Iris Kaddis Hanna, M.D., PAMF Pediatrics

The economic crisis, strife around the world, natural disasters and the latest celebrity scandal may feature big in the daily news but eavesdrop on any group of parents of preschoolers and one of the top topics under discussion will probably be – potty training! Questions abound from when you should start training to the best way to go about it. The most important thing for parents to know is that much like crawling or walking, potty training readiness is a developmental milestone. According to Iris Kaddis Hanna, M.D., a pediatrician at the Palo Alto Medical Foundation, every child will reach this step at a different age, when they are physically and emotionally ready to ditch the diapers and take the trip to the toilet. In this blog post, Dr. Hanna answers some commonly asked questions.

How can I tell if my daughter is ready to start potty training?

Most children will be ready for potty training sometime between two and four years of age but there are factors that are much more important than age.

Diapers may be on the way out if your child:

• Stays dry for at least two hours at a time
• Can follow simple instructions
• Is becoming uncomfortable with dirty diapers and wants them changed
• Goes and hides to urinate or have a bowel movement
• Asks to use a potty or the toilet
• Asks to use regular underwear

My three-year-old son is asking to use the potty. What’s the best way to start potty training?

Start by swapping the diapers with some thick cotton underwear that has several layers. Diapers are amazingly absorbent and your son needs to experience what it’s like to be wet to encourage him that getting to the toilet or potty will help him feel a lot more comfortable. Avoid pull ups as well, as they have the same absorbency as diapers and children can get very attached to them – especially if they picture a favorite princess or superhero!

If your son is showing signs of readiness, it’s an opportune time to prepare him by letting him see others using the toilet, introducing books or DVDs on the subject and talking to him about using the potty. Be encouraging and praise successes!

If your son resists, don’t insist. You don’t want toilet training to be a stressful time by pushing him too fast or punishing mistakes. Accidents and mistakes are bound to happen. Essentially, potty training should take one day, if you pick the right day. If it’s taking weeks, months or years, it’s likely that you are trying to make it happen before your child it ready.

My three-year-old daughter has been potty trained for a while but since her little baby brother came along she has been having accidents again. What should I do?

Any change, especially such an important one as a new sibling coming into the family, can make your child regress. These accidents can also occur because your child is seeking your attention. Remain matter-of-fact and give the accident as little attention as possible – otherwise she’ll learn this is the best way to get your full attention. Ask her to help you clean up the mess, then move on to something else. Praise her next time she uses the toilet in time.

My daughter is showing signs of being ready to use the toilet but is very attached to her diapers. What’s the best way to wean her from them?

Try the following four-week plan to ease her into toilet training:

1. Week one: let her wear a diaper but make sure she goes into the bathroom to get down to business.
2. Week two: allow her to keep the diaper on but encourage her to sit on the toilet or potty when she needs to go.
3. Week three: cut a hole in the diaper so that when she sits on the toilet to urinate or have a bowl movement this goes into the toilet.
4. Week four: graduate to underwear and using the toilet or potty.

Remember that although it might feel like your daughter will never let go of her beloved diapers, this is just a stage and she will soon much prefer regular underwear and using the toilet.

My five-year-old son never has an accident during the day but often still wets his bed at night. What should I do?

Night time dryness is a completely separate developmental milestone from daytime potty training that may take a lot longer to reach. Many children under seven still wet the bed at night and this is considered very much within the normal range. Simply continue to use a diaper at night to keep him dry. Children older than seven can use a bedwetting alarm that is triggered by moisture and wakes the child up, so he or she can get up and use the bathroom. Speak to your doctor if you are at all concerned about your son’s bedwetting but know that he will most likely outgrow this issue.

Iris Kaddis Hanna, M.D., a pediatrician at the Palo Alto Medical Foundation’s Mountain View Center, contributed to this blog post.

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Radiosurgery is a noninvasive treatment, where doctors use advanced technology to deliver a precise dose of radiation to a cancerous tumor – without having to cut into the body. Radiosurgery destroys the targeted area without harming the surrounding healthy tissue.  

“The technology allows us to track the patient’s position in real time – so we can be sure we’re hitting the target every single time,” said Pauling Chang, M.D., a radiation oncologist at the Palo Alto Medical Foundation. Another benefit for patients, Dr. Chang says, is the convenience of one-day treatment. “I had a patient who had radiosurgery in the morning, and was able to attend a dinner party that same night.”

PAMF is an early adopter of innovative technology – and was the first health care organization in the world to offer this new, precise, radiosurgery technology as part of its comprehensive Cancer Care Program. Learn more about radiosurgery and take a virtual tour with Dr. Chang in this video.

Watch Dr. Chang’s philosophy of care video.

