Dealing with Excessive Heat/How to recognize Heat Stroke/Tips for keeping cool

 

Temperatures are soaring.

Memorial day means the beginning of the summer season. It seems like a good time to update this post that we ran a couple of years ago. There are some important additions, especially for teen athletes.

As many of you can attest, the hot weather hasn’t waited for summer this year.

Not only is it hotter earlier than usual, but it is more extreme.

Even places that are used to hot weather are seeing heat waves that are sadly breaking all kinds of records.

We are anticipating that most of the country will likely be dealing with temperatures over 90 degrees, many over 100, as the norm.

The important number is actually the heat index. This is calculated based on the temperature and the humidity. Humidity does make things worse. If you are in a place with high humidity the sweat doesn’t evaporate as quickly and this keeps the body from releasing heat as fast as it may need to. If you want to calculate the heat index of where you are, you can use this link.

Even in San Francisco, where we often are blessed with our lovely fog, we have more hot days than I can ever remember.

Being overheated can have serious consequences, especially in young babies.

Symptoms of heat exhaustion might include:

• Fevers 100-104

• Clammy skin

• Muscle cramps

• Nausea

• Dizziness

• Lethargy

If not tended to, this can lead to heat stroke, which can be deadly! Signs of Heatstroke include:

• A temp at near or above 104 (fever reducing meds are not useful in this circumstance)

• Flushed skin

• Elevated heart rate

• Weakness

• Dizziness

• Loss of consciousness

Medical intervention is essential!

A quick word about intense exercise in the heat (pay attention, teen athletes):
Most kids are not going to develop anything this serious from a hot day at the playground, but older kids, teens, and adults can occasionally get into trouble when they push themselves really hard in extreme heat. This is especially true during sports practices, intense hikes, boot camps, or suddenly trying to “power through” after not being acclimated to the heat yet. It’s most commonly seen on the first or second day of practicing a new sport.

When muscles overheat and break down too quickly, it can lead to something called rhabdomyolysis (“rhabdo” for short). This can actually damage the kidneys. Warning signs can include severe muscle pain or cramping, unusual weakness, swelling, vomiting, dizziness, or urine that looks dark brown like cola.

You’ll know you’re at risk for this if you reach the point where it feels like “my muscles have physically stopped being able to do this” and you decide to power through nonetheless. If that’s the sensation, it’s important to listen to your body. The most severe rhabdo victims are the ones that try to “power through” on a hot day.

The best prevention is not trying to be a hero in triple-digit weather. Take lots of breaks, hydrate before you feel thirsty, replace electrolytes if you are sweating heavily, and avoid the hottest part of the day whenever possible. Coaches, parents, and athletes should all know that pushing your body in extreme heat is usually not the right answer.

If someone seems confused, collapses, has severe muscle pain, or develops dark urine after heavy activity in the heat, they need medical attention right away.

Hydration is an essential part of preventing heat related complications.

It is important to replenish the fluids as well as the electrolytes that you lose when you are hot and sweaty. Pedialyte or similar electrolyte drinks may be better than plain water. Breast milk is perfect (of course). Even if your baby seems to be nursing well, if it is very warm out, keep an eye on the number of wet diapers! You may need to sneak in some extra fluid.

Nursing moms need to remember that they are losing fluid every time they feed their babies. It is essential to replace that as well as adding extra, so drink up! Perhaps start your day with one of the large water bottles that measures the amount. Fill it at the start of the day and it makes it much easier to track your intake.

Someone who is dehydrated will have:

• Less urine, and the urine will be dark

• Low energy

• Dry mouth

• No tears

Even if they are no longer in diapers, pay attention to how often your child is peeing and look at the color. Darker, infrequent urine might be your first clue that they need to be drinking more.

Ideas for staying hydrated:

Set a timer on your phone as a reminder that it is time for everyone to take a sip.

• Maybe have an iced-tea party.

• Pedialyte comes in popsicle form which can be a big hit.

• Other good hot weather treats are watermelon and some mildly salty snacks.

• Frozen breast milk can make a wonderful ‘milk-sicle’

Ideas for staying cool at home:

• Heat tends to rise, the coolest room in the house might be downstairs.

• Families may end up sleeping on the living room floor if it is less oppressive. Make it an adventure and call it camping.

• Keep the shades down during the day.

• Have a fan going if you are lucky enough to have one. Make sure the fan is placed in an area where curious kids can’t poke their fingers in there. Even better, get one of the fans that is toddler safe. For those of you without fans, put your order in now. Often in the midst of a heatwave there are none available. It is worth owning at least one so you are prepared for the next heatwave.

• Baths are great. Unless the water is obviously dirty, don’t drain it and you can get in and out throughout the day.

• Keep wet washcloths in the freezer and offer the frozen clothes throughout the day. Sponges are also fine to freeze.

• There are cool little ‘cooling towels’ that can make a big difference. Once you wet them, they stay nice and chilly for hours.

