Problem solving skills 2017

Some of our patients are heading off to school within the next couple of weeks. It is a big adjustment for everyone. When you are no longer with your child 24/7 you want to make sure that they are prepared to deal with unexpected situations.

Today's topic is a about an important activity that you can do with your child that teaches them to be "problem solvers".  Adults need to learn to be problem solvers also. Some people 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
• If you are on a highway, wait for assistance. Getting out of the car is often dangerous!
• Do you have an AAA membership? Know where the card is.
• Know where your insurance info is kept (make sure you have a copy accessible)
• Take a photo of any damage
• Take a photo of the other driver's insurance card and driver's 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.

But I do want to add one more benign tidbit here. What if you lost your cell phone or it ran out of batteries and you don't happen to 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.

I lived in New York back in the early eighties. It was a different city back then. At one point there were a rash of home break-ins and burglaries. A friend of mine who was an actress obsessed quite a bit about this. She went as far as rehearsing made up scenes for any given situation to avoid being frozen by fear. Go figure, one day someone did break into her apartment. She went right into her pre-rehearsed mode. Figuring that acting a bit cuckoo would get any 'bad guy' off balance, she immediately broke into the character that she had prepared. In a loud, shrill British accent she yelled, “Welcome!!! Would you like to stay for tea?" She did the Mad Hatter proud. She went on with a list of options. "Would you like herbal or black? I have delicious honey from local bees!" As expected, the intruder was completely caught off guard. He mumbled something, turned and ran. Brilliant. Not that I am recommending that particular course of action, but having a plan in advance is always a good thing.

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 was all about building on the concept of planning in advance for an assortment of situations. 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. 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. 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.

Preparation is power.

It saddens me we have to be prepared for things other than losing track of our kids on Muni, but that is the world we live in.

Have a family plan in place in case of emergency.  If someone other than one of the regular people is going to pick up your child, have a family “safe word” so that they know they were sent by you.

Do you have your earthquake/emergency kit ready? Does it include adequate diapers, medications, pet food? Where will everyone meet up if home is not a safe option? Find out from your school what kind of emergency plans they have in place. Teach your kids to get in the habit of looking for emergency exits, especially for your older kids who are at a concert, theater or a club.

I think that the "what would you do" exercise is actually something that you might want to do with a nanny or caretaker. Training to keep calm in any type of emergency situation is essential.

Food Heroes and Villains

Up until just recently coconut oil was considered heaven sent. It cured all sorts of things. When I saw the recent news putting it back on the list of terrible foods, I groaned out loud. I feel the need for a little rant. I hope you will bear with me! Everyday we have different foods take turns getting a blast of media attention. We see lists of the world's healthiest foods and list of foods that should be avoided at all costs. Some things that are on the ‘wonder food’  list one day might be on the ‘avoid at all costs’ list the next. Take red wine for instance, one minute it is the best thing to help you avoid heart disease...oops but it might increase the risk of some cancers. Of course some of these headlines are often followed by frantic calls to the advice nurse. When the organic rice was found to have measurable amounts of arsenic the phones practically exploded. In fact arsenic is pretty hard to completely avoid and is found in other foods as well. The list goes on….. Probiotics will save the world Soy will cause your sons to grow breasts Gluten should be completely avoided Even my favorite kale and its fellow cruciferous veggies are now thought to be not as perfect as they were made out to be due to potential thyroid disrupting risks and high oxalate levels that could lead to kidney stones Eggs have been moved to the good guy list. Sugar is more likely to be the cause of high cholesterol than eating eggs every  day. You get the idea. Navigating through all of this info is so challenging when you are trying to feed your family a healthy diet. The food pyramid has been turned upside down and there are so many fads that come and go. I asked Nurse Lainey and her internet savvy sister Katie to do a little poking around for me and within a short period of time they came up with an extensive list of dietary trends, including something that sounds particularly alarming called ‘souping’. I am not about to sort through all of  the fads (the posts are often too long as it is.) Rather I am going to give you the message, "take a deep breath and do the best you can. Everything in moderation!" If you are lucky and you have a child who will eat plenty of different foods, make a valiant effort to give variety and not to binge on any one thing. Below is my take on some obvious current heroes and villains. Organic and Non GMO: Hero We probably can’t really count on any labels to be completely accurate anymore, but if you can  afford it, I prefer organic produce if it is available: The Dirty Dozen: What to Buy Organic Sugar: Bad Guy! Try to minimize added sugar. You might be shocked by how much sugar is added to things. Be a good label reader. Agave, which used to be considered a healthier alternative is no longer on the “good guy” list.  If you are looking for a natural sweetener, current consensus would put honey at the top of the list for healthiest option. Remember that this is NOT a good choice for any baby under one year. No honey for them! My preference would be that sugar and dessert not be used as a reward on a regular basis. If our body has had enough “growing food”, an occasional sweet treat is fine. Gluten: Mixed. I get aggravated when folks dismiss this. More and more people can really not tolerate gluten, regardless of what testing shows.  Both of my kids ate plenty of bread their entire lives but developed fairly severe gluten reactions as young adults. I have had many patients do an elimination diet and find that they feel much better when they cut it out of their diets. Not everyone suffers the same symptoms. It makes no sense to get rid of gluten if you show no signs of being impacted by it. That being said, in general white flours, breads and pastas are pretty low on the nutrition scale.  Rice/arsenic: just don’t overdo! There are in fact measurable levels of arsenic in rice. There is more found in the brown rice than white. Rinsing the rice well prior to cooking it might reduce some of the levels. I would not recommend more than a couple of servings of rice per week. We are fortunate that there are plenty of other options. Most other grains out there that don’t have this issue: Yes, There Is Arsenic In Your Rice. Here’s What You Need To Know Trendy food Pouches: Read the labels! Just because something is organic, doesn’t mean it is good for you. I know all the pouch foods are quite popular. The are convenient and the kids generally like them, but some are loaded with ingredients that you really don’t need. They are also a nightmare for the landfill. Baby Food Pouches/Huffington Post As with anything, find some balance. Wise words from Nurse Lainey. If you want to do some creative eating for yourself, please keep in mind that your children have different nutritional needs. They are not just little adults!

