Mother's Day Musings

Maternal -  How would you define that word? For me it evokes, unconditional love, guidance, nurturing.

For those of you in that middle generation, savor these years. You have your mom and your kids. If you are lucky, maybe there are some grandparents in the mix. Being the magic middle of the sandwich might present some challenges, but please TREASURE these years.

For the daughters and sons looking for the perfect gift, give the gift of time.

Go on a special outing, take lots of photos. The memories are more valuable than jewelry. Okay go ahead and throw in some chocolate covered strawberries, but you get the idea.

Actually forget the strawberries; give mom a nap!  Or a candle lit bubble bath (remove the bath toys!)

Make it a Mother’s Day tradition to tell your kids stories about your mothers, grandmothers, and great grandmothers. Did they have some favorite pieces of wisdom? Share them! Did they have some favorite songs? Sing them! 

On the other side of that coin, and not to put a dark cloud on the day for folks who are fully celebrating, but for many people Mother’s Day is one of those made up Hallmark Holidays that can range from being moderately uncomfortable to downright painful.

For me, it has been looming for weeks now like an impending shadow. This will be my first motherless Mother's Day. I am very aware and grateful I still get to revel in the wonderful relationship that I have with my daughters (and many of their friends), but but but but……..

Every time I turn on the TV or the radio, there it is, Mother’s Day, Mother’s Day, Mother’s Day. What are you going to buy your mother this year?  Where will you take your mother?  Show your mother how much you love her. Newspapers, magazines, Muni signs; Richard, my brother-in-law, calls it a capitalist plot.  It got me thinking. There must be so many of us out there. People who never had a mom, people who have lost a mom. Moms who lost a child, women who couldn’t have children, women who made the choice not to have kids but feel a twinge every once in awhile.

There are also so many wonderful families with no mommy but two amazing daddies.  How about immigrant families who are forced to be separated? The list goes on and on. Ouch!

What would my mom do? She would reach out and touch people who needed some love this week.

Let’s go back up to the word maternal at the beginning of this post. In my mind that word has very little to do with gender or biology. Who are the maternal figures in your life?. Reach out and give them a little acknowledgment (or a chocolate covered strawberry!)

