Friday, February 21, 2020

Adverse Childhood Experiences/ We need to pay attention

Adverse Childhood Experiences
One of the things I have enjoyed the most about doing my blog posts is the research and personal education involved. I have years of experience under my belt, and while there is a great deal that I know about a lot of things, I have no shame accepting that there is even more out there that I don’t know. I am eager to keep learning.

Last week I went to the 2020 UCSF Chancellor’s Health Policy Lecture. The speaker was the brilliant and inspirational Doctor Nadine Burke Harris. Dr. Burke Harris was a pediatrician in San Francisco’s Bayview-Hunters Point neighborhood. She is currently the very first surgeon general for the state of California.

The topic of the lecture was Adverse Childhood Experiences, known as ACEs. This is a subject that she is clearly passionate about. The American Academy of Pediatrics is now asserting that ACEs are the single greatest unaddressed public health threat facing our nation today. That is quite the statement!

This isn’t new groundbreaking information. In fact, the data has been there for over 30 years, which makes it even more frustrating that it was not on my radar. Why isn’t there more general awareness?

The more I learned, the more intrigued I became. The findings are clear. Adverse Childhood Experiences (ACEs) experienced during childhood can have lifelong health implications. It makes so much sense! 

Often western medicine focuses on treating symptoms. It is not surprising that out of 3 trillion dollars spent on healthcare only 5% of that money is spent on preventive medicine.

I will borrow a metaphor from Dr. Burke Harris. If people are drinking from a well and many of them are getting sick, it is all too common for many doctors to treat the diarrhea rather than checking to see if the water is contaminated.

Fortunately, there are doctors who make an effort to get to the root of problems. In 1985, Dr. Vincent Felitti was frustrated that patients in his San Diego obesity clinic, after initial success, were failing to keep the weight off. When he took a closer look, he was astonished to find that more than half of the clients who kept regaining their weight had some history of sexual abuse.
He realized that it couldn’t be a coincidence. Ultimately, he linked up with another doctor Robert Anda. Dr. Anda had been studying how depression and feelings of hopelessness affected coronary heart disease. They decided to collaborate on a much larger study and the findings were significant.

The ACEs study looked at the following risk factors:

  • Parents divorced or separated
  • Physical abuse
  • Physical neglect
  • Emotional abuse
  • Emotional neglect
  • Sexual abuse
  • Witnessed domestic violence
  • Substance abuse in household
  • Mental illness in household
  • Family member in prison

Since the original study, questions about other obvious stressors, such as loss of a parent, food scarcity, homelessness, disability, exposure to gun violence, and discrimination, have been added to the screening tools. However, the issues bullet-listed above were the ones that were tested and scored. They found that, as suspected, there was a link between childhood trauma and onset of chronic disease through the lifespan. What they weren’t expecting was how common of an issue this was.
While it may come as no surprise that poverty is associated with higher scores, it turns out that very few of us got a free pass. This initial large study was done through Kaiser and the participants were mostly college educated, middle to upper class:

  • 67% of people in the study had a score of at least 1 ACE
  • 17.6% had a score of 4 or more ACEs

This relates to so many of us. You may be one of the more fortunate with a low score, but unless you live a remarkably isolated life, someone you know is impacted.

There is a dose response relationship between ACE scores and health outcomes. This simply boils down to the higher the risk, the more an effect there is likely to be. A person with an ACE score of:

  • 3 or more is twice as likely to develop heart disease
  • 4 or more is three times as likely to suffer from depression
  • 4 or greater is 32 times more likely to have learning issue
  • 6 or greater has a 20 year lower life expectancy!

A high ACE score can be a predictor of high blood pressure, smoking, teen pregnancy, and suicide. The list goes on and on. This actually may be one of the biggest health discoveries we have ever seen! There seems to be a fairly strong relationship between cause and effect. 

The connection between these childhood stressful experiences and subsequent issues like depression, substance abuse, suicide and other social issues seemed fairly obvious. The reason for the connection to physical ailments such as cancer, heart disease, and immunity issues was a bit more baffling to me until I heard Dr. Burke Harris speak. Then the clouds lifted and it made total sense. DUH.

In her analogy, if you see a bear in the woods, you would have a full on “fight or flight” stress response. Your body is doing what it needs to escape. You also have an immune response to help you recover in case you are injured. This is just what your body needs to help you survive this emergency. But, if the bear comes home from the bar into your house every night, this frequent response is going to have serious implications. That frequent stress response is impacting the body and quite literally getting “under the skin”. 

I did a blog post several years ago about how your stress level can add up silently before it overflows:


Of course, not all stress is the same. Positive stress stems from adverse experiences that are short-lived. We learn how to cope and adapt. For a child, examples might be the first day at school, falling off of a bike, or even having to share a toy when they would rather not. For some infants, it can be something as simple as exposure to a stranger. This type of stress might cause an increase in heart rate and changes in hormone levels. With the support of a caring adult, children can learn how to manage and overcome positive stress. This type of stress is considered normal adaptive stress and coping with it is an important part of the developmental process. Kids learn to ‘go with the flow’. They learn to get back on the bike and learn how to ride. They learn to get along with others. Babies learn that some people other than mommy or daddy are safe.

