Copyright Page and Low-Impact Pilates Workout

Saxophone, lead guitar by Denise Fields

Drums, rhythm guitar and interior layout by Alan Fields
Cover/interior design and keyboard solo by Epicenter Creative
Catering by Mark Brown and the Salt Lick
Backing harmony vocals and keyboards by Andy and Julia Brown
Percussion and additional guitar by Ben and Jack Fields
Index by New West Indexing
Band photography by Tracy Trahar

All rights reserved. Copyright © 2016 by Ari Brown, M.D. and Denise & Alan Fields.
Published by Windsor Peak Press, Boulder, CO. This book may not be reproduced in
whole or in part by any means without the expressed written permission of the authors.
Printed in the USA.

To order this book, order online at Baby411.com or call 1-800-888-0385. Questions or

comments? Please call the authors at (303) 442-8792. Or fax them a note at (303) 442-
3744. Or write to them at Windsor Peak Press, 436 Pine Street, Boulder, CO 80302. E-mail
us at authors@baby411.com. Baby 411 is a registered trademark of Windsor Peak Press.

The latest info on this book is online at www.Baby411.com

Distributed to the book trade by Ingram Publisher Services, (866) 400-5351

Library Cataloging in Publication Data

Brown, Ari, M.D.

Fields, Denise
Baby 411: Clear Answers & Smart Advice for Your Baby’s First Year/Ari Brown, M.D.
and Denise Fields
616 pages.
Includes index.
ISBN 978-1-889392-51-6
1. Infants. 2. Child rearing. 3. Infants—Care.

Child Care—Handbooks, manuals, etc. 2. Infants’ supplies—Purchasing—

United States, Canada, Directories. 3. Children’s paraphernalia—
Purchasing—Handbooks, manuals. 4. Product Safety—Handbooks,
manuals. 5. Consumer education.
649’.122’0296—dc20. 2016.

Version 7.0

Do you have an old copy of this book? Check our web site at Baby411.com to make
sure you have the most current version (click About, then Which Version?).
 BABY 411 MEDICAL ADVISORY BOARD

Steven Adair, DDS, MS

Pediatric Dentist
Professor and Chair, Pediatric Dentistry
Medical College of Georgia

Mark T. Brown, MD, FACS

Ear, Nose, and Throat, Sleep
Medicine Specialist
Great Hills ENT
Austin, TX

Jose C. Cortez, MD
Pediatric Urologist
Dell Children’s Medical Center
Austin, TX

Lewis First, MD, FAAP

Professor and Chair
University of Vermont Department of Pediatrics
Burlington, VT

Corinne Frank, Esq.

Professional Mother

Linda Hill, RN, IBCLC

Certified Lactation Consultant
Midland, TX

Joyce Jordan, LVN

Pediatric Triage Nurse
Capital Pediatric Group
Austin, TX
Randy Kunik, DDS
Orthodontist and Cosmetic Dentist
Austin, TX

Arlinda Michael, RN, CIMI, IBCLC

Certified Lactation Consultant
Infant Massage Instructor
Minneapolis, MN

Paul Offit, MD, FAAP

Director, Vaccine Education Center
Children’s Hospital of Philadelphia
Philadelphia, PA

Edward Peters, MD, FAAAI

Allergist, Pulmonologist
Allergy & Asthma Assoc. of Austin
Austin, TX

Sidney Seidman, MD, FAAP

Pediatrician
Baltimore, MD

Gabriella Shaughnessy, RNC, BS, IBCLC

Manager, OB Education
Hoag Memorial Hospital
Newport Beach, CA

Shelley Solka, MS, CCC-SLP

Speech Language Pathologist
Austin, TX

Karen L. Wright, MD
Pediatric Cardiologist
Children’s Cardiology Associates
Austin, TX
Mark Zamutt, RPh.
Pharmacist, H-E-B
Austin, TX

R. Jeff Zwiener, MD
Medical Director, Pediatric Gastroenterology
Dell Children’s Medical Center
Austin, TX
 ACKNOWLEDGEMENTS

So how’d a pediatrician like me end up writing three books and being on

national TV? I ponder that myself every once in a while!
As we put the finishing touches on the seventh edition of Baby 411, it
makes me look back on the past fourteen years. Boy, time flies. I was
perfectly content with life as I knew it prior to June 2002. I had a great
pediatric practice with the nicest families I could ever dream of. And I
found child advocacy for my local and state medical societies to be very
rewarding.
Then I had a conversation that changed my life. Alan and Denise Fields
were long-time friends and bestselling authors of Baby Bargains. Based on
our collective experiences, we came to the following conclusion: despite the
surplus of parenting books, today’s parents needed help.
The Information Age led parents to more questions than answers. The
Fields were experts in writing books but did not go to medical school
(maybe a wise decision!). I could answer all the questions, but I didn’t have
the time (or so I thought) or the skill (I learned along the way) to write a
book. But I had a passion to educate parents—just like I did in my office
every day.
“Write a couple chapters and send them to us,” said my friends.
So I did.
“We like it,” said my friends/future co-author/editors/publishers. “Give
us 15 chapters by Thanksgiving.”
“But that’s a chapter a week!” I protested.
“Yep. Welcome to the book business.”
Jotting down ideas between seeing patients, pulling an all-nighter to
write the sleep chapter, and missing a few bedtime stories with my own
kids . . . Baby 411 was born. Toddler 411 and Expecting 411 followed to
complete the trilogy.
Since the first edition was published, many aspects of pediatric
healthcare have changed: New recommendations to prevent SIDS . . . new
studies shedding light on colic . . . completely new recommendations on
feeding babies solid foods. And that’s just to name a few. It’s no wonder
parents are confused about what to do!
It’s sad but true: any parenting book written before 2015 is already
outdated. So, in retrospect, writing the first edition of Baby 411 was the
easy part. Revising the book to keep up with the pace of medicine has been
the challenge. (Note to self: next time, write a book on a topic that doesn’t
change but every ten years.)
Life as an author, speaker, and full-time pediatrician is a bit chaotic at
times, but it has taken my mission of child advocacy to a larger stage. And I
wouldn’t change a thing. Well, more sleep would be nice. The wonderful
notes from our readers keep me energized. Keep ‘em coming—we love
hearing from you!
I owe many thanks to the Fields for believing in me and in this project.
Biggest thanks go to my husband, Mark, for walking down this road with
me. I never could have done it without you. I also thank my sister and
brothers for their grassroots marketing efforts, giving books to everyone
they know, and approaching random pregnant women in Costco parking
lots across the country. (I swear I had nothing to do with this idea.)
To my patients and their parents. You are my inspiration. Thank you for
sharing your experiences to help other families. You teach me everyday!
I thank the citizens of Austin and the Austin medical community for
their extraordinary encouragement. I am so proud to call you my friends,
neighbors, and colleagues. I vow to Keep Austin Weird.
Other special folks, friends, and spiritual advisors include: the stellar
communications department of the American Academy of Pediatrics, Texas
Pediatric Society, and the staff at Parents Magazine.

And finally, I dedicate this book to Andy and Julia. I love you so much
and am so very proud to be your mom.
—Ari Brown, M.D.
 OVERVIEW

SECTION ONE: 3-2-1 BABY! PREPARING FOR THE NEW ONE

Your baby is here! This section explores your baby’s first few
days . . . plus how to survive the first two weeks. Next we explore finding a
pediatrician, the latest news on newborn screening and other timely topics.
What are the insider tips to scheduling appointments and what to do on
weekends and holidays. Also in this section: picking a parenting style and
navigating the world of child care.

SECTION TWO: CARE & FEEDING

How do you care for your newborn? The first part of this section
explores cleaning your newborn, diaper rash and other hygiene issues. Next,
let’s talk nutrition and growth—what do growth charts mean? What
nutrition does your baby need for the first year? We’ve got the low-down on
your baby’s nutrition, including tips on vitamin supplements, avoiding
obesity and getting enough calcium, fiber and iron. Finally, we’ll break
down nutrition into separate chapters that focus on liquids and solids. We’ll
discuss breastfeeding, formula and other liquids like cow’s milk. Next,
we’ll discuss how to tell when your baby is ready for solid foods, including
advice on avoiding food allergies. The last chapter in this section is titled
“The other end”—everything you wanted to know about baby poop and
more!

SECTION THREE: SLEEP, DEVELOPMENT & DISCIPLINE

Let’s talk sleep—this section will give you the scoop on your baby’s
sleep (or lack thereof). We’ll talk about setting up good habits and look at
the different sleep “gurus” that haunt the bookstore aisles. Next, we’ll look
at how your baby will develop, including milestones and social/emotional
growth. Finally, it’s a topic every parent must deal with: discipline. We’ll
give you advice on how to soothe a newborn, how to develop a good
discipline style and dealing with temper tantrums.
SECTION FOUR: SICKNESS & HOW TO AVOID IT!
Here, we’ll discuss vaccinations—what’s required and what’s optional.
We’ll hit the vaccines controversies head on, including the autism debate
and thimerosal. This section also covers the most common infections and
diseases, with separate chapters devoted to such topics as the common cold,
bacterial infections and more.

SECTION FIVE: FIRST AID—TOP 12 PROBLEMS & SOLUTIONS

What should you do when your baby gets sick? This section will give
you advice on taking your baby’s vital signs and what to have in a first aid
kit. We’ll hit the Top 12 problems and solutions for newborns, including
fever, rashes, trauma and more.

SECTION SIX: THE REFERENCE LIBRARY

This section includes detailed information on medicines, alternative
therapies, lab tests, the glossary, references and footnotes.
 TABLE OF CONTENTS

Introduction

SECTION ONE: 3-2-1 BABY! PREPARING FOR THE NEW

ONE
Chapter 1
BIRTH DAY

Cutting the Cord and Your Baby’s To Do List

Should We Wait to Cut the Cord?
Does My Baby Need To Study For His APGARs?
Your Baby’s First Physical Exam
Getting To Know You: Your Baby’s 1st Days
What’s THAT In My Baby’s Diaper?
Why is My Baby Shrinking?
More tests and procedures: hearing screen, newborn screening
That Wasn’t in the Birth Plan!
The 411 on Jaundice
Optional: Cord Blood Banking & Circumcision
The Baby 411 Two-Week Survival Guide
New Dad 411: Tips & Advice
The Baby Blues
The Handy Feeding And Elimination Table
Special Situations: Pre-term Babies, Twins, Adoption

Chapter 2
YOU & YOUR BABY’S DOC: INSIDER TIPS & ADVICE

Selection a Doctor
9 Screening Tests
The Schedule Of Well Baby Checkups
Who Is The AAP?
The Difference Between A Sick Visit And A Consultation
Insider Tip: The Best Time To Schedule An Appointment
What To Do: Evening and Weekends

Chapter 3
PARENTHOOD

Picking A Parenting Style

Childcare
The 5 Options For Childcare
Six Commandments For Balancing Work & Baby
Day to Day Tips on Juggling Family & Career

SECTION TWO: CARE & FEEDING

Chapter 4
HYGIENE: THE SPA TREATMENT

The First Manicure

When Can I Use Diaper Wipes?
How Often Do I Clean The Belly Button?
Diaper Rash: 5 Tips & Tricks
Bathing Baby
Cradle Cap
Eczema: Advice And Tips
Insect Repellent
The Boy Parts
The Girl Parts
Mouth care: Thrush, Dental Care, and Drool
Chapter 5
NUTRITION & GROWTH

What Growth Charts Mean

How Infants Grow (Height, Head Size, Weight)
Flat Heads & Tummy Time
Calories & Nutrition For The First Year
The Big Picture: Nutrition For The First Year
Feeding Schedules, Or Lack Thereof
Special Concerns: Dropping Down The Growth Chart
Does My Baby Need A Vitamin Supplement?
Fluoride: Does Baby Need A Supplement?
Overeating, Obesity, And The Body Mass Index
New Parent 411: How To Avoid Obesity
Feedback From The Real World: Avoiding The 4C’s
The Rise in Childhood Obesity
Calcium, Fiber, Zinc And Iron
Happy Birthday! You’re One! Food guidelines and hunger strikes

Chapter 6
LIQUIDS

Breast Milk
The Advantages Of Breast Milk
Why Women Stop
Day-By-Day Guide
New Parent 411: Anxiety At Checkout
Top 10 Tips To Survive The First Two Weeks
Is It Ok to Supplement With Formula?
Top 8 Breastfeeding Problems and Solutions
Troubleshooting: When Breastfeeding Goes Wrong
Sore Nipples: 6 Tips For Relief
 Expressing Milk: Breast Pumps, How to Serve Breastmilk
Mom Concerns: Work, Diet, Medications
Special Situations: Adoptions, Twins, Preemies
Weaning: The Guide
The Big Picture: Breastfeeding For The First Year
Formula
Coke Vs. Diet Coke: The Types Of Formula
Soy Formula
The Gourmet Formulas
Powder Vs. Liquid: Which Formula is Best?
Bottles: Which Are Best?
The Big Picture: Formula Feeding For The First Year
Other Liquids: Water, Juice, Milk

Chapter 7
SOLIDS

The Five Types Of Solid Foods

How To Tell When Your Baby Is Ready?
What is The First Solid Food I Should Offer?
How Do I Know If Baby Has A Food Allergy?
Gluten Allergies
Six Months & Beyond: Textures, Feeding Oneself, Fish
The Big Picture For Liquid And Solid Nutrition

Chapter 8
THE OTHER END

What Is Normal Newborn Poop?

The Top 5 Worrisome Poops
5 Trade Secrets For Constipation Relief
Older Babies: Solid Foods = Solid Poop
Fun Fiber Foods
Spit Up, Regurgitation, And Vomit
What Is Gastroesophageal Reflux (GER)?
Tricks Of The Trade: Treating GER
Quiz: Does Your Baby Have GERD?
Top 5 Worries About Vomit
Urine And Bladder Infections
Burping, Hiccups, And Gas

SECTION THREE: SLEEP, DEVELOPMENT & DISCIPLINE

Chapter 9
SLEEP

The Science Of Sleep

How Long Should Newborns Sleep?
Sleep Safety Tips: SIDS And Other Dangers
Deciding On Your Family’s Sleep Routine
Family Bed: Pros & Cons
Solitary Sleep: Pros & Cons
Setting Up Good Habits
Top 10 Commandments For Establishing A Sleep Routine
Undoing Bad Habits
Top 10 Mistakes Parents Make With Infant Sleep
The Sleep Gurus: 6 Approaches Explained
Progressive Waiting or Rapid Extinction?
Naps
Special Situations: Multiples And Preemies

Chapter 10
DEVELOPMENT

What Does Development Mean?

How Do I Know My Baby Is Developing Normally?
Bookmark this page! Our Development Checklist
Failing Milestones: What To Do
What Is Autism And When Do I Worry?
Other Developmental Differences
How Your Baby Learns
Your Baby’s Social And Emotional Growth
Development By Age
Birth to Two Months
Two to Four Months
Four to Six Months
Six to Nine Months
Nine to 12 Months
Watching TV: When And How Much Is Appropriate?
New Parent 411: Top 14 Safety Tips
Good Toys And Books

Chapter 11
DISCIPLINE & TEMPERAMENT

Getting To Know Your Baby’s Temperament

The 3 Rules Of Cry Management
10 Tips For Soothing The Savage Beast: Newborns
The Great Binky Debate
What Is Colic And What Can I Do About It?
A Miracle Cure for Colic?
Planting The Seeds Of Discipline
11 Tips For Developing A Discipline Style
Special Situations: Separation Anxiety, Thumb Sucking

SECTION FOUR: SICKNESS & HOW TO AVOID IT!

Chapter 12
VACCINATIONS

Vaccines: A Bit Of History

The 5 Biggest Misconceptions
The Top 15 Vaccine Questions
7 Truths About Vaccines
The Vaccination Schedule
Vaccines And The Diseases They Stop
Vaccine Controversies: MMR/Autism, Thimerosal & More
Thimerosal 411
Vaccine Additives: What are They?
Alternative Vaccine Schedules
Aluminum 411
Vaccine Shortages

Chapter 13
COMMON INFECTIONS

What Are Viruses?

The Common Cold
Humidifiers & Vaporizers
What Are Bacteria?
What’s The Difference? Bacterial Infection Vs. Virus
Antibiotic Resistance
When Your Child Can Return To Childcare Or Playgroup
Viral Infections: Flu, Croup, Chickenpox
Bacterial Infections: Food Poisoning, Pneumonia and more
Things That Make You Itch
Special Feature: Ear Infections
7 Risk Factors For Ear Infections
The Infection Hit Parade

Chapter 14
COMMON DISEASES

Eyes: Lazy Eye

Lungs: Asthma, Bronchiolitis
Heart: Murmurs
Blood: Anemia, Sickle Cell Disease, Iron Deficiency, Lead Exposure
Skin: Eczema
Muscles/Bones: Intoeing, Bow-Legged, Flat Feet
Endocrine: Diabetes
Allergies: Seasonal, Environmental
Genitals
What’s That Smell? Unusual Odors

Chapter 15
THE ENVIRONMENT AND YOUR BABY

Why Are Children More Vulnerable?

The Top Eco Hazards
Food: Additives, Contaminants, Facts & Fables
Formula, Breastmilk
6 Ways To Reduce Pesticide Exposure
RBGH, Nitrates, High Fructose Corn Syrup
Artificial Sweeteners, Food Coloring, Grilling
Home: Water, BPA, Phthalates, Lead
Formaldehyde, Cleaning Products, Carpeting, Pesticides
Air: Indoors/Outdoors
28 Tips for Reducing Eco Hazards

SECTION FIVE: FIRST AID—TOP 12 PROBLEMS &

SOLUTIONS
Chapter 16
FIRST AID

9 Hints: Making The Most Of A Call To Your Doc

Your First Aid Kit
How To Take Your Baby’s Vital Signs
Making A Diagnosis Over The Phone?
The Top Problems & Solutions
Abdominal Pain
Allergic Reaction
Bleeding And Bruising
How To Avoid Food-Poisoning
Burns
Breathing Problems (Respiratory Distress)
Everything You Wanted To Know About Croup
Choking Emergencies: 4 Tips
Cough & Congestion
Diarrhea
How To Tell If Your Baby Is Dehydrated
Vomiting
Eye Problems: Pink Eye, Blocked Tear Ducts
Fever: A Special Section
How To Take Your Baby’s Temperature
10 Commandments To Treating A Fever
Poisoning
The Most Dangerous Household Products
Rashes
Seizures
Does It Need Stitches?
Trauma: Injuries To The Head, Neck, Back, Eyes

SECTION SIX: THE REFERENCE LIBRARY

Appendix A: Medications
Appendix B: Alternative Medicines
Appendix C: Lab Work & Tests
Appendix D: Glossary
Appendix E: References
Appendix F: Footnotes
Index
How To Reach The Authors, Baby411.com
Our Other Books: Toddler 411, Expecting 411
ICONS

Helpful Hint

Reality Check

Bottom Line

Red Flags

Feedback from the Real World

Old Wives Tale

Insider Secrets
New Parent 411
 WHY READ THIS BOOK?
Intro

WHAT’S IN THIS CHAPTER

MEET THE AUTHORS
HOW TO USE THIS BOOK
NO ADS! NO PLUGS!
SHOW US THE SCIENCE
THE 6 GROUND RULES FOR BEING A PARENT

Welcome to the world of parenthood. Yes, having a baby is both

exciting . . . and terrifying.
Soon, you’ll be responsible for taking care of this little urchin 24/7, with
no time off for good behavior. We’ve been there—and know what it feels to
stand on the edge of the new parent abyss wondering just what the heck we
were doing.
Once your baby is born, your thoughts will be swimming with dozens of
questions . . . from the mundane (what’s THAT in my baby’s diaper?) to the
serious (Why won’t my baby stop crying? Does he have a fever? Should I
call the doctor?).
That’s why we are here. Think of us as your sherpa guide as you climb
Mt. Everest Baby. You need detailed, up-to-date info about taking care of
your baby—we’ve got it. You want straight answers on hot topics like
vaccines, circumcision and toxic baby cereal—again, we’re there.
 Yes, we realize there are many other baby books out there, all promising
to reveal the secrets to taking care of your baby. So, does the world really
need another baby book? Let’s put that into bold type.

Does the World Need Another Baby Book?

Well, darn it, we think so. Yes, if you stand in the parenting aisle of your
local bookstore, you’ll be assaulted by an avalanche of baby books with
titles like Your Baby’s First Year: Second by Second . . . and our personal
fave, We Know More Than You: What Celebrities & Supermodels Can
Teach You About Being a Parent.
All that is well and good, but we found that MOST baby books miss the
mark when it comes to nuts and bolts issues—like how do you clean a
baby? And feed it? And what happens when something goes wrong, like
God forbid, your baby gets sick?
And let’s not forget about the new addition to your family—no, not your
baby. We’re talking about your baby’s doctor. How do you pick a
pediatrician? And how do you get along with this person? Can you call your
doc at 2am and ask a question about diaper rash? (Short answer: yes, but
don’t expect the doc to be real cheery on the phone).
When it comes to offering advice about medical issues with newborns,
most baby books fail because, well, they aren’t written by someone who’s
actually been to medical school. Yes, there are guidebooks written by
“girlfriends” and other so-called experts . . . but for actual medical advice,
we’d prefer someone who knows more about medicine than you can learn
from watching Grey’s Anatomy.
Okay, to be honest, there are a few baby books written by doctors and
nurses. But we found many so boring and dry, they are listed as FDA-
approved cures for insomnia. (Not that new parents will ever have that
problem, of course).
And other good books on babies by respected docs haven’t been updated
since the Reagan administration. Sorry, the world of baby care moves at
Internet speed these days, so a book published ten years ago isn’t going to
cut it when it comes to a topic like cord blood banking. We’re proud that
this book contains the very latest recommendations and controversies
swirling around the world of babies.
Finally, let’s talk about our biggest pet peeve when it comes to baby
books: generic advice. Too many books on babies are marred by a lack of
specifics and detail.
We get the feeling that authors water down their advice and opinions so
as not to offend any reader. While that’s nice, it doesn’t help when you want
a specific answer to a question you have at 3am with your baby. As new
parents, we wanted detailed, specific answers to our questions about our
newborn—not bland generic platitudes.
Yes, despite all the resources available to new parents (books,
magazines, the web), it is amazing how we all end up asking all the same
questions as new parents: will we ever sleep through the night again? How
come this breastfeeding thing is so difficult? How do I take my baby’s
temperature? And another 337 questions like that.
That’s why we wrote this book—think of it as an FAQ for new parents.

Meet the New Authors, Same as the Old Authors

This book was created by the same team that brought you Baby Bargains
—Denise & Alan Fields. This time, we’ve added a twist: a co-author, Dr.
Ari Brown.
Actually, Dr. Brown has written the majority of this book . . . especially
the detailed medical advice. An award-winning pediatrician in private
practice in Austin, TX, Dr. Brown graduated from the Baylor College of
Medicine. She did her pediatric residency at the renowned Children’s
Hospital in Boston, and serves as a spokesperson for the American
Academy of Pediatrics. In short, Dr. Brown knows her stuff.
Denise Fields brings her 25 years of experience as a consumer advocate
to Baby 411—as the co-author of Baby Bargains, Fields has been featured
on Oprah and in the Wall Street Journal. For Baby 411, Denise adds in her
experience as both a mom and author—many of the questions we get on our
message boards hit the same hot button issues you’ll see here.
As always, the secret sauce to our books is reader feedback. First, you’ll
notice readers of our previous books contributed to this book—you’ll see
their “Real World Feedback” when it comes to topics like child care,
feeding and more. Second, look at the questions we list in each chapter.
These are the frequent questions asked by patients of Dr. Brown and the
readers of Baby Bargains . . . and the same questions that most first-time
parents ponder.
Yes, both of the authors of this book are also mommies. They have four
children between them. Best of all, the authors are from your generation—
we know you want detailed info, the latest research and trends, plus handy
online resources.

How to Use this Book

Instructions: Open cover. Start reading.

Just kidding! We realize you know how to read a book, but let’s go over
a few details on how to get the most out of Baby 411.
First, let’s talk about BIG UGLY LATIN WORDS. You can’t discuss
baby’s health without whipping out the Latin. To keep the jargon from
overwhelming you, we have a handy glossary at the end of this book. When
you see a LATIN WORD in bold small caps, turn to the back to get a quick
definition.
Second, if you flip through the chapters, you’ll note boxes with Dr. B’s
opinion. As it sounds, these are her opinions on several hot button issues.
Feel free to disagree with these thoughts, but they are based on years of
seeing real-world patients and talking with parents. Unlike some other
parenting books, we think readers deserve to know where the line is drawn
between fact and opinion. You can then decide what works for you and your
family.
Finally, let’s talk footnotes—we’ve footnoted the sources used
throughout this book. These references are in Appendix F in the back of the
book.

What? No one paid you to recommend a treatment?

 Yes, it’s true. No pharmaceutical or formula company has paid the
authors to plug their products or treatment in this book. Dr. Brown does
NOT go on all-expense paid junkets to Aruba to learn about the latest drug
or medical research (although she could use a beach vacation after writing
this book). The opinions in this book are those of Denise Fields and Dr.
Brown—in the latter case, based on her training and experience practicing
pediatric medicine.
Here’s how we make a living: we sell the book you are reading. Dr.
Brown also moonlights as a pediatrician in Austin, TX.
Full disclosure: we do have affiliate links on our web site. We use
software to affiliate links posted by users of our message boards, which are
free. If you click on a link and purchase the product, we may receive a
small commission. There are ads on our message boards (visible only to
unregistered users) and other parts of our web site. These revenue sources
are used to pay for bandwidth and server maintenance.

Show us the Science!

The goal of Baby 411 is to provide you with the most up-to-date medical
info on your baby. We’re talking state-of-the-art when it comes to your
baby’s health and nutrition.
So, in the age of Internet rumors and 24/7 cable news, let’s take a
moment to talk SCIENCE.
When it comes to your baby’s health, our mantra is SHOW US THE
SCIENCE! Before we recommend a particular treatment, parenting method
or medicine, we expect there to be good science behind it.
What is good science? Good scientific research is conducted by
reputable researchers and published in a major medical journal, like the
New England Journal of Medicine. Good science is based on a large enough
sample to be statistically significant—and verified by peers before it is
published.
Contrast this to junk science. Much of what you see online is,
unfortunately, junk science—“research” done by questionable individuals
who are usually trying to sell a miracle cure along with their theories. Junk
science is often based on flawed studies that use too-small samples to be
relevant. Just because four of your friends have babies with blue eyes does
not mean there is an epidemic of blue-eyed babies on your block.
Much of the junk science you see online or read in the media is there to
push a political agenda. Sure, these zealots are well meaning, but they harm
their cause by hyping some obscure study from a doctor in Fiji as medical
“truth.”
Of course, this isn’t always so black and white—sometimes good
science is “spun” or hyped by groups who want to push their cause. And,
sometimes bad science is too tempting for the media to ignore.
To put this in perspective, let’s look at this example: a 2008 study from
Cornell University compared the rates of autism and the amount of rainfall
in a community. Researchers took a weak hypothesis (that spending
excessive time indoors would increase the chances of having autism),
performed mathematical acrobatics and presto! Rain = autism. If you live in
a community with lots of rain, your child has an increased chance of autism,
the study declared.
Bottom line: this was a flawed study that never should have been
published in the first place.
Of course, that didn’t matter to the media. Outlets like USA Today and
MSNBC reported that rainfall and autism were linked. And some autism
advocacy groups used this study as proof that indoor environmental toxins
were surely the reason for their children’s diagnoses. None of which is true.
This is just one example of how “science” gets distorted and warped as it
winds its way through the meat grinder of the web and media these days.
Here’s the take-home message: as your guides in Baby Health Land, we
hope to steer you toward the good science when making decisions for your
baby.

