Sleep tidbits part one/infants

Sleep tidbits part one/infants

 I spend a lot of time talking to parents about sleep. Most folks have told me that they have had at least some measure of success from the following tips. For the tough cases there are some great sleep consultants out there in the community, but these tips are a good start

For the most part I am a big believer that decisions involving sleep are very personal choices Many families do some sort of co-sleeping for the first couple of weeks. Some folks are happy keeping a family bed. Others move the baby out to a separate room fairly soon. Some families are fortunate enough to have a night nurse present for the beginning stretch.

Each family has a different tolerance level for how much crying they are comfortable with. Everyone needs to figure out what works best for their unique family. Some people live in close quarters and others have plenty of space so that any crying won’t impact others. Ideally both parents have been able to discuss this and be comfortable with their sleep plan.

I tend to fall somewhere in between the attachment parenting and the cry it out methods. I do NOT worry that your baby will have future psychological damage or attachment issues from a bit of  crying at night. That is a lucky thing, because I also have found that even with the best routines, and watching for sleep cues, it is the rare infant who learns how to fall asleep without some fussing.

There are many books out there on the subject and many of them make good points. The essential starting point is to accept that we all have sleep cycles and may have periods during the night where we are semi awake. You might fluff your pillow, go to the bathroom or have a sip of water and then go back to sleep. But if you woke up and your pillow was missing, you wouldn’t simply turn over and go back to sleep. You would be fully awake!! Where the heck is your pillow?

Guess what. If you are nursing your baby, they fall asleep and you sneak them into their bed, it is no surprise that when they enter a lighter sleep cycle they become aware that something is amiss. Hey, where is that breast, bottle, pacifier, rocking body?

With a new baby, most parents are just trying to figure things out. If we train our babies that the best way to fall asleep is with rocking and feeding. That is the lesson they learn right from the start. I once heard this referred to as accidental parenting. That term fits.

As much as our instincts lead us to PUTTING the baby to sleep, we are better off letting them soothe themselves down with a minimum of assistance. It is certainly okay to pat them or put a firm loving hand against their forehead or chest. Go ahead and surround them with gentle shushing noises. Of course it’s fine for your baby to fall asleep during a feeding, but every time you are able to put your baby down while they are still drowsy, you are a giant step closer to getting a baby who can sleep through the night. If they are awake, Don’t sneak them into bed. Let them be aware of how they get there. Watch for little cues that they are getting sleepy. Rubbing the eyes is a classic one. Believe it or not, it is much easier to get a baby to go to sleep if you catch them before they are over-tired.

Sleep consultant, Anya Furst, says that once you get to eye rubbing it might even be too late. Her suggestion is to first watch for several days to get familiar with the general amount of time between your baby’s waking and their first eye rub. When you have a good sense of your baby’s pattern, try putting them down ten minutes before they are actually showing that they are sleepy. Babies often take a few days to adjust to new routines so don’t give up if the miracle you’re looking for doesn’t happen overnight. 

Feeding at night

Young infants need to eat around the clock. but I really want them to start learning the difference between day and night as soon as possible. Daytime feedings can be fun; it’s light in the room and you can interact with your baby as much as you like. Nighttime feedings are business; keep the room dark and interactions to a minimum. During the day, I would encourage you to feed every 2 ½ -3 hours and don’t let any nap go longer than 2 ½ hours. I fully acknowledge that not everyone agrees with me about that. Some people would claim that it feels criminal to wake a sleeping baby. Listen, on occasion, if they are taking a super long nap and you are in heaven with a bit of free time, go ahead and let them sleep. Don’t let the  daytime naps that last longer than 3 hours become a habit.

Once your baby is over 3 months of age and at least 11 pounds, they can start giving you a longer stretch without eating. The goal is for that stretch to be at night.

Keep an eye out for their ability to sleep for longer stretches at a time. Once they have shown you that they can go 4 or 5 hours at night, try not to backslide. It is okay to comfort them if they wake up, but I would do my best to avoid falling into the “feeding because it is easy” trap. Their little bodies have a lot of growing to do while they are sleeping.

