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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

Jaundice in Newborns

1:30 to read

It is not at all uncommon for a healthy newborn to develop jaundice in the first several days of life. Bilirubin is produced when red blood cells are broken down. It is a yellow pigment that we all metabolize in the liver and then it is excreted in urine and stools. In an newborn, the body produces almost 2-3 times the bilirubin that an adult does. Because newborns are also “immature” their liver cannot keep up with the bilirubin production and therefore bilirubin levels rise. In some cases the bilirubin is high enough to cause a yellowing of the skin (jaundice), and this is termed physiologic jaundice of the newborn. 

 

Your infant will have their bilirubin level checked while they are in the hospital and your pediatrician will follow any bilirubin levels that seem to be rising. In most hospitals the bilirubin is tested transcutaneously (through the skin), and you may never know that you baby has been tested. If bilirubin levels seem to be high, a blood test will be performed to more accurately assess the bilirubin level. If bilirubin levels continue to rise a baby may then be put under phototherapy (special blue lights that breaks down bilirubin in the skin and help it to be eliminated). Phototherapy prevents extremely high levels of bilirubin which may get into the brain and could be toxic to the baby and cause brain damage.

 

When a baby is put under phototherapy they may be in a basinette or wrapped in a “bili-blanket”  and they will wear sunglasses to prevent any damage to their eyes from light. They are usually naked or only in a diaper so that as much skin is exposed as possible. In most cases the bilirubin levels have peaked by day of life 3 or 4 and the baby will no longer need phototherapy. While the baby is under the “bili-lights” they will continue to have blood tests (from their heels) to follow the bilirubin levels.

 

As babies are now being discharged in 24-48 hours after delivery some babies will develop jaundice after they have already gone home…so you your doctor will plan on seeing you 1 to 2 days after your are discharged. But, should you notice that your baby seems to be getting more jaundiced you should call you doctor and be seen sooner.  

 

Just this week I saw a baby who continued to become more jaundiced after he went home. At times I see this when a mother is breast feeding and her milk has not yet “come in”.  If a baby is not getting a lot of milk then they cannot poop and pee out bilirubin…somethings just take time to get going with feeding, peeing, pooping and liver maturation. So…this baby boy was started o home phototherapy. Rather than re-admitting him to the hospital, a pediatric home health care company sent out a nurse with a bill blanket who instructed the parents on the use of it. The baby was then able to feed at home every 2-3 hours, and the bili-blanket was used throughout the day and night. The parents lived so close to the office that they would bring the baby in for bilirubin tests, while in other cases the nurse will go to the home to do the testing.  Home phototherapy in an otherwise healthy infant does not disrupt the new family and really helps the mother establish her breast feeding and lets “everyone” sleep in their own beds!

 

This baby only required phototherapy for 24 hours…in some babies it may be longer. Once the bilirubin was back in a “safe range” the lights were discontinued and he will continue to process the bilirubin on his own. His little yellow face and eyes will be the last evidence of his newborn jaundice and “one for the baby books” as it should never be a problem again.

 

Daily Dose

Why Is Your Baby Not Sleeping?

1.15 to read

I recently received an email from a mother who was beginning to have new sleep problems with her 6 month old. Whenever I get questions about a 6-9 month old and new sleep issues, most parents relate the problem to either teething and or not getting enough cereal/solids before bed time. 

In fact, new sleep issues often arise around this age as your baby is beginning to think and use those frontal lobes. Many babies had been sleeping for 6-10 hours a night by now and then suddenly begin to awake and they are crying.  This must be pain from teething, right?  So in response to that, many parents start giving their baby a pain reliever, such as acetaminophen nightly, but the sleep problems do not go away and still no teeth! 

At the same time, most babies are eating solid foods beginning around 6 months, and parents were convinced that starting solids would also cure the sleeping issues.  The baby is eating cereal and  waking up in the middle of the night. What gives? 

I think the most important milestone for this age baby to ensure good sleep:  the baby must put themselves to sleep. Many of the babies who are having awakenings are being rocked to sleep, or having the pacifier put back in their mouth all night long.  They are routinely rocked every night and then put down, so when they have arousals (as we all do all night long) they want to be rocked back to sleep, they are smart now and know what they want!   Similar to wanting a back rub every time you wake up, sounds good right? 

While all of this is going on in your baby’s mind your parent mind is telling you it has to be teething pain or lack of food or something worse, and not just a new phase of baby sleep!  Suddenly habits are started, the baby is getting fed in the middle of the night again, or you are giving acetaminophen every night, and typically the arousals continue.  

Sleep is precious for both baby and parent and a baby between 6-8 months of age should be able to not only put themselves to sleep at bedtime, but self console to go back to sleep in the middle of the night. Makes sense but takes a bit of work. This usually requires letting your baby cry for awhile. I am not a propionate of letting an infant cry it out or (CIO as this cute mom emailed), but I do see the need in this age baby. They have to learn to self-console and it is easier to break a bad habit sooner than later. Some babies have more stamina too, so each baby is going to be different in how long they can CIO. 