Flat heads/physical therapy/chiropractor resources

FLAT HEADS In 1992, the American Academy of Pediatrics initiated the "back to sleep" program in order to try to combat Sudden Infant Death Syndrome. Since this program began, the rate of SIDS has decreased by over 40% . An unintended consequence though was the number of babies who have flat heads from spending so much time on their backs. Nice round heads are becoming a real rarity. Newborn’s skulls have a lot of plasticity, so they are pretty susceptible to external pressure. Up until about six months of life, the skull is naturally thin and flexible. It can easily change shape. It turns out that if you drop a cell phone on your baby’s head it will actually leave a little dent! (Don’t worry he’s fine.) Babies  don’t have a lot of motor control during their early months, so they can’t always easily re position. This flat head condition is called plagiocephaly. It occurs about once in 300 births.  Interestingly, little boys are twice as likely to have issues with this, and right side flattening is more common than left. Positional plagiocephaly does NOT affect brain growth or development, and by ages 4-6 months, most heads have developed a normal shape. But early intervention and recognition can speed up the rounding process Let's start tummy time early and often. It doesn’t need to be hazing. Even one minute at a time can count. The first tummy time can be within their first couple of days, having your baby simply laying on you. Don’t worry about the cord (you most likely aren’t that firm of a surface.) Tummy time is an excellent way for them to develop muscles and work on their head control. Infants lack head control, but they should be able to turn their heads to either side at rest. There are little steps that you can start early to try to avoid letting them have one favorite side. Try to  give each side equal attention. Make sure you swap feeding positions. Offer objects from either side. Alternate directions on the changing table. Consider changing the position of the crib or the orientation of the baby in the crib to reduce the baby’s tendency to look in the same direction. When awake and supervised, prop the baby onto one side with a foam wedge or a towel rolled lengthwise along the baby’s back. Change positions when feeding, carrying, and holding the baby. Provide supervised upright play as soon as the baby has upright head control. During quiet alert times, also encourage mid-line control. Place their hands together and have them look straight at you. Pay attention to  places other than the crib where their little head is up against a hard surface. Anytime that the baby doesn’t have their heads in contact with a firm surface is a bonus! It is not recommended that babies have a pillow for night sleeping, but I am fine with one of the memory foam infant pillows for changing tables. There are quite a few options for this available on Amazon. Janet Green Babb, one of the PT’s listed below, says that one product that her clients have found helpful is a pillow called Mimos Baby Pillow. Some babies, particularly those with shortened neck muscles may develop a more serious kind of flattening. You may hear this condition referred to as torticollis.  If you find that they don’t easily move their head from side to side easily I would suggest a visit to a Physical Therapist or Chiropractor. It is never too early for an evaluation. I have some resources listed below. If all of your tummy time and intervention have not been as successful as we like, the next referral will be to the cranio facial or neurosurgery team for an evaluation. Either of those specialists  might end up sending you along to the  pediatric orthotist team. The orthotists do some scanning (no radiation) and become part of the team that is monitoring your child’s head shape. In some cases, the kids may end up with helmets. Insurance companies vary greatly with their coverage of helmet therapy. The orthotist team at UCSF is top notch. Although helmet therapy is usually not started prior to 5 months of age, there is little downside to having a referral sooner. For those of you interested in further details about the cranial helmet remolding process, see the information at the very bottom of this post. Although we sure do see a lot of kids with flat heads, very few of them end up needing a helmet. Annie, one of my mom’s whose baby ended up requiring a helmet shared her story and wisdom. Her little guy is a second child with a mellow temperament so she wonders if that led to a bit more time hanging out in his infant seat. Her doctor repeated the need for tummy time at each visit, but Annie thinks that with a bit of hindsight, if she had seen a helmet in her future she would have been more aggressive with it. At 2 months she did end up at the chiropractor who loosened up the neck muscles. These treatments made a big difference in his favoring one side over the other, but this little guys head was seriously flat and keeping him off of it did not seem to be helping as much as we needed it to. Annie adds a healthy dose of perspective:  “There are worse things, We are fortunate to live in a place where this can be fixed.” Physical Therapists Pinnacle Kidz is a terrific pediatric physical therapy resource in our neighborhood. The owner Bethany, has been making a big difference for quite a few of my patients. 1772 Church Street www.pinnaclekidz.com 415-654-5324 ------------------------------------------------ The UCSF physical therapy is still over at 500 Parnassus, Room MU-09. At some point they will likely move over to Mission Bay, but not in the near future. Ph: 415-353-4972 Fx: 415-353-4974 ------------------------------------------------ Janet Green Babb is a physical therapist that we have been working with for years. Her office is out in the avenues, but many folks find it worth the “schlep.” 4200 Irving Street San Francisco, CA 949122 415-664-6061 Babb.devprog@gmail.com Janet notes that It is interesting how many babies are experiencing flat heads and preferential head turning. Early intervention seems to be so effective in preventing further asymmetry and for promoting midline and symmetrical orientation. -------------------------------------------------- Starfish Therapies is a pediatric physical therapy provider with several locations in the Bay Area. They have one of their clinics right in the wonderful KidSpace at 2401 Mission St. here in SF To inquire about services call 650-638-9142 or email admin@starfishtherapies.com --------------------------------------------------- Michelle Foosaner Diamond, PT at Children's Therapy Associates Children's Therapy Associates They will do home visits in SF with a prescription from your pediatrician. Michelle says that  as few as 1-3 physical therapy visits can teach parents how to prevent the progression of, or correct, positional plagiocephaly when initiated early enough in development. ------------------------------------------------------- Laurel Condro at the Feldenkrais center is another excellent option for physical therapy. She does group classes as well as individual therapy 415-271-2683 www.feldenkraissf.com Chiropractors Claudia Kindler, a local chiropractor in Noe Valley, shared the following statement:"I love working with all of my patients but I hold a special place in my heart for infants.  Their transition into the world is impressive but not always smooth.  I love holding them and feeling their spine and all of their joints and muscles. Because they are so “new”, they are an open book.  As I investigate their spine and come across a subluxation, or a point of interest to me, the infant frequently pauses and makes eye contact.  They are telling me, “Yes, that spot is the problem”. In working with torticollis in an infant, I am curious how the baby is transitioning- do they prefer to nurse on one side to the other?  Do they only look to one direction?  Do they detest tummy time?   These patterns provide me skeletal clues that should be addressed.  When I feel their neck, upper back and shoulder girdle, I note skeletal challenges that are limiting symmetrical development.  