How to make sense of the ever changing covid guidelines

So many parents are struggling to navigate the tricky balance as some of the quarantine restrictions are lifted. I have gotten many questions about this. 

Having kids that are too young to be vaccinated and little ones who are too young to comply with masks, makes it even more complicated and stressful. As wary as we might be about normalizing, many folks have not seen their extended families since 2019 and are busting to finally visit important people they have been separated from. Zoom is a poor substitute for an enormous, in person hug.

 I started out looking for answers by asking an expert, my friend Dr. Bob Wachter who has been a respected voice during this pandemic. He shared a recent podcast. Here is the link if you want to listen to the hour. It is worthwhile. https://podcasts.apple.com/us/podcast/toolkit-safe-or-not-safe-summer-edition/id1504128553?i=1000517710799 

Dr. Bob had two very bright epidemiologists as his guests. The striking thing about listening to them was that they were grappling with the questions of travel, mask/no mask...etc. and they didn’t always agree on how they would answer some of the questions. Alas, there are not always clear answers. 

Every family is unique. People have various levels of concern as well as different levels of risk. Interestingly these don’t always correlate. I know of some at risk families who are fairly bold and families who are really at minimal risk but remain extremely cautious. 

 This is not going to come as news for folks who have read my previous posts, but as usual, it comes down to a risk/benefit analysis. Think about this - I have so many parents who are really nervous about having their babies start eating solids. They are worried about choking. If they had their way, they would only feed pureed food for the first several years! Obviously that isn’t a reasonable choice. Kids need to learn how to eat and chew. Parents need to learn the safest ways to feed and how to do a choking rescue maneuver if needed. 

 In the same vein, there might be some risk involved in leaving the safety of your quarantine bubble, but kids need to be social. Keeping them at home is not an option that I would agree with.

 In an effort to reach a larger audience, Dr. Ted and I did a live Instagram event on June 3rd, and I will do a little summary here for those of you who were not able to join us. 

I am not going to address all of the specific questions that we tackled; instead I will review the basic guidelines that I have used to find the answers. 

 As we grapple with the choices here are some things we know: 

 Outdoors is safer than indoors when it comes to Covid transmission You are unlikely to get COVID from a surface; it spreads from close person to person transmission. At the beginning of the pandemic, I know people who left mail and packages untouched for 72 hours as if they were radioactive. The data came in pretty conclusively that that was unnecessary. No one seems to be doing that anymore. Of course people can still pick up other nasty germs from surfaces, but that is not the focus of this post. 

 Handwashing a great. Make sure you use soap and water for 20 seconds. If you are using hand sanitizer use at least a dime sized amount. No, you don’t have to follow your kids around and wipe down their hands every second, but I would do a good wash when coming in from outdoors and also prior to every meal. 

 Most kids who end up getting COVID are not terribly ill. While there is the very scary multi system inflammatory syndrome, it is incredibly rare. Vaccinated people are mostly safe from getting severe illness or dying from Covid.

 Keep in mind that prior to covid, we frequently made the choices to travel during flu season. The risk to young kids is similar. In some instances influenza is actually harder on the little ones. 

 No person’s situation is exactly the same as another's. If you opt to be more cautious and want to keep your mask on, there is no need to apologize or defend yourself. 

 As you look at the risk benefit here are essential questions that will make a difference in the answers. Are eligible people in your family fully vaccinated? 

 Are there family members who are at high risk? 

 How are the numbers in your area? 

My advice to someone in the Bay Area would differ from that to someone in Brazil or India. Find a trusted resource where you can keep tabs. Everything could change if a new variant comes along or numbers spike up again. 

 To close, I love gathering pearls of wisdom from sources that I trust. Emily Oster just did an article about this same issue. For data lovers, she is fabulous, but one thing she said that really resonated with me was that people ask “should I be worried?” She suggests that that is the wrong question. Instead people should ask if there is an action that they can or should take that is different from what they are doing. Once you figure out what feels like the best path for your family, march on down it, knowing that you made the best choice at the time. 

Choosing to be worried is a choice that will only leave you feeling helpless. I know I know, easier said than done. https://emilyoster.substack.com/p/family-planning-unmasked-offices My mom’s favorite piece of wisdom is always worth repeating. “It is what it is, do the best you can.” Gather the data, and don’t get frustrated if the data changes as new information surfaces. Make the choices that feel best for you.

Talking to your child about homelessness

In Memory of Roosevelt. 

 Many years ago, when I was still working at Noe Valley pediatrics, I was sitting at my desk, (more than likely talking to someone about their child’s poop). A frantic passerby rushed into the office. She told us that someone had fallen and was bleeding profusely, and thought that since we were a medical office, perhaps we could help. 