Water safety/Secondary and Dry Drowning

When frightening stories make the news, I know that I can anticipate some calls about whatever the issue is. There were some recent stories in the media about secondary drowning. Several parents have reached out and asked me to address the topic in a blog post. Next week I will continue the swimming theme. I had it all rolled into one but it was way too long. You would be surprised how many different body parts we get calls about that are swimming related. You can read all about those next week.

Let’s get the scary stuff out of the way first. Drowning is the second most common cause of death in children in the United States. Prevention is key. A person who is drowning may not thrash about and call attention to the fact that they are having trouble. They can slip silently under the water without being noticed until it is too late. Even if your child has proven themselves to be solid swimmers, you need to stay actively focused and engaged on watching them like a hawk while they are in the water.

If you are staying anywhere with a pool, make certain that your child has absolutely no access to the pool area when there is no adult present. If you do have pool access, there are lots of pool alarms and safety monitors on the market. Hotels or apartments with fountains need to be treated with caution as well.

 

We had a scare with one of our families a few summers ago. Several adults and children were enjoying a day at a friend's pool in the East Bay. They got out of the pool to have some lunch. Some of the oldest kids started to bicker. While the adults turned their attention to the squabble, a one year old got back into the pool unnoticed and submerged. Thank goodness another of the adults looked up, noticed and was able to get her out and perform CPR. The little girl is perfectly fine, but this was terrifying for everyone. Dr. Karen Makely, one of the wonderful urgent care physicians over at St. Lukes, says that sometimes having a lot of adults around lends a false sense of security. Consider having each adult take turns being on a shift as the designated lifeguard.

 

Drowning is horrible, but the recent stories that scared the bejesus out of my families were about delayed drowning. You may have heard of dry drowning as well. They are not the same thing.

The primary difference between dry drowning and secondary (or delayed) drowning is the presence or absence of water in the victim’s lungs.

Dry drowning is something that can be brought on in several different ways. The first theory is that a sudden rush of water into the throat causes the airway to go into spasm. During this event, although no water enters the lungs, no air enters either, so the victim dies of asphyxiation. Another explanation is that  the shock of a swimmer’s suddenly entering extremely cold water causes the heart to stop.