• If you have a yard or a place to put it, investing in one of the little plastic wading pools can give your kids hours of cooling fun. (even if it is very shallow, remember that adult supervision is required.

• Dress in minimal lightweight clothing.

Come up with some fun indoor activities that don’t require a lot of running around. Lots of kids love water play. Cover an area with a plastic sheet (a shower curtain is a great cheap option). Fill a plastic bin with water and then there are unlimited options (including cleaning the bin with a big sponge!)

An extended heat wave may require a little bit more screen time than you like; don’t stress about it. Try to be clear that there are some ‘hot weather’ rules that can be a little more relaxed.

If you don’t have air conditioning, see if you can find local places where you can hang out for a cooling break. Malls and libraries are often good options.

If you do go outside...

Beware of hot metal. Make sure you test the temperature of any slides or metal equipment before you let your child play on them. We have had patients get burns on their fingers from pressing a metal doorbell, so we are not kidding around. Seatbelts can be pretty bad as well! Metal can get very hot.

Shade is best, but if you are in the sun, make sure your kids have a big floppy hat, sunglasses and sunscreen.

Don’t forget about your pets. Make sure they have plenty of water (add some ice cubes.) If possible when walking them, keep to grass. Extremely hot pavement can actually burn their paws.

Also…never ever leave kids and pets in the car. This is especially critical when the weather is hot. Folks with some modern cars do have pet comfort settings (but it’s not okay to leave kids in there).

Keep in mind that in many hot areas of the world, the cultures have embraced the concept of the siesta. They take a collective break during the hottest part of the day. That sounds like a plan that most parents would be soundly in favor of…. Now we just have to get the kids on board.

Remember that heat is the normal for babies in many countries

Bay Area parents, this section is especially for you. We see a lot of anxiety around the idea that babies must exist only in a perfectly climate-controlled environment between exactly 68 and 72 degrees at all times or else catastrophe will strike. Deep breath.

Yes, we want babies to be comfortable and safe. Yes, overheating is something to take seriously, especially for newborns. But it is also important to remember that babies are born and raised all over the world in a huge range of climates. There are babies in Cambodia. There are babies in India. There are babies in Arizona in August. Not all of them have AC. Humanity has not survived exclusively in homes with central AC and a Nanit room-temperature alert.

What we are generally trying to do is optimize comfort and reduce risk, not maintain laboratory conditions. A room drifting up to 75 degrees for part of the afternoon does not mean your baby is suddenly unsafe. A baby taking a stroller walk on a warm day is not automatically in danger. Parents can become so anxious about achieving the “perfect” temperature that they lose sight of the bigger picture and stop trusting their own observations.

The most important thing is how your baby actually looks and behaves. Is your baby feeding okay? Making wet diapers? Reasonably alert when awake? Not flushed, lethargic, or drenched in sweat? Those clues matter more than obsessively refreshing the weather app every seven minutes.

Try to think in terms of flexibility and common sense rather than precision engineering. Dress babies lightly in the heat. They can even be naked. Avoid direct sun exposure. Use fans safely. Offer feeds frequently. And remember that a loving, attentive caregiver matters a whole lot more than whether the nursery briefly hit 75 degrees.

Other heat-related considerations:

Fungal diaper rash

With increased heat and sweating, fungal rashes can become a problem. Fungus loves damp dark warm places, so a sweaty diaper area (or underwear area for potty-trained kids…or adults) is the perfect breeding ground for fungal rashes. Fungal rashes in diapers can look like discrete red dots, occasionally coalescing into lumpy bumpy raised patches. Unfortunately, this can mimic the red papules of hand-foot-and-mouth. Dr. Ted has seen kids with diaper rashes sent home from daycare to get assessed for hand-foot-and-mouth. For any concern for a fungal rash, air out the diaper area and add over-the-counter Lotrimin three times a day. It’s extremely safe and well tolerated at all ages. You can also add some apple cider vinegar to the bathwater, which is antimicrobial and balances the pH (white vinegar is probably fine, but skip the balsamic).

Swimming considerations

The excessive heat warming fresh waters has created some unfortunate growth of naturally occurring bacteria, such as pseudomonas. Pseudomonas can present in a couple of ways. It can live in poorly controlled hot tub waters, creating a red spotty rash called hot tub folliculitis, but more importantly it can cause an excruciatingly painful swimmer’s ear. Luckily, pseudomonas can’t grow outside of wet environments, so drying the ears fully after swimming will not allow the bacteria a place to grow. We do not recommend Q-tips as they can traumatize the eardrum. Try using Debrox drops after swimming to dry out the ear, and any bacteria inside won’t be able to grow.

Blue green algae

If you’re going to any rivers or lakes, check your local resources to make sure there aren’t any dangerous blooms. He is the website for California, but it is easy enough to google wherever you are.

This is important for your pets as well as the humans.

Dr Ted’s Tidbits: Time to nerd out with science!

