A Pediatrician’s Survival Story: Remembering the Children

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pediatrician, pediatric residency, child death, infant death
Photo by geishaboy500, Flickr Creative Commons

I have just turned on my computer. It is midnight. I should be trying to sleep right now.

My 5 year old is sick and I am on call for the next few nights. Fortunately, my daughter should get better in a day or two. She needs Tylenol for her fever, mama’s love and time to kick this virus. But as I sat in bed holding her and waiting for her fever to break, the memories of other sick children started to come back. I completed my pediatric training over 10 years ago. I have repressed the memories of that time for so long now. Slowly, painfully they have started to come back. I lived a different life then, and it almost broke me.

I went into pediatrics because it was the only thing I was passionate about. When I entered medical school I was determined to do anything but pediatrics because I was so crazy about kids; I didn’t  think I could handle children hurting and dying every day. As I went through my rotations: emergency medicine, family medicine, obstetrics, surgery; I quickly learned that I was always drawn to the children. As it turns out I am amazingly calm under pressure, and the intensity of taking care of severely ill or injured children was something I was really good at. I ended up matching at my first choice program at the Children’s Hospital of the Kings Daughters in Virginia. Then my life took a detour.

My intern year I married and divorced. I married someone who was broken, but trying to put himself back together. And I was just starting to break. During that time I learned about how resilient a child can be, but I also saw the cruelty of cancer, AIDS, whooping cough, lupus, drownings, child abuse… The lack of sleep, unrelenting hours, and the pain and death around me took huge tolls on my mind and my body. I gained weight, I felt angry, I felt sad, I felt anxious, and I stopped crying my intern year. I finally ended up on antidepressants. On my rare weekend off I drank and danced until the wee hours of the morning. The day after residency ended I hopped on a plane to California. I left my memories and my medication behind, and my new life began. I was 30 years old.

It took a few days to start living and eating healthier. It took almost 2 years for the anxiety to dissipate. It was probably 3 years before I cried again.

My friends here don’t know the “before” me. I have never drank my sadness away here. I have never danced on a table to forget the pain. I am thankfully quite boring now. I run or hike almost every day. I am a loving mother and kind wife. I am a better daughter. I have thought for years about how much I disliked the person I became in training. But the truth was I was a survivor. I always have been and I always will be. I believe I am strong enough to let the memories come back now. I can picture some of the kids faces now. I can hear their words. I remember hugging them. But I still can’t picture the parent’s faces. As a mother there is a limit to how much pain I can process. The pain of a parent losing a child is too personal. Maybe that memory will come back in another decade. I kind of hope it doesn’t.

When I started writing this I thought I would share some of my memories of the tragedies I experienced within the walls of that hospital. It turns out that they are still too personal for me. It is enough for me to know that I remember now. And I am better now. As for the parents of those children lost, please know that everyone who cared for your child was forever changed by the experience. We loved them too. Pediatricians did not choose this field of medicine for money or for glory. We chose this field because we wanted to heal children. There is a part of us that breaks every time that we can not. I may not always remember, but I will ultimately never forget.

Previously published on KevinMD.com, February 22, 2014

I want to thank my strong and compassionate friend Sheila Cason. She first wrote about her experiences on her blog, DrCason.org, years ago. Many of her memories were also my memories. I just wasn’t ready to face them yet.

I would also like to thank Dr. Nadia Wasylyshyn at the Children Hospital of the Kings Daughters. She was a great source of support for so many of us through those tough years. The high rates of depression and burnout are well documented for physicians in training. It is so important to find someone to talk to.

Parenting MD: Guide to Baby’s First Year

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This book, written exclusively for e-readers, is filled with straightforward and up to date information to guide you from preparing for your baby’s birth to celebrating her first birthday.

The ebook format includes links to useful resources within the book and online.

Quickly access helpful information about feeding, sleeping, development, and common ailments, as well
as a glossary of terms and conditions.

Every day, research continues to expand our knowledge about keeping our children safe, healthy, and thriving. The information and recommendations contained in this book are based on the most current evidence available. Printed books can take years to get to publication, and medical knowledge and safety recommendations often change before the book even hits the shelves. This electronic format allows the reader to have access to the information within days of the final edit. Dr.Raja will also provide periodic updates to the ebook for free. Subscribe to ParentingMD.com and follow Dr.Raja on Facebook to find out more.

