Hepatitis A: Are you protected?

Hepatitis A: Are you protected? Please see updated post June 2022

Scroll to the bottom for a new vaccination recommendation Parents, have you gotten your Hepatitis A vaccine? Hepatitis A is an inflammatory disease of the liver that is caused by a virus. Some people consider the Hep A shot a travel vaccine because it is the most common vaccine-preventable illness that folks get infected with when traveling. We think that everyone over a year old should get it even if you aren't going anywhere. Hepatitis A is certainly more common in countries with lower standards of sanitation, but this virus doesn’t care about borders. There are plenty of cases right here in this country. Transmission occurs through direct person-to-person contact (fecal-oral transmission), contaminated water, ice, or shellfish harvested from sewage-contaminated water. You can also get it from contaminated raw, inadequately cooked, frozen fruits, vegetables, or other foods. Hepatitis A is quite hardy and can live outside the body for quite a while. It can survive being frozen. This is a nasty virus. Hand washing is important and can stop you from spreading it, but won't protect you from catching it. It makes no sense not to get the vaccine if eligible. Poor hand washing and then handling food is a common mode of transmission, but so is changing a diaper. Thus diaper age children, infected with the virus, are a large reservoir for spreading it. People are most infectious 1–2 weeks before the onset of clinical signs and symptoms, and can shed the virus in the stool for months and months. Dr. Schwanke had read somewhere that in some cases poop can remain contagious for up to a year! The incubation period averages 28 days (range 15–50 days). Infection can be asymptomatic or range in severity from a mild illness lasting 1–2 weeks to a severely disabling disease lasting several months. Most common symptoms include the abrupt onset of fever, malaise, poor appetite, nausea, and abdominal discomfort, followed within a few days by jaundice. Urine may be very dark colored and stool is often clay colored or freakishly light. The likelihood of having symptoms with a Hep-A infection is related to the age of the infected person. Fortunately, although it is rarely fatal, adults with this can become quite SICK! Here is one of the most important facts worth emphasizing: In children aged <6 years, most (70%) infections are asymptomatic. In the young children who are actually acting ill, jaundice is not a common symptom, so it might be awhile until someone figures out that they are dealing with a form of Hepatitis. Most of the time,young children don’t usually exhibit many symptoms at all, or appear too ill, but they pass the virus along to their caregivers who get walloped. We have seen it sweep through a daycare, with many of the caregivers and parents catching it. The vaccine first became available in Europe back in 1993 and started getting phased in to our vaccine schedule in 1996. It has been a routine childhood vaccine in the United States since 2005. It is nearly 100% effective. Interestingly, although it is recommended, it is not one of the vaccines that are required for school entry. It can be given as soon as a child reaches their first birthday and should be followed by a booster six to twelve months later. Protection against hepatitis A begins approximately two to four weeks after the initial vaccination. Because the protection isn’t instant, the recommendation for travelers is to get it at least 2 weeks before your trip, so plan accordingly. The vaccine comes only in preservative free form (no thimerosal concerns). I rarely see any side effects at all. Once in awhile a baby post vaccine might be extra fussy, but that is rare and not necessarily shot related. This one requires little thought. You should make sure that Hepatitis A vaccine is included in your child’s immunization schedule. Parents, also please check your own health records and make sure that you are protected. Adults are often quite clueless about their own vaccination status! This is new! Recommendations for Preexposure Protection Against Hep A Infection for Travelers Infants aged 6–11 months: Hep A vaccine should be administered to infants aged 6–11 months traveling outside the United States when protection against Hepatitis A Virus is recommended. This travel related dose for infants aged 6–11 months should not be counted toward the routine 2-dose series! Therefore, the routine 2 - dose Hep A vaccination series should be initiated between age 12-15 months according to the routine, age-appropriate vaccination schedule. High risk travel zones include all parts of the world except Canada, western Europe and Scandinavia, Japan, New Zealand, and Australia.

