Kids and Pets

Kids and pets

Personally I think that most families are enriched by having a pet. Of course, as an advice nurse I have a bit of an unusual take on things. I get plenty of animal related calls. A little knowledge and planning can help keep the relationship between your pet and your child happy and safe, and can help avoid incidents with animals who don’t belong to you. For those of you who already have pets living with you, I understand that animals are essential and much loved members of the family. In some cases they may actually feel like your first child, but here are a few things to consider: Cats: Many cats are quite happy to welcome a baby to the family, but cats are cats. Once your child has the ability to chase after them, the cat will usually establish dominance once or twice with a good swipe if someone is invading their space when they aren’t in the mood. Kids (and new puppies figuring out how to get along with the family cat) learn pretty quickly what the rules are. Watch out for cat scratches, they can get infected fairly easily. It is essential to clean them well and apply an antibiotic ointment. (Don't use peroxide, current thinking says to avoid it because it causes tissue irritation). If there is any increasing redness or red streaking appearing around the scratch site, that might be a sign that it is infected and it should be evaluated.   If your crawling child starts getting little red spots, consider that they might be flea bites. Fleas are rampant here in San Francisco year round. When not on your pet, fleas tend to hang out in the carpets and while they might not bother you, your child is spending more time on the rug and presents a tasty treat.   Please do your best to keep your kitties out of your baby's crib or bed. I know I sound like an old grandmother, but it is a safety hazard for a cat to snuggle around an infant's face.   Meow mix generally doesn't hurt anyone, but you want to make sure that the cat food is not left out where your toddler can get into it.   Now, getting a little more disgusting, make sure the litter box is somewhere where the child has no access. You don't want to be the parent who calls me horrified that their baby just had a snack of cat poop.   If any family members seem to be plagued with allergies, consider checking out Advanced Allergy Solutions. I have seen them make a huge difference for some people with allergies to cats and/or dogs   Dogs: Make sure you closely supervise any interactions with your dog and your new baby to make sure the dog is not exhibiting any behaviors that you need to worry about. If the dog is at all growly, as heart wrenching as it may be, they might need to be placed in a home with no kids.  Earlier signs of doggie stress can include: Licking lips Panting Yawning when they are not tired Pacing By the time the dog is growling, it is possible that these other signs weren’t noticed. There are some apps out there that can help you and your older children learn how to have appropriate interactions with dogs. http://ios.me/app/1290238272/the-blue-dog Puppy Prep’s Steph Miller, owner of Recess With Steph,shared the following excellent tips:   Dogs, Babies, and Expectations – Getting YouReady!   Here are some suggestions to help you prepare your dog for Baby’s arrival:   1. Practice basic manners and tricks so that your dog has plenty of cues he knows well and you can direct him to do. Examples: sit, touch, place, out, down, leave it, settle, target.   2. Socialize your dog around children in a positive and controlled environment. Observing kids while you give your dog treats or enjoy a game of fetch is a wonderful way to build a positive association. Short exposure is perfect!   3. Replace unwanted attention seeking behaviors with desired behaviors. Example: sit to be petted instead of pawing you on the couch. 4. Practice short times of separation with a “success station” while you are home! Crates, gates, indoor tethers, or a doggie room are all great success station options.   5. Know your dog’s sensitivities. Research his breed or mixture of breeds. Observe whether the dog startles with fast motion, noises, or other sudden events.   6. Begin a “baby flexible schedule” vs. a rigid schedule. For example, if your dog always eats at 6 am, you may want to vary this time so that your dog gets used to changes and won’t wake you up early for breakfast!   7. Allow your dog to become familiar with the baby equipment. Focus on teaching him how you would like him to behave near this equipment. Doing this ahead makes a world of difference!   8. Place a baby doll or teddy bear in the baby’s carrier and move through the house and yard with it. Practice helps you to get the idea of what it will be like to use this equipment around your dog.   9. Walk your dog with an empty stroller, or put a heavy doll or a 10 lb weight in it for a more realistic feel, in order to learn more about the skills your dog needs to learn before a walk with a real baby.   10. Use a CD of baby noises to introduce new sounds and create a positive experience prior to the baby’s arrival. You can purchase dog expert Terry Ryan’s baby sounds as a CD or digital download by visitinghttp://www.legacycanine.com.   11. Have partner bring home a blanket with the baby’s scent on it (partner will smell like the baby, too). Let the dog become accustomed to the scent in positive ways.   12. If your dog is due for his yearly check-up and vaccinations, schedule your visit well ahead of time, and be sure to stock up on all necessary medications and supplies.   