10% of proceeds will be going to St. Jude Children’s Research Hospital

 

Fiber: It’s Not Just for Pooping

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Photo by Aaron McIntyre, Flickr Creative Commons

Photo by Aaron McIntyre, Flickr Creative Commons

A recent study from the University of Minnesota found that only 3 percent of American children and 8 percent of adults are getting the amount of fiber recommended per day by the U.S. Department of Agriculture and Department of Health and Human Services.

Why do we care?

High fiber intake has been shown to lower risk for heart disease, stroke, high blood pressure, high cholesterol, diabetes, and obesity. It is also great for pooping.

How much should my child get?

This really depends on his age and energy requirements. The basic formula is 14 grams of fiber for every 1000 kcal consumed. This equates to about:

19 grams for a toddler
25 grams for a preschool through elementary school aged child
26 grams for a middle school aged girl
30 grams for a middle school aged boy
29 grams for a teenage girl
38 grams for a teenage boy

This really means feeding your kids at least 5 servings of fresh fruits and vegetables each day, as well as beans, nuts, and whole-grain breads and cereals. Cereals should have at least 3 grams of fiber and less than 10 grams of sugar per serving.

What specific foods are high in fiber?FiberTable

Can I get enough fiber on a gluten-free diet?

Yes, but… gluten-free often means fiber-deficient unless you pay close attention to what you are eating. A gluten-free diet that includes plenty of fruits, vegetables, nuts, seeds, and beans can be sufficient. This can be hard to achieve with a carbo-crazed toddler. Children are better off eating multigrain cereals and snacks instead of gluten-free puffs of nothing (unless they have true celiac disease).

References

Nutr Rev. 2009 Apr;67(4):188-205. doi: 10.1111/j.1753-4887.2009.00189.x. Health benefits of dietary fiber. Anderson JW, Baird P, Davis RH Jr, Ferreri S, Knudtson M, Koraym A, Waters V, Williams CL.

American Heart Association

Mayo Clinic

7 Signs That You Did NOT Have the “Flu”

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Photo by CMRF Crumlin, Flickr Creative Commons

Photo by CMRF Crumlin, Flickr Creative Commons

Whenever I talk about influenza I am told stories about the horrible stomach “flu” someone had the previous week. I agree the stomach “flu” is horrible, but it is not influenza. It should be called a stomach virus or a stomach “bug”. The term stomach “flu” confuses everyone and likely will for years to come.

You probably did NOT have the real “flu”, meaning influenza if ….

1- you were able to get out of bed

2- your symptoms came on gradually

3- your main complaints were vomiting or diarrhea

4- you did not have a cough or sore throat

5- you did not have a fever (greater than 100 fahrenheit)

6- your body didn’t ache from head to toe

7- you were better in 2 or 3 days

There are over 200 viruses that cause bad colds, and almost as many that cause the stomach “flu”. These are not influenza. Influenza is an illness you remember 20 years later. Influenza hits you like a ton of bricks and knocks you down for at least a week. The influenza virus changes so much from one season to another. Some years it is mild, meaning not as contagious or as life-threatening, and some years it is severe.

This year influenza is severe. It is hitting the young and the healthy. 50 young people have died in California this past week, and 50 more died in the week before that. I have not cared for any kids with influenza on my pediatric unit this season. They all bypassed me and were flown to the nearest pediatric ICU. They were all critically ill.

If you think you have influenza it is best to contact your physician within 24 hours. There are antivirals that can help, but they are most effective if started within 48 hours of symptoms. And remember: It is not too late to get your flu shot. Influenza will likely stick around until April or May.

For more information go to: flu.gov

“Prevention is better than cure”- Elizabeth Blackwell, first woman physician in the U.S. and the U.K., 1849

Photo by Future Atlas, Flickr Creative Commons

Photo by Future Atlas, Flickr Creative Commons

Naturopathic cures for the common cold?