What’s New In This Edition?

As usual, we just can’t leave well enough alone! This updated and
expanded version of Baby 411 covers the latest, breaking health news on
babies. Here’s a quick look at what’s new:
The best way to introduce solid food is a hot topic in parenting circles—
leading to more angst than answers. Is baby-led weaning the way to go?
When should you give your baby his first taste of peanut butter to avoid
food allergies? Can you give your baby squeezie food pouches until he goes
to college? We’ll break it down for you and make the experience stress-free
(but still very messy).
After the 2015 Disneyland measles outbreak made national headlines,
we’ve got the updated guidelines on how to protect your child from this
potentially deadly infectious disease.
And what about technology and babies? Even though your baby might
be able to navigate an iPad better than you, is it a good idea to let him?
We’ll give you some straight talk on screen time, as one of the authors of
this book (Dr. Brown) wrote the national policy statement for the American
Academy of Pediatrics on media use and young children.
And, like every new edition, you can be sure you are reading the most
recent research and data on every child health topic.
Now that you know what’s new, let’s go over some ground rules.

The Six Ground Rules for Being a Good Parent

1 THERE ARE NO GROUND RULES. Well, what we mean is there are no

absolute truths. Thanks to that quirky thing called DNA, every baby is
different. Yes, there are “general” guidelines that will help you be a good
parent (and we’ll spend the next 500+ pages giving you those guidelines),
but there are no absolute truths. Your baby will consistently amaze,
surprise, frustrate and confound you. Did we mention surprise?

2 CHECK YOUR PRIORITIES AT THE DOOR. Make a list of all things that
are important in your life—your friends, house, etc. Now, crunch that list up
into a little ball and throw it out the window. Your baby is now priorities #1
through #17. Example: your house. Don’t expect it to be clean again until
2026.

3 GO WITH YOUR GUT. Well-meaning people—friends, your parents,

book authors, complete strangers—are going to try to advise you as to
what’s best for you and your baby. That’s nice, but after a while you are just
going to have figure out this parent thing on your own. Think of it like
flying a plane . . . you can sit in a flight simulator all you want, but taking
the controls in a 747 zipping along at 500 MPH at 30,000 feet is more like
what it feels like to be a real parent.

4 SCHEDULE TIME FOR YOURSELF. Want to take a shower after your

baby is born? You’ve got to schedule that 15 minutes. After the first couple
of months (or sooner), take time OFF from being mommy and daddy. Have
a friend or babysitter watch the baby and go out to dinner and a movie.
Give your spouse a break once a week for an hour of “hobby time.”

5 CALLING ALL FAVORS. Don’t be afraid to ask for help—and feel free to
lean on your friends and relatives, at least through the first few weeks.

6 BELIEVE IN YOUR CHOICES. No matter what you decide for your family
(breastfeeding, work, child care, etc), you’re going to hear sniping from
others. Often, guilt-driven folks feel defensive about what they decided for
their own kids . . . so, they take it out on you. Nice, eh? The best advice:
surround yourself with supportive friends who can counter any negativism.

Baby411.com: Advice, Updates & More

Pop by our web site at Baby411.com for all sorts of goodies—advice,

updates and more. Our famous Rash-o-Rama lets you see pictures of
common rashes. And don’t forget to like us on Facebook
(facebook.com/expecting411) and follow us on Twitter (@baby411) for the
latest breaking news on infant health, reader questions and answers and
more.

Major Legal Disclaimer

 No medical book about babies is complete without that ubiquitous legal
disclaimer . . . so here’s ours:
The information we provide in this book is intended to help families
understand their baby’s medical issues. It is NOT intended to replace the
advice of your doctor. Before you start any medical treatment, always check
in with your baby’s doctor who can counsel you on the specific needs of
your baby.
We have made a tremendous effort to give you the most up-to-date
medical info available. However, medical research is constantly providing
new insight into pediatric healthcare. That’s why we have an accompanying
website at Baby411.com to give you the latest breaking updates (and why
you should also discuss your baby’s medical care with your baby’s doc).

Okay, enough of the introductions—let’s get rolling. First up: preparing

for your new baby. You’ve got decisions to make . . . we’ll discuss this first.
BABY
411
 Section 1

3-2-1 Baby!
Preparing for the New One
BIRTH DAY
 Chapter 1
“Giving birth is like taking your lower lip and forcing it over your
head.”
~ Carol Burnett

WHAT’S IN THIS CHAPTER

CUTTING THE CORD, LITERALLY
DETAILS OF YOUR BABY’S FIRST PHYSICAL EXAMINATION
VITAMIN K, EYE OINTMENT
YOUR BABY’S FIRST MEAL
THE FIRST FEW DAYS WITH YOUR NEWBORN
MORE TESTS AND PROCEDURES
THIS WASN’T IN THE BIRTH PLAN
JAUNDICE
OPTIONAL TESTS AND PROCEDURES
GOING HOME/2 WEEK SURVIVAL GUIDE
SPECIAL SITUATIONS: PREEMIES, ADOPTION

Birth Day is finally here—the most incredible day of your life. You have
prepared the nursery and taken the childbirth class, breastfeeding class, and
baby care class. You’ve bought too many childcare and parenting books.
Hopefully, you’ve also met with your pediatrician (see Chapter 2, “You and
Your Baby’s Doc”). So you’re ready, right?
There is no way anyone can prepare you for this, but this chapter will
guide you through your baby’s first days of life. Let’s leave the giving birth
part to the pregnancy books (see our other book, Expecting 411) . . . Instead,
we’ll focus on what happens once your baby is born. This chapter will give
you an overview of your newborn, head to toe. It also includes a handy two-
week survival guide, which you will want to bookmark!
Many people are not aware of this, but your baby’s healthcare begins with
his first check up right after birth. Why, you may ask? Because entering the
world is a big transition. Babies who are still inside the womb may have
certain medical problems that do not show themselves until they take their
first breath of fresh air. It is very helpful in the world of modern day
medicine to have ultrasounds, lab tests, and amniocentesis to get a glimpse
of potential problems in your baby—but they don’t cover every issue.
Also in this chapter, we’ll explain a few decisions you should make
before giving birth. You may desire additional tests and procedures for your
baby post-delivery, which are only options if you plan ahead. And we will
address the unique issues related to having a premature baby or adopting a
newborn.
This chapter will also cover things you don’t have in your birth plan, such
as delivering a premature baby or one who needs some additional medical
attention after delivery.
That is a ton of ground to cover, so let’s start with your baby’s first
moment of life.

Cutting the Cord, and Your Baby’s To Do List

Q. Can my partner cut the umbilical cord?

Yes. But, your partner is also allowed to say no—especially if the sight of
blood induces nausea or fainting.
If your partner wants to cut the baby’s cord, this event occurs after the
baby has come out and after your practitioner has placed two clamps (about
one inch apart) on the cord. (Don’t worry, your doc will give the cue).
Your partner cuts the cord with a pair of scissors (provided by your
practitioner) between the two clamps. The umbilical cord is a little rubbery
so it often takes a few snips to complete the job. It also can spray blood—
you’ve been warned!
Q. I’ve been told that we should wait to cut the
umbilical cord until after it stops pulsating. Why?
This is debatable. Experts disagree regarding the benefits of cutting the
umbilical cord right after delivery or waiting for up to three minutes for the
cord to stop pulsating (giving baby additional blood from the placenta).
In the U.S., docs routinely cut a newborn’s umbilical cord sooner rather
than later. If your baby is in distress and there is a concern for his health, the
obstetrician (OB) wants to cut the cord right away and immediately hand the
baby over to the pediatric team. The OB also needs to cut the umbilical cord
quickly if you want to store your baby’s cord blood. Otherwise there is not
enough cord blood to save.
However, some studies show a small benefit to waiting a few minutes for
babies whose birth weights are five to six pounds because it gives them a
mini blood transfusion. Unfortunately, these are often preterm babies who
are in distress and need a quick cord cutting and immediate care.
A 2015 Swedish study found that four year old boys outperformed male
counterparts in fine motor skills if they had delayed cord clamping at birth.
Researchers attribute this to the additional iron-rich blood that delayed cord
clamping provides to newborns.
So, should you cut the cord sooner or later? Later—if you have a healthy
baby and do not plan to store the cord blood.

Q. When does the OB collect blood for cord blood

banking?
Within minutes after delivery. So, if this is something you want to do (it’s
optional), you need to plan ahead for it. We’ll discuss optional tests and
procedures later in this chapter.
Here is how it typically goes. The baby comes out and your practitioner
(usually) puts her right up on mom’s chest. If a couple wants to bank their
baby’s cord blood, your practitioner places two clamps on the cord right
after delivery and the cord is cut (either by your partner or by your
practitioner).
 Once the cord is cut, your practitioner places a needle into the largest
vessel in the umbilical cord to drain as much blood as possible into a bag or
syringe. The goal is to get as much blood as possible before the vessels
spasm and the placenta begins to separate from the wall of the uterus. Once
that happens, no more blood flows through the umbilical cord.

Q. When will I be able to hold the baby for the first

time?
If the delivery goes smoothly and the baby is doing well, you can hold
your baby pretty soon after his big entrance.
He will be covered in blood and white cheesy stuff (VERNIX) and
sometimes poop (MECONIUM). In other words, he’s all wet. And that means
he is going to get cold pretty fast. So, the staff needs to vigorously dry him
off with towels first and either places him skin to skin on your chest or puts
him on a small exam table that has a heater (warming table). The vigorous
rubdown stimulates your baby to breathe and gets his circulation going. The
delivery team staff also suctions his mouth and nose to remove thick
secretions.
The team will do a quick assessment (see APGAR test below), and then
you get to snuggle for the first time together.

Q. Does my baby need to study for the Apgar test?

No. He probably won’t score a perfect “10” either—those foreign judges
are so critical of the dismount. Just kidding. The Apgar test determines
which babies need extra help adjusting to life outside the womb. They are
given a score from zero to ten. Your baby’s Appearance (color), Pulse (heart
rate), Grimace (reaction to stimulation), Activity (tone), and Respiration rate
are assessed at one minute of life and again at five minutes. Babies who
endure difficult deliveries often have low (less than five) Apgar scores at one
minute then perk up (greater than seven) at five minutes. The babies that
don’t rise in their scores may need observation and assistance by medical
staff. Rest assured, low Apgar scores do NOT correlate with low SAT scores
and future intelligence.
Reality Check
If the baby has an immediate problem (such as trouble breathing), he may
get whisked over to the warming table in your delivery suite or even off to
the neonatal intensive care unit.
If your newborn has an urgent health issue, the hospital may ask a
neonatologist (newborn intensive care specialist) or a staff pediatrician in the
hospital to care for your baby immediately.
If you deliver at a birthing center or at home and there is a problem, your
baby would need to be transported to the nearest medical facility via
ambulance.
This is very unsettling if you have a perfect vision planned of those first
moments together with your newborn. If this should happen to you,
remember that your baby’s health is the utmost priority. Even if you don’t
get to bond in those precious minutes right after delivery, you still have time
later—and we promise it won’t impact your long-term relationship with your
child.

Q. When is my baby examined for the first time?

Your baby will be examined several times, so be prepared. If you deliver
at a hospital, the delivery healthcare staff performs the first overall exam on
your baby after you have a little bonding time. They measure his weight,
length, and head circumference. They also place an ID band on his ankle as
well as a security clip. Eye ointment and a Vitamin K shot are routinely
administered at this point. We’ll explain the importance of these two
therapies in the section to follow.
He will eat his first meal, and then while you are getting cleaned up
(childbirth is pretty messy), your baby will be observed for the first couple
of hours in the nursery. That is when he will have a complete head to toe
exam by the nursery staff. They will monitor his heart rate, respiratory rate,
body temperature, and oxygen level. That’s the time your baby also gets any
blood drawn for lab tests should any be necessary (blood sugar, blood count,
blood culture).
Your baby can get cleaned up after she proves she can maintain her body
temperature. After all those hurdles, your baby is ready to join you in your
postpartum room.
The nursery staff notifies your baby’s doctor about the birth. The doctor
will examine the baby and visit with mom and dad (that’s you—has a nice
ring to it) within 24 hours of the birth and then daily until you are discharged
home. If your personal pediatrician does not make hospital rounds, a
pediatrician on the hospital staff will take care of these initial exams.

Reality Check
If you deliver at a birthing center or at home, the midwife/practitioner does
the initial and follow up examinations of your baby; the pediatrician meets
your baby at two weeks of age. (Alternatively, your pediatrician may enter
the scene at two months of age if the midwife handles the two-week visit).

Q. Tell me about the baby’s first exam. What are you

looking for?
Bear with us—this stuff is a little dry, but we think it will help you to
understand what your doctor is doing. It will also make you appreciate how
fortunate you are to have a baby who makes an A+ on his first exam!

Vital Signs
This includes heart rate (pulse), breathing rate (respiratory rate), body
temperature, and weight. Abnormalities can indicate infection, dehydration,
and heart/lung abnormalities. These are checked at least every eight hours.
Babies are weighed daily. Input (length of breastfeeding/amount of formula)
and output (number of pees and poops) are also documented.

The Head
 Shape of the head. (Your baby will not be a permanent member of the
Conehead family—it rounds out after a few weeks). The skull bones
often overlap right after delivery (that’s what allows the baby’s head
to leave the birth canal) so there may be a firm ridge present. Those
ridges go away in the first week of life.
Bruises from the trauma of delivery caused by forceps, vacuum, or
pushing on your pelvic bones for two-plus hours. Big bruises can
take six to eight weeks to resolve (see CEPHALHEMATOMA)
Soft spot. The soft spot (ANTERIOR FONTANELLE) in the middle of the
skull is open with room for the brain to grow (see
CRANIOSYNOSTOSIS). There is also a very small soft spot on the
back of the skull called the posterior fontanelle, which is sometimes
large enough to feel at birth.

The Eyes
Red reflex. Doctors use a special light to see the baby’s red reflex (the
“red eye” you see in flash photography pictures). CATARACTS and
eye tumors (see RETINOBLASTOMA) are two problems doctors are
trying to catch here.
Broken blood vessel. SUBCONJUNCTIVAL HEMORRHAGES are broken
blood vessels in one or both eyes that can happen when the baby is
pushed through the birth canal. These are common and go away in a
few weeks.
Tear ducts. Many newborns get clogged tear ducts (see
NASOLACRIMAL DUCT OBSTRUCTION). The ducts are narrow and
cause the tears to get goopy and make the eye look infected. This can
come and go for your baby’s entire first year of life. We’ll cover this
issue later in Chapter 15, “First Aid” in the eye problems section.

Reality Check
Newborns can only see 8 to 12 inches in front of them. They can see you if
you bring their face up close to yours. They frequently look cross-eyed for
the first two months. Most newborns are born with blue eyes—we can’t
predict their true eye color until about six months of life.

The Ears
Eardrums are checked, as well as abnormal formations of the outer part
of the ears (see PREAURICULAR PITS, SKIN TAGS).
A hearing test should be performed on all newborns. No, we don’t ask
them to raise their hand when they hear the beep. The baby wears
headphones and we measure the electrical activity of the brain when
a noise is made. (See BAER). We’ll discuss more about hearing
screening in the Tests section of this chapter.

The Nose
Can baby breathe through his nose (see CHOANAL ATRESIA)? By the
way, all babies have stuffy noses at birth and continue to have nasal
congestion for the next four to six weeks (see NEWBORN NASAL
CONGESTION).

The Mouth
Formation of the mouth. A doctor will check to make sure the roof of
the mouth (palate) has formed and the funny thing hanging in the
back of the mouth (uvula) is there (see CLEFT LIP and CLEFT
PALATE). Some babies are born with white pimples on the roof of
their mouths (see EPSTEIN’S PEARLS) that go away on their own.
Tongue. Your baby’s tongue is checked for a forked tip or any trouble in
moving it. This is called a tongue tie or a tight frenulum (see
ANKYLOGLOSSIA). This can be a significant issue when it comes to
successful and comfortable breastfeeding (see more in Chapter 6,
“Liquids”), so it is important to identify this abnormality shortly after
birth.
Gums. Many babies have white pimples on the gums that go away on
their own. These are not teeth—the first tooth usually comes out
between six to 12 months of age. However, every once in a blue
moon (I’ve never had a patient with one in 20 years), a baby is born
with a tooth. These are called NATAL TEETH!. They usually fall out
on their own, but occasionally need to be pulled.
The Throat
Breathing. Occasionally, babies make unusual noises when breathing.
Some babies are born with floppy breathing tubes (see
LARYNGOMALACIA) that they will outgrow. This squeaky noise
really concerns parents (because it sounds strange), but is usually of
no consequence.

The Neck and Shoulders

These areas are checked for any unusual lumps, bumps, or cysts (see
BRANCHIAL CLEFT CYST).
If birth was difficult (big baby, small mommy), the collarbone can break
(see CLAVICLE FRACTURE, SHOULDER DYSTOCIA).
Can your baby turn its head to each side? Some babies will have a stiff
neck muscle that limits head motion (see TORTICOLLIS).

The Chest
Doctors look for any signs of labored breathing (see RESPIRATORY
DISTRESS). Adults breathe 12 times per minute at an even rate.
Newborns breathe 30 to 40 times per minute and have episodes of
PERIODIC BREATHING. So, your baby will breathe rapidly several
times, p-a-u-s-e, then breathe again. That pause will seem like an
eternity to you. It is normal. Signs of respiratory distress are:

1.A pause between two breaths that lasts 15-20 seconds (see APNEA).
2.Baby is consistently breathing over 60 times per minute. (see
TACHYPNEA OF NEWBORN)
3.Baby’s ribs are sucking in at each breath, nostrils are flaring, grunting
noises are heard (see RETRACTIONS, RESPIRATORY DISTRESS)

The Heart and Circulation

Murmurs (unusual noises), irregular heartbeats, fast or slow heart rate,
unusual discoloration (pale or dusky blue). Many heart problems,
especially severe defects (see CONGENITAL HEART DISEASE) are
now detected on fetal ultrasounds. However, doctors listen carefully
with their good old stethoscopes to pick up abnormalities.
 Baby’s pulses are carefully checked, particularly those in the groin area
(femoral pulses). The main blood vessel (aorta) supplying oxygen
rich blood to the body can have kinks and narrowings (see
COARCTATION OF AORTA) causing a weakened pulse in the groin.
Most hospitals routinely assess for potential heart defects by
checking a newborn’s oxygen supply with a non-invasive monitoring
device.
A normal, benign murmur is often heard in the first 24 hours of life, as
the newborn’s circulation transitions from that of the fetus. This
murmur, often called a TRANSITIONAL MURMUR resolves within the
first few days and does not represent a problem.
Purple hands and feet (see ACROCYANOSIS) are due to newborn
circulation. Your baby is merely attempting to adapt to life outside
the womb. This is normal and can last from weeks to sometimes
months, especially after exposure to cold, or following a bath.

The Abdomen
Your baby’s doctor will feel her belly to check the size of her liver and
spleen. The belly should be soft and not hurt to touch. Abnormally
large body organ size can be caused by problems metabolizing foods
(see METABOLIC STORAGE DISEASE) or poor heart function (see
CONGESTIVE HEART FAILURE). Abnormal fullness or distention
alerts doctors to look for ABDOMINAL TUMORS.
Firm or full bellies may be a sign of abnormal intestine formation (see
MALROTATION, DUODENAL ATRESIA). An abnormal exam and
problems feeding—that is, vomiting, especially bile, will be a tip off
to investigate things further.
A baby is expected to pass one stool called MECONIUM in the first 24
hours of life. If a baby doesn’t poop on Day 1, we evaluate for
abnormal anus formation (see HIRSCHSPRUNG’S DISEASE, ANAL
ATRESIA) or poor stool formation that can be seen in cystic fibrosis
(see MECONIUM PLUG, CYSTIC FIBROSIS).
Sometimes the belly button (umbilicus) pops out. This is the extreme
form of an “outty” (see UMBILICAL HERNIA) and often resolves on
its own.
Factoid: Your doc will check the umbilical cord stump to make sure the cord
had two umbilical arteries and one vein. In rare cases, cords have only one
umbilical artery—this can be a sign of kidney malformation. Your doctor
may order an ultrasound of your baby’s kidneys to rule that out.

Old Wives Tale

Placing a coin or a Band-Aid on the belly button will help the “outty” belly
button go in. FALSE. Time is the best therapy.

The Genitals
BOYS
For boys, the baby’s doctor makes sure both testes are in the scrotum.
Occasionally, one or both testes will not make the pilgrimage south
(see UNDESCENDED TESTES).
For boys, the fullness of the scrotum is also checked. Many boys are
born with extra fluid in the scrotum that goes away over the first six
months of life. (see HYDROCELE) The other thing that causes
fullness is a hernia—part of the intestine that has pushed into the
scrotum (see INGUINAL HERNIA). Cool doctor trick: we can tell the
difference by shining a light on the scrotum. Fluid (hydrocele) is
light and intestine (hernia) is dark.

Normal penis

For boys, the baby’s doctor will make sure the opening (urethra) is at
the tip of the penis. The opening can abnormally develop on the
under-surface of the penis shaft (see HYPOSPADIAS, see picture at
 right) or on topside (see EPISPADIAS). Boys with this problem are
not routinely circumcised because the foreskin is needed to surgically
correct it around six months of age.

Hypospadias

GIRLS
For girls, the vagina and urethra (the holes tucked inside the lips) are
checked. The lips (labia minora) can be stuck together (see LABIAL
ADHESION). Usually, you see some white mucousy fluid (see
VAGINAL DISCHARGE). This is normal. Occasionally, newborn girls
also have some vaginal bleeding (see What’s That in My Baby’s
Diaper? question in the “Getting to Know You” section later in this
chapter). Dads—you need to learn how to clean this area well. (See
Chapter 4, “Hygiene” in the “Girl Parts” section for details.)

BOTH SEXES
When the clitoris looks too large, or the penis looks too small, your
doctor will evaluate for problems with the baby’s hormones or
chromosomes. (see AMBIGUOUS GENITALIA)
Breast or nipple enlargement: For both sexes, the breasts can be swollen
due to Mom’s hormones passing through to baby. It is temporary and
they shrink back down on their own. And just to really freak you out,
a baby’s breast will also occasionally secrete milk (called Witch’s
Milk) in the first weeks of life.
Accessory (or SUPRANUMERARY) nipples: About one in 40 babies will
have extra nipples (more common in African-American babies).
They are usually brown and flat and just look like a birthmark.
They’re not functional and don’t cause any problems.

The Kidneys and Bladder

 Expect the baby to pee (urinate) once in the first 24 hours of life. We
start investigating if this does not occur.
Abnormal formation of the passageway from the kidneys to the bladder
(see VESICOURETERAL REFLUX, POSTERIOR URETHRAL VALVES)
can occur in rare occasions. An evaluation for this is done if a baby
develops a bladder or kidney infection. (see URINARY TRACT
INFECTION, PYELONEPHRITIS)

The Spine and Nervous System

Your baby’s doctor will look for dimples or tufts of hair near the
buttocks. Abnormalities on the skin can be a clue to a spine
abnormality underneath the skin (see SACRAL DIMPLE, NEURAL
TUBE DEFECT, SPINA BIFIDA).
Also checked: the newborn’s unique reflexes that fade over the first six
months of life. It tells us their brain and nerves are coordinated. (see
CEREBRAL PALSY) These reflexes include: Rooting (turning the head
when the cheek is rubbed), Sucking (automatically sucking on objects
placed in the mouth), Palmar Grasp (closing fingers on object placed
on the palm), and Moro (body startles when head is dropped back).

The Arms and Legs (Extremities)

Do both arms move? A weakness of the nerves causes a limp arm. (see
ERB’S PALSY)
Many people are familiar with purebred dogs with hip problems.
Humans can have similar problems. We check the hips by rotating
them in and out. If there is a concern, we’ll order an ultrasound to
look at the hips. Breech babies have a slightly increased risk of this
disorder. (see HIP DYSPLASIA)
Rarely, babies will have extra fingers and toes, and some that are fused
together (see POLYDACTYLY, SYNDACTYLY).
A severe deformity (see CLUB FOOT) makes the bottoms of the feet
face each other and requires casting. This occurs in about 1 in 1000
births.

The Skin
 Brown birthmarks: Moles (see CONGENITAL NEVUS) and light brown
oval shaped areas (see CAFÉ AU LAIT SPOTS) are permanent
markings and rarely are related to other medical problems.
Purple birthmarks: These marks (see PORT WINE STAINS) are
permanent and can be quite large. If they are located on the face,
your baby’s doctor will look for other medical problems (see
STURGE-WEBER SYNDROME).
Red birthmarks: These marks (see STRAWBERRY HEMANGIOMA) may
be seen at birth, or by the first month of life. They start out flat, grow
much larger and become raised. These particular marks shrink and go
away by the age of ten.
More red birthmarks: Red marks known as stork bites and angel kisses
(see NEVUS FLAMMEUS, FLAT ANGIOMATA) are on the back of the
neck or eyelids and fade over the first few months of life. When your
baby gets mad at you, you will see them turn even redder.
Blue, bruise-like marks: These spots (see MONGOLIAN SPOTS) are
found on the buttocks of dark skinned babies. They fade over several
years.
Yellow skin: This is a whole topic in itself—see JAUNDICE in the
“Getting to Know You” section later in this chapter.

Go to our web site Baby411.com for pictures of all of these common

birthmarks. Click on “Bonus”.

Reality Check
Newborns are really rashy. Most rashes will come and go. You’ll have a
window of “photo opportunity” from two to three weeks of age when their
skin is clearer. Then more rashes crop up at four to eight weeks of age.
These are all due to fluctuating hormone levels. No matter what you do, they
will go away. A good thing to remember is your baby could care less. The
names are listed below. For details, refer to the glossary. (see ERYTHEMA
TOXICUM, MILIA, MILIARIA, NEONATAL ACNE, PUSTULAR MELANOSIS).
For pictures of these rashes, check out our web site Baby411.com (click on
“Bonus.”)

Q. Why do all babies get a shot of Vitamin K?

Vitamin K is essential for blood clotting. Most newborns have a
deficiency in Vitamin K because it does not efficiently cross the placenta
while fetuses are in the womb. Babies who are born with a severe Vitamin K
deficiency can have significant bleeding into vital organs (such as the brain,
see HEMORRHAGIC DISEASE OF THE NEWBORN). Since time is of the
essence, it makes more sense to give all babies Vitamin K than to test them
all and find out too late who really needed it.
Some parents have decided to decline the Vitamin K shot for their baby.
Why? A few alternative/natural parenting web sites have cast suspicion on
the Vitamin K shot, saying the shot itself is too invasive. Others question the
additives and preservatives in the shot.
We highly recommend the Vitamin K shot—there can be serious
consequences if you skip it. In 2013, four babies in Nashville needlessly
experienced brain hemorrhages when their parents opted out of this
extremely safe and simple vitamin injection. No, the shot does not cause
leukemia, autism, or any other malady. What about giving the Vitamin K
dose orally? Giving an oral Vitamin K supplement is not an effective
alternative to prevent this potentially tragic problem.

Q. Why do all babies get eye ointment?

Having a baby is messy. Some mothers carry bacteria that can lead to
serious eye infections in the baby. Again, it makes more sense to treat every
baby immediately than to test every mother at delivery and figure out which
baby needs it. Antibiotic ointment has low risk with great benefit.