Young infants don’t regulate their body temperature very well, so this puts them at greater risk. “Heat regulation in newborns is fascinating. We rely on sweating to get rid of heat. Water from our skin absorbs heat and carries it away with evaporation (see Nurse Judy’s bit of this, above), but newborns don’t make a lot of use of those valuable sweat glands for at least the first couple of weeks. Newborns also have an immature part of the brain that regulates body temperature called the hypothalamus. Without input from the hypothalamus, babies rely on outside forces to control their core temperature. In particular, babies are bad at cooling themselves off. So if you’re in a place with a heat index over 90, it’s important to be proactive about keeping your baby from overheating.

Tylenol vs Motrin. When to use/ How to choose/ Dosage charts

 Introduction

It should go without saying that none of us want to give our kids medication unless it is necessary. We always like to see if there are some natural remedies that can do the trick. Many low-grade fevers don’t need medication at all. Cool compresses, light clothing, fluids, and comfort might be enough. Of course there will be times that we need to move to plan B and break out the standard over the counter fever medications (antipyretics).

When to give an antipyretic

Antipyretics are medications, like Tylenol (acetaminophen) or Advil/Motrin (ibuprofen). They lower fevers and treat pain, and ibuprofen sometimes decreases inflammation. That’s basically it. So if your child is not in pain, does not have a fever, and is not inflamed, you don’t need to give it. We’ll talk later about how to think about these medications with shots.

Acetaminophen

Liquid

Acetaminophen is most often found under the brand name Tylenol. Acetaminophen is usually given every 4-6 hours. Too much Tylenol can be toxic to the liver, so it is important not to exceed the recommended dose. Do not give more than 5 doses in 24 hours.

It’s worth mentioning - acetaminophen is a bit more forgiving than ibuprofen. What matters most is the total amount over 24 hours, so you don’t need to stress about hitting every dose perfectly on schedule, as long as you’re staying within the recommended daily limit.

The only difference between infant and children’s Tylenol is that the infants packaging comes with a handy syringe for accurate dosing. Otherwise they are the same concentration of 160mg/ 5 ml (1 teaspoon). We like the “dye-free” formulations.

Suppository

This is very useful if you have a child who is vomiting, or simply hates taking meds. Even though a rectal medication feels intrusive to parents, most kids don’t tend to mind them at all.

Pro tip: keep them stored in a cool place, refrigerator fine. Giving a mushy suppository is very difficult.

Gummy

Some reluctant medicine takers will eagerly accept a gummy.

Pro tip: watch to make sure they chew and swallow. There are absolutely kids who stash a partially eaten gummy under the couch.

Powder

These quick dissolve powders are often a great choice. They can also be mixed with a spoonful of yogurt or applesauce and are a good option for fussy kids.

Acetaminophen Dosing Chart

Ibuprofen

Ibuprofen may be sold under the brand names Motrin or Advil but generic brands are acceptable. Ibuprofen is generally not recommended before 6 months unless cleared by a clinician.

Ibuprofen has a double concentrated infant version:

The infant version is 50 mg/1.25 ml

The children’s version is 100 mg/ 5 ml

It is very important to make sure you pay attention to which one you are using.

Ibuprofen is usually given every 6-8 hours.

Ibuprofen Dosing Chart

The correct dose adjusts with your child’s weight. That dose that the doctor calculated for you when your infant came in for their first shots? It is not going to cut it for your 25 pound toddler!

Keep in mind that neither of these medications work instantly. It is common to have to wait at least 30 minutes or so before you notice any relief or decreased fever, and for most fevers it can take 90 minutes to get to the full effect.

Milligrams? Milliliters? It can be confusing.

The above charts tell you how many milligrams of each medication your child needs, followed by the milliliters. The doses are based on the child’s weight. The different concentrations can be confusing. Let’s go back to school for a moment for a quick review.

If you take a 500 mg Tylenol tablet, crush it and then dissolve it in a teaspoon (5 ml) of water, you will have 500 mg of Tylenol. If you take the same 500 mg tablet and dissolve it in a cup of water (240 ml). You will still have 500 mg. It is simply in a different concentration.

The first step is to see how many milligrams are appropriate for your child. Your next step is figuring out what volume of fluid will deliver the proper dose. That will depend on the concentration of the medicine.

How to choose

For illness, we don’t have a strong preference between acetaminophen or ibuprofen. Ibuprofen does tend to last a little longer which makes it a good choice for a night dose.

For injury, ibuprofen is a better choice because it is also anti-inflammatory.

One down side is that it can cause tummy upset if given on an empty stomach, especially for repeat doses. This is challenging for sick kids with poor appetites.

Ibuprofen can also inhibit platelet function, thus acting as a blood thinner. Because of this it is typically not used after surgical procedures.