The Four Month Sleep Regression/Nap tips

The four month sleep regression

Ah, the dreaded 4 month sleep regression. I get calls about it all of the time. Noe Valley Pediatrics Dr. Elizabeth doesn’t like to call it a regression and she makes a good point. Think of it as moving into a new phase. Similarly, Parentline founder and clinical psychologist Dhara Meghani says, we tend to encourage parents to think about the 4 month sleep regression as a time of reorganization, rather than a setback. An (imperfect) analogy is to compare it to when you are cleaning and reorganizing your closet or kitchen cabinets. Often times we have to pull everything out, may have to shuffle things around, discard what no longer fits, and even install some new hardware to make the storage more efficient. The brain does exactly this every few months during infancy, and even years into development -- it goes through what we refer to as phases of "synaptic pruning" in the service of increasing efficiency and speed of important neural connections. So while there is all this work occurring underneath the surface, what may temporarily go by the wayside are the infant's developing skills of falling and staying asleep, feeding fully without being distracted, and being consolable when overtired, cranky, hungry, or bored. While your baby's brain is going through this enormous growth spurt, they are more aware of everything around them. You might find that they pop off the breast or bottle more frequently to pay attention to their surroundings. There are lots of developmental changes going on. Babies are trying their best to roll over, but usually can only flop over from tummy to back. Daily tummy time exercises are even more important now so that they can work on mastering the roll in both directions. In the first few months of life there is usually no real set schedule. Babies eat, they snooze, they are awake for a bit, maybe another snack and then some more sleep. Ideally you have made a clear distinction between daytime and nighttime feedings and have encouraged longer stretches at night. But here you are, your baby seemed to be doing pretty well. You were getting a nice enough stretch at night that you couldn’t tell your other friends with young kids without sounding like you were boasting. Now, just when you thought you were about to see the light after this stretch of new parent sleep deprivation, suddenly horrors, your previously good sleeper is back to waking up at night. This phase will vary from baby to baby. Sometimes it is only a night or two, and for the more unfortunate, it can last a few weeks. The not knowing how long it might last adds a degree of frustration. Let’s consider some of the more obvious causes of what could be stopping them from going back to sleep when they have those middle of the night wake ups . Step one is making sure that they have some self soothing skills! The sleep cycles are becoming a bit more like those of an adult, with the light sleep, deep sleep and REM. When babies hit those light cycles they may wake up. It is essential that they have the ability to get themselves back to sleep without relying on you. If you put your baby to sleep with help, nursing and rocking rather than letting them drift off to sleep on their own, then when they become aware of their surroundings and you are no longer present, they are going to object. Shooshing and quiet singing with a hand on their chest may be a nice compromise. Your message is, “you are fed, your are changed, I am right here. You need to sleep.” Right from the beginning (brand new parents, I hope you are paying attention) it is essential that you allow them to do some self soothing. Of course they will fall asleep when they are feeding; that’s fine. But, when you transfer them to their crib and they stir a bit, that’s okay! Don’t return them to the breast; simply give them some little pats, and see if they can settle back down. Every single time that your drowsy baby is able to drift off to sleep on their own it should be considered a win. My mother in law tried to gently give me that wisdom which I soundly rejected. What did she know? My baby wasn’t going to allow me to simply put her down! I nursed and vigorously rocked Lauren to sleep for at least 4 months at which point we (who am I kidding, it was all on my husband!) had to do a phase of tough sleep training to teach her some sleeping skills. Once they are finally asleep, tiptoeing around in utter silence to avoid waking the sleeping baby gets pretty old. Some parents find that turning on a white noise machine for the sleeping period helps. A Hepa filter works well for this and serves a purpose at the same time. Soft music playing is another option. If you have Alexa she can play some nice lullabies for a set period of time. If they can learn to sleep with some background noise you won’t have to worry so much about them waking from a sudden sound. Baby might be hungry. My sleep advice doesn’t get terribly strict until