Practice putting the baby down awake and going back into the room to let them know you are present but not active in getting them to sleep.  Lengthen the time between each visit to their room. Repetition and consistency are the key.  It takes a while but most babies will then get back into even better and longer sleep at night, and you can stop all of that acetaminophen. They get teeth forever (well, at least for 12 years) and that is usually not the reason for waking up. Ask them when they are 5 and getting molars and sleeping well! 

That’s your daily dose for today.  We’ll chat again tomorrow.

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

Maternity Leave & Breastfeeding

1:15 to read

When Facebook’s Mark Zuckerberg and Priscilla, his pediatrician wife, had their baby last year he announced that he would be taking off 2 months to be at home with his wife and baby. For those fortunate enough to work for Facebook or Google or another company with a generous maternity/paternity leave policy they too may get anywhere from 2-6 months of paid leave after the birth of their baby. But for most workers, it is more the “norm” that a mother receives anywhere from 4-6 weeks of maternity leave, and in many cases it is not paid.   The first several months of being a new parent are often overwhelming, but knowing that you have 4-6 months of paid leave which allows you time to “become a family” certainly makes the adjustment to parent hood a bit easier.

Unfortunately, physicians (including pediatricians) are faced with returning to their practice often “as quickly as possible”.  I found that going back to work after 12 weeks (which I had to beg for) and trying to juggle a full load of patients, answering phone calls, taking night call and making hospital rounds really did impact my mood as well as my breastfeeding. Although I enjoyed breastfeeding,  I could not figure out how to find any time to pump between patients (talk about running late) to keep my milk supply up. So….I eventually made the decision that in order to keep working I would need to stop breast feeding, which was a bit traumatic for me…..in retrospect I was tougher on myself than I needed to be, but 30 years ago I didn’t realize the numerous other difficult parenting decisions that lay ahead.

Interestingly, a new study just published in Pediatrics is what made me ponder all of this.  Many studies have shown that mothers may have trouble continuing to breast feed after returning to work. This latest study from Australia actually found that the amount of time to return to employment was actually “far less significant than the number of hours a woman worked”.  The study found that working 19 hours or less per week was associated with a higher likelihood to continue breastfeeding.  Those women who returned to a work week of 19 hours or less “experienced no decline in the likelihood that they were breastfeeding regardless of when they returned to work and they were more likely to sustain breastfeeding as well”.  In other words longer breastfeeding, a win win for mother and child. 

As more and more women are employed during their child bearing years, the ongoing debate surrounding the appropriate length of time for maternity leave continues. While there have been many studies to show the importance of family leave after the birth of a baby ( better bonding, less post partum depression) this study is one of the first to show the benefit of a reduction of hours worked upon re-entry to the workplace.  It is my hope that this research may open the door for discussions examining the feasibility of reduced work hours for women who return to work after giving birth.  This new data may be pivotal in improving longer breastfeeding rates in the U.S.  

I am sure many women, although not included in the study,  who have juggled a career and breast feeding would agree.

Daily Dose

Breastfeeding Anxiety

1:30 to read

I am a huge proponent of breastfeeding and having breast fed 3 babies of my own I do remember several things about “learning to breast feed”.  Now that my children are grown and I am taking care of my 2nd” generation of babies, I have decided that “we” (doctors, hospitals, lactation consultants etc.) are making breast feeding more and more stressful rather than just letting it happen “organically”, the way it has been done for hundreds if not thousands of years.

 

I make newborn nursery rounds and see new mothers within 24 hours of their baby’s birth, and then everyday until discharge. I am noticing more and more tearful, anxious mothers who are completely “stressed out” about breastfeeding and their milk is typically not even “in” yet.  So, how is it that they already feel as if they have failed, or “can’t do this”??  We have so many different people coming into their room telling them to cluster feed, not to use a pacifier or that their baby is tongue tied, and they are overwhelmed - and the baby is one day old!

 

Sometimes too much information is detrimental rather than helpful. Being a bit “clueless” and having no expectations did not make breast feeding seem stressful. A foreign sensation yes, awkward at times absolutely!!  A mother’s milk will “come in” on day 2, 3 or 4 even if you don’t cluster feed for hours at a time and even if you decide to use a pacifier. Nature has a plan….whether we do or not.

 

Just like many things in life….it is easier for some mother’s and harder for others.  Some babies just seem to latch on immediately, while others take a while to figure it out.  But, practice is the name of the game, and you cannot practice breast feeding. It is postpartum on the job training..and some mothers may need extra help and some “tutoring”. No new mother needs to hear discouraging words…encouragement and reassurance is the name of the game in the first few days after giving birth.

 

Babies are expected to lose weight after birth…but parents are now told how much weight their baby has lost and what will happen i”f they lose more than 10%”of their birth weight”. They are also told the transcutaneous bilirubin level every morning even though they “are not sure what that means”, but it is another number thrown out there to add to their worry list.  Maybe I am old school, but I tell my patients that my job is to “tell you if there is a concern”…and not have you worry about 7% weight loss on day 3 of life or a bilirubin of 10 mg/dl, so that parents can “Google” hyperbirubinemia and worry about kernicterus and brain damage. 