Alternating Dosing

If a fever is lasting longer than a few days in a row, it is worth getting seen by your doctor. If you are dealing with a stubborn fever and have a diagnosis (such as the flu or hand-foot-mouth), it is okay to alternate both of the medications. These are the kids that need help just to be comfortable enough to keep drinking liquids. An example of this would be:

9 am Tylenol

12 noon Advil

3 pm Tylenol (etc…)

If the fever is staying under control, spread out the doses:

9 am Tylenol

1 pm Advil

5 pm Tylenol (etc…)

Dr. Ted’s Tidbit

There are some viruses out there that really send kids over the edge. Hand-foot-mouth disease is usually not so bad, but it has the potential to create so much mouth pain that kids can’t drink any liquids and get dangerously dehydrated. For these kids, when the cause is known and you know they’ll get better with time, I recommend dosing both acetaminophen and ibuprofen simultaneously, just to jumpstart the comfort and help them to drink enough to stay out of the hospital. This shouldn’t be something you’re doing regularly around the clock for days, but for a dose here or there, it’s okay.

Avoid medication errors

Medication errors happen more often than you can imagine. Consider putting a piece of masking tape on the bottles and mark off times and dates of dosages. This can help sleep deprived parents keep track of when they gave what. It also alerts partners if a dose was recently given by another caregiver. This is a good habit with antibiotics as well.

Another option is to keep a notebook nearby and document your doses there. Figure out which method works best for you and make sure that all the caregivers stick with the plan.

Administration strategies

A syringe is worth having on hand. Not only is it more accurate, but it is less likely to spill when your crabby child bats your hand away compared to a teaspoon or medicine cup.

Click this link for a full post full of tips for helping get the medicine down without a battle. It includes a very silly TikTok that Dr. Ted and I did to demo one effective technique

Can you give less than the suggested dose?

When it comes to medicine, some folks want to give as little as possible and try to give partial doses. We understand that instinct. The problem is that sometimes the smaller dose might make a dent, but doesn’t get your child comfortable enough to actually feel better. If you gave a smaller-than-recommended dose, and it only gave a little relief, it’s ok to give the remaining dose to get the full effect. You’d be surprised, we’ve seen instances where the difference between 3.75mL and 5mL is huge in terms of kid outcomes.

In some cases your child might in fact respond to a smaller dose. If that is the case, by all means give the smallest amount that you can get away with. Alas, in our experience, most kids need the full dose to achieve relief.

Are there interactions?

Most of the time, acetaminophen and ibuprofen are safe to give with other medications.

Be careful if you are giving any of the multi-symptom cold remedies (such as DayQuil or NyQuill, which we recommend against anyway). Many of these already have the fever reducer as one of the ingredients; you don’t want to double dose.

Considerations for Young Infants

If your child is under 3 months of age, and you feel that they need any medication, check with your doctor’s office. Any young infant with an elevated temperature needs to be evaluated.

If your child is teething, those symptoms can linger for weeks at a time. Even though they are safe, we try to reserve Tylenol and/or Advil for occasional use. Getting a good night’s sleep if your child is having a ridiculously fussy day seems reasonable once in a while.

For teething, there are many other comfort measures to try first: Teething Blog post

A note on antipyretics for shots

Many parents will ask about giving something Tylenol or Motrin preventatively before or immediately after getting shots. Because there are studies that demonstrate that doing this decreases antibody production to some vaccines, this is not something we universally recommend.

That being said, it’s perfectly acceptable to give something at the first sign of fever or fussiness. This timing will vary from child to child: some kids don’t get fussy for over 8 hours, others will start after 3-6 hours. The only time we recommend doing preventative dosing is if there was a massive fever response to shots previously.

While studies have shown decreased antibody production, most kids still produce enough antibodies to be clinically protected from infection.

However, because we don’t know who will and who will not produce enough, our preference is to play it safe and hold off unless it is needed.

So, if you feel strongly that you want to give preventative dosing regardless, knock yourself out. Be aware that a dose of Tylenol will not impact the actual shot experience. It would be nice, but we promise you it doesn’t.

In summary, middle of the night fevers happen. Everyone should have these medications on hand and stay familiar with the correct doses.

Earthquake preparedness/My Loma Prieta story

 The following story was going to be in my book but it didn’t make the final edit.

I figured I will post it here in honor of April being official earthquake preparedness month.

Here is my Loma Prieta earthquake story

(scroll down if you want to skip to the preparedness aspect of this post).

The 6.9 magnitude Loma Prieta earthquake struck at 5:04 pm on Tuesday, October 17th, 1989. The shaking lasted 20 seconds. Many of you reading this weren’t even born or might be too young to recall it. Like many monumental events, people who lived through it can tell you exactly where they were and what they were doing when it struck.

I can remember it like it was yesterday.

The morning of the earthquake as per our daily routine, I dropped 26 month old Lauren off at the ‘family daycare’ in the home of a magical person named Jeanine. ‘Gigi’ lived out by the zoo and tended to 4-5 kids at a time. They took walks, read poetry and did yoga. Everyone should be so lucky to find such a loving and wise childcare provider. In the playroom where they spend much of their time was an ornate vintage telephone that was off limits. The kids all knew the rules. No touching the phone. More about this later.

