Dealing with Altitude 2018

This is the time of year when we get a lot of calls from folks wanting to take a road trip up to the mountains and asking about whether or not altitude is a problem for the baby. Keep in mind that many babies are born in places quite a bit above sea level and live their lives in high altitude year round. Some folks in general are more sensitive to altitude issues than others, but there is no real difference between adults and children.Most people can tolerate altitudes below 2500 meters/8200 feet with only mild discomfort. If your child has significant heart or lung issues if is worth checking in with your specialist prior to travel. For the majority of my patients, Tahoe is generally okay for any age. Mild symptoms can still have an impact. Folks may have headaches, tire easily and be a bit short of breath. Dr. Kaplan adds that tummies can get upset because the gas in your gut expands. Make sure your bring gas-X or simethicone along to help deal with this. It is essential to make sure that you and your kids stay hydrated. Breastfeeding moms should take extra care that they are drinking enough. Sunburn can happen easily in the high altitude. This is even more of an issue when there is snow or water to reflect the sun. Make sure you have appropriate sun protection for skin and eyes. In the winter time, the air tends to be drier. The need to use heat in your accommodations can exacerbate that. It is worth bringing along your humidifier. (If you are flying, consider purchasing an inexpensive one when you get there.) The biggest difference between adults and young children is that the adults can communicate what they are feeling. Babies can’t. If your baby appears pale, fussy or has labored breathing, get them to a travel clinic to be assessed. Make sure they have the oxygen level checked. On the other hand, young babies aren’t generally hiking around or doing anything strenuous so in some cases, they may have an easier time. If you are traveling to a place that is higher than 8,200 feet, see if you can get there in stages so that your body has a little bit of time to acclimate. Know ahead of time what medical services are available should any family members run into trouble. Dr. Kaplan has had some patients, traveling to Colorado high country, who needed supplemental oxygen. I personally am an altitude wimp. I like my oxygen and have trouble if I am anywhere over 5,000 feet. I will NOT be accompanying my husband and oldest daughter on their next adventure this, month when they go to Everest Base camp. They successfully summited Mt. Kilimanjaro… just a bit under 20,000 feet in 2016. Base camp is only a measly 18,192...piece of cake. OY.

