Impetigo

I have been getting a lot of calls lately from concerned parents who have gotten a notice from school or daycare that their child has been exposed to impetigo.

Our world is full of bacteria. There are beneficial ones and dangerous ones.

We are constantly surrounded by potentially harmful bacteria that seem to have the "if you don't bother me, I won't bother you attitude". Many folks, without being aware of it, are carriers and routinely  have bacteria such as staph on their skin.

Our skin is our all important protective barrier. Bacteria that is not causing any trouble as long as it remains on the outside of the body can wreak havoc if it makes it's way in. When there is a break in the skin from a cut, bite, or an itchy rash that has been scratched, the bacteria can take advantage of that, enter the body and cause an infection.

Impetigo is one of the most common skin infections out there.

It is usually caused by either Staph or Strep. By far, most of the time Staph is the culprit

There are two types of impetigo.

Bullous impetigo is less common and usually shows up in much younger children. This is characterized by large pus filled blisters.

More common is the non-bullous impetigo, this will have crusty, rashy areas that may have a honey colored glaze. Most of the time you will see these lesions around the mouth and the nose.

This also often affects the diaper area, but  can show up anywhere, more often on exposed parts of the body.

These spots and rashy areas can spread. They don't seem terribly painful and most of the time your child might seem quite well. The spots simply may flare up on and off  but usually don't  clear up completely without treatment.  

(super red/open rashy areas around the butt might be strep. We can do a test for that in the office) 

Young children and school age children are the most common victims of Impetigo, likely because they tend to come into more 'close contact' situations with others.

It is easily spread from direct touching with an infected person,or from coming into contact with contaminated surfaces like toys.

The incubation period is 1-3 days.

If you are dealing with  a very small area, the standard treatment  is an antibiotic ointment. With a really mild infection over-the- counter Neosporin may take care of it. If you don't notice an obvious improvement within 48 hours you may need to be seen or talk to your doctor about getting a prescription ointment called Mupirocin (Bactroban is the trade name).

Some cases are severe enough to warrant a course of oral antibiotics. In our office we will almost always want an office visit to help make that determination.

If a family member has been diagnosed, wash any sheets, towels, toys etc

To prevent getting this in the first place, good hand washing is key.

Do your best to keep skin safe and intact. Dry, itchy skin is more at risk because of the tendency to scratch. Eczema seems to easily  get infected areas. Keeping the skin well moisturized can help. Calendula cream is thought by some to have a natural antibacterial property.

Keep nails short to avoid damaging scratching.

To prevent infection, any mild cut or open lesion should be kept covered  with an antibiotic ointment applied 2 or 3 times per day.  

If your child has a case of impetigo or has been exposed you may also want to put a thin film of Neosporin or Mupirocin  under the fingernails and inside the each nostril twice a day to prevent spreading. Dr Schwanke is a big advocate of getting the ointment inside of the nose since that is often the source of the bacteria.

Another thing to consider is a bleach bath. "What?" you say.

I know, the first time I learned about this I was fairly dubious, but it is currently a strong recommendation from many dermatologists.

Adding ¼ cup of basic bleach to a standard tub can be useful for preventing and treating a multitude of skin afflictions. This will kill any staph or bacteria that is hanging out on the skin. It turns out that it is usually not at all irritating and has very few adverse effects.

I just learned another fact that knocked my socks off. A recent study claims that at least 30% of our tubes of various ointments are contaminated with bacteria. It doesn't take much thought to figure out how that would happen. We touch the tube tip with our unwashed fingers, or we touch the tube to the surface of our skin.

Do me a favor, from now on, try to keep any new tube sterile. Squeeze the dose of ointment or cream onto an applicator (you can use a spoon) and avoid having any direct contact with the tip or rim.

Okay, to sum it up.

If you are one of the families who got the Impetigo warning....

Hopefully your school setting has done it's job and has thoroughly cleaned toys, surfaces etc.

Aside from that, checking your child to make sure they have no spots anywhere is the only action plan that I would advise.