Q. When do I get to feed the baby for the first time?

Assuming all is well after vaginal delivery and baby doesn’t need to go to
the nursery for any reason, you can start feeding him right away. If you have
a C-section, you may be able to nurse in the recovery room. If not, you can
nurse when you reach your postpartum room a few hours later.
Some babies want to eat immediately. It is easy to tell because they start
moving their lips and sticking out their tongues. They are usually very alert
for the first hour of life (and then they just want to get some shut-eye for a
few hours). So, it is best to try to get in a feeding while you have the
opportunity.
But some babies are coughing and sneezing to try to get all the fluid out
of their lungs. They have little desire to feed. Don’t worry if your baby
doesn’t want to eat right away. Breathing is a higher priority than eating, so
she will need to get the hang of it first (remember, she just learned how to do
this the moment she came out).
Whether you are nursing or formula feeding, those first feeding moments
can be awkward since you probably have no idea what you are doing. Don’t
be embarrassed to ask for help. Your baby is very forgiving.

NEW PARENT 411: WHY DO ALL THESE

TESTS?

Some parents feel uncomfortable with all the poking and prodding
their newborn endures. Trust us—there is a method to the madness.
Your doctor wants to make sure you are taking home a healthy baby!
Remember the key rule to all these tests: if it weren’t important, we
wouldn’t be doing it!

Q. Should I “room-in” with my baby at the hospital?

Yes. Once you and your baby get cleaned up after delivery, and all the
initial assessments are complete, your family will move to a postpartum suite
if you deliver at a hospital. The American Academy of Pediatrics
recommends baby stay in the same room (“rooming in”) to help make
breastfeeding successful. This will allow you to learn your baby’s hunger
cues and nurse before your baby is screaming and demanding to be fed.
However, we should warn you that babies are very noisy sleepers. Try not
to obsess over every squeak your baby makes. You need sleep to recover
from the delivery and produce milk.
If you are formula feeding, it is your call. We recommend rooming-in to
bond and get to know your baby. On the other hand, the nursery staff is
happy to baby-sit for a few hours while you get some shut-eye.
If you have a vaginal delivery, expect to spend 48 hours at the hospital
before heading home. If you have a C-section, plan to be recovering for
three to four days before discharge home.

Getting to Know You: Your Baby’s First Few Days

After your baby passes his first exam, the fun is just beginning—it’s time
for you the parent to get to know your little guy or gal. Let’s talk about what
you’ll experience for the first few hours . . . and days. This section will cover
changing those first diapers and more.

NEW PARENT 411: BIRTH TRAUMA

This is what happens when your baby is larger than your pelvis can
handle or just simply doesn’t want to leave the womb. Your newborn’s
head may be pressed against your pelvic bones for 2 hours or he may
have had forceps or a vacuum applied to his head. The result: a huge
bruise on his head caused by bleeding just under the skin that clots
and looks rather dramatic. (see baby411.com for a great picture).
Because the skin is also injured, a scab will form and peel off (like
a sunburn). The blood clot will get hard and leave a lump for up to
eight weeks. Not to worry, none of this is permanent.
Q. How often will my baby need to eat?
Eight is the magic number.
If you do that math, you might think that means that your baby will need
to eat every three hours over a 24-hour day. Sorry, newborns do not follow
any type of schedule. There is a time and place to begin routines and
schedules, but that happens around two to three months of age. Be patient.
Newborns like to cluster feed. They may want to eat every 90 minutes for
two or three feedings, then take a snooze for two or three hours.
Unfortunately, those cluster feedings often occur during the hours you would
like to be asleep. But somehow, they usually get to the minimum
requirement of eight feedings a day. Why do we let them be in charge? A
newborn that eats “on-demand,” eats better than one who is awakened and
told that it is time to eat.
Your baby will be very sleepy in the first couple of days of life, so
feedings will be relatively short (5-10 minutes per breast on Day 1, 10-15
minutes per breast on Day 2) or low volume (1-2 ounces if formula feeding).
But as long as he gets to the magic number of feedings, he is likely getting
enough to eat and your milk supply is getting revved up if you are
breastfeeding.
Check out Chapter 6, “Liquids” for more details on nursing.

Insider Secrets
Nursing feels like having a mini-vacuum attached to your nipple. So, it’s no
surprise that new moms feel a little discomfort with nursing until they get
used to that sensation. But if it hurts more than 10-20 seconds beyond the
initial latch, break the suction seal, reposition the baby, and try again. If you
have a bad latch, you will pay for it. See Chapter 6, “Liquids”, for more tips.

Q. Why am I being asked to track my baby’s feedings

and diapers?
 Keeping track of feedings—both duration of feeds and the number of
feeds—is very important in the first week of life to be sure breastfeeding is
going well and your baby is getting his nutritional needs met. See Chapter 6,
“Liquids” for more details.
Additionally, monitoring diapers (both pee and poop) tells us that your
baby is meeting his nutritional needs because what goes in is what comes
out. For the first four days, we expect to see the same number of wet and
poopy diapers as your child’s age (that is, one pee and one poop on Day 1,
four pees and four poops by Day 4). The poop also changes in color and in
texture over the first few days, signaling that your baby is actually eating and
eliminating his body garbage properly. We’ll want you to describe what you
see in that diaper as well—entertaining, no?
After you get the green light from your baby’s doctor, you can stop
tracking these things.

Q. What’s THAT in my baby’s diaper?

We’ve got an entire chapter (Chapter 8 “The Other End”) with
accompanying pictures on our website dedicated to poop (yippee!) but let’s
give you a brief primer on what you’ll be seeing in those first few diapers.

Black tar poop. The official name is MECONIUM. Doctors expect one of
these poops in the first day of life. If you see more, congratulations—you’re
on your way to being a diaper changing pro. See Chapter 8, “The Other
End,” Newborn Poop section for details.

Brick dust. Babies should urinate (pee) at least once in the first day as
well. If your baby is hovering around that 10% weight loss (see box in this
section, Why is My Baby Shrinking?), you may see a red-orange brick dust
spot in the diaper (see URIC ACID CRYSTALS). You’ll think it is blood, but
take a closer look. Blood gets absorbed into the diaper since it’s a liquid. The
crystal powder sits on the surface. It just means your baby needs to drink.
For a great picture of this, go to Baby411.com/bonus and click on the Visual
Library.
 Blood. Baby girls will have a “period” thanks to Mom’s hormones. Don’t
worry, they don’t get the PMS to go with it! This should only happen in the
first month of life and not again until puberty.

Gel balls. This did not come out of your baby. It is your super absorbent
diaper. When the volume of urine (pee) exceeds the diaper absorbency, the
gels rise to the surface. Your baby is not an alien and it is not a health
hazard.

Q. My baby sleeps all the time. Were my prayers

answered?
Wait until the baby gets home . . . you will find out then! All babies sleep
through their first two days of life. They have been through the same
experience as their Mom. They realize they have left the womb about the
exact moment you take them home (if you deliver vaginally). It is not the
magic of the nursery nurse’s touch (although you will feel inadequate when
faced with a screaming baby). Newborns don’t have the skills to pull it
together and settle down. You will need to figure out what soothes your
baby. We answer all of your sleep questions from birth to the first birthday in
Chapter 9, “Sleep.”

Q. I am getting a lot of different advice from nurses

and lactation specialists—who is right?
Everyone, sort of. You will meet many health care professionals in your
baby’s first few days. They will all have different approaches to the same
child health issues. To avoid frustration and confusion, realize that there are
many ways, for example, to position a baby to nurse. Just take it all in, then
figure out what works for you and your child. P.S. If you feel like you have
NEW PARENT stamped on your forehead, you do!
 NEW PARENT 411: WHY IS MY BABY
SHRINKING?

The shrinking baby phenomenon! No, it’s not a headline ripped

from the tabloids. Babies travel out of the womb with extra baggage.
They have about 10% more fluid than their bodies need. Over the first
few days of life, they will lose 10% of their birth weight, then quickly
gain about an ounce a day once they start eating (about their third day
of life). This is sure to cause you anxiety, particularly if you are
breastfeeding. For details, see the “infant calorie and nutrition needs”
section in Chapter 5, “Nutrition and Growth.”

More Tests & Procedures

Q. What other procedures and tests are done on my

baby?
Before your baby is discharged home, he will have a hearing screening
test, a newborn metabolic screen (blood test), and a bilirubin blood test to
assess for jaundice. Read on for more information about each test. It is also
standard of care for all babies to receive a Hepatitis B vaccination.

Q. When is the hearing screen done and will my

insurance cover the cost of it?
The American Academy of Pediatrics recommends hearing screening for
all newborns. The reason? Congenital hearing loss occurs in 3 per 1000
newborns. Early detection can make a considerable difference for a child’s
language development. The simple, non-invasive screening test is done
before your baby goes home from the hospital. Some birthing centers are
able to offer this screening, but if not, your pediatrician can advise you on
getting it done elsewhere.
Thirty-six states require the testing by law. However, only 17 states
enforce their legislation by requiring insurance companies to foot the bill for
the test. Even if a hearing test is not a covered benefit, however, you should
have the test done. (AAP) For more information on state laws and testing see
http://j.mp/hearingscreeninglaws.

Q. What is the newborn screening test?

The first newborn screening test dates to 1961, when Dr. Robert Guthrie
discovered he could diagnose a newborn with a genetic metabolic disorder
called phenylketonuria (PKU) using a little dried blood on some filter paper.
This was a huge deal because babies with PKU weren’t ordinarily
diagnosed until at least six months of age . . . after they were permanently
neurologically impaired.
Newborn screening has come a long way since then. Every state in the
U.S. now requires an extensive panel of blood tests on every newborn—
done with just a few drops of blood on filter paper.
Most of the tests detect “inborn errors of metabolism.” Translation: these
are diseases caused by a failure of the body to break down (metabolize)
certain products. If these products are not broken down, they start to build up
in the body and create problems—heart enlargement, intellectual disability,
and even death. Other tests screen for hormone abnormalities, blood
disorders, and cystic fibrosis.

Q. Do all babies get tested for metabolic diseases?

Yes. Every state in the U.S. performs a panel of blood tests on every
newborn. All states test for at least 26 standard or “core” disorders.
There are also tests for 25 additional disorders. Whether or not you are
required to do these tests varies by state. These 25 other diseases are very
rare and there’s no treatment, even if a diagnosis is made in the first weeks
of life. That’s why some states don’t require these tests. The five states that
offer the fewest tests on their state screen are: Arkansas, Kansas, Kentucky,
Louisiana, and Rhode Island. To find information on required screenings in
your state, go to the National Newborn Screening & Genetics Resource
Center (genes-r-us.uthscsa.edu). Or simply click on the link on our website
at Baby411.com.

Q. Are there more newborn metabolic screening tests

available other than those required by the state?
Yes. If you live in a state that only tests for core disorders, you can get
your baby tested for many more disorders on your own dime. Private
laboratories and academic institutions offer a low-cost expanded test that
screens for up to 60 metabolic disorders.
When blood is drawn for the state-mandated screening test (shortly after
birth or at the two week well check), additional blood can be used for these
optional tests. You can get more information from either your obstetrician or
pediatrician or check out genes-r-
us.uthscsa.edu/resources/newborn/commercial.htm for a list of non-profit
and commercial labs that perform expanded screening. The cost varies, but it
is usually about $35. You probably spent twice as much on a diaper bag.
Keep in mind that disorders tested for in the optional screen are quite rare
(about 1 in 56,000). That’s why some states weigh the cost of testing, the
low number of abnormal results, and lack of treatment and opt to test only
for the more common disorders.
Our opinion: in an ideal world, there would be one NATIONAL standard
for newborn screenings. But that just isn’t reality today.

BOTTOM LINE: Although most metabolic diseases are rare, early

detection is very important.

BEHIND THE SCENES: MORE ON OPTIONAL

SCREENS
 Although most metabolic diseases are rare, early detection is
critical to the health of an affected baby. Many states have expanded
the number of government-subsidized tests. However, some states still
only offer a bare bones minimum. If your state is one of those, you
can pay for additional testing on your own. FYI: If you choose to bank
your baby’s cord blood, you may get a “free” supplemental newborn
screen to go with it. For more information, here are some groups you
can contact:

1. Baylor Medical Center. Web: baylorhealth.edu (800)-422-9567

2. Mayo Clinic. Web: mayomedicallaboratories.com (800)-533-
1710
3. University of Colorado (303) 724-3826.

Q. Will my baby’s blood type be tested?

Sometimes. Blood types are not routinely tested in the hospital. This
might worry some parents, who are concerned that not knowing their baby’s
blood type immediately is dangerous. You should know that any person with
a medical emergency (such as a car accident) that requires a blood
transfusion gets type O negative blood regardless of his or her blood type. O
negative blood is compatible with ALL blood types. For less urgent
situations that require a blood transfusion, a person’s blood type is tested to
find a donor blood match.
Your baby’s blood type will be tested if Mommy has O blood type
because blood type incompatibility (i.e. baby is A or B) can lead to problems
with jaundice. See jaundice (ABO INCOMPATIBILITY) information in “The
411 on Jaundice” section later in this chapter.

Q. I am Group B Strep positive, does my baby need to

be tested?
Mothers are routinely screened at the 35th to 37th week of their
pregnancy for the presence of a bacteria that lives harmlessly in the genitals
and intestines of some healthy women. This bacteria, called Group B Strep,
can infect a newborn as he passes through the birth canal.
If Mom is a carrier for Group B Strep, she is given intravenous (IV)
antibiotics during labor to suppress the growth of this bacteria. If Mom goes
into labor before 37 weeks, has her water broken for more than 18 hours or
has a fever greater than 100.4 degrees, she also gets IV antibiotics because
of the risk of Group B Strep infection. (Women who have a C-section before
going into labor don’t have to worry about this stuff).
Doctors get worked up about Group B Strep because it can cause blood
infection (bacteremia), pneumonia, and meningitis in newborns. All
newborns are watched closely, but those babies with moms who test positive
for Group B Strep are watched even more closely.
It is standard protocol to get a complete blood count and blood culture on
a newborn if:
Mom is Group B Strep positive and she didn’t get pretreated with at
least one dose of antibiotics at least four hours prior to delivery
Mom appears to have a womb infection (chorioamnionitis)
Or if a baby starts misbehaving (temperature instability, labored
breathing, etc.). (CDC)

Reality Check
Don’t be too alarmed if you carry Group B Strep. This does not mean you
are Typhoid Mary. Most babies with Group B Strep positive mothers do not
get sick—they are just at a slightly higher risk.

Q. Are there any vaccinations given to the baby at the

hospital?
The Hepatitis B vaccine is recommended for all newborns as part of the
universal immunization series. Infants usually get the first of three doses
between birth and two months of age. It is ESSENTIAL to get the first dose
at birth if Mom tests positive for Hepatitis B to prevent infection in the
newborn. For more information see Chapter 12, “Vaccines.”

This wasn’t in the birth plan!

While most full-term deliveries and post-partum days go smoothly, your

newborn may throw you a curve ball. While we don’t mean to freak you out,
here are some of the more common complications that might happen:

Group B Strep. As we discussed in the section above, your baby may

have blood tests done in certain situations to look for infection.
Blood sugar testing. If your baby is very large (over eight pounds), very
small (under five pounds), feeding poorly, jittery, cold, or very sleepy, he
will have his blood sugar tested to be sure that his level is high enough
(usually that magic number is 40 mg/dl during the first 24 hours of life).
Blood sugar is also routinely tested in babies whose mothers have diabetes
or gestational diabetes. Be aware that some hospitals will test at-risk babies
several times in the first couple of days. If your baby’s blood sugar is low,
you may need to supplement with formula for a day or two, even if
breastfeeding is your long-term plan.
Meconium. Babies who are stressed prior to or at delivery may pass their
first poop before they leave the womb. That poop can be seen in the
amniotic fluid. If the meconium enters the baby’s lungs, it can cause
inflammation and problems breathing. So, it’s important to clear the baby’s
airway before he takes his first breath. If your water breaks and your OB
sees the meconium, a neonatal team is called to attend the delivery. Yes,
even more people get to see you naked—you won’t care at that point, trust
us.
Labored breathing. Babies who are delivered by C-section don’t get their
fetal fluid squeezed out of their lungs because they don’t squeeze through
the birth canal. As a result, some babies may have temporary labored
breathing for the first few hours after delivery (called Transient Tachypnea
of the Newborn, or TTN). Occasionally, babies delivered vaginally will have
this too. If your baby has TTN, the medical staff monitors him for a little
while in the nursery before he gets his first snuggles with you.
Fever. Your baby’s body temperature will be watched closely during the
first two days. If your baby runs a fever of 100.4 (taken rectally), he will
have lab tests done to rule out infection. Occasionally, a baby will have an
elevated body temperature (in the 100 to 100.3 range) if he is dehydrated. If
your breastfed baby has lost close to 10% of his birth weight and his body
temperature is rising, you may need to supplement with formula to avoid
extensive testing for infection.
Jaundice: See the next section in this chapter for details.

The 411 on Jaundice

Q. Why is my baby turning yellow? What is jaundice?

Here’s the 411 on jaundice. While it sounds scary, there are two types of
jaundice when it comes to newborns: NORMAL jaundice and ABNORMAL
jaundice. Yes, you read it right—there is a form of jaundice that is
NORMAL in newborns.
So what is jaundice? Short answer: it’s body garbage that hasn’t been
eliminated yet. Long answer: humans make body garbage called bilirubin.
Bilirubin breaks down in our livers and comes out in our poop. The problem:
a newborn’s liver is not working at full speed yet, nor are his intestines.
So, for most newborns, the body garbage (bilirubin) will start to collect in
the skin. This is normal jaundice. Bilirubin has a yellow pigment, causing
the whites of the eyes and skin to yellow. The level of yellow (jaundice)
correlates with how far down the yellow gets on the body (increasing from
head to toe.) The level will continue to rise until baby is eating and pooping
regularly (day four to five). You will notice that the poop changes from
black to a yellow/green/brown color at that time.
Again, by day four or five of life, bilirubin normally comes out in the
poop and no longer collects in the skin. For LATE PRETERM INFANTS (born
at 34 to 36 6/7 weeks gestation; see more on this in the “Preemie Primer”
section later in this chapter), it is no longer an issue by day five to seven of
life.
What about abnormal jaundice? See the following red flags.

RED FLAGS: Abnormal Jaundice.

These are signs for ABNORMAL jaundice (see the previous discussion of
normal versus abnormal jaundice):
Jaundice is seen in the first 24 hours of life
Jaundice persists more than five days of life
Level of jaundice descends below the belly button

YELLOW BABY 411: JAUNDICE

Although most newborns turn a little bit yellow, pediatricians

monitor all babies closely for a rare, but preventable form of brain
damage (see KERNICTERUS) caused by excessive bilirubin levels.
Levels of bilirubin (see JAUNDICE) start to rise just as babies go home
from the hospital at 48 hours of life. The levels usually peak between
3-5 days of life. Breastfeeding can be a risk factor for jaundice if the
baby is not feeding at least eight times a day or there is a delay in
mother’s milk coming in.
The American Academy of Pediatrics wants to improve
identification of any babies at risk for brain damage. The AAP
recommends that parents ROUTINELY schedule an appointment with
their baby’s medical provider at three to five days of life—even if that
 means an appointment on a weekend! And if your baby starts to look
like a pumpkin, don’t wait to call your doctor.

Q. What happens if my baby has ABNORMAL

jaundice?
In most cases of jaundice, doctors check bilirubin levels with a blood test
on a daily basis until the level plateaus or drops, and the baby is eating and
pooping well.
There is a graph based on gestational age and number of days old (called
a nomogram; see below) that doctors use to predict how high the bilirubin
level is likely to rise. So, for instance, your doc might be concerned about a
full-term baby who has a bilirubin level of ten at two days of life, but not
concerned at all if it is ten at five days of life. That’s because on day two,
that baby’s bilirubin level is just beginning to rise. On day five, it’s unlikely
that the bilirubin will go anywhere but down as the baby’s body metabolizes
and eliminates it properly.
If the blood bilirubin level continues to rise and could potentially reach a
point that might result in KERNICTERUS, doctors intervene and help the
baby break down the bilirubin until he is capable of doing it himself.
Some babies either have a delay in eliminating bilirubin, or produce
higher levels than their bodies can eliminate effectively. Those reasons
include: being a late-preterm infant, having a traumatic delivery (see
CEPHALHEMATOMA), or having a blood type incompatibility with mom
(see ABO incompatibility below). These babies are more likely to need help
for a few days to get rid of the bilirubin.
Bottom line: Your baby may need his blood drawn every day to monitor
his bilirubin level until his doctor gives him the “all clear.” If the level is
significantly high, he may need treatment to bring it down.

Factoid: ABO Incompatibility: What is it? When mom and baby’s blood
types are different (mom is O and baby is A or B). Mom’s blood can
potentially mount a response that destroys some of baby’s red blood cells.
This leaves the baby with even more bilirubin to break down than your
average newborn. If Mom’s blood type is O, a blood test called a COOMBS
TEST is done to see if mom mounted a response to her baby’s blood. If the
Coombs test is positive, the baby routinely gets a bilirubin level check at 24
hours of life since we know that baby is at risk to have abnormal jaundice.

Jaundice: which babies are at highest risk?

Q. How is jaundice treated?

One or more of the following interventions are used to reduce the
bilirubin load:
1. Supplementation with formula until Mom’s milk comes in. Remember
the more your baby eats, the more he will poop, and the more he will get rid
of his bilirubin. If your mature milk isn’t in yet, this is a justifiable health
reason to supplement with formula.
2. Phototherapy. This technique uses blue light to breakdown the bilirubin.
Babies either rest with a lighted blanket around them or under a bank of
lights similar to a tanning booth. If your baby is jaundiced while at the
hospital, either method may be used. If your baby needs treatment after
you’ve been discharged home, you can rent a “bili blanket” or a “bili bed”
from a home health agency or medical supply company. Warning: many
insurance companies do not cover the cost of these appliances, but they are
worth it even if you have to pay out of pocket for a couple of days. That’s
because these devices will save you and your baby another hospital stay!
3. Intravenous fluid. Dehydrated babies have more trouble with jaundice.
In rare cases, a baby might need an IV to get fluid and nutrients.

BOTTOM LINE: If you are nursing, the first line of treatment is to

supplement with expressed breast milk and formula. If your baby needs
more aggressive intervention and you are already at home, a phototherapy
blanket/bed can be rented temporarily. Your doctor will check bilirubin
levels everyday and continue therapy until the levels drop significantly.
Another warning: that drop could take a day or two or it could take up to a
week! Be patient.
If the bilirubin level is extremely high, or it’s not dropping enough with
home phototherapy, or your baby is severely dehydrated, he may need to be
readmitted to the hospital for additional treatment.

FYI: It is NOT recommended that you lay out poolside with your newborn,
or place him by a sunny window to treat jaundice. It’s not that effective and
can overheat him. Yes, everyone will tell you to try this, but it’s not a good
idea.

Optional Procedures: Cord Blood Banking, Circumcision

These are decisions you’ll want to make before your baby is born. So, we
are hoping you read this chapter ahead of D-Day (Delivery Day). Why the
rush on these decisions?
If you decide to privately store your baby’s cord blood, you need to
contact the cord blood bank before delivery so you have the supplies
necessary for your obstetrician to collect the blood.
 If you decide you want to have your son circumcised, you will want to
find out if your obstetrician performs this procedure or if you need to make
arrangements with a different healthcare provider. (And, if you are planning
a ritual bris, it is good to have a mohel lined up to call once your baby is
born.)
If neither of these situations applies to you, skip to the next section!

Cord Blood Banking

Q. What exactly is cord blood banking anyway?

The era of modern medicine has given us the opportunity to collect and
store the blood and tissue from your baby’s umbilical cord.
Why is this a cool idea? Well, that blood is loaded with the “seeds”
(hematopoietic stem cells) that later grow into white and red blood cells.
These very special cells are also found in the bone marrow of all humans.
As a result, the umbilical cord blood/tissue can be used like a bone
marrow transplant. These cells are currently used to treat some genetic and
blood disorders and certain types of cancer. One of the advantages of using a
cord blood transplant as opposed to bone marrow transplant is that you don’t
have to have a perfect genetic match to the recipient and there may be less
transplant rejection.

Q. Does cord blood contain “embryonic stem cells”?

No.
The cells in cord blood come from your baby’s blood after birth, not from
an embryo. The only similarity here is that both cord blood cells and
embryonic cells are considered “stem” cells because they can develop into
mature cells. Stem cells from cord blood are considered “hematopoietic”
(blood) stem cells because they can become white and red blood cells and
other specialized types of cells. To make things even more confusing,
umbilical cord tissue contains “mesenchymal” stem cells that have the
ability to grow into other cell types, raising the possibility of additional
medical uses. The placenta is also rich in stem cells, which is why some
private cord blood banks offer placental storage options.

ParentsGuideCordBlood.com is a fabulous site, run by an astrophysicist who

lost her own daughter to leukemia. It includes a terrific sample
questionnaire for parents to use when they interview cord blood banks.

Q. What can cord blood be used for?

Cord blood transplants are now used for several diseases, and there are
more potential therapeutic uses in the pipeline.
Note: your baby may not be able to use his own stem cells for certain
diseases, though. For example, if your baby ends up having leukemia, his
frozen stem cells cannot be used to treat it. Those stem cells may already
have pre-cancerous changes in them.
But here is the good news: your healthy baby’s stem cells could be used
for another family member (sibling, parent, etc.) who has a disease treatable
with cord blood.

Q. Are there options for storing the cord blood?

Yes. There are basically two options for banking your baby’s cord blood:
private and public.
With a private, or “family” bank, you pay a company to store your baby’s
cord blood for potential personal use. If you bank your blood privately, only
your family or loved ones who need it and are an acceptable match can use
it.
Public banks are donation programs, where families contribute cord blood
for use by the general public. If you donate cord blood to the public bank,
anyone who needs it can use it. Every day, 6000 patients worldwide are
looking for a match in the national donor registry to treat their leukemia,
lymphoma, or other disease with a bone marrow or cord blood transplant.
Unfortunately, a public cord blood donation program is only in an infancy
stage as of this writing. There are 200 participating hospital programs in the
U.S—a tiny fraction of the nation’s 5700+ hospitals. You can find out if your
hospital if one of them by going to the National Marrow Donor website at
BeTheMatch.org (bethematch.org/support-the-cause/donate-cord-blood/).
If your delivery hospital doesn’t participate, Cryobanks International
(800-869-8608 or cryo-intl.com) accepts donations anywhere in the
continental U.S. and sends them to the national donor bank.
If you want your baby’s cord blood to go to the public donor program,
you just need to pass some screening questions before the program accepts
the donation. You should contact these folks before 34 weeks gestation if
you want to donate. We’ll discuss private cord blood banking next.

Insider Secret
If you have twins (or more) you cannot donate to the National Donor
Program. The reason? With two or more umbilical cords, there is a potential
to mix up the blood, making it too risky.
Q. Is it worth the money to privately store cord blood?
And you thought selecting a crib was a major decision . . .
Here’s some information to help you decide if you want to open an
account at the local blood bank:
What are the odds your or a family member will need to use the cord
blood? The estimates vary from 1 in 400 to 1 in 200,000. (AAP, Pasquini)
The odds are a bit of a moving target because no one can look into a crystal
ball and predict the potential uses of umbilical cord blood in the future. If
you already have a family member with a disease known to be treatable with
cord blood, obviously the likelihood of ever needing it goes way up. (AAP,
Pasquini)
Bottom line: cord blood isn’t a panacea for every problem. There are
some cases when a sick child can’t use his own cord blood—for example,
cord blood stem cells may already have pre-cancerous changes, so a child
who later develops leukemia cannot use his own stored cord blood to treat it.
However, the stored cord blood of a healthy child could be used for another
family member who has a disease treatable with that cord blood. (AAP
Section on Hematology/Oncology)
The stem cells may have great potential to treat many diseases, but many
of the treatments are experimental at this point. The chance you’ll use it will
depend on a variety of factors, like scientific advances and if the blood
specimen is still viable when you are 70. At this moment, these potential
uses are being tested in the research labs of academic medical centers and
pharmaceutical companies. If your family has a genetic disorder, banking
might be worth it for you.
Here are the costs: there is an initial enrollment fee ranging from about
$1700 to $2200. Then there is a storage fee of $130 to $200 per year. Those
fees are just for cord blood; there are additional fees to store umbilical cord
and placenta tissue, both of which have promise to treat medical disorders in
the future.
Some banks charge a one-time, lump sum fee to store the cord blood
“forever.” (With current technology, banks can freeze and utilize cord blood
for at least 20 years.)
Reality Check
Be sure to use a company that processes and stores cord blood in their
own facility. Why does that matter? Because some companies subcontract
the storage to another company.