Distinct from “Dry Drowning” is secondary or delayed drowning. This is also very rare, but  is something that parents need to know about. Symptoms usually develop within 6-24 after an incident. If someone had a near drowning or accidentally swallowed a lot of water, they are at risk for pulmonary edema from the fluid imbalance to the lungs. They may seem fine initially but then present with cough and increased labored breathing. This usually shows up within 24 hours of the event.

Caregivers of young swimmers should try to head off some of these issues by training their kids to keep their mouths closed when jumping into water and to enter very cold water slowly.  This should help avoid aspirating large amounts of water. There is a big difference between water in the lungs and water in the belly. If your child swallows a lot of water they may end up with a tummy ache but it is rarely dangerous. The recent tragic news story about a child who died in Texas with this diagnosis is a bit of a puzzle. He had days of vomiting and diarrhea. Every physician that I spoke to says that it is respiratory, NOT tummy symptoms, that they would be on the lookout for. There is likely more to that story than is getting reported. It is the outliers that make the news.

Here is the takeaway message. It is important to closely monitor any child who has come out of the water coughing and sputtering. Especially keep an eye out for any further difficulties in breathing, extreme tiredness, or marked changes in behavior, all of which are signs that a swimmer may have inhaled a dangerous amount of fluid. If there is any concern, an emergency room or immediate medical intervention is needed. The first 24 hours are probably the most critical period. It is important to know what to look for, but to reiterate, in over 30 years with a practice full of swimmers, I am not aware of any of our patients having any serious complications from a mouthful of water. 

I spoke to Dr. Tamariz from the CPMC ER. He reiterates how extremely rare this is, but stresses that if any CPR or resuscitation was needed, a follow up emergency room visit is essential regardless of how well they may appear. For the majority of swimmers that accidentally get a mouthful of water, observation at home is fine unless they are showing the obvious symptoms that are listed above. If you are concerned, go the the emergency room. They will check the oxygen level, listen to the lungs, and keep an eye on things until everyone feels comfortable. If clinically indicated they might do an x-ray but it is not automatic.

I am going to close with a little tidbit of common sense. Labored respirations should ALWAYS prompt you to seek medical attention, even if there is no concern about recent swimming.

Next week I will continue the swimming theme, sharing all the possible swimming related call that the advice nurse team receives!

And now a word from Mr. Nurse Judy - Father's Day 2017

Happy Father's Day to all who are celebrating this weekend. 

Warning: Last year when Sandy wrote his first Father's Day Post for my blog, I got reports of parents sniffling all over Bart. Welcome to "Mr. Nurse Judy's" annual post.

XOXO  Nurse Judy

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I want to thank you all for the kind comments I received after last year’s post about my wonderful relationship with my children, a relationship that continues to get better, even now as I close in on the end of my 6th decade of life, and my daughters near the end of their 3rd decade. It is a role that is paramount to me, and I refuse to let time and distance interfere with my efforts to continually improve it. So far, I think I’ve been pretty successful, and the rewards are immeasurable. Certainly it’s a lot easier when they are young, living in your home, and “need” you to be involved in their lives. But the foundation you create early for how you want that relationship to be makes it a lot easier to enable it to grow, flourish and blossom at any stage of life, even now as they establish their own lives, careers, and relationships. For those of you who didn’t have the chance to reads last year’s post, you can find it here:

 https://nursejudynvp.blogspot.com/2016/06/a-fathers-day-post-from-mr-nurse-judy.html

I want to make clear that I have no special training or educational background in this area. What follows are simply my own philosophies about fatherhood; you may disagree with some or all of them. But this is what has worked for me and I cannot really imagine a father with a better relationship with his adult kids than I have!

So first an update on my relationship with my daughters.  At this time last year, Lauren and I were weeks away from traveling to Tanzania for the challenge of a lifetime. AND WE DID IT!!! We summitted Kilimanjaro on the morning of July 19th, an absolutely grueling climb that took me to the very limits of physical, intellectual, and emotional endurance. In fact, I couldn’t have done it without Lauren’s support, and I was quick to make sure she knew that. We spent two weeks together in very close quarters, most of that time unwashed, extremely sleep deprived, and cold. Summit temperature was 24 below zero! The only cross words that were exchanged were over a misplaced towel (I both misplaced it and spouted those cross words!) I never want to face an ordeal like that again!! At least not until April 2018 when we climb to the base camp on Mt. Everest! See – the relationship just keeps giving!

