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Daily Dose

Pregnancy & Sleep

1:15 to read

Why is it that as you get further into your pregnancy you sleep less?  I am sure that it is just a factor of being “bigger” and as one mother said to me, “having another human inhabit your body”. It is often hard to find a comfortable position to sleep in, and even if you do, the baby may not want to stop moving when it is your bedtime.

But, I also really think this is all in God’s plan to get a mother (and father who often says his wife keeps him up) ready to be new parents. It is just foreshadowing of the weeks to come when you bring that newborn home from the hospital.  You have already learned to “survive” with less sleep.

The first few weeks at home with that most precious baby is really just about survival. I don’t care what you read or how many classes you take...there really are no “rules” or “tricks” to get thru the first 6-8 weeks of being a new (or seasoned) parent.  

I tell my parents the only “rule” is that the baby MUST sleep on their BACK..other than that try to do the feed, play, sleep routine that you think will just happen, but know at times your baby just does not want to go to sleep when you want them to!! They are not abnormal and you are not a “bad” parent.....they are just newborns with developing brains and sleep cycles. I promise, this too shall pass and longer sleep cycles will come.

So, if you are awake one night toward the end of your pregnancy and reading this, look at the bright side.  Your body is just getting you even more prepared to be a “great” parent....you already know how to survive with interrupted and less sleep.      

Daily Dose

Fussy Babies

1:30 to read

I have written a lot about fussy infants, spitting up and gastro-esophageal reflux (GERD). The diagnosis of GERD in infants in the past 10 - 15 years has soared….especially in irritable infants some of whom arch their backs and act as if they are uncomfortable while feeding (both breast and bottle fed babies) and spit up frequently,  to those who are diagnosed with “silent reflux”. 

 

When new drugs came to the market for adults with GERD, initially H-2 blockers like Zantac (ranitidine), Pepcid (famotidine) and Axid (nizatidine) they were soon prescribed for children as well. These drugs were followed by the introduction of proton pump inhibitors (PPI) which also inhibit gastric acid production, and include Prevacid (lasoprazole), Nexium (esomeprazole), and Prilosec (omeprazole).  Suddenly, younger and younger children were being placed on either H-2 blockers or PPI’s and many of these prescriptions were being written for infants under 6 months of age.

 

Being a pediatrician who had practiced for a long time and also had a incredibly fussy, irritable and colicky baby myself….I could never really decide if these drugs worked well or if “we” wanted them to work. There were some cases where it was quickly evident that the baby’s symptoms improved, while in many others the parents “were not sure”.  But, the use of these drugs has soared.

 

I have more and more young parents who want to start medication within their baby’s first month of life…”just because they are fussy”.  But there are new studies showing that the use of these medications in young children, especially those under one year, may have lasting side effects including an increased risk of fractures. In a retrospective study looking at over 850,000 children born between 2001-2013, those prescribed PPI’s had a 23% increased risk of fractures and those prescribed H2 blockers had a 13% increased risk while those prescribed combination therapy had a 32% increased risk of fractures. The risk also increased if children took these medications before 6 months of age, and there was also increased risk for those who used medications for longer periods of time.

 

Take home message for both doctors and parents….if these drugs need to be used it is preferable to limit it to one type, preferably H2 blockers and for the shortest amount of time possible. The use of other remedies including herbal remedies, thickening of feeds and probiotics should be first line treatment. When symptoms persist or are worsening and GERD is suspected, a 2 week trial of medication may be considered with ongoing discussion as to improvement in symptoms. Use the lowest dose for the shortest period of time as well.

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Daily Dose

A Baby's Neck Issue

1:30 to read

Torticollis is becoming more and more common and it may be related to several different things. Torticollis is defined as a “twisted neck”, or as my grandmother used to say, a “wry neck”.  Most of us have experienced a tight neck after a bad night’s sleep, and you can hardly turn your head to back out of the garage it is so painful, but be reassured your baby does not have any discomfort, but will just hold their head somewhat “tilted”.