If a company you’re interested in does other lab work besides cord blood
banking, make sure their storage facilities are intended for long-term use.
Special cryogenic techniques are required to make sure the blood is stored
properly.

Ask about the bank’s storage method. Studies show that cord blood can be
preserved and used for at least 20 years. Virtually all American cord blood
banks store the blood in multi-compartmental bags to prevent contamination.

Be sure your obstetrician is experienced in cord blood collection. It is

imperative that the blood be collected quickly (within ten minutes) and that
enough blood is collected. Obviously, if you don’t get enough cord blood,
the specimen cannot be stored. Multiple births and low birth weight reduce
the chance of getting enough blood. Most companies offer training resources
for doctors. Obstetricians will charge a fee ($100 or more) to collect the cord
blood even if it is for donation. Be sure to find out this cost in advance.

BEHIND THE SCENES: DONATING CORD BLOOD

The American Academy of Pediatrics supports donating umbilical

cord blood to a public donation bank. While we support this policy,
realize that donating cord blood isn’t always easy. As of this writing,
the ability to donate to the national donor program is limited. If you
want to donate your baby’s cord blood, find out if your hospital
 participates in the national donor program at marrow.org (click on
Donor Resources).

DR B’S OPINION

“Don’t let potentially life-saving cells go to waste.

Donate them or bank them privately.”

Q. If I want to privately bank my baby’s cord blood,

which company should I choose?
An excellent non-profit web site with advice on evaluating cord banks
is ParentsGuideCordBlood.com. The site is run by an astrophysicist who lost
her daughter to leukemia.

Q. What happens to cord blood if it isn’t saved or

banked?
It clots in the umbilical cord and gets sent to the pathology lab with the
placenta. Ultimately, it gets disposed of in a biohazard bag. If you don’t
authorize it to be publicly or privately banked, the blood is discarded.

Circumcision

Before we delve into this hot topic, we have a major disclaimer.

Discussing circumcision is like a “friendly” discussion on abortion—this is a
topic that provokes very strong reactions in some people. And like other
parenting decisions, the pendulum swings back and forth. Today, only 58%
of U.S newborn males are circumcised. In previous generations, that
percentage was much higher.
We realize no matter how “fair and balanced” we are, some readers will
NOT be happy (believe us, we’ve tried). Even a discussion of “pros and
cons” of circumcision is considered blasphemy—anti-circumcision groups
believe circumcision should not be an option at all. They also complain that
the studies showing medical benefits of circumcision are flawed and biased.
Our goal for this section is to let parents hear both sides of the argument
so you can make an informed decision on your own. Honestly, we don’t have
an agenda here (beyond providing a balanced look at the subject)—what you
decide to do with your son’s penis is your decision.

Q. What is a circumcision anyway?

Circumcision is the surgical removal of the foreskin of the penis. It’s been
done as a religious ritual for centuries.
The practice of circumcision (surgical removal of foreskin) became
common in the United States in the late 1800’s for hygienic reasons as well
as a proposed way to reduce masturbation (ha—didn’t work, did it?). It has
continued to be a popular choice for most American boys . . . and the subject
of much controversy.

Q. When do I need to make this decision?

Before your son is born, you should decide whether or not you want to
have him circumcised. That’s because doctors typically perform the
procedure before a baby goes home from the hospital, or within the first
week or two of life in the doctor’s office. When a circumcision is part of a
Jewish religious ceremony (a “Brit milah” or “bris” for short), it is done at
eight days of life.
Alternatively, you could wait and let him decide on his own, but it is a
much bigger ordeal to go through circumcision as an adult (wasn’t that a
Seinfeld episode?). If you feel weird thinking about the future of your son’s
penis, join the club.
Q. What are the arguments FOR circumcision?
In a nutshell, lower risk of HIV, sexually transmitted infections, hygiene
problems, and risk of cancer.

1.Reduced risk of HIV. Why? In uncircumcised men, the area under the
foreskin makes a nice spot for the HIV virus to set up shop. A
landmark study in South Africa found that circumcised men were
60% less likely to acquire HIV from infected female partners.
(Quinn). Based on this and additional research, the Centers for
Disease Control created new guidelines about making an informed
choice about this procedure. (Centers for Disease Control)

2.Reduced risk of sexually transmitted infections. Besides HIV,

circumcised men are also 30-45% less likely to become infected
with nasty little germs like genital herpes (HSV-2). (Centers for
Disease Control)

3.Better hygiene. Compared with a circumcised penis, it is harder to

keep the uncircumcised penis clean. The foreskin can get infected
and swell (see BALANITIS). Although balanitis doesn’t occur often,
it really hurts. The foreskin can also get stuck in a pulled back
position (see PARAPHIMOSIS)—OUCH!

4.Fewer bladder infections. Bladder infections (see URINARY TRACT

INFECTION-UTI) occur more frequently in girls. However, boys
who are uncircumcised have a three to 12 times greater risk of
infection than their circumcised friends. This risk is greatest in the
first six months of life. This again is due to hygiene reasons. In
general, boys have about a 1% risk of getting a bladder infection.

5.Less risk of cancer. Again, the foreskin of an uncircumcised penis can

harbor germs. When it comes to cancer risk, the issue here is a virus
called HUMAN PAPILLOMAVIRUS–HPV. HPV infection can lead to
cancer of the penis, anus, throat, and cervix. (Note: oral, vaginal,
and anal intercourse allows HPV virus to spread to these areas.)
Circumcised men have a 30% lower risk of being infected with
cancer-causing strains of HPV. They have a lower risk of
 developing cancer of the penis, and their female partners may have
a lower risk of developing cervical cancer. (Centers for Disease
Control).

Reality Check
Since the HPV vaccine is recommended for both young women and men,
your daughters and sons can reduce their risk of HPV-related cancer by
being vaccinated—making that last argument for circumcision less relevant.

Q. What are the arguments AGAINST circumcision?

Like any surgical procedure, circumcision has risks:

1.The risk of surgery. Circumcision involves cutting the foreskin away

from the head of the penis. As with any surgical procedure, there is
a small chance of bleeding (1 in 3000 risk) or infection (1 in 1000
risk).

2.Penile adhesions. Occasionally, the skin between the shaft and the
head of the penis will get stuck together due to a collection of
sticky, cream cheesy stuff called smegma. The penis will look like it
is uncircumcised. Minor adhesions will resolve on their own. But if
the adhesions are really tight, they may need to be treated by using
steroid cream, having a doctor pull the skin back, or having another
surgical procedure (“circumcision revision”). For more details, see
Chapter 4, Hygiene, and PENILE ADHESIONS).

3.The hidden penis. It sounds like a concealed weapon, doesn’t it?

Chubby baby boys have a fat roll above their genitals. It causes the
circumcised penis to get sucked inwards. The penis looks normal as
the boys grow up, but it’s always concerning to parents.
 4.Reduced sexual pleasure. Some concerns have been raised about the
removal of sensitive nerve fibers in the foreskin when a male is
circumcised. Anti-circumcision groups contend that circumcision is
genital mutilation. So what’s the latest science on this subject?
Studies that address this question report conflicting results. Some
studies show a decrease in sexual pleasure; others show no
difference. The data is based on men who were circumcised as
adults who subjectively rated their sexual pleasure before and after
circumcision. (Collins, Masood, Kim)

Q. What do the experts say about circumcision?

What’s the right thing to do? Let’s see how the experts weigh in.
Based on the findings of the significant 2007 study done in Africa, the
World Health Organization supports circumcision in countries with high
HIV rates to reduce the risk of HIV in men. The 2012 American Academy of
Pediatrics policy statement also acknowledges that the health benefits
outweigh the risks of circumcision. Should families choose it, they say the
benefits justify doing the procedure. (AAP). The American Urological
Association has a neutral stance, but feels that circumcision “should be
presented as an option for health benefits.” (American Urological
Association). As of 2015, the Centers for Disease Control recommends that
parents, teenage boys and adult men should make an informed choice. In
short, healthcare providers should explain the risks and benefits . . . like we
just did here.
Ultimately, you have to make the call.

Q. Who performs the circumcision?

Most often, your obstetrician performs the circumcision procedure just
before your baby leaves the hospital. But family practitioners or
pediatricians may also do it. As long as the person has been trained to do the
procedure, it does not matter what the doctor’s specialty is.
Why the obstetrician? Many pediatricians, like me, do not perform any
surgical procedures—for good reason. You wouldn’t want to see the way I
slice my Thanksgiving turkey! Obstetricians have surgical training and are
already at the hospital taking care of Mommy. Ask your OB first what the
usual protocol is. Urologists can also perform a circumcision on your baby.
This requires special arrangements, however. Urologists do not generally
come to the hospital to perform routine circumcisions. You’ll need to do
some homework if you choose this option.
What if you decide to circumcise your son after he leaves the hospital?
That’s fine, but there is one caveat: some insurance providers will NOT
cover the cost of the procedure once baby leaves the hospital.
Circumcision is performed as a religious ritual for some families. The
person performing the procedure is called a mohel. Families pay out of
pocket for this service.

Q. Is any pain medication used during the

circumcision?
Most of the time, yes. Every doctor has her own approach. You can ask
your doctor what she feels comfortable doing. Here are the options:

1.Injecting numbing medicine directly into the area (nerve block).

2.Applying topical numbing cream one hour before the procedure.
3.Giving the baby sugar water just prior to the procedure.

Q. How do I care for the area once the procedure is

done?
You will need two things to make a dressing for the wound: gauze pads
(2”x2” or preferably 3”x3”) and a big tube of petroleum jelly (Vaseline).
The goal: keep the scab on the wound from sticking to a diaper and
pulling off with each diaper change (that sounds excruciating and we don’t
even have male parts!). And one cautionary note: the yellowish stuff stuck to
the penis is the scab, NOT pus. Do not try to brush or scrub it off!
At all poopie diaper changes and whenever else the need arises, remove
the dressing and gently clean the penis with gauze soaked in warm water.
Because urine is sterile, you don’t have to change the dressing just for a wet
diaper. Once the penis is completely healed, you can use diaper wipes.
 Put a big glob of petroleum jelly in the center of the gauze pad and place
it over the penis. Fold the gauze in half over the penis so it looks like an
envelope. You will “seal” the ends of the gauze with all that petroleum jelly
squishing out. Voila.
Continue to apply a dressing until the skin of the penis is covered with
new skin. That’s usually three to five days after the procedure.
If your doctor used a “plastibell” for the procedure, the plastic ring falls
off around one week later.
Once the penis is completely healed (usually seven to 14 days later),
make sure you can always see the head (glans) of the penis distinctly from
the shaft. It should look like a helmet with a rim. Pull back at the base of the
penis at your son’s diaper changes so you can specifically clean that area. If
you don’t, your son will end up with a circumcised penis that develops
adhesions and looks somewhere between circumcised and uncircumcised.
Avoid this, obviously!
We realize this care sounds a bit daunting, if you are a first-time parent.
Ask your baby’s doc for more advice or if you need help.

Check out Chapter 4, Hygiene, for more details on circumcision care after
the initial healing is over.

Red Flags: Circumcision Complications

Excessive bleeding.
Pus draining from circumcision site.
Fever of 100.4 F or above.
Extreme lethargy more than four hours after procedure

Bottom Line
The whole procedure is relatively brief. Yes, it hurts—but pain medication
minimizes most of the discomfort. Most babies will go to sleep afterwards as
a stress response and wake up happy to see you.

DR B’S OPINION: CIRCUMCISION

While there are some medical benefits to circumcision (and the

HIV research is certainly intriguing), the benefits are not clear
enough for every medical group to advocate for the procedure. One
might argue that if everyone engaged in safe sexual behavior, there
would be fewer sexually transmitted infections, including HIV. I
think it is a very personal decision, without a right or wrong answer.
And while it is hard to assess how circumcision affects sexual
pleasure, I don’t think either group of men is complaining.

The Baby 411 Two-Week Survival Guide a.k.a. What Do I

do NOW?

Okay, now you are ready to take your baby home. Without the luxury of
the nursery nurses right down the hall, you are probably scared to death.
Hopefully, this book will be helpful in answering all those questions you
have. But remember, your pediatrician or family practitioner is only a phone
call away. We’ve covered the basics in this section, but each chapter in this
book has information pertinent to newborns. We’ll refer you to those
sections for more details.

Q. When will I need to use a car seat?

Every time you take your baby with you in the car! This includes your
trip home from the hospital. It’s the law, folks. Here’s what you need to
know:
All 50 states require that infants under one year of age be restrained in
an approved car seat. Laws vary from state to state beyond a year of
age. However, the American Academy of Pediatrics advises that
children be in a safety restraint (convertible car seat and then a
booster seat) until they are 4’9” tall.
Infants should ride rear-facing until they are at least two years of age, as
long as they do not exceed the seat’s height and weight limits.
Kids under age 13 should be in the back seat of your vehicle. Front air
bags deploy right at the level of a child’s head, which can be fatal.
So what do you need to buy now? Newborns can sit in either an infant
car seat (birth to 30+ pounds) or a convertible car seat (birth to 40 or
65 pounds). To save money, you can conceivably use only a
convertible car seat from birth. But most parents choose the more
expensive option of getting the infant car seat (knowing they’ll have
to get the convertible car seat after their baby outgrows the infant
seat) because it’s more portable. When your baby falls asleep in the
car, you’ll find it’s worth the investment.
Practice using the car seat before game day so you don’t feel foolish. In
fact, the hospital staff will only let you take your baby home by car
in a properly installed car seat (and no, they will not install it for
you!) You may need an engineering degree to figure out how your
particular car seat works, especially if you bought a fancy Swedish
one. Our advice: get your seat safety-checked BEFORE the baby is
born to make sure it is correctly installed.
Where to get help: The National Highway Transportation Safety
Administration is the government entity that regulates car seat
restraints. Check out their extremely helpful website at
safercar.gov/parents/Car-Seat-Safety.htm. There, you can determine
which car seat your baby needs, watch videos on proper installation,
and even find a car seat inspector nearest your home.
Car seat test: hospitals test premature and small babies in their car seats
to be sure they can breathe properly while restrained. Ask your
healthcare provider about this simple test if your baby is born before
37 weeks or weighs under six pounds.
Insider Secret
Shopping for a car seat can be pretty overwhelming. Check out our sister
book/website Baby Bargains (babybargains. com) for ratings and reviews of
infant car seats. They even have a special site on infant car seats
(infantcarseats.babybargains.com), which lists good, better and best picks in
the category.

BOTTOM LINE
According to researchers at Oregon Health and Science University,
newborns are at risk from poor car seat installation. They found 84% of new
parents make at least one critical safety error when installing the car seat or
securing their newborn in it. Most often, parents install the car seat too
loosely, install it at an improper angle, or forget to lock the seat belt. And up
to 70% of parents do not adjust the harness tightly enough to keep their baby
secure. Take the time to properly install your child’s car seat. Get help from
experts if you need it. (Hoffman B)

Q. When can I take my baby outside?

It is perfectly fine to go outside with your baby at any age. Dress him in
the same layers you would wear.
However, I recommend avoiding crowded restaurants, grocery stores, and
airplanes in the wintertime until your baby is four weeks old (if possible).
This minimizes exposure to cold and flu viruses that are spread from
respiratory droplets (coughs and sneezes). For details, see Chapter 13,
“Common Infections.”
Next: our detailed two-week survival guide. We’ve divided this advice
into five areas: breathing, feeding, elimination, sleep and skin. Let’s go:
1 BREATHING. As adults, we breathe about 12 times per minute at an even
rate. As we discussed earlier in this chapter, newborns breathe 30 to 40 times
per minute and have episodes of periodic breathing. This means that your
baby may breathe rapidly several times, p-a-u-s-e, then breathe again. This
pause can last several seconds (less than ten seconds). This is normal, but is
bound to freak you out.
Nasal congestion is normal in the first several weeks of life. Use saline
nose drops to flush the secretions.

RED FLAGS: Breathing

When a pause between breaths lasts 15 to 20 seconds.
If your baby is panting, or breathing over 50 to 60 times per minute.
If your baby’s rib cage sucks in (retractions), nostrils flare, or he makes
grunting noises.

OLD WIVES TALE

My baby will catch pneumonia if he gets cold.
Pneumonia is an infectious disease. It does not infect people who are
cold; pneumonia infects people who have a cold. Here are two more old
wives tales:
Baby will catch pneumonia if he is out in cold weather. FALSE!
Baby will get an ear infection if the wind blows in his ears. FALSE!
Wind blows into the outer ear canal. Ear infections are due to pus
behind the eardrum, where the wind cannot reach anyway.

Q. My baby has a snotty nose. What can I do about it?

 All newborns have nasal congestion for four to six weeks after birth. It’s
not a cold. And it’s not an allergy to your cat.
Some congested babies are extraordinarily loud. They may snort, snore,
cough, and sneeze. That’s all normal. If the congestion interferes with
feedings or sleep, use saline nose drops to clear the mucous.
Saline is just salt water (1/2 tsp salt to 8 oz. water). You can make it
or buy it. It is impossible to overdose and can be used any time your baby
has thick mucus or congestion. Shoot several drops in each nostril before
feedings. You do NOT need to suck it out with a bulb syringe or a Nose
Frida “Snot Sucker” (yes, this is a real product).
The saline will either make your baby sneeze or loosen the mucous
enough for the baby to swallow it.

NEW PARENT 411: GERM-O-PHOBIA

Many new parents (especially parents of premature babies) have a

mortal fear of germs. And we can understand that. As a doctor, I
recommend avoiding crowd scenes and airplane travel for the first
four weeks of your baby’s life. Why? If your baby catches a bug and
develops a fever of 100.4 or more during his first 28 days of life, he
must be admitted to a hospital. Yes, even if it is just a cold.
Of course, that doesn’t mean you must live in fear and never have
contact with the outside world! Here is a Q&A with some practical
suggestions to limit your newborn’s exposure to germs . . . without
going overboard.
Can your newborn go for a stroll around the neighborhood? Yes.
Can a few family members and friends come over to your house
and hold the newborn? Yes. But, ask them to wash hands first
and not visit if they are sick.
Can you hold your newborn if you are sick? Yes, but wash hands,
don’t touch your face, and try not to breathe on her! If your
spouse can take over the baby chores, go for it. Yes, you can and
should continue breastfeeding.
 Can your newborn be around other children? Yes, as long as they
are not sick. You can have a rule that the children can touch
baby’s head or feet, but not her hands or mouth.

BOTTOM LINE
Leave the bulb syringe at the hospital!
Bulb syringes can irritate a baby’s nostrils to the point of nosebleeds. And
if you don’t evacuate the air in the bulb before sucking out the snot, you may
get some unpleasant results. One family I know tried this . . . the baby was
shocked and held its breath. The parents were shocked and called 911. Saline
drops are a more effective and less traumatic way to deal with baby snot.

2 FEEDING. Whether you breast or bottle-feed, your newborn will be very

sleepy for the first few days. The result? He may fall asleep during a feeding,
sometimes after only a few minutes. Encourage your baby to stay awake by
rubbing his head, playing with his feet, or unwrapping him and placing him
away from your warm body.
How often does a newborn eat?
A breast-fed baby usually eats every two to three hours (at least eight
times in 24 hours).
A formula-fed baby eats about two to three ounces every three to four
hours (six to eight times in 24 hours).

Either way, your baby should wake up spontaneously and eat frequently.
In the first two weeks of life, do not let your newborn go more than FOUR
hours without eating. You need to wake him up to feed him if this occurs.
(Note: after two weeks of age, if your baby wants to sleep longer at night
and is gaining weight appropriately—let him!)
Mom’s breast milk usually arrives on the baby’s third to fourth day of
life. Until then, the baby gets antibody rich (but lower-calorie) colostrum
when he nurses. This is all your baby needs right now.
Spitting up some milk is normal. It can look fresh or curdled. Both are
normal. Vomiting up large volumes at every feeding is not normal.

RED FLAGS: Feeding

You consistently have to awaken your baby to eat.
Your baby is consistently vomiting large volumes of milk (i.e. the whole
feeding)
If nursing, your milk has not come in after three or four days.

NEW PARENT 411: THE NEWBORN HOLD

If you have never held a newborn, keep reading. Newborns have

poor control of their neck muscles, and thus, cannot hold their
relatively large heads up. If possible, hold your newborn with two
hands, one supporting the body, and one supporting the head. If you
don’t have two free hands, cradle her head in the crook of your arm
(kind of like a football, dads). With a little practice, you’ll be an old
pro in no time.

Q. Can I put my newborn on a feeding schedule?

Nope. You need to let go of being in charge for a little while.
Newborns are learning how life works outside the womb. Before birth,
they had a 24/7 all-you-can-eat buffet coming through the umbilical cord.
Now your newborn feels hungry (and will tell you about it) when her body
needs energy. She will eat better when she is hungry than when you decide it
is time for her to eat. That is why experts advise feeding on demand.
 Newborns need to eat about eight to 12 times in a 24-hour day. This may
be every 1 1/2 hours for a few cycles, then four hours later, then two hours,
etc. Most babies manage to eat at least eight feedings a day—without any
prodding from their parents. Obviously everyone would like their baby to
have ‘“cluster feeding’” of every 1 1/2 hours during the day and a nice four
hour stretch at night. But trying to control the feeding behavior of a newborn
will backfire. Trust us, let it go for now. And sleep when you can.

For more information on this topic, check out Chapter 5, Nutrition and
Growth, Chapter 6, Liquids and Chapter 8, The Other End. See the end of
this section for a handy guide to keep track of feedings.

3 ELIMINATION. Your newborn’s body is just learning how things work

initially. In the first 24 hours of life, he may pee (urinate) and poop (stool)
only once. When he really begins to take food in, things should start to come
out. This is a good way to tell if your infant is eating enough, particularly if
you are nursing. Your hospital may give you a diary to keep track of intake
and output. Or, buy an app on your smartphone to tally those feedings and
diapers.
Urine: By the fourth day of life, your baby should pee at least four times a
day. By one week of age, six to 12 wet diapers a day is normal.
Stool: The first few poops are called MECONIUM and are black and tarry
looking. They will change to a dark green color on Day of life 2-3, and then
a yellow, seedy, watery texture (if breastfed) or a lighter green and pasty
texture (if formula fed) on Day of life 3-5.

NEW PARENT 411: DR. BROWN’S STOOL RULES

1. Once your baby starts to eat, his poop will change colors and
texture.
2. Breastfed babies often have yellow, watery, seedy poop. Seeing this
color and texture of poop reassures you that your baby is eating
mature breast milk.
 3. Formula fed babies often have green, pasty strained-peas poop.
4. Any shade of yellow, green, or brown is normal.
5. Stool frequency can vary from once every feeding to once a week.
The frequency is not an indication of constipation—the texture is.
However, in the first two weeks, frequency of stool is a reassuring
sign that your baby is getting enough to eat.
6. All babies (not just yours!) turn red and grunt when they poop.

RED FLAGS: Elimination

Your baby is not urinating at least every six hours by the fourth day of life.
Your baby’s poop looks red, mucousy, or does not change from the black
meconium.
Your baby’s poop looks like yours.

For more information, check out Chapter 8, The Other End as well as our
website at Baby411.com for pictures!

4 SLEEP. Your baby sleeps 17 to 20 hours a day, but rarely more than four
to five hours at a time. He may be very hard to console initially and force
you to walk with him or rock him to sleep. You can’t spoil a newborn. Do
what it takes to get him to sleep. Bad habits happen AFTER two months of
age. Yes, you can swaddle your newborn with a light receiving blanket (see
details on the “baby burrito wrap” in Chapter 9, Sleep). Just be sure to wrap
the legs loosely so your baby can move his hips around.

NEW DAD 411: 4 TIPS FOR NEW FATHERS

 Hello Dads! Yes, we know you read baby books too—so let’s go
over a few specific new dad tips to help out in those first days.

1. BYOW. That is, Bring Your Own Wipes Surprise! You, Daddy-o,
will be doing most of the diaper changes at the hospital—especially if
your partner had a C-section. But as we discussed earlier, those first
poops will not be pretty (meconium, that black, tar-like stuff). Now,
the hospital will probably give you gauze pads and water for this
task . . . and that frankly won’t be up to the job. Our advice: bring in
your own baby wipes. If for some reason your baby’s skin is super
sensitive, you can go back to the gauze if necessary.

2. Pay attention to the lactation consultant (LC). If your spouse is

breastfeeding, you will need to watch how the baby latches on to the
breast (that’s where a LC works her magic). After the LC departs, you
may need to help position the baby’s mouth on mom’s nipple (it
sometimes takes four hands to maneuver this in the early days). You
will be the lactation consultant at home, so take notes!

3. Sleep when you can. The first few days of your baby’s life is so
exciting. Well-wishers are calling and visiting you throughout the day.
Guess what—that’s when your baby is sleeping! You will then be up
all night with the little rugrat. So, take advantage of daylight hours to
catch a nap and encourage your spouse to do the same. Turn off all
electronic devices for the duration of the nap!

4. Smile, nod and be supportive. Your partner will be on a hormonal

roller coaster after delivery. That will equate to laughter one moment
and tears another. Be on the lookout for something above and beyond
normal emotions. (See the discussion on baby blues and postpartum
depression on the next page.)

RED FLAGS: Sleep

 Your baby consistently needs to be awakened to eat.
Your baby is completely inconsolable for over three hours straight. For
more information, check out Chapter 9, Sleep.

5 SKIN. Your newborn may have a few bruises from delivery that will fade
with time. He may also have a few rashes—also normal.

Jaundice, is often normal, but is something that should be followed. Your

baby’s liver is just starting its job of breaking down a body waste called
bilirubin. Until this happens, the skin on the face may be a little yellow as a
result of the bilirubin’s pigment. That’s okay. What is NOT normal: if you
see this in the first 24 hours of life, or if the yellow color descends below
your baby’s waistline.

The umbilical cord takes one to four weeks to fall off. Until then, the
stump is gooey. This is normal. If the skin around the cord is getting infected
(see OMPHALITIS), the area is red, tender, and foul smelling.

BABY BLUES

Here is a newsflash for you . . . your life will never be the same. I
know, everyone has told you this during your entire pregnancy. But by
now reality has hit you like a sledgehammer. Becoming a parent is the
most amazing experience of your life—so why are you crying right
now?!!
Let’s see. Your physical body feels like it was run over by a truck.
Your hormone levels are off the charts. You haven’t had a good night’s
sleep since the baby was born. You understand why sleep deprivation
is used as a form of torture in POW camps. You find it difficult to
make rational decisions, or any decisions for that matter.
Here’s another newsflash for you . . . you are normal. No matter
how wonderful it is to become a parent, it takes time for your body
and mind to adjust to it.
 RED FLAGS: When Mom has Postpartum
Depression
The Baby Blues are short-term feelings of sadness that subside after a
few much needed breaks provided by supportive family and friends.
Postpartum depression doesn’t go away that easily. Here are the clues
that professional help is needed:

1. Frequent episodes of crying or weepiness.

2. Lack of enthusiasm for living (big clue: Mom doesn’t smile
anymore).
3. Lack of interest in the family or the baby.
4. Loss of appetite.
5. Difficulty sleeping. (This is a big clue since new moms sleep
whenever they can!)