If you are an avid reader of Nurse Judy’s blog, you may remember that when she was in grade school, Alana ended every night by telling one of us all about her day…in exquisite, and often lengthy, detail! The big, the little; the important and the minutiae. Well, more than 20 years later, I get to do that with her all over again. Every day. And I look forward to it and resent it when another friend has a need for Alana’s time! After obtaining her MSW last June, Alana is now a practicing therapist in a community mental health center in Michigan. She has about a 30-minute commute in each direction and on her car ride home, I get to keep her company!!!! And we talk all about our respective days. The time flies past and she is home before we both know it, but not without each of us learning a little bit more about something in each of our lives. What I have primarily learned is that her counseling clients are the luckiest people in the world because they have Alana as their therapist. I listen in wonder and respect as I get to share in the progress they make dealing with the issues that brought them to her in the first place. She is changing lives on a daily basis and I get to be the fly on the wall. I am overjoyed that she still wants to spend that time of her day with me. I frequently tell her that I am in awe of what she is doing and remind her that she has to take the time to sit back and reflect on that also, and not just move on to the next client…  which brings me to my first point of this year’s father’s day recommendations for building that relationship with your children:

Find reasons to be proud, and praise them whenever you can!  From the first time they can lift their head by themselves, to the first crawl, to standing up, and that first use of the potty, let them hear your voice filled with pride and encouragement. Let it become ingrained in them that you are their number 1 supporter, for both the little and big accomplishments in life.  As I mentioned last year, that’s why I took a day off of work to go see a very shy 2nd grade Alana (right now, all her friends are saying “who the heck are you talking about?”) get up on stage just to say one line in a play; it was a grand small accomplishment that deserved to be recognized. When younger, even though they can’t understand the words, they can hear and feel the sentiment in your voice, and for the rest of their lives, that sound will provide great sources of satisfaction and comfort, and it will provide a lifetime of encouragement for future exploration. Now, I am not one of those in favor of participation trophies and I am not saying that everything they do should get this level of exuberance. But be generous with the praise, especially in their formative years.  This brings me to my next recommendation:

Value the efforts too, not just the successes! There is an old saying that good judgement comes from experience; experience comes from bad judgement! It is a cycle that cannot be completed without falling down. So let them fall down, but don’t bemoan the failure; commend the attempt, and any part of the effort that will help them gain “good judgement” next time. It is quite easy for children to focus on your critical evaluation of whatever it is they are attempting, while underappreciating the praise you may simultaneously be conveying. For example, if you’re trying to teach them to throw a ball, don’t focus on the fact that the ball landed by their feet. Appreciate that there are things they may simply be incapable of at any given age. It’s up to you to understand that, not them, so focus on the things that they can do well (gripping the ball, placing the feet, shifting the weight…) and celebrate these building blocks that will one day end up in those ultimate tasks being that much easier, and enjoyable! Simply focusing on the failure of achieving the end result will certainly lead to frustration, and possibly anger and resentment.

It's ok to be wrong. In fact, it’s good! Admit it, and apologize!It is sad when I see a parent who either insists they are never wrong, or twists circumstances to make it seem that they were not wrong in a specific situation. It’s very easy to play that mental game with a child in an effort to demonstrate that you always know what’s best, or think you will be respected because you are always right. Satisfied that you out-strategized a child in this mental arena? Get over it; it’s not that hard. And it’s not that smart. I (and I think my daughters would agree,) created some of our most profoundly important relationship building moments by admitting I was wrong about something, and apologizing for it. Think about it – is there anything more empowering to your young child than having a person in a position of authority implicitly say to them “I not only heard you but I really listened to what you had to say. I thought about it with all my years of advanced experience, education, and knowledge, and I realized that you were right and I was wrong.” Trust, confidence, consideration, kindness, communication…. there are innumerable benefits to acknowledging your own fallibility to your child! And it tells them it’s ok to be fallible too! You don’t expect/need/want perfection, and they don’t have to live up to that standard. And it teaches them that being wrong is a part of life, not something to be defensive about, and can be dealt with responsibly and respectfully.