The Back to work transition 2018

The first couple of weeks home with your baby is a tumultuous time to say the least. It is full of so much amazement, sleep deprivation, joy, learning, and love. You might be in such a haze that you may or may not even remember this period very clearly. It is the minority of families in our practice who have the luxury of having one parent stay home with the baby full time. Most families are faced with the huge transition that hits when one or both parents need to return to work. The luckiest families have flexible, understanding jobs and a local grandparent who can’t wait to babysit. If you can work part time, that is often the perfect balance. The rest of you are left trying to figure out the best option. One of the biggest issues that many of the breastfeeding moms face is how to successfully continue to nurse. If your baby has never taken a bottle, try to give yourselves enough time for them to get used to one. Babies may simply refuse to take the bottle from mom. They know that breast is right there! They can smell it! It is best to have the other parent or caregiver be the one to offer the bottle. Ideally offer fresh breast milk, so that there aren’t too many changes at once. Try the bottle a bit before the baby is genuinely hungry. Some babies are remarkably easy and go back and forth between breast and bottle with ease. Others like my daughter Alana, can make it much more stressful. Alana screamed for an entire day. Luckily she was with a very patient and experienced caregiver who eventually had success. They all figure it out when they get hungry enough. I know that this battle of wills is a tough one. If you are planning on pumping and keeping the baby on as much breast milk as possible, local lactation guru Nurse Charity shared some successful pumping tips. She suggests that you start pumping 7-10 days prior to going back to work. Nurse Charity's Wisdom about various pumps Yes, this will bump up your supply, but going back to work usually does tend to decrease the supply over time, so starting at a higher level is good. Prior to pumping do an all over breast massage. Bring a photo of the baby or an outfit with that wonderful baby smell. Hopefully your job will be supportive of your need to pump and you will have a comfortable area. Frequent short pumps are just as good as trying to carve out one or two long sessions. Nurse Kenlee suggests making a “nursing playlist” or having some strong association with nursing that you can take with you when you are pumping away from the baby. In general in order to protect your supply, make sure you drink plenty of fluids. Eat a healthy diet and make sure you get adequate rest. (I know, I know, but I had to add that) Do lots of skin to skin contact when you are with your baby. It takes some effort but many moms are able to successfully produce enough milk that supplementing is not needed. KellyMom is an excellent source for guidelines on storing the milk. If you have fresh milk, use it prior to defrosting your frozen stores. I always suggest putting a baggy full of ice cubes in the freezer. As long as they stay frozen as cubes, you are assured that the freezer has maintained the correct temperature. If the ice cubes refreeze into one clump, the milk can no longer be trusted. Get in the habit of clearly dating all the milk and rotating the stock. Use up the oldest stores first. Make sure that your milk freezes well. Some moms have an excessive amount of the enzyme lipase in their milk. The milk remains safe but has a nasty smell. Scalding the milk prior to freezing it will eliminate this issue. You don’t want to be the one who discovers this after you have a freezer full. The lipase has some health benefits, so if it isn't causing problems, don't bother scalding the milk. While many moms have no trouble keeping up with their supply, others are not so lucky. Please don’t spend even a minute beating yourself up. Do not be the parent who limits the amount of milk the baby is allowed to have due to supply. Do not be the parent who is incredibly stressed out if they are an hour late home from work because the baby will starve. Simply do the best you can and take advantage of the fact that there are many excellent formula supplements out there. Being a good parent is not only about the breast milk. Be careful that your child doesn’t swap their days and nights. If moms aren’t careful, some babies refuse the milk from the caregiver during the day, but wake up every couple of hours to nurse during the night. Sure, the baby is getting the milk they need, but mom will lose her mind from sleep deprivation. Let me repeat myself. An intact mom is more important than breast milk. Beyond the issue of feeding is the huge question of finding a loving caregiver in your home or a safe place to send the baby while you are at work. Many of our parents have success with small family day cares or nanny shares. Once kids are away from the safe relative quarantine of your home, they are going to start getting all of the little childhood colds and viral syndromes that are a rite of passage for most kids. Having a solid conversation with the daycare, other parents and/or nanny is essential so that everyone is on the same page regarding which symptoms necessitate staying home. Do your kids still have cooties? Take a moment to click on one of my all time favorite blog posts. It is all about striving to find balance between all the various aspects of your life. It is never more relevant than during this transition. Nurse Judy's Pie Theory of Life