If they have any questionable spots, treat as discussed.

As I mentioned in my recent post about contagiousness, A notice about impetigo exposure would not be a reason to keep them home from school.

Chances are, unless you have been out of day care for an extended period,  they have already been exposed.

Vicks VapoRub on your feet?

 

The internet is a minefield.

It is a goldmine of valuable information.

Unfortunately, it also has the power to terrify unwitting folks who go online to look up symptoms or whatnot.

Most wise folks know enough to realize that the good information is muddled up with loads of crap. It is hard to know what is real.

Therefore, when I got an email several years ago touting the magic of applying Vicks VapoRub to your feet to stop a cough, I promptly dumped it into my spam.

Frankly anything that tells you that it works 100% of the time is 100% false (Have fun with that statement!)

But then a variation of the same email came to me again and I thought it might be fun to see if there was any merit to it.

The claim is that covering the soles of the feet with the VapoRub and then putting socks on is very helpful for coughs.

I am always looking for safe, natural remedies to help relieve symptoms of colds and coughs for my patients without loading them with systemic medications.

So, several winters ago I set out to do a completely unscientific study.

While talking to the hundreds of my Noe Valley Pediatric parents who were trying to relieve the coughs that were keeping their kids up at night I enlisted them to give the Vicks on the feet a try. I asked them to report back.

To my surprise, well more than 50% of the folks who tried this seemed to find that it was quite helpful....imagine that! Even Snopes doesn't completely debunk it, just labels it as unproven.

No one who tried it had any ill effects.

I occasionally completely forget about this, but someone asked me about it the other day. With the colds and coughs out there in full swing, this might be something you want to try.

Before applying anything topical, it is important to make sure you or your child do not have a reaction. Place a small dab on the leg and rub it in. If there is no irritation within 30 minutes or so, you should be fine. (I do this same test with a new sunscreen) 

If you have an infant who is under 4 months of age with a cough that is keeping them up or interfering with their eating, they need to be seen.

Nurse Charity talks about biting

Now that preschool is in full swing for fall we have been getting a fair amount of calls about biting.  Unlike other forms undesirable behavior- (pushing, hitting, scratching, hair pulling, pinching, verbal and social bullying), the emotional fall out from biting seems to escalate quickly, emotions run high and very soon it is family against family, teacher against parent, and some very bewildered children.  So lets talk about biting, how to create a safe space for your child (either biter or bitee), basic first aid and in the process- put some common biting myths to bed.    

 We get two types of calls at our office-  The angry, upset parent of the bitee convinced their child has been set upon by a rabid entity bent on the destruction of their child.  And tearful, panicked parents of the biter, worried they have a human vampire on their hands, facing informal expulsion from their playgroup, or  worse, formal expulsion from the pre-school.

So here is the cold, hard truth- 

 Biting is a normal developmental stage for a lot of little mammals, humans included  (aged 2-4).  And the children of some pretty fantastic, present, kind, thoughtful limit setting people get to be the parent of the casual and habitual biter.  

What follows is a nice run down of what actually works for Biting (No, biting them back does not work- trust me I tried it.  My son wandered around for a week, showing the bruise on his arm to random strangers, and saying "My Mama bit me!"  Do not let this be you!) 

1.  Make this a Safety issue.  This is a goal all parents, teachers
and children can get behind.

2.  The play group/pre-school should make it their goal to prevent aggressive behavior of any kind by members, not just biting.  So the plan should apply universally to undesirable, unsafe behavior.

3. Create a "safe place" to help isolate the biter.  Remember they
maybe just as upset and bewildered as the child who is bitten,  and
kids tend to strike back very quickly.  Teachers and volunteers need
to move quickly to separate children, and KEEP CALM!
Depending on the age group, I would suggest a cozy
playpen type space, so even one adult can manage the situation. Pick
up the biter (or hitter or scratcher etc), say- "no don't bite, biting
hurts" and set the child into the safe place.  Then the teacher/parent is free to put all of his or her attention to the child who was hurt.  