Learn More About Radiosurgery:

What is Radiosurgery?

How is Radiosurgery performed?

Benefits and Side Effects of Radiosurgery Treatment

Overview of Radiosurgery on the International Radiosurgery Association Website

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“I get to be in people’s lives,” says Pediatrician Melissa Braveman, M.D. “Whether it’s in trying to continue in good health, or in illness trying to provide support and make sure that kids get the treatment they need. I also get to interact with parents and help parents find their way – no matter how little or much experience they have in parenting – or in life.”

Dr. Braveman looks forward to Halloween, where she occasionally shows up at the hospital as a ladybug. She creates stickers for the children, tells jokes and enjoys role playing. “It gets me up in the morning – I get excited to come and to learn about kids and be a part of their lives as they grow. I actually imagine myself here until the very end. If this is the last job as a primary care pediatrician, I’ll be thrilled.”

Dr. Braveman sees patients at the Palo Alto Medical Foundation in Santa Cruz. Learn more about her philosophy of care below, in this video which is part of a series highlighting the diverse voices of PAMF physicians.

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Betsy Franklin

“I could barely see,” says Betsy Franklin.

56-year-old Franklin was legally blind in one eye due to cataracts. And, because of a large amount of astigmatism, she also had to wear thick, uncomfortable glasses.

A few days before the Christmas holiday, Franklin went to see Yichieh Shiuey, M.D., her PAMF specialist in cataract, Lasik and cornea surgery, for a post-operative visit.

Two years previously, Dr. Shiuey had performed a successful corneal transplant on Franklin. But now a worsening cataract threatened to steal Franklin’s sight. “I recommended a new astigmatism-correcting lens that would permanently fix her vision as well as her cataracts,” says Dr. Shiuey.

Unfortunately, the special corrective lenses are not covered under medical insurance. When Franklin learned the cost, she told her doctor that she would have to do without. Determined to provide his patient with the best option possible, Dr. Shiuey waived his operating fee and convinced Alcon, the lens manufacturer, to do the same.

“I was shocked,” says Franklin.

Lens implants are regularly used in cataract surgery to restore the focusing power of the eye. Generally a 15-20 minute procedure per eye, the cloudy lens is replaced with a clear, artificial lens. But now, if the person also has an astigmatism, nearsightedness or farsightedness, using new intraocular lens implants, their vision can be corrected at the same time.These lenses are usually made of acrylic (a type of soft plastic) which is readily accepted by the body and last a lifetime.

Tiny incisions, about 2.5 millimeters long, ensure a quick recovery and most people return to their normal activities within several days. “Our success rate is really high,” says Dr. Shiuey. “Over 95 percent of our patients who get these types of lenses end up with vision that is 20/40 or better, which means they can legally drive without glasses.”

“My surgery took less than an hour, I was awake the whole time and there was no pain at all,” says Franklin. “I can’t believe the difference!” she says. “It was as if God had come and given me sight.”

Yichieh Shiuey, M.D.

“Betsy cried and gave me a huge hug,” Dr. Shiuey recalls. “Seeing her so happy with her new vision was my best Christmas present of all.”

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Allen Namath, M.D., a physician within PAMF’s Pulmomary Disease and Critical Care Department, has lived in the Bay Area for 40 years, which he feels keeps him connected to the community.

“When you know your grocer or the person that works at your gas station for 20 years, it does become personal and you do become attached to people,” says Dr. Namath in this philosophy of care video. “I take care of people who used to teach me when I was in school 20 years ago.”

Dr. Namath sees patients at PAMF’s Fremont Center. Learn more about his philosophy of care below, in this video which is part of a series highlighting the diverse voices of PAMF physicians.

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From the very first day he attended medical school, cardiology was a natural interest says Chad Rammohan, M.D., FAAC, an interventional cardiologist at the Palo Alto Medical Foundation’s Mountain View Center.

As an interventional cardiologist Dr. Rammohan performs minimally invasive procedures to improve his patients’ quality of life. “It’s really exciting being in the forefront of these cutting edge techniques and seeing how they help people every day.”

“I get to interact daily with people and share their experiences and stories,” says Dr. Rammohan in this video, which is part of a series highlighting the diverse voices of PAMF physicians. “The best part of this job is seeing people who are really sick get better quickly.”

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Ongoing Project Provides Insights into Best Breastfeeding Support for New Mothers

Knowing that breastfeeding is the healthiest choice for you and your baby is one thing – but what motivates moms to start and continue breastfeeding and what makes them stop? To learn just that and tailor our support for new mothers and their families, PAMF’s Education Division is conducting a large, ongoing survey of breastfeeding mothers called the Bay Area Breastfeeding Experience Survey (BABES).