they are getting some extra calories during the day with the addition of some solid food. Until they seem ready for that, I would consider offering a dream feed before you go to sleep. If your superstar was giving you 9-10 hours without a meal before this unwelcome change in their sleep pattern, do not go down the slippery slope of offering extra meals at night aside from that dream feed. If you offer them more frequent nursing, I would imagine they will be happy to accept it. That doesn’t mean they need it. At this age, the body benefits from a break from digesting at night so that it can concentrate on other growing tasks. Is it dark enough? Try to make the sleeping room as dark as possible. Making sure that you have blackout shades or thick curtains can extend your mornings and help out at nap time. Make sure they are not over tired! This is also when you can start establishing a more regular nap schedule. A 4 month old should be getting a total of 13 -16 hours of sleep in a 24 hour period.This ideally includes 3 naps a day. More often than not, 2 of the naps tend to be shorter and there is one longer one. Some babies absolutely don’t seem to need quite as much sleep as others, but if you have a cranky kid on your hand, I am going to suggest you make sure that their sleep schedule is adequate. You might think that a baby who didn’t nap well will catch up with a great night sleep, but you would be wrong. When a baby is overtired you are trapped in a nasty cycle. The first nap is usually about 2 hours after their morning wake up. The second nap is about 2 & 1/2 hours after they wake up from nap number 1. The third nap is 2 & 1/2 hours after nap number 2, but it is essential that the 3rd nap is over before 5 pm or it will interfere with bedtime. If you are lucky you can get into a grove with this for a couple of months. At some point between 6-9 months they usually get rid of the third nap and go down to 2. Naps don’t need to be written in stone. I don’t think you need to be pinned to the house because of a nap schedule. Second babies don’t have that luxury and nap on the go. If you are lucky enough to have a baby who snoozes in a stroller or carrier, that can count as a nap as you go about your day and get some errands done or go for a walk with a friend. I would try to have at least one nap that is in the crib. That nap is great practice for letting them drift off on their own. Make it dark, turn on the Hepa filter, sing a song while you do a little massage and then leave them be. Some babies need to fuss a bit as they go down. If they are absolutely screeching when you leave, go back and soothe them. Starting good habits from the start will make everything much easier. Trust me on this. Sleep begets sleep. If your baby still doesn’t seem to be getting enough sleep, you might need to start your bedtime earlier. I understand that this isn’t always easy to do. Working parents want to have time with their babies for a bit in the evening and it can be a challenge. Have a bedtime routine that signals that the day is winding down. Make sure it is calm, this is not the time for jumping around. Having a special song and massage routine right before bed is also a nice way to wind down. Hands, ears, feet are especially relaxing. Pacifiers. I am fine if they use a pacifier to fall asleep. DO NOT get into the habit of replacing it every time it falls out. That is akin to a dog with a ball, it never stops. Room Temperature/sleep suit options Keep the baby’s room somewhat cool and use a sleep suit when swaddling is no longer an option. Because this is the age when babies are growing out of the swaddle, many of my families have found the Baby Merlin's Magic Sleepsuit will help you out of this transition. Dhara sent a few other links to share that look like they are worth checking out. 2. Zipadee Zip: zipadee-zip 3. Puck-A-Baby: puckababy The Puck-A-Baby has a higher price but can follow your child through their early toddler years and through seasons. Try to be as consistent as you can. Remember, any time that your baby has an extended period of tough nights, it could also be an ear infection or something else going on. It is worth calling about a fussy baby if you aren’t able to get things under control. Dhara reminds you: --Get support. If baby's not sleeping, chances are you aren't either. Can you find a neighbor, family member, or friend to come by and help with the dishes or the laundry? Can they take the baby for 15 minutes so you can get a shower in? If you have a partner to split up the shifts at night that can also reduce the burden on any one person. Don’t forget that Parentline is one more terrific resource for parents who are trying to figure things out. It is a free service hosted by the University of San Francisco. More info down in the bulletin board section 1-844-415-BABY Parentline@usfca.edu Thanks so much to Dhara Meghani from the University of San Francisco Parentline for her valuable input and feedback on this post!