Eventually we want your baby’s nighttime to be food free. There are plenty of books by experts who say that an 11 pound baby can give you 11 hours. If they naturally do it, fabulous; enjoy. But don’t worry if they don’t. I don’t usually start to really focus on dropping 100% of the night feedings until they have started solids, and you are sure they are getting adequate calories during the day. If your 11 pounder is not giving you at least a four hour stretch, you need to take some action.

There are lots of lessons that must be taught in the quest for your child to sleep through the night. First is learning to fall asleep on their own. Second is learning the difference between day and night. Finally when they have started solids, it is time for the all important lesson: nighttime is NOT the time for a meal. Imagine if you woke up in the middle of the night and someone offered you a lovely warm chocolate chip cookie. Of course you would accept it. That doesn't mean you need it!

I don’t know of ANY sleep training that doesn’t involve some fussing, but my method is relatively gentle. I tend to start with fairly low expectations. If a baby is getting adequate milk during the day, no one should need to eat more often than every 3 hours during the night (let’s consider nighttime as soon as you go to bed and until the sun comes up.) If they wake up sooner than 3 hours, someone can check on them. You will have much more success with sleep training if the non-breastfeeding partner is involved. Breastfeeding parents should not enter the room until it is actually time to feed. The baby might need some type of comfort measure but feeding should simply not be an option until the magic 3 hour mark. After a few days stretch it to 3 ½ hours and so on. You can certainly check on them, change the diaper, even offer ½ ounce of water. If you think they might be teething go ahead and try some homeopathic teething gel. You are present for them, just not offering food (think chocolate chip cookie.)  If you want to sit next to the crib and sing, that is up to you. The main lesson is that nighttime isn’t meal time.

Some  methods involve going in to check on them and trying to settle them in increasingly longer increments. First time might be 5 minutes, then waiting 10, then waiting 15…etc. I have actually found that some babies tend to get much madder if you go in at all and  many parents just leave them awake and crying until the next feeding opportunity has come. You guys need to figure out what works best for you.

If you absolutely can’t bear the thought of letting them fuss, you can do the “pick up/put down” method. This method takes a tremendous amount of patience and takes much longer than the simple let them fuss strategy.

If they are in a full scream, pick them up and jiggle and shoosh until they are calm. Avoid eye contact. If they were really furious, this might take a while. Don’t say much. The minute they are calm. Place them back into the bed. Yes I know, they will immediately go back into fury mode. Once again pick them up until they quiet, and then put them down. 

No one can dispute the clear message you are giving. “I am here. If you are crying I will calm you. It is time for you to be in bed. It is not time to eat.”  Sometimes your job as a parent involves saying “NO”. I am the parent. I need to show you the rules. 

I understand that it is really wrenching to let your baby cry. In my case I had to remind myself often of what we were doing and why we were doing it. It also helped that my husband accepted the responsibility of being the primary sleep “trainer.”

Here are some of the factors that convinced me that it had to happen:

·         Many people are lousy sleepers their entire lives. If you can potentially give your child the tools that it takes to be a good sleeper, and it only costs a week or two of crying, it is worth it, and you are giving them a gift for life. Many parents make the argument that you don’t have teenagers crawling into bed with their parents, but sleep specialists see this all the time. The later sleep training is done, the more difficult it is. 

·         You have to “put your own oxygen mask on first”. Sleep deprivation is an awful thing. In order to be the best parent that you can possibly be, you need to be rested.

Extra Tidbits

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·                     If you are lucky enough to be in a two parent household, there is no reason for both of you to be up all night. Figure out a way for each parent to get a three or four hour shift of being off duty. Once you have spread out the feeding expectations, this will get easier to figure out. It is amazing how wonderful that little stretch of being off duty feels. No guilt. You each get a turn.

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·                     Even the best sleeper will need a tune up once in a while. Traveling babies almost always need an adjustment but these little tweaks are much easier than that first round of sleep training.

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·                     If you suspect that your baby may be ill, in my opinion, that is not a good time for ‘crying it out’. I often get folks into the office for a quick visit with their doctor so that we can make sure they are well (sometimes ear infections can cause sleep disruption.)