 

4. Safety Break- Biter in the safe place, bitee being looked after and smothered in kind loving attention.  I suggest a 3-5 minute break to allow emotions to cool, and normal activity to resume.  

5. First Aid- Wash with cold water, small amount of antiseptic soap, and apply a cold compress if necessary.  Don't panic- they very, very rarely break the skin, and prompt washing with antibacterial soap, and a good water flush is enough to clean a superficial wound.  A bandaid is often helpful even if the skin is not broken. Fill out required paperwork (if any). Notify parents.

 

6.  Allow the separated child to return to the activity in progress.  (and this is KEY) Be warm and welcoming to both children.

7. If the skin is actually broken, a bite can become infected and might need to be evaluated.

 

 

Things to avoid! 

Apologies- they are not developmentally appropriate for this age
group.  Your child can apologize till they are blue in the face- it
might make the parent feel better- it will not sway or help the child
bitten. 
This is something that happens when adults overlay their
feelings onto small children, and it opens up a huge can of worms.  You ask your child to apologize before he is ready it comes out forced, the other parent gets even more upset.
Or they refuse all together.  Yikes!!  The child bitten refuses to accept the apology!  Double yikes!!   Other parents often take this as an opportunity to yell at your child, which is not helpful and can undo many of your family rules and consequences.

Wound tending- Many attachment parenting books talk about letting the biter help tend the wounds of the bitee- More trouble than it is worth.  Sometimes the child who was hurt will not let the child help- leading to more tension.  Or the care taking role your child wants to take is
prohibited- for example my child once wanted to provide a band-aid to
the child he hurt.  The pre-school refused to let him.  

A lot of reasoning, yelling, shaming, etc.- Keep the talking about biting age appropriate   A lot more discussion other than- "Biting Hurts, no biting."  in a clear firm, almost dead pan voice is all that is required.   Even a baby genius does not have adult empathy or rationalization skills, and yelling at them does not actually make them anything but tense and afraid- which sets the stage for (yep, you guessed it), more biting.  Also after having followed a lot of biting children in the past few years, including my own, some children are not biting out of aggression.  Often times they are biting out of love (no really- biting feels good to the biter- and so they assume it feels good to the bitee as well), or a simple desire for more personal space.

Now for the hard part-  if biting becomes a pattern 

Someone needs to shadow the habitual biter at school/playgroup and keep a log, who does s/he bite?  when does s/he bite?  what happened that day, what is the weather, what is happening at home.  Is there anyone who gets bitten more than others? Why is that? (friend who is always in close proximity, love bites to favorite people, too noisy of an environment, too many kids in one play area, not enough toys to child ratio, retaliation of aggression).

Ok then one needs to teach the other kids to help the habitual biter/hitter/scrathcer/pincher stop-
again this is a safety issue.   Many parents and teachers will resist
this step making a single child the scapegoat.  Do not let this happen!  It
is a safety issue- everyone will be safer if the kids know what to do
if they notice their playmate is getting upset.  It empowers potential
victims.  It does not in anyway condone biting (or hitting or pushing
or scratching or any other aggressive behavior).

Usually kids are taught-

Take a step back
say "No bite" (no Hit, No scratch").
put out a stop hand

This also helps teachers who may have not been paying attention to come quickly.

Books and videos you may find helpful!! (Trust me I read and watched them them all, so you did not have to!)

Book: Teeth are not for Biting! Elizabeth Verdick and Marieka Heinlen 

Video: Time Out Tot, the Behavior Coach.

Should you give tylenol before the shots? / vaccine reaction discussion

With the exception of the Hepatitis B, the first round of vaccinations is usually given at the two month visit. I get plenty of calls from parents wondering if they should dose their baby with Tylenol or Ibuprofen before actually getting the shots.

This is one of those situations where you will likely get a different answer from anyone you talk to.

In my experience children respond to the shots in different ways.

About one third of my patients have almost no discernible reaction at all except for a moment or two of crying after the injections. Some of these babies are sleepier than usual for the first night (Which most parents enjoy once reassured that this is normal).