Tolerance! I mentioned above that you should “appreciate that there are things they may simply be incapable of at any given age. It’s up to you to understand that, not them…”  You must acceptvery early on that you are incapable of thinking like a child, nor they as an adult. Kind of like the “Men are from Mars, Women are from Venus” paradigm, you and your children speak the same language, live in the same environment, are familiar with the same behavioral mannerisms, yet you have such different frames of reference, experiences, emotions, intellect…that at times it will seem to each of you that the other is speaking a foreign language. And you are!! It is so very easy at those times to get frustrated, and even worse, angry. But it is unrealistic for you to expect them to be able to think, analyze, and express themselves at the level you do. They don’t have your emotional and intellectual development and it is unfair to simply use your advanced capabilities as the measure of their intent. When you feel that coming on, take a break, remind yourself of this, and try your best to see things as they do. You most surely won’t completely succeed, but every little bit of empathy you can muster will bridge that gap just a little. It’s also never a bad idea to voice this self-realization; let them know that you are consciously aware that you are cross communicating and invite them to help think about how each of you can get your respective thoughts out. They’ll develop patience, compassion and problem solving skills!

Establish ground rules for how to disagree! My girls and I had a very useful rule – we weren’t allowed to go to sleep mad! The rest of the argument or disagreement could proceed along its natural course, but ultimately it had to end at this rule. It was really quite simple in its effectiveness since it forced (encouraged?) us to resolve our differences. There were times long after bedtime that one of them would either come out of their room to say “I’m still mad” or amusingly, would slip notes under our door detailing the issue (Alana was the talker; Lauren the writer!) This led to frequent comical exchanges of notes going back and forth under each other’s doors but it was such an easily understood rule that it almost always worked! The key though is to take it to heart! As my brother-in-law sometimes says “gravity, it’s not just a good idea, it’s the law,” my daughters and I made this a law, and if one of us was “violating” the law by claiming fatigue, or anger, or issue complexity, or…etc., the other party was free to demand that we follow the law, sometimes leading to late nights and missed bedtimes! But always successful resolutions of the issue. And guess what? Most of what I wrote above represents the philosophies that I tried to use to help make sure each day ended on a happy note.

Happy father’s day to all. See you next year when we get back from Everest!

Mother's Day Musings

Maternal -  How would you define that word? For me it evokes, unconditional love, guidance, nurturing.

For those of you in that middle generation, savor these years. You have your mom and your kids. If you are lucky, maybe there are some grandparents in the mix. Being the magic middle of the sandwich might present some challenges, but please TREASURE these years.

For the daughters and sons looking for the perfect gift, give the gift of time.

Go on a special outing, take lots of photos. The memories are more valuable than jewelry. Okay go ahead and throw in some chocolate covered strawberries, but you get the idea.

Actually forget the strawberries; give mom a nap!  Or a candle lit bubble bath (remove the bath toys!)

Make it a Mother’s Day tradition to tell your kids stories about your mothers, grandmothers, and great grandmothers. Did they have some favorite pieces of wisdom? Share them! Did they have some favorite songs? Sing them! 

On the other side of that coin, and not to put a dark cloud on the day for folks who are fully celebrating, but for many people Mother’s Day is one of those made up Hallmark Holidays that can range from being moderately uncomfortable to downright painful.

For me, it has been looming for weeks now like an impending shadow. This will be my first motherless Mother's Day. I am very aware and grateful I still get to revel in the wonderful relationship that I have with my daughters (and many of their friends), but but but but……..

Every time I turn on the TV or the radio, there it is, Mother’s Day, Mother’s Day, Mother’s Day. What are you going to buy your mother this year?  Where will you take your mother?  Show your mother how much you love her. Newspapers, magazines, Muni signs; Richard, my brother-in-law, calls it a capitalist plot.  It got me thinking. There must be so many of us out there. People who never had a mom, people who have lost a mom. Moms who lost a child, women who couldn’t have children, women who made the choice not to have kids but feel a twinge every once in awhile.

There are also so many wonderful families with no mommy but two amazing daddies.  How about immigrant families who are forced to be separated? The list goes on and on. Ouch!

What would my mom do? She would reach out and touch people who needed some love this week.

Let’s go back up to the word maternal at the beginning of this post. In my mind that word has very little to do with gender or biology. Who are the maternal figures in your life?. Reach out and give them a little acknowledgment (or a chocolate covered strawberry!)