13. Familiarize your dog with the person that may care for them while you are away.   14. Find a good, safe spot for your diaper pail.   15. Find a licensed Family Paws Parent Education presenter in your local area: http://familypaws.com or contact me directly at recesswithsteph@gmail.com.   16. Have fun and enjoy your family! Most dogs are perfectly wonderful with the children but even with the most loving dogs please make it a rule that your baby or toddler is not allowed near them at meal time. The innocuous infant might become more of a threat when they start getting more mobile. Let your doggy have a baby free zone where they can eat in peace. By far most of the bites that I get called about are food related.   I recall one situation where we had a toddler who got bitten by the family dog. One of those "treat balls" was unearthed under the sofa where it had been hiding for months. The dog got very territorial when the toddler tried to get it and the baby took the brunt of it. In another instance, Grandma’s cosseted little dog didn’t like the fact that a visiting grandchild got on the bed. The child got a severe bite on the face. It wasn’t the first time that dog had bitten someone. Grandma should have been more wary of the interaction. Just an FYI, A study of dog bites in Calgary finds no breed group can be singled out for serious bites. It has much more to do with the training, or lack thereof. The Family Dog cites the chilling statistic from a study that was done of Philadelphia emergency room visits that found that 77% of dog bites are actually from a dog that belongs to a family or friend. https://www.thefamilydog.com/families/st77/ Always make sure your dog has a safe, kid free zone that they can retreat to if they need a break. If they have a crate, make sure that it is off limits for the kids. If you are visiting a friend or relative's house and they have a pet ask them explicitly if the animal has any history at all of aggressive behavior with children. Some folks have a blind spot where their beloved pets are concerned and lose their common sense. If there is any doubt please ask that the pet be kept away from your child. Never reach through a fence or into a car to pet a strange dog.   If you are walking down the street, teach your child that before you pet any unfamiliar animal you ask the owner for permission. Alisha Ardiana empawthy.com,  who is a local dog trainer (she works with my grand dog Bowie) says that she believes that dogs deserve access to public spaces without being put in the position of having to interact with strangers. Some animals, walking on leash or tied up outside a store may be stressed and don't feel comfortable being approached. Don’t take it personally if the owner prefers that their dog be left alone.   If you do get the 'all clear' to say hello, demonstrate the safest and best way to meet any new animal. Show them how to hold out their hand first. Tuck the thumb inside the fist so that there are no fingers sticking out. Respect the animal’s personal bubble. Let the animal come to them to give them a sniff. Even if the owner says its fine, but the doggie isn’t interested, move on. After that initial sniff, for younger kids who are learning how to do gentle petting, consider teaching them the one finger petting technique - have them make a fist except for the pointer finger. Alternatively they can pet with the back of the hand. These methods can keep the kids from grabbing hunks of fur. Even with the best training and intentions, my youngest Alana kept me on my toes. From the minute she could crawl, she was scampering across the park to say hello to anything with fur. If you don't have a pet and are considering getting one:   I am a total animal lover and I think that having a pet is a wonderful thing. In our case, our family was adopted by a semi-stray Siamese cat when Lauren was still a baby. George (we didn’t name him) lived a very long life and I am sure never regretted choosing us as his family. A cat who comes to seek out ‘toddler love’ is indeed a cat starved for affection.   We also wanted a dog. My mother-in-law had plenty of strong opinions. Among them were some pearls of wisdom that resonated with me. Her theory was: All children need a dog, teenagers especially so. There is nothing quite like the unconditional love of a dog to get you through tough times. The last thing an adolescent needs is to lose their dog during those tumultuous years. Barring an unforeseen tragedy, the lifespan of a dog is roughly predictable, so plan accordingly.   When she first mentioned this to me I was actually a little horrified. It felt so callous and calculating, but I thought about it a little further and it made perfect sense. We ended up getting our beautiful golden Java when my girls were 9 and 12. We were blessed to have her with us for 12 wonderful years. Our family was much richer for it. For an extra pet safety tip and a story, click this link to an old post: https://nursejudynvp.blogspot.com/2018/07/a-pet-safety-tip-java-and-bologna.html   Please accept ahead of time that as much as you bargain with your child and make agreements about how the dog responsibility will be shared, just give up right from the start. The dog is yours. You (in my case it was my husband) will be the one remembering to feed them, doing all the walks in the rain and probably 100% of the poop scooping. Trust me on this. Luckily the value of getting a family pet goes way beyond teaching your child responsibility.   Keep in mind that a dog bite impacts everyone involved. Let's do everything in our power to prevent them! No offense to the fish, birds, snakes and other more unusual animals out there since most of the focus of this post was on the more popular furry cats and dogs. Pets regardless of species, give us many life lessons. They teach us how to deal with loss, but also about unconditional love. Big thank you to Stephanie Miller and Alisha Ardiana (Dog trainer extraordinaire) for their valuable input on this post