The second group is fussy and has a mild to moderate fever. This typically starts about an hour or two after the shots.

The third group (my daughters were in this crowd) seem fine until about twelve hours or so after the shots and then the reaction kicks in.

Knowing this, giving medication ahead of time doesn't make sense to me. Although I have no hesitation using Tylenol or Ibuprofen as needed, instinctively I don't like to give any medication unnecessarily.

There is a two thirds chance that giving the meds ahead of time is not needed, either they are the group that won't react, or they are the group that won't react until hours later.

The medication ahead of time does NOT make the shots hurt less.

But of course nothing is ever quite so simple. There are many folks that opt to give the medication ahead of time and they have valid reasoning. 

The fact is that the Tylenol/ Ibuprofen do seem to work better if you catch the reaction before it has reached it's peak. If your choice is giving it too soon, or waiting until your baby is miserable  I would say give it early to be on the safe side.

Somewhere there must be a happy medium. 

My advice is to watch your baby very carefully. Certainly have the medication on hand and make sure you know the proper dose. (I do not have a strong preference between the medications)

After the vaccines (let them calm down for a bit, that first bit of crying from the shot doesn't count), at the first sign of fussier than usual behavior go ahead and give them some medication.  

We can use the first set of shots as a learning experience.

If your baby is really miserable after the first vaccinations, I would plan on giving that dose ahead of time for the next shots. 

To calm your baby immediately after the shots I have found that dancing with them is the best solution. Big bouncing and shoooshing often does the trick pretty quickly.

Some moms choose to nurse during the injection. I personally prefer not to do it that way. In my mind, breast feeding should be considered a safe and pain free situation. I don't like the idea of messing with the 'sanctity of the boob'. 

Most of the time babies who are having a vaccine reaction will have mild to moderate fevers for a day or so. They appear like they just don't feel well.

They may have some redness and a little lump at the injection site.

(I like to put Arnica or little black tea bag compresses at the site for some relief)

Some of these lumps feel like the size of a pea and  may last for several weeks.

Redness at the site might be a reaction to a band aid. 

If your baby is having a rough time, make sure you give Tylenol/ Ibuprofen as needed those first couple of days.

An inconsolable child who has had the full dose of pain reliever is one who you should check in about.

We rarely see super high fevers ( >102) from the shots these days. As with any fever, please notify someone if it doesn't respond to tepid bath or medication within an hour.

I often have folks calling me a few days after the shots, The babies did okay for the days immediately after the vaccinations, but now they are worried that their child now seems ill.

My speculation is that the vaccinations do tweak the immune system as they work on getting the body protected from big bad diseases. When this happens, the door is open for other mild illnesses to take the opportunity to come along. Unfortunately it is not that unusual.  

It is hard to watch your child get miserable after shots. Keep in mind that the diseases that you are protecting them from are very real. 

How much sugar is too much???

Nurse Jen is taking the summer off to spend quality time with her lovely daughters.
She is keeping her brain active by doing some writing for the blog on some interesting topics.
 Here is Jen's  first contribution.


Summer is officially here and many of us are planning out of town visits with friends and family. Ice cream at the pool, cookies and juice at a doting grandparent's house and a general lapse in regular healthy eating routines all spell out an increase in SUGAR INTAKE. While the occasional sweet is nothing to get worked up about (in fact, eliminating altogether will probably only make your child want sweets more) a lot of media attention has been paid to sugar lately. Although there are a lot of conflicting opinions about sugar out there, below you will find my summary of today's 'sugar buzz.'

If you're short on time,  I start by listing the current recommended levels of how much sugar kids can consume. If you're inspired to read more, read on (additional reading suggestions are listed below.)