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opiumAs a pediatrician I have come to realize that I don’t always get the whole story when I see my patients. Teenagers will often deny that they smoke (because pot smoking is not smoking, right?), and parents will often deny that they are giving their toddlers medications (because over the counter meds or homemade remedies don’t count, right?). I have learned to ask the same question multiple ways if I am concerned. Parents, unlike some of the teens, are not trying to withhold information. It is usually because the vaporub or herbal remedy seems risk-free or unimportant. I hope it is never because they believe I will disapprove of more natural remedies.

The truth is I am a “naturopath”. I believe in our body’s natural ability to fight off infections and heal itself. I believe in the power of good nutrition, exercise and balance. I do not prescribe cold medicines or antibiotics for viruses. But I have also lived and worked in places where modern medicine is not available. I have seen many children die. Thankfully, modern medicine (antibiotics, chemotherapy, vaccines, screening labs) continues to save the lives of millions of children around the world. I also get to see this every day.

My own children are fully vaccinated. My own children have had antibiotics (once each) for bacterial infections that would have otherwise put them at great risk. My children have had Tylenol and Motrin when they had a fever or were in pain. But mostly my children have had salt water (saline) for their snotty baby noses, honey for coughs (over 1 year old) and chicken soup for their colds. I have spent many nights holding my babies in my arms while they ran fevers or coughed incessantly for hours, but I knew nothing but time would cure their viral illnesses. I so desperately want to fix every hurt but most importantly I need to …. DO NO HARM.

This means I do not use vaporubs (menthol and camphor) or essential oils for my kids. I do not give them alcohol baths for fever. I do not give them herbal remedies or teas. I do not give them antibiotics for viruses, and I do not give them cough or cold medicines. These are the risks:

  • Menthol and essential oil rubs can actually worsen respiratory distress in young children.

  • Alcohol baths can lead to alcohol poisoning, seizures, or death.

  • Herbal supplements are not FDA regulated and up to ⅓ of them don’t contain any of the ingredients listed.

  • Numerous studies have found high levels of lead in tea leaves.

  • Thanks to vaccines, the majority of infections today are viral and antibiotics will not help.

  • Over the counter cold medicines have shown no benefit to kids under 6 years old and they can cause dangerous heart arrythmias in young children.

I have an amazing cousin who is the mother of a very cute one year old. She is a wonderful, very intelligent, and caring mother. Thanks to her great questions and Facebook posts, I continue to learn what she and other parents are trying to help their little ones get through the toughest nights with their sick babies. I continue to research every remedy that it is proposed to find out…. what are the risks? what are the benefits?

In the past, people have tried whiskey, cocaine, and opium (called Svapina in the ad above) to relieve a child’s cough. The truth is, medicine is constantly changing and we can all learn together. Talk to your child’s doctor about what you are using for your kids, or what your friends have tried. Give them the chance to learn from you or to teach you about potential risks. We all want our kids to be safe and healthy. There is no better common goal.

To find out more about complementary medicine practices (both safe and unsafe) please go to the National Center for Complementary and Alternative Medicine.

Would you buy a car without seat belts?

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tvBuy a car without seat belts? Probably not. But this holiday season millions of TVs, appliances and furniture are being purchased without safety straps.

Every 3 seconds a child in the U.S. is injured by a falling TV, appliance, or piece of furniture. Every 2 weeks one of these children dies. Every 2 weeks.

As a pediatrician I once tried (and failed) to save a child who was crushed by a falling TV, and I cared for another child who had permanent brain damage from a falling TV. These two children have been a driving force in my focus on safety education. This holiday season please keep safety in mind in your own home, as well as the homes of family and friends that you may visit.

I live in earthquake country so one of the first things we did in preparation for our new baby was strap everything down (in our house and the grandparent’s). There are earthquake straps available in hardware stores throughout the country because the greatest risk is not an earthquake. The greatest risk is a toddler who climbs everything in her path, a preschooler wrestling with a sibling, or a young child trying to turn on the TV.

You wouldn’t buy a car without seat belts. Why would you buy a TV or dresser without safety straps?