The project, which follows BABES participants until they stop breastfeeding, has now been underway for two years. You’ll find the most recent highlights from the survey on our BABES website. Data is updated regularly by the team.

“PAMF is already a very strong advocate of breastfeeding and we have some wonderful services, classes and resources in place,” says Sally Twesten, a health education manager, who together with Nancy Brown, Ph.D., an education projects manager, and Leigha Winters, a research coordinator, directs the BABES team. “The findings from the survey will help us take the next step and further improve our programs and support for our breastfeeding families.”

“Although we have a small number of women participating in the survey and early conclusions may not be representative, we have already learned a lot from our project,” says Brown. “For example, we found out that pregnant women who know their obstetrician strongly recommends breastfeeding only, without adding formula, for the first year of the baby’s life are more likely to make that their goal. These new moms are also more confident they can do it.”

As well as the survey outcomes information on the BABES website, you can also take a look at the BABES findings summary that includes information of interest to the public and possible teaching opportunities for doctors and their care teams.

Almost 400 new moms have participated in the online survey so far.

BABES Is Still Looking for Participants

The BABES team invites all PAMF patients who are currently breastfeeding or are in the last trimester of pregnancy to take part in the BABES project. Find out more on the BABES website or call the hotline at 650-565-4474.

 “PAMF cares for 6,000 new moms every year – we’d love to have them all participate in this project and learn from their experiences,” says Brown.

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The Palo Alto Center Radiation Oncology Department’s three newest employees bring some very special qualities to work – gentle natures, soft fur and wet noses! Therapy specialists Sparky, Sunny and Wallie are the first three dogs who are part of PAMF’s Irene Davidson Animal Assisted Therapy Program that launched in January 2012.

Although Gordon Ray, M.D., medical director of the Palo Alto Center’s Radiation Oncology Department, had read about the benefits of pet therapy for cancer patients in scientific journals, it was a real live dog visit to his department that inspired him to start PAMF’s Animal Assisted Therapy Program.

“One of our patients had his service dog with him during an appointment,” says Dr. Ray who launched the program together with Tina Pierce, administrative director of PAMF’s Programs of Excellence; Inger Saxe, a director of  risk management and quality improvement; and Jan van Boeschoten, director of the Palo Alto Center Radiation Oncology Department. “I noticed the positive effect the dog’s presence had on patients in the waiting room. Patients were talking to each other more and the atmosphere seemed lighter and more relaxed.”

Wallie

Wallie, a cute-as-a-button poodle mix and the department’s first therapy dog, has been working his magic on patients for a couple of weeks now.

 “We have seen a strong attachment grow between some of our patients who specially request to see Wallie when they come in for treatment,” says Dr. Ray. “There’s also a real sense of joy when he is present during their follow up exams.”

Furry colleagues Sparky (beagle), Sunny (golden retriever) and Wallie currently hang out in the department’s patient waiting room several hours a week on Mondays, Wednesdays and Fridays ready to be stroked and petted. These specially certified pet therapy dogs come from the Peninsula Humane Society (SPCA) and Furry Friends who also train and provide the handlers who accompany the dogs to work.

“These are all quiet, well-behaved dogs,” says van Boeschoten. “They don’t jump up or lick, are very friendly and always happy to be touched and petted. Our department is very high-tech with big machines and serious treatments – the dogs offer a welcome distraction and help make the whole treatment experience less frightening.”

The department provides two waiting rooms so patients can choose a dog-free environment if they prefer. Staff also note in each patient’s record if they prefer the therapy dogs’ presence or not.

Sparky shares the love with a patient

Sunny brings his mellow disposition to work

The Animal Assisted Therapy Program will be offered in the Mountain View Center Oncology Department next month and at the new Sunnyvale Center when it opens in 2013.

The program was named after longtime PAMF patient Irene Davidson. Davidson was a radiation therapist and a strong believer in the positive role that animals can play in promoting wellness among cancer patients. She dedicated funds in her will to PAMF’s Animal Assisted Therapy Program.

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“You’ll often hear me say, ‘If I were you…,’ or ‘If this were me,’ – I put myself in my patient’s situation and try to live my advice,” says Ritika Aulakh, D. O., a family medicine doctor at the Palo Alto Medical Foundation’s Fremont Center. Dr. Aulakh is a doctor of osteopathy which means she has additional training in musculoskeletal care as well as being board certified in traditional medicine.

“The most rewarding part of being a doctor is the relationship I develop with my patients and the trust they give me,” says Dr. Aulakh in this video, which is part of a series highlighting the diverse voices of PAMF physicians. “Health is the most important thing in your life.  I look forward to seeing patients and finding out about their personal life and keeping up with their health.”