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Common questions:

Pacifiers, good or bad? I would rather have a baby be in charge of their environment but some folks find that pacifiers make falling asleep much easier. Unfortunately some parents end up being woken up every hour or so to replace the pacifier. That sucks (sorry I couldn’t resist.) Some of my parents end up putting dozens of pacifiers in the crib with the hope that the baby will be able to reach one and manage to replace it on their own. Personally I would either keep them out of the crib completely or let them fall asleep with it but then let them figure out how to self soothe once it falls out.

Swaddle: what to do when they grow out of it? At some point every baby is going to have that transition. There are current swaddle blankets that can work with larger babies than there used to be.There are also some special sleep sacks that ease this transition. Do make sure you do daily tummy time. The sooner your baby can master rolling in both directions, the easier it is for them to deal with their new found freedom. Once they have learned to reliably flip over, they may well end up on their tummy. It is not reasonable for parents to wake up constantly to put the babies back onto their backs. Instead, it is very important to make sure that their crib is safe.

 http://nursejudynvp.blogspot.com/2013/07/crib-safety.html

Are you concerned about disturbing your neighbors with night time noise? Sometimes a proactive bottle of wine, some ear plugs and little note explaining that you are sleep training goes a long way.

May the force be with you. You will get through this.

Good night.

Nurse Charity to the rescue/ Care for Open Nipple Wounds

Care for Open Nipple Wounds

(nipples that are excoriated, scabbed, bleeding, or have pus)

OUCH!   A great latch fixes most problems, so the first step is to find expert help ASAP. (Your IBCLC needs to watch a latch or two, and check the baby's mouth for unusual anatomy).   But while you and your new cutie are learning, sometimes you get a painful latch, and within minutes those tender nips are in need of some serious TLC.  Or you got a little aggressive with the pump suction, and there are blisters or cracks at the nipple base.

Pro-tip:   Pumping should be comfortable, not just tolerable- if it is pinchy at all turn down the suction, even at the lowest setting, the pump will still work. Don't fall into the trap of suction beyond comfort will move more milk.  Pain interferes with letdown.

Once you have an open wound, there is greater risk for infection so nipple care is very important- we aim to lower your risk of infection, and support moist wound healing.  I have tried many things over the past years- this is what seems to work best.

Saline Soaks twice a day (minimum) for 3-5 minutes-  Saline helps flush the wound, promote healing, and feels great.  Just make your own.  ¼ teaspoon of SEA SALT (not table salt) in 1 cup therapeutically hot  water (not asking you to boil your nipples, that would be a bad idea- but the water should not be tepid either- good hot bath water temperature).  Make it in a small coffee cup (two if you have damage on both sides), and then lower your breast into the cup.  Some gentle pressure with your hand will allow you to seal the cup to your breast, and you can sit comfortably upright (or walk around).  Sometimes the cup becomes unsealed, a towel on hand to clean up any water spills is wise.  Twice a day is great, but you can do it more if you love it.

Now to protect from infection!

Antibiotic Ointment-  I like to use a small amount of antibiotic ointment after each feed or pump. Not picky what kind, but should be ointment, not cream (bacitracin and neosporin are what most people have at home- check the expiration date, throw away anything that looks old).  Just a little dab, and then do not wash it off.  New skin needs to be left alone, washing the nipples before each feeding can do more damage than good.  The very small amount of residual ointment will not hurt anyone.   If you have a prescription for mupirocin ointment (Bactroban), or APNO (All purpose Nipple Ointment- a combination antibacterial, antifungal, plus steroid potion) that can be used instead of the OTC options.

Gentle Cleansing- if signs of active infection are present- If you have any kind of ooze or pus (sometimes looks like yellow/greenish crust), you need to add another step.  A once to twice a day wash with mild antibacterial soap, very gently, and then pat dry.  NOTE: If the nipples are open and scabbed but do not have any oozing, you can skip this step.  Soap is very drying and can create irritation if over used.

Help!  My nipples keep getting stuck to everything and are rubbing against my clothes!

Open to Air- best course of action is to leave them open to the air as much as possible, Yay for topless parenting!  