Tolerable stress refers to more intense experiences that are hopefully short-lived. This could be an earthquake, death of a loved one, or family disruptions such as separation or divorce. The initial impact packs a wallop, and then eases somewhat.
Here is the important thing to note. If the child has support from a caring adult, this stress remains tolerable. Kids can learn how to adapt thereby building resilience.

Let me put this in a context that many can relate to. Think of your child as a bank account. Stress is a debit, nurturing is a deposit. The positive stress that I mentioned previously could be like using your credit card and paying it off in full every month. This actually gives you a good credit score. If you use the card for a much larger purchase, you may begin to have a negative balance if you don’t have enough to pay it off right away. This is tolerable if you are able to make regular payments. It becomes a real problem when you can’t keep up and are now accruing more and more interest. It is easy to slide deeper and deeper into debt.

If you are filling up the “account” with positive nurturing behaviors, hopefully your child can “afford” the occasional larger expenses because you have helped them have a robust savings account filled with positive past experiences that can be used to inform current and future expenses.

Without “funds in the account” constant stress is no longer tolerable and can become maladaptive and is referred to as toxic stress. This toxic stress can result in direct and measurable physical impact by altering healthy brain development and causing multi-system effects. It can lead to disruptions in the ways that the neurological, endocrine, and immune systems operate. This then can affect other systems throughout the body as well. MRIs show that actual changes are taking place in the brains of kids who experience early adversity.

Science is telling us that ACEs are risk factors that have real implications for our children’s health...the mind may forget but the body remembers. You might not even recognize that there is an issue. Some research revealed that many children who develop emotional and behavioral problems don’t begin showing symptoms until the 4th grade.

Bear with me as I bring in another analogy. Think about lead poisoning. Generations ago we didn’t realize that exposure to lead in our environment was a problem. In fact, most of our homes were covered in lead paint. Eventually, we learned that exposure to lead levels had dramatic implications. The higher the exposure the more of a problem. Some folks live in homes with flagrant peeling old paint and we knew we needed to take action. Others might be getting exposure from a sneakier source such as soil, a brightly colored painted toy, lead pipes, even the varnish on a bathtub. We wouldn’t know until we tested. Now, it is standard for every child to be screened for lead.

This post is simply an attempt to build awareness about an important issue. Every child should be screened for ACEs.

There are easy ways to do this (think audit) and more and more ways to make changes and make real differences for people (think deposit). Those will be addressed in a future post.

What is your score?????


I want to thank Dr. Michelle Stephens, PhD, PNP for her valuable input on this post!

If you are interested in what I have been up to lately aside from blogging and classes
check out oath.health/waitlist

Friday, February 14, 2020

Personal Musings/The End of an Era

Personal musings

I am taking a break from writing about illness for a week.
In the years that I have been doing my weekly emails, some of the posts have been personal stories. Those are often the ones that have gotten the warmest responses. For you loyal readers this one's for you.

I am one of the lucky people who until this week still had my childhood home. With such a transient society I know how rare that is. Especially at my age. 

My family moved into our house when I was four years old. Since I met my husband when we were both teens, the house was also part of his life for almost 43 years. It was the hub, for my sisters, daughters,nieces, nephews, friends and neighbors.

Pittsburgh, Pennsylvania is a hilly city. One of my mother's important criteria for choosing a home was picking one on the flat side of the street. With the new house, there was only one step up onto the porch in order to get to the front door. Once residence was established, there was often a pause to sit on the front porch swing before going in.


Mom was in her thirties when my parents bought the house. Her insistence that they pick a house with an easy entry wasn’t for her. Although it would be a relief not to have to schlep her cello up a flight of stairs, she was thinking about her older relatives and friends who would visit. I don’t think she was planning for her own future, but having an easily accessible house ended up enabling both of my parents to live out their years there.

It was a magic house. It was infused with a welcoming, loving atmosphere. It was also filled with stuff. We called it the house of requirements. If there was something you needed for an art project or a costume, it was somewhere in the house. One of the many medicine cabinets likely had just the medication you needed.

In the house were any number of games and books on every subject. A  romance with the classic muscled Fabio on the cover (mom called these her key to relaxation) would share the shelf with physics textbooks and poetry books from the 1800s. There were enough children’s books and toys to keep the generations of grandchildren and great grandchildren captivated.
There were pets, of course! This included many cats, fish, gerbils and birds.

There were musical instruments of all kinds. Better yet, people actually played them! There was a trove of old photos and hand written letters. Thousands. 

My mom passed away 3 years ago and it has taken that long to carefully clear out the house. My older sister was the local one and she insisted on honoring every item by finding a home for it. It was a herculean effort. Nothing was carelessly discarded. Now, finally it is empty.