Vaporizers/Humidifiers: What's the difference? Do you need one?

Vaporizer vs humidifier A lot of folks who live in San Francisco keep their homes fairly cool. My husband actually prefers the cold and our own house is usually pretty chilly. Our out of town guests and my daughters are likely rolling their eyes at that blatant understatement. Having visitors is a fairly regular occurrence and I confess that they tend to keep their coats on as they shiver on our couch while wrapped in a blanket. East Coast folks aren't used to cool houses in the winter time; they keep the furnaces are on steadily for the colder months making making the indoors actually warmer and dryer than I like. Recently the weather got chilly enough that even the most stubborn of us cranked up the heat. When the heat goes on, I know that I will be getting more calls about nosebleeds, snoring, night coughing and even worsening eczema. If you have sparks and static electricity in your house or apartment, I am talking to you. Getting out the Humidifier/ Vaporizer will make sleeping much more comfortable. Humidifying the air is also one of the first things I recommend for patients who have colds/cough and congestion. Added moisture will usually ease irritated airways. I find it essential for kids with croup and RSV (both of which are going around). As a bonus, some researchers have found that humidity levels above 40 percent might help deactivate virus particles, making them less infectious It’s important to match the humidifier to the room size. A small room is roughly considered 26-299 square feet and a medium room is 300-499. Do a quick measure of the rooms that you are shopping for. The ideal indoor humidity should be 30 to 50 percent. If you want to be a real science nerd, invest in a hygrometer. They are available for less that $15 on Amazon and they can help you fine tune the humidity level in your house. Even without the hygrometer, if the air in your house or apartment feels dry, it is time to invest in a machine. Using a humidifier that’s too small won’t be as effective, and using one that’s too big can cause indoor allergies. Dust mites are the number one indoor allergen and they thrive on moisture from any source. It is a fine balance. We really don't want to keep the rooms overly damp. In San Francisco you can grow mold very quickly, which is another allergy trigger for many people. My suggestion would be that you don't run the machines 24/7. Make sure you turn them off during the day and dry up any dampness on walls or around windows. Many of the machines will recommend using distilled water instead of tap. Unfiltered tap water usually contains higher levels of minerals and other particles. The humidifier can push these particles into the air. They will either get inhaled or settle around the room as dust. Neither is ideal. The harder the water, the bigger the issue but using distilled or purified water is always the better option. Aside from the health issues, the minerals from hard tap water will build up in the machine and cause it to wear down much faster. Vaporizers and Humidifiers essentially do the same job, but they have a few differences that you should be aware of. The world has changed a bit since I last updated this article in 2013. Now when you look for vaporizer ratings, it is more likely that they are cannabis related. (calm down, it is legal here!)You may have to scroll down a bit in the google search to find the type that I am referring to. Vaporizers heat the water to make steam. The downside for them is the potential for getting burned (and it does happen, trust me, I get the calls.) On the plus side, Vaporizers have LESS chance for growing bacteria (still change the water please.) On a cold night, I find the warm mist more comforting but if you opt to use a vaporizer it is essential that you have it placed so that kids and pets can’t get close enough to knock it over or even get burned by getting too close to the steam. Make sure you place the machine on a level surface that can’t get knocked over. It should be at least 4 feet away for a crib or bed. Humidifiers use a cold mist. A humidifier has a greater chance of growing bacteria if not cleaned properly. The technology is always improving and you can get machines that claim to kill the bacteria. There are a lot of great machines out there with huge price ranges. I have seen some for under $30. If you are just going to bring out the machine for the occasional cold symptoms, you should be fine with an inexpensive machine. In a recent Consumer Reports ratings, one of their favorites, and best buys, is a $30 unit from CVS. You don’t have to spend a lot. There are tons of sites out there that rate different machines. I do not have a favorite and you should have no trouble finding a list of the most highly recommended units. A few features that I would pay attention to would be the ease of cleaning and an auto shut off. Some machines also give you the choice of hot or cold mist. Many of my patients travel with theirs, especially if driving up to the mountains where the air is even dryer, so you might also consider how portable it is when choosing a machine. Some machines give you the option of pairing with Vicks or other inhalants. When you are doing your shopping, you might want to pay attention to that. You should not add anything to a vaporizer or humidifier unless it specifies that you can. I find that Vicks smell quite soothing, but I wouldn’t use if for babies under 3 months. Don't be lazy! When you use a humidifier, you need to at least change the water every day no matter what type it is. Not all manufacturers make that recommendation, but Consumer Reports does. They have done quite a bit of testing to lead them to that conclusion. Here’s a good routine to follow: Every day: Empty, rinse, and dry the base tray or reservoir before refilling. Every week: Remove water scaling with vinegar, and disinfect the unit with a bleach solution following the manufacturer's instructions. Before storing: Clean to remove scaling, disinfect with a bleach solution, and dry thoroughly. After storing: Before using again, clean to remove scaling, disinfect with a bleach solution, and dry thoroughly. Don’t fill it before you need to. Every year we get calls from people taking the old machine out from the bottom of the closet, finding it covered in mold and freaking out. Alas, we don’t have a magic wand to remedy that. It is easily avoided if you follow the directions above.

Keep a journal & document your milestones!

Keep a journal &

document your milestones!