With simple, small and gentle adjustments to the spine and shoulders the skeletal system can relax and return to optimum functioning." Two other chiropractic options are Sandra Roddy Adams and Laura Sheehan. They both work out of an office in the inner sunset at 915 Irving Street Laura Sheehan R.N., D.C. 415-681-1031 or  sheehanchiropractic@gmail.com laurasheehan.com.  Laura says that she has helped many a flat head round out and sometimes with only one visit if it's due to upper cervical strains. Sandra Roddy Adams happens to be my chiropractor, but she works with all ages. She can be reached at 415-566-1900. Dr. Austin Davis works on infants and the whole families. One of my readers contacted me to get him added to this list because she has found him enormously helpful Life Chiropractic (415)626-5433 (O) www.LifeChiroSF.com --------------------------------------------------------------------------- The following information is provided by the UCSF Orthotic and Prosthetic Center How The Helmet Works Approximately 85% of head growth occurs within the first 12 months of life. During this time the head is moldable and responds to light contact/pressures over extended periods of time. Static positioning (laying in one position for long periods of time) on the back or one side of the head often contribute to the development of plagiocephaly. In a similar fashion, the helmet places contact over the areas that are more prominent and allows space over flattened areas. This encourages the head to grow in the “path of least resistance”. The helmet does not push in areas of the head; it directs growth of the flattened areas of the head. Depending on the severity of the flatness and the child’s age will determine the treatment options. Under the age of 4 months we typically observe and have parents actively reposition the baby throughout the day, nights and naptime. Babies this young with a mild flat spot can be fully corrected with repositioning alone. Around the age of 5 months the effectiveness of repositioning is reduced and most health care providers will recommend the initiation of a helmet if the flatness is significant. Ideally if a baby needs a helmet we are starting the treatment between the ages of 5 and 8 months of age. Insurance As with all areas of medical care, health insurance is complicated and specific to each individual plan. The authorization staff at UCSF will perform a check with your insurance around the time of your first appointment with an orthotist. Craniofacial Evaluation After your pediatrician/family physician has placed a referral for a cranial remolding helmet evaluation. First you must see a Craniofacial specialist to confirm the baby’s presentation is plagiocephaly and not something else called cranial synostosis. This appointment is a requirement prior to making a helmet and is much better if this is done before your first appointment with the orthotic team. The Helmet Process Beginning the process for cranial remolding helmets can be daunting for families. The practitioners at UCSF are here for you as you go through this journey. Below is an explanation of the helmet process at UCSF.  First Appointment – Evaluation o The first appointment you have with an orthotist (person that is educated and trained in cranial remolding helmets) to assess your baby’s head shape, size and gather relevant information. Now is a good time to ask questions you have about the treatment and what your expectations should be. o Measurements: regardless of how the orthotist chooses to capture to shape of your baby’s head (by hand vs scanning) measurements will be taken to use as a way to track changes over time. These measurements will be referred to throughout the helmet treatment to ensure progress is being made o Impressions: In order to make a helmet the orthotist must capture the shape of your baby’s head. The two primary ways are with a cast and with a laser scanner. The most important piece is that the shape is well captured and matches the shape of your baby’s head; this will make the helmet fitting process (we will discuss later) much easier. It is common for babies to become fussy during this point in the appointment.  Casting: Plaster of paris will be used to lay over the baby’s head to capture the shape of his/her head. This process is messy and takes about 15 minutes.  Scanning: The baby will have a laser scan taken to create a virtual 3-D image of his/her head. The scan itself can take as few as 3 seconds, but the baby must be extremely still (typically multiple attempts are made).  Fitting Appointment o The helmet has been made and is ready to fit to your baby. The appointment will take 1-2 hours, so bring diapers and food just to be safe. The orthotist will put the helmet on the baby’s head and mark the helmet in areas that are too long and need to be removed. The orthotist will take the helmet off and on the baby’s head multiple times throughout this appointment to ensure it is fitting properly. It is common for babies to be upset/fussy throughout this appointment. o The helmet should not be immobile on the baby’s head. A small amount of shifting and rotation on the baby’s head is acceptable, so long as the helmet is not: coming in front of the baby’s eyes, touching the baby’s ears, or squishing the forehead. o You will be given a break-in schedule to slowly increase the amount of time your baby wears the helmet. Even after she/he has built up to wearing the helmet full-time you will need to monitor the skin for excessive redness every time you take the helmet off. Red marks lasting more than an hour or skin irritation require the helmet to be removed and your orthotist should be contacted for an adjustment.  One week follow-up appointment o Over the first week of having the helmet you and the baby slowly increase to wearing the helmet full-time (23 hours/day). This appointment is to check the fit of the helmet now that they are able to wear the helmet full-time. Minor adjustments are expected at this appointment. o Typically, redness that lasts less than an hour is okay. If you are concerned about the redness on your child’s head make sure to discuss this with the orthotist at your appointment.  One month follow-up appointment o These appointments should occur every 3-5 weeks to assess the progress being made with the helmet and to accommodate for any growth that has happened in the last month. Typically the orthotist will take measurements and/or a scan to evaluate the changes in your baby’s head shape. o In general, a change in your baby’s head shape happens if there has been growth over the last month. It is common for babies to have large growth spurts followed by smaller growth spurts. There may be some appointments where you see a large change in your baby’s head shape, and some appointments where you see very little change in your baby’s head shape. For this reason we are measuring and checking the baby’s head shape every 3-5 weeks to ensure the helmet is doing what it should be.  Adjustments o Despite trying to accommodate for growth on a regular basis (by having an appointment every 3-5 weeks), sometimes the babies go through large growth spurts and need adjustments sooner than planned. This is okay. o When to call the orthotist for an adjustment: Redness lasts for more than 1 hour and is still very red The helmet seems too tight The baby is suddenly resistant to wearing the helmet when previously they tolerated it well Determining the end of treatment o The typical length of treatment is 3-5 months, this will depend on the age when the baby begins wearing the helmet and how severe of a flattened spot is to begin with. With older babies we expect to have a longer treatment time because their heads do not grow as quickly. They can wear the helmet up to 15 months of age, beyond this age there is limited evidence to support the effectiveness of the helmet. o Clinical markers are used to numerically compare your baby’s head shape to “normal”. These markers are helpful in determining a slowing of growth and provide an objective assessment of the changes in the head shape over time. o Satisfaction with head shape and appearance is the ultimate goal. This is used in addition to the clinical markers to decide the end of the treatment.