Mothers who experience postpartum depression often don’t

recognize the clues. If a family member expresses concerns about you,
be smart and let them get you some help!

RED FLAGS: Skin

Jaundice occurs in the first 24 hours of life or below the waistline once
you get home.
Redness of the skin around the umbilical cord, or pus draining from it. See
Chapter 4, “Hygiene” and the glossary for more information.

6 FEVERS. We’ll discuss fevers in-depth in Chapter 15, “First Aid.” For
now, read the red flags below for the basics.
RED FLAGS: Fever
From birth to three months of age, any fever can be a sign of a serious
infection. You need to call your doctor immediately if your baby has a
temperature greater than 100.3 F taken rectally. (See the section how to take
a rectal temp in Chapter 15, “First Aid”).
Ear thermometers tend to be unreliable and since a fever in an infant is so
concerning, these are not recommended for use. Fever medications should
not be used for infants under three months of age unless recommended by
your doctor (for example, when your baby is vaccinated).

Q. My mother/mother-in-law will be helping me for the

first couple of weeks at home. Do you have any
suggestions to keep my sanity?
Some people get along with their parents and in-laws better than others.
But even if you have a terrific relationship, a newborn makes things more
stressful. New moms are sleep deprived, healing from childbirth, and off-
the-charts hormonally. Throw in a well-meaning grandmother who wants to
share her sage advice—which often is interpreted as criticism—and it takes
you over the edge.
So, before the fireworks start, think about how you and your mother (or
mother-in-law) will spend time together. A few suggestions:
Baby chores. If you are breastfeeding, put grandma in charge of
everything else baby: diaper changes, rocking, bathing. It will be her
pleasure.
Household chores. Don’t be a control freak. Let her cook, clean, or even
run a few errands.
Ask for advice on small matters. “How did you swaddle your babies?” It
will make her feel important—and that her opinion is valued.
Avoid conflict. If you run into conflicting parenting approaches, feel free
to quote your pediatrician’s advice (feel free to blame any controversial
decision on your baby’s doc).

Nearby is a useful chart to help you track your newborn’s pee and poop
for the first seven days. After day eight, you’ll be an old pro. Of course,
there are also iPhone and Android apps that do this as well! Reader favorites
include Baby Connect and Total Baby.

Handy Feeding & Elimination Table: The First 7 Days

Instructions: Circle the hour your baby nurses.

Circle W for wet diaper (urine). Circle S for soiled diaper (poop).
Special Situations: Preterm Babies

Premature babies (before 37 weeks gestation) make up 12.5% of all

babies born in the United States each year. (Hovert) While this is certainly
not in the master plan for any pregnancy, it could become reality with little
notice.
Instead of that special bonding time with your newborn post-delivery,
your baby may be whisked away to a neonatal intensive care unit (NICU).
Scary? Yep. What a way to be initiated as a new parent! Keep your chin up
—most parents graduate from the NICU with healthy babies . . . it just may
take a while.
Key point: Babies born between 34 weeks and 36 6/7 weeks are
considered premature. They are called LATE PRETERM INFANTS (LPI). In
fact, late-preterm infants make up 70% of all preemies. These little peanuts
account for most of the surge in preterm deliveries in the past decade.
Although they don’t have many of the major medical complications that
more premature babies do, they still need to be treated with more care than
their full-term friends. Here’s some more advice on LPI’s.

FEEDBACK FROM THE REAL WORLD: TWINS!

Meet Agustina, mom of twins, who’ll give you some great real
world tips throughout this book:

“When my twins, Malena and Gael, were born, I wanted

everything to be perfect. It is natural for expectant moms to over-
prepare (i.e., overspend) to meet the challenges and demands of
raising infant twins. Hopefully some of my tips and strategies, which I
learned from experience, will save you time and money.
Tired, dazed and confused summarizes my first six months of
motherhood with twins. Call on family and friends for support, or hire
a night nanny—well worth the money if it is within your means.
My head was spinning between pumping milk, feeding babies,
changing diapers and cleaning all the equipment every two or three
hours. Once the cycle was complete, it was time to go at it again. I
found feeding logs from the hospital very helpful to keep track of
feeding times and amounts, diaper changes and medicines.
One of our twins was born with a congenital heart defect while the
other one was born at a low birth weight, so keeping track of their
calorie consumption and medicine was very important. With little
sleep, it was hard for me to see through the fog. At times I couldn’t
remember whose diaper I had changed or who I had fed! The log
 sheet was also a great way of communicating with my night nanny. At
one glance, I could see a quick overview of the night.
The log sheet also helped me understand my twins’ natural
tendencies of awake/sleep time and the amount of calories consumed
during the day. I came to realize that their calorie consumption during
the day was a good predictor of how the night would go. The logs
were a systematic and organized way of keeping track and also proved
pivotal in putting them on a schedule.”

Q. My baby is a late preterm infant. Is there anything

special I need to look out for?
Yes. Just like babies are not little adults, late preterm infants are not little
versions of full-term babies. Your baby is immature. Here is a list of his
unique issues:

Neurologic: About one-third of a baby’s brain volume grows in the last

eight weeks of gestation, so it’s no surprise that your newborn will be
neurologically immature. What does that really mean? Well, he’ll probably
be very sleepy and need to be awakened for feedings. He may have a poor
ability to suck, which can make feedings (especially breastfeeding) a real
challenge. He may be cranky, startle or get over-stimulated easily, and have
difficulty being soothed (don’t get too discouraged). He may also not be
great at regulating his body temperature yet (in addition to having very little
body fat to retain heat). All of these things resolve, they just take a little time
until your baby’s brain and body matures.
And because long-term studies show that late preterm infants are at risk
for mild learning disabilities in the school years, you should watch your little
one extra carefully for developmental delays.

Respiratory: Your baby is being born just about the time his lungs are
fully mature. If you baby is on the younger end of the spectrum of LPI’s (34-
35 weeks), it’s still possible that he will have respiratory distress and need
temporary breathing support because of immature lungs. Due to neurologic
immaturity, your baby is also at risk for forgetting to breathe (also known as
APNEA OF PREMATURITY or AOP). Obviously, your baby won’t be allowed
to go home from the hospital until he proves that he does remember to
breathe! You also need to take extra care when holding your newborn
upright, as he has very poor head control and can collapse his airway.

Infectious Diseases: Being born early is considered a risk factor for

newborn bloodstream infection (sepsis). So although the chance of this is
very small, your baby may have lab work and tests to rule it out.

Gastrointestinal: Your baby will be a pokey eater (more on that below)

and as such, he also won’t be pooping very much. That, and an immature
liver, make your baby more at risk of developing jaundice than his full-term
peers. And while term newborns may encounter jaundice for the first four to
five days of life, late preterm infants may have jaundice issues for the first
five to seven days.

Growth/Nutrition: This is a major issue with late preterm infants. They

are notoriously difficult feeders. They are sleepy. They don’t wake up on
their own for feedings. They tire easily and fall asleep feeding. And their
sucking ability, to put it bluntly, sucks. So your baby is at risk for excessive
weight loss or poor weight gain—both of which can lead to dehydration. To
complicate matters even further, your baby is also at risk for low blood sugar
in the first 24 hours of life—which would prevent just about anyone from
having the energy to eat. Don’t worry—we have lots of tips below to help
with all these problems.

So, here are some top tips to navigate your baby’s special challenges.
More feeding tips are covered in the breastfeeding section in Chapter 6:

Temperature regulation: Swaddle your baby with two or three receiving

blankets and have him wear a hat for those first days after birth.

Feedings: Aim for eight feedings a day. Wake your baby up if he doesn’t
wake on his own. Maximum feeding time should be 40 minutes because
your baby will tire easily. If you are breastfeeding, use a nipple shield if your
baby has a poor latch. (See more details on this in the breastfeeding section
in Chapter 6, Liquids). Don’t be discouraged. Your baby may also
temporarily need formula supplements if his blood sugar is low.

Late discharge: Your baby is not ready for primetime. Don’t head out the
door for home until he is ready to go. That means 48 hours in the hospital at
the very least! Here are the criteria established by the American Academy of
Pediatrics for Late Preterm Infant discharge: stable vital signs (body
temperature, blood pressure, heart rate, and respiratory rate) for at least
twelve hours before discharge, 24 hours of successful feedings with
coordinated sucking/swallowing/breathing, formal breastfeeding assessment
by a trained caregiver, at least one spontaneous poop, dehydration
assessment if baby loses over 3% of his birth weight per day or more than
7% during hospitalization, jaundice assessment, and a plan for follow up
with pediatrician in 24 to 48 hours. (AAP Clinical Report)

Car seat test: Your baby should have a formal car seat test done by the
hospital staff before you go home (see details in this chapter). But here are
some specific tips: Your car seat should have a starting weight limit of less
than five pounds. It should have a five-point harness, with multiple shoulder
slots with the lowest slot less than ten inches from the seat bottom, and
multiple crotch slots with the closest slot less than 5.5 inches from the seat
back.

Jaundice: Remember that your baby’s peak jaundice issues will occur
between five to seven days of life. If your baby looks yellow at home, take
him back to your baby’s doctor to check him out.

Watch development: While your baby does not necessarily need a

special evaluation with a developmental specialist, keep your eyes out for
any delays in developmental milestones and mention them to your baby’s
doc. Be sure to give your baby lots of tummy time when he is awake. With
his floppy head and increased sleep needs, he’s more at risk for developing a
flat head. (AAP)

Q. My baby was born before 34 weeks. What should I

be prepared for?
 Well, that really is a book in and of itself. But the basic concept is this:
your baby needs to mature outside the womb and will not go home until he
is ready to face the world. Discharge Day usually equates to near or at his
actual due date. Hopefully, that path to maturity goes smoothly, but there can
be some unpredictable bumps along the road.
While we don’t have enough room in this book to go over all the medical
issues you may face with a premature baby, there are two books we’d
recommend for further reading: Preemies: The Essential Guide for Parents
of Premature Babies, by Dana Linden and The Preemie Primer, by Dr.
Jennifer Gunter.
Once you are ready to head home with your preemie graduate, here are
some key issues. You’ll also find more preemie advice scattered throughout
the rest of this book. (Sturgeon)

Neurologic/Developmental
Intraventricular hemorrhage
If your baby was born before 34 weeks gestation, he’s probably had at
least one ultrasound to rule out bleeding in the brain (INTRAVENTRICULAR
HEMORRHAGE or IVH). If an abnormality was detected, you will need to
follow up with a pediatric neurologist.

Eye exams
If your baby was born before 32 weeks gestation or weighed less than
three pounds, a pediatric ophthalmologist has already seen him at the
hospital, looking for immaturity of the eyes (RETINOPATHY OF
PREMATURITY OR ROP). Premature babies are also at risk for AMBLYOPIA,
STRABISMUS, and REFRACTIVE ERRORS (see Chapter 14, “Diseases” in the
eye section for details). Your baby will need to have his vision checked
periodically by the eye doctor once you go home.

Hearing tests
A routine hearing screen is done on all newborns. Babies who are born
prematurely have a ten to 20 times greater risk of hearing loss than full term
babies. If an abnormality is detected or concerns arise later, you should
follow up with an ear, nose, and throat specialist and an audiologist.
Developmental assessment and therapy
Babies who are born prematurely are developmentally delayed compared
to their peers who are the same age. To know where your child’s milestones
should be tracking, subtract the number of months missed in pregnancy from
the baby’s current age to determine the “adjusted age.” For example, your
four-month-old baby who was born two months early will be expected to
have the milestones of a two-month-old. Preemies should catch up on their
milestones by two years of age. However, very low birth weight babies
(under three pounds), are at risk for the following delays: communication
(including autism), large and small muscle group, and learning. All
premature babies should be assessed by developmental assessment program
(often referred to as “Early Childhood Intervention”) in your community.

Respiratory
Apnea of prematurity
If your baby has trouble remembering to breathe (APNEA OF
PREMATURITY OR AOP), your doctor may prescribe medication (caffeine)
and a breathing monitor. Parents will need to download data from the
monitor periodically and review those findings with a lung specialist.

Chronic lung disease

If your baby has chronic lung disease (BRONCHOPULMONARY
DYSPLASIA OR BPD), you will also need to consult with a lung specialist.

Infectious Diseases
After being a NICU veteran, you have learned the art and science of good
hand washing. Keep up the good work at home. No doubt the NICU nurses
have instilled the fear of God in you when it comes to infections (especially
RSV—see below).

RSV/Synagis injections
Depending on the time of year and the age of your baby, she will
probably get an injection of Synagis, a medication that contains antibodies to
a virus called RESPIRATORY SYNCYTIAL VIRUS or RSV. Your baby will
need to continue to get Synagis injections on a monthly basis during the
peak time RSV hits your community (usually the fall/winter/early spring).
You may need a referral to a community resource that administers this
injection—many pediatric offices do not routinely stock it. For more
information on Synagis, see the Medications section in the Appendix A.

Flu vaccine
If you are bringing baby home during flu season, be sure your entire
household has received a flu vaccine.

Other vaccinations
Babies who weigh under 4.5 pounds under one month of age do not
routinely get their first Hepatitis B vaccine because they do not mount an
adequate immune response. This first dose may be given at one month of
age, as long as the baby is medically stable. If your baby spends his two-
month birthday in the NICU, he can get his other first shots there before
heading home.

Gastrointestinal
Gastroesophageal reflux
If your premature baby has GASTROESOPHAGEAL REFLUX (GERD), he
may be on a prescription medicine even after you come home. The
therapeutic dose of that medication is based on his weight. Since he’ll be
growing like a weed, be sure to ask your pediatrician to re-calculate his dose
based on his weight each time you visit the doctor.

Growth/Nutrition
Catch up growth
Your baby will be doing catch up growth for several months. Full-term
newborns gain 3/4 to one ounce a day. Ideally, your baby should grow at
least one ounce a day for the first four months of life. Consider buying or
renting an infant scale to weigh your baby once a week for at least the first
four to six weeks. Alternatively, you can pop in and borrow your doctor’s
scale. For information about preemie growth, see the special growth chart
for premature babies at the back of this book.

Breastfeeding a preemie
Many preemie grads go home on a diet of both breast milk and high-
calorie premature formula (which has 22 calories per ounce).
 If you are breastfeeding, you’ll probably find that your little one gets tired
out long before he fills his tummy. And since your baby is small or weak, he
may not be able to rev up your breast milk supply with his demand.
Therefore, it’s a good idea to pump after nursing sessions to improve your
milk production. You may be doing a combination of feeding at the breast,
and supplementing with expressed breast milk from a bottle. Our advice: it’s
wise to meet with a lactation consultant to make sure breastfeeding is
successful. If you are exclusively breastfeeding, your baby may need
“human milk fortifier” added to expressed milk to increase his calcium,
phosphorous, and caloric intake. We have several more tips on breastfeeding
a preemie in Chapter 6, Liquids.
Babies who were less than 3 lbs. at birth (very low birth weight or
VLBW) and those who had poor growth in the NICU should probably get at
least two bottles of high-calorie premature formula a day. This should
continue until the baby is nine months old (adjusted age) to improve bone
growth. (Abrams)

Premature formula
Whether you are breastfeeding and adding human milk fortifier,
breastfeeding and supplementing with high-calorie premature formula, or
exclusively formula feeding with high-calorie formula, there is no magic age
or weight at which you can discontinue fortifying or switch to the regular
(and cheaper) formula. As we discussed above, very low birth-weight babies
(under three pounds at birth) should probably remain on the premature
formula until nine months adjusted age. For bigger preemie grads, there’s
less consensus on when to make the switch. (Shaheed)

Vitamin supplements
Premature babies may benefit from a daily multivitamin and iron
supplement, depending on what they are eating (breast milk/formula). If
your baby is sent home from the NICU on these supplements, you can
continue them for the first year of life.

Feeding schedules
Your baby was probably on a rigid feeding schedule of every three hours
in the NICU. Once you are home, if your baby sticks with that routine, great.
Depending on how old your baby is when he leaves the NICU and how he is
growing, you may be able to relax that schedule a bit, and even let him sleep
at night if he wants to—be sure you have the green light to do this from your
doc, however.

Dental
Premature babies are at increased risk of poor development of tooth
enamel (ENAMEL HYPOPLASIA) as well as cavities. Be aware of these
potential problems. You should visit a dentist at your baby’s first birthday.

Sleep
You may still need to wake your baby up at night for feedings, depending
on his age and growth.
But even if your doc gives you her blessing to let him sleep through the
night, your baby may have his own ideas. As you will see in our chapter on
sleep, the ability to sleep through the night is based on a baby’s neurological
maturity. So, if your baby is six months old, but was born three months early,
he’s really only three months old (brain-wise) . . . don’t expect miracles.

Safety
You may not be able to use a standard infant car seat to transport your
child home from the hospital. Why? Infant car seats do not fully recline so
you may find your baby’s head plops forward when placed in the car seat
causing a blocked airway. For situations like this, you can purchase a car
bed, a seat that allows your child to lay flat but still be protected in case of a
crash. FYI: your child will be given a car seat test before leaving the NICU
to be sure you have the appropriate safety seat.
Another tip: parents and caretakers should all take an infant CPR course
before going home.

So, let’s sum up your to-do list with a preemie:

Follow-up eye exam.
Assessment by
developmental assessment program (often called Early Childhood
Intervention).
Monthly Synagis injections.
Flu shots for the entire household.
 Rent/buy infant scale or weigh regularly with pediatrician.
Get help with breastfeeding. Use human milk fortifier.
Feed or supplement with high-calorie formula made for premature
babies.
Continue multivitamin and iron supplement, if prescribed.
Do car seat test before checkout.
CPR Class for Mom and Dad.

Special Situations: Adoption

Having a child is quite an exciting experience, no less so for parents who

choose to adopt. In their case, there’s more to it than just picking up their
new baby and heading on home. Here are some topics for adoptive parents to
consider while you’re waiting to adopt.

Q. I plan on adopting a baby. Is there anything special

I should know?
It depends on the age of the baby at the time of adoption, and from whom
you are adopting the baby (for example, international adoption). Here are
some considerations:
1. If you are adopting the baby in infancy, adoptive mothers can try to
stimulate their breast milk production with a prescription medication. If
this is something you are interested in, contact your doctor.

2. It is helpful to know the medical history of the birth parents (if possible).
Parental drug use and high-risk sexual activity are important to find out. For
all babies, screening tests for HIV, Hepatitis B and syphilis are encouraged.

3. For infants adopted internationally, additional testing is suggested

including the following:
Stool culture for intestinal parasites (especially adoptions from Russia,
Eastern Europe, China).
 Complete blood count.
Hepatitis A screening.
Hepatitis C screening (especially adoptions from Russia, Eastern
Europe, Southeast Asia, China).
TB (tuberculosis) screening test.
Tests routinely done in U.S. on state metabolic screens (thyroid,
phenylketonuria, sickle cell disease, etc.). You can also opt for the
expanded metabolic screening.

4. Vision, hearing, nutrition status, anemia testing, and developmental

milestones can be assessed when your baby meets the pediatrician.

5. If the baby’s immunization status is unknown, he is presumed NOT to

be immunized and will start the series at the beginning. (AAP, Centers for
Disease Control) If there is any doubt about the quality of the country’s
vaccine supply, it is better to err on the side of repeating the entire
vaccination series.

Q. Are there special doctors who care for children who

are adopted?
Because adoption is an increasingly common choice for families, most
pediatricians and family practice doctors feel comfortable taking care of
these children.
However, there are some physicians who have an additional level of
expertise in the field. For a listing of these physicians and general info on
adoptions, check out the AAP website (aap.org/section/adoption). Another
good site is the National Adoption Information Clearinghouse,
calib.com/naic.

Whew. Congratulations on your newborn and getting through this very

large chapter! Up next, getting to know your baby’s doc.
YOU & YOUR BABY’S DOC
INSIDER TIPS & ADVICE
 Chapter 2
“There is no such thing as fun for the whole family.”
~ Jerry Seinfeld

WHAT’S IN THIS CHAPTER

FINDING A DOC
THE SCHEDULE OF WELL BABY CHECKUPS
HOW AND WHY TO SCHEDULE A SICK VISIT APPOINTMENT
THE DIFFERENCE BETWEEN A SICK VISIT AND A CONSULTATION
INSIDER TIPS FOR BOOKING APPOINTMENTS
WHAT TO DO IN THE EVENING AND ON WEEKENDS
GETTING IN TOUCH: PHONE CALLS, VOICE-MAIL, EMAIL, ETC

Welcome to your baby’s second home—the doctor’s office. Since you will
be spending some quality time with your child’s pediatrician, it’s important
to select someone you like and trust! Ideally, you will want to make that
decision before you deliver, since that doc will see your newborn at the
hospital or at the first office visit between 3-5 days of life. We’ll give you
insider tips on how to meet potential healthcare providers and find a
medical home for your little one.
Once you’ve picked the person you want to be your baby’s doctor, it’s
important to understand how their office works—and the insider tips and
tricks to making your time here as smooth as possible. We’ll take a walk
around to familiarize you with the place.

Selecting a Doctor
Q. Do I need to select a pediatrician before the baby is
born? If so, why?
Yes. It’s helpful to meet a pediatrician (at a prenatal consultation or meet
and greet event) before the baby is born. Here are three reasons:

1.It gives the pediatrician a chance to review any medical problems

during your pregnancy or with your family members that could
affect the baby. (The doctor appreciates being prepared.)
2.You can get advice regarding medical decisions you’ll be making in
the first few days of your baby’s life. (You’ll appreciate being
prepared.)
3.You will be more relaxed knowing who is examining and advising
you in those first days after your baby is born—yes, your
pediatrician’s job begins after delivery. (More details in Chapter 1,
Birth Day.)

Q. So, how do I pick a pediatrician?

Ask your OB-GYN for a recommendation or consult with friends,
relatives or other parents. Then, schedule a “prenatal consultation” visit or
attend a meet and greet session with each candidate (keep the list short to
maintain your sanity). While doctors consider this meeting a consultation,
it’s really a job interview—you are considering hiring this doctor to take
care of your baby, from birth to college. Consider your prenatal consultation
as parent-doctor bonding time.

Q. When should I schedule a prenatal consultation?

Hopefully, you are reading this book and this chapter before you have
the baby. Ideally, it is best to schedule a consult in your third trimester of
pregnancy. Why so early? Two reasons: first, to get some help making the
medical decisions you need to make about your newborn. Second, because
your pregnancy and due date are unpredictable—your baby could be early.
You don’t want to be shopping for a pediatrician while you are recovering
from labor!
If you are reading this chapter after you have the baby, the best way to
meet a pediatrician is to schedule an appointment for your baby and see
how it goes!

Q. Do pediatricians charge a fee for prenatal

consultations?
Some do, some don’t.
Pediatricians are about the only physician specialists who routinely
schedule “meet the doctor” visits. Such visits aren’t just for the parent’s
benefit—it helps give the doctor a heads up about any potential medical
problems the baby may have. Don’t be offended if you get a bill—it is
perfectly kosher. Pediatricians are offering their time to answer parenting
questions—and some parents come in with lots of questions! A smart move:
when you schedule the appointment, ask if there is a charge for the prenatal
visit.
If you have already delivered, most pediatric practices will ask that you
schedule a real appointment for the baby at which time you have a chance
to meet the provider. “Meet and greet” visits are typically only offered to
expectant parents.

Q. What general questions should I ask at a prenatal

consultation?
If you’ve read any pregnancy book, you’ve seen a list of questions to ask
at your prenatal visit. Here is some advice: ignore those cookie-cutter lists
and make your own, based on the issues that are important to you. This
could include:

1.Ask questions about topics you are wondering about. You may be
so overwhelmed, you can’t come up with specifics and that’s okay
—just pick the topic and we can fill in the details. Example:
 allergies. You might discuss how to avoid food allergies or the
history of allergies in your family.
2.Ask open-ended questions. You definitely want to get a feel for how
you and the doc communicate. Questions with “yes” or “no”
responses don’t lead to conversation.
3.Ask questions about how the practice flows. There is more to your
office experience than your doctor. You need to be an informed
consumer. Medical care has changed dramatically since you were a
kid. We’ll discuss more details on this next.

BOTTOM LINE: You don’t have to ask every question that you have in your
first meeting with your pediatrician.

Q. Okay, what smart questions SHOULD parents ask

of a pediatrician?
Let us walk you through a typical prenatal visit and tell you what parents
USUALLY ask . . . and what questions parents SHOULD ask instead.
(Note: at the end of this section, we’ll organize all these questions you
should ask in one handy list).

Parent asks: What is your training?

A better question: How did you decide on pediatrics?

All pediatricians have about the same training. Just look on the wall. We
spent a lot of time and money to get all those degrees. Our parents would
kill us if we didn’t get them framed and hung up in our office. Pediatricians
complete four years of medical school and then three more years of a
residency program focused only on children’s medical care. Family
Practitioners complete four years of medical school and then three to four
years of residency that includes child and adult health care. Regardless of
where a doctor trained, we all take a Board Certification Exam to prove we
learned our stuff. Look for the letters F.A.A.P. or F.A.A.F.P. after our
names. The “F” stands for Fellow, a distinguished title doctors get for
passing our boards in either pediatrics or family practice. All pediatricians
take continuing medical education courses annually and recertification
exams every ten years to make sure we are keeping up with current trends
in medicine.
Ask why the doctor chose pediatrics for a career, instead of say, urology.
It’s a more open-ended question. You’ll likely hear her credentials in the
answer, but you’ll get a better idea of whom this person is.

Parent asks: Do you divide the sick and well waiting rooms?
A better question: How long will I be sitting in your waiting room?

Even if the practice’s waiting room is divided into sick and well areas,
the patient/exam rooms are not. Don’t expect the entire doctor’s office to be
germ free. View your trip to the doctor like a trip anywhere else—where
there are kids, there will be germs. One tip: bring your own toys and wash
your hands after the visit.
I’d rather know how long I have to entertain my child before the doctor
sees us. You’ll get an idea by how late the doctor is for the prenatal visit.
We all try to be as punctual as possible, but unexpected things happen. A
practice that flows well should get you and the doctor face to face within 30
minutes of your scheduled appointment.

Insider Secrets
Real world mom advice: first, call BEFORE you leave home and make sure
the doctor is on schedule. If your doctor is running behind, you can prepare.
Bring extra entertainment for you and your child and even snacks. Another
tip: if you are sitting in the office and are not called within 20 minutes of
your appointment time, it’s time to find out what’s going on—ask the front
desk for an update on the doctor’s situation. Finally, don’t add to your stress
—never schedule another appointment or meeting immediately after your
doctor appointment. Doing so (and then running late) will only add to the
frustration.
Let’s talk about acceptable wait times to see your baby’s doctor. On the
message board for our books, when discussing how to select a pediatrician,
we were shocked that some parents were left waiting for up to three hours!
Obviously, that was the extreme . . . we found “average” wait times to be all
over the board. Some parents wait as little as ten or 15 minutes while others
reported average wait times of an hour or more. In our opinion, acceptable
average wait times should be about ten to 15 minutes during non-flu season.
When doctors get slammed with sick patients at the height of flu season, it
is understandable that wait times can slip to 30 minutes or more. Bottom
line, waiting longer than an hour to see your doctor for a scheduled visit is
not acceptable–you need to shop for another pediatrician.
So, what are doctors doing back there while you cool your heels in the
waiting room? Are they watching CNN? Shooting the breeze over a latte
with other doctors? No, there are several things that usually conspire to
make a doctor run late. See the box, “Behind the Scenes” for more on this.

Parent asks: How do I schedule well child visits/sick visits?

A better question: How does your daily schedule flow? How much time
is allotted for visits?