The misadventure of Nurse Judy/Managing Stress

The misadventure of Nurse Judy Last Sunday I was taking a hike along Land’s End. I tripped and fell forward. My right wrist took the brunt of the fall. The triage nurse part of my brain knew that bones were broken. What an impact one little misstep can make! Blessings I didn't fall off a cliff, break a leg or sustain a head injury. I was with sensible people who helped hike the mile back to the car. One person had a large scarf that we were able to fashion into a sling. All of the passing hikers stopped and offered to help. Humanity put on it’s best face. Lessons I had no id or insurance cards with me. It’s time to update the first aid kit in the car and make sure it has arnica and instant cold packs. WATCH YOUR STEP! I spent a few hours in the Davies ER. It's OK to call ERs to see how long the wait is for non-critical care. UCSF was 3 hours. Davies was none! That is a gem of a resource for adult patients. I was able to get an early Monday appointment with an orthopedist. Both of the bones in my right forearm are broken. Yes OUCH Blessings I have a wonderful support system (thank you Sandy), family, friends, good insurance, and access to good health care (way to meet the deductible early in the year!) Noe Valley Pediatrics is a very supportive work environment and is trying to muddle along the best they can with the office manager mostly out of commission. Lessons Ongoing trying to figure out how to manage for 6 weeks without use of right hand. Trying to Learn how to say yes to the friends who have reached out with offers to help Impact on the office Nurses will be short staffed. Every effort will be made to return calls in a timely manner, but please understand we won’t have the luxury of time for longer conversations. The turn around for emails may be as long as a week. Please call if you need to speak to a nurse. I have cancelled February classes. I will update this after my next ortho appointment. I may end up requiring surgery, so it is difficult to plan. Don’t count on weekly emails, but I will try to keep them coming.  This post is short and simple, but hopefully it can give you a new awareness or way of looking at things.   Topic of the week: Managing Stress My kids grew up having to deal with all of mom’s theories. One of the classics is the “stress theory”. My daughter Alana, who is now a therapist at a community mental health center in Michigan, finds herself referring to some of these with her clients. She let me know that she used this one the other day and I realized that I had never put this one in a post. So here goes. Is there a water bottle near by? Take a look at it, Imagine that you are that bottle. There is a thick label. You can not easily see how much liquid is inside. Elements of your life are varying amounts of fluid. Every aspect of your life adds liquid to the bottle. Some things may add a few ounces, others only a tiny drop (drops can add up!) Being a sleep deprived parent is easily a couple of ounces. A new job? An illness in the family? Moving? Ounces! Large changes or stresses are of course equated to larger amounts. Breaking your wrist - half a cup! We generally don’t pay too much attention to how full our bottle is until it is near the top. The smallest drop of water, something that normally you could handle with no problem, may make the entire bottle overflow. This is the proverbial straw that broke the camel's back. Are you crying because you burnt your toast? Take a moment to figure out what is going on that has your bottle so full that the littlest thing can set you off. One of Alana’s clients found that this way of looking at things really resonated with him. He coined the term “dump the cup,” which in turn resonated with me. What can you do to dump out your bottle a bit? Arrange a little time for yourself? Take a walk? Have the perfect cup of tea? Sometimes making a list of all the things you feel like you need to do helps quite a bit. With your young kids, they can’t hold as much. Simply being tired or hungry will fill their little ‘bottle’ right up to the top. That’s when the temper tantrums and meltdowns happen. Everyone who you interact with has their own stress level. It is good to keep that in mind if someone seems to be ‘overreacting’. Are you past the sleep deprivation hell? Do you have a friend with a new baby? If you are thinking about giving a gift, consider skipping the outfit that the baby will grow out of in a minute. Give them a certificate or two that can be redeemed for a 2 hour nap while you watch the baby. Helping your friends "dump their cup" feels pretty good.