A baby’s 40 weeks spent in utero may cause some positional deformities of the head and neck.  Due to the intrauterine positioning a baby may “favor” turning their head to one side rather than another. At the same time back sleeping which is recommended for all babies, may also contribute to torticollis.  

In order to help the baby resolve the tightness in the neck which is actually due to the sternocleidomastoid muscle being tight, your doctor may have you do several things early on to help stretch the neck muscle.  

If your baby prefers to look to the right they have left sided torticollis. In this case turn your baby in the crib so they have to turn to the left to look out (they don’t want to face a boring wall). When you are feeding them have the bottle on your right arm. When changing diapers, place the baby so that they have to tur left to see you.  Hold the baby on your left hip as well and burp them on your right shoulder. All of these strategies will help to stretch the muscle.  On top of this the baby needs to have tummy time, when awake, and work of having them turn to the left during this time too. Lastly, do gentle neck stretches 3-4 times a day and massage the tight muscle.  

If your baby prefers to look to the left also called right sided torticollis, reverse the above.

Your baby should continue to work on stretching so that their head will also not get flattened on one side or another, which is called plagiocephaly.  By continuing to have tummy time and neck stretches, most cases of torticollis will resolve. In severe cases or when you don’t feel that the baby is improving,  ask you doctor about the possibility of physical therapy.

Daily Dose

When Is The Best Time To Potty Train?

1:30 to read

Every parent wants to know, when is my child ready to potty train? A study that was recently published  in an issue of the Journal of Pediatric Urology is one of the first to show that timing of potty training children seems to be more important than the technique.

I found this quite interesting as the lead author, Dr. Joseph Barone stated, this is the first study “that gives parents an idea of when it’s a good time to toilet-train”.  The best time to potty train has typically been thought to be somewhere between the second and third birthday, but that is a wide range. This study suggests that age 27-32 months is the appropriate time to move a child out of diapers. In the study, children who were toilet trained after 32 months  were more likely to have urge incontinence, and problems with daytime wetting and bedwetting when they were between the ages of 4 and 12 years. This data was gathered from a retrospective study of children who were being seen by pediatric urologists for problems with urge incontinence (daytime wetting episodes) and their answers to a questionnaire on when they started potty training and what method they used, was compared with children who did not have urge incontinence.  The results showed that the mean age for  children with the wetting problems to have been trained was 31.7 months while those children who did not have problems were toilet trained at 28.7 months. 

Potty training continues to be at the top of the question list for parents with toddlers. I still believe and this study tends to support that children who are potty trained younger seem to have “less issues” than those that are older. That is not meant to say that your child will be potty trained by 28.7 months, but in most cases if you begin discussing the potty and following a child’s cues and follow through with reinforcement and consistency that the majority of toddlers may be potty trained by age 2 ½  (which would be 30 months). In my experience as both a mother and pediatrician, those toddlers who are put in pull ups and never asked about going to the potty or are not taken to the potty seem to be the ones that I see at 3 year old check ups still wearing their pull-ups. By this time if you ask them if they want to go potty they all say, “NO”.  I believe this is termed “the child directed approach” which seems analogous to me as saying “what time do you want to go to bed?”

In most cases, if a toddler is introduced to the toilet, goes with their parent to “sit or practice or watch Mommy and Daddy potty” during the early 2’s, and given some incentive to perform, whether that be a sticker or M & M or both,  they will become interested in the potty and then they will become ready to potty train. I guess this is a combination of both the parent directed and child directed approach. Once you see your child is interested you have to “go for it” and put them in good ‘ole cotton training pants and go to the bathroom frequently. You can’t ask if they want to go, again it is a statement, “time to go potty” and most will be trained by the “magical” 27-32 months of age. To me potty training is somewhat like a space shuttle launch. “The window is not that wide” and you have to potty train during that magical window or the launch window may not come around again for a long time!

That's your daily dose. We'll chat again soon.

Daily Dose

Why Babies Develop Jaundice

It is not unusual to see a newborn appear slightly jaundiced during their first week of life.

I received an email via our iPhone App from a mom who asked "why babies get jaundice and why we check a bilirubin level on newborns?"