Most practices schedule well child checks in advance. A smart tip: in a

busy practice, schedule the next well child visit when you are in the office
having one. The office staff can advise you when another well child visit is
needed.
Sick visits are usually scheduled on the same day you call. Obviously,
you can’t predict when your child will get sick and you won’t settle for
waiting until tomorrow to be seen. This is probably different than what you
are used to with your own doctor. I once tried to see my doctor for a sick
visit and was told I could have an appointment a week later. I told the
receptionist, “Thank you. I could be dead by then.” But I digress.
What you really want to know is how much time you will spend with the
pediatrician. Every practice varies, but well checks usually get more time
than sick visits. A typical well check may be a 15-minute appointment.
A sick visit may be ten minutes. If there is a chronic problem (e.g.
headaches, constipation, school problem, behavior problem), we may
schedule consultation appointments which are 30 minutes or longer. You’ll
note these time guidelines are never published or posted in a doctor’s office.
Why? Because doctors will take as long as needed to address the issues at
hand—even if this means making other patients wait (which leads us back
to the earlier discussion of why it takes so long to see a doctor). Remember
appointment slots are just a framework for a doctor’s day.

BEHIND THE SCENES: WHY IS MY DOCTOR SO

LATE?

Do you ever wonder why your doctor is late? I’ll let you in on the
secrets behind the waiting room door. Let’s look at a typical morning
at my practice:
“Dr. Brown, your 8 am well child appointment is stuck in traffic,
can you see them at 8:20 am?” (Answer—“Yes.”) That patient
actually arrives at 8:25 am and is brought to an exam room at
8:30 am.
My 8:15 am well-child appointment is brought back to a room at
8:35 am because they had new insurance that needed to be
verified first (HINT: Always bring your insurance card to every
office visit—especially if your insurance has changed.)
My 8:30 am sick child with the flu also has asthma and needs a
breathing treatment. I need to go back and examine him a
second time after my nurse administers a treatment.
“Dr. Brown, your 8:45 am sick visit has a sister who is sick, too.
Do you have time to see her?” (Answer—“Yes,” . . . but now I
am double booked at 8:45 am.)

So, at 8:35 am, I have five patients in four exam rooms that all
need to play catch up. It’s about this time I’m dreaming of sitting on
a beach somewhere with a drink adorned with a cute umbrella.
All hope is not lost. Some sick visits are simple and will take less
time than the appointment slot (i.e. rashes, ear infection rechecks).
Some days, there are only sick kids that are “sicker than billed” and
parents that need extra handholding. I will be behind all morning.
 Reality check: doctors are notoriously behind schedule because
we try to address the needs of each patient, no matter how long it
takes. It helps if we can anticipate those needs. If you want to discuss
your child’s school problems during an appointment for a sore throat,
tell the appointments person. Otherwise, it’s likely your doctor will
ask you to schedule another appointment so there is more time to
talk.
Finally, another point to remember: some doctors now have
amazing office hours. More practices are offering evening and
weekend office hours to compete with the after-hours and urgent care
clinics popping up everywhere. Yes, these are typically larger
practices in bigger cities, but they do exist. And if a practice has
longer “operating hours” and more doctors, odds are the waits will be
less. Again, the key is to shop around and see what is available in
your community.

BOTTOM LINE
Sick visits are “problem oriented.” Be prepared to ask all your questions up
front. If you have numerous issues or chronic issues to discuss, schedule a
separate consultation. Doctors expect your list of burning questions at well
check appointments, not sick visits. You can always call or utilize a patient
portal (if the practice offers one), for questions that come up between visits.

Parent asks: What is your philosophy? (This one must be on some

parenting website because everyone asks it.)
Better questions to ask: How do you approach the doctor-parent
relationship? How do you feel about complementary/alternative
therapies? How do you feel about vaccinations?
 Doctor-parent relationships have changed since you were a child. When
you went to the doctor, he told your mother what she needed to do to make
you feel better. Your mother said “thank you” and did what she was told.
There was no debate . . . and no “alternative therapies” mom could look up
on the Internet. Doctors still wistfully reminisce about these days like a
retired hall-of-famer recalls the ’64 World Series.
When some parents ask about “philosophy,” they really want to know
about what type of medicine the doctor practices. An M.D. (medical doctor)
educated in the United States is almost exclusively trained in traditional
medicine. She is a scientist who learns how the body works and
malfunctions and how to fix the body with medicine or surgery. Doctors
also learn how scientific research is done and how to read medical studies
critically. As a rule, doctors are skeptical of new therapies unless they see
data and good science to support the treatment.
If you want to integrate complementary or alternative therapies into your
child’s healthcare, consider a medical provider who is on the same page so
you will have a good fit. And if you have significant vaccination concerns,
now is the time to speak up. It’s good to get honest, reliable advice from
your baby’s potential doc before it’s time for all those shots. (See Chapter
12, Vaccines to read up on this subject)

NEW PARENT 411: WELL-CHILD VERSUS SICK

VISITS

Doctors divide their visits with your baby into two categories: well-
child and sick visits. Well-child visits are what you might think of as
a routine check-up—these are scheduled at regular intervals to check
your child’s general health, do vaccinations, etc. Sick child visits are
when your child is, well, sick. FYI: Each of these visits is scheduled
differently by most doctors.

Parent asks: Do you accept our health insurance?

 A better question: Do you have a list of health insurance plans you
accept?

Both big and small businesses switch insurance plans as frequently as

the weather changes. Hello, Affordable Care Act—if you like your health
care plan, you can keep your health care plan!* (*Offer not valid in the 50
United States). The result: doctors lose patients when they change
insurance. There is a reasonable chance that the doctor you select now may
not perform your baby’s college physical. Watching your child grow is one
of the most rewarding parts of any pediatrician’s job. So losing a family to
another practice due to insurance change is something most doctors try hard
to avoid. A smart practice tries to negotiate reasonable contracts with
several insurance plans.

Parent asks: Are you on staff at my delivery hospital?

Better questions to ask: Who cares for my child after delivery, if he
needs to go to the emergency room, or if he needs later hospitalization?

The answers to these questions will vary significantly depending on

where you live. Gone are the days of the “Do It All Doctor” unless you live
in a rural area.
Although continuity of patient care is important, doctors are starting to
realize they only have so many hours in a day. The current trend in
medicine is to divide outpatient care (office-based practice) and in-patient
care (hospital-based practice). Our patients get more specialized care and
our spouses are happier with us. So, this is how some practices work:

1.An office-based pediatrician may or may not go to the hospital to

examine newborns. If your pediatrician does not make hospital
rounds, a hospital-based pediatrician will care for your newborn
until he goes home. And if there is a problem with the baby at the
time of delivery, there is likely to be a hospital-based pediatrician
or neonatologist to handle emergencies.
2.An office-based pediatrician is available by phone in emergency
situations. But if an emergency room visit is warranted, an
emergency room physician may evaluate and treat your child. That
doctor will call your doctor to discuss a plan.
 3.An office-based pediatrician will coordinate a child’s admission to
the hospital. But a hospital-based pediatrician (“hospitalist”) may
be responsible for your child’s care while he stays in the hospital
overnight (an admission). That doctor will call your doctor to make
discharge and follow up plans.

BOTTOM LINE: You may not see your own doctor if you have an
emergency or a hospital stay.

Parent asks: How are phone calls handled?

Better questions to ask:
1. Who answers your patient calls during the day?
2. Who answers emergency calls at night?
3. What is the expected waiting time for a phone call to be returned?
4. Do you offer a patient portal or electronic communications with your
office staff?

Phone calls during office hours are handled in a variety of ways. On one
extreme, a nurse will screen and answer all phone calls. On the other
extreme, the doctor will answer all calls (a rarity now, as most doctors are
busy seeing patients). Most practices fall somewhere in the middle. In
general, most practices will have a nurse who can answer routine calls
efficiently and hand the more complicated calls over to the doctor.
Some practices offer health privacy compliant patient e-mail portals
where, yes, you can actually email your doctor. While this is obviously
convenient for all of us living in the digital age, this communication is best
reserved for non-urgent or behavioral/developmental concerns. Your doc
may only check portal e-mail during regular business hours. You don’t want
to wait a day or two for a reply about a potentially serious or emergency
health issue. (By the way, sending your doc a note on Twitter or Facebook
or by regular e-mail is a no-no. Your doc would violate federal health
privacy laws by responding.)
After office hours, practices usually have an answering service that
dispatches emergency calls to the physician “on-call.” The on-call doctor is
usually (but not always) an associate in the practice. You will likely see or
speak to all of your doctor’s partners at some point in your child’s life.
Some practices utilize a nurse call center after hours to handle routine calls.
Call centers use strict protocols to manage every type of emergency
imaginable. Even with a call center, the on call doctor is still available for
questions.
Here are more questions to ask about phone calls:

1. What is the name of the nurse who handles phone calls? You two
will be on a first name basis soon, so ask now.
2. If you want to speak to the doctor, can you? You should never feel
that there is a fortress built around your doctor. You have every right to
talk to your doctor directly. If it’s not an urgent call, it may take until the
end of the business day to get back with you . . . but it should be an
option.
3. How long does it take for the nurse or doctor to return calls? You’ll
want to know how long to sit by the phone (you can also leave a cell
phone number). If you don’t hear from us in a “reasonable” amount of
time you should call us back.
4. Do you charge for phone call consultations? Many (but not all)
doctors charge a nominal fee for phone call consultations or calls that
occur after regular office hours. It’s wise to know this up front!

BEHIND THE SCENES: CALLING YOUR DOC AT

3AM

When doctors are on call at night, we are not sitting by the phone
in our offices waiting for your call. We go to sleep at home with our
cell phones at our bedside table. So if you talk to us at 3 am and we
sound sleepy . . . we are. In our residency training (the medical
equivalent of boot camp), doctors become experts at answering
questions while sleep deprived. I’m not gonna lie. Don’t expect us to
schedule appointments or be excited about discussing diaper rash
creams at 3 am. Be a friend and save those calls for office hours.
Insider Secret
If your pediatric practice offers a patient portal, utilize it for non-urgent
issues. It’s great if you want to touch base on how toilet training is going,
for instance. But if your baby has a potential health emergency such as a
fever, breathing problems, or a head injury, always call the office or after
hours line.

BOTTOM LINE: THE 13 QUESTIONS YOU SHOULD ASK

Okay, let’s sum it up again. Here are the 13 questions we suggest you ask
any potential pediatrician. (See earlier in this chapter for an explanation of
why we think these questions are important—and some good answers you
should hear from the doctor).

1. How did you decide on pediatrics?

2. How long will I be sitting in your waiting room?
3. How does your daily schedule flow?
4. How much time is allotted for visits?
5. How do you approach the doctor-parent relationship?
6. How do you feel about complementary/alternative therapies? Vaccines?
7. Do you have a list of health insurance plans you accept?
8. Who will care for my newborn during my hospital stay?
9. Who cares for my child in an emergency hospital visit, or
hospitalization?
10. Who answers your patient calls during the day?
11. Who answers emergency calls at night?
12. What is the expected waiting time for a phone call to be returned?
13. Does your practice offer a patient portal or electronic communications
with the office?
Q. How do I decide which doctor is right for my child?
Go with your gut instincts. Think to yourself, “Will I feel comfortable
asking this person some really embarrassing questions?” If the answer is
yes, go for it.
Pediatricians develop a relationship with you and your child. Doctors
enjoy being a part of your family and watching your child grow with you.
Unless you move or change insurance, your doctor will see your child until
he moves out of your house. That means you will probably see him more
than any other medical provider until you get your AARP card and senior
discounts at the movies.

Welcome to your baby’s medical home

Sometimes you want to go where everybody knows your name. No

worries. With the number of trips to your child’s pediatrician, you will be
on a first name basis with the entire staff. Welcome!

Q. Does my baby need to be seen by a doctor

regularly?
Yes. The very first office visit occurs at three to five days of life. Then,
there are many well-child visits that follow.
Bringing your child in at regular intervals is an important part of his
health care. These visits let your doctor evaluate your child’s health,
growth, and development. It lets you address issues that concern you. Smart
advice: make a list of questions to discuss at each appointment. At the first
few visits, your list may be quite lengthy (up to several pages!). But by the
one-year well check, your list will probably fit on a sticky note. That’s
when you know you have graduated to professional parenthood.

Q. Is there a standard well child visit?

 Yes. Most pediatric practices follow the guidelines of the American
Academy of Pediatrics (AAP) for routine well child checks. At every visit,
we examine your child head to toe. Some visits involve screening tests and
immunizations. Below is a standard well child visit schedule up to age five.
Note: the immunization schedule has some variability, but this gives you a
rough idea of what to expect.

* What the heck is a DTaP? IPV? HIB? Yes, the world of immunizations
has a language all its own. We’ll explore the topic of immunizations (and
decipher these codes) in Chapter 12, Vaccines.

Screening Tests
Metabolic Screen. This is a blood test performed at 24 hours of life and
repeated at two weeks of age. The number of tests varies by state, but at the
minimum includes screens for (big words alert) phenylketonuria, congenital
hypothyroidism, galactosemia, sickle cell disease, and adrenal gland
insufficiency. (See Chapter 1, Birth Day and the glossary.)
 Hearing Screen. The AAP recommends all newborns have a hearing test
before leaving the hospital. This simple test identifies children with
congenital deafness (Again, see Chapter 1, Birth Day and BAERS in
glossary). A hearing screen is often repeated before starting kindergarten.

Hematocrit. This is a blood test performed at nine months or one year of

age to determine if your child is anemic. This test may be repeated as
necessary.

Body Mass Index. This calculation (which compares the height and the
weight) measures the risk of health-related consequences due to overweight
and obesity. It is measured annually at each well child visit, starting at two
years of age.

Urinalysis. A urine sample is no longer done as a routine screening test.

It may be done as needed to evaluate for infection, diabetes, or kidney
function.

Vision screen. A formal vision test is performed at age four to five and
may be repeated as necessary. If your school district screens annually, this
may be omitted from your child’s physical exam. Some practices offer a
high-tech device to assess lazy eye and refractive errors as young as one
year of age, but many insurance plans do not cover the cost of this cutting
edge screening test (yet).

Lead Screen. This blood test demonstrates exposure to lead. High levels
can cause anemia and neurological problems. A child is screened for
potential exposure with a series of questions asked at nine, 12, and 18
months old. Routine testing is performed in high-risk areas. If you live in a
house built before 1978 that has peeling paint or has been renovated, notify
your baby’s doctor. If you have other concerns about potential lead
exposure, your child can have a blood lead level tested at any time.

Developmental/Autism Screen. Parents fill out a standardized

questionnaire at the 18 month and two year well check to assess for autism.
 Immunizations. This is a whole chapter unto itself, literally. (See Chapter
12, “Vaccines.”)

BEHIND THE SCENES: WHO IS THE

AMERICAN ACADEMY OF PEDIATRICS (AAP)?

Just who is the AAP? And why are their “policy statements” so
important? The AAP is an organization of 60,000+ pediatricians who
are “dedicated to the health, safety, and well being of infants,
children and adolescents in North, Central, and South America.”
This active group makes recommendations (called policy
statements) that allow doctors to maintain the highest standard of
care for their patients. The policies are reviewed and updated
frequently. You can check the AAP’s policy statements online at
aap.org.
Doctors who bear the letters, F.A.A.P. after their names are
pediatricians who are Fellows of the American Academy of
Pediatrics. Fellowship is granted after passing a standardized board
certification exam and learning the secret handshake (just kidding on
that last one). Fellows must take recertification exams every ten years
to remain board certified. Look for the FAAP designation from your
pediatrician. This means your doctor is not only trained in her
specialty, but also has proof of her competency.

Q. What kind of appointment do I make if my baby is

sick?
A sick visit. This is a problem-focused appointment. Your child has a
problem (fever, ear ache, rash) that needs to be evaluated. Your doctor will
focus on the issue and likely do a physical exam limited to the problem. We
point this out so you can appreciate the difference in appointments.
Reality Check
Your baby can get his vaccinations at his well child visit even if he is sick.
Many families cancel a well child visit if their baby wakes up ill on the day
of his appointment. This causes delays in getting the baby immunized.
Unless your baby has a fever of 102 degrees or greater, he can still get his
shots. There are also lots of other things to do at a well baby check besides
shots. Bottom line: keep your well child appointments!

Q. What kind of appointment do I schedule if I have

several/chronic issues I want to discuss?
See if your doctor schedules consultations.
Many doctors offer longer office visits for patients with chronic medical
problems or several involved issues. Typically these concerns are
behavioral issues, sleep problems, school problems, or medical problems
that have been occurring for more than three or four weeks. If the
appointment is scheduled this way, your doctor can provide ample time to
assess these problems.

Insider Tips: How To Make Friends With The Office

Staff
Bringing cookies is helpful. Just kidding! Seriously, here are five tips to
make a nice impression in the doctor’s office:
1.Bring your insurance card. Most doctors’ staffs verify proof of
insurance at every office visit.
2.When you come for your first office visit, arrive 20 minutes
before your appointment time. You’ll need to fill out a lot of
 paperwork and the office staff needs to verify your insurance. The
same is true if you have changed insurance plans. If the practice
posts their new patient forms online, take advantage of the
convenience. Fill them out ahead of time!
3.If you are an established patient, come a few minutes early for
well child visits.You will soon understand why. You will need to
completely undress your baby to take his measurements. This itself
can be an event. Then, inevitably, the baby will either poop or pee
on the measuring scale, which then further delays the
measurements being taken. Multiply this experience by two if you
have twins.
4.If you have more than one child that needs to be evaluated by the
doctor, schedule an appointment for each of them. It shows that
you respect your doctor’s time. If everyone would follow this
mantra, there’s no doubt that wait times to see your doctor would
decline.
5.If you are running late for an appointment, call your doctor. Most
medical offices can modify their schedule if they know when you
are coming.

NEW PARENT 411: WHEN DOES MY CHILD STOP

GOING TO THE PEDIATRICIAN?

It depends on the child. Some teenagers wouldn’t be caught dead

in their pediatrician’s waiting room. Other teenagers never want to
leave the nest. Most pediatricians feel comfortable seeing their
patients until the age of 18-21 years, if they still want to see us. (My
pediatrician kicked me out after he performed my physical
examination for medical school.)
Family practice physicians are comfortable seeing teenagers.
Internal medicine physicians (internists) are not. They often limit
their practice to age 18 and up.
 DR B’S OPINION: WELL CHECKS

Don’t try to squeeze in a well-child visit when you come in

for a sick visit. Busy families frequently bring their baby in for a
sick visit and ask, “So, can’t you do a well check today since we are
here?” I usually say no, unless my schedule is light. I need time to
do a complete exam and evaluation. Doing a quick once-over isn’t
doing justice to the importance of a well-child visit.

Insider Tips: The Best Time To Schedule

Appointments
Let’s make an analogy to an airport. Your baby’s doctor’s office is a bit like
La Guardia. When is the best time to fly? In the early morning, before
delays pile up.
When is the worst time to fly? Monday mornings, Friday afternoons, and
national holidays.
Now let’s look at some trends in the doctor’s office. Because many
doctors’ offices are closed on the weekends, parents tend to bring their sick
kids in either before the weekend or after enduring a long weekend with
them. Translation: peak volume days are Mondays and Fridays.
Seasons also cause volume trends. Cold and flu season (October through
April) is the highest patient volume all year. Christmas Eve is always busy
because no good parent will allow his or her child to be ill on Christmas.
National holidays are popular times to visit because many parents have the
day off from work.
In the summer (June through August), our older patients keep us busy
with well child visits because they don’t have to miss school. They also
need camp or sports physicals. May and September are the slowest months
of the year (that’s when I usually take a vacation!)
If you want to visit your doctor when the office is quieter (or running
less behind) here are some tips:

1.Schedule well checks on Tuesdays, Wednesdays, or Thursdays.

2.Try to get the first appointment of the morning or afternoon to
avoid delays.
3.Schedule well baby visits that occur in the winter months far in
advance. There are often fewer well child visits offered to make
room for the sick visits.
4.If you want to avoid the rush for school or camp physicals, consider
booking in May or September.
5.See if your doctor offers weekend hours. Then you can avoid the
Monday/Friday crunch.

Insider Tips: How To Save Money

With medical care costs soaring, how can you save on your baby’s
healthcare? Follow these tips to save hundreds of dollars:

Insurance
If you don’t have insurance for your kids, apply for CHIP (Children’s
Health Insurance Program). Administered by your local state health
department, CHIP is intended for working parents or those between jobs.
More folks can qualify for CHIP than Medicaid because the income
requirements are not as strict.

If you don’t have health insurance or have a restrictive plan that doesn’t
cover the cost of shots, consider the Vaccines For Children program
(VFC). While the program includes all public health clinics, many private
practices also participate. The government supplies doctors with free
vaccines. Ask your doctor about it. There should be no reason that your
baby gets behind on his shots.

Medications
Ask your doctor or pharmacist for a generic medication, if one is
available. Good news: almost all routine oral antibiotics for kids are now
available in generic form.

If the prescription is a brand name medication, ask your doctor if he has

any coupons. Many pharmaceutical companies provide coupons to medical
offices that defray or eliminate the co-pay of a medication. If your doc is
like me, she may forget about the pile of papers (and coupons) the sample
fairies leave behind. So as a patient, it pays to speak up.

Ask for samples. Again, don’t be shy. As a doc, I try to give samples out
as much as possible. I’m happy to give them to families—especially those
who are uninsured or paying out of pocket.

Make your own. Two obvious examples: saline and Pedialyte. Saline is
just salt water that can be made at home (1/2 tsp salt in 8 oz water).
Pedialyte is 4 cups water, 1/2 tsp salt, 2 Tbsp sugar, 1/2 tsp instant Jello
powder for flavor.

Avoid unnecessary appointments

If you are on the fence about whether your child really needs to be seen
for that cough or cold, call the nurse/doctor before booking your
appointment. You may be able to wait it out a day or two and if so, things
may clear up without an appointment.

Avoid going to the emergency room. Some visits are impossible to avoid,
but you may be able to make it until morning for others (like an earache,
which is not an emergency). Consider using a pediatric after-hours or
pediatric urgent care center instead of the ER. Find out your doctor’s office
hours—some offer extended and weekend hours. And if she isn’t open, ask
if there is another practice in town that offers appointments to non-patients.
 If your child has PE tubes and has an ear infection that is just draining
(no fever), he only needs ear drops (which usually doesn’t require an
appointment). Find out what your doctor specifically does, so you don’t
have to pay a co-pay. The same sometimes goes for allergy med
refills/asthma meds, etc.

Get a home nebulizer if your child has asthma. This will save you office
visits, ER visits, and maybe even a hospitalization. Insurance companies
know this and some cover the cost of purchasing the machine.

Use this book and our website’s rash-o-rama. We give a guarantee that
we’ll save you at least one co-pay if you take the time to read about your
child’s symptoms. What’s worrisome? And what’s not? You’ll find all the
answers here. Common rashes like yeast diaper rash do not require an
appointment (and can usually be treated over-the-counter).

BEHIND THE SCENES: CONFIDING IN YOUR BABY’S

DOC

If you found yourself struggling with depression after your baby

is born, who would you turn to for help? A doctor? Friends? The
‘net?
A recent study looked at mothers of young children and whether
or not they felt comfortable discussing their “emotional health” with
their pediatrician. Although pediatricians could be a resource for
help, many moms said that discussing stress with their pediatrician
would be admitting failure. (Hello? Isn’t stress part of the job
description?) Moms relied on breastfeeding groups, postpartum
groups, playgroups, and the Internet as sources of support. Yet, over
50% of pediatricians feel it is their responsibility to recognize
postpartum depression.
Bottom line: it’s okay to confide in your baby’s doctor. She might
just steer you in the right direction.
Q. Who will I meet in the doctor’s office?
Let me introduce you to the office staff. Practices vary a great deal, but
these are the usual folks that you will encounter.

The medical provider or “primary care provider:” This is the person

responsible for your child’s medical care. This may be a pediatrician or
family practice doctor, depending on whom you select. Their initial medical
school training is through a certified medical school (M.D.) or a school of
osteopathic medicine (D.O.). Their specialty training is either in children’s
healthcare (pediatrics) or a combination of both adult and children’s
healthcare (family practice). When all is said and done, either type of
provider will have at least seven years of training beyond college before
they have their own office.

Mid-level providers: These people have been popular additions to busy

offices. Nurse practitioners (NP’s) and physician assistants (PA’s) help with
straightforward sick visits and well child visits. They can evaluate patients,
make decisions, and treat patients with the supervision of a medical
provider. Nurse practitioners have at least two years of training beyond their
bachelor’s degree in nursing (B.S.N.). Physician assistants complete a two-
year master’s program after completing college.

Nursing staff: The staff may have a variety of degrees. The head nurse
may have either a R.N. (registered nurse) or L.V.N. (licensed vocational
nurse) degree. Many pediatric offices utilize medical assistants who are
trained to administer shots and perform screening tests.

Q. What do I do if my baby gets sick in the evening or

on the weekend?
It is Murphy’s Law: your baby will only get sick when the office is
closed.
Be prepared for this and have a game plan. Some offices offer limited
evening and weekend hours. Find out the specifics for your doctor’s office.
 If the office is closed, the next option is a minor care center or an
emergency department of your local hospital. Ask your office for their
recommendation. The most convenient location may not be the best place to
go. Look for some practical tips on navigating the ER in Chapter 15, First
Aid.

BOTTOM LINE: Always call your doctor first before you go running
anywhere. What may seem like an emergency to you may not be. Your
phone call might save you a trip in the middle of the night.

Q. What is the best way to contact my doctor’s office?

Ah, the age of technology. So many options—email, text message, etc.
Despite the digital age, the most effective way to contact the office is by
picking up the phone. Doctors’ offices anticipate numerous calls during
office hours and have systems in place to answer the calls efficiently.
Some progressive offices answer questions online via a health privacy
secure patient portal. However, most offices still rely on the telephone to
communicate with patients. Why are docs resistant to change? Thank your
federal government. The law protecting medical information (HIPAA) is
rather onerous, with stiff fines for knowingly or unknowingly violating a
patient’s privacy. As a result, medical offices cannot transmit medical
records via unencrypted email or text message—or leave medically
sensitive information on answering machines or voicemail. Although this
may seem like a hassle, these restrictions are meant to protect you.

Reality Check
You should feel comfortable talking to your child’s pediatrician about any
topic that might impact his health and development. Any pediatrician worth
her salt will be honest and provide scientifically sound advice. In other
words, she may not agree with all of your parenting approaches if they may
be hazardous to your baby’s health (cue up discussions about making DIY
baby formula!). View your conversations as a chance to learn from an
expert! That’s why she is there for you and your baby.
PARENTHOOD
 Chapter 3
“When choosing between two evils, always choose the one you haven't
tried yet.”
~ Mae West

WHAT’S IN THIS CHAPTER

PICKING A PARENTING STYLE
CHILDCARE OPTIONS

Yes, your job as a parent begins the moment your baby is conceived. You
will find yourself instinctively making decisions from a parent’s viewpoint.
Maybe it’s the hormones. Or, maybe for the first time in your life, you have
a sense of responsibility to a helpless little urchin inside of you. Yes, YOU
are now a GROWN-UP.
This sense of responsibility will cause you to ponder the questions that all
parents ponder.