What's new with Zika?

What's new with Zika
Last year Zika was all over the news. Some viruses make a big splash in the headlines, but then fade away. Unfortunately Zika is still something that we need to pay attention to.
Here are some facts about Zika:
Zika virus was first identified in 1947 in a rhesus monkey in Uganda's Zika forest (which gave the disease its name.) For decades Zika was a virus that turned up in monkeys and occasionally in humans in Africa and southeast Asia. Its symptoms were mild and the number of confirmed human cases was low.
This virus is still on the rise. Until a few years ago almost no one on this side of the world had been infected. Few of us have immune defenses against the virus, so it is spreading rapidly. Millions of people in tropical regions of the Americas may have been infected within the past couple of years
The world is shrinking, and mosquitoes don’t pay too much attention to borders. This year Zika has made it’s way to our country, There are now pockets of reported cases in Florida and Texas.
It is constantly evolving. Some areas where it was very prevalent are perhaps seeing a decrease.  Other countries like Mexico are seeing more cases.
For up to date information on which countries are impacted, check the CDC website:
http://www.cdc.gov/zika/
The Zika virus is spread to people through mosquito bites. The most common symptoms of this disease are fever, rash, joint pain, and conjunctivitis (red eyes). The illness is usually mild with symptoms lasting from several days to a week. Severe disease requiring hospitalization is uncommon. Only about 1 in 5 people infected with Zika virus even become symptomatic.
The nasty type of  mosquito responsible for Zika also spreads dengue virus, yellow fever virus and Chikungunya. Mosquitoes that spread Zika virus bite mostly during the daytime. Just as with malaria, people are the source for spreading the virus. This is how it works: a female mosquito bites an infected person and then can carry the virus to the next person she bites, so when people travel, they can bring the virus with them. An infected person is thought to be infectious the first week only. The virus can take hold if enough people become infected for it to become endemic, meaning it's in a region permanently. Mosquito bites and mother-to-unborn baby aren't the only ways this virus is transmitted. The CDC now confirms documented cases of infection from sexual transmission and blood transfusion. Although the Zika virus can be found in breast milk, to date there are no confirmed cases of mothers passing the virus to the baby through nursing. Either way, the benefits of breastfeeding way outweigh the risk and exposure would not be a reason to stop nursing. People infected with Zika virus don't infect one another through casual contact. 
Men who have been in a Zika hot spot should be careful to use birth control for 6 months after any possible exposure. Women should avoid pregnancy for 2 months after any possible exposure.
There is no vaccine or specific antiviral treatment available for Zika virus disease. Treatment is generally supportive and can include rest, fluids, and use of acetaminophen (not ibuprofen) for fever and/or discomfort. 
Because of similar geographic distribution and symptoms, patients with suspected Zika virus infections also should be evaluated and managed for possible dengue or Chikungunya virus infection. People infected with any of these illnesses should be protected from further mosquito exposure during the first few days of illness to prevent other mosquitoes from becoming infected and reduce the risk of local transmission.
Zika has a few especially  frightening aspects. Approximately 1 in 4,000 cases are having the complication of Guillain-Barre syndrome. Guillain-Barre is a nerve disorder that causes muscle weakness. Most people recover in a few weeks, but severe cases can require life support to help with the breathing. Anyone of any age can get Guillain-Barre, although it is pretty rare. It is thought to be triggered from an infection. 
Even more widespread  is the documented connection between birth defects and pregnant women infected by the Zika Virus. In Brazil, where most of the reported cases seem to be, there have been many babies born with microcephaly (small heads) and the associated significant health issues. The most dangerous time is thought to be during the first trimester – when some women do not even realize they are pregnant.  Unfortunately there are new studies showing that a young baby’s developing brain can be impacted even if they did not get infected in utero. Infants under 18 months may be at risk for developmental delays if they contract this virus.
Okay how does all of this impact you? If you have not been traveling lately and have no plans to travel, Zika is not something that you need to fret about here in the Bay Area. If you have recently returned from a trip to any of the Zika hot spots AND have any illness symptoms, make sure that you share that info with your doctor or nurse. If you are pregnant and may have been exposed, contact your OB as soon as possible. Testing used to be coordinated with the local health department but It is now available at commercial labs. Testing should only be done for someone who has been in one of the impacted areas and is showing symptoms. The the tests are far from perfect.
Testing for Zika is not recommended for any non pregnant patients.
If you have an upcoming trip planned, keep in mind that until there are firm answers, the CDC has issued a travel advisory to pregnant women to avoid traveling to any countries where the Zika virus is rampant. If travel is not optional, strict mosquito avoidance is essential. 

• Make sure that you have intact screens on all windows
• Get rid of any standing water that is around where you are staying; do a double check to make sure there are no pots, bird baths...etc. that are places where mosquitoes can breed. The larvae are dependent on water for breeding. 
  