Interestingly, it turns out that even though it is has been cleared out, the echoes of joy and love remain. The imprint of the positive energy is just as strong. It is hard to let go of the house but it's time. It is the end of an era. Change is hard. We can’t stand in it’s way. We  can just do our best to handle it gracefully.

Here is a piece that I wrote about the house and one special piece of furniture.

The Diaper Dan Drawers
My grandmother Flora Isaacs lived on Darlington Road, just a few blocks away from the house where my own family lived. Our Pittsburgh roots go way back. Her father, Morris Meyers, moved there in 1860 and also lived for a time in the same triplex as my grandmother. For the record, their house was on the hilly side of the street. It was a long and steep set of steps getting up to the house.

When we would visit grandma, my mother’s childhood bedroom held a certain allure. The furniture was dark antique wood and included a large vanity with an enormous mirror. It is a lovely, but odd piece of furniture. It is too low to sit in front of it on a regular chair. One must sit on a very low stool in order to make use of the surface and mirror. There are two large drawers on either side. My sister Marjie named them the ‘Diaper Dan’ drawers. I have absolutely no idea where that moniker came from, but the Diaper Dan Drawers they were.
Grandma would store all sorts of odd and ends in those drawers. We were allowed to take whatever we wanted. Good move wise grandmother; what a simple way to rid yourself of junk!

These drawers became our treasure chest. When we would get to grandma's, we would say our hellos and then scamper upstairs to see if there was anything of interest that had appeared in the drawers. One item that comes to mind was a porcelain bowl in the shape of a set of hands. I thought they were beautiful. 

We carefully wrapped them and bestowed them as a gift to our mother for her birthday. She couldn’t contain her laughter. Of course it had been a gift to her from a long ago boyfriend. Who knows where it had been all those years, until grandma was cleaning up and tucked in in the drawer. This time my mom kept it. It stayed on the dresser in her bedroom and was used as a container for the odd safety pin or general  knickknacks.
(When we were dividing the family treasures after mom died, I kept the hands.)

When my grandmother was in her 90’s she moved in with my parents for her final years. Some of her furniture, including the Diaper Dan drawers came with her. 

Alas, time passed, Grandma was gone, my parents were gone, the difficult decision was made to sell the house. We embarked on the epic task of emptying it of all the stuff and furniture. The sisters and grandchildren routinely gathered to clear and sort.
“ Do you want this? No! Do you?” “What on earth is that?”
My daughter Alana was clearly the easy mark. She had a hard time refusing things that were connected to the house. Because of that there are boxes with her name on it, stored in our garage. These are filled with mystery items for when the time comes that she has room for them. Lauren was quicker to say "no thanks", but my dad's barometer is now on the wall of her house and she has her own collection of mystery cartons in her garage. The letters and photos were taken in boxes to my sisters house. The local historical society took its share of things as well.

One by one things were claimed. We had a “give it away day” and family, friends and neighbors came and chose mementos.
The process continued until there was almost nothing left. Just  like kids being picked to be on the sports teams at the playground, there was something sad about being the last one selected. No one chose  the Diaper Dan drawers.

Then, the magic continued. It was as if the house got to choose it’s new family.. There was no need to have it listed with an agent. Friends knew friends. A lovely family had been searching for the right home for two years. The new mom nodded in approval that there are no steps; her older relatives will have no trouble visiting. The new children scampered around the house claiming which rooms would be theirs.
When asked, the family said, "Sure! The Diaper Dan drawers, as well as some of the books, are welcome to stay." They gathered and listened as I told them the story of the drawers.

There are treasures waiting in the drawers for them when they move in later this month! I wish the new owners as much love and happiness in the house as we had. 


Friday, February 7, 2020

The Novel Coronavirus/ Do you need to be wearing a mask?

The Novel Coronavirus

I worked a shift at Noe Valley Peds this week and it was lovely being there. While I was there an email alert and update from the Health Department was sent about the Novel Coronavirus. Of course it is all over the news. Not surprisingly people want to know how worried they need to be and also if they need to be wearing masks.

Over the many years that I have worked as an advice nurse I have seen dozens of scary viruses make headlines. Thankfully most of them have quieted down soon after stirring us all into a tizzy.


As a quick summary, coronaviruses are not new. They are a large and diverse group of viruses, many of which are animal viruses. 

Coronaviruses are zoonotic. That’s a great cocktail party word. It means that some strains can be passed between animals and humans. Prior to this new one that was first recognized in 2019, only six coronaviruses were known to affect humans. Four of these predominantly caused only mild to moderate upper respiratory symptoms. In fact they are thought to be responsible for 10-30% of all colds. Two of the six have been strains that have been responsible for more severe illnesses. The one that leaps to my mind is SARS (Severe Acute Respiratory Syndrome.)

I remember when that was starting to circulate. My girls were teens at the time. They were taking a flight and I tried to convince them that they should wear a mask on the plane. They refused. I remember the conversation.