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Lauren Brave, M.D., Pediatrician, Palo Alto Medical Foundation Pediatric Urgent Care

A bump on the head is one of those painful yet common childhood experiences that can happen at any age – whether it’s the newly mobile baby rolling off the bed, the elementary school kid falling off the jungle gym, or the teenage athlete colliding with an opposing team member during a high school football game. Pretty scary stuff for parents – should you rush straight to the emergency room? If your child loses consciousness, even briefly, you should seek immediate medical attention. For many minor head bumps, however, careful observation of your child for the first 36 to 48 hours is the most important thing you can do. If you are at all in doubt, don’t hesitate to follow your instincts and consult your doctor.

My 13-month-old daughter has just started walking and has been close to falling and bumping her head a couple of times. If she falls and hits her head should I take her to the doctor?

New walkers, teetering near the sharpest corners of your furniture or on a hard concrete sidewalk, can be real heart-stoppers for parents. Fortunately, most baby head bumps are benign and your little walker will soon become steadier on her feet.

If your daughter does fall and bump her head, but is alert and responds to you, watch her carefully for the next 36 to 48 hours to see if any symptoms develop that could indicate a head injury. Changes to watch for include:

• Inconsolable crying
• Vomiting more than once
• Unable to respond to you
• Balance difficulties when trying to sit or walk

 As children get older, they may be able to share or you may notice the following symptoms:

• A sustained headache
• Slurred speech or confusion
• Dizziness
• Numbness or weakness in the arms or legs
• Amnesia from the event

If your child is exhibiting any of these symptoms, or has any significant swelling over the site of the injury, you should take her to the doctor.

If it is nap or bedtime and your daughter has none of these described symptoms, you can let her sleep, but check on her every two to three hours to make sure all is well. It’s also best not to give her any pain medication so that any pain or other symptoms are not masked.

My daughter fell off her bike and hit her head. Should she get a CT scan?

Getting a CT (computerized tomography) scan may seem like the best way to see what’s really going on inside your daughter’s head but it not always advisable as this does involve a dose of radiation which might not actually be necessary. Instead, your doctor will examine your daughter and ask about the specific symptoms she has. This is a much better indicator of how serious her head injury is and what treatment is best for her. CT scans are usually only administered for patients who are displaying symptoms that indicate a serious head injury.

My son hit his head on the goal post during a soccer game a couple of weeks ago. He’s still complaining of a headache. Is that normal?

Most likely, after this head injury, your son experienced a concussion. A concussion is actually a mild traumatic brain injury caused by an impact and the symptoms reflect this. Symptoms may include dizziness, nausea, fatigue and forgetfulness which can last anywhere from 15 minutes to a couple of weeks.

Recovery time from a head injury can vary greatly for each individual, so it is possible to still experience symptoms of a head injury long after the accident occurred. Children’s and teenagers’ developing brains, in particular, can take seven to ten days (or more) longer than an adult to return to normal after a head injury. Other possible head injury symptoms that can linger include being a little more tired than usual, more sensitive to lights, more emotional, or having trouble concentrating in class. Make sure that your son does not return to soccer before he is completely back to normal. After any significant concussion, a child should be examined by a doctor before returning to sports.

Although it is not possible to prevent all head injuries, there are several ways you can reduce the risk, including always having your child wear the correct protective gear (such as helmets and mouth guards) and knowing and adhering to the rules of the sport.

My 15-year-old son suffered from concussion when he collided with another player during a lacrosse game a couple of weeks ago – now the coach wants him back in the game. When is it safe for him to return?

It’s extremely important for him not to go back too soon and risk another head injury that could result in much more serious damage or, although rare, death. Just remember, ‘when in doubt, sit it out!’ The best treatment for concussion is rest from both physical and mental activity.

A child should never go directly back into the game after he or she has experienced a head injury and your son also shouldn’t return to sports until he is back to his baseline (his normal health before the injury). A five-day step-by-step progressive return to sports is now recommended by the American Academy of Pediatrics after any head injury. When your son is feeling completely back to normal and has no symptoms, he can increase his level activity, day-by-day in the following way:

• Day 1: light aerobic exercise such as walking or using a stationary bike
• Day 2: sport-specific drills and running drills
• Day 3: add drills that involve resistance
• Day 4: return to practice
• Day 5: return to game and full participation

Your son will need to complete each step without experiencing any symptoms before he can move on to the next step. If symptoms persist beyond 48 to 72 hours, he should be assessed by a doctor.

This blog post is contributed by Lauren Brave, M.D., a board-certified pediatrician in the Palo Alto Medical Foundation’s Pediatric Urgent Care Department.

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