin 2022/ Is it safe? Is it useful?

Melatonin has been in the news recently.  Here are the shocking statistics that are making the headlines… melatonin ingestions by children accounted for almost 5% of all of the calls to the poison control centers in the US this year! Basically the number of pediatric melatonin ingestions increased a whopping 530% from 8,337 in 2012 to 52,563 in 2021. This is no doubt due in part to the fact that it recently has become more widely available with a variety of pediatric friendly options.  By far the majority of these were young kids getting access to it because it wasn’t stored safely. Your kids are smarter than you think. Just putting something on a high shelf does not mean it is childproof. Don’t underestimate the lure of yummy gummies.   Fortunately 83% of these overdoses were completely asymptomatic; only 1.6% lead to more serious outcomes. Those who showed symptoms had Headache Dizziness Nausea Drowsiness So what is Melatonin anyway? Melatonin is a hormone that occurs naturally in the body. It is produced in an area of the brain known as the pineal gland. Melatonin is released and helps control the body's circadian rhythm. It is not a sedative, but works in combination with light to get the body drowsy when it is time for sleeping. It may help adults and children fall asleep faster and improve the quality of sleep. It is not habit forming. It is interesting to note that melatonin production tends to decline with age (hmm, maybe that’s why I sometimes have trouble sleeping?)   There are no known ill effects, but there is no conclusive research yet on what the impacts may be from long-term use in children. For children older than 3, short term use seems quite safe.   The most common and most widely sanctioned use, is to help combat jet lag. Dr. Kaplan, over at Town and Country Pediatrics, says that it is fine for her patients who want to use it to help get adjusted to a new time zone.   Jet lag can make the first couple days of a trip pretty rough. Your best bet to get over it quickly is a multi pronged approach. It is very important to focus on hydration. Also, try to get as much daylight as possible when you land. If you are arriving someplace after 2 pm, try hard to stay awake and then crash early. If you are getting in earlier than that, a short nap might be necessary.   Then, by all means, add the appropriate dose of Melatonin to the mix. Unfortunately there are no clear dosage or safety guidelines in place. The studies range from 0.1 to 10 milligrams of melatonin. Most doctors think that 2-3 milligrams are a good amount to start with. The common recommendation is: Preschool-age: 1 to 2 milligrams School-age: 2 to 3 milligrams Adolescents: 5 milligrams In all cases however, experts recommend always starting with the lowest dose of melatonin available, then increasing the amount only if necessary. It is best to give it about 30-60 minutes before bedtime. As I mentioned above, melatonin comes in a wide variety of options for how to take it. Aside from tablets, chewables, quick dissolving and liquid, it also comes in sprays, creams, powders, and patches. Not all the forms have the same absorption. Choosing the right one is all about personal preference. For routine sleep .  For a healthy child, melatonin should NOT be part of a regular sleep routine, but there is no harm in giving it for several days to help reboot and get on a good schedule. If sleep issues persist, it is worth having a consultation with your pediatrician. Here are some things that can contribute to healthy sleep habits   Going to bed and waking up at the same time can get the body into a healthy rhythm. You may hear this referred to as 'sleep hygiene'. Make sure your child is getting plenty of physical activity during the day, but avoid too much rough housing right before bed. Try to avoid eating a large meal right before bedtime. Also, if any caffeine or sugar sneak into the diet several hours prior to bedtime, this can make it harder to get a good night's sleep Have a regular bedtime routine. Do some soothing activities, make the room progressively darker and darker. Don’t include any electronic devices as part of the bedtime ritual. The blue lights that are emitted are disruptive and should be avoided for at least an hour before bedtime. A pre bedtime massage is a lovely way to wind down.   White noise machines are fine. A hepa filter can do double duty.   Keep the bedroom cool. According to the National Sleep Foundation the ideal bedroom temperature is actually between 60 and 67 Fahrenheit. You can bump that up a bit for infants and toddlers to 65-70, but cooler rooms are better for sleeping. Consider trying the natural calm gummies. These are magnesium based. They can help you get a good night’s sleep (as well as a good poop). I am a big fan.   Not everyone knows that low iron and/or vitamin D levels can impact sleep. If you or your child are having insomnia, it might be worth getting those levels checked.   Other potential Melatonin benefits My 'go to' pediatric dentist, Dr Rothman shared the following: In the anesthesia literature it has been shown that giving melatonin does not increase depth of sedation during a procedure and therefore may be helpful in getting a good night's sleep prior to dental work, thereby decreasing anxiety. Keep this in mind and chat with your dentist if you have a procedure coming up.   There are ongoing studies exploring other potential benefits for all sorts of issues including migraines, eye health, calming kids on the autism spectrum as well as GERD. It will be fun to see what the future findings are.   Other safety considerations In the United States, melatonin is categorized as a dietary supplement, rather than an actual medication. There is no prescription needed. Supplements are not regulated by the FDA and are subject to less regulatory oversight.  A recent study measured the actual amount of melatonin in 31 different brands and found enormous variations from what was on the label and what was actually in the bottle. Some had significantly more or less than the claimed amount. Because of this, some countries such as Canada have banned the sale of over-the-counter melatonin. It is worth checking to make sure that the brand you buy is USP certified.   There are no safety studies for use in children under 3, pregnant or breastfeeding moms. Melatonin might interact with some medications, so for you grown ups out there, it is important for you to check with your primary physician. Medications that you need to pay attention to include some contraceptives, blood pressure medications, diabetes medications and most sedatives.   The biggest takeaway from this post? If you have melatonin sitting around on the counter, go and properly store it right now.