So what do we know NOW about how much kids can consume?
Preschoolers with a daily caloric intake of 1,200 to 1,400 calories shouldn't consume more than about 4 teaspoons (or 16 grams) of ADDED sugar a day. Children ages 4-8 with a daily caloric intake of 1,600 calories should consume no more than about 3 teaspoons of ADDED sugar a day (approximately 12 grams.) In order to accommodate all the nutritional requirements for this age group, there are just fewer calories available for discretionary allowances like sugar. (www.family education.com)

As your child grows into his pre-teen and teen years, and his caloric range increases to 1,800 to 2,000 a day, the maximum amount of added sugar included in his daily diet should be 5 to 8 teaspoons (approximately 20-32 grams). (www.family education.com)

Keep in mind when you're reading labels, four grams of sugar equals one teaspoon of granulated sugar.

What are Added Sugars?
Added sugars are sugars and syrups that are added to foods or beverages during processing or preparation. They do not include naturally occurring sugars such as those found in milk (lactose) and fruits (fructose). Added sugars (or added sweeteners) include natural sugars (such as white sugar, brown sugar and honey) as well as other caloric sweeteners that are chemically manufactured (such as high fructose corn syrup.) (American Heart Association, 2013).

How can I tell by looking at a Nutrition Facts panel if a product has added sugars?
Unfortunately, current nutrition labels don’t list the amount of added sugars (alone) in a product. The line for “sugars” you see on a nutrition label includes both added and naturally occurring sugars in the product. Naturally occurring sugars are found in milk (lactose) and fruit (fructose). Any product that contains milk (such as yogurt, milk, cream) or fruit (fresh, dried) contains some natural sugars. (AHA, 2013)

But you can read the ingredient list on a processed food’s label to tell if the product contains added sugars. Names for added sugars on labels include:
Brown sugar
Corn sweetener
Corn syrup
Sugar molecules ending in “ose” (dextrose, fructose, glucose, lactose, maltose, sucrose)
High-fructose corn syrup
Fruit juice concentrates
Honey
Invert sugar
Malt sugar
Molasses
Raw sugar
Sugar
Syrup

And what are we really consuming?
 A study conducted by the AHA found children as young as 1-3 years already bypass the daily recommendations, and typically consume around 12 teaspoons of sugar a day. By the time a child is 4-8 years old, his sugar consumption skyrockets to an average of 21 teaspoons a day. The same study found 14-18 year old children intake the most sugar on a daily basis, averaging about 34.3 teaspoons. In general, a statement from the National Health and Nutrition Examination Survey conducted from 2001-2004 found the average American consumes the equivalent of 22.2 teaspoons of added sugar. That is about triple the recommended adult amount! (www.family education.com)

There is more added sugar in our food today so it is important to read labels- and look at your child's plate! Have you seen the myplate picture that replaced the nutrition pyramid we grew up with? Keep it in mind every time you make your child's plate.  (www.myplate.gov)

An interesting fact
In 1822 Americans consumed the amount of added sugar in one 12-ounce can of soda every five days. Today we consume that amount every ten hours...which is equivalent to 12 cans of soda in five days. ("Are we too sweet?," 2012).

If you'd like to learn more....
Sugar Crusader Dr. Robert Lustig's recent book Fat Chance has received a lot of attention ( we have an office copy if you'd like to borrow it.)  Lustig’s name probably sounds familiar - more than 3.6 million people have watched his 2009 viral YouTube mini-series Sugar: The Bitter Truth.

Dr. Lustig is Professor of Pediatrics in the Division of Endocrinology at UCSF and Director of the UCSF Weight Assessment for Teen and Child Health (WATCH) Program. He is nationally recognized in the field of pediatric neuroendocrinology and a leading expert on childhood obesity.

Lustig investigates not just the detrimental biological effects of consuming sweets. He is also interested in identifying how hidden sugars find their way into our diet and how our society's sugar consumption has contributed to declining health in the general population, not just among those who are classically obese.  (Hoffman, 2013).