“Masks are so dorky”

My response of “better dorky than dead” did not change any minds. They kept the masks in the carry on. Happily for all involved they survived.

The other more severe strain is called MERS (Middle East Respiratory Syndrome). That one made its first appearance in 2012. It is known for its ability to pass from camels to people. If you are not riding camels in the Arabian peninsula, you likely don’t need to worry too much about catching it.


The strain that is going around now is called a Novel Coronavirus because it is new and until now was not seen in humans. It was first identified amid an outbreak of respiratory illness cases in Wuhan city, Hubei province, China. It was declared a global emergency by the World Health Organization (WHO) on January 30, 2020.
The incubation period seems to be between 2 days and 2 weeks.

Common signs of infection include fever, respiratory symptoms, cough, shortness of breath and breathing difficulties. Fevers occur in 98% of the cases. Many of these same symptoms are what you can expect from the flu. Most cases are not serious and people recover without intervention. In the worst cases, infection can cause pneumonia, severe acute respiratory syndrome, kidney failure and even death. Older adults with prior health concerns are the ones being hit the hardest. Early estimates are that the mortality rate for this is between 2-3%. This might decrease as more studies are done. Because some people might actually not show any symptoms at all getting an accurate count is a challenge. One of the big dangers of course is that because it is new, this is not something most people have immunity to, making it terribly contagious.


My heart goes out to all the folks in China who are dealing with this, but for my local patients at this time, I would say that there is no need for panic. The health department is doing an amazing job trying to stop the spread here.

This is an emerging, rapidly evolving situation and CDC will continue to provide updated information as it becomes available.


Hopefully in several weeks we will be able to see that we were able to contain it. As things stand right now, we need to be more concerned with the flu which is actively circulating.

Standard recommendations to prevent any infection from spreading include regular hand washing, covering mouth and nose when coughing and sneezing. Sneezing into your elbow is a good tip and one worth modeling and teaching to your kids. Avoid touching hands to faces, especially the mouth, nose and eyes.

If you can, avoid close contact with anyone showing symptoms of respiratory illness such as coughing and sneezing. This is especially important if you have a young infant or someone in the family with a compromised immune system.

If you are getting sick and you have recently traveled to China or have been exposed to anyone who has been in the impacted areas, it is essential that you let your doctors office know that before simply showing up there.

Make sure you thoroughly cook all animal products and wash your hands especially well after contact with any animals (especially camels.)

You will note that wearing a mask is not on the list.

If you have been one of my readers for a while then you already have a box of N95 masks in your house, right?? I like all of us to be prepared.

But, while it is nice to have them, masks are more useful if you are sick and wearing one to keep from spreading than they are at protecting you from catching something.The N95 masks, if they are fit properly with a nice tight seal, can offer some protection, but they aren’t hazmat suits. 
Also, good luck getting one that fits your young child. You then need even better luck having them keep them on! In general many studies feel that masks offer a false sense of security.

What you should focus on is avoiding crowds and encouraging good hand washing. Here is a do it yourself science project to help your kids see the importance of hand-washing.

I read about a brilliant “hands on” experiment that you can do at home with your kids. Take several pieces of bread. Store them in some baggies, and monitor the pieces to see what gross stuff grows on them.

One piece should be untouched by hands...use clean tongs when you place it in the baggy

One piece should be touched by hands that were cleaned with soap and water

One piece can see how well the just hand sanitizer worked.

One piece should be rubbed all over your phone or computer keyboard.

Friday, January 31, 2020

Building and Protecting your immune system



My background is in western medicine but my patients over the years have been on the receiving end of advice from me that includes some more natural or holistic suggestions.
 
This post in particular strays a bit from the basic western medicine path and includes a combination of conventional wisdom, along with some anecdotal remedies shared with me by healers from a variety of modalities. Some of the things that I suggest can be found, as my husband laughingly describes it, down the “placebo aisle” of the local drugstore, but as we are in the full throes of a variety of illnesses, many families are ready to try anything.
 
My kids grew up with my husband's grandma’s recipe fondly referred to as Muggala Guggala, (see below for recipe*) I imagine many families have their own health rituals. As long as you are not ignoring a condition that warrants medication such as asthma inhalers or antibiotics, there is little harm in exploring some natural options. Who knows, you might find something that helps.
 
Good Hand Washing is the cornerstone to staying well.
 
If you were out and about in a crowd of sniffling,coughing people make sure you scrub up and change your clothes as soon as you get home. Try not to touch your hands to your eyes. I just did my post on habits. If you are someone who is constantly touching your face, this might be a good habit to try to conquer. Recently, in the news, was a story about how Purell and hand sanitizers are NOT as good as soap and water. Those are convenient to have as a back up when you are out and about, but as soon as you are near a sink, scrub up.
 