Most babies will develop physiologic jaundice (noted by yellow discoloration to their skin and whites of their eyes) due to the fact that a your-baby's liver is still not working at full speed when first born. Bilirubin, a breakdown product of the red blood cell, is metabolized through the liver. It is also excreted in the stool, and the young newborn is just getting all of those organ systems up and running in the first 24- 2 hours of life. As cute and snuggly as a brand new your baby is, it does take a few hours to days for everything to ramp up to full working speed. So, it is not unusual to see a newborn appear slightly jaundiced during their first week of life, and how I learned with my own first child, yellow is not a good color on most newborns. Stick with pink and blue. Sometimes babies will develop higher bilirubin levels than expected, (numbers in the teens) and depending on how old they are may require phototherapy to help breakdown the bilirubin. You might have seen those babies basking under the glow of "sunlamps" wearing your-baby sunglasses. The blue lights breakdown bilirubin in the skin. Excessive bilirubin can lead to a condition called kernicterus, and may actually cause brain damage. By following an infant's bilirubin levels and treating promptly you can avoid this, and I have never seen an infant develop kernicterus. Your pediatrician will discuss bilirubin levels with you while you are in the hospital with your newborn. If they don't bring it up, typically there is nothing to worry about. If you have concerns, you should ask. If your your baby seems to be getting more jaundiced once you are home, give your doctor a call, it may mean they need to have another bilirubin level drawn as occasionally a your-baby will develop more jaundice once they have been discharged. That's your daily dose, we'll chat again tomorrow. Send your question to Dr. Sue!

Daily Dose

Staph Infections Often Appear Quickly

1:30 to read

There has been a lot of questions lately about staph skin infections.  In fact, I am typing this just after seeing one of my patients with a fairly “classic” staph infection on their leg. 

Staph is the common term used when doctors are discussing Staphylococcus aureus, a bacteria that is known to cause infections and is  commonly seen with skin infections. These skin infections present as a boil, or cellulitis (infection of the skin and soft tissues), or impetigo, or other infections related to the skin. But in this case we are going to look at a boil (an abscess within the skin) and  surrounding cellulitis.

Staph infections often appear quickly, “almost overnight”, when a parent or child may notice a bump that may resemble a bite. But in this case this “bite” rapidly reddens and becomes tender and warm to the touch. It really looks “angry” and as my grandmother used to say “festers”. Parents will often call and say, “I think my child has a spider bite”, when in reality it is a brewing staph infection. When I hear spider biter, out of the blue, I think staph. I jokingly tell parents, “I don’t think there are enough spiders in the world to cause all of these “bites” that are really staph infections.” Since staph is a bacteria it is susceptible to antibiotics. But over the last several years we have seen children of all ages presenting with resistant staph infections, typically with MRSA or methicillin resistant staph. This is an important distinguishing factor, as this will determine which antibiotic is used to treat the infection.

In order to figure out which antibiotic to use, the doctor needs to culture the “pus” that is in the boil. That means growing the bacteria from the “bite, boil, infection” and identifying the bacteria, and from that culture the lab will also determine which antibiotic the bacteria is susceptible to. All of this information will ensure that your child is put on the appropriate antibiotic to treat the infection. At times it is necessary to drain the infection and in more serious cases, a child may be admitted for IV antibiotics. I often have parents ask, “Where did we get this?” Staph is everywhere, on our hands, in our noses and on other commonly shared objects like towels, changing tables and in locker rooms. Encourage your child to wash their hands, try to avoid touching their noses, and to avoid picking at cuts and bites.

Despite all of this, we all have micro-abrasions on our skin that are not even visible and that tiny staph bacteria can just hop on in and develop a random infection. Staph skin infections really do have a “typical” appearance. That is why I am showing you this picture. If you see your child suddenly develop a “bite” that looks like this, you need to call the doctor. The sooner the infection is treated the better. That’s your daily dose, we’ll chat again tomorrow! Send your question to Dr. Sue.