 

Letting a new mother get some rest while encouraging her to feed her baby every 2-3 hours while practicing different positions for latching seems to be a much more natural and relaxing method to promote breast feeding and not anxiety provoking “rules”. 

 

I do not encourage a new mother to  cluster feed for hours at a time so that her nipples are already blistered, bleeding and painful,  before even leaving the hospital. I also let her know that it is not abnormal for breast feeding to be a bit “painful” , and for her breasts to feel engorged as the milk “comes in”. There are lots of new “feelings” going on in the initial postpartum days, including all of those raging hormones!

 

So…try to relax, enjoy your baby and not et overly anxious about “breastfeeding” correctly…as one way does not fit everyone. 

 

 

 

 

 

 

 

 

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

Brown Spots on Your Baby?

1:30 to read

I was examining a 4 month old baby the other day when I noticed that she had several light brown spots on her skin. When I asked the mother how long they had been there, she noted that she had started seeing them in the last month or so, or maybe a couple even before that.  She then started to point a few out to me on both her infant’s arm, leg and on her back.

These “caramel colored” flat spots are called cafe au lait macules, (CALMs) and are relatively common. They occur in up to 3% of infants and about 25% of children.  They occur in both males and females and are more common in children of color.  While children may have a few CALMs, more than 3 CALMS are found in only 0.2 to 0.3% of children who otherwise do not have any evidence of an underlying disorder.  

Of course this mother had googled brown spots in a baby and was worried that her baby had neurofibromatosis (NF).  She started pointing out every little speckle or spot on her precious blue eyed daughter’s skin, some of which I couldn’t even see with my glasses on. I knew she was concerned and I had to quickly remember some of the findings of NF type 1.

Cafe au lait spots in NF-1 occur randomly on the body and are anywhere from 5mm to 30 mm in diameter. They are brown in color and have a smooth border, referred to as “the coast of California”. In order to make the suspected diagnosis of NF-1 a child needs to have 6 or more cafe au lait spots before puberty, and most will present by 6 -8 years of age.

For children who present for a routine exam with several CALMs ( like this infant), the recommendation is simply to follow and look for the development of more cafe au lait macules. That is a hard prescription for a parents…watch and wait, but unfortunately that is often what parenting is about.

Neurofibromatosis - 1 is an autosomal disorder which involves a mutation on chromosome 17 and may affect numerous organ systems including not only skin, but eyes, bones, blood vessels and the nervous system. Half of patients inherit the mutation while another half have no known family history.  NF-1 may also be associated with neurocognitive deficits and of course this causes a great deal of parental concern. About 40% of children with NF-1 will have a learning disability ( some minor, others more severe).

For a child who has multiple CALMs it is recommended that they be seen by an ophthalmologist and a dermatologist yearly,  as well as being followed by their pediatrician.  If criteria for NF-1 is not met by the time a child is 10 years of age,  it is less likely that they will be affected, despite having more than 6 CALMs.

The biggest issue is truly the parental anxiety of watching for more cafe au lait spots and trying to remain CALM…easier said than done for anyone who is a parent. 

Daily Dose

Red Cheeks In Winter

1:15 to read

Why do children get red cheeks in winter?

It is the time of year for cold temperatures, low humidity and dry skin. It is funny, every year as the temperatures drop, I we start seeing these cute little babies and toddlers who have those bright red cheeks. I always say that they “look like British babies”.

Dry skin is just one of the many issues we see with colder temperatures, and babies red cheeks are one of the most evident. During the winter months we all experience dry skin and using moisturizer becomes very important.

I have written previous blogs about eczema, and while chapped skin is not synonymous with eczema, there are some similarities. The most important thing to prevent dry skin while the weather is cold is to use a moisturizer, and applying moisturizer is best on damp skin. After bathing your baby or child, pat them dry until they are just “a tad bit moist” and then take a moisturizer and apply it to the almost dry skin. The thicker the moisturizer the better, so a cream is preferable to a lotion. It will take a little more time to rub the cream in when the skin is a bit moist, but it will help the moisturizer penetrate the skin. The same thing goes for the face.

I always found that the best time for me to moisturize those rosy cheeks was really after the child had gone to sleep. When my children were younger I found that if I put the cream on when they were awake, that they either rubbed their faces more, or if they were verbal, complained about lotion on their faces. So…I decided that it worked best to have their bedtime routine, with baths, books, and prayers, and then once they were asleep I would slip in and lather up their faces and also even used Chap Stick on their dry little lips. Now, there is no science in this routine, but it seemed to work, and they were much more tolerant of lubricants when asleep than awake.

We are definitely in the low humidity season and the heat is on in the house (I am typing this as I sit by the fire with a blanket over my feet), so you can expect several months of dry skin and chapped cheeks. If moisturizers like Vanicream, Cerave, Aquaphor and Eucerin go on sale, stock up!!  April is a long way away.

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