After depositing Lauren at Jeanine’s, I headed to work in Noe Valley. Sandy worked downtown. Parking was often challenging, so at the end of his day he would take the underground Muni back to our house where he would get his car and then go pick her up.

My day at the Noe Valley Pediatrics office was wrapping up and I was on the phone with a remarkably long winded mom. I tend to be fairly patient, but this woman wasn’t even coming up for air. She was going on and on about something or other when suddenly she stopped mid sentence and shouted “earthquake”. The call ended abruptly. I confess that I looked upwards and mouthed a little ‘thank you” for getting her off the phone.

It took a moment or so until I also felt the shaking. The entire building rocked and rolled. The lights went out. A tidal wave of water sloshed out of the aquarium that we had in the waiting room. Don’t fret, the fish survived. (Fish that live in a pediatricians office tend to be hardy stock…they endure kids wapping on the glass and dropping all sorts of things into the tank on a daily basis. Earthquake? No big deal)

It was a long 20 seconds. All of us who were in the office ran to the doorways and held on. When it was over I was consumed with only one thought. I had to get to Sandy and Lauren to make sure they were okay.

Back at Gigi’s, Jeanine had stepped out of the room for a moment and at 5:04 exactly, Lauren took the opportunity to be a little naughty and picked up the forbidden telephone receiver.

Sandy had just arrived at Jeanine’s when the shaking started. He was right outside the gate and had a clear view of Lauren.

Her expression was priceless. ‘Oh, this is why you shouldn’t touch the phone’! She hurriedly returned the phone to its cradle and looked around to see if anyone noticed what she had done. For years, thanks to her dad, she was pretty convinced that she caused the earthquake.

This was long before we all had cell phones. I had no way of knowing if Sandy was stuck on muni or if he had picked up Lauren before the earthquake struck. There is no question about it; being away from your child adds a whole new element to any natural disaster.

I left immediately for home. Hats off San Francisco. Along the way I was struck by how well cars were behaving in a mannerly fashion. Every corner became a 4 way stop since all the traffic lights were out. At some of the bigger intersections, good samaritans were out directing traffic.

I made it home safely, but in the car, listening to the radio and hearing reports coming in of collapsing highways and bridges was terrifying. I was doing my best to remain calm. It wasn’t easy. I was finally able to breathe when I saw that Sandy and Lauren were at home waiting for me and that was when I burst into tears.

Once we were all home and together, the situation was much easier to handle. We spent the evening outside with neighbors taking turns listening to radios and trying to get a handle on damage and casualties. We had no power, but fortunately our house is on bedrock and didn’t sustain any damage.

Here is where it gets weird and why I was going to add this to my book.

I happened to have airline tickets for a flight at 7am on October 18th to go to visit my parents in Pittsburgh. This turned out to be the day after the quake. On this particular visit, I would be doing a solo parent trip with Lauren. Sandy was not coming with us.

Without a clue of what would happen later that day, on the morning of October 17th, I got a call from the now defunct USAir. There was an equipment change. Would we be willing to switch our October 18th reservation from the 7 am flight to one that departed at 11 am? In return we would get 2 round trip tickets for a future flight. We could still keep the bulkhead seats at the front of the plane. To this day, I have never since heard of an airline reaching out the day before travel and offering something like this. In any event, this was a no-brainer, I was happy to make the swap.

It was a good move on my part. It turns out that the original 7 am one ended up being canceled along with hundreds of other flights. The 11 am one that we were on turned out to be the first plane to take off from SFO post earthquake.

Those were the good old days when anyone could go through security. Was there actually security? I don’t even remember.

In any event, my parents were at the gate waiting for us with baited breath. The area was also packed with reporters waiting to interview the ‘survivors’.

True to form, my mom had been chatting with one of the reporters.

Since Lauren and I were in the front of the plane we were the first to get off. The light bulbs were flashing and we ended up on the front page of the now defunct Pittsburgh Post Gazette.

The front page article was full of wild misquotes, but so it goes. The photo is of my mom giving me a big hug. My dad is grinning in the background. (For those readers who have read previous posts about my family, there should be no surprise that they kept a copy of the paper)

Preparation is power

It is perfectly normal for the thought of natural disasters to create a hum of anxiety.

Different locations seem to have their specific menu of terrors. Here in the Bay Area our big ones are wildfires and earthquakes. The key to dealing with potential disasters in a sensible way is to do some preparation ahead of time.

If you have children, then you simply must have a plan. Sandy and I had certainly talked about needing to do that, but it never got off the to do list.

This is the nudge for every family that hasn’t done so yet, to take care of this now.

How will your family reunite if you are separated? Check with schools and daycares to see what their plan is.

Remember that cell phones might not work, so you can’t count on them as part of your plan. Landlines are sometimes a better bet, but so many people no longer have those. (As an aside, Sandy, who worked for one of the world’s largest telecom companies, says that while the cell phones might not work for calls, there is a chance that texting might still work.)

I am not going to completely reinvent the wheel. At the bottom of the post are some comprehensive checklists from some excellent sites, but here are some of the basics that come to mind. Some of these are absent from the standard lists and are things you may not have considered.