Bed-wetting

Nocturnal enuresis, otherwise known as bed-wetting, is something that many patients and families have to deal with. More than half of the bed wetters are boys. To give you a sense of numbers and make you not feel so alone, 15% of 5 year olds still wet the bed; 5% of 10 year olds continue to have issues of staying dry at night. Most of the persistent older bed wetters will grow out of this by puberty without any intervention, but hopefully you don’t need to wait until your child is a teenager to get this resolved; that is the purpose of this post.

There is definitely a genetic tendency at work. Unless on-line dating has taken it to a new level, history of bed-wetting is typically not a subject that comes up on the first date, but now it is worth knowing if one of the parents had the same issue. For those of you washing the sheets every night for your twelve year old, please keep in mind that there is a reason that most camp forms ask about bed wetting. This is not an uncommon situation. The goodnight pull-ups come in such big sizes because there are plenty of older kids needing them

If a child had been dry at night and the bed-wetting is new, check in with the doctor to make sure there isn’t something else going on. This post is referring to patients who have never consistently been able to stay dry through the night.

This can be a really frustrating issue and there are many opinions about how to deal with it. Wetting the bed should not a punishable offense. Waking up wet and feeling loss of control is punishment enough. It is not okay to humiliate your child. Having your child begin to accept some responsibility however, is not a punishment.

The natural consequence for having a wet bed is to be part of the clean up team. Perhaps your child can be in charge of stripping the wet sheets off the bed. Let them be part of the solution rather than being the cause of the problem.

Until your child has shown that they can be dry at night, I would have them in special nighttime pull ups and make sure you have waterproof pads on the bed. Expecting dry sheets before your child has shown they are ready is just going to be aggravating for everyone.

There are some basic considerations and common sense approaches to start with.

The very first thing is to figure out if there could be any constipation issues. (click here for a link to my previous blog post)

Once the kids are out of diapers and off at daycare or school, many parents lose track of the kids bowel habits. Are they pooping daily? Do they have to sit for a while before the poop comes out. Does it come out in hard little pieces? Constipation is a huge factor and is your first step to eliminating bed-wetting issue. Often times, kids are found to be constipated even if they are pooping once or twice a day and the poops seem normal. According to Anne, the wise and wonderful nurse at the UCSF Continence Clinic, this may be because the kids don’t always take the time to get all of the poop out. When we end up sending patients to the continence clinic at UCSF to treat the enuresis, they start off by cleaning almost all of the kids out with a combo of Miralax and sometimes suppositories.

Other common sense steps include  having them better hydrate during the school day. Some kids are “camels” at school and don’t drink. Talk about what the fluid options are. Is there an accessible fountain? Do you send something to drink with their lunch?