Getting enough sleep is essential. If kids seem tired, you might need to start the bedtime routine a bit earlier. For older kids and adults make sure you limit the screen time for at least an hour before going to bed. Most experts suggest longer than that, but I accept that it often isn’t that realistic. Sleep tips

Nutrition
Make sure you and your kids are getting enough Vitamin D. Many folks have vitamin D levels that are significantly below where they should be and would benefit from a daily supplement .
 
Make sure you are getting enough IronMagnesium, iron and vitamin D are all connected to sleep as well as to a healthy immune system. (Magnesium also helps with pooping.)
 
I don’t love to binge on most vitamins, but a multivitamin that has A and C is especially important during the cold and cough season. Check out Ester C. This is an exclusive form of vitamin C that is designed to give round the clock immune support. Sandra Roddy Adams, my chiropractor, gives this a big thumbs up.
 
Zinc is an important cold fighter and some studies show that it can decrease the duration of a cold by 50%. Zicam lozenges are what I like. I actually think that the generic orange flavor tastes the best. These work better if you catch it early! With any zinc product, it might be best to take with something in your stomach to avoid nausea. Kids need to be old enough to safely take a lozenge or chews
 
I asked my cousin Sam, who is a retired family practice physician if he had any favorite supplements. Echinacea,
ginger, garlic, myrrh, cayenne, vitamin C, vitamin B6 and bioflavonoids all made his list. For the grown ups out there, he recommended a Source Naturals Wellness Formula that has a lot of the good stuff in one capsule.
 
More and more experts are suggesting that having a healthy gut is essential to the immune system. My friend Sari is a craniosacral therapist in Arizona. When I reached out to pick her brain about this post she concurred with me that many current studies are finding that having a healthy gut is essential to the immune system.
 
Probiotics are good for any age
For newborns The product evivo is a good one to look into.
 
Oil of oregano is thought to be a great immune booster. I would recommend this for grown ups or kids over 6 who are very cooperative. It has a very strong taste and causes some oregano burps but can work pretty well
 
Omega 3s are mostly found from eating fish, but most people probably don’t get as much as they should. This supplement makes it to most of the lists as a worthy supplement.
 
Local honey has antioxidants and is thought to be helpful for the immune system. Dr. Anne was the one who added this to the list. She actually adds honey to her coffee! I tried it and it isn’t bad. Remember that infants under one year should NOT eat honey
 
Chinese Medicine
As I mentioned in a post several weeks ago, I was poised to fall into the abyss and was coming down with a cold and cough. I ended up getting an acupuncture treatment and started taking some herbs. The cold ended up quite mild and didn’t go down into my lungs.
 
There are some Chinese formulas that are very safe and effective. Choosing which one to use isn’t easy without the advice of an expert. The right herbs depend on exactly what type of cough is going on. Chinese herbs are not a one size fits all answer. Our local acupuncturist Den Bremond in Noe Valley is also an RN. She is a lovely resource for not only helping build that immune system, but also helping you get back to health if you are already ill.
 
My amazing friend Anita is another acupuncturist on my team of healers. I wish she was local, but she is based in Colorado.
She encourages warming foods for her patients. These keep the internal temperature up. Viruses prefer the cold environment. She suggests that drinks be room temperature or warm/hot. Don’t add ice to drinks. Use warming spices and herbs such as garlic, cinnamon and cloves. Soup is always good!

Here is a bonus acupressure point good for boosting the immune system: acupressure point stomach 36
 
While staying warm and eating and drinking warm foods is good when you are sick, there are studies that suggest that for healthy folks who are trying to stay that way, doing a cool water rinse at the end of your shower can be an immunity booster.

Herbs and Homeopathy

Sambuccol is at the top of my list when it comes to my personal self care. This is an elderberry base, fairly widely available that has some scientific studies backing up it’s immune boosting properties. (Even Sandy doesn’t scoff at this one.) I actually start taking these the moment that I feel the scratchy throat feeling that makes me worried that I am starting to come down with something.The earlier you start, the better it works. The bottle says for children over 2. The UK version gives the dosage for over 1.
 
 These are homeopathic sprinkles that I refer to as fairy dust.
I don’t understand homeopathy, but many folks swear by these. I take a tube every time I fly. Sandy tried to figure out what’s in them and the only ingredient he recognized was duck liver.
 
This herb is on many folks list of remedies. The studies have been mixed as to whether or not it works. Make sure you are a label reader when getting this supplement
 
Reflexology
My friend Oran is a wonderful healer who lives in Israel. Both of my daughters had moments during their travels there when they showed up on her doorstep with various illnesses and she nursed them back to health. She has the ‘No White’ rule when people are sick. No white sugar, no white flour and no dairy. All of those can contribute to inflammation.
 
Environment
It is very important to avoid secondhand smoke. If you are someplace where the air is dry, or in SF you have turned the heat on, consider using a humidifier at night. Make sure you keep it clean and turn it off during the day. Running it 24/7 can create a mold situation.