Pro-tip: Here is the litmus test for helpful postpartum care- anyone in your home for longer than 15-20 minutes should be able to watch you breastfeed (which includes seeing your bare breasts for extended amounts of time), be cheerful and willing to scrub your toilet (or fold laundry, or run the vacuum- anything you need), and be able to provide a meal (they can cook it, they can order in, but they must provide sustenance).   Everyone else should ring the bell, leave the casserole at the door, and blow you air kisses from the sidewalk.  No exceptions. People who just want to admire/hold/coo the baby and cannot do the above need to go in a hurry.    

If that is not practical for you here are some other suggestions-

Food grade Oil-

Some coconut oil or olive oil can promote moist wound healing, and help the skin from sticking to things, go ahead and be liberal.  Do not wash it off.  The fancy things you got as shower presents also work (nipple butter, mother love etc etc etc), but I find food grade oils to be just as good, and less expensive.

Medical Grade Lanolin- same directions as above.  I sometimes get people who are allergic, and unfortunately no one sells just pure lanolin any more- they have all added emollients so it is easier to spread, but it is tried and true.

Hydrogel Dressing-   If you are using the antibacterial ointment, you can use a product call hydrogel dressing (Soothies or Hydrogel) to soothe, protect and promote moist wound healing without having the wounds stick to your breast pads or bra.  It is what we use for burns in the hospital setting.  Because it is a warm moist environment, a little dab of antibacterial ointment will help keep the bacterial levels modest (do not skip this step, studies show that hydrogels used incorrectly can increase your risk for mastitis- do not let this be you!).  The directions will tell you to wash your breast before each feeding- OVERKILL- again over washing is bad for healing wounds, so skip that step unless you see that the hydrogel dressing is crumbly, and you have some hunks on the breast.  Then of course you would rinse those bits off, and throw away the hydrogel (it has outlived it's usefulness). The pad itself is sticky and attracts lint, so do rinse the pad with water before each use. Some moms love storing them in the fridge so they can have something cool to soothe their nipples.  

Using the above methods, and a stellar latch, your nipples should look significantly better in 3 days, and be healed in 7-10 (maybe even faster).  So check in if you are struggling at the 3-5 day mark.   

*Any potion, gel pad, disposable breast pad or soap has the potential to* *cause an allergic reaction or aggravate sensitive skin*

If anything you try for 24-48 hours seems to be making things worse, please discontinue and give us a call to check in.

If you think you have YEAST, please see my guest blog about Thrush.

http://nursejudynvp.blogspot.com/2014/07/nurse-charity-blogs-about-thrush.html

Does your kids still have the cooties?

 
Please visit the updated post February 2018

There is so much stuff going around right now that it may be useful to update this post from last winter.

When is your child contagious? (In other words, can they go back to school or daycare?)

Some of my most common questions revolve around when kids are contagious and when are they ready to go back to nanny-share, daycare or school. There is not always a simple answer. On one hand, of course we want to be responsible parents and not expose others to our sick child. On the other hand we want to protect our own recovering child from going back too quickly where they may come down with something new. In order to logically best make these decisions there are many issues that we need to consider.

Some parents have an easy time taking time off and others simply can't afford to. It is naive to think that these aren't real factors. What makes this so tricky is that most viral syndromes can be spread a day or two before the kids show clear signs that they are ill. Many kids may be a little fussier than usual. Perhaps they don't eat quite as much. It is also usually a big "Ruh Roh" when your normally active child tells you that they think they will go take a nap now. Your antenna might be up that something is brewing, but are those reasons to miss work and keep your child at home??? Of course not!

The fact is, if you child comes home from school in the afternoon and is sick that evening, most likely everyone they were with earlier that day has already been exposed and I am going to take that into consideration when we try to come up with the most sensible plan on when they can return. Frankly, more than likely they got exposed there in the first place. 

If you are in a small share care situation, it is essential to have a talk with the nanny and the other families involved to make sure you are all on the same page. I would suggest that you create a "sibling" relationship. This simply means that you all accept that the kids are most likely going to get each others mild illnesses. Seriously, if you plan on staying at home until your little toddler is free from a runny nose, you will be waiting a very long time before you leave the house.

Remember that some clear runny noses are not contagious. Teething as well as some allergies can be the cause. As far as common colds go, the average child under 2 years of age has EIGHT colds a year. While I would like to keep my youngest and most vulnerable patients free from viral syndromes and colds as long as possible, exposure to these common viruses is in fact developing their immune system. At some point they are going to have to deal with some mild illnesses. Think of it as a rite of passage.