Recommended fluid intake for children is measured by weight:

<2 year/<10 kg        30-35 ounces/day

2-5 years/<20 kg     40-50 ounces/day

6-12/<50 kg             50-60 ounces/day

Teens                      60-70 ounces

While we want to bump the fluids during the day, it is time to start  limiting fluids after dinner. Consider taking your child for a “dream pee” before the adults go to bed.

Often you can walk your sleepy child to the bathroom without having them fully wake up. If these "twilight trips' to the bathroom appear to be  disrupting their sleep cycle, see if you can adjust the timing.

If they are impossible to rouse enough to get to the bathroom without you practically carrying them, Dr. Schwanke would suggest that this is a big sign that they aren’t ready yet.

Let's give that bladder some exercise. The continence clinic does not generally recommend “kegels”  exercises for their patients, but once in awhile it is okay to have them practice starting and stopping the urine stream if they can. Another activity is to see if they can hold the pee for a couple of moments when they first realize that they need to go. Without good relaxation of the perineum, children are unable to empty their bladder completely. Try to teach your child to relax when they are peeing. One way to do this is to have them give a big sigh. Sighing is a normal relaxation trigger.

If none of the above actions has made a difference, it is up to you when you want to stage an intervention. I usually wait until your child has expressed readiness to tackle this. Dr Kaplan says that in her opinion, once the kids are old enough to read, they are old enough to be dry at night. She gives her patients a little talking to and tells them that they are in charge of telling that good brain of theirs that they need to not pee at night. She claims a degree of success!

Sometimes, once they are old enough for summer camp or sleepovers, kids are more invested in a cure. If they don’t care one way or the other, you can increase their role in the clean up, but until they are an active and motivated part of the team, I would wait a bit.

Once you are ready to intervene there are several options.

Some of my families have had long lasting success with the bed-wetting alarms. There are several on the market. Here is an email that was sent to me from a mom who wanted to share her experience"

"We purchased a Chummie bed-wetting alarm (along with an extra sensor so we'd have two of those) and I read a really helpful book called "7 Steps to Nighttime Dryness" (by Renee Mercer) which I read through quickly and highly recommend.  

Some takeaways from the book:

-- kids who wet their beds after age 6 likely will benefit from an intervention (like a bed-wetting alarm, which is the most effective intervention available) WHEN both the parents and the child are ready to take the time and effort to do so and are willing to have the disruption to their sleep (which can be tough on everyone).

-- When first starting use of the alarm, parents need to respond promptly when the alarm goes off to scaffold the learning process for their child -- i.e., they'll have to help the child wake up and get to the toilet to start developing and patterning that behavioral response.  Slowly, over a period of time (12 weeks total on average), the child's body will start to learn to wake up when their bladder is full and they'll be able to get themselves to the toilet... until eventually their bladder learns to hold urine until the morning.

-- The author recommends using a chart to track progress. This helps you see and feel a sense of progress, which is helpful to everyone involved.  For example, at first our son would pee heavily twice each night (those wake-ups every four hours reminded us of our prior sleep disruption patterns when we had a baby!)... then it became lighter pees since he started to stop himself mid-stream and would get the rest into the toilet with our help... and then he would pee once per night lightly, and so on until he was dry and slept through the night without disruption.

-- Once your child consistently has dry nights for 2 weeks straight, you wean them from the alarm for another 2 weeks by using it every other night.  This weaning leads to the most effective long-term results.

Before starting the alarm intervention, I had imagined in my head that perhaps our son's bladder got full while he was sleeping, his bladder communicated its fullness to his brain, but he didn't wake up to respond properly so he simply would pee while sleeping.  The alarm helps that transmission of info work properly.