Make sure your home is safe and well stocked

• Anchor furniture to walls! If you have a climbing toddler, then you should make this a priority and not wait for an earthquake!

• Have an accessible flashlight and plenty of batteries. Where are they? If the lights went off right now and it was dark out, could you find that flashlight? Remember that your cell phones do have a flashlight feature that can help you get situated, but you are likely going to want to not squander the charge on your phone if you have a better option

• Have extra charging banks that are charged and ready

• Have plenty of food. Make sure you have a can opener that doesn’t require power. Do you have a camp stove or option for boiling water and making pasta? That can significantly expand your food options

• Have enough water. Experts suggest 1 gallon/per person/per day for a minimum of 3 days. But it is also a good idea to have unscented bleach on hand. https://www.epa.gov/ground-water-and-drinking-water/emergency-disinfection-drinking-water

• make sure glassware and delicate objects can’t fall

• If you do have things fall and break, have some heavy duty gloves on hand to help you clean up any sharp items that may have broken during the shaking.

• Have enough diapers, pet food and any medications

• Consider getting a fireproof safe for important documents

• Uncle Joel’s rule... Have cash on hand. Make some of it small bills. There is a good chance that the ATMs won’t be working. We took this lesson from our Uncle Joel who survived Hurricane Andrew in Miami. He had very little cash and without family getting him some funds, he would have had a tough time until the power was restored. Not only might ATMs be unavailable, but apple pay will likely not be an option either.

• If you don’t have working plumbing, you can make temporary commodes with an inflatable inner tube and a garbage bag.

• Sign up for an alert It may only give you a few seconds, but those can potentially make a difference

Okay, what if it is a situation where you need to evacuate?

• Try not to let your gas tank go below ⅓ of a tank

• It is a good idea to have a “grab and go” backpack full of emergency stuff in your trunk. This might come in handy much more often than you think and not just in a natural disaster. You never know when an extra layer, change of clothes or snack will come in handy. Include some games or activities.

• In any case, make sure that you routinely restock and rotate supplies.

The twice a year clock shifts are a great time to do this. When you are done changing the battery in your smoke detector, take a look at your emergency stash. Get rid of anything that is about to expire and make sure that you update sizes for spare clothes and diapers.

This list was just a start. I highly recommend checking out the links below and use them to help you create a comprehensive plan.

https://www.ready.gov/earthquakes

https://www.cdc.gov/natural-disasters

https://www.sfchronicle.com/survival/

Do you have a favorite resource? Let me know and I can add it!

So, Am I ready?

Doing this post is a nudge to myself!!

I have my flashlight and I know where it is, wahoo.

I have some water, but probably not enough. I will likely be eating a lot of cold beans, which is not ideal.

Lets get prepared!!!

Spitting up and Gerd.

 

If you are a new parent, comparing your situation to that of other new parents is rarely helpful.

But sometimes there is some comfort in knowing that you are not alone.

Reminding yourself that issues you are dealing with are fairly common, can be somewhat of a relief.

And if your baby has just thrown up all over the place, this one is for you.

Let’s start with some empathy from Nurse Judy:

All babies spit up. It is just a fact of life. Of course some of them do it more than others.

My oldest daughter Lauren rarely spit up. I simply didn’t need to pay much attention to the occasional ‘urp’

But as you will learn if you have multiple children, kids do things differently.

My younger daughter gave me a clear understanding of what so many of my patients were fretting about. Alana was a prodigious spitter. It was shocking to me how much this baby could regurgitate! I marveled that any of the milk was actually staying in, but fortunately she grew in leaps and bounds. She was enormous and never dropped her growth percentiles. Alana was the example of a perfectly happy spitter.

I wasn’t quite as blissful. I often didn’t bother changing my shirt unless there were 15 splots of spit up all over it; it simply wasn’t worth it.

My husband Sandy, the clean freak in our family, would follow after her with a spray bottle of Resolve carpet cleaner and a scrub brush, so that she didn’t completely ruin the carpets with the constant puking. (No, he isn’t for rent)

With large babies like Alana, sometimes the spit up is simply the overflow. I know that it is very hard to estimate how much milk your baby is actually spitting out. When I was working at Noe Valley Pediatrics, parents would call me all the time reporting that the baby seemed to spit up the entire meal and yet, there they were, gaining weight just fine. In most cases, the spit ups are not nearly as much volume as you think they are.

In Alana’s case, she ignored the rules, as she most often did, and didn’t slow down with her spitting up until she was seven months old. Most kids will slow it down long before that.

It’s important to distinguish between “reflux” (normal) and GERD (gastro-esophageal reflux disease).

Simple reflux describes what happens with almost all babies: they might be described as “happy spitters.”

This common spitting up resolves with ‘tincture of time’; all babies grow out of it, unlike the disease.