• The type of mosquitoes that carry Zika don't care what time of day it is. While may mosquitoes prefer biting at dusk and dawn, there is always risk with these nasties.
• Try to wear (keep your child covered with) long pants/ long sleeves etc. Light colored clothing is recommended.
• If you are going into a heavy mosquito area use bug spray on exposed skin and clothing. The EPA has five registered insect repellents. Of those, there are three products that are more easily available.

 - DEET is one of the more popular options. It is considered safe for infants over the age of 2 months.

 - Oil of Eucalyptus is considered one of the least toxic options but interestingly, the age recommendation for it is for 3 years and older.

 - Picaridin is a newer option. It is odorless and is approved for children 2 years and older. It is great as a mosquito repellent but it is not thought to be as effective against ticks as DEET if you are going into the deep woods.

/www.iflscience.com/health-and-medicine/what-is-the-best-mosquito-repellent-science-comes-to-the-rescue/

As with any new  product, do a little test patch on the skin to make sure there is no sensitivity before you widely spritz it. They all come in different concentrations. You will need to read the labels to see how often you need to reapply. Avoid contact with eyes.

Mosquitoes don’t like fans! The nasty insects are lightweight enough that a good breeze may make it hard for them to zoom in on their target.

The good news is while it's not certain, scientists believe once an individual has been infected with the virus, they are immune and won't become infected again.There is currently no concern for future pregnancies.

When can you take your baby out into this germy world ( 2016)

The discussion with new parents about when it is safe to take the baby out and about and risk exposure to crowds comes up quite a bit. This is one of those questions that gets a lot of differing opinions from anyone you ask. The only opinion that really matters in the end is that of you and your partner. All the well meaning friends, family and healthcare professionals can only advise. It is up to you to pick a path that feels right for you.  It is an especially popular question this time of year with the holiday season looming. Many folks have celebrations and gatherings ahead. Lots of folks are considering traveling.

It is often not a black and white case and we end up trying to identify all the considerations specific to your situation. There is a vast difference between a single parent taking the baby with them to get provisions, and the choice to take a newborn out to a crowded concert.

Travel questions come up a lot. I would rather avoid having a very young baby on a full airplane but some travel is worth the risk. I would likely say "go for it"  to a baby going to see aging great-grandparents, or to a once in a lifetime family event like a wedding. I would say "are you absolutely nuts???" to a family taking an infant to a beach vacation in Mexico.

What time of year is it? Are there any active viruses circulating? We are just coming into the winter cold and flu season. I am going to be stricter in my recommendations this month. RSV is actively going around. I posted about it a few weeks ago and since that post we have had positive tests in the office. I want my newborns safe.

I have a very different standard when dispensing advice about the under two month crowd. That two month old check up and first set of vaccines is a significant milestone. If you know that you have upcoming travel, bring that up at your early doctor appointments. In our office we can accelerate some of the first vaccinations.

Any fever in a young infant gets my attention. Babies are the most vulnerable the first 6-8 weeks of life. If one of these young babies gets a fever, it is going to be taken very seriously by any doctor that they encounter. In an emergency room, a fever in a young baby will most likely trigger diagnostic testing such as blood work, a urine catheter, x-rays and even a spinal tap. If in fact that baby has a serious infection, early intervention can be life saving, so the doctors aren't kidding around. No one wants their baby to have to  go through that.

I know that many new parents get cabin fever, but whenever possible, keep your newborn away from any circumstance that may expose them to anyone who is sick. In general, crowds should be avoided. If someone is coming to the house to visit make sure they are healthy before they come in. If they feel like they may be coming down with something, they are not doing you any favors by exposing you and your newborn. If you have family staying with you I prefer that anyone who is planning on spending time with your baby be vaccinated.  Ideally they have gotten the TDaP and Flu vaccines already. It takes a week or so for immunity to take effect. Plan ahead and make sure that family members get the shot now if they haven’t yet. Send them over to a pharmacy for the shots as soon as possible if they haven't gotten around to it. As long as visitors appear healthy and are more help than hindrance, don't hesitate to take advantage of your support network even if they haven't gotten the shots yet. Good hand washing is essential. We haven’t started seeing true influenza, but it is coming.

First time parents have the luxury of protecting and isolating the baby and should take advantage. That being said, in my opinion, a walk outside on a lovely day is usually perfectly fine for even the most conservative family.

Second kids are a different story by necessity.  They are often born into the situation where they have a loving, snotty nosed older sibling that wants to kiss and handle them from the start. These babies generally get exposed to things much earlier. Anyone who has multiple kids can tell you that it is really sad watching the young babies struggling with their first illness. As I mentioned in my sibling post, tell your older child or any children who will be in close contact with the baby, that they are in charge of the “germ patrol.” It is their job to make sure that anyone who is going to touch the baby washes their hands first or uses a hand sanitizer. Good hand washing is essential but quarantining your kids from each other is not reasonable. Common sense also dictates that kids are likely contagious before you realized they were getting sick, and by the time you realize that something is up, it is already too late.