Our experience:

Our son was highly motivated to stop wetting the bed, so we decided to try this alarm approach to see if it might help him.  At bedtime, our son put on his undies, taped the sensor to the outside of his undies as instructed (so the alarm goes off when the sensor starts to feel pee), and then he wore a pull-up outside of all that (so we didn't have to change his bedding a gazillion times).  Our son's first dry night happened 3 weeks into the alarm intervention (although we had forewarned him that it would take 12 weeks so his expectations were realistic).  At 3 weeks, for a few nights he was dry every other night, and then he was miraculously dry every single night from thereafter.  We continued with the alarm for another several weeks and did the weaning process and he has been dry ever since (we first used the alarm 3/26 so it's been 2 months. Woohoo!).  We are thrilled and surprised since he is such a deep sleeper and always has peed at night.  He was a quick-results case, which we were not expecting.  It feels like the alarm kind of magically connected a synapse that wasn't there before!

We used a weekly chart to track his progress.  We used tiny reward stickers both for cooperation (in the "good determination award" cell) and for "dry night" (the latter obviously doesn't happen for a while so it's nice to feel rewarded for at least trying.)"

There is no medication that cures enuresis, but there are some medications that can address the symptoms. The most commonly used is DDAVP. This is a prescription approved for children over 6. It comes as a  tablet. It used to be available as a nose spray but that has been discontinued due to side effects.

When the drugs are stopped, the bed-wetting usually returns unless the child has naturally outgrown the condition. It is nice to know that this possibility exists for use on an intermittent basis such as an overnight or summer camp.

Please note that even when you feel like you have successfully put this behind you, it is possible for mini relapses to occur with little illnesses or increased stress.

​

Night Terrors/Update with new treatment option

Night Terrors/Update with new treatment option 5/16

Night terrors rank up there with things that are pretty horrible for parents, but ultimately usually not dangerous. If you want to practice your Latin, they are also known as Pavor Nocturnus. These are not your typical nightmares. Your child might wake up screaming and thrashing. They may be sweating, wide eyed and terrified. Their hearts are racing. They seem frantic but you can't calm them down. No one is going to sleep through this. Except your child. They seem awake, but they won't remember a bit of this.

Your job is simple. Keep them safe until this passes. Of course there are some conflicting opinions about how to handle these. If your child is small, I have found that it is helpful to try to swaddle them with a big sheet. Think straight jacket! Hold the sheet wide and try to wrap around the thrashing arms until they are snuggled tightly. Sing quietly until they are calm. If you can't manage that, just make sure they don't hurt themselves until it is over. These rarely last longer than 20 minutes. Bigger kids might get even wilder if they feel restrained so see if you can put a comforting hand on them, but mostly you are just being present.

If your child is toilet trained, see if you can manage to walk them to the bathroom and have them pee. Believe it or not, that might settle them down.

Pediatric night terrors happen to between 1-6% of kids. The typical age range is 3-12 years of age. There seems to be a genetic component. If you put your parents through this yourself, it is payback time. I think I may have had a few younger patients over the years that had bouts of these, but with really young infants, a sudden wake up is more likely from gas pains or something illness related.

These tend to happen in intervals and you may have days or weeks with frequent episodes and then they go away. It is worth trying to figure out if there is some extra stress or changes going on. Are they on any new medications? Any change in their diet? Lots of extra sugar perhaps? Are they overtired? Have they been watching any over-stimulating videos, movies or games (if they are in the room when an adult is playing or watching something, that counts)? If night terrors are happening on a routine basis and there is no obvious cause it is worth having them checked out by their physician. Some kids who are plagued with these for an extended period might have sleep apnea at the root of the problem.

Unlike dreams or nightmares, night terrors do not occur during the REM sleep. They usually occur during a phase of the sleep cycle that comes about 2-3 hours after falling asleep. If you are going through a stretch where you dealing with them nightly, some experts suggest breaking the cycle by waking your child about 15 minutes before they routinely occur (this would be a fine time to walk them to the bathroom for a "dream pee.") This assumes that you are on a regular bedtime routine and the terrors are happening roughly at the same time nightly.

Take comfort in knowing that extensive studies have found absolutely no correlation between kids with night terrors and an increase in occurrence of psychiatric disorders.

NEW INFO

A new product came on the market in 2016, called the Lully Sleep Guardian. This is the first device scientifically proven to stop night terrors. One of the founders of the company grew up with a twin sister who suffered from these. He understands as well as anyone how disruptive they can be.

https://www.lullysleep.com/