 

SIDS prevention/ New AAP guidelines

 

SIDS prevention/ New AAP guidelines

The American Academy of Pediatrics just came out with their newest guidelines updating the best safe sleeping practices for babies. It is hard to believe that it has been 30 years since the ‘back to sleep’ recommendations were first instituted. That change made a measurable difference and cut the SIDS incidence by roughly 50%. The annual number of sleep-related deaths has remained steady since then. Unfortunately that case count is still too high. There are still approximately 3,500 infant deaths every year here in the US. These incidents usually occur when an infant with an intrinsic vulnerability to SIDS is placed in an unsafe sleep environment. The most common risk factors include: Male sex Prematurity Low birth weight Genetic factors (There is some preliminary research that has found a link between certain enzymes and SIDS, but it is in the very early stages) Race (non white babies tend to be at higher risk) Under 4 months Prenatal exposure to drugs, nicotine or alcohol Second hand smoke Obviously, aside from the smoking, most of these are not in your control. So, what is in our power? That is what the guidelines are all about. Here are some considerations for creating the safest sleep situations. Back to sleep is basic. Generations ago, kids were put to sleep on their tummies. Grandmas knew that they slept more soundly that way. Here’s the thing. It is actually better for infants to be having lighter sleep for the first couple of months. Because the sleep isn’t quite as deep, babies can rouse more easily if they have unmet needs. Believe it or not, the goal at this age is not to get your baby to sleep through the night. They need to wake up to feed. Ideally a baby wakes up periodically and then can settle themselves back to sleep without too much assistance. The safest position is on their back, not on their tummy or their side. Some parents worry about choking being more of an issue in that position. In fact, healthy babies naturally swallow or cough up fluids. It is an evolutionary reflex. Babies may actually clear such fluids better when sleeping on their backs.  Infants don’t have very good head control, so another benefit of them being on their back is that they are less likely to smoosh their little faces into the mattress. Make sure they are getting some regular tummy time. That head control will improve more quickly with your help. You can start this within the first couple of days. Even having them lay on top of you, for several seconds bobbing their little heads up, counts. The amount of time per session can increase gradually. This supervised time is so important for strength and development. It also can help you avoid a flat head (positional plagiocephaly). Here is one of my blog posts on that topic. Once they can roll, it is common for parents to stress because all of a sudden babies have the ability to flop onto their tummy. Please note, it is not reasonable for you to stay awake and keep flipping them onto their back. Your job is to place them on their backs and make sure the crib is safe. Keep doing plenty of tummy time and floor exercise. This will help them work on the skills so that soon they have more control. The AAp recommendation is for babies to sleep in the room with the parents, preferably for at least the first six months. They want you in the room but not the same bed. The guidelines are clear about co-sleeping. The AAP gives that a big no. I understand that this is a tough one, I know that in many cultures folks sleep in a family bed. Unfortunately the statistics are jarring. The risk of SIDS is 10 times higher when sleeping with someone who is impaired because of their use of sedating medications, drugs, alcohol or simply exhaustion. Show me a new parent who isn’t exhausted… It isn’t just a risk at night time. The risk of SIDS is up to 67 times higher when sleeping with someone on a couch or soft armchair or cushion.  By all means snuggle them to pieces when you are awake, but when you are at risk of dozing off, they are safer in their own little bed. The guidelines also advise parents to take steps to ensure that the baby doesn’t get overheated. They are not hothouse flowers. A cooler room is better than a hot one. It is interesting that the risk for SIDS is higher during colder months. This is likely because in the colder weather, caregivers might be tempted to use extra blankets or clothes. Over bundling may cause overheating, which elevates an infant’s risk for SIDs. The ideal temperature for babies is between 68 to 72 degrees fahrenheit or 20 to 22 degrees celsius. It is common for infants to start off in the smaller infant bassinets before moving into a full sized crib. The safety consideration for bassinets and cribs are the same. Some of the infant beds, like the snoo, have movement and sound to help soothe them. There are no safety issues with those, just make sure that any infant sleep product