When making decisions about how much contact your infant is going to have with the outside world, it is nice to have choices. Unfortunately situations will come up when it’s not so simple. When faced with these types of decisions, recognize that things are usually not clear cut so explore your options. Sometimes they are limited so do the best you can and use your best judgement!

Antibiotic considerations

Fortunately  the majority of my patients understand that antibiotics need to be used with care. Antibiotic resistance is a reality and it is essential that we don’t exacerbate the problem by giving these important medications unless they are really needed. Antibiotics should not be given for viral illness. Of course, sometimes a viral syndrome does morph into something bacterial. Fluid in the sinus cavities, ears, or lungs can become infected. To be certain that we are dealing with a bacterial infection, the best practice would be to do a culture prior to starting treatment. Reality sets in and considerations such as cost and invasive testing are complicating factors. In our office the doctors use their best clinical judgement when deciding whether or not antibiotic treatment is appropriate. If a bacterial infection is suspected and treatment is started, here are some factors to consider: UNDERSTAND THE DOSE Many antibiotics come in different concentrations. Some conditions will warrant higher dosing and longer courses. Some doctors also will also have individual dosing habits and practices. Dr Schwanke has his own favorite way of using Zithromax. When he first started ordering it his way, it was routine for me to get calls from the pharmacies saying ??????     Parents, please don’t hesitate to check with your doctor/nurse if you have any question about the dosage. Read the directions on the bottle to see if refrigeration is necessary. I suggest keeping a checklist with the bottle. Check off each dose when you give it. This will help you keep track of the doses. It is not unusual for me to get  calls about double dosing when both parents realize that they had each given the scheduled dose. (Usually not a big deal, aside from possible GI upset, but keeping track is a worthwhile habit.) Some antibiotics like Septra can make you more sensitive to the sun. It is a good idea to be especially cautious about exposure if you or your child is on any medication. Antibiotics usually are better absorbed on an empty stomach, but medications like Augmentin can be tough on the tummy and taking them with food helps make them easier to tolerate. Ask the pharmacist if there are any food interactions to pay attention to. Some antibiotics don’t interact well with very acidic foods such as grapefruit juice. Some naturopathic doctors suggest that green tea is a positive thing to drink when taking medications. Warning to women on birth control pills - while this is not universal, some antibiotics do interact with, and minimize the effectiveness of, the pill. Unplanned pregnancies have happened. Sometimes parents report a miraculous improvement after the first dose, but that isn’t typical. Although folks are considered to no longer be contagious after 24 hours of treatment, It can take several days before the patient starts feeling better. If 3 or 4 days has passed with no change, it is worth checking in with your doctor to make sure you are on the right medication. DON’T PARTIALLY TREAT The goal of the treatment is to knock out the bacteria. Stopping the medicine mid course may allow the hardier bacteria to develop resistance to future treatment. http://www.cdc.gov/getsmart/community/about/antibiotic-resistance-faqs.html If you start the treatment and can’t complete the course, confirm with the doctor that the infection you are treating has cleared up prior to stopping. PROBIOTICS The job of the antibiotic is to kill bacteria. Our body has a host of necessary good bacteria that might be caught in the crossfire. If this balance gets out of whack, issues like indigestion and yeast can occur. I think that taking a good probiotic while taking antibiotics is a good move. Do not take them at the same time as the antibiotic, but space them out.  If the antibiotic is twice daily, give the probiotic mid day. BRUSH TEETH Most antibiotic liquids are loaded with sweetener to make them more palatable (I wish that the sweetness was magic, many are still pretty nasty.) You can also ask the pharmacy to add a flavoring to help with compliance. It is essential to brush teeth after every dose. I have seen teeth get discolored when this isn’t done. ALLERGIC REACTIONS As my favorite allergist says, “not all drug rashes are created equal.” Anything that seems drug related and involves blisters should be seen immediately. These can indicators of serious complications. If the patient gets hives, that is a sign  of a classic drug allergy. With hives or blisters no further doses of that medication should be given. Less serious rashes are more common, but are still worthy of attention. Some patients develop a rash once they have been on the medication for several days (8 seems to be the magic number for some reasonand Amoxicilin seems like a frequent culprit for this.) This might be a T-cell mediated hypersensitivity. Some physicians feel comfortable completing the treatment as long as the patient seems comfortable, but anytime a patient develops a rash when they are on medication it is worth having them seen. Remember, they were on medications for a reason. We don’t want to simply stop a partially treated infection.The doctor can make the decision if the condition still needs treatment, in which case we will likely swap to a different medication. If you child has any type of rash, their chart should be flagged with an allergy alert. If this was a hive reaction, that medication should not be given again. If it was a non hive rash, it is possible that it can be tried again cautiously in the future. There does seem to be some family tendencies toward allergies but no firm rules.  It is important that parents keep track of allergies, and don’t count on a notation in their child's records. With multiple children in the family, many parents actually have a hard time keeping track of who is allergic to what. If you are traveling, you should know what your child should not be treated with. The travel doctor most likely won’t have access to your child’s history.