It’s almost the New Year. This is often the time when people find themselves making all sorts of plans for how to generally improve aspects of daily life. I have a suggestion for one resolution that is fairly easy to keep. This will be useful and has the potential to bring plenty of smiles in the years ahead. Start keeping a journal! Sure, we all take a lot of photos and movies these days, but there is nothing like the written word. If you haven’t done it from the first, it is never too late to begin. Start keeping track of milestones and illnesses. Having things written down can be a valuable resource. I am not advocating keeping a list of every bowel movement (yes there are parents who do that; you know who you are) but knowing how often your child has had strep throat, an ear infection or any significant illness can be quite handy. Especially if you have more than one child, it is often easy to get things mixed up. I have more that one parent who has said, “I know one of my kids gets a rash on Amoxicillin, I am just not sure which one.” Keeping record of milestones and illnesses alone makes keeping a journal worth the effort, but immortalizing memories and anecdotes is what makes it fun and even more valuable. We have tracked all kinds of odd statistics. My 28 year old Alana has been on 262 flights. 31 year old Lauren will be completing #379 later this week when she returns from her honeymoon. Two of Lauren’s flights were skydiving expeditions and both of my girls have managed to be at the controls flying a private plane. (This mom knows how to feel somewhat proud and somewhat horrified at the same moment.) If you give me a moment I can also retrieve all sorts of random facts, like the first movie they ever saw in a movie theater and when they lost their first tooth. I actually started keeping track of things when I found out that I was pregnant for the first time. Clearly you don’t need to write things daily, but keeping track of milestones and fun things that kids come up with can create a wonderful database of stuff that you are sure to refer to and enjoy as your children grow. My journal unfortunately does have some huge gaps, when I never got to it; just do the best you can. What started out as my personal musings written in a notebook, morphed into a family journal when I transferred it to a word document. If you like you can create a shared document that both parents can add to. Google drive would be perfect. (Make sure you backup any important documents!) In our journal (both kids share the same one) daddy’s voice was written in italics. My husband had the wonderful habit of documenting conversations. The following was from when Alana was seven and daddy was picking her up from school: Alana:  I'm doing a picture in reds and pinks. Sandy:  Why? Alana:  Because Van Gogh had a red period. Sandy:  You're learning about Van Gogh? Alana:  Yeah. And then I'm going to do a painting in different shades of blue. Sandy:  Why Alana:  Because Van Gogh also had a blue period. Sandy:  Well that's terrific. Alana:  And Miss Price is going to bring a real artist to class so he can teach us. Sandy:  Well that will be very exciting. Alana:   But it won't be Van Gogh because he's dead! In our case I am delighted that we were able to track early milestones like first words and motor skills. Over the years random facts like teachers names, the revolving door of boyfriends and life events have all been documented. One of my favorite posts recounts about the time that 5 year old Lauren and I took a family ceramics class at the local Randall museum. At the start of the first class, the instructor had everyone get a feel for the clay. We stretched and pulled in into all sorts of shapes. As we played, the teacher asked ”Who knows where clay comes from?” Lauren was never shy. Without missing a beat, she called out the answer in a loud, authoritative voice. “Cows! Clay comes from cows!” There was a moment of stunned silence as all the grown ups at the table did our very best not to break out in laughter. “Hmmm”, said the teacher, handling it very nicely. “Great guess, but it actually comes from the earth.” Cows?? I remember that being one of the hardest giggles I ever had to stifle. Laughing in the face of my five year old was not something I wanted to do. Kids do come up with some wonderful stuff. Another one that became part of family lore was the time that 3 year old Alana bit her sister: Mommy: “Alana, why did you bite your sister?! You know you shouldn’t bite!” Alana: “I forgot not to.”  That “I forgot not to” line still comes up every once in awhile. When does it stop?? My kids say never. They especially insist that I keep up with their flight tallies! (We still count every take off.) You might be dealing with any of the more challenging aspects of parenting like sleep deprivation, the “terrible twos” or teens that are giving you a run for your money. Warning, time zips by. Blink and they are out of the nest. Carpe Diem! The online journal is a great way to capture moments forever. Grandparents might want to start their own version. A new friend that I met on my recent trip recounted an experience. Her twin grandsons were visiting. Clearly she wasn't in the habit of locking the bathroom door. One of her 5 year old grandsons showed up in her bathroom while she was in the shower. He was wearing a hat and carrying a fishing pole: “Grandma, You need to stay where you are for a bit. There is a triceratops in your bedroom, but don’t worry about it, I’ve got this.” Capture your moments!!