My medical assistant, the amazing Josie, had the sense to grab some gloves and gauze, and we rushed out to see what was going on. There were several other people already at the scene assisting an elderly woman who was on the ground. 

As luck would have it, one of the helpers was a doctor. She was holding pressure to the wound with a nice, large towel that another passerby who was on his way to the gym happened to have with him. (Any Hitchhiker’s Guide to the Galaxy fans out there? Always carry a towel!) 

Somebody else had already called 911. This supportive group of onlookers were holding the victims purse, talking to her, and keeping her calm until the ambulance arrived (a disappointing 11 minutes wait). 

 While I never did get a follow up report and hoped that the accident victim was okay, I was struck at the time by how quickly a group of people acted like caring human beings and got involved. They put their busy lives on hold for the moment and stayed on the scene until it was clear that they were no longer needed. 

Sadly, this response is not something to take for granted. The streets of San Francisco often are filled with people who need help and we all walk past them, myself included. It doesn’t always feel safe to intervene. Mental illness and drug use are real issues. So sometimes it is scary, or overwhelming, or we have nothing to give, or we want to choose carefully how we do give, and choose not to offer random handouts. 

Regardless of the reason, walking past someone who is on the ground simply feels wrong! Having a child with us often compounds this issue. What do we say when we see people who are so much less fortunate than we are?

 THE CONVERSATION

 I think it is safe to say that anyone living with a child in an urban area is likely to get the question at some point.

 “Why is that person lying on the street? 

Why don’t they have a home? 

Why? Why? Why???” 

 Consider putting some thought into your answer now so that you can be prepared with a response that you feel comfortable with. Beware, words are powerful and kids can make connections that are not intended. 

If a child hears you point to poverty, job loss, or illness as the simple cause for homelessness, they could worry that if someone they love gets sick, or complains that they are having trouble paying a bill, they might end up on the street too. 

Kids under five need to be reassured that they are safe, that they have a warm bed and plenty of food. Keep the discussion age appropriate. 

You can wait until they ask, rather than initiating the conversation. A simple “they don’t have a place to live” might be enough. 

They will learn quite a bit simply by seeing your actions and reactions. 

 Five to eight year-olds are transitioning to seeing themselves as part of a community rather than having the world revolve around ‘me’. They are becoming interested in solving the problems they see. Beyond reassuring them that they are safe, invite them to ask questions and think about options. 

Just like every single person is unique, every situation is different and everybody has their own story. Your answers might include talking points such as 

 Poverty: Maybe bad luck; no money, no job in combination with no family or friends to help, not enough housing. Societal marginalization also plays a part (sadly, society isn’t set up the same way for all people from all walks of life). 

The recent pandemic and its economic impact has made the situation even worse. 

 Mental illness: Maybe the person is not well. Bodies can get sick and so can minds. Often there is medicine that can help make things better, but some people get so confused that they don’t know how to get help. Drug use: Medicine can be very good when it is used for the right reasons. Some people use drugs they shouldn’t use and may have ended up not being able to make good choices. If the opportunity presents, taking the time to hear the personal stories of a homeless person can be pretty impactful and remind you that everyone has a name and is somebody's parent/child/sibling/....... 

 In any case, it is important not to make sweeping generalizations. The goal of this discussion is to cultivate feelings of empathy and action, not shaming.

 We want to help, but Safety First! The Neighborhood Emergency Response Team ( NERT) holds classes, free to the public, to train us for how to deal with an emergency such as a large earthquake. They spend several weeks teaching people how to help, but NERT's first rule is the most important one: Don’t go in to rescue someone if it feels unsafe. 

If someone who looks like they need help call 311 and report it. How can we prepare our children for these inevitable encounters with people who are homeless? While we want our kids to have compassion, this same rule needs to be taken to heart here. 

If you are walking and have any concerns that an interaction with a stranger on the street could pose a danger, then walk right by.

Most of you have probably heard this tale, but if not, now it is time for the starfish story (now known as the sea star) 

A young girl was walking along a beach upon which thousands of starfish had been washed up during a terrible storm. When she came to each starfish, she would pick it up, and throw it back into the ocean. People watched her with amusement. She had been doing this for some time when a man approached her and said, “Little girl, why are you doing this? Look at this beach! You can’t save all these starfish. You can’t begin to make a difference!” The girl seemed crushed, suddenly deflated. But after a few moments, she bent down, picked up another starfish, and hurled it as far as she could into the ocean. Then she looked up at the man and replied, “Well, I made a difference to that one!” 

 We can’t help everyone, but even simple kindness can make a difference for one person. Most people appreciate even the gesture of a smile, but here are some more tangible things that you can do with just a bit of planning.

 First of all - don’t assume anything, ask a person if they would like the help. 