Why is sugar so bad for us?
The easy and widely accepted answer is  that refined sugar and it's popular substitute high fructose corn syrup (H.F.C.S.) don’t come with any protein, vitamins, minerals, antioxidants or fiber, and so they either displace other more nutritious elements of our diet or are eaten in addition to what we need to sustain our weight, which is why we get fatter.  Lustig (and some biochemists) argue, however, not about the consumption of empty calories. They state that sugar has unique characteristics, specifically in the way the human body metabolizes the fructose in it, that may make it harmful on its own, at least if consumed in sufficient quantities.  (Taubes, 2011).

To simplify this theory, Gary Taubes of The New York Times  writes "the fructose component of sugar and H.F.C.S. is metabolized primarily by the liver, while the glucose from sugar and starches is metabolized by every cell in the body. Consuming sugar (fructose and glucose) means more work for the liver than if you consumed the same number of calories of starch (glucose). And if you take that sugar in liquid form — soda (or fruit juices) — the fructose and glucose will hit the liver more quickly than if you consume them in an apple (or several apples, to get what researchers would call the equivalent dose of sugar). The speed with which the liver has to do its work will also affect how it metabolizes the fructose and glucose."

The last time an agency of the federal government looked into the question of sugar and health in any detail was in 2005, in a report by the Institute of Medicine, a branch of the National Academies. The authors of the report acknowledged that plenty of evidence suggested that sugar could increase the risk of heart disease and diabetes — even raising LDL cholesterol, known as the “bad cholesterol”—– but did not consider the research to be definitive.   (Taubes, 2011).

Currently, the National Institutes of Health are supporting surprisingly few clinical trials related to sugar and high-fructose corn syrup in the U.S. All are small, and none will last more than a few months. Lustig and his colleagues at U.C.S.F.  are doing one of these studies. It will look at what happens when obese teenagers consume no sugar other than what they might get in fruits and vegetables. Another study will do the same with pregnant women to see if their babies are born healthier and leaner.  (Taubes, 2011).

So what to eat? 
Lustig says (in his January interview with Oprah Magazine) "Real food! That's it. If it came out of the ground, or it's from an animal that ate what came out of the ground, you're good to go. But if a human processed it in between, either something was added, usually sugar, or something was removed, most likely fiber and micronutrients like vitamins and minerals. The key for most people is reducing insulin, and to do that, you have to put back fiber into your diet and cut back on refined carbohydrates and sugar. If you're buying food that has a nutrition label, it's been processed. And if any form of sugar is one of the first three ingredients, consider it a dessert. When I was a kid, we had dessert once a week. Now we have it once a meal, and it's almost always processed. That's the problem. " (Schomer, 2013).

Is sugar as bad as Lustig claims is?
The answer is......it could be. It very well may be true that sugar and high-fructose corn syrup, because of the unique way in which we metabolize fructose and at the levels we now consume it, cause fat to accumulate in our livers followed by insulin resistance and metabolic syndrome, and so trigger the process that leads to heart disease, diabetes and obesity. They could indeed be toxic, but they take years to do their damage. It doesn’t happen overnight. Until long-term studies are done, we won’t know for sure. (Taubes, 2011).

In the meantime, I suggest you try your best to stick with the AHA current guidelines and practice the delicate balance of limiting your child's sugar intake without making it into a major battle. Good luck!



Are we too sweet? Our kids' addiction to sugar. (2012). Retrieved June 26, 2013, from http://life.familyeducation.com/nutritional-information/obesity/64270.html

Hoffman, Jacquie (2013, January 30). Dr. Robert Lustig: UCSF’s Sugar Crusader.  Synapse, the UCSF student newspaper. Retrieved from http://synapse.ucsf.edu/

Taubes, Gary (2011, April 13). Is Sugar Toxic? The New York Times. Retrieved from  http://www.nytimes.com/

Schomer, Stephanie (2013, January). The Sweet Lowdown: Exposing the Unhealthy Truth About Sugar. O, The Oprah Magazine

Blocked tear ducts

We get calls all the time from parents with a young baby who has eye discharge.

Between 5-20% of babies are born with a blocked tear duct. The medical lingo for this is dacryostenosis. You may also hear it referred to a nasal lacrimal duct stenosis.