Assessing the impact of the recent smoke exposure

Assessing the impact of the recent smoke exposure

Everyone living in the Bay Area or anyplace within 100 miles of the recent fires has been exposed to unprecedented poor air these past couple of weeks. Aside from dealing with the tight lungs, burning eyes, sore throats and stir crazy kids and pets, families are worried about potential lasting impact that this might have on their children’s health. Chronic exposure to pollution can lead to issues with our hearts, our bones, and our lungs among other things. There are some anxiety provoking studies out there suggest that a fetus is not immune even though they are not directly breathing the air. I tend not to let different studies cause too much of a stir. Studies on things that we have no control over can get people spinning. One headline this week claimed that exposure to this unhealthy air was the equivalent of smoking 10 cigarettes. Gee, thanks for that extra dose of terror. Of course we would have had to have been outside, without a mask for an extended period of time to be affected like that. Please keep in mind: Millions of people live in large cities where this terrible air is the norm. Here in Northern California, we only had to deal with it for just a few weeks. I imagine that we all breathed some nasty air, but hopefully most of us were able to limit our outdoor exposure. Assuming that the air quality index is no longer in the red zone, take a deep breath and prepare to review an important life lesson; my mom had a saying that she would repeat frequently “It is what it is. You do the best you can.” There are some things that are within our control and some things that are not. We need to be able to identify which is which Lets focus on things that are in our control. Being kind Being honest Friends we choose Taking care of ourselves Working hard Apologizing Asking for help How we respond to others What we do in our free time Things Out of our control Others being kind Others being honest Others forgiving us Who likes us The family we were born into The color of our skin Past mistakes Natural disasters Death Taxes Are you beating yourself up because you stayed in town? Really? Assuming you had the time, the money, the ability and the fortune telling magic to know how long this bad air was lingering, was hightailing it out of here the right solution? Are you feeling like a terrible parent because you couldn’t stand being cooped up and you let your kids run around outside for a bit and now you are worried? It’s easy enough to be the Monday morning quarterback. ‘Woulda Coulda Shoulda’ are simply not worth much. My husband was an executive for many years and his employees knew that after bitching about something or another that had happened, they would inevitably hear him say: “you can’t manage the past” My daughter Alana who is now a therapist here in SF taught me that Dialectical Behavior Therapy (DBT) refers to my mom’s “it is what it is” as radical acceptance. There are an infinite number of things that cause pain, suffering and anxiety, but only 4 different actions that we can take: Problem solve: Is there something within your control that you can do? Find the silver lining or lesson :There is always a lesson but sometimes the silver lining doesn’t become apparent until sometime in the future, if at all. If you look hard enough there is usually at least a sliver. Practice radical acceptance: It is what it is and you do the best you can (Just like mom...repeat this frequently) , or Stay stuck While we can’t problem solve past exposure to poor air quality away, what we can do is learn any lessons that may come in handy in the future. It is safe to say that this could happen again. We need to make sure that we are prepared. Order masks in advance so that you have them on hand if the need arises. Have a HEPA air cleaner (change the filter periodically. We just changed ours and it was beyond gross). My sister-in-law and brother-in-law just purchased one of the newer ones that gives you a reading of the air quality in the area of the machine. Before they even plugged in it, the air in their house rated just fine. Being inside does make a huge difference. Have an evacuation plan for your family. Earthquakes are just as much an issue as fire. Now is the time to check your earthquake kit and update it as needed. Get familiar with local resources that can help you out in an emergency. For those of you in the Bay Area, this is an important site for guidance in case of all sorts of emergency situation: https://www.sf72.org/ If you are looking for some more benign and possibly helpful actions? Personal Lets tend to our bodies. Stay hydrated Decrease mucus producing foods (Dairy products are often the biggest offenders) There are multiple sources that claim different foods can help keep lungs healthy. That list includes pineapple, garlic, ginger, turmeric, dried figs, tomatoes, apples, green tea A steamy shower with essential oil (like eucalyptus) Get or give a massage with warm oil. This will relax and open the airways Do some good deep belly breathing Global Be a voice for to help protect our ailing planet from climate changes. This should not be a partisan issue. If there are tangible, sensible things that we can do to minimize pollution everyone should be on the same page. I reached out to my dear friend Brenda Ekwurzel who is a senior climate scientist and the director of climate science at the Union of Concerned Scientists and asked her for advice on a good fund to donate to. She suggested theNature Conservancy Climate Changes Everything is another good site to check out. This is a friend of a friend who has taken on climate change as his personal mission. Check it out. Or you might give money to folks impacted. Charity Navigator can help you research effective organizations to make donations to. In any event, taking some sort of positive action can help us not 'stay stuck.' Don’t be afraid to have conversations with your kids. Here is the situation. These are the things we can do. The review of things in and out of our control is an important one. It is the rare child under 5 who will get it, but you are the model. They will learn by example.

Air Quality update November 2018

Air Quality Update

Wishing all of you a happy and healthy Thanksgiving.

I was all set with my Thanksgiving topic on how to deal with turkey leftovers and general food safety, but all the calls I have gotten in the office today prompted me to add a bit of focus on the air.

What would make us all jump for joy is a bit of rain. For those of you not in the Bay Area, go outside and take a deep breath of air for all of us. Today our air quality moved into the purple range. Very unhealthy for everyone. If you are traveling, I would think hard before returning home until things start to clear.

Air Quality index

It is Horrid. It is eerie. It is scary. It is claustrophobic. As bad as it is for us with our scratchy throats, tight lungs and irritated eyes, my heart goes out to all those thousands of people who have lost loved ones, homes and are even closer to the fire. This feels even worse than last October, and those fires were weren't even as far away.

What can we do to deal with this smoke?

• Stay indoors as much as possible!