 Have some extra socks to hand out 

Give small containers of hand sanitizer 

Get some Starbucks cards or gift cards that can be redeemed for food 

Donate part of an allowance to a homeless shelter 

Restaurant portions are so big, perhaps split your meal and box it up before you start eating and give it to someone on your walk back to the car. 

Somebody with poor teeth might not be able to eat that bagel; don’t be offended if your gesture is rejected. 

 Birthdays and holidays are a great time to talk about how fortunate we are. 

Some kids ask their friends to donate to a non-profit instead of getting presents, or do a “toy-purge” – giving outgrown toys and games to charity before receiving new presents. 

 Alas, the cure for homelessness has proven to be elusive, but we can brighten the day of one person at a time with some simple kindness and teach our kids how to have compassion. We can also learn a lot from our children. 

Thanks to my daughter Alana, who is now a social worker, my family had a warm relationship with an older gentleman who spent his days on the sidewalks of West Portal. About fifteen years ago Alana was still in high school and had left the local movie theater on a dark drizzly night waiting for her dad to pick her up. Roosevelt decided to wait with her because she shouldn't be out ‘alone’ and they began a friendship that lasted until his recent passing. He called her bright eyes and tossed his cane in the air and ran into her arms for a big hug every time he would see her. RIP Roosevelt. We will miss your smile.

Astrological Shenanigans

It is always somewhat interesting having a sister who dabbles in astrology.

 When I was nearing my due date with my first born Lauren, and my older sister Marjie suggested that I wait several days so that the moon would be in a better aspect, I gave her exactly the response (not suitable for this piece) that you would expect from someone who was more than ready to be done with pregnancy. 

 When Alana was born, Marjie didn’t bother trying to fine tune my timing, but she did predict from reading Alana’s chart that she would take her time with things getting started, but would master them quickly. 

 It was fascinatingly accurate. Using walking as an example. Alana waited until she was roughly 15 months old and took her first steps, carrying a chair across the room. Most of her milestones followed a similar pattern. 

 But for the most part, when Aunt Marjie came out with her predictions, we would lovingly roll our eyes. 

 I didn’t pay too much attention until 1998 after I had an especially irritating day. I had driven the carpool full of kids to school that day. We drove there without incident, but once we had arrived, there was smoke coming out from under the hood of my car. I called a tow truck, and Sandy, always the hero, left his office downtown to pick me up and drive me to work. On the way, I ended up spilling coffee on my lap, so I spent the rest of the day needing to explain to people that I had in fact NOT peed in my light colored pants. Then, to compound things, my wallet was stolen from my purse during lunch. Really??? 

 Once I got home and did all the calls cancelling credit cards and all the other hoopla that is required when you lose your wallet, I placed a call to Marjie. 

 “Is there something going on up in the planets that I need to know about"? 

It turns out that according to her charts, indeed there was. 

Uranus was transiting my Neptune...or something of that ilk. She went on and on trying to explain it, but I cut right to the chase.

 “Is it done?” 

 Alas, Marjie went on to tell me that this was somewhat of a figure eight situation that would happen again in several months. Of course that didn’t mean I would necessarily have any issues, these were just tendencies. Just tendencies or not, I asked her to please make a note of it and let me know when Uranus was going to be back to causing me trouble. 

 Life went on. Several months later, I got a call from Marjie. 

“Remember that business several months ago? Tomorrow might be tricky for you. I don’t think you should drive anywhere.” 

 The aggravation of that previous nasty day had been relegated to distant memory. 

“I don’t think the other carpool families would be happy with me if I opt out of my driving tomorrow.” “Do what you need to do, but make sure you have your cell phone charged and have your AAA card with you.” 

 Safe to say, I was back to being pretty dismissive all of this. The following day, I drove to school with all the kids and parked in the lot to do a bit of shmoozing with some of the other parents. Imagine the range of my emotions when I got back in the car and it wouldn’t start. You had to be kidding me! 

The emotion that won the battle was humor. I figured that I may as well just laugh at the absurdity. I had my phone and AAA card at the ready. 

 “What seems to be the problem?” 

 I couldn’t help myself and I actually answered, “It appeared that Uranus is transiting Neptune” 

 They laughed, Tow truck came, Shoulders shrugged. 

 Fast forward to this January when Lauren was due with my first grandchild; of course the charts came out. 

When Lauren went into labor, Marjie got very active in our family chat. The actual time of birth was going to be the fine tuning, but now that she was pretty clear on the date, she started with her predictions. 

 “He is a very wise soul that spent lifetimes in pursuit of knowledge. Mercury in proximity to the sun indicated strong mental abilities. He will be stubborn. He will be very generous. Saturn is squaring Mars. I am guessing that he will have a visible birthmark that could well be an indicator of a trauma from a past life” 

 Whoa. I went into a private chat.