Dr. Ted reminds his patients there’s a light at the end of the tunnel:

Spit up often peaks around 3-4 months of age before it starts to spontaneously show signs of improvement in practically all children. So if things seem like they’re getting worse before they get better… you’re not imagining it. That’s a very normal part of the timeline. And no matter which interventions you try, whichever one you do at 3-4 months will seem like the ultimate cure.

On the other hand, GERD is actually a disease and as such shouldn’t be ignored. It is defined by reflux that seems to cause problems - poor weight gain, excessive fussiness with feeds, arching the back, coughing or sleep disruption linked to spit-ups. The spit-ups usually appear uncomfortable.

Here are some things it is helpful to know about spitting up.

When babies spit up it is not unusual for it to also come out of the nose. This can be scary. If they seem to be having a moment of difficulty when this happens, having a Nose Frida or aspirator handy will help you clear the nasal passages. I remind new parents to always know where it is kept so that you can easily grab it at the moment’s notice.

Once in a while you might note some blood in the spit up. To no ones surprise this tends to freak many parents out, but take a deep breath. Most of the time this is simply a symptom of mom’s sore nipples. There is a good chance that if the nipples are cracked at all, the baby might get a little blood when they are sucking. If it is persistent, there is a way for a lab to check the blood to see if it is from the baby or the mom.

As an aside, if your little baby vampire swallowed some blood during nursing it is also possible that you may see some of it show up in the poop. It will no longer look like fresh blood by the time it makes its way through the system but would more likely look very dark and tarry. If the baby seems perfectly fine, it is very unlikely that they have any type of active bleeding going on.

While most spitting up is fairly benign, projectile vomiting is something that warrants attention. There is a fairly uncommon condition called pyloric stenosis that usually shows up between 2-6 weeks of age. For some reason it is more common in little boys. There is no need to fret about the occasional more forceful spit up, but with pyloric stenosis it might remind you of the movie the exorcist. The spit up literally flies out of your baby and this happens multiple times a day and can land about 3 feet away from the body. Of course you never want to have anything wrong with your baby, but on the scale of things, this condition is very treatable with a simple surgery when caught early (so don’t ignore it). If untreated, it can lead to electrolyte issues and dehydration.

If it feels like your baby is getting thinner, regardless of how fussy they are, it is never the wrong answer to get a weight check! If they’re dropping percentiles they may need an intervention.

Here are things to try if your baby spits up a lot

These are appropriate for ALL spitters. They are also often the first step in managing a GERD diagnosis.

Feeding Strategy Interventions:

• Smaller more frequent feedings. This might look like doing multiple “snacky” small feeds during the day, especially in the latter half when the kids are generally more fussy. This might make it feel like you’re constantly feeding your baby, but it’s worth it. Better to spend your time feeding, than cleaning up vomit, or soothing a fussy baby.

• If you are bottle feeding, try something called “paced feeding.” This slows the flow of milk to mimic breastfeeding:

  • You hold the baby more upright (not flat)

  • Keep the bottle horizontal (not tipped straight down)

  • Let the baby actively suck to get milk, rather than gravity doing the work

  • Pause every ~20–30 seconds or every 1–1.5 oz to give breaks and burp

• Experiment with different nipples. You want the flow that causes the least air to be swallowed and delivers milk at a slow enough rate that doesn’t promote too much spit-up. There are also bottles out there that tout ‘less air’. There might be some trial and error figuring out what works best for your baby.

• Gently warming the milk in the bottle can impact the amount of spit-up. Dr. Ted recognized that his baby Ori was spitting up much more if the milk was cool. We don’t fully understand why this works, but if you notice a difference with your baby it is worth a try.

• Gravity helps! After the feed, keep your baby upright as much as possible. The recommendation calls for at least 15-20 minutes of upright time after a feed. That sounds reasonable enough until you actually try to be a rule follower. We recognize that in reality, that 20 minutes is a luxury that you just may not have and you’re lucky if you can get 10 minutes. Do the best you can and try for at least 5 minutes.

• There are some wedge pillows available that some parents find helpful. These are not safe to be used for sleep, but are fine for supervised awake time. Wedge pillows can keep babies in an up-angled position to help the milk to flow down.

• Some babies are very burp dependent. You will notice that if you aren’t patient enough to get a good burp, part of that meal is going to come back up. Other babies never seem to burp and have no issues. Nurse Judy’s favorite method is to move them from a flat position on your lap and flip them up and over your shoulder. Dr. Ted is a burp evangelist and has a library of at least 10 different moves to ensure an effective burp. Sometimes getting that bubble out includes some creative calisthenics.

• Pressure on the belly might make some kids spit up. That might come from a tight diaper (imagine trying to eat a Thanksgiving dinner while wearing spanx), or from tummy time on a hard floor right after a feed.

Dietary Interventions

• Breast feeding moms should see if there are any dietary factors that impact the spitting. This doesn’t mean you need to go on a full elimination diet right away (please don’t make your life harder than it already is). But if you start to notice a pattern, like more spit up, fussiness, or gassiness after certain foods, it’s reasonable to experiment with cutting one thing out at a time for a week or two. The most common culprit is dairy, but it’s not the only one. If you do try eliminating something, give it a little time, these changes aren’t immediate. And if you don’t see a difference, don’t be afraid to add it back in. The goal here is not perfection, it’s just seeing if there’s an obvious trigger that’s easy to fix.