Achieving a healthy weight

Helping your child maintain a healthy weight is a goal that we all share.

In my solid foods class, one of the things I talk about is how important it is for you to help your child establish a healthy relationship with food. It is never too early to start.  

Don't push food. When you baby indicates that they are "all done", don't coax them to take that last bite or fuss over a clean plate. In order not to waste food, only give them a small amount at a time. Add more on request. Of course give them as much as they want (unless they routinely eat until they barf!)

Offer a wide assortment of healthy meals and snacks. Pinterest is a fabulous resource for creative ways to make food interesting and appealing. Most young children will eat what they want/need. If you have concerns about health or adequate weight gain, it is reasonable to check in with your doctor's office and see where they are tracking on the growth chart. We like to see the height and the weight increasing at a reasonably parallel rate. If your child seems happy, healthy and is growing well, please trust them.

Give positive feedback for trying new foods. (Click here to review my past post on picky eaters) I generally suggest allowing a reasonable amount of sweets (the definition of what constitutes reasonable will vary from family to family.)  I have found that kids completely banned from sugar love it all the more when they have an opportunity to get a hold of anything sweet.

That being said, Dr Kaplan thinks that every family should check out the online documentary called FED UP, which gives some disturbing information about how bad sugar is for all of us.

In our family we tried to stress "growing food first". Anything with some nutritional merit could fall into that category. Once your body had enough growing food, if there was room for something extra, that was fine. I would rather not to consistently set dessert aside as a reward.

In spite of our best efforts it is sadly typical in our society to have folks on either end of the healthy weight spectrum. On one end are the kids who are way too thin. While some completely healthy kids are genetically predisposed to be very thin, Anorexia and Bulimia are a real concern. It is real. It is rampant. It isn't limited to girls. If you have a child (teens and preteens are most at risk) who is losing weight and/or has any food aversions, it is easy to be in denial but please keep your antenna up and check in with your doctor's office.

In San Francisco, one resource The Lotus collaborative

offers free support groups every Sunday to patients and families who are dealing with  eating disorders.

On the other end of the spectrum are kids who are heavier than they should be. As much as we recognize the importance of healthy eating and getting more exercise, putting these things into practice can be a challenge.

Keep in mind that it is not unusual for kids to have a bit of "pre-puberty pudginess"

I generally don't like to focus on numbers. It also may feel like a veritable minefield opening up the weight discussion with your preteen or adolescent. I would make the focus on health for the entire family. Everyone would benefit from more exercise. The entire family will benefit from eating a healthy nutritious diet.

We are always on the lookout for local programs to support young children and families through this process. The ones that exist are expensive, have fairly long wait lists and require a significant time commitment. Therefore we were delighted when several years ago we found out about fabulous resource called Kurbo. This is an app that helps get the kids engaged in a healthy eating/exercise plan. The folks behind it started out with the Stanford weight loss program. They know what they are doing. The app is free, but to get the most out of this, you can sign up for some coaching. It is significantly less expensive than comparable programs. Even one month of the coaching can get you started on the right track.

The Kurbo folks wanted to share some articles on Kurbo kids & families. The first is about a family in Los Angeles whose young son was told by his doctor that he had to lose weight, and he has lost over 17 pounds on Kurbo.  The second is by the Editor of Parents Magazine who did Kurbo with his daughter.  The results: she lost weight, looks and feels better.  It is great seeing results experienced by these Kurbo Kids!

http://www.laparent.com/unique-health-program-appeals-to-digital-kids/

http://www.parents.com/blogs/parents-perspective/2015/03/11/news/my-daughter-eats-better-by-following-the-traffic-lightshttp://www.mercurynews.com/business/ci_30074298/palo-alto-based-kurbo-health-tackles-childhood-obesity

https://kurbo.com/blog/

   

If you are interested in checking it out, We have a promo code that will give you some savings: NoeValley (no space, capital N, capital V).

Here in the city, The Community Health Resource center offers nutritional counseling for all ages.
They are at 2100 Webster Street by the CPMC Pacific campus.
415-923-3155
This service is covered for Brown and Toland HMO patients.
For all others, they have a sliding scale fee schedule.
http://chrcsf.org/

If you don't mind traveling down to the peninsula, Stanford Weight control Program has some openings

http://www.stanfordchildrens.org/content-public/pdf/ppwcp-flyer.pdf

Vision Health/ when does your child need to see an eye doctor?