• If kids are stir crazy, consider a mall like Stonestown (especially if you can park underneath and avoid walking outdoors) Consider creating an indoor activity there like a scavenger hunt or bring a pad of paper and colored pencils; practice drawing

• Sometimes we just need to turn on the tv or watch some videos on our ipads. Do what you need to do to get through this smokey period. As long as you control it and use tech time as a tool it's okay to make some exceptions and allow a little more than you might in normal circumstances. Your sanity counts for something.

• If you are outside wear an N95 or N100 mask. There are cute children's ones available on Amazon.

• After two years in a row, I fear that this seems like the new normal. I suggest ordering some extra N95 masks to keep on hand so that you are always prepared.

• Avoid ANY strenuous activity.

• If you have a HEPA filter keep it running.

• If you are in your car, keep the air on recirculate.

• Avoid adding to indoor pollution. Don't light candles or vacuum. No Smoking!!! DUH

• Pets shouldn't be exposed to the smoke any more than we should. ( I know, try explaining that to them!)Toss the ball a little bit more indoors, but limit their outdoor time as much as possible.

• Be aware that food delivery services are being impacted. Today, many of the couriers were not delivering due to safety concerns. Plan ahead with your meals.

Smoke is bad enough, but if we are ever in the situation that we need to be dealing with actual fire, I am sharing this essential information from a friend of mine who lives in Santa Barbara and has been through this a number of times.

Home Evacuation Checklist – How to Prepare for Evacuation:

Inside the House

• Shut all windows and doors, leaving them unlocked.
• unlatch the garage door
• Remove flammable window shades, curtains and close metal shutters.
• Remove lightweight curtains.
• Move flammable furniture to the center of the room, away from windows and doors.
• Shut off gas at the meter; turn off pilot lights.
• Leave your lights on so firefighters can see your house under smoky conditions.
• Shut off the air conditioning

Outside

• Gather up flammable items from the exterior of the house and bring them inside (patio furniture, children’s toys, door mats, trash cans, etc.) or place them in your pool.
• Turn off propane tanks.
• Move propane BBQ appliances away from structures.
• Connect garden hoses to outside water valves or spigots for use by firefighters. Fill water buckets and place them around the house.
• Don’t leave sprinklers on or water running, they can affect critical water pressure.
• Leave exterior lights on so your home is visible to firefighters in the smoke or darkness of night.
• Put your Emergency Supply Kit in your vehicle.
• Back your car into the driveway with vehicle loaded and all doors and windows closed. Carry your car keys with you.
• Have a ladder available and place it at the corner of the house for firefighters to quickly access your roof.
• Seal attic and ground vents with pre-cut plywood or commercial seals.
• Patrol your property and monitor the fire situation. Don’t wait for an evacuation order if you feel threatened.
• Check on neighbors and make sure they are preparing to leave.

The Pie Theory of life 2018/ Nurse Judy's Pie shifts

Somehow or other I currently have 2,400 subscribers who now get my weekly posts. The blog has had 270,000 visits which astonishes me. Thanks to all of you who read them and share them. Writing these has been a pleasure. I am always learning. Your feedback has been something that I cherish. In honor of this being my 100th post since starting the weekly emails on Constant Contact I am running one of my all time favorite posts. My kids and I live by the “pie theory.” My personal pie is going through some shifting pieces. Detail are at the bottom of the post.