• Probiotics may be useful. This is one of those “might help, probably won’t hurt” interventions. Some babies seem a little less gassy and a little more comfortable on them. Others may show absolutely no change. If you decide to try one, give it a week or two and see if you notice a difference. If not, no need to keep going. There’s no prize for the longest probiotic streak. When the issue is excessive spitting, we tend to reach for ones that contain Lactobacillus reuteri, which has a bit of data behind it in infants. But again, this is not a magic fix, it’s more of a gentle nudge in the right direction for some babies.

• Babies getting formula might improve using one of the sensitive formulas. Every formula reacts differently. Dr. Ted has noticed anecdotally that many of his patients do very well starting off with the Kirkland brand formula, but if your baby has reflux disease, most brands have a separate “sensitive” version. There are some very good specialty formulas to investigate as well, but they tend to be fairly pricey.

  Reminder: If you’re going down the formula rabbit hole, try not to change five things at once (we know…easier said than done when you’re tired and your baby just spit up on your last clean shirt). Pick one formula, give it a solid 5–7 days if you can, and see how your baby does. These changes take a little time, and switching too quickly can make it hard to know what’s actually helping. If things aren’t improving, it’s reasonable to step up gradually, from a standard formula to a “sensitive” one, and then to a more specialized option if needed. Most babies do not need the very expensive formulas, but there are situations where they can make a big difference. And just to say it out loud: if your baby is gaining weight and generally content, a lot of spit up alone doesn’t mean you need to keep switching formulas in search of perfection. Sometimes the best formula is the one your baby tolerates reasonably well… and that you can actually find at the store without stress.

Medical Interventions

If you have done 2 to 4 weeks of the above interventions and have seen no significant improvement it is time to make a plan with your doctor. Start the discussion and evaluation with a weight check, so an office visit is usually needed.

Your pediatrician may suggest thickening the feeds. To do this, start small with a teaspoon of oatmeal or rice cereal to 2-4 ounces of formula. This can help the milk stay down in the stomach a bit better. Keep in mind that a faster flow nipple might be required for the thicker milk. If you want to keep it simple, there are some formulas that are thickened with rice starch, such as Enfamil AR.

Medications are used as a last resort for babies that have a true diagnosis of GERD (reflux disease), not the happy spitters. If you’ve tried everything on the list above, and you’ve committed a good 4+ weeks to the behavioral and dietary interventions without good effect, medications can be considered if it is suspected that stomach acid is the cause of the reflux symptoms. These are the babies who are consistently arching, refusing feeding and or struggling to gain weight.

Medications are usually tried for a short window ( about 4-8 weeks) with the goal of using the lowest dose for the shortest amount of time possible.

If it’s not clearly helping, it is time to stop and rethink the plan. This might be time for a referral to a specialist.

Reminder:These medications are helpful in the right situation, but they’re not a magic fix—and most babies don’t need them.

Alternative approaches to consider

Traditional Chinese Medicine (TCM)

Nurse Judy asked her ‘go-to’ acupuncturist to weigh in on this topic.

Traditional Chinese Medicine (TCM) views spitting up and reflux as an imbalance in a baby’s immature and developing digestive system. TCM approaches are extremely gentle and safe, including some possible changes to feeding practices (that of a nursing parent and/or the baby), massage, warming the baby’s digestive system, activating specific acupuncture points (needles NOT necessary), and sometimes an herbal remedy for the nursing parent and/or the baby. Dr. Den specializes in pediatrics, and regularly works with babies experiencing a lot of spit up or reflux, and the relief can be tremendous, for both the baby and their concerned parents. Reach out to Dr. Den with any questions, or schedule an appointment directly through her website: The Acupuncture Den.

Chiropractic

While clinical data proving that this works is limited, anecdotally, Nurse Judy’s chiropractor Sandra Roddy Adams, says that she has treated many babies who appear much more relaxed following a gentle adjustment. She speculated that the all important vagus nerve is part of that equation, although there have been no studies to definitively prove this.

Random Extra thoughts

Skin folds

Kids who do a lot of drooling and spitting up can be prone to skin irritations in the skin folds of the neck and the area behind their ears. Make sure you do a daily skin check. Being proactive will work in your favor. It is much easier to prevent a nasty skin fold rash than it is to clear it up.

Sleep

Parents often express concern about the baby spitting up and choking if they are on their back. Fortunately, repeated studies are reassuring. Babies’ anatomy actually makes choking more likely when they are lying on their bellies.

So, even if they are frequent spitters, it is still strongly recommended that you place them on their backs when they are sleeping. The data backs that up!

You might have noticed this marvelous new model!

Introducing Ori Handler!

Mazel Tov to Dr Ted and his husband Chris!