 “Marjie..you need to hold off on all of this. Lauren is in active labor, I don’t know if she is checking her phone in between panting and blowing, but I don’t think this is helping.” 

 She kept the rest of her predictions to our private chat. It turns out that the baby does indeed have a little strawberry birthmark on his upper back, right behind his heart. Lauren wouldn’t let us tell her aunt...until now.  

Marjie, in honor of your birthday this week, we can let you know that once again, you got it right.

Poisonous plant guide/

Different events can trigger me to update old posts. 

I have brushed off the toxic plant blog several times over the years, but I have a different twist on it this time around. 

The earlier version of the post focused solely on young kids and plant safety but the incident that brought this to mind for me recently involved grown ups. 

 A group of people who are quite close to me were out in the country. 

They came across what they believed to be some wild onions and cooked them up as part of the dinner. It was only after several of them started to feel ill that they got suspicious and did some checking to find that they had actually eaten something called a death camas. 

Nothing like a name with death in it to ramp up the anxiety level! 

I think most people have been taught over the years the dangers of wild mushrooms and potentially toxic berries. I personally had never even heard of wild onions or their poisonous twin. 

 Fortunately they hadn’t eaten enough to have severe issues, but it could have been so much worse. 

One of the women who had eaten the poisonous plant was breast feeding; no one was able to give her much information about this, so the poor mom ended up pumping and dumping her breastmilk for two full days just to be on the safe side.

 Another of the people who ate part of the meal and did not get terribly affected said afterwards that he had a feeling that this was less than prudent, but didn't speak up. 

 My brother-in-law who is a national park ranger told me of a time that he had to have someone airlifted for emergency medical care after eating death camas. 

This person was a Native American man who had grown up eating wild onions and got caught off guard by the look alike plant. 

 The takeaways here are clear. Don’t eat any wild plants unless you are 100% certain that they are safe. If you see others taking chances, don’t be shy about being a party pooper, SPEAK UP! 

Foraging plants in the wild has become more and more popular. Please be cautious! Most of the time when toxic plants are a concern of course, is when young kids decide to nibble on some house plants. This is a good reminder for all of us that we need to be knowledgeable about plants that our kids come in contact with. 

 In most of the cases of these plant eaters, the kids aren’t showing any obvious signs that there was an issue. 

Typically if someone eats something that is toxic, and there is cause for concern, you would expect to have obvious symptoms. 

To be on the safe side, the best course of action if you know your child has eaten something you aren’t sure about is to check in with the Poison Control Center. In California that number is 1-800-222-1222 

 The Poison Control Centers here in the United States report that they get more than 100,000 annual calls about plant or mushroom exposure. 

Knowing what plant your child actually came in contact with is very helpful to them. 

Unfortunately, most of the time all we know is that it has leaves and is green. I would place a bet that many of us can't actually identify the plants we have in our homes and yards, and therefore have no idea about whether or not they are a potential hazard. 

 Different plants will cause a variety of symptoms. Just like a sensitivity to food, not all kids will be equally reactive to an exposure. Reactions can range vomiting, diarrhea, cramping, a rash or fussing, to more severe seizures, paralysis, heart irregularities and/or death. Mushrooms are the biggest culprits for severe reactions, but as I mentioned they are by no means the only thing to be aware of.

 Step one is to teach your children not to put any part of a plant in the mouth (yeah, good luck with that…..) This means leaves, stems, bark, seeds, nuts, berries, and bulbs. 

Unfortunately kids will chew or eat things regardless of how they taste or the level of disgustingness. Depending on the plant, eating a tiny amount might not be an issue, but large or repeated doses can be harmful. 

I know it just about impossible to watch them every second, so it is important for you to be able to recognize plants that are more hazardous and limit access to those. Some plants will cause irritation just by coming in contact with them. 

Locally the most common culprit for that is poison oak. Some succulents and cacti aren’t poisonous but can cause a wicked scratch from getting too close to their spikes. 

 If you have small children or curious pets, consider removing toxic or hazardous plants. 

If you are attached to a plant that is on the list, perhaps lend it to a friend or neighbor until your little one is out of the "everything in the mouth" stage. 

 In general, toxic or not, house plants should be placed out of reach of the very young. You also need to pay attention to falling leaves, which can be a choking hazard. If there are other houses or places that you frequent with your kids, make sure those plants are safe as well. 

 If you are a gardener, make sure you store labeled bulbs and seeds in a safe place where your kids and pets don’t have access to them. 