Another breeding ground for germs in your house is the pet food bowl. Your pet’s food bowl could actually be making you and your family sick if you don’t wash it frequently. A study by NSF International showed that pet food bowls ranked as the fourth dirtiest place in the house. Regardless of if you feed your pet dry or wet food, the bowl may have a residue that can harbor bacteria like E. coli and Salmonella. I am guilty of this one but Sandy has it covered. When our grand-dog Bowie is over, he scrubs out the bowl every time he leaves!
 
It is fairly common for parents to call the doctor, incredibly frustrated when their kids seem to be sick all the time. It makes sense when you think about it. If they are depleted from illness number one, when illness number two comes around they are more vulnerable. Everyone is being exposed to so much this season. Unfortunately most viral syndromes simply take time. Antibiotics are NOT useful for a virus.
 
If you are stuck in a cycle of catching one thing after another and the above suggestions haven’t helped, explore your options and see if you can keep your child out of daycare for a week or so. Sometimes that break makes a big difference.
Don’t forget to swap out the toothbrush or put it in the dishwasher.
 
Muggala Guggala - 1 cup milk, 1 Tbsp of butter, 2 Tbsp honey - heated in a saucepan.

Friday, January 17, 2020

Flat Heads/The Importance of Tummy Time



Once upon a time, people had their babies. They lived in multi-generational homes with lots of support. Life was simpler.

Now we are surrounded by gadgets and high tech contraptions. Many of us have less family around. There seem to be more rules. Some of the new rules are science based, including the very important ones about safe sleeping.

In 1992, the American Academy of Pediatrics initiated the "back to sleep" program in order to try to combat Sudden Infant Death Syndrome. Since this program began, the rate of SIDS has decreased by over 40%. An unintended consequence though was the number of babies who have flat heads from spending so much time on their backs. Nice round heads are becoming a real rarity.

This flat head condition is called plagiocephaly. Statistics claim that It occurs about once every 300 births, but I think more babies than that have at least mild cases.  Interestingly, little boys are twice as likely to have issues with this, and right side flattening is more common than left. Many babies with plagiocephaly were predisposed to it because of their position in utero.
 
Newborns' skulls have a lot of plasticity, so they are pretty susceptible to external pressure. Up until about six months of life, the skull is naturally thin and flexible. It can easily change shape. It turns out that if you drop a cell phone on your baby’s head it will actually leave a little dent!  Yes that is a real call that I got from a frantic mom. (Don’t worry his little head is fine.)

Positional plagiocephaly does NOT affect brain growth or development, and by ages 4-6 months, most heads have developed a normal shape. But early intervention and recognition can speed up the rounding process and hopefully keep things from getting worse.

Babies  don’t have a lot of motor control during their early months, so they can’t always easily re position themselves. Babies who do tummy time will have an advantage.
Tummy time should be started early and often. It doesn’t need to be hazing. Even one minute at a time can count.
The first tummy time can be within their first couple of days. Start by having your baby simply lay on you. Don’t worry about the cord (you most likely aren’t that firm of a surface.) Tummy time is an excellent way for them to develop muscles and work on their head control. It is also great for their digestion! 
 
Even though Infants lack head control, they should be able to turn their heads to either side at rest. Some babies, particularly those with shortened neck muscles may develop a more serious kind of flattening. You may hear this condition referred to as torticollis. If you find that they don’t easily move their head from side to side easily I would suggest a visit to a Physical Therapist or Chiropractor. It is never too early for an evaluation. 
 
There are little steps that you can do right from the beginning that minimize your baby having one favorite side. You would be surprised how many parents don’t recognize the fact that their babies heads are a bit tilted.
Try to  give each side equal attention:

  • Make sure you swap feeding positions.
  • Offer objects from either side.
  • Alternate directions on the changing table.
  • Consider changing the position of the crib or the orientation of the baby in the crib to reduce the baby’s tendency to look in the same direction.
  • When awake and supervised, prop the baby onto one side with a foam wedge or a towel rolled lengthwise along the baby’s back.
  • Change positions when feeding, carrying, and holding the baby.
  • Provide supervised upright play as soon as the baby has upright head control.
  • During quiet alert times, also encourage mid-line control. Place their hands together and have them look straight at you.

Jennifer Maeder, a local lactation consultant and Tummy Time Method provider adds:

Parenting today includes the use of a lot of ‘containers’ - equipment such as swings, bouncy seats, car seats, and other infant containers to help hold babies in our modern world. Another influence is ‘containment,’ or the over reliance on excessive swaddling with products like the SNOO and restrictive swaddling blankets. Too much of this can have a negative effect on hip development and inhibit movements vital for optimal breastfeeding and maybe even neurodevelopment. I’m all for making parenting more manageable, but consistent, daily tummy time is essential to counter these practices that decrease natural floor time that is key to supporting motor and sensory development. 
 