Daily Dose

What New Babies Need

1:30 to read

I have many friends whose own children are now having babies and they always ask, “what all do we need to have/buy for a new baby these days?”  While many things have changed since I had my own children, many have not,  and I still think “less is more” is a good adage to follow, especially for a newborn.  We all have a tendency to buy too much, or the “latest and greatest” only to find out that it is not necessary.

Carseat - a rear facing car seat is a must for your newborn!!!  Look at all of the reviews on line and pick which seat works best for you.  Do you want one with a base that you can also clip on to a stroller?  Remember your baby will sit in a rear facing car seat until 2 years. This is one item I would spend my money on!!

The baby needs a place to sleep so buy a crib and a good mattress.  If you are going to have more than one baby I would buy something that will last through several children. I like having a crib (rather than a toddler bed), as your baby will be in the crib for several years and then can move to a regular bed…no need for an “in between”.  Do not use an “old” crib that has drop sides, due to safety concerns. So that means the one that I had kept in the garage (from my kids) was a throw away! I usually move the first child to a bed when I need the crib for the next baby…no specific age. Bumpers are no longer recommended, so that saves money too!

Changing table or dresser for the millions of diaper changes.  It is so helpful to not have to bend over each time. I would also buy a diaper cream (Dr. Smiths, Destin or Butt paste) to have on hand….your baby will probably get a diaper rash at some time during their time in a diaper.

Baby bath tub: while you can bathe your baby in the sink, the newer bathtubs do make it easier for a newborn and you can use it in the tub as well until your baby can sit up alone. Remember, you will NEVER leave your child in the tub alone…even with all of the seats, rings and things  that they sell to support your baby!!  For bathing I like gentle bath wash like Cetaphil, Cerave, and Eucerin products….good for all skin types.  Pick one!

Swaddle blankets: WOW there are a million on the market and they all “claim” to help your baby to sleep better. I don’t think any of the products say “it will also takes weeks to months for your baby to sleep through the night” , no matter what you use.  I do like the thin swaddle blankets as they are useful for a number of things besides swaddling. Once you have your baby have the nurses show you how to swaddle (quick and easy).  The Miracle Blanket, Woombie and Halo also make it easy to swaddle as well. Pick one (or two) and stick with that.  Remember, your baby is going to be put in their crib on their back whether swaddled or not!! NO TUMMY SLEEPING.  

Diaper Bag: again their are a million out there in all shapes, sizes and price points. In the beginning you need to have a pad for changing (you will end up changing that baby all sorts of weird places), diapers, burp clothes, wipes…as your baby gets bigger you will have bottles, cups, toys all shoved in there too. All of my patients seem to have a travel size Purell strapped to the side of the bag as well. I would get a bag that you can wipe out as there will be spills of all sorts of stuff in that bag I assure you!  Somehow, over time you go back to “less is more” and the diapers end up in your purse!!  

So…that is a start. Will do another post on some other products in the future. 

 

 

Daily Dose

New Dietary Guidelines

1:30 to read

The United States Department of Agriculture issued their new dietary guidelines for 2015-2020. This seemed like a good time to re-visit the topic of healthy eating habits for families…..always a topic of conversation with my patients.

While so many of us talk about healthy eating and reducing needless calories, the government is now also focusing on one of the main culprits, SUGAR.  The new guidelines recommend that we limit sugar intake to about 12 tsp of sugar a day which may sound like a lot until you realize that a can of Coke contains nearly 10 tsp of sugar.  Studies have shown that the “average” (not defined) American currently consumes 22 tsp of sugar /day.  It seems that nearly half of the sugars in our diets are from sweetened beverages and sports drinks. While I know that many the families in my practice have cut out soft drinks, their kids do drink a lot of sports drinks. If it’s a sticky drink it probably has sugar.

At the same time the FDA is also proposing that food labels be changed yet again, to list added sugars. While the current labelling lists “total sugar”, this is a combination of added and natural sugars.  There is a difference between natural sugars found in fruits such as apples and berries, than there is in the processed added sugar found in a chocolate chip cookie or granola bar.  Kids can attest to that all day long!  There are also added sugars in many of the pouches that are marketed for babies and young children…despite the fact that they may be “organic” some have a lot of sugar that also sticks to their teeth as they “suck” on the yogurt or applesauce rather than eat it from a spoon.