These babies have eyes that are crusty or watery. Some discharge is noted as well. It is usually worse when they first wake up from sleep.

My favorite approach is the most natural. Reach up to your own eye. Do you feel that little bulb on the inside corner near your nose? That is the tear duct. Gently massage it. It actually feels sort of good ( okay now stop rubbing your eye)

Now it is your baby's turn.

With a very clean finger, massage their tear duct. ( watch out for sharp nails)

If you are fortunate to have breast milk, add a few drops to the eye. You can tap it in with your finger, an eye dropper or squirt it in directly.

Now clean off the eye with a warm, wet cotton ball. I was always taught to wipe from the outside towards the nose. This direction avoids spreading the mucous throughout the rest of the eye, but there doesn't seem to be any consensus about this

If you don't have breast milk, Simply do the massage and clean with the wet cotton ball.

Think about having a clogged drain, if you can clear it without pouring in DRANO that is a better option. Massaging the duct often takes care of it. The breast milk is a bonus and more and more studies are finding remarkable healing properties in it.

Kids with blocked ducts are going to have the crusty eyes on and off.

If:

Baby seems happy and well

Eyes remain clear for several hours after treatment  

(remember, it is normal for them to be especially crusty when they first wake up)

There is no significant redness or swelling around the eye

Then:

I am fine with the "watch and see" approach.

Treat with the massage and breast milk for a day or so and then report back

If, however:

The baby seems very fussy

The eyes have green or yellow discharge that needs to be wiped off more than once an hour

There is significant redness in or around the eye

Then:

call for an appointment.( For older children, Goopy eyes can be conjunctivitis or a sign of an ear infection)

If we suspect an eye infection we will likely prescribe a course of antibiotic eye drops or ointment. 

Having a blocked tear duct is quite common. Most infants grow out of it within a few months. 90% will resolve on their own. Some kids don't clear until they are almost a year old. If it doesn't seem to be resolving or your baby is getting frequent eye infections, we will send you to see the ophthalmologist. They will schedule a simple procedure that unblocks the duct.

creative and inexpesive things to do with your child

I saw a bumper sticker the other day that said good parenting requires Twice as much time and half as much money.

I agree!!  Below is one of the hand outs from my parenting class.

Nurse Judy’s Inexpensive and creative activity list

• Collect and decorate rocks with colorful paints and glitter for a rock garden.

This is a great one to use as a reward for good behavior. When they see the pretty rocks, they will remember that they earned them.

• Make a collage. Old magazines and old photos are great for this activity.

• Make an musical instrument... Use your imagination: a shoe box with rubber bands can be a guitar; Glasses filled with different levels of water make different tones; Tapping different surfaces with chopsticks makes different sounds.

• Go on a ‘use all your senses’ walk. What do they see, smell, hear, and feel?

• Create a scavenger hunt walk. Plan a list ahead of time of thing to find…like a dog, an airplane, or even a girl with purple hair.

• Go on an ABC walk. Find things that start with all the different letters…or find the actual letters on signs and license plates. This is a great game in a supermarket.

• Download Free coloring pages from the internet. With a little searching, you can get a picture of just about anything.

• Draw with chalk. Make a hopscotch board.

• Make your own play dough. You can find the recipe on line

• Make a fort using the couch cushions

• Write a story and illustrate it together.

• Decide on a recipe and bake or cook something. Kids will often try foods more eagerly if they helped with the cooking. Let them help sprinkle in different spices and be the taste-tester.

• Have a Tea party. Invite the dolls, and get out the good china that you never use.

• Trace your hands and feet and color them in.

• Have some down time while watching a video or a special TV program. There are some lovely educational TV programs and videos out there.

• Play a computer game. Don’t be afraid of controlled use. Children that don’t learn how to be comfortable on computers at a young age are at a distinct disadvantage in this high tech culture.

• Blow bubbles

• There is little out there that is as much fun as a big appliance box to get inside of . If you buy a new appliance or see a neighbor buying one, ask for the box.

• Wash the car!

• Read!