Typically if I have a child with a fever over 101, a  new case of diarrhea, or a brand new green mucous producing cough or cold, it is worth keeping them home for at least a day to see what  is coming next. If your child has an infection that is being treated with antibiotics, we generally consider them no longer contagious after they have been on the medication for at least 24 hours. Bacterial conjunctivitis is also usually given the all clear after 24 hours of eye drops (of course you need to finish the course.)

There is never any complete assurance that can be given that your little one is "not contagious." Use your best common sense. When in doubt avoid contact with anyone who is vulnerable. This would include newborns, or someone with a compromised immune system.

If you are questioning whether or not to go on an upcoming play date, explain your situation to the other parents. They may be perfectly fine hanging out with you and your snotty nosed child, or perhaps they have an important event coming up and want to be more cautious. Let them decide. Full disclosure ahead of time is the best practice.

Unfortunately this week I have spoken to many parents who are ill. Of course careful hand washing is essential, but quarantining yourself from your child is not usually realistic unless you have a way above average support system. If you are a breast feeding mom we are usually going to have you to continue to nurse. Do make sure you are taking care to drink extra fluids and rest as much as possible.

Spring will be here before we know it! 

Problem solving skills

Strange stuff happens to my daughter Alana all the time. Folks that know her refer to her life as "Alana Land". Aspects of this range from winning an incomprehensible percentage of raffles to creating lasting friendships with random people that she meets on public transportation. Once, as she walked to Muni after her late night shift working at the suicide hot-line, an odd procession of old men playing Dixieland jazz music followed her for several blocks on the otherwise empty streets When she got to the station, they tipped their hats and veered away. So, when I got a text from her earlier this week telling me that she had the "weirdest evening ever" I couldn't wait to hear the tale.

Alana is currently living in Ann Arbor working on her Masters in Social Work. She shares a house with 5 other grad students. The other night the doorbell rang and one of her housemates opened the door to find an "old woman" there having trouble breathing. His idea of problem solving was to holler for Alana who appeared and took over.

Among the things this stranger was saying was that although she was not a religious person, God had told her to come to this house where she would get help. She also talked about wanting to kill herself. Alana managed to calm her down, get contact info for family members, contact the social work department at the hospital, and ultimately get this woman to an emergency room. There are a lot of adults who would have found this overwhelming.

Since we all can work on our problem solving skills, in honor of her handling that situation so well, I am updating and rerunning this post from last year.

What  would you do if?

I have been doing these little weekly emails for just about 2 years now. Some posts are clearly more relevant to parents with young children while others are much more applicable to older children. Some are more global and your child's age doesn't matter so much. This is the latter.

Today's topic is a about an important activity that you can do with your child that teaches them to be "problem solvers".

Although at first glance it may seem targeted to parents with older children, in fact everyone could learn from it. Adults need to learn to be problem solvers also. Some are much better at this than others. For instance, if you got in a fender bender, what would you do? Many folks would just freeze and panic. What should you do?

*Assess for injury' call 911 if needed

*Know where your insurance info is

*Take a photo of any damage

*Take a photo of the other driver's insurance card and drivers license...etc.

*Always have a charger in your car for your cell phone so that a low battery is never an issue.

Having a plan in advance could help you stay calm. That is the main theme of this post.

Years ago, the concept that everyone would carry around an individual cell phone seemed as futuristic as the communicators on Star Trek. Now, of course it is hard to imagine how we got along without them. It was, however, the lack of the cell phone that prompted me to create a game that became a favorite in our family.

It must have been 1994 and I was on my way to pick up Alana from preschool. She was about 4 years old at the time. It was one of those days. I was uncharacteristically running late. Then, I got stuck in terrible traffic. To compound things, I took some random turns to try to work around the congestion and ended up utterly lost. (Remember that this was also before Google maps or GPS)  My stomach was in a knot and I wondered what my younger daughter would do when mommy was late picking her up.

It turned out that she was calmly waiting for me in the office, but that was the day that the "what would you do if" game was created.