Flat heads/physical therapy/chiropractor resources

FLAT HEADS In 1992, the American Academy of Pediatrics initiated the "back to sleep" program in order to try to combat Sudden Infant Death Syndrome. Since this program began, the rate of SIDS has decreased by over 40% . An unintended consequence though was the number of babies who have flat heads from spending so much time on their backs. Nice round heads are becoming a real rarity. Newborn’s skulls have a lot of plasticity, so they are pretty susceptible to external pressure. Up until about six months of life, the skull is naturally thin and flexible. It can easily change shape. It turns out that if you drop a cell phone on your baby’s head it will actually leave a little dent! (Don’t worry he’s fine.) Babies  don’t have a lot of motor control during their early months, so they can’t always easily re position. This flat head condition is called plagiocephaly. It occurs about once in 300 births.  Interestingly, little boys are twice as likely to have issues with this, and right side flattening is more common than left. Positional plagiocephaly does NOT affect brain growth or development, and by ages 4-6 months, most heads have developed a normal shape. But early intervention and recognition can speed up the rounding process Let's start tummy time early and often. It doesn’t need to be hazing. Even one minute at a time can count. The first tummy time can be within their first couple of days, having your baby simply laying on you. Don’t worry about the cord (you most likely aren’t that firm of a surface.) Tummy time is an excellent way for them to develop muscles and work on their head control. Infants lack head control, but they should be able to turn their heads to either side at rest. There are little steps that you can start early to try to avoid letting them have one favorite side. Try to  give each side equal attention. Make sure you swap feeding positions. Offer objects from either side. Alternate directions on the changing table. Consider changing the position of the crib or the orientation of the baby in the crib to reduce the baby’s tendency to look in the same direction. When awake and supervised, prop the baby onto one side with a foam wedge or a towel rolled lengthwise along the baby’s back. Change positions when feeding, carrying, and holding the baby. Provide supervised upright play as soon as the baby has upright head control. During quiet alert times, also encourage mid-line control. Place their hands together and have them look straight at you. Pay attention to  places other than the crib where their little head is up against a hard surface. Anytime that the baby doesn’t have their heads in contact with a firm surface is a bonus! It is not recommended that babies have a pillow for night sleeping, but I am fine with one of the memory foam infant pillows for changing tables. There are quite a few options for this available on Amazon. Janet Green Babb, one of the PT’s listed below, says that one product that her clients have found helpful is a pillow called Mimos Baby Pillow. Some babies, particularly those with shortened neck muscles may develop a more serious kind of flattening. You may hear this condition referred to as torticollis.  If you find that they don’t easily move their head from side to side easily I would suggest a visit to a Physical Therapist or Chiropractor. It is never too early for an evaluation. I have some resources listed below. If all of your tummy time and intervention have not been as successful as we like, the next referral will be to the cranio facial or neurosurgery team for an evaluation. Either of those specialists  might end up sending you along to the  pediatric orthotist team. The orthotists do some scanning (no radiation) and become part of the team that is monitoring your child’s head shape. In some cases, the kids may end up with helmets. Insurance companies vary greatly with their coverage of helmet therapy. The orthotist team at UCSF is top notch. Although helmet therapy is usually not started prior to 5 months of age, there is little downside to having a referral sooner. For those of you interested in further details about the cranial helmet remolding process, see the information at the very bottom of this post. Although we sure do see a lot of kids with flat heads, very few of them end up needing a helmet. Annie, one of my mom’s whose baby ended up requiring a helmet shared her story and wisdom. Her little guy is a second child with a mellow temperament so she wonders if that led to a bit more time hanging out in his infant seat. Her doctor repeated the need for tummy time at each visit, but Annie thinks that with a bit of hindsight, if she had seen a helmet in her future she would have been more aggressive with it. At 2 months she did end up at the chiropractor who loosened up the neck muscles. These treatments made a big difference in his favoring one side over the other, but this little guys head was seriously flat and keeping him off of it did not seem to be helping as much as we needed it to. Annie adds a healthy dose of perspective:  “There are worse things, We are fortunate to live in a place where this can be fixed.” Physical Therapists Pinnacle Kidz is a terrific pediatric physical therapy resource in our neighborhood. The owner Bethany, has been making a big difference for quite a few of my patients. 