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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

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. 

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

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

Car Seat Safety

1:30 to read

I recently received a text from a patient who asked if she could turn her 17 month old child’s car seat around and have it forward facing in the back seat. She said that her car seat instructions read “may forward face after the child weighs 20 lbs”.

 

Not long after that, another patient came in for her 18 month check up and during the course of the check up I always ask about car seat position.  I remind them that they should continue to have their child in a rear facing car-seat until they 2 years of age.  The child’s mother said that she had turned the car seat around to forward facing because the child “did not like rear facing”.  Interesting discussion with a toddler.

 

So, this just so happens to be Child Passenger Safety Week and National Car Seat Check Saturday as well. What a better time to remind parents that the safest way to restrain your child who is under the age of 2 years (depending on your carseat height and weight restrictions)  is in a rear facing car seat.  

 

In a recently published article in the journal Pediatrics, about 38% of 17-19 months olds were not following AAP recommendations to ride in a rear-facing car seat. The recommendations were changed in 2011 as studies found that young children in a forward-facing car seat were 5 times more likely to be seriously injured than those in a rear-facing seat. 

 

In the study many of the families involved who had their children forward-facing often said that they “thought their child was too tall or too heavy to be rear-facing”. Others commented that “their feet were touching the back seat and they looked uncomfortable”. 

 

Interestingly, your child has been in a rear-facing car seat since birth, so it is strange that they “prefer” to forward face.  Kind of like being in the middle seat of an airplane, if you have never been seated on the aisle you don’t know the difference in seats.

 

If you are concerned about the appropriate car seat for your child or how to install it, this is a good week to have a car seat expert help make sure that your child is riding in the safest car seat possible. If your child is under the age of 2…that also means rear facing!  

 

 

 

 

 

  

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Daily Dose

Babies & Bow-Legs

1.15 to read

Fact or fiction: if a young baby puts any weight on their legs they'll become bow legged? Dr. Sue weighs in.I’m sure you have noticed, babies like to stand up! With that being said, I still hear parents coming into my office who say, “I am scared to let my baby stand up as my mother (grandmother, father, uncle) tells me that letting a baby put weight on their legs will cause bow-legs!  How is it possible that this myth is still being passed on to the next generation?

If you look at a baby’s legs it is easy to see how they were “folded” so that they fit inside the uterus. Those little legs don’t get “unfolded” until after delivery. A newborn baby’s legs continue to stay bent for awhile and you can easily “re-fold” those legs to see how your baby was positioned in utero. Almost like doing origami. So, how do those little bent legs get straight?  From bearing weight. If you hold a 3-5 month old baby upright they will instinctively put their feet down and bear weight.  A 4 month old likes nothing more than to jump up and down while being held. They will play the “jumping game” until you become exhausted. That little exercise is the beginning of remolding the bones of the leg, while straightening the bones. If you look at most toddlers many do appear bow-legged as the bones have not had long enough to straighten. Over the next several years you will notice that most children no longer appear bow legged. For most children the bow legs have resolved by the age of 5 years. I child’s final gait and shape of their legs is really determined by about the age of 7 years. Next time you hear the adage about bow legs, you can politely correct the myth. Standing up is going to make that baby have straight legs! That’s your daily dose for today.  We’ll chat again tomorrow.

Daily Dose

Baby Bling Can Be Dangerous!

1:15 to read

I recently saw a TV segment on “blinging” your baby and toddler. It seems that the latest craze is decking out not only little girls, but also little boys. Being the mother of three sons I can understand wanting to “dress up” boys as well (little boy clothes can be a bit boring) but a few of the models on TV were wearing necklaces. 

Now, a boy wearing a necklace doesn’t bother me at all, but a baby or toddler with a necklace worries me!  This isn’t about gender, rather about safety.  

A necklace is a real choking and strangling danger for babies and young children. I know that many parents receive necklaces for their babies on the occasion of a baptism and in some cultures an infant is given a necklace made of string or beads to wear soon after birth. 

But, whenever a baby comes into my office with a necklace on I discuss the possibility, even if remote, of the child suffocating if the necklace gets caught or twisted around the child’s neck. There is no reason to even risk it! 

Baby bling is great if you want to put your child in cute shirts, hats, or even trendy jeans. Go for it!  But I would never put a necklace on a child. It is akin to the adage about peanuts...when should a child be allowed to eat peanuts?  When they can spell the word!  

We pediatricians are no longer worried about peanut allergies in the young child, it is the choking hazard that is the real concern. It’s the same for a necklace. Let your child wear it when they can spell the word, or put it on when your 3 year old plays dress up, but take it off once finished. There is no need to ever have a young child sleep in anything like a necklace, or anything that has a cord until they are much older. 

Children ages 4 and under, and especially those under the age of 1 year, are at the greatest risk for airway obstruction and suffocation.  So, put the necklace back in the jewelry box for awhile. You can re-wrap for re-gifting and re-wearing at a later date. Safety before bling! 

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Daily Dose

A New Baby

1.15 to read

I must say...being able to have texts and emails from my patients does make it easier to communicate. A quick question or a picture of a cut on the knee can quickly be sent over a handy phone, and I can often reassure a parent that a visit may not be necessary.   

At the same time, messages from my patients make me feel more connected to them and their family. This was the case the other day when I was out of town and missed the birth of one of my newest patients. The good news? The tech savvy, mother kept me in the loop throughout her delivery! 

This mom was having her 4th baby, and 1st girl after 3 boys. (hmmm....wonder if I should have had that 4th baby after all - a bit late to ponder that question?) 

She sent me a quick text that she had gone into labor, but it was 3 weeks early. I had hoped to be at the hospital for her delivery as it is still fun for me to be in the delivery room. There really is nothing better than observing a delivery, as you are always a reminded of the miracle of birth. 

So....out of town, missing the birth..but, she sent me a picture of her in labor, followed by quick text telling me it was almost time and then......a picture of a precious, healthy baby girl, all 7’ 2” of a new life! This picture is of the new proud dad (I think she’s already got him wrapped around her finger).  It was almost like I was there...while still enjoying a few days at the beach.   

So, one of the best parts of my job is being a part of a family and watching that family grow.  Doesn’t get better than that. 

Congratulations to sweet baby girl Roberts. You are perfect!

Daily Dose

CPR

1:00 to read

I was seeing a newborn the other day and the parents had a great idea. Their baby had spit up and they were concerned about how to clear his airway.  When we discussed how to hold the baby to clear the airway they had the great idea of having a CPR “teaching party” for a group of their friends who also had young babies!

 

I do encourage new parents (actually all parents and even grandparents) to take a CPR class. I am fortunate that we have yearly CPR class in our office which keeps us all up to date. 

 

It is fairly easy to find local CPR classes either through the YMCA, the American Heart Association and often through the hospital where you deliver your baby.  But, in these cases you have to take the class on “their schedule”. What a great idea to host a party with your friends and hire a certified CPR instructor to come to you!!

 

You know I do like to “isolate” my newborn patients from crowds (for 6-8 weeks), but it is fun to gather with other parents of newborns to get some social interaction. If everyone brought their baby, and a dish for dinner, it could be a mini dinner party followed by CPR training….ending with wine!

 

So…let’s start planning CPR parties, I may even do one for my friends who are becoming grandparents!

 

 

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DR SUE'S DAILY DOSE

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