It went something like this:

I would ask a question such as, "What should you do if mommy is late picking you up? What are some of the choices? Which is the best one?"

Getting a teacher or trusted grown up to wait with her or take her to the office was clearly the right answer and I praised her for figuring that out on her own.

Alana loved this game. We created all sorts of situations

" What if we were at a store and you couldn't find me?

Alana.." I would go to the check out and ask them to page you"

We never made it too simple...

Mommy :"What if they refused?"

Alana :"I would demand to talk to the manager"

Our scenarios covered any number of little emergencies including earthquakes, fires, and getting lost or separated. We didn't cover the "what would you do if a strange, suicidal old woman shows up at your door?"  It turns out that the better you are at problem solving, the easier it gets to improvise.

This game came in handy more than once. The shining example that comes to mind happened after years of playing this game. Alana and I were walking the dog on the beach one day. I had donated blood earlier that morning and didn't realize how foolish I was for doing anything strenuous. I got very light headed and ended up down on the sand trying hard not to completely pass out. Alana was ten at the time and she went right into problem solving mode. We did have cell phones at this point. She got the dog on the leash, patted some water on my forehead and calmly called daddy. I could vaguely hear her talking. "Mommy fainted...I think she is okay"

The game was such a success that my sister taught it to her kids. Hers had an interesting spin because they lived in Alaska at the time:

"What would you do if you saw a bear?"

"What would you do if a Moose wanders into the yard?"

There were actually times when these things happened, and my nephews were able to act calmly and appropriately!

Topics can range from handling a bully to getting separated on Muni. Being prepared for unexpected situations can be invaluable.

If your child finds themselves without you and in need of assistance, finding a grown up wearing a uniform is often a valid option for some of the difficult situations. Finding a parent who has a child with them and asking them for help, might be another safe option.

This game is meant to empower. It is wonderful for some kids, but could be terrifying for others. You need to assess your child's temperament before playing. Either way, identify a problem or situation. Start with simple, less scary ones. Discuss all the possible solutions and then agree what the best plan should be for any given situation.

Stressful situations happen. Teaching your child to take a deep breath and use their problem solving skills is one of those things you can do now that can have lasting implications for them when they grow up.

Even teaching a very young child to dial 911 in an emergency can be life saving!

You have to figure out if this will be empowering for your child as it was for Alana. My daughter Lauren never liked to play it. In fact, I remember one day when Lauren and I were taking a walk, I tripped on something, stumbled and fell. I was perfectly fine, but Lauren's reaction was to start screaming. I think she was ten at the time. As she says, "mommies aren't allowed to fall". Every kid is different.

 

As your child grows, the situations that you might want to bring up will increase in scope.

Just this month a child right in Noe Valley avoided a potential kidnapping situation by making good choices in that terrifying situation.

I think that the "what would you do" exercise is actually something that you might want to do with a nanny or caretaker. Having them be able to manage a crisis with a clear head is essential.

I want to add one more tidbit here. What if you lost your cell phone or it ran out of batteries and you don't have a charger? Do you know important phone numbers, or do you count on speed dial. Having a list of important numbers in an accessible place is a good idea for everyone.

Preparation is power.

Temper Tantrums

It is  the rare parent who hasn't had to deal with the occasional tantrum.

Here are a few tips for managing them.

When you are a parent, imagine that you are the coach of a football team. Keep in mind that most of the coaching takes place before and after the games. Your team may win big or they might completely screw up. During the game you are mostly just a spectator. Leading up to the game you strive to prepare your players the best you can. After the game you can be the Monday morning quarterback and identify ways to improve.

I have found it very  helpful for parents if they can recognize the difference between "game time" and "coaching opportunities." If we follow my theory, transition times, mealtimes, getting out of the house in the mornings and bedtimes are considered game time. You can't do any effective coaching or teaching during these moments. Hopefully you have created  a "game plan" so that generally things go smoothly. When you encounter a situation that sets off a tantrum, do your best to just get through it as calmly and creatively as you can. If you notice that you are stuck in a rut and you can identify routine behavioral issues, you need to work on creating a new plan.