is JPMA certified (Juvenile Products Manufacturers Association). When it is time to move into a full sized crib, you want to look for that same JPMA certification. Older models might not meet the current safety standards. It is essential to get one with stationary sides. The older cribs used to have rails that you could lower. This was easier on your back, but no longer considered safe. If you do have an older model, double check with the cpsc.gov to make sure there are no recalls associated with it: https://www.cpsc.gov/Recalls?combine=cribs By law, the production date of a crib must be displayed on it and on its shipping carton. Take a photo of that so you have it for your records. Check for any obvious safety hazards. Slats should be no wider than 2 & 3/8 inches wide. If you buy a crib online, get your ruler out and measure any openings immediately when it arrives at your home. Check for sharp edges and protruding screws, nuts, corner posts, decorative knobs, and other pieces that could catch your baby's clothing. The mattress should fit tightly in the crib with no gaps. If you can place more than two fingers between the mattress and the crib frame, the fit isn't snug enough. Here is one list of best mattresses for 2022 Use a tightly fitted sheet. There is nothing wrong with a quality hand-me-down sheet as long as the elastic at the corners is still strong. Test the sheet, whether new or used, by pulling up on each corner to make sure it doesn't pop off the mattress corner. There should be nothing else in the bed. No stuffed animals, pillows, blankets or crib bumpers. I confess that my kids had a crib full. Lauren used to have long conversations with her Winnie the Pooh bumpers. Those days are gone. Infants can be kept cozy in a swaddle until they start to roll. At that point I would switch to a sleep sack. One good brand is the Woolino, it isn’t too hot or too cold. The weighted swaddles are not on the AAP list for safe sleep products. I am trying to get more info about some of the specific products and will update this post when I am able to get more information. The mattress should be a firm, flat surface. If they are at an incline they can slide down and there is a risk of suffocation.  The new guidelines specifically state that devices such as car seats, strollers, swings, infant carriers and infant slings are not recommended for routine sleep, especially for infants younger than 4 months. These infant seats and carriers are fine if you need to have the baby hanging out in the room with you during a wake window. I am going to permit a loophole and say that for a closely supervised nap these are still okay, just not at night. Supervised means that you are keeping an eye on the baby as they sleep, not completely engrossed in another activity or taking a nap yourself. Flat is best, but if you have been reading my blogs these past years you know that if your little one has a cold or congestion, I have always suggested putting them on a little bit of a slant. You can still do that by putting a little towel under the mattress but now it needs to be more subtle. The angle should be no more than 10%. The new guidelines also suggest avoiding the use of home cardiorespiratory monitors as a strategy to reduce the risk of SIDS. The concern is that they might provide a false sense of security. Breastfeeding is ideal. Being a good parent is NOT about how you feed your baby. Not everyone is able to nurse. But, data shows that breastfeeding reduces the risk of sleep related infant deaths. During the first 2 months, feeding at least partial human milk has been found to significantly lower the SIDs risk. If your baby got any at all during those early attempts, that might make a difference. If you do produce enough milk and can manage to nurse at least for the first 6 months, that is consistent with the AAP recommendation. Of course, if you can make it through the first year with some breastmilk as part of their diet. that is even better. Pacifier use is associated with reducing risk.  I have no issue with a baby falling asleep with a pacifier in their mouths. I would not force it, if they don’t seem to want one. I would also try hard NOT to get into the habit of replacing it every time they fall out. As kids get older, there are fresh safety issues to consider. Make sure the mattress is at the lowest level so that your little one can’t climb out. Make sure the crib isn’t near any wires, lamps, window shades or cords that they can reach.  The good news is that once they are a year old, I am fine letting them have a little comfort object in the crib with them. You might feel like you are in the dark tunnel of sleep deprivation right now, but babies grow fast. I know it can feel overwhelming and a bit terrifying when they are little and at their most vulnerable, but there are actions listed above that can help keep them safe. Blink and they will be asking for the car keys, Then you will have a whole new set of things to worry about!