Old letters and Photos

Old letters and photos

I was just back in Pittsburgh, Pennsylvania with my sisters, Marjie and Amy, sorting through boxes of stuff in the house that I grew up in. Pittsburgh in January is cold and snowy, perfect weather for hunkering down and staying inside. I equate this undertaking to taking a teaspoon full of liquid out of a 50 gallon aquarium. It is hard to see progress; there is so much to do. We have opted to take our time and gather together every few months so that we can celebrate the memories and poke through things together. It is a luxury that we are able to do that. As a bonus, my younger daughter Alana flew in from Michigan to join us for the weekend. I grew up in a house that was filled to the brim with books on every subject. (We will start dealing with the books at the next visit.) There were plenty of costumes and odd clothes with which to play dress-up. At one point there was even a hoop skirt; I have no idea where that came from. Having a mom who was a kindergarten teacher made it a given that we had plenty of odd things on hand for variety of arts and crafts activities. The last visit was geared toward ridding the house of the obvious junk: https://nursejudynvp.blogspot.com/2017/09/organizing-your-crapi-mean-treasures.html This visit we focused on the shoe boxes jam packed with letters, papers and pictures. My family, going back to great grandparents, were faithful correspondents and it seems that they didn’t believe in throwing away letters. This is now truly the proverbial mixed blessing. Even though it is a daunting task, there is something magical about holding an old letter. We lose something in this digital age. In regards to the photos, my father loved to take pictures of everything. Some are in envelopes, many are duplicates, some are in albums ( my mom’s efforts), but the majority are loose in boxes. The unflattering, out of focus photos got the same treatment as the good ones. They are all waiting to be sorted, all gazillion of them. My grandmother’s photos and letters are there as well. Some of the photos date back to the 1800s! I took the opportunity to reach out to some cousins that might be interested in checking out old family treasures and we had a fabulous gathering of people who had driven hundreds of miles to get together and help us identify the people in some of the older photos Here is a copy of the Facebook post that I added during the trip: I got a gift from the universe today. We have been going through an amazing stash of family letters and photos this week. Reading the love letters from my grandfather Asher to my grandmother Flora was one of the highlights. We realized that somehow or other, none of us knew the story of how they met. How could that be? The loss of my mom last year was staggering. We couldn't just turn to her and ask her for the story. I then remembered that 30 years ago or so, my grandmother had been interviewed by the National Council of Jewish women as part of an Oral History project. I googled, Flora Isaacs Oral History and there it is, two hours of my grandmother talking, divided into 4 parts. This is something to savor. We listened to the first side last night. This evening Amy and I listened to part 2 and sure enough we got to hear Grandma tell us the tale of how she and Grandpa met. We had all sorts of lovely serendipity. My sister found an old pair of rhinestone folding opera glasses tucked out of the way in a small box in the attic. She brought them down for us all to see. Later that day, as I sorted through piles of letters, I happened to take the time to read one from my grandmother to my mom: “Mrs. So and So brought you a gift. They are wonderful little opera glasses that fold up; make sure you write a thank you note.” Okay lovely readers, here is your takeaway assignment. Figure out who are the people in your photos. Even if they are digital, make sure that you manage to accurately label them. If you have old photos, get your parents, grandparents, aunts, uncles... etc. to look through them with you, and tell you who the people are. This information is lost otherwise. Don’t save the crappy photos. Having a smaller collection of good pictures is much more valuable. Get the stories! Do you know how YOUR grandparents met?

Building and Protecting your immune system

Topic of the Week:

Building and Protecting your immune system
Please see updated post 1/2020

This is the season to focus on boosting your immune system. I have had multiple requests to address this topic in a post.

One of the blessings of working at Noe Valley pediatrics is that although we are a western medicine, science based practice, the advice nurse team is allowed to stray off the rigid telephone triage guidelines that most advice nurses must adhere to. 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 way off the basic western medicine path and includes a combination of conventional wisdom, 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 of my patients 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.

Getting enough sleep is essential. If kids seem tired, you might need to start the bedtime routine a bit earlier. If you are interested in really finding out more about the actual quality of your child’s sleep, Knit Health is an interesting, reasonable option.

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. (For the record, binge watching Game of Thrones right before bed is NOT a good idea.)

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 Iron. Magnesium, 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 multi 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,myrhh, cayenne, vitamin C, vitamin B6 and bioflavanoids 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 studies are finding 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 more and more studies are finding that having a healthy gut is essential to the immune system.

Probiotics are good for any age

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 3 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. Hey, working in this office gives us a lot of exposure to everything that is going around. We will try anything!

Remember that infants under one year should NOT eat honey

Chinese Medicine - Dr Schwanke started using Chinese herbs in our office many years ago, but only carry a limited line that we use for ear infections and congestion. We are fortunate to have the creator of those formulas right in the neighborhood at the Chinese Medicine Works. It is important that any Chinese medicine comes from a reputable source. I like the gentle warriors brand because it is made locally

It might be worth exploring some herbs if you or your kids keep getting sick.

My amazing friend Anita is an acupuncturist 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

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 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 this, the better it works. The bottle says for children over 2. The UK version gives the dosage for over 1.

Oscilloccoccinum

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.

Echinacea

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 right 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.

She also shared something that I confess I had never heard of. She suggests cutting an onion in half and leaving it on a plate right near the head of the bed.

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.

It is fairly common for parents to call us, incredibly frustrated when their kids seem 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. I have patients who actually have more than one illness at a time. RSV and Flu together seems to be a popular combination at the moment. 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.

PS Mama Jaime chimed in to share that she has found that Thrive Market is a good place to get many of these supplements at a good price.