 For the older kids, I would do some active teaching about plant safety. Make a point of teaching them that it isn’t safe to suck nectar from flowers or make "tea" from mystery leaves. Never chew, or let children chew on jewelry made from seeds or beans. You might even do some role playing to help them avoid peer pressure: “I dare you to eat one of those berries” “You can dare me all you want, My family rules are more important and we don’t put mystery plants in our mouth”  

 Below is a list of some of the common house and garden plants with poisonous parts. Plants causing severe or fatal poisoning are marked *. Plants causing rashes are marked with°. 

Plants                  Poisonous Parts

African violet              Leaves

Amaryllis-garden              Bulbs

Azalea *                       Leaves

Castor bean                  All parts

Cherries *                 Seeds and leaves

Citrus fruits                  Leaves

Crown of thorns°              Milky sap

Cyclamen*                    Tuber

Daffodil*                       Bulbs

Delphinium                    Young plant, seeds

Elephant ear*                   All parts

Figs°                          Milky sap

Four o'clock*                   Root, seeds

Foxglove*                     Leaves

Holly-English                   Berries

Hyacinth*                     Bulbs

Hydrangea                     Leaves

Impatiens                     Young stems, leaves

Iris°                         Rhizomes

Ivy:

English; German; ground  Leaves, stems, berries

Larkspur*                     Young plants, seeds

Laurel

Australian; mountain     All leaves

Lily-of-the-Valley                Leaves, flowers

Lilies                         Bulbs

Lupines                      Leaves, pods, seeds

Mistletoe*                     Berries

Narcissus*                     Bulbs

Oaks                         Acorns, foliage

Oleander*                    All parts

Peaches                      Seeds, leaves

Philodendron                   Stems, leaves

Plums                       Seeds, leaves

Poinsettia*                     Milky sap

Potato-Irish                   Green skin on tubers

Primrose                     Leaves, stem

Rhododendron*                Leaves

Rhubarb*°                   Leaves

Sweet peas                     Stem

Tomato                      Green foliage

Tulip*                       Bulbs

Wisteria                       Pods and seed

Yew*                        Foliage, bark, seeds

Here is a more comprehensive list of toxic plants :

Pets can also have different reactions to certain plants. This link provides a list of plants that are toxic for your pets:

When I wrote this piece a few years ago it prompted Alana to rehome some lilies with us. I am happy to report that her kitties and the plant all doing well.

Passover Musings

Passover musings 

 On October 27,2018, the Tree of Life synagogue was attacked Eleven people were killed simply because they were Jewish. Many others were injured. 

 The Tree of Life synagogue happens to be less than a mile away from my childhood home in Pittsburgh Pennsylvania. 

While I did not personally know any of the people who were killed, I knew many people who were directly connected to those who were impacted. 

 The daughter-in-law of one of the victims emerged from the ashes of this tragedy with the agenda to make a difference. 

 In memory and honor of her mother-in-law Joyce Feinberg, she created a program called 2 to the Seder, with the goal that Jewish people who were having the traditional Passover dinner invite at least 2 people to join them who were NOT Jewish. 

In her words, her goal was to push back on antisemitism with love. 

If people from different backgrounds can allow themselves to open up just a bit to connect with one another, might this help? 

 There is too much hate and prejudice in the world. We need to teach our children to do better. This idea completely resonated with me. 

The April following the shooting we opened the doors to our Seder. We were honored to have Muslims, Christians, Buddhists, Hindus, Amish, quite a few atheists. and of course some Jews. 

The conversations that we had that evening were fascinating. Passover is the holiday that celebrates the story of the Jewish people escaping from slavery in Egypt. 

The ritual dinner is called a Seder. For me the Seder is all about tradition. I feel the connection with generations past through the meal, story and the songs that have transcended thousands of years. 

I keep in mind that many Jews over the centuries risked their lives to have a seder when they were living in places where simply being identified as a Jew could be a death sentence. 

 It is also tradition for my husband to point out that the entire story is most likely completely fabricated, at which point I counter that the accuracy of the story isn’t what it is all about. 

It is about gathering with family, celebrating Spring and freedom, and having discussions about how we can end oppression for everyone. 

And of course, the Matzo Balls.

 He then acquiesces with the two little words that keep the marriage humming along - “yes dear.” 

 This holiday has certain smells that embrace me as I am preparing for it: Matzo Ball soup, horseradish, Manischewitz wine, apples and walnuts chopped up to make something called charoset that is meant to represent the mortar that the slaves used. 

I can feel the presence of my mother and grandmother as I putter in the kitchen. One of the parts of the seder is a song that is supposed to be sung by the youngest participant, Ma Nishtana ha Lila ha zeh? Why is this night different from all other nights? 

 While frankly eating matzo and drinking the traditional cloyingly sweet wine is fine for once a year, talking about freedom and oppression should NOT be a topic for just one night. There should not be an ‘Oppression Olympics.’ 