Please see the updated Post March 2018

Doing an eye exam on a young child can be challenging but more entertaining than you might think. I used to get a kick out of the creativity of some of the kids when I would point to a picture on the eye chart. A circle could be anything from a simple circle, to a zero, a bagel or a donut (my kind of kid), The crescent could be a moon or a banana. I fondly remember a little 4 year old who had just finished testing his first eye. He stood there with his hand over his right eye waiting for directions. “ Okay, great job, now cover your other eye” Without removing his right hand from his right eye, He quickly raised his left handup. He stood there for a moment with both eyes now covered before I figured out what was going on. Early intervention for eye abnormalities is very important. Parents are often the first to note if there is something abnormal going on. There are always individual variations with developmental milestones,  but many babies eyes don’t track too well until they are about 3 months. Once they are old enough, watch to see if they can follow an object with both eyes. If one eye wanders , that is something we want to get checked out. Check the pupil size. Are both the same? There are some kids with normal variations, but it is worth noting this ahead of time. I have had parents frantic after a mild head injury when the pupils were noted to be of mildly different sizes. It turned out that this was just the baseline. Noting it in advance would have saved some stress! If you take a photo with flash and there is “red eye” make sure the reflection seems to be equal in both eyes. Are the eyes watery or gooey? This could be a blocked tear duct. That usually resolves in a few months, without any intervention http://nursejudynvp.blogspot.com/2013/06/blocked-tear-ducts.html In our office we actually start doing eye screenings for our patients as early as 6.months. We can screen for a variety of abnormalities with our iscreen machine.http://www.iscreenvision.com/ Dr Good, one of our favorite pediatric ophthalmologists says he has been pretty impressed so far with issues that have been discovered early. While some of the conditions don’t actually require any intervention, having the patients identified so young is very valuable, because we can now know to monitor them closely Once the kids are four or five years of age and old enough to cooperate, we do the Snellen eye test. This screening for nearsightedness is usually  done in conjunction with the routine annual well child check up. The operative word here is screening. Farsightedness or astigmatism are usually not picked up without a full eye doctor exam. The gold standard recommendation  is a complete eye exam by an eye doctor at 3 and 5 years. At that point, the decision for how often routine exams are needed may depend on your child. Obviously if your child seems to be squinting it is worth getting them in sooner. There is a genetic component to eye issues, but kids should be checked even if the parents have perfect vision. What is difference/ need between ophthalmologist or optometrist for basic child eye health? Ophthalmologists are specialists that deal with the full range of eye care, but they are also surgeons who can deal with any eye abnormality or condition. Optometrists might be your best bet for any simple vision issues. Finding someone who regularly works with kids is pretty important. If there is a medical diagnosis some insurance companies will cover the cost of an eye exam. It is worth checking in advance with the eye doctor's office as well as your insurance or vision plan  to see if there is an advantage to seeing one or the other. I don’t think people necessarily need to add vision and dental plans for the kids the first year, but after that, especially if they come bundled, it is probably worthwhile. There are some common sense things you can do promote good eye health. Get outside! Of course, get in the habit of wearing sunglasses when outside during the day. Ideally they should be made out of a strong poly-carbonate plastic that is shatterproof. Floppy hats or visors are also a good idea. Recent studies show a 30-40% decrease in myopia (nearsightedness)  with daily time outdoors. Try to minimize the “blue lights” that we are surrounded with by screens in our world. The American Academy of Pediatrics recommends no more than 2 hours of recreational screen time/day. Eat well! Carrots and foods with Vitamin A are good, but the dark green leafy vegetables are the real super helpers of the eye because they have lutein and zeaxanthin (go ahead and impress people at your next cocktail party with that one) These two eye nutrients help replenish the pigment in the retina and can prevent diseases of the eye. Peppers turnips and paprika are also a good part of an eye healthy diet. Avoid smoking or exposure to secondhand smoke. If your child does need glasses, make sure they get their vision checked yearly (or more frequently as needed)  to make sure the prescription is correct. If the myopia is getting progressively worse, believe it or not multi-focal contacts may help slow things down. They can be started with some cooperative children as young as 5! You might not make an obvious connection but headaches, dizziness, motion sickness and ADD can all be associated with eye problems. I have sent more than one patient who were having trouble concentrating in the classroom to my favorite optometrist Dr Vincent Penza. The difference that he was able to make for them was astounding. http://www.city-optometry.com/team/vincent-penza-o-d/ Josie takes her son down to Dr Kim Cooper and loves the care she receives there Dr Cooper shares that her most important eye tip is the need for quality safety goggles. If your child is playing any sport where there is danger of getting hit in the eye by a ball or body part, they should be wearing eye protection. Not a week goes by that she isn't dealing with a sports related eye injury. Most are minor, but the serious ones are devastating. Her office happens to be great resource for getting quality goggles. In fact, they are having a trunk sale on August 1st. http://mypedeyedr.com/ Dr Cooper also told me about another good office. Dr David Grisham and Dr Jeremy Shumaker at Vision Academy and Rising Star Optometry are terrific and do see pediatric patients. http://risingstaroptometry.com/ Dr Good and Dr Martin are another office where we send a lot of our patients http://www.cpmc.org/dr-william-v-good.html Berkeley Eye Institute is a great resource. It tends to be lower cost because it is associated with the school. 510-642-2020 Fun Facts: You may not be able to know your child's ultimate eye color until they are a year! Your baby might be crying, but they usually don’t develop actual tears until they are between 4-13 weeks The eyes are the fastest muscle in the body and blink an average of 17 times/minute