If your baby struggles to enjoy tummy time, has plagiocephaly, torticollis or other asymmetries, or you just want to optimize postural development and a healthy nervous system function (including digestion) - daily, consistent tummy time (3-5 sessions per day, 4-5 waves per session) can help. Remember, we frequently expect babies to learn to self regulate quickly. Babies need practice to succeed. The interaction between parent and baby in tummy time provides the chance for connection, interaction and play. Check out this video for a step by step how to on “tummy time waves” from neonatal occupational therapist and founder of the Tummy Time Method!, Michelle Emanuel:
 

For anyone interested in finding out more, or having a little coaching, Jen holds her Tummy Time Method classes at www.noevalleylactation.com check them out!

As Jen mentioned, pay attention to  places where their little head is up against a hard surface. The crib is the main culprit, but anywhere you put them down for a bit counts. Anytime that the baby doesn’t have their heads in contact with a firm surface is a bonus!
 
Sandra Roddy-Adams, a San Francisco based chiropractor who does cranio-sacral works on a lot of babies, weighed in on the importance of tummy time.

 
Supervised tummy time is important because babies begin developing their cervical lordosis (neck curve) around 3-6 months. This curve is formed as the baby begins to lift his/her head. This helps train the surrounding postural muscles and enhances visual awareness. A noticeable flattening of the base of the skull (occiput) or a spine out of line, can also interfere with tummy time and development.

If the birth was challenging or if you begin to notice some things like the base of the skull not changing/rounding, difficulties nursing on one side, or a continued head tilt on one side in the car seat or stroller, bringing them sooner than 3 months to see if a gentle adjustment is needed to align their spine can help create symmetry and ease in their bodies and brains. I actually recommend that babies get their nervous system/spine checked as newborns. (I am also a huge advocate of wearing your babies in slings.)
 
It is not recommended that babies have a pillow for night sleeping, but I am fine with one of the memory foam infant pillows for changing tables. There are quite a few options for this available on Amazon. Janet Green Babb, a SF PT, 
says that one product that her clients have found helpful is a pillow called Mimos Baby Pillow.
 
She suggests to parents that they should feel their baby's neck, shoulders, arms with gentle massage. This can give  information about symmetry. She agrees that if there are any concerns, it is important to begin therapy early to develop a home program of stretches and exercises. 
She has a list of gentle exercises that she shows parents how to do at home.
 
If all of your tummy time and intervention have not been as successful as we like, the next referral will be to the craniofacial or neurosurgery team for an evaluation. Either of those specialists  might end up sending you along to the pediatric orthotist team. The orthotists do some scanning (no radiation) and become part of the team that is monitoring your child’s head shape. In some cases, the kids may end up with helmets. Insurance companies vary greatly with their coverage of helmet therapy. The orthotist team at UCSF is top notch.

Although helmet therapy is usually not started prior to 5 months of age, there is little downside to having a referral sooner. For those of you interested in further details about the cranial helmet remolding process, see the information in my old post; the link is at the bottom. Although we sure do see a lot of kids with flat heads, very few of them end up needing a helmet.
 
Annie, one of my mom’s whose son ended up requiring a helmet, shared her story and wisdom. Her little guy is a second child with a mellow temperament so she wonders if that led to a bit more time hanging out in his infant seat.
Her doctor repeated the need for tummy time at each visit, but Annie thinks that with a bit of hindsight, if she had seen a helmet in her future she would have been more aggressive with it. At 2 months she did end up at the chiropractor who loosened up the neck muscles. These treatments made a big difference in his favoring one side over the other, but this little guys head was seriously flat and keeping him off of it did not seem to be helping as much as we needed it to. Annie adds a healthy dose of perspective: “There are worse things, We are fortunate to live in a place where this can be fixed.”
 
 
For more information about Helmets or local resources check out my old post on this topic:


Friday, January 10, 2020

Thumb sucking/nail biting/ dealing with habits

Habits
Most of us have habits. Some are good. Some are irritating. Some can be harmful. During my years as an advice nurse, I have had countless conversations with parents who were at their wits end due to their kids nail biting and/or thumb sucking. When it comes to children's habits, those are possibly the first that come to mind.

For the record, the American Academy of Pediatrics doesn’t feel the need to intervene with thumb sucking until a child is over five. Your dentist might not agree, but thumb sucking isn't usually a concern until a child's permanent teeth come in. At this point, thumb sucking might begin to affect the roof of the mouth (palate) or how the teeth line up. The risk of dental problems is related to how often, how long and how intensely your child sucks on his or her thumb.I usually try to get a start on it when they are about four.

The first day of kindergarten or when other transitions are taking place are not a good time to tackle a comforting behavior.

Other kids come up with some pretty creative nasty habits that make the parents of the thumb sucker consider themselves lucky. One of the more unusual was the 4 year old who wouldn’t stop licking shopping carts (yuck!) If your older child is consistently putting non food items in their mouth, that behavior can be related to low iron or even an elevated lead level and is worth checking out.
 