This week's Topic Finding Balance/ The pie theory of life

Here is an update of one of my top ten favorite posts. Scroll to the end of the post for an update in the shift in my personal PIE The "pie theory" got its inception many years ago. For a number of years (many years ago) I was the Parent Association president at my daughters' elementary school. It took an inordinate amount of my spare time, including meetings several times a week. On many levels it was rewarding being so involved but I assure you, I was delighted to pass the reins when my stint was over. Though I was really genuinely relieved to have my time back, I felt off balance by all the sudden free time in my schedule, and at first I couldn't figure out why I was so unsettled. I finally realized that although the new empty hours were welcome, they had created a bit of a vacuum. I filled it quickly (started taking up karate a few evenings a week), but it was right around that transition period that the "pie theory" helped me make sense of things. Imagine that your identity is a circle (or whole pie). Who you are is divided into many pieces; some pieces are large, some small, some temporary. Some are constants that are with you life long, some are optional, some are good for your soul, while still others are energy sappers that give you little in return. Are you: Daughter? Son? Sibling? Friend? Spouse? Ex spouse? Grandparent? Student? Volunteer? Pet owner? In a job/occupation or seeking one? Doing a hobby that takes time and energy? Member of a book club or any club for that matter? Churchgoer? Exerciser? House cleaner? Carpool driver? Event planner? Adventure seeker? and of course last but not least....Parent? The list goes on and on. What activities make up your day, your week, your month, your year? What pieces make up your pie? Take a few moments to figure it out. Get a piece of paper and a working pen (if you can find one) and create your pie. It's interesting to think how you can be identified in different ways by the various pieces of pie. Many folks recognize me as Nurse Judy. More than once I have actually looked at a rash, or given advice from a restaurant table (as my patient husband rolls his eyes.) There was a time years ago when I came to work one day and saw a construction worker on the roof of a neighboring building. He looked awfully familiar and I was struggling to place him; was he a parent from the practice? Someone from school? I could see that he recognized me as well; we kept looking at each other and a moment passed. I could see that he had figured it out first. He gave a big grin and called out "Ahoy there Java's mom!" Of course! I ran into him several times a week with his pack of dogs when I walked my dog Java. Not only did being a dog owner dictate my daily schedule and get me out walking rain or shine, it also included me as a member of a distinct social network in the neighborhood for many years. All the dog owners knew each other by sight and all the dogs by name. Being "Java's mom" was a wonderful piece of my "pie" for 12 years. If you are a pet owner, that piece has a very special place allotted to it. I am now proud to be grandma to my daughter's giant puppy Bowie. Your pie is finite. You can only do and be so much, as there are only so many hours in the day. Some folks have too many things competing for time and attention, and figuring out which pieces can be compressed can be quite stressful. Sometimes we make poor choices. For busy working parents this might be a foreign concept, but some folks don't actually have enough pieces to begin to fill the shell. A big empty pie can be just as unsettling as a full one. Have you ever noticed that when you are super busy you can manage to get through an entire to-do list very efficiently? On the other hand, on a quiet day you may have only one or two things on the list but somehow nothing gets done. A healthy pie has plenty of interesting pieces that can grow and shrink according to your needs. The more forgiving and elastic the pieces, the easier time you will have finding a good balance. Your pie will naturally change from year to year, but some changes are enormous. Some people are comfortable having a very crowded pie, while others are quite fine and happy doing nothing at all. Part of this is figuring out what your ideal is, and work towards that. Any large sudden changes to your pie will make you feel unsettled, way less so if you have a glimmer of what is going on; hence this theory. Both of my daughters have taken this to heart. In fact Alana has permitted me to share her own blog post on the Pie Theory that she wrote several years ago: Alana's blog about the Pie Theory (Blogging runs in the family I guess) When there is a large shift in your pieces my girls and I refer to this as "pie disequilibrium." Common culprits might include: Event planner: Folks planning a wedding or large event can spend months dealing with all the fun details. When the event is over, that planner piece is gone, your pie has a gap. Sports Fan: My daughter Alana has a twinge of "Pie Disequilibrium" every October when baseball season is over. Actor: My daughter Lauren had to learn how to deal with the extra time that appears after a show run is over. . Caregiver: Folks that spend much of their time and energy tending to someone else’s needs might find themselves suddenly with a large vacuum when that person is gone or no longer needs them. Parent: As your children grow up it can be a tough adjustment (don't worry, they still love you.) Luckily this happens in stages. Kindergarten...a full day of school...college. Parents who have the "parent piece" taking up the entire pie may feel a twinge when their kids don't need them in quite the same capacity. Huge life changes will create seismic shifts. Nothing will ever match the huge transitions that take place when you add the parent piece to your pie. My best advice to you as you shuffle all your pie pieces and see how things fit comfortably is to identify pieces that need to be protected so that they don't get too small. DO NOT IGNORE YOUR PARTNER! Protect that piece. Get creative and make sure that you have time for the two of you; have some moments being a couple. DO NOT IGNORE YOUR OWN NEEDS! Being the best parent that you can be includes living by example. Let your kids have parents that are multifaceted and not consumed by any one thing (be that parenting or a job.) Best of luck finding a balanced, interesting, and fulfilling pie! Nurse Judy's shifting pie: As many of you know, I have been working at Noe Valley Pediatrics for over 30 years. In July of this year I opted to remove the office manager slice of my pie. I am continuing with the parts of the job that I love, which are teaching parents, giving advice and writing. I am now in the office Mondays and Thursdays. I am fortunate to be enlarging my mom piece, as both of my daughters and now my son-in-law, live several minutes away from me. My travel piece gets to stretch a bit in December. My husband and I will be doing an exciting trip to Southeast Asia. I don’t do the mountain climbing with him; this is his turn to do some tamer traveling with the wife. But the big news is that I am planning to expand the “piece of pie” that involves my writing. I have been encouraged by many, (gently nagged by a few) to go beyond the blog and write a book. I am at the very beginning of the process. I would love to hear from folks who are writers, or are in the business. I am currently gathering info and advice and would appreciate any wisdom or tips that you are willing to share.