1. Will I be a good parent?

(Babysitting and pet ownership are helpful job experiences.)
2. Can I be as good a parent as my parents were? (Yes. You’ve
learned from their mistakes!)
3. Will I handle discipline dilemmas better than my friends do?
(Maybe. It’s very easy to be critical when you aren’t yet a parent.)
4. Will I make the right decisions for my child’s health? (That’s why
we’re here—to help point the way to the best choices for you and your
child).
 As you enter parenthood, it’s important to have a united front with your
partner. And that means you need to select a parenting style for your
household—yep, you should pick one BEFORE any other decisions are
made. That’s because your style will impact all those other choices.
We’ll also tackle that endless debate of parenthood: childcare. Is it better
to stay at home with your baby or can you work outside the home and be
guilt-free? We’ll discuss the latest research and give our perspective as real-
life moms. What are the options for childcare? We’ll discuss the choices.
Our advice: try to mull over this issue before or shortly after baby is born—
that’s because other expectant parents are already putting their names on
waiting lists for the hottest day care options in your community.
Finally, we will give you some insider tips on how to balance work and
family life.
First and foremost is determining your team’s parenting style.

Picking a Parenting Style

Q. How do I pick a parenting style?

Remember Dorothy in the Wizard of Oz? She always wore the shoes she
needed to take her home, but didn’t realize it. You, New Parent, are wearing
the shoes. You have the skills and instincts to be a great parent. TRUST
YOURSELF.
Your style reflects your approach to certain situations. Note: there are
parenting decisions (such as opting to use environmentally friendly diapers)
and then there are healthcare decisions (following the standard
recommended vaccination schedule). Sometimes parents blur the lines
between these decisions and then feel like their healthcare provider is
judging his or her parenting choices. (We’re not. We are just guiding you to
make wise healthcare decisions!)
Every generation of parents faces “trendy” choices, but honestly, there are
really just a few child-rearing philosophies and the pendulum has been
swinging back and forth for years. The styles differ in parents’
responsiveness and expectations of their kids.
 Whichever approach you choose, the hallmarks of good parenting are
fairness, consistency, and parent-child relationships based on mutual love
and respect.
Here are the four basic schools of thought:

1POSITIVE PARENTING. This household is run like a democracy. Positive

parents set up rules and expect their children to follow them. These rules and
limits guide children’s behavior. Although there are clear expectations,
positive parents are willing to listen to their children’s perspective and
problem-solve together. Positive parents are inclined to establish sleep and
feeding routines for their babies. Kids who grow up in these households turn
out to be pretty independent and have high self-esteem.

2AUTHORITARIAN PARENTING. This is a dictatorship. Mom and Dad

know best. Authoritarian parents have firm rules and high expectations and
do not want to hear the child’s opinion. Because these households are more
parent-centered than child-centered, authoritarian parents try to establish
rigid sleep and feeding routines very early in infancy. They tend to use
negative forms of discipline, like spanking. Children who grow up in these
households are more likely to have poor self-esteem and rebel later in life.
This parenting style is less popular today, but some families still choose it
based on their personal values.

3PERMISSIVE PARENTING. Welcome to anarchy. Permissive parents are

very responsive to their children, but they don’t set up limits, rules, or
expectations. In these households, parents are friends with their kids, but not
leaders or advisors. As you might expect, the result is usually chaos.

4ATTACHMENT PARENTING. Sorry, we don’t have a government analogy

for this one. Attachment parents are highly responsive to their child, 24/7.
The Attachment Parenting movement of today pays homage to 1950’s
research that showed children who form a tight parent-child bond are more
confident and secure. That seems obvious, right? Well, this was ground
breaking at the time, as other experts were warning that parents who were
too affectionate to their kids made children weak or clingy. Attachment
parents respond to their child’s needs day and night—hence, sleep training
that involves crying is discouraged. The emphasis is on human touch,
breastfeeding, baby-wearing, non-physical forms of discipline, and parents
being the primary caregiver.

You will find that some parents (and experts) can be very passionate
about these camps. Don’t let friends, family, or random bloggers dictate how
you raise your child.
You and your partner will need to discuss these issues and come to terms
that are agreeable to both. Remember when you had to agree on a china
pattern for your wedding registry? (Hopefully there will be fewer
arguments). You both need to be happy about your strategy. This can be
modified once you really have a baby to care for, but it helps to have some
of the ground rules in place.
Be flexible—sometimes the best parenting style is a combination of
approaches, mixing a bit of this and some of that. Your style may change
over time as well. And yes, your parenting style will change out of sheer
necessity when you have more than one child. You will be more confident in
your skills, and you won’t have time to sweat the small stuff. That’s why
children have certain personality traits based on their birth order.
Remember, you are giving your child roots and wings—a solid
foundation that fosters her independence.
Finally, federal law requires us to warn you of the following: you may not
agree with some parts of this book . . . especially if you feel strongly about
one parenting school of thought. We don’t mean to be flip, but we didn’t
write this book to advance a political agenda. Instead, our goal is to be pro-
science. We want to arm you with the best and latest research and medical
information. Then you decide how to raise your baby.
Yep, we realize folks feel passionately about certain healthcare issues
(just take a look at the debate on circumcision in Chapter 1). So take the
parts of this book that work for you and combine them with other parenting
advice (from friends, other books) to create your own parenting style. There
are lots of ways to be a terrific parent.
 Baby 411 Decision Timeline

DECISION WHEN IT NEEDS TO

HAPPEN

Childbirth classes 28-34 weeks (of pregnancy)

Breastfeeding class 32-38 weeks
Infant CPR class Ideally, before delivery
Recommended tests First 20 weeks
Cord blood banking Anytime before delivery
Circumcision decision 32-36 weeks
Expanded newborn screen Before delivery
Hire a doula Start interviews at 28 weeks
Select a pediatrician 28-34 weeks
Find lactation consultant Ideally, before delivery
Work/childcare options Ideally, before delivery
Make a will Now

Childcare
It’s probably safe to assume that if you are a woman without children,
you have been working outside the home before becoming a parent. And no
doubt, there was an office pool going on behind your back about the odds of
you returning after your baby is born.
Raising a family is one of life’s major crossroads that makes you ponder
which path to take. Should you drop your current career and make raising
your child your new career? Can you carve out some creative combination of
working part-time and staying at home with your little one? Or, will you
return to the daily grind and make the most of your family time when you
are able? These decisions weigh heavily on the minds of today’s working
moms, and for some, choosing to stay at home is not an option because their
salary is paying the bills.
For those who have a choice whether or not to work, this decision can be
very stressful and laden with guilt. Perhaps you’ve heard of the “Mommy
Wars.” There is no doubt: you will feel pressured about your decision from a
variety of sources—your spouse, your mother, even your best friends.
Our advice? Make your decision and then make the best of it. You can
always re-assess down the road and change your mind.
We give you this advice based on scientific data. Research shows that
quality time is more important than the sheer number of hours you spend
with your child. Kids do best when their moms focus their attention, engage,
and respond to them. (Huston)

Q. When do I need to start thinking about childcare?

Now.
It’s best to begin the process before you even become a parent. Yes, it IS
that competitive. The best daycares and preschools in town will have your
baby’s due date (instead of birth date) listed on the waiting list application.

Q. Why is my selection for childcare so important?

That seems like an obvious one—your baby is the most precious gift in
the world to you. And you want to give your baby the best childcare you can
find. Here are some things you should think about:
Studies have consistently shown that the first three years of life are
critical times in your child’s development. This is when your baby learns to
trust others, function independently, problem solve, and learn the boundaries
of acceptable behavior. The person/people you choose to care for your baby
are incredibly important. Of course, there are economic decisions as well.
Consider what your family can afford.
Reality Check
Your child’s illness may cost you a lost workday, and the price of co-
payments and deductibles when you visit the doctor.

Q. So what are my options for childcare?

Your baby stays at home with someone, goes to someone else’s home, or
goes to a licensed childcare facility. Let’s go over these options so you can
get moving on this one.

1PARENT AT HOME. This is not just an option for moms anymore. More
dads are staying at home these days. Your childcare cost is the loss of one
parent’s salary—which may be significant unless you already have a single-
earner household. Think of your parenting job as a career change. Full time
parenting is hard work, and an admirable profession. (I have great respect for
stay at home parents! My job at work is much easier than my job at home.)

DR B’S OPINION

“If you decide to be a stay-at-home parent, enjoy

your new identity and don’t look back. You will
never regret being there to watch your baby grow.”

Reality Check
First babies in the household rarely get sick from birth to one year. They
spend their days playing on the living room floor with their own toys. When
playgroups get together (a good sanity break), the infants play independently
of each other. When children start playing with each other and sharing toys
(12 to 24 months), they start sharing germs. Firstborn babies who stay at
home don’t get sick that often.
However, your second child will get much sicker in his first year of life.
Why? Big brother or sister brings illnesses home from preschool, the drop-
off childcare at your gym, Gymboree, etc. Second babies also get dragged
around to more family activities. It’s almost guaranteed that you’ll have
more trips to the doctor with each subsequent child.

2FAMILY CARETAKER. This is when a grandparent or some other willing

family member cares for your baby while you go to work.
It is a great alternative if you have someone who is able and willing. It
lets you pay the bills while your baby is at home with someone you can trust.
Not only is family childcare free, but your child develops a special
relationship with a family member.
Your child’s frequency of illness is the same as if a parent stays at home.

Reality Check
Be sure you have a healthy grandparent! Infants require lots of lifting and
time on the floor to play.

3NANNY/AU PAIR. YOU hire someone to parent your child in your home.
This may be a professional, or someone who just enjoys taking care of kids.
This is a great way to have a consistent caregiver. Your child will have a
special relationship with another caring adult. Because you are paying her
and she isn’t your mother-in-law, you can set up the parenting guidelines you
have in mind. If your child gets sick, you don’t need to miss work. You’ll
only have a problem if your provider gets sick, needs to take a vacation or
(yes, it happens) quits.
And it is the most expensive form of childcare. Some parents fear that
they cannot trust someone (other than a family member) alone with their
child. This option requires good instincts of both the parents and the
provider.

Reality Check
You won’t need a home surveillance system (a.k.a. a nanny cam) to check on
your nanny or manny. An infant will tell you if he is uncomfortable with
someone—he won’t be happy to see that person. Obviously, you need to do
an extensive background check on a nanny BEFORE you hire them. See our
other book, Baby Bargains (see the back of this book for details), for tips
and advice on how to do a background check on potential nannies.

Tips for finding a nanny

There are various ways to find a childcare provider who will come to
your home. If you use Care.com or put an ad on Craigslist, you’ll need to
rely on your first impression to make a decision. If you go through a nanny
or au pair placement service, you can pay huge sums of money to them to
screen candidates for you. (They will do a police, credit, and reference
background check.) Our advice: we’d recommend a trial day with your
prospective provider to see how it goes before hiring her/him.

DR B’S OPINION

“You won’t be able to call all the shots on

childrearing. It’s difficult to tell your mother-in-
 law what to do! Set up a consistent parenting plan
with your caretaker before differences in
parenting styles arise. Otherwise, it could get
ugly!”

4IN HOME DAY CARE. A parent has a license to care for a few children (in
addition to her own kids) in her home.
This is a way to hire a mother for your child. It can be great. Your child
will be around different ages of children. Often, older kids enjoy playing
with the little ones. Your child may get lots of love and attention. He may
also see these kids as role models. Sick child policies with in-home daycare
tend to be less rigid than those in licensed daycare facilities. So, you can go
to work occasionally, even if your child is ill. The cost is moderate but if
your child gets sick, you may need to take off work.

Reality Check
As discussed in the stay-at-home scenario, second kids always get more
illnesses. You will be adding your child to an existing household of children,
so expect the same result. Also, those older kids may not be great role
models. You might want to interview both the provider and the children she
cares for before you make any decisions.

Tips for finding in-home daycare

To find these hidden gems, you’ll need to start asking friends, neighbors,
and co-workers for possible leads of in-home daycare providers. It’s
definitely a word-of-mouth kind of option.

5LICENSED DAY CARE FACILITY (CENTER CARE). This is a popular

option for many parents, so I’ll spend a bit more time talking about it. If you
plan to have your child in daycare, you should already have done some
homework. If not, put this book down right now and start!

Tips for finding a good daycare facility

Here are some quick tips on finding a good center care facility:

Look for a program that is NAEYC (National Association for the

Education of Young Children; web: www.naeyc.org) approved. This
organization sets high standards for childcare facilities. If a program has
been accredited, you are more likely to be in good hands. You’ll be able to
do a search on their site based on your zip code.

Look up your potential program’s last inspection. Thirty-three states now

post childcare facility inspections, citations, and complaint investigations
online. Unfortunately, the amount of info can vary dramatically from state to
state. And some inspections only happen once every three years—so the
information may not be totally up to date.

Talk to parents whose kids are in the program.

Find out how approachable the teachers and director are. Are
modifications made if there is a problem?

Spend some time observing in the classroom.

How do the teachers manage discipline?

Do the teachers get down on the floor and play with the kids?

Are both the children and the adults having fun?

What are the program’s policies regarding infection control (sick child
policy)? Some programs are so strict that they require a doctor’s note for
your child to get back in.

Center care is the most popular form of childcare in the United States.
Parents have a sense of security knowing that the providers are licensed
professionals. You can always check up on them. Also, good news—many
daycares are trending towards a “preschool” format. Translated, they
emphasize a more structured environment and learning through play.
Center daycare is relatively inexpensive as far as childcare goes. But
there are hidden costs: you will have to factor in several missed workdays
and doctor bills into the price tag.

Reality Check
Hopefully, you are sitting down for the following statistic: young children
have an average of eight to ten viral infections per year. (Celedon) Infants
are at highest risk of getting respiratory infections in the first several months
of daycare attendance. In fact, six-month-olds who are day-care attendees
have a 79% greater risk of being admitted to the hospital for an acute
respiratory infection than their stay-at-home friends (who don’t have
siblings). (Kamper-Jorgensen) Your child will be asked to leave daycare
every time he gets sick and asked not to return until he is fever free for 24
hours. With each illness, expect your child to be contagious for the first two
to four days of the illness.

GOOD NEWS FOR WORKING PARENTS: QUALITY TIME IS KEY

You can have a nurtured, well-adjusted child even if you and your
partner both work outside the home. A recent study in the journal
Child Development proved that “quality time” is more important than
the sheer number of hours parents spend with their young children.
(Huston)

The Monster Virus from Venus

As parents (we, the Fields) of a new baby, we got a quick lesson on
daycare sickness—and it wasn’t pretty. Our oldest son, Ben, was about two
years old when he started a part-time program at a local daycare center.
When the MONSTER VIRUS FROM VENUS struck, we didn’t see it
coming.
See, as parents who worked at home, the most human contact we had was
with the UPS guy. And as long as he wasn’t coughing on us when he made a
package delivery, we were fine. Then our son started at the day care center.
About a month into the adventure, he came home with a new friend—we
called it the monster virus. Sure, he had a slight fever and stuffy nose—one
day later, he was fine. But not Mom and Dad. Somehow, this little virus
mutated and by the time it hit us it had become a cross between Ebola and
the Black Plague. We were so sick, we couldn’t get out of bed for three days
and had to call in the emergency parent response team (that is, grandma).
The lesson: be prepared to be struck by all sorts of bizarre diseases if your
baby starts daycare. And it won’t only be your baby that will
suffer . . . everyone in your family is going to have to deal with this!
Feedback from the Real World
There’s nothing more vexing than searching for the right childcare for your
child. And the “answer” is always a moving target—your childcare needs
will change as your child grows. We asked our readers how they made sense
of all the childcare options out there. Here are their tips on finding the best
childcare:

Look for a referral service. MK Krum of Ohio points out that many local
YMCAs “offer a free or low-cost referral service. You tell them what kind of
daycare you are interested in (center, provider’s home, your home, etc) and
they match it up to you by zip code.” Each year the providers are required to
resubmit their info along with letters of recommendation. “It gave us several
options both close to work and home.”

Evaluate your commute. You may find it makes more sense to use a day
care close to your home or work, depending on the circumstance.

Look for red flags when you visit a childcare facility. Do children seem
unattached to their caregivers? Or vice versa?

Consider going slow to ease the transition. Instead of dropping your child
in to a new childcare situation cold turkey, take it slow. “Bring her for a few
hours one day while you’re with her,” said one mom we interviewed. Or do
a new program part-time for a week or more to ease the transition.

Don’t make any firm decisions about childcare until AFTER your baby
is born. Now that sounds like a contradiction with the previous tip, but it
isn’t—getting on a waiting list for a popular childcare alternative in your
town does NOT mean you have to take the spot. Meanwhile, many parents
advise waiting until after baby is born before you make your decision about
whether to go back to work. Deb Steenhagen, Muskegon, MI emailed her
advice: “You may feel completely differently once the baby is born. Give
yourself as much time for maternity leave as possible, it helps to bond with
the baby strongly before you go back to work and then you’ll have those
memories to hold onto after you do go back.”
 “If you can find one, go with an in-home provider,” emailed E. White of
Maple Grove, MN. “They are much cheaper. The different centers I looked
at cost twice as much as in-home daycares.”

“Talk to friends and co-workers about what they did. You might stumble
upon a great nanny referral or a nanny share option. My co-worker turned
me on to a great service (non-profit organization) in our area that links
parents to home daycare providers. While I was leery of home daycare
providers (because they have no standards governing their behavior), these
particular providers are subject to rules and regulations set by the non-profit
organization. Now our son is being watched after by a wonderful woman
and we could not be happier!” T. Ross, Arlington, Virginia.

“In Texas, some of the best center care to be found is provided by

churches, which don’t advertise heavily like private day care centers. Ask
around, visit lots of places, and ask the tough questions.” L. Alvarado,
Houston.

Consider an au pair. Au pairs are authorized cultural exchanges—a young

woman in her 20’s comes to live with you to do childcare. Pros: you have
one person who takes care of your baby in your home and the au pair
becomes part of your family instead of just hired help. Downsides: you have
to have a separate bedroom because you have a new family member and
they must leave after two years. For more info, go toAuPairAmerica.com.

Accept the fact that your babysitter or nanny will do things differently
than you do. As long as your child is content and healthy, that is just fine.
Don’t try to micromanage day care.

Laura L. of Hot Springs, AR says getting some help cleaning your house
was critical to her sanity: “Hiring a housekeeper, even one that comes every
two weeks, is worth every penny you pay. Amazing how much more time it
gives you with your baby and family to have that help, even if your budget is
already strained!”
 BEHIND THE SCENES: IS DAYCARE SICKNESS
GOOD?

From a health standpoint, it’s not all bad that your child gets
exposed to infections. A recent study showed that children who were
in daycare/center care from birth to at least one year of age had fewer
allergies at age two than their “sterile” stay-at-home peers. It’s called
the “Hygiene Hypothesis.”

Feedback from the Real World

If you plan on returning to work after your baby is born, be prepared for a
fine balancing act. I suggest you strongly consider how your life will
“work.”
Just getting out the door in the morning may be more stressful than any
board meeting you’ve attended. Getting yourself ready is the easy part. If
you use out-of-the-home childcare, you will have to get your baby ready and
fed, plus pack up his food for the day. This can take awhile because your
baby has no idea what your schedule is, nor does he care. He also won’t care
if he spits up on your silk blouse or suit jacket.
Another point: be prepared for that phone call from childcare telling you
that your baby is sick and needs to be sent home.

Balancing Act: Juggling work and family

How do you balance family, career—and your sanity? While the ideal
situation would be to be at home for your baby 24/7, some parents find they
want to work outside the home at least some of the time. For others, it is a
necessity.
 So, let’s take a look at how moms and dads do the seemingly impossible
—juggling baby, career, marriage and more. How do they do it all? To get
the answers, we asked the readers of our books to share their wisdom. First,
check out our Six Commandments for Balancing Work & Baby. Next, we’ll
look at this issue day to day, with 15 tips and tricks for juggling family and a
career.

Six Commandments for Balancing Work & Baby

1FORGET BALANCE. When we say “balance” work and family, this implies
some kind of happy equilibrium. Forget it—the best you can hope for is
OCCASIONAL peaceful coexistence between your family and job.
Something will always be working to upset the balance, however . . . a
childcare situation, sickness, job demands, etc.

2DO THE MATH. Sit down with a piece of paper and do a serious
cost/benefit analysis before returning to work. Kelly Anderson of San Diego,
CA emailed her advice to moms: “Most people would be shocked to see how
all the hidden costs of working outside the home add up (dry cleaning, taxes,
eating out, gas, plus the fact that someone else will be essentially raising
your child for you). For many people, the benefits just don’t outweigh the
costs.” Good point: even if you have a good job with excellent pay, the cost
of childcare and other hidden expenses may wipe out a good part of the
earnings.

3DUAL CAREERS, DUAL SACRIFICE. Both you and your spouse must make
sacrifices for this to work. While nothing in life or marriage is always 50/50,
both parents must help to make the schedule work.

4MEET THE NEW BOSS—YOUR BABY. That means your old boss at work
must adjust to your new life. “You don’t want to work for a boss who does
not put family first,” says reader Tricia Gagnon. She’s right—if your boss
doesn’t understand why you need to take a day off to care for a sick child,
you need to find a new job.
5 AVOID THE GUILT TRIPS. Whatever you decide for your baby, get ready
for second-guessing from friends, relatives and complete strangers. E.
Moeller, Boulder, CO, wrote in to stress this important point: A happy
mommy (and daddy) makes for a happy baby. “If you are fulfilled and
enjoying your work and have made good childcare choices, your baby will
thrive.”

6 WILL IT MATTER NEXT MONTH? OR NEXT YEAR? When you have to

decide whether to work late or another weekend, ask yourself: “How
important is my job as a ________ compared to my job as a father or mother.
Will this project matter next month, year or in five years?” Your child will.

Day-to-Day: Tips & Tricks for Juggling Family & Career

Sometimes it is the small details that make the difference—here are our
readers’ tips and tricks for balancing work and family in their daily routines:

The routine is KING. Reader Wendy Stough emailed: “Create one that
works for you and do your best to stick to it, to some degree. It cuts down on
the chaos of little things like lost keys and forgotten diaper bags and allows
us, as parents, to take advantage of those special moments when our children
need us most. Even when chaos reigns, you’ll still know where the keys
are!”

Make up snacks in advance. Reader MK Krum of Toledo, Ohio makes up

snacks and even sippy cups for snack-time a week in advance. “In the
morning, just grab what you need and stick it in the diaper bag and go!”

Organize your baby’s closet. One reader uses a hanging organizer marked
with the days of the week. “On Sunday, we load it up with the clothes for
each day and any diaper bag refills.” Of course, as your baby gets older, she
may want a say in what she wears, but that’s a story for the next book in this
series, Toddler 411.
 Don’t be afraid to ask for help. When you feel overwhelmed, ask friends
and relatives to pitch in.

Look for a local “Mom’s Day Out” program to get a break once in a
while. Laurie Galbreath of San Antonio emailed us this tip: “Many churches
offer this and you don’t have to be a member! It is also very reasonable.”

Create shortcuts to make your life easier. Example: use white boards in
each room of your house to write down needed supplies. This tip was sent in
by Debby Moro of Cumming, GA. She emailed: “I stuck a small write
on/wipe off board on the back of every door in the house. When I was in a
particular room and noticed I was getting low on some supply, I jotted it
down then and there. Before I hit the store, I walked through the house,
made out the list, and avoided forgetting something.”

Use the web. You have one advantage that previous generations of parents
didn’t—the Internet. The web is your friend . . . use it to shop for everything.
Reader Area Madaras uses the web to order groceries. “It’s cheaper for me to
pay $10 for Albertsons.com or Vons.com to deliver my groceries than it is
for me to pay a babysitter.” And always consider the value of your time—it
may be better to shop online and save a car trip.

Pack the car the night before. Avoid forgetting something during
morning rush by packing that diaper bag and wallet in the car the night
before (assuming you have a secure garage).

When you cook, double the quantity—then freeze the extra portion for a
quick meal later in the week.

Get up a bit earlier. This will give you a jump-start on the day—many
moms and dads find they can get some chores done in the 30 minutes or so
before baby wakes up.

Have a “two stop” rule. We found our children would get very
cranky/hungry/(fill in blank) when we tried to do more than two errand
stops. While it is tempting to try to sync errands together by stopping at X, Y
and Z after work, we found there was a limit to our children’s patience—
usually more than two stops would make life less than pleasant for all.

Know your employer’s sick leave policy. The Family Medical Leave Act
(FMLA) allows parents to stay at home with a sick child without penalty
(except for lost wages).

Schedule fun time. One mom takes ten minutes out of every morning to
jump on the bed or read stories with her toddler. A few stolen moments like
that can make the difference.

Cook on the weekend for the rest of the week. “That way we always have
home-cooked meals that are healthy and tasty ready to pack for lunches or to
re-heat at dinner time,” emailed Lori Lankey of Woodbury MN. “It saves
time and energy during the week, not to mention calories and money if we
ended up eating out instead.”

Have a backup sitter plan. And then get a backup for the backup. That
way, if an emergency strikes, you have a plan B. And plan C.

So, let’s sum it up. Here are the Top Tips to Balancing Work & Family:

1.Be organized.
2.Trust your instincts.
3.Prioritize.
4.Stick to the routine.
5.But be flexible too.
6.Ask for help when you need it.
7.Lower your expectations.
8.Control freaks need not apply.
9.Laugh! Keeping a sense of humor about EVERYTHING is key.
10.Schedule a little “me” time.

Now that we’ve covered the important highlights of establishing care

with a medical provider, creating a parenthood plan, finding childcare, and
juggling your new life, let’s move on to taking care of your little one. Next
up: hygiene!
BABY
411
 Section 2

Care & Feeding

HYGIENE
THE SPA TREATMENT
 Chapter 4
“Ray! You take that diaper off your head, you put it back onto your
sister!”
~ Raising Arizona

WHAT’S IN THIS CHAPTER

THE FIRST MANICURE
YES, IT’S OKAY TO USE DIAPER WIPES
HOW MANY LAYERS OF CLOTHING YOUR BABY REALLY NEEDS
WHAT TO DO ABOUT DIAPER RASHES
BELLY BUTTON/CORD CARE
SOAPS, CREMES, AND DETERGENTS
NATURAL SKIN CARE
CRADLE CAP
ECZEMA
SUNBLOCK AND INSECT REPELLENTS
THE BOY PARTS
THE GIRL PARTS
THRUSH, DENTAL CARE, AND DROOL

You survived nine months of pregnancy, Birth Day and the hospital food
after your baby was born. Now the fun begins—it’s time to take baby home.
Due to budget cutbacks at the federal government, babies are no longer
sent home with personal butlers or detailed care instructions on cleaning
and hygiene. Just kidding! They never used to do that. You are expected to
know about this stuff on your own. Consider this chapter your baby care
primer.
Warning: we’ll talk candidly about diaper rash. No it isn’t pretty, but
there are several steps you can take to stop it. Next, it’s on to belly button
care. Also, we’ll discuss the topic of dressing your baby as well as tips on
cradle cap, sun block, dental care and more. And let’s talk about your
baby’s private parts—you’ve got questions and we’ve got the answers!

Q. When can I clip my newborn’s nails?

Around three to four weeks of life.
The fingertip and nail are stuck together for the first few weeks.
Attempts to use a nail clipper will result in drawing blood. For now, you
can use a nail file and give your baby a manicure.

Helpful Hint
You can place socks on your baby’s hands if he is scratching his face and
you want nice pictures.

Q. When can I use diaper wipes?

Now.
Most hospital nurseries use gauze pads soaked in water for diaper
cleanups. This is done to prevent potential skin irritation. If nurseries don’t
use wipes, should you? Short answer: yes. Wipes are safe—98% of babies
have no problem with typical diaper wipes. Diaper wipes do contain a
preservative called methylchloroisothiazolinone (MCI), which can be
irritating to about 2% of the population. (Chang WU) If your baby develops
a rash, just switch back to gauze pads.
 DR B’S OPINION

“Bring your own diaper wipes to the hospital. If

your baby’s skin gets irritated, then you can use
water and gauze pads. After your first diaper
change cleaning meconium, you will understand
why I recommend using diaper wipes.”