Is it your new year's resolution to tackle your child’s habit? Here is a truth - nagging doesn’t work. In fact, giving a lot of negative attention to a habit might even make it worse.

The most effective way to address a habit is to work on it as a team, which means that your child has to be involved and motivated to make a change. Change will only happen when your child is willing to take an active role with the problem solving. Maneuvering so that you can even have this discussion with your child without them shutting you down is easier said than done. You need to find the magic opportunity.

I like to share the “supermarket analogy” for this. Many of the parents who have picked my brain about parenting issues have heard this one before, but it is worth refreshing.

Imagine your child is the checkout clerk at a supermarket. You are the shopper. There you are, putting the items on the conveyor belt and the checker is systematically scanning them. But then, you aren’t sure quite what the issue is, but something you placed on the conveyor triggered something. The clerk made the abrupt choice to close the line mid transaction. It doesn’t matter that you are not finished, you haven’t paid, or that you have ice cream melting in the cart. There will be no more shopping at this moment. This lane is closed.

In spite of this, many of us still stand there, putting more and more items on the belt. We are wasting our time of course. There will be no transaction completed right now.
The parents of teenagers are probably nodding.

Whenever you want to have a conversation that has an agenda or a teaching moment, you need to find the right moment. Make sure the “line is open”. You might need to use the express lane (or pick one short topic.) If this is a pattern, try to figure out if you recognize what triggers the line to abruptly shut down and approach that subject delicately.

It is tricky, but it can be done. When is your child most likely open for a ‘transaction’? Maybe broach the subject when you are in the car, taking a walk, or sitting on the side of the bed during bed time. One-on-one time is usually best if you can manage to carve some out of your schedule. Allow your child to be involved in the choice of whether or not they want to invite other family members or wise friends to the brainstorming.

Before you even start the 'habit discussion' consider reading a general book about habits. Berenstain Bears and the Bad Habit, is a good one.

 
In this classic, Mama Bear explains what a habit is by comparing it to her pushing the wheelbarrow back and forth between the shed and the garden. Over time the wheels have made a deep rut. It is easy enough to wheel the barrow on that well worn track but it would take some effort to push it in any other way. As Mama and Sister walk along to the garden, they talk about the habit in question. Sister Bear nibbles her nails. They brainstorm together about a solution. Reading a book or telling a story about habits is a great launching point for the discussion.
Identify the habit that you want to address. Point out other folks you know with different habits so your child doesn’t feel singled out. Do you have habits that you are willing to address and deal with at the same time?

What are some of the consequences of the habit? Downsides of nail biting or thumb sucking could include broken and irritated skin, germs, crooked teeth, teasing from other children...

Keep in mind that talking about germs can be a slippery slope for some sensitive kids. We don’t want to end up with Lady Macbeth on our hands by terrifying them about living in this germ filled environment. Find a middle ground. There are indeed germs in our world. We can’t get rid of all germs, but good hand washing and keeping our hands our of our mouths is important for everyone. Freaking them out by teaching them about pin-worms should be reserved for older kids.

What is the benefit of breaking the habit? Pretty nails, no broken skin, no teasing, less risk of germs. Sore fingers can hurt!

What is a good reward to work towards if they succeed? A special outing is my favorite. It also might work to earn points towards a bigger ticket coveted toy or game. What are some ideas that you might come up with to help break the habit?

In the Berenstain Bear book, they start the day giving Sister Bear 10 pennies that she will need to give back through the day every time she is caught nibbling. Sometimes the act of having to give something back is indeed more effective than the promise of earning it.

There are some products you can apply to make the fingers taste nasty, but I only like to use those when the child has agreed that they are motivated to stop the hand to mouth habit and want to give that a try. A jingly bracelet might serve as a reminder. Having lots of healthy crunchy snacks available to chomp on can help too. When you first start out, small goals might be easier to attain. Maybe a sticker can be earned every hour that they succeed in remembering to keep their hands out of their mouth (or whatever the habit is that you are working on.) Talk about mindfulness.
One simple mindfulness exercise is to take a deep breath. Think about where your hands and feet are. Tighten them and then relax them. Take another deep breath. This is good for any habit, but especially for those that involve the hand in the mouth.
 
Make an agreement about how your child would like you to be their cheerleader. Do they want you to verbally remind them when you see them failing? Do they actually have the power to ask you to stop with the nagging? (This might be you own habit!) They might be relieved to have the power to take your frequent reminders off the table.

How about a finger snap,a quick whistle or a tap on your nose if you see them doing the habit? What is their preference?

Don’t forget about positive reinforcement for times when you notice they are NOT doing the habit. Experts support that positive reinforcement is one of the best ways to reinforce behaviors. Obviously you don’t need to overdo this by making comments every minute, but giving attention for progress can go along way.

Not all habits are bad ones of course. Think of some good ones that you might all want to work on this year! Practicing gratitude and thinking about things in our lives that we should be grateful for is a great one. It is by no means automatic.