For more information:

TV

 

 

Fever Phobia

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sick childTrue confession: I don’t have a thermometer…. or at least I have no idea where it is. The truth is I haven’t used one since my youngest was 6 months old because I didn’t need it. A fever is many things (uncomfortable, dehydrating), but a fever itself is not dangerous. So why do doctors and nurses always ask you, “how high was his temperature”? Because many times families report a fever when a child’s temperature is 99 degrees fahrenheit. Everyone’s temperature varies greatly throughout the day and the definition of a fever is a temperature of 100.4 fahrenheit or greater. Your child’s doc only wants to know that because a true fever is a sign that your child is fighting a viral or bacterial infection. Here are some facts about fever that you may find helpful:

1- Fever is your body’s way of raising your internal temperature enough to kill whatever virus or bacteria is attacking you. Your body is brilliant and this is a completely normal response.

2- A fever is always an emergency in a child less than 3 months old. Children this age can still have infections that they picked up in the womb (like GBS or HSV). They can also have a urinary tract infection that can quickly travel to their bloodstream or spinal fluid (meningitis). This is because the barrier between their blood and spinal fluid is still very permeable at this age.

3- The only accurate way to check a temperature in an infant less than 1 year of life is using a rectal thermometer. There are NO other thermometers as accurate in this age. It should be digital, not glass and not mercury. Newer studies have shown that temporal artery thermometers can be used in infants over 3 months old.

4- A fever can NOT cause damage to your child’s brain, even at 105 degrees! Hyperthermia (body temperatures over 107) can cause brain damage or death, but extremely hot environments, not infection, cause this.

5- Height of a fever does not help us determine if the cause is viral or bacterial.

6- Teething does not cause fever.

7- Although a fever is not dangerous, it can make a child very uncomfortable and unwilling to drink fluids. Using acetaminophen or ibuprofen at appropriate doses for your child’s weight is the safest treatment. Aspirin and alcohol baths or rubs are not safe. There is also no reason to put your child in a cold bath.

8- Almost 5% of young children will have a febrile (fever) seizure. The seizure itself is terrifying to watch but this type of seizure is not dangerous. Treating a fever will not prevent a febrile seizure.

Bottom line:

If your child is over 4 months old and fully vaccinated, a fever alone is not a reason to worry. Everyone looks and feels crummy when they actually have a fever. If your child is still playful when the fever comes down that is a very reassuring sign. If your child is dehydrated, lethargic, has a rash, seizure, trouble breathing, or scares you in any way call your doctor or seek medical attention immediately. If your child has been running a fever for a few days then you should also call your child’s doctor for recommendations.

Is Swaddling Risky?

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SwaddleAs new parents we are always looking for ways to get through the toughest first months with our newborns. How can I get my baby to sleep better? How can I get my baby to stop crying? There are a million answers to these questions: gimmicks, gadgets, and folklore that promise to solve all of these normal baby problems. The bottom line always comes back to time. Give it time and your baby will develop the ability to soothe herself. Give it time and she will learn to fall asleep on her own. In the meantime how do we, as sleep deprived parents, manage to get through these months?

When my oldest was 5 weeks old and in the peak of her crying (and mine) and sleepless nights, we watched The Happiest Baby on the Block by Harvey Karp, M.D. His tips on soothing a crying baby gave us hope, and swaddling was the one recommendation that proved to be the most effective for us. It wasn’t that we were able to stop her from crying every time; what he gave us was another tool to put in our new baby survival toolbox. It was something to do. It was a glimmer of hope. It was not a cure for her crying every time, but it was a cure for our sanity. But….. is swaddling safe?

There have been numerous studies looking into the risks of swaddling. This is what we know today:

  • Swaddling does NOT increase the risk of SIDS when a baby is placed on his back to sleep. In fact two studies have shown a decreased risk of SIDS in babies swaddled when sleeping on their backs.1,2  It is important to stop swaddling him when he is able to roll over onto his stomach, because a baby swaddled in the prone position (face down) is at greater risk for suffocation or SIDS. Some babies can roll over on to their stomachs by 2 months of age.

  • Swaddling CAN increase your baby’s risk of hip dislocation or dysplasia IF done incorrectly. If you swaddle your baby correctly her legs should still be able to bend up and out at the hips. Click here for instructions on how to do a “Hip-Healthy Swaddle”.

  • Swaddling CAN comfort a crying baby and DOES help babies sleep. The key to swaddling is to keep his upper body secure. This will prevent his Moro or startle reflex from waking him up. It also mimics the snug and secure environment he had in the womb.