The new guidelines also state that teenage boys and men are eating too much protein. The guidelines now recommend, “men and boys reduce their overall intake of protein foods such as meat, poultry, and eggs”.  This group (and all of us I think) should add more vegetables to their diet.

The newest guidelines really seem to focus more on healthy eating habits, rather than on individual nutrients, which seems to have been the take home message. I think we all “know” that eating more fruits and vegetables is good for you, but many people need more guidance than that broad statement. Eating a diet that is colorful which means more fruits and veggies and less carbs and meat has been the goal for a long time.

These guidelines are especially important as they affect the foods that are chosen for our children’s school lunch programs which feed more than 30 million children each day.  The guidelines also contribute to how food assistance programs like WIC are determined.

But, back to basics….eating family meals at home is always important. Making even small changes towards a broader, colorful diet rich in lean meats, fruits, veggies and whole grains will be beneficial to everyone. Lastly, why not try a meat free night once a week as well…have you tried cauliflower steaks yet?

Daily Dose

Baby's First Foods

1:30 to read

Have you heard of “baby led weaning” (BLW)? Many of my patients who have infants that are ready to start “solid foods”, also called complementary foods, have questions about this method. Most babies begin eating foods along with breast milk or formula somewhere around 5 - 6 months of age.  So BLW is not really “weaning”,  as your infant will continue to have breast milk or formula in conjunction with foods…so this really should more aptly be named “baby self feeding”. 

In this method you never offer your baby “mush” or pureed foods, but rather offer them foods from the table.   While I am a huge advocate of self feeding (old term is finger feeding), I also think that early on offering a baby “mushy” food on a spoon is an important milestone. In fact, for most babies at 5 -6 months, it is difficult to pick up a small piece of food to self feed as the pincer grasp has not developed. So, a baby is trying to get food to their mouths by cupping it or hoping it sticks to their hand while pushing pieces around their tray. Some parents will put the food into their baby’s hand.  But, by 8-ish months most babies have developed their pincer grasp and the finger feeding should be preferred.  

Parents are also concerned about starting solid foods and the possibility of choking.  I am always discussing how to make sure that your child avoids choking hazards with foods. In other words, no whole grapes, or hot dogs, or popcorn or chunks of meat.   Other hazards are raw carrots, apples, celery and any “hard” food that your baby might be able to bite a chunk of and then choke. But, if you cook the carrots and then cut them in small bites they are easily handled by a baby who is self feeding.  It is really all about the consistency of the food as once your baby has lower teeth they can easily bite/pry off a big “chunk” of food that could lead to a choking hazard.

Interestingly, there was a recent study that looked at the incidence of choking in children who started with self feeding vs those fed traditionally with pureed foods from a spoon. In this study of about 200 children between 6 - 8 months of age the incidence of choking was similar, while there were more gagging events in the BLW group.  Fortunately, “the choking events resolved on their own”. Gagging is quite different than choking. Some children will gag on pureed foods just due to texture issues. 

I am an advocate of what I am going to call parent led feeding followed by early self feeding of appropriate foods. By the time a child is 9 months of age they should be able to finger feeding the majority of their meals. But there are some foods that are just not conducive to finger feeding at all….yogurt, apple sauce, puddings…and they will be spoon fed until your child is capable of using a spoon which is anywhere from 12 -18 months.   But as a reminder, whenever you offer your child a finger food you should remember two things, #1 is the piece small enough that my child cannot choke and #2 is the food cooked well enough to not pose a choking hazard.  

Several years ago there was a 1 year old in our practice who was given a piece of an apple to chew on… she bit off a chunk of the apple, aspirated and died. It was a terrible accident.  I will never forget that….and re-iterate to all of my patients…a pork chop, or chicken leg or any number of foods can become a choking hazard if your child bites off a chunk. Children really don’t chew until they are around 2 years, they just bite and try to swallow so I pay a great deal of attention to what foods they are offered.

Old school and new school…the combo seems to make sense to me. 

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Potty training can be tricky.

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