Reactive Airway/Wheezing/Inhaler tips

PLEASE SEE THE MOST UPDATED VERSION OF THIS POST  AUGUST 2021 We get calls all the time from parents worried that their child is wheezing. I am always going to pay attention to this complaint but not all breathing noises are the same. A whistling noise from congested nasal passages is not always something that we need to worry about. The wheezing that is going to get my antenna up is the noise from down in the lungs. Any squeak, crackle or wheeze can be a sign of inflammation. When a person is well, air can move easily in and out of the lungs through a network of airways. There are several things happening during a wheezing attack. The airway becomes irritated and inflamed; this produces mucus which can clog up the airway. The inflammation also causes the lining of the airways to swell and the muscles around these airways tighten; this is called a bronchospasm. Wheezing is actually quite common in infants; it is estimated that up to 25 to 30 percent of infants develop wheezing in their first year of life. Wheezing may be more common in babies because of their smaller airways. Also, children under two are susceptible to a common, but easily treatable condition called bronchiolitis. This is caused by a viral respiratory infection and is a frequent cause wheezing. If your child has multiple episodes of wheezing they may get diagnosed as having a reactive airway. Reactive airway is exactly what is sounds like. Something is “triggering” the lungs, and the airway gets inflamed. Triggers range from a new cold, a change in the weather, secondhand smoke, dust, pets and or other allergens. Having a season or two of wheezing does not mean they have a lifetime of asthma ahead of them. Some kids can grow out of this. If your child is wheezing it is important that they get prompt medical attention. If this is a first time event it is even more critical to get educated about medications and treatments so that you are prepared to recognize and deal with it in the future. In general, having a doctor take a good listen with a proper stethoscope is a good idea, but you will have important clues if you know what to look for. Pay close attention to the patient’s breathing. Is it faster than normal? Getting a sense of what normal looks like when they are well is a good idea. Age Category Age Range Normal Respiratory Rate Infant 0-12 months 30-60 per minute Toddler 1-3 years 24-40 per minute Preschool 4-5 years 22-34 per minute School Age 6-12 years 18-30 per minute Lift up the shirt and watch. Do the respirations appear labored? Look for the tummy going in and out, or any retractions. How are they feeding? If your baby needs to take more frequent breaks from eating that can be a warning signal that they are ill. For older kids, can they take a big deep breath without it triggering a coughing fit? If a patient is wheezing they are likely to get some special medicine prescribed. Albuterol (Ventolin/ Proair) and levalbuterol (Xopenex) are the common “fix it” medications. These help open up the airway by relaxing the tight muscles. Unfortunately it is not uncommon for patients to get a little amped up from the treatment. These medications should start to work within 6 minutes or so. Some parents report that the kids seem to cough even more after a treatment. Remember that this medication is loosening up an airway that was previously very tight. All of a sudden there is more room for the mucous to rattle around. A productive cough is normal. We would use either albuterol or Xopenex, not both at the same time. Some folks find that Xopenex is less likely to make them jittery. Insurance companies will often need to see documented failure with albuterol before the Xopenex is covered. These medications can be given through a nebulizer machine or through an inhaler. Most young kids do better with the machine, but as soon as they are old enough to cooperate with the puffer it is a quicker and much more convenient way to give the medication. If this is a short little illness, sometimes a few days of the albuterol-type medication will see you through. If you are requiring albuterol for longer than a week or find that you need to use it more than several times a month, it is a sign that the situation is not well controlled. An absolute key treatment for a reactive airway is the use of inhaled steroids and other anti-inflammatory drugs. In our office we use something called budesonide (Pulmicort) in the nebulizer, but switch over to an inhaler when the kids are old enough. Common brands are Flovent and Qvar. These can control and prevent future attacks. The steroids work by reducing the inflammation, swelling, and mucus production in the lungs. As a result a person is less likely to react to the triggers. All the studies agree, inflammation in the lungs is bad and can lead to scarring. The choice between allowing persistent inflammation or using proper dose of inhaled steroids is an easy one. Please don’t be reluctant to use the inhaled steroid if it is appropriate. The word steroid