Here's an example of a "game time" situation. Many years ago I was a solo parent on a flight, returning home from grandparent visit/family visit. My sister Marjie had bestowed each of my daughters with a "my little pony" gift to entertain themselves on the flight. Alana the two year old had chosen the pink one, and Lauren the five year old was happy with the blue one. Mid way through the long flight, Alana wanted to make a trade. Lauren, wasn't interested and quite within her rights she soundly refused. Alana was usually a fairly mild mannered child, but I could see the tantrum brewing and she was about to cause a serious disruption. I did a quick negotiation with Lauren: "Hand over the blue pony now, and we get home they are both yours." Lauren took only a second or two to recognize the value of this and gave Alana the blue pony. Crisis averted. This wasn't the moment to teach about sharing, or fairness. This was game time. Get off that plane intact. If we had been at home I may have handled it quite differently.  It is absurd to think that you will handle a tantrum in the middle of a crowded public area the same way you would in your home. Home field advantage???

Watch for clues and do your best to ward off an impending tantrum if the warning signs are clear, but once your child has already entered the meltdown zone, it is time to change tactics. There is a popular parenting book that counsels parents to get down on the child's level and loudly evoke their inner caveman by chanting "You are mad, you are mad,  you are mad mad mad!" When that book first came out, I would routinely hear parents out in our waiting room making more of a racket than the fussing kids. I must confess, that when I still hear the occasional parent grunting "you are mad" I do roll my eyes a little bit, but the premise is actually a solid one. When your kid is having a tantrum, acknowledging that you are trying to understand what is going on in the first step.

"You seem mad, sad, frustrated etc"  are often exactly what your child needs to hear.

If you told me that you have a headache and I responded by discussing the weather, it would not be very satisfying. Distraction is all well and good, but not until they get it that you are trying to understand what has them so upset. Validating a feeling is not the same thing as giving in to an unreasonable request. Try to hold them close, get them on your lap and wrap your arms around them so that they can't thrash around. Make shushing noises. Keep it simple. This is not the time for lots of words. Those come later.

If your child has frequent tantrums, see if you can figure out what is setting them off. Look for patterns. Many parents realize that kids get more fragile when they are getting hungry. Try having little snacks on hand and pay attention to any cues that might be leading up to a melt down. Are they tired? If tantrums are routine, you need to examine your child's nap/sleep schedule. Are they frustrated by something? In a calm moment, if your child is old enough, help them work on their problem solving skills.

Problem solving activities work very well after a situation has happened. Talk about what went wrong. See if they can help plan a better way to deal with it the next time.

Step one is always identifying the problem. Break it down to a small but manageable issue. Rather than the diffuse "fighting with sister" get down to a very specific issue, such as "sister won't share yellow crayon."

Step Two is talking  about some choices one might have in that situation:

Some are good choices, others not so much. They all make it to the list. Adding a silly one is just fine and makes this feel more like a game. Choices could include:

Using a different color; Using words and asking sister nicely to share (may need to wait a minute for her to finish coloring her own yellow parts.) Asking  a grown up for help; start screaming; drabbing the crayon; draw a frowning face on your hand with a black crayon; use your "walking away power" and take some deep breaths. Hopefully with some gentle guidance they can identify the more positive choices.

Problem solving exercises are very empowering for your child. The age range for when kids are able to take part in these is fairly variable, but they will all get there.

For kids over 3, see if they can recognize their own warning signs before losing control. This is a tool that will serve them so well for their entire life. Perhaps create a song together that they can sing when they are approaching tantrum stage:

"I am mad mad mad

I want to stamp my foot

I want to clench my fists

but I am going to shake out my hands

I am going to take 3 deep breaths

I am going to use my words"

Any time that you see your child get calm without losing control give them loads of positive feedback.

Kids can also get a lot out of a well told story. Create two little children that you can tell tales about. They are the same age as yours, with very similar family circumstances. One tends to make good choices and the other also gets into trouble often. Allow your child to chime in and talk about why these other children had a tantrum and what they ended up doing about it. Kids do much better talking about these very relatable characters than they do about their own actions. Once they come up with a plan for the made up child, you can bring it back around; "Maybe you could try that also."

Even the best kids have occasional meltdowns.

All tantrums can be turned into learning experiences for you and your child. Stay calm and be consistent.