1772 Church Street www.pinnaclekidz.com 415-654-5324 ------------------------------------------------ The UCSF physical therapy is still over at 500 Parnassus, Room MU-09. At some point they will likely move over to Mission Bay, but not in the near future. Ph: 415-353-4972 Fx: 415-353-4974 ------------------------------------------------ Janet Green Babb is a physical therapist that we have been working with for years. Her office is out in the avenues, but many folks find it worth the “schlep.” 4200 Irving Street San Francisco, CA 949122 415-664-6061 Babb.devprog@gmail.com Janet notes that It is interesting how many babies are experiencing flat heads and preferential head turning. Early intervention seems to be so effective in preventing further asymmetry and for promoting midline and symmetrical orientation. -------------------------------------------------- Starfish Therapies is a pediatric physical therapy provider with several locations in the Bay Area. They have one of their clinics right in the wonderful KidSpace at 2401 Mission St. here in SF To inquire about services call 650-638-9142 or email admin@starfishtherapies.com --------------------------------------------------- Michelle Foosaner Diamond, PT at Children's Therapy Associates Children's Therapy Associates They will do home visits in SF with a prescription from your pediatrician. Michelle says that  as few as 1-3 physical therapy visits can teach parents how to prevent the progression of, or correct, positional plagiocephaly when initiated early enough in development. ------------------------------------------------------- Laurel Condro at the Feldenkrais center is another excellent option for physical therapy. She does group classes as well as individual therapy 415-271-2683 www.feldenkraissf.com Chiropractors Claudia Kindler, a local chiropractor in Noe Valley, shared the following statement:"I love working with all of my patients but I hold a special place in my heart for infants.  Their transition into the world is impressive but not always smooth.  I love holding them and feeling their spine and all of their joints and muscles. Because they are so “new”, they are an open book.  As I investigate their spine and come across a subluxation, or a point of interest to me, the infant frequently pauses and makes eye contact.  They are telling me, “Yes, that spot is the problem”. In working with torticollis in an infant, I am curious how the baby is transitioning- do they prefer to nurse on one side to the other?  Do they only look to one direction?  Do they detest tummy time?   These patterns provide me skeletal clues that should be addressed.  When I feel their neck, upper back and shoulder girdle, I note skeletal challenges that are limiting symmetrical development.  With simple, small and gentle adjustments to the spine and shoulders the skeletal system can relax and return to optimum functioning." Two other chiropractic options are Sandra Roddy Adams and Laura Sheehan. They both work out of an office in the inner sunset at 915 Irving Street Laura Sheehan R.N., D.C. 415-681-1031 or  sheehanchiropractic@gmail.com laurasheehan.com.  Laura says that she has helped many a flat head round out and sometimes with only one visit if it's due to upper cervical strains. Sandra Roddy Adams happens to be my chiropractor, but she works with all ages. She can be reached at 415-566-1900. Dr. Austin Davis works on infants and the whole families. One of my readers contacted me to get him added to this list because she has found him enormously helpful Life Chiropractic (415)626-5433 (O) www.LifeChiroSF.com --------------------------------------------------------------------------- The following information is provided by the UCSF Orthotic and Prosthetic Center How The Helmet Works Approximately 85% of head growth occurs within the first 12 months of life. During this time the head is moldable and responds to light contact/pressures over extended periods of time. Static positioning (laying in one position for long periods of time) on the back or one side of the head often contribute to the development of plagiocephaly. In a similar fashion, the helmet places contact over the areas that are more prominent and allows space over flattened areas. This encourages the head to grow in the “path of least resistance”. The helmet does not push in areas of the head; it directs growth of the flattened areas of the head. Depending on the severity of the flatness and the child’s age will determine the treatment options. Under the age of 4 months we typically observe and have parents actively reposition the baby throughout the day, nights and naptime. Babies this young with a mild flat spot can be fully corrected with repositioning alone. Around the age of 5 months the effectiveness of repositioning is reduced and most health care providers will recommend the initiation of a helmet if the flatness is significant. Ideally if a baby needs a helmet we are starting the treatment between the ages of 5 and 8 months of age. Insurance As with all areas of medical care, health insurance is complicated and specific to each individual plan. The authorization staff at UCSF will perform a check with your insurance around the time of your first appointment with an orthotist. Craniofacial Evaluation After your pediatrician/family physician has placed a referral for a cranial remolding helmet evaluation. First you must see a Craniofacial specialist to confirm the baby’s presentation is plagiocephaly and not something else called cranial synostosis. This appointment is a requirement prior to making a helmet and is much better if this is done before your first appointment with the orthotic team. The Helmet Process Beginning the process for cranial remolding helmets can be daunting for families. The practitioners at UCSF are here for you as you go through this journey. Below is an explanation of the helmet process at UCSF.  