The bottom line: swaddling is a safe and incredibly useful way to comfort a baby and help her sleep. Just make sure you do it correctly and keep your baby’s sleep environment free of loose bedding, crib bumpers, stuffed animals, bags or pillows.

Do you have any tips that helped your baby stop crying or sleep better at night?

References

1  Factors potentiating the risk of sudden infant death syndrome associated with the prone position. Ponsonby AL, Dwyer T, Gibbons LE, Cochrane JA, Wang YG. N Engl J Med. 1993 Aug 5; 329(6):377-82.

2  Clothing and bedding and its relevance to sudden infant death syndrome: further results from the New Zealand Cot Death Study. Wilson CA, Taylor BJ, Laing RM, Williams SM, Mitchell EA. J Paediatr Child Health. 1994 Dec; 30(6):506-12.

Snot-Nosed Kids

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A child Cleaning her nose with TissueDid you know that on average kids get 10-12 colds per year? A cold can be anything from a snotty nose for a day to a full blown fever, aches, congestion, wheezing or cough. The cough from some colds can last up to 4 weeks. For my littlest one this meant her first two winters pretty much involved about 5 snot free days! Here are some common questions parents ask me:

What is a cold?

     A cold is an upper respiratory infection that can be caused by any number of viruses (over 200 different ones and counting). It causes inflammation and swelling of the upper airways that can give you a fever, headache, muscle aches, congestion, cough, sneezing, sore throat and sometimes trigger wheezing. Antibiotics kill bacteria only so in this case they will NOT help.

What is bronchiolitis?

     Bronchiolitis is basically a cold (same viruses) that moves into the small airways of infants and young children. RSV (Respiratory Syncytial Virus) is most notorious for causing bronchiolitis in the winter, but again there are hundreds of viruses that cause the same symptoms.  The airways of infants are smaller than older kids or adults so the mucus and swelling can cause significant difficulty with breathing or feeding. Young infants, or children exposed to secondhand smoke, are often hospitalized with bronchiolitis if they have significant trouble breathing or get too dehydrated.

When should I seek medical attention?

     If your child is having trouble breathing, wheezing, is not drinking well, or has decreased wet diapers, then you should call his doctor. A fever lasting more than 3 days, severe headache or ear pain could be indicative of a secondary bacterial infection and should be evaluated as well. The color of his snot is not important and really tells you nothing.

How can I prevent them?

    Wash your hands and stop touching your face. An average person touches their face over 5,000 times a day! Obviously these are hard things to enforce for a young child, but if you at least get them to wash up before eating then you are doing better than most. For infants less than 6 months old it is really helpful to try to avoid being around others with snotty noses, fever or cough. You still want to get outside, but in cold and flu season it is best to keep strangers and sick people from touching your child. Most viruses are transmitted by direct contact only, but a few can be transmitted through the air a few feet away.

How do I treat a cold?

     Grandma was right. Chicken noodle soup is still about the best thing we have. A study out of the University of Nebraska Medical Center actually showed that there are some anti-inflammatory properties in chicken noodle soup. It is not clear whether there is any noticeable reduction in cold symptoms, but it is a safe option to try. Most of us still need to rely on acetaminophen or ibuprofen for real anti-inflammatory effect and pain reduction. Most important, you need to make sure your little one keeps drinking (and peeing). Saline drops and gentle bulb suctioning can be helpful to clear out little noses and make breastfeeding or drinking a little easier. Over the counter cold medicines are NOT effective for infants and toddlers and they have too many potentially dangerous side effects. Honey can be a helpful cough suppressant to try once your child is over a year old. We used it so often for E’s second winter I was afraid her baby teeth might rot out! She slept better so it was a risk I was willing to take.

Could it be allergies?

     If your child is under 2 years old the answer is usually no. It takes multiple exposures to develop an allergic response to environmental allergens. For plants, grasses, and tree pollen these exposures are usually seasonal so an allergy would be uncommon before 2 years old. Indoor allergens can be present year round so these can develop sooner.  If your child has a stuffy nose, watery or itchy eyes, frequent nose rubbing, snorting, or sneezing that doesn’t resolve in a few weeks then it could be an allergy. Mold, dust mites, pet dander or smoke can be frequent culprits. If you are concerned then please talk to your child’s doctor.