Antisemitism and bigotry are not just reserved for Jewish people. I understand that I have the privilege of being able to ‘blend in’ if I chose to, while most people of color cannot. This week, the country experienced yet another unfortunate display of racism and hatred, this time falling on the Asian community. 

Until everyone can be outside without fear of being belittled or harmed because of who they are, we have work to do. There are so many differences, races, faiths, genders, ages, sexual orientations, abilities, personalities.

 Underneath, we are human beings, mothers, fathers, siblings, grandparents, family members, friends, community members. We need to celebrate the differences instead of attacking them. 

 This year with COVID we are having a small family Seder. Next year, I hope once again to open my doors, have vibrant discussions and link with people from every walk of life. Happy Passover to all who celebrate.

Cleaning up made simple

This week's topic Cleaning up without the battle 

 Here is a post from several years ago that might help you out with your own version of Spring cleaning.

 If you start good habits early on, you will benefit on many levels... 

 Some time ago I had a phone chat with one of the moms of a patient, about some behavior issues. Her daughter was 2&1/2. 

At home, there was an unpleasant amount of parental nagging and child tantrums. Mom was astonished when she spent a few hours at her daughter’s daycare co-op. 

She watched in awe as the kids all immediately followed the request to clean up the toys. 

After lunch, this little group sat nicely, eating their healthy meal and then got up to clear their plates.

 What completely stunned this mom was watching all of the kids line up to compost whatever food scraps there were. Composting! Really?!? 

As she told me, this was a completely different child than the one she had living with her. This is a pretty good example of how important rules and consistency are. 

It is, in fact, not at all uncommon for kids to behave beautifully in some situations and completely act out in others.

 If rules are clear and simple, most kids will follow them. 

As long as rules are in the child’s best interest and reasonable, kids thrive in a consistent environment. Kids need to understand what the rules are. 

 If there are rewards/incentives what are they?

 What are the consequences for not following through? 

 Once the kids are old enough, have them be involved in negotiating the new “official guidelines.” 

What do they think would be a reasonable consequence. 

Are there certain incentives that they would like to work towards? 

 How can you implement this at home?  

Think small. Not everything has to be regimented but let’s address one common area of conflict, such as cleaning up toys, and make it simple. 

 Easier said than done, but try to have an organized system so that putting toys away is straightforward. Know where they came from so that they can be returned to where they belong.

 If you can’t do that, you possibly have too many toys and you should take some of them out of circulation. 

 Large toy boxes/trunks are okay for really large items, but they tend to become a dumping ground. You are better off investing in shelves with different bins. 

Low shelves are for toys that kids can have easy access to. 

Have a designated high shelf area for setting aside toys that need adult involvement. 

 Take a photo of the toy that lives in the bin and glue the image on.

 This can be a family project. (Great rainy day activity!)

 Maybe the picture can include your child holding the toy. 

There can be a box for little cars, a box for dolls, a box for crayons...etc. 

Perhaps have a rule about only 2 or 3 boxes being down at a time until your child shows you that they can manage cleaning up more of a variety. 

 Sorting can be a game. 

Give a transition time: “Ten minutes until clean up." 

“Five minutes until clean up." 

 Some kids may do well with a timer. Everyone needs to understand what the new clean up rules are. When playtime is over, it is time to do the full clean up. 

Put on some music or have a clean up song. 

 Children have a set amount of minutes to put the toys away. 

While you might start by helping out and setting a good example, the ultimate goal is that your kids can do this on their own. 

Make sure that they are doing most of the work. 

When the time is up, make sure you give positive feedback. The toys are safe and ready for the next time they want to play with them. 

If they did NOT clean up, now it is your turn. Anything that you clean up is yours to do with as you please. You can put it high up where the kids don’t have access until they agree to do a better job cleaning up. 

Tell some stories about children who did a good job cleaning up. Parents were so proud! Their toys stayed safe and organized. 

Tell a parallel story about a less successful outcome. Parents ended up doing the clean up and the toys went high up and away. This process eliminates potential sources of nagging: These are the clean up rules; they are clear and simple. Cleaning up is easy. It takes a few minutes. It can even be fun! Kids remain in control of the toys that they put away. Or mommy/daddy can clean up but the toys are gone for a while. Many of our kids have so much stuff (mine were no exception) that you may wish to consider rotating toys.

 If you take something out of circulation for a while it might feel new and fresh when you bring it back. Doing a toy swap with friends is another good way to have an assortment of things to play with that feel new and exciting. Keep in mind that some kids are rougher than others. Don’t lend out anything that you care too much about. It may not come back in the same shape that it went out! 