First Appointment – Evaluation o The first appointment you have with an orthotist (person that is educated and trained in cranial remolding helmets) to assess your baby’s head shape, size and gather relevant information. Now is a good time to ask questions you have about the treatment and what your expectations should be. o Measurements: regardless of how the orthotist chooses to capture to shape of your baby’s head (by hand vs scanning) measurements will be taken to use as a way to track changes over time. These measurements will be referred to throughout the helmet treatment to ensure progress is being made o Impressions: In order to make a helmet the orthotist must capture the shape of your baby’s head. The two primary ways are with a cast and with a laser scanner. The most important piece is that the shape is well captured and matches the shape of your baby’s head; this will make the helmet fitting process (we will discuss later) much easier. It is common for babies to become fussy during this point in the appointment.  Casting: Plaster of paris will be used to lay over the baby’s head to capture the shape of his/her head. This process is messy and takes about 15 minutes.  Scanning: The baby will have a laser scan taken to create a virtual 3-D image of his/her head. The scan itself can take as few as 3 seconds, but the baby must be extremely still (typically multiple attempts are made).  Fitting Appointment o The helmet has been made and is ready to fit to your baby. The appointment will take 1-2 hours, so bring diapers and food just to be safe. The orthotist will put the helmet on the baby’s head and mark the helmet in areas that are too long and need to be removed. The orthotist will take the helmet off and on the baby’s head multiple times throughout this appointment to ensure it is fitting properly. It is common for babies to be upset/fussy throughout this appointment. o The helmet should not be immobile on the baby’s head. A small amount of shifting and rotation on the baby’s head is acceptable, so long as the helmet is not: coming in front of the baby’s eyes, touching the baby’s ears, or squishing the forehead. o You will be given a break-in schedule to slowly increase the amount of time your baby wears the helmet. Even after she/he has built up to wearing the helmet full-time you will need to monitor the skin for excessive redness every time you take the helmet off. Red marks lasting more than an hour or skin irritation require the helmet to be removed and your orthotist should be contacted for an adjustment.  One week follow-up appointment o Over the first week of having the helmet you and the baby slowly increase to wearing the helmet full-time (23 hours/day). This appointment is to check the fit of the helmet now that they are able to wear the helmet full-time. Minor adjustments are expected at this appointment. o Typically, redness that lasts less than an hour is okay. If you are concerned about the redness on your child’s head make sure to discuss this with the orthotist at your appointment.  One month follow-up appointment o These appointments should occur every 3-5 weeks to assess the progress being made with the helmet and to accommodate for any growth that has happened in the last month. Typically the orthotist will take measurements and/or a scan to evaluate the changes in your baby’s head shape. o In general, a change in your baby’s head shape happens if there has been growth over the last month. It is common for babies to have large growth spurts followed by smaller growth spurts. There may be some appointments where you see a large change in your baby’s head shape, and some appointments where you see very little change in your baby’s head shape. For this reason we are measuring and checking the baby’s head shape every 3-5 weeks to ensure the helmet is doing what it should be.  Adjustments o Despite trying to accommodate for growth on a regular basis (by having an appointment every 3-5 weeks), sometimes the babies go through large growth spurts and need adjustments sooner than planned. This is okay. o When to call the orthotist for an adjustment: Redness lasts for more than 1 hour and is still very red The helmet seems too tight The baby is suddenly resistant to wearing the helmet when previously they tolerated it well Determining the end of treatment o The typical length of treatment is 3-5 months, this will depend on the age when the baby begins wearing the helmet and how severe of a flattened spot is to begin with. With older babies we expect to have a longer treatment time because their heads do not grow as quickly. They can wear the helmet up to 15 months of age, beyond this age there is limited evidence to support the effectiveness of the helmet. o Clinical markers are used to numerically compare your baby’s head shape to “normal”. These markers are helpful in determining a slowing of growth and provide an objective assessment of the changes in the head shape over time. o Satisfaction with head shape and appearance is the ultimate goal. This is used in addition to the clinical markers to decide the end of the treatment.