Could it be a sinus infection?

     Kid’s sinuses are not fully developed until they are teenagers. This makes sinus infections less common in young children. Even so, cold viruses cause swelling and inflammation of the upper airways that can prevent even a child’s sinuses from draining well. This can cause bacteria to flourish in the sinuses. In this case antibiotics are appropriate. A severe headache, cold symptoms that last over a week, fever lasting more than 3 days, fever with facial pressure, or swelling around the eyes can all be signs of a sinus infection.

Do you have any advice from grandma or home remedies that may have worked for your family? If you do please share them. I would love to research them and share with you what I find.

Having “the talk”

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Talking to kids about stranger danger, safety, and sexual abuse

Thankfully my girls are still little enough that “the talk” is not about SEX but rather about SAFETY.  Last week I had a really Bad Mommy moment. Apparently the kindergarteners were getting out of school early and I had missed the memo. Unfortunately my daughter’s teacher released her out into the play yard without noticing that I WAS NOT THERE! She then locked the classroom and left. Although I have played the “what if” game in my head a hundred times since then, it all turned out fine. One of the daddies, a good friend, was out there with his son and noticed her alone. He called me and thankfully grandma was able to rush over immediately and save the day. Yikes. The rest of that day I kept wondering: Was I teaching my daughters enough to protect them from others who may try to harm them?

There are so many safety issues that go through my mind everyday. At the hospital I see babies who have fallen off beds, toddlers who have swallowed grandma’s pills, preschoolers who have been crushed by a falling TV, and helmetless teenagers who have fallen off their skateboards. The list goes on and the memories of these kids have turned me into a neurotic safety freak at home. Thankfully I have not seen or known anyone whose child has been abducted. I would have really fallen apart last week if I did. According to the US Department of Justice “there are about 115 stereotypical kidnappings, defined as abductions perpetrated by a stranger or slight acquaintance and involving a child who was transported 50 or more miles, detained overnight, held for ransom or with the intent to keep the child permanently, or be killed”. More children actually died from  chicken pox in the U.S. each year until the varicella vaccine became available. The news media has not made us fear chicken pox, but watching CNN will give us nightmares about losing our babies to a stranger. The crime numbers that we should probably pay more attention to are the statistics on sexual abuse. Nearly 25% of all girls and 15% of boys in the U.S. will be sexually assaulted or abused. Look around your child’s classroom. That is 1 in 4 of those girls and 1 in 6 of the boys. Depressing stuff.

The good news is that we can better protect our children from others who may harm them by educating ourselves and educating them. This is what you can do:

  • Talk about it! From the time my girls were toddlers we talked about who should be changing their diapers, and why other people should not touch or look at their “private parts”. I want them to be proud of their bodies. I want them to streak through the house squealing after baths. But I also want them to know that their bodies are their own. No one else has a right to touch them or hurt them. It is important to let your child know that other people should not be asking your child to touch them either.  Using correct anatomical terms will help them explain and understand the concepts better. I talk to every child I see about this in the office before I examine them.
  • Teach your children about good secrets and bad secrets. Good secrets would be something like a surprise party or present. Bad secrets would be anything that makes your child feel sad, guilty, or anxious. These are secrets that have to be shared with a trusted adult.

  • Give them “what if” scenarios. “What would you do if mommy was in the shower and someone knocked at the door?”; “What would you do if someone approached you and said mommy was hurt and they needed to take you to her?”; “What would you do if someone lost his puppy and asked you to help find it?”; “What do you do if an adult you don’t know pulls up in a vehicle to ask you a question?”

  • Read books about stranger danger and safety. We have a Winnie the Pooh book that the girls love. We read it over and over again and talk about what Piglet and Pooh learned from Christopher Robin. If you engage a child’s imagination then she is more likely to remember the lesson you are trying to teach her.

  • More tips: teach your kids your address and phone number, teach them how to call 911, label their clothes with your phone number, do not let your child use a public restroom alone.

Resources

National Children’s Alliance Child Abuse Resources

The National Center for Missing and Exploited Children