As Marie Kondo from the popular Netflix series would say, it if doesn't bring you joy, get rid of it. Start small, be clear and consistent, and problem solve so that you don't end up in nagging cycles, to kids who ignore you. Who knows, the next step might be composting!

Eczema management 2021

Eczema/Atopic Dermatitis 

 Kids get a lot of rashes, but the most common diagnosis is probably eczema. 

This is one of those topics that I routinely get questions about year round. It doesn’t appear to have a season. 

 The term eczema is broadly applied to a range of persistent skin conditions. 

There seems to be a hereditary component so it is pretty common for eczema to run in families.

 One piece of good news is that some kids can grow out of it! Some babies have buttery soft skin. Others are not so lucky. 

My patients with the diagnosis of eczema generally have fairly dry skin with rough patches. 

 Learning some basic facts about the skin can help you understand what is going on and how to deal with it. 

For the data nerds among you, the next paragraph is for you; for the rest of you, sorry if this makes your head spin... 

 The top layer of the skin is called the epidermis and the top layer of the epidermis is called the stratum corneum (SC). The SC is incredibly thin but it is the main barrier of the skin. It keeps chemicals that come in contact with the skin from being absorbed into the body, and it keeps fluid inside the skin from leaching out. The SC contains 3 types of lipids that have different chemical compositions and functions; ceramides, cholesterol and free fatty acids. But it gets even more complicated. There are nine different types of ceramides in the SC, conveniently named ceramide 1 through ceramide 9, and they account for 40-50% of the lipids in this outermost layer. Scientists are doing a lot of research on the important function that ceramides play. What they are now discovering is that people with eczema have significantly fewer ceramides in the SC than folks with healthy skin. (Don’t worry there won’t be a test on this.) 

 Skin Care

The obvious focus is to try to re-balance and add back some of those deficient ceramides. Thus, the key to treating basic eczema is moisturizing! Well lubricated skin does not get as itchy and doesn’t break down as easily. It is important to moisturize at least once a day, (twice a day is better!) but there is no downside to greasing up your kid more often than that. It is really important to break that itch cycle. 

Aside from causing misery, scratching can tear the skin, and an infection can occur. 

There are some very good products that can make a big difference. Dr. Lawrence Cheung is my go to dermatologist. He lists the following products as some of his favorites: 

 Cetaphil Restoraderm Cerave Hydrating Cleanser and Moisturizing Cream Aveeno Eczema Therapy.

 Dr. Cheung particularly likes this Aveeno product for hands. With people washing their hands more than ever these days, the dry hands can tend to get rashy.

 The Aveeno does a great job of protecting that can last through several washes. 

 Eucerin and Vaniply are a few other good brands. 

Read the labels and make sure that ceramides are on the list of ingredients. 

 If you like home remedies, my sister-in-law Barbara swears by coconut oil mixed with a bit of tea tree oil. 

A local pediatrician, Dr. Jessica Kaplan, advocates the “greased pajama” method. Put the jammies on right after applying the moisturizer. The pajamas will be a little greasy. As long as they stay clean otherwise, wear those for several nights in a row. 

 People used to recommend infrequent bathing, but it turns out that this is a myth. 

If your child likes their bath, you can give one as often as you like. 

Baths are fine, but sitting in soapy water for extended periods is not such a good idea. 

Let them do their “fun in the tub” session for most of the bath first and then do the actual washing and rinsing with gentle soap and shampoo right before getting out. 

Bubble baths and harsh soaps are pretty high on my list of suspects when I am sleuthing around for the cause of a rash. 

 Some folks find that adding a splash of apple cider vinegar to the bath water (about ¼ - ½ cup for a big tub) is soothing and may even prevent some rashes. 

 Do you have some extra breast milk leftover that is out of the safety range for feeding?

 Dump it in the tub! Milk baths are great for the skin.

 If the eczema is severe, believe it or not, a bleach bath is often recommended by many dermatologists. Here are important steps for giving a bleach bath: 

 Use regular strength (6 percent) bleach for the bath. 

Do not use concentrated bleach. 

 Use plain bleach; avoid those with various scents added. 

 Use a measuring cup or measuring spoon to add the bleach to the bath. 

Adding too much bleach to the bath can irritate your children’s skin. Adding too little bleach may not help. 

 Measure the amount of bleach before adding it to the bath water. For a full bathtub of water, use a half cup of bleach.

 For a half-full tub of water, add a quarter cup of bleach. 

For a baby or toddler bathtub, add one teaspoon of bleach per gallon of water. 

Obviously these are approximate measurements since baths will have varying amounts of water. Never apply bleach directly to your child’s eczema. While the tub is filling, pour the bleach into the water. Be sure to wait until the bath is fully drawn and bleach is poured before your child enters the tub. 