sounds scary, but when they are inhaled, they are not generally absorbed by the body, but are going straight to the lungs. If your child is given a prescription for inhaled steroids,It is not unusual for them to be on them for weeks or months, especially during the winter cold and flu season. Both of my kids had a few seasons of using the Pulmicort. As soon as I would try to wean off the daily dose, the dry hacky irritated cough would start right back up. Here are some tips regarding inhaler use: For younger kids, I start with some really basic teaching. Get a tissue and hold it up to their mouth. Have them practice blowing on it and then inhaling so that it sucks up to their mouth. This can help them to understand the difference between inhaling and exhaling. It is really important to shake the canister before each use. For the first use and any subsequent use if you haven’t used it for more than a week, the inhaler needs to be primed by spraying 2 to 3 puffs into the air. I know it seems wasteful, but it is necessary. If you child is having trouble, you want to make sure that you are actually giving the medication. Read the directions carefully for the specific information about each inhaler! Hold the medicine upright so that it doesn’t stick to the tongue. Breath coordination is difficult. Using a spacer will make the inhalation much more effective. For younger kids, the spacers come with a mask. Keep lips firmly around the mouthpiece. The spacers should not make noise. If there is a whistle, try to make the breath slower. Activate the medication and make sure to keep the spacer at the mouth for at least 5 breaths. Wait about 30 seconds in between puffs. If you are using albuterol and an inhaled steroid, give the albuterol first. It is a good practice to rinse the mouth out after the medication. This is especially true after the steroid. If your child has a history of wheezing, it is a good idea to keep track and make sure that you have un-expired medication on hand. If you are traveling have them with you! Most inhalers have counters now so you can see how many doses are left, but if yours does not there are some tricks for figuring out how much is left. Take the canister and place in glass of water. A full one will stay mostly upright. If it floats at a 45 angle, it is time to replace it. If it goes sideways, it is probably empty. Shaking it is not a reliable indicator because there is propellant inside, so it is hard to tell how much is in there. It is good practice to keep the inhalers in their box. When you come to a doctors appointment, please bring them with you so that you can show the doctors exactly what you have been taking. Please be aware that in February 2018 QVAR will be coming out with a new activation system that will not require a spacer or shaking of the cannister. It also won't require priming. The is approved down to the age of 4 years. Please make note if you have the old or new system. If you are using a nebulizer machine, make sure that you change the tubing at least every 6 months. If it is the disposable tubing, that should be used for no more than 15 treatments. I have found that a little tech time or videos are very useful in getting your child to sit still. This is one of those situations that bribery might come in handy. I shouldn’t have to add this, but please remember that the correct call for a child in true respiratory distress is to 911, not the doctor’s office.

The impact of a single sentence

Social media in general and Facebook in particular have their benefits and drawbacks There is no doubt that it is way easier to reconnect with long lost friends than it used to be.

Recently my husband got tagged in a 6th grade class photo from his good old PS 32 in New York City. This started a flurry of conversation between people who hadn’t been in touch for many many (many) years. There is really nothing quite like an old friend who knew you when. I believe he may actually stay reconnected with some of these folks.

With all the catching up that was going on, there was a comment from a girl in his class that caught my attention. She wanted to let Sandy know that after all this time, she still thought about his mother.

It turns out that way back when, after a school performance, my mother-in-law had made a bee-line straight over to this girl just to tell her what a wonderful job she had done. It wasn’t the simple “good for you”; mom had told her how moved she had been and that this young lady should be very proud of the performance. Fortyeight years later, this woman says that she still remembers how impacted she was by the interaction. Wow!

There are more people out there than we can count for whom a crumb of positive feedback is rare and important. Words, either kind ones or mean ones, are often put out there without much thought and the speaker moves on. This story illustrates how much a message can sometimes stick and make a profound impact.

Go out there on this Thanksgiving weekend and make a lasting positive impact with your conversations!