 Talk with your dermatologist about how long your child should soak in the tub. Most dermatologists recommend a five to 10 minute soak. All baths should be followed up immediately with some lotion!!!

 Identify Triggers 

 I tend to refer to atopic dermatitis as ‘reactive skin’. 

It will be under control for a while and then something will come along and ‘flare’ it up. I refer to these as triggers. 

Playing detective and learning to recognize what triggers are aggravating the rash is another important key to management. 

 Triggers can range from changes in temperature, dry air from heating the house, a new detergent, teething or a new food. 

Acidic foods seem to be a big culprit for some kids. 

Berries and citrus are big offenders. 

Dairy and eggs are way up on the list as well. 

When food sensitivity is to blame you will often see chapped cheeks and a red ring around the anal area. 

 Treat inflammation 

 There is absolutely no downside to lots of moisturizing and/ or eliminating the triggers that are flaring up the eczema. But if those measures are not taking care of things, it is really important to take steps to minimize inflammation. 

Think of it in this way - a mild rash is like embers; add inflammation and it becomes a wildfire.

 Once you have an actual fire, the entire body becomes more reactive and even more food reactivity can take place. 

I like to take the natural route as much as possible, but sometimes it is necessary to use medication or topical creams. 

Don’t hesitate to treat and ‘put out the embers before things get out of control’. 

 As I already mentioned, it is essential to minimize itching. 

If your child is doing a lot of scratching, they can break through the skin; infection and inflammation ensue. 

Make sure you keep their nails trimmed to minimize damage to the skin from the scratching. 

 Your doctor will likely suggest an antihistamine. Zyrtec (cetirizine) and Benadryl (diphenhydramine) are the two main brands that we tend to use. 

Benadryl is shorter acting. Most of the time it makes the kids sleepy, but once in a while it has the opposite effect (not something you want to find out at night.) 

Zyrtec is longer lasting and doesn’t tend to cause either the sleepiness or the jitters. 

Although the label will warn you to check with your MD if your child is under 2 years, most pediatricians have no hesitation giving Zyrtec or Benadryl to kids as young as 6 months if necessary.

Both of these  come in a liquid form. There are dosage charts at the bottom of the post. 

 Hydrocortisone creams or ointments can also be used to spot treat especially itchy areas. Start with the weaker over-the-counter strength. 

If that isn’t helping, it would be a good idea to have a doctor take a look.

 There are several options of different prescription strength ointments, creams and oils that can be tried. Most of the time simple eczema can be handled by your pediatrician's office. 

Once in a while complicated cases that are not responding to treatment may end up at the dermatologist. If the eczema is mild to moderate and not responding to simple moisturizing and OTC hydrocortisone, there are prescription medications available that range from topical to injection options and even phototherapy. 

Dr. Cheung mentioned to me that there are all sorts of new treatments now available, with more coming within the next couple of years. 

For severe cases, it is absolutely worth seeing a dermatologist who is current with updated treatment options.

 If you like to think out of the box, I have seen some patients have a big improvement in their skin from some treatments from the folks at Advanced Allergy Solutions. 

They are not the magic wand for everyone, but have been very helpful for many of my patients. 

 There are also some ongoing studies about gut health and eczema; it makes sense that there is a connection. 

The studies are speculating that probiotics containing Lactobacillus might be helpful, but there are no official guidelines yet.

 For your little ones who are eating solid foods, adding fermented foods, and decreasing sugar are easy and worthwhile things to consider. 

 In summary: 

 Keep your child moisturized daily with one of the recommended lotions or creams 

 Make sure your kids nails are kept short. 

Infants can have little mittens on their hands at night if they are doing a lot of scratching. 

 See if you can figure out what the triggers are and avoid them. Sometimes it is simply cutting out berries. 

 Zyrtec and Benadryl are fine for itching but don’t treat the underlying cause. 

 Don’t be hesitant about treatment.

 In a risk/benefit calculation, taking appropriate steps to decrease the inflammation is the right thing to do 

 Zyrtec Dosage Chart The dose of cetirizine depends on age as below: 

6 - 12 months of age: 2.5 mg given once daily (maximum dose 5 mg daily) 

12 - 24 months of age: 2.5 given once or twice daily (maximum dose 5 mg daily) 

2 - 6 years of age: 2.5 - 5 mg given once daily (maximum dose 5 mg daily) 

Over 6 years of age: 5 - 10 mg given once daily (maximum dose 10 mg daily)

 Zyrtec comes in a 1mg/ml solution (so 2.5 mg = 2.5 ml). There is also a 10mg/ml oral drops preparation (so 5 mg is 1/2 ml). 

Make sure you check the strength of the solution.