Helpful Hint
Some parents like to keep alcohol-based hand sanitizer at the changing table
(for mom and dad’s hands). It’s not a bad idea, since you need to keep your
hands and your eyes on your baby.

Q. How many layers of clothing should my baby

wear?
As many as you do.
Babies live at the same body temperature as we all do. They will be
comfortable in the same number of clothes as you are. It is true that your
baby loses heat a little more quickly than you, so keep an eye on him in
cooler weather.
If you have a late preterm newborn (34 to 36 6/7 weeks gestation), you’ll
want to wrap her up in an extra receiving blanket or two in the first several
days of life. But once she’s got her temperature regulation under control and
a little meat on her bones, the same rules apply as with full-term newborns.
Reality Check
Parents often dress their babies for an arctic freeze in July. Then they
wonder why their baby has a heat rash.

Q. How often do I clean the belly button?

While the idea of cleaning your baby’s belly button may seem a no-
brainer, there is actually quite a bit of debate about it. According to the
American Academy of Pediatrics, “no single method of umbilical cord care
has proved to be superior in preventing . . . disease (that is, infection of the
belly button).” (AAP). Hence, there is some variability in what hospital
nurseries do. Some apply antibiotic solutions, “triple-dye” (an antiseptic) or
alcohol to the cord. The current trend among hospitals, however, is moving
AWAY from these treatments. Why? Some research suggests the stump may
heal faster if simply left alone. (Palazzi) Your doctor will probably have his
or her own preference.
So what do you do with the umbilical cord stump once you get home?
Well you can’t just pretend it’s not there and ignore it! Check on it at diaper
changes, and clean it at least once a day. Keep an eye out for infection too.
Infection clues: redness and swelling around the cord, continued bleeding,
yellowish pus and/or foul smelling discharge from the area.
How should you clean the belly button? You have two choices: sterile
water or rubbing alcohol. The time-honored method is alcohol. But we now
know that using rubbing alcohol does not prevent infection or make the
cord fall off any faster. The only benefit to using alcohol on the cord stump
is to keep the belly button from getting stinky. Alcohol should be applied to
the BASE of the belly button, where the gooey stuff is—exactly where you
are afraid to go. (Zupan)
The alternative: you can spot clean the cord with sterile water on a gauze
pad if it gets dirty. Whichever method you choose, just make sure the cord
stump stays clean.
 TREATING DIAPER RASH: 5 TIPS & TRICKS

There are basically two kinds of diaper rashes:

Irritated skin. Flat red rash caused when poop and pee break
down the skin, causing redness and irritation.
Yeast infection. Raised, pimply rash surrounds an area that looks
like raw meat. (Yeast likes the diaper area because it is dark, warm,
and moist.)
Curious to see exactly what these different rashes look like?
Check out our web site at Baby411.com (click on Bonus Material).
For basic skin irritation, creating a barrier to protect the skin from
further insults is key. Here are our tips:

1.Use petroleum jelly (Vaseline) or zinc oxide (store

brand: Balmex, Desitin) at every diaper change. Avoid
powders—baby can inhale the powder into his lungs when it is
poured out. Creams are a better bet.
2.Let your baby “air dry.” If you are feeling brave, let your baby
go bare bottomed for a while. For the less ambitious types, use
a blow dryer on a cool setting and dry the diaper area after
cleaning.
3.For more severe rashes, try Dr. Smith’s Diaper Ointment, Triple
Paste, or Boudreaux’s Butt Paste. These products are a little
thicker and more protective. Although they are available over-
the-counter, you may have to ask your pharmacist to order
some for you.
4.Use pure lanolin Many women use this for cracked nipples
caused by breastfeeding. It’s very expensive to recommend as a
first line of defense against diaper rash, but if you have it in the
house, use it. If you want to buy it in bulk and save some cash,
look into Corona Ointment (coronaproducts.com). Yes, it’s
 designed for horses—but the active ingredient, lanolin, is the
same!
5.If the rash looks like yeast, try an over-the-counter antifungal
(e.g. Lotrimin AF or Triple Paste AF)—the package will say
it’s for jock itch and athlete’s foot. Don’t be alarmed. Apply
twice daily for a week.

If none of these tricks work, check in with your doctor. Most docs
have additional tips for stopping diaper rash.

RED FLAG: Belly Buttons

A foul smelling belly button with pus draining from it and surrounded by
red skin indicates infection (see OMPHALITIS). You need to call your doctor
immediately.

Q. When will my newborn get his first bath?

Your baby will get cleaned up shortly after delivery. Most hospitals will
sponge bathe newborns and recommend parents do the same at home until
the umbilical cord falls off. Babies don’t get that dirty and sponge bathing
minimizes heat loss.
Sponge-bathing also keeps the umbilical cord dry until it falls off. You
can sponge bath your baby with soap, water, and a washcloth every few
days. Once the cord falls off, you can give him his first real bath.

Q. I heard in my childbirth class that it’s better NOT

to bathe your newborn in the first 24 hours of life. Is
this true?
 Let’s go over the usual hospital protocol first. After you give birth in a
delivery room, you spend about the next hour getting to know your
newborn and having your first nursing session. (That’s assuming you are
nursing, your baby is full term, and he has no immediate medical issues to
deal with.)
Then, you get cleaned up and transferred to your postpartum room, and
your baby heads to the nursery to be examined, monitored, and bathed.
While this is the norm, it does have a couple of disadvantages.
Occasionally, the baby gets cold after his bath and then has to stick around
the nursery under warming lights until his body temperature rises. This
delays getting the baby back to you.
The other issue with the first bath is that it usually washes off the baby’s
VERNIX (that white cheesy stuff that protects the fetus’ skin from getting
pruny in the amniotic fluid). Vernix also fights off germs so it’s not a bad
idea to let it stay a little while longer. In fact, the World Health Organization
recommends waiting on that first bath until six hours after birth. (World
Health Organization)
But here’s a little reality check and the downside to delaying a bath: your
baby isn’t just covered with vernix. He’s also covered in your blood and
vaginal secretions after delivery. If you choose to wait and give baby his
first bath after 24 hours (or even later, at home), anyone handling your
newborn (healthcare providers, grandparents, other well wishers) will need
to wear protective gear and gloves. This avoids any handling of bodily
fluids that are caked all over your baby’s skin.
Bottom line: If you deliver at a birthing center, or at home and no one is
going to be handling your baby but you, do whatever you like. If you
deliver at a hospital, get a good nursing session in and some skin-to-skin
bonding time—then let him get cleaned up. Waiting beyond six hours of life
makes handling baby a hassle and doesn’t have any major health
advantages.

Feedback from the Real World

Some hospitals have changed their bath procedures for newborns. For
example, Hoag Hospital in Newport Beach, CA has abandoned the age-old
tradition of sponge-bathing and are now immersing their newborns in a full
bath. The Association of Women’s Health Obstetric and Neonatal Nurses
supports this practice, so you may see it popping up in a hospital near you
in the future. We should point out that while your hospital may do an
immersion bath, we advise a sponge bath until the umbilical cord stump
falls off.

Q. How often should I bathe my baby?

As often as you wish.
You can bathe your baby every day if you like. Many parents and babies
enjoy the time together. On the other hand, your baby does not make body
odor or play in the sandbox yet. You can bathe him as infrequently as two to
three times per week.

Q. What soap products should I use on my baby?

We like Dove (bar soap) or Cetaphil soap, because they are perfume and
dye free. Plus, they contain a moisturizer (particularly good for babies with
eczema). Johnson’s hypoallergenic baby shampoo or the generic off-brand
is fine for most babies (although most of them are slightly
scented). Aquaphor 2-in-1 Baby Gentle Wash and Shampoo is an option for
supersensitive babies (although we should note this product contains
chamomile, which is a scent).

Helpful Hint
A good rule for baby products—if it smells good or has a color, don’t use it
on your baby.
Q. Can I put lotion on my baby’s dry skin?
Sure. Just be sure it is perfume-free and dye-free.
Most newborns have dry skin from swimming around in water (technical
term: amniotic fluid) for nine months and they are just exfoliating. But, if
you really feel compelled to do something, we personally recommend
hydrated petroleum jelly (Creamy Vaseline or Cerave are examples of brand
name products). When it comes to dry skin, the greasier the better.

BATHING BABY 411: THE 10 STEP METHOD

Never bathed a baby before? Relax. Here is your 10 step how-to

guide for a sponge bath:

1.Get everything ready first. Have two baby towels, washcloth, a

bowl of warm soapy water and a bowl of warm water for
rinsing, baby comb, shampoo, fresh diaper, and clean outfit.
2.Place a towel in the infant tub (you won’t be filling the tub with
water).
3.Put naked baby onto the towel in the tub. Cover all body parts
not being cleaned at the moment.
4.Expose one body part at a time (starting head to toe) and
wash with soapy water except eye areas. Rinse.
5.Take the other towel and dry the area that has been cleaned.
6.Be sure to get into the creases, especially under the chin/neck.
7.Shampoo hair, rinse, and dry quickly.
8.Move baby from the towel he is sitting in and dry him
completely with the other towel.
9.Diaper and dress.
10.Clean up mess later
Q. I’d prefer to use natural, non-petroleum based
products on my baby’s skin. Any suggestions?
Parents preferring non-petroleum based products often gravitate to skin
lotions and creams using food products.
Warning: products claiming to be “hypoallergenic” or “natural” can
contain food products that are highly ALLERGENIC. Avoid skin care
products that contain milk, almonds or peanuts (also referred to as arachis
oil) in their ingredients. And think twice about using trendy coconut oil-
based products. For some people, the active ingredient in coconut oil,
cocamidopropyl betaine (CAPB), can actually irritate the skin!
If your baby’s skin condition gets worse when you apply a certain
product, stop using it and let your doc know. It may influence how and
when you introduce a particular food into his diet.
The take home message: read those labels! And, remember this mantra:
just because it is natural, does not mean it is safe and harmless.

Q. My baby has acne. Should I buy some Oxy 10?

No. Do nothing and it goes away by eight weeks of life.
Acne develops from your baby’s rapidly changing body hormones. It is
the worst from age four to eight weeks. Putting creams and lotions on the
skin only makes it worse. Most importantly, your baby is not bothered by it.

Q. What laundry detergent do I use to clean baby’s

clothes? Do I really need to wash everything before I
use it?
It depends on the baby.
Stick with the perfume-free and dye-free rule, especially for babies with
sensitive skin. But, that does NOT necessarily mean that your baby’s
laundry needs to be washed separately with his own expensive detergent.
The whole family’s laundry can be done with a product like ALL Free and
Clear or Tide Free.
 For the baby with sensitive skin, pre-wash items that will be touching
him. It may also be helpful to double rinse the laundry. And remember to
avoid dryer sheets (they all contain perfume).

Helpful Hint
Have a spray bottle of stain remover next to baby’s laundry basket. You’ll
probably need it for the shoulders on all of your shirts, too.

Q. What is the scaly stuff in my baby’s hair?

For twenty points, Alex, what is cradle cap?
Cradle cap (see SEBORRHEA) is caused by baby’s hormonal changes and
possibly yeast. It causes dry, flaking patches on the scalp, eyebrow and
behind the ear. It can last for several months and sometimes, even years.
Because it is similar to dandruff, it can be treated the same way. Anti-
dandruff shampoos (Head and Shoulders, Selsun Blue, Sebex) work well if
used two or three times a week. You can also massage vegetable oil into the
areas and lift the scales up with an old toothbrush. You can use an anti-yeast
product like Nizoral AD shampoo (over the counter) for resilient cases.
Eyebrows can be treated with 1% Hydrocortisone cream (over the
counter) twice daily for a week.
Reality Check: Cradle cap may bother you, but it doesn’t bother baby.

Q. Does my baby need a waxing? She has hair on her

ears and on her back.
Nope. We know it is cosmetically undesirable (especially for those baby
girls), but it’s not permanent. What’s not normal: pubic hair or armpit hair
—time to call your doctor if you see this before puberty.
Q. When can my baby start using sunblock?
Now. Sunblock can be applied to newborns, although staying out of the
sun (especially during peak hours of 10am to 4pm) is a better choice to
avoid sun damage and sunburn.
The AAP previously recommended that sunblock be used only in infants
over six months of age (because of the potential for skin irritation).
However, the risk of skin cancer (1 in 75 over a lifetime) has outweighed
concerns over potential skin irritation. Sunblock is critical because sun
damage and sunburn at an early age is correlated with a higher risk of skin
cancer later in life. Translation: use the sunblock on that baby.
Select a sunblock with a SPF of 30 or higher. FYI: Avoid sunblocks with
the chemical PABA—sunblocks with PABA are more likely to cause skin
irritation than PABA-free sunblock.
Other tips: try to keep baby out of the sun, especially from 10am to 4pm
every day, apply sunblock liberally (at least a half ounce each time) and
reapply frequently (every two hours and after swimming or sweating).
Both UVA and UVB sunrays can cause skin damage and cancer. The
SPF factor refers to UVB protection only. But, obviously, it is best to cover
for both UVA and UVB rays. Look for products that contain titanium
dioxide, zinc oxide, oxybenzone, or Parsol 1789 to be certain of UVA
protection.
What sunblock is best? Consumer Reports has a report on sunblock on
their web site (consumerreports.com) that includes product tests and ratings.
The key to preventing sunburn is to RE-APPLY the sunblock frequently
—don’t buy the combo sunblock and bug repellent (we’ll explain why
later).

ECZEMA: ADVICE ON DEALING WITH DRY SKIN

Some babies develop dry, scaly patches on the skin (see eczema).
It gets worse when the skin is dry. The key to keeping it in check is
using a moisturizing soap and frequent applications of moisturizing
 cream. For some reason our family (the Fields) has been unlucky
enough to be plagued by eczema. Perhaps it’s thanks to the ultra-dry
climate here in Colorado, where the relative humidity is often
measured in single digits. Mom, Dad and both boys have had it,
including one child with severe, chronic eczema. Here are our tips for
living with this itchy-scratchy skin condition:

1.Baths: Avoid bubble baths, oils, perfumes, dyes, and detergents.

Try Dove bar soap (not the liquid), Cetaphil, Aveeno, or Cal-
Ben’s Seafoam soap (available online or at natural food
stores). Consider adding a half-cup of bleach to a full bathtub
of water for bath time twice a week to reduce skin germs
known to worsen eczema. (Huang)
2.Moisturize constantly. As a side benefit, this is a great way to
bond with your baby when you massage lotions or creams into
his skin frequently. A room humidifier will help introduce
moisture as well.
3.Use “clear” detergents. For laundry, use perfume-free and dye-
free detergents such as Tide Free & Gentle or ALL Free and
Clear.
4.Observe whether eczema shows up when you start adding new
foods to baby’s diet. Eliminating the offending food will
obviously help. And if it happens frequently, you should
consider seeing a food allergy specialist.
5.Don’t be afraid to get a referral to a dermatologist if your baby’s
eczema gets really bad. Dermatologists are skin experts with
knowledge of the newest treatments.

Old Wives Tale

Dark skinned people do not need to wear sunblock.
 All humans who have skin need to wear sunblock. While it is true that
darker-pigmented people have less risk of skin cancer, there is still a risk
and prevention is easy.

Q. My spouse and I are both African-American and

our newborn looks white! Is this normal?
Yes. The skin pigmentation, called melanin, develops as the baby grows.
Babies born with light skin may get significantly darker with time.

Q. When should I apply insect repellent on my baby?

Apply it when your baby (of any age) is hanging out in the great
outdoors, especially at dawn or dusk in the summer months.
Mosquitoes and ticks are known carriers of illness. The most notable
diseases in the United States spread by these bugs are West Nile Virus
(mosquitoes) and Lyme Disease (deer ticks). The safest option to avoid
mosquitoes is to stay inside at dawn and at dusk, when they are out in
greatest numbers. If you go out and about, have your baby wear light
colored clothing, long sleeves, and long pants. And you can get insect
netting to cover little ones who are just sitting in their infant carriers or
strollers.
As far as insect repellents go, the most effective products contain DEET,
picaridin (sold as Cutter Advanced or Off Skintastic), or Oil of Lemon
Eucalyptus. But the age of your child limits your options. Picaridin based
products are the only ones approved for use in babies from birth to two
months of age. DEET based products are considered safe for babies over
two months of age. And Oil of Lemon Eucalyptus is only recommended for
kids over three years of age (because even small doses in young children
have led to serious side effects—like coma and seizures).
Many parents want to avoid using harsh chemicals on their child’s skin
and have turned to citronella-based repellents. However, products
containing citronella repel mosquitoes for a mere 9.6 minutes, while 23%
DEET will repel mosquitoes for five hours. (Fradin) Picaridin is the most
effective non-DEET alternative for kids zero to age 3.
 The problem with DEET is that it can be absorbed into the body via the
skin and cause “neurotoxic effects” like dizziness (and rare, more serious
adverse effects in massive doses). Therefore, you should wash the DEET
repellent off once returning indoors. Here are some additional safety tips for
using insect repellents on your baby: (Wall Street Journal)
1.Young children should not apply repellent themselves—that’s
mom and dad’s job.
2.Don’t apply repellent under clothing or to wounds. It goes on
exposed skin—yes, that means ALL exposed skin areas, not just
the arms or legs.
3.Don’t put any repellent near children’s mouths or eyes—and
avoid getting it on their hands.
4.Insect repellents come in several forms—the liquids, sprays,
washcloths, and lotions are effective. Exception: The DEET wrist-
bands don’t work.
5.When you come back inside, WASH your baby’s skin.
6.DEET products with a concentration of 30% are as safe as those
with 10%. 30% DEET lasts for five hours, 10% just two hours.
7.How much DEET should you use? That depends on how long you
plan to be outdoors—10% is fine for less than two hours, etc.
8.DEET should only be applied once a day. Picaridin based products
should be re-applied every 3-4 hours.

The Boy Parts

Q. When can I stop using gauze around my newborn’s

circumcision?
Once a scab starts to form (around four days after circumcision).
This question usually comes up at the two-week well baby check—but
you can stop long before that! The nurses at the hospital will show you how
to apply a gauze dressing and petroleum jelly (Vaseline). I tell parents to
place a big dollop of jelly in the center of the gauze, position the penis right
where the jelly is, fold over the gauze, and seal it like an envelope (the
petroleum jelly will allow it to stick together).
You’ll want to change that dressing at least three times a day and every
time your son has poop in his diaper. Since urine is sterile (germ-free), you
don’t necessarily have to change the dressing if he has only peed.
The skin starts to heal around three or four days after a circumcision
procedure is done. It starts to look gross with a yellowish scab. You will
think it looks infected, but it’s not. When it looks like that, it no longer
needs gauze to protect it.

Helpful Hint
A parent remarked to me, “You need to tell me the endpoint for certain
things. Otherwise I’ll think I’m just supposed to keep doing it.” If you are
still putting gauze on your six month old, you have gone above and beyond
the call of duty! Bottom Line: If you don’t know when to stop, ask your
doctor. It will save you a lot of time and labor.

Q. How do I care for my son’s circumcised penis in the

long term?
Make sure you always see a definite separation between the head
(technical term: glans) and the shaft of the penis. In the first week after the
circumcision, you won’t see this separation due to swelling from the healing
process. But once it is completely healed, you should see what we are
talking about—the head of the penis should look like a helmet, with a
defined rim.
When you change your baby’s diaper, gently pull down at the base of the
penis and clean the area where the head meets the shaft. This area collects
dead skin (this is called smegma; memo to Seattle-area musicians, this
would be a great band name). If the smegma remains there, it can cause the
head and shaft to adhere together (see PENILE ADHESION; second memo to
Seattle bands—this is NOT a good name).
 Be sure to follow these instructions and ask your baby’s doc for help if
you are uncertain. Over the past decade, there has been a steady rise in the
number of re-do circumcisions to remove adhesions.

Q. My son’s circumcised penis is stuck and I can’t see

the head. Now what do I do?
There are a few options to “Free Willy” (a patient’s father gets the credit
for coining this term). If the skin on the shaft is stuck to the head of the
penis (see PENILE ADHESION), it can be unstuck. The options: applying a
prescription steroid cream, manually pulling it apart, or having a surgical
procedure to correct it. Check in with your doctor to decide on the best
plan. If the adhesion is minor, it may even un-stick on its own.

Reality Check
Often, a boy with a penile adhesion is also one with a hidden penis (we also
discuss this in the circumcision section of Chapter 1, Birth Day). These
thriving little boys have fat rolls above their genital area, which allows the
penis to naturally sit in a sucked in, or concealed position. Bring that penis
out (by pulling down at the base) for a cleaning at diaper changes, or you’ll
be dealing with a penile adhesion later. No, you won’t still be doing this
when your son is a teenager. It’s usually not an issue after your son is about
two years old.

Q. How do I care for my son’s uncircumcised penis?

Here are four rules:

1.Do NOT forcefully pull the foreskin back to clean the penis.
2.Dead skin (smegma) collects under the foreskin and will come out on
its own.
3.Once the foreskin pulls back on its own (usually by age five years),
clean under the foreskin one or two times per week with water.
Always push the foreskin back down after pulling it up to clean it.
4.Teenagers need to clean under the foreskin daily.

The foreskin is attached to the shaft of the penis with tight tissue called
adhesions. Most of the time, these adhesions loosen up by the age of five.
Some boys, however, may have adhesions into their teen years and this is
still okay (but check it out with your doctor).
Rarely, the foreskin remains tight and hard to pull back (see PHIMOSIS).
The foreskin can also get pulled back and unable to be manually brought
back down (see PARAPHIMOSIS).

BOTTOM LINE
If your son has a red, swollen penis, or an abnormal stream of urine, call
your doctor.

The Girl Parts

Q. How do I clean my daughter’s private parts?

 Front to back, and in every crease. Dads—time to pay attention.
Poop has bugs in it (bacteria). Pee (urine) does not. If the poop ends up
in the opening to the bladder (urethra), the bacteria will climb in and grow
there (see BLADDER INFECTION/UTI). This is a bad thing.
Look at your daughter’s private parts. Gently separate the lips (labia).
You will see two holes. The top hole is the urethra; the bottom hole is the
vagina. These areas, including the lips, need to be poop-free zones. Wipe
from the top of the genitals, down to the anus. Never go backwards and use
several wipes if you need to.

BOTTOM LINE
Don’t ever hesitate to change your daughter’s poopy diaper, even if it isn’t
your turn. Delay can lead to a bladder infection.

Q. When can I get my daughter’s ears pierced?

Although ear piercing is a safe procedure for your infant, there is no
consensus on the right time to do it. Here are some things to consider:
Infection: Inserting a needle through the skin carries a small risk of
infection. You might want to wait until your baby is at least 4 mos.
old.
Allergy: Some people are allergic or sensitive to the metal in the posts
or backing. Use either surgical steel or 14k gold products.
Scarring: Some people have poor wound healing where a thickened
area of skin forms at the break in the skin. If a family member has
this problem, you might want to wait and let your baby decide if she
wants to take this risk.
Cosmetic result: Babies can be moving targets. Be sure the person
performing the procedure is comfortable with infants or you could
end up with uneven results!
Mouth Care

Q. Why is my baby’s mouth coated in white? Is that

milk?
It is either milk or thrush (a yeast infection in the mouth).
When babies are toothless, their mouths don’t have many bacteria
(germs) living there. Teeth provide a home for bacteria (that’s what plaque
is). Remember the yeast diaper rash? Yeast likes dark, warm, wet places
that don’t have other germs around. A newborn’s mouth is a perfect locale.
How do you tell the difference between milk and thrush? Milk wipes off
and is only on the tongue. Thrush collects on the gums and inner cheeks and
can’t be wiped off. Thrush requires a prescription anti-fungal mouthwash to
be treated. Call your doctor.

Helpful Hint
If your baby gets thrush, you need to sterilize any products that go in baby’s
mouth (rubber nipples, pacifiers), as yeast will continue to grow on these
items. Breastfeeding moms frequently develop a yeast infection on their
nipples when their baby has thrush. See Chapter 6, Liquids, in the
breastfeeding troubleshooting section for top tips to treat yeast infections
with nursing moms.

Q. When do baby’s teeth come in?

Around six to 12 months old. There are some kids whose teeth come in
earlier or later, though. Universally, the first tooth to erupt is a bottom,
middle one. The rest come in randomly. See the chart on the next page for
more info on which teeth come in when.
Q. How many teeth should my baby have at his one-
year birthday?
When it comes to one-year olds, teething varies widely.
Some babies have several teeth at their one-year birthdays, others may
just have one. Don’t worry if your child only has one tooth at his first
birthday and his other friends have more than that.
Your baby’s doc is looking for at least one tooth that is in the midst of
eruption or has already erupted by the first birthday. That means your
baby’s tooth development is okay.
If there are more teeth than that, terrific. If not, no worries.

Reality Check
Drool is not a reliable indicator of teething. All four-month-olds are
drooling and usually toothless. Why? The salivary glands are getting revved
up at this age to start digesting solid foods. Yes, a baby may drool more
when he is teething, but he may just drool a lot with or without a tooth
coming in.

Q. How can I tell if my baby is teething?

Babies who are teething have a lower coping threshold and trouble
settling down. But, they usually forget the pain of throbbing gums when
they are busy playing.
As a doc, I think I have heard it all when it comes to symptoms blamed
on teething—from runny nose, diarrhea, and fever, to sleep disruption.
Teething pretty much gets blamed for everything and is usually responsible
for nothing. Your baby is allowed to have a cold virus AND teething . . . or
acid reflux AND teething. It’s a good idea to check things out and not just
blame every problem on teething.
 First-year molars come in somewhere between 12 to 18 months, even if
the more central teeth are not in yet. And yes, these do hurt more than the
others when they start to erupt. Don’t be fooled when your baby starts
pulling on his ears—it’s most likely not an ear infection. Look in his mouth.
It’s often the jaw pain from the molars that causes the ear pulling. It will
save you a trip to the doctor.

Old Wives Tales:

Teething causes a fever. False. Teething causes diarrhea. False. Teething
causes a runny nose. False.
Q. There’s something purple in my one year old’s
mouth. Is this an emergency?
Nope, it’s just a one-year molar trying to break through.
When teeth are trying to erupt through the gums, they sometimes form a
bruise or blood blister in the surrounding gum area. It looks swollen and
purple or blue. This is particularly true for molars, but can happen with
other teeth as well. It’s called an ERUPTION HEMATOMA. No worries. It
doesn’t hurt and it goes away on its own once the tooth erupts. If you see
the hematoma, the tooth will be coming through in about two or three
weeks.

Feedback from the Real World

Seth Silber, a seven-month-old from Austin, TX likes to gnaw on frozen
celery when he is teething. His dad claims it works like magic.

Helpful Hint
Acetaminophen (Tylenol) is the safest and most effective medication choice
for teething pain at bedtime. Ibuprofen (Motrin, Advil) is also fine for
babies who are at least six months of age. For daytime, try frozen mini-
bagels or a cold teething ring to gnaw on. Teething gels (Numzit, Orange)
can have adverse health effects and the FDA warns against using them.
Homeopathic teething tablets, which contain trace amounts of
belladonna (a toxin) and caffeine, were taken off the market in 2010 after
the FDA issued a safety warning. Teething tablets have since returned to the
market, but we don’t recommend them.
New Parent 411: Teething Necklaces
Another product to avoid: amber teething necklaces. Sellers claim these
necklaces offer a “natural” remedy of succinic acid that gets absorbed
through the skin while wearing this nifty accessory. But makers also warn
that the product is NOT intended for children under three years of age or
children who are sleeping. Hmmm. That pretty much eliminates the target
market for teething!

Q. When do I start cleaning baby’s teeth?

You should wipe your baby’s mouth with a soft cloth after every feeding
even before he has teeth, according to Steven Adair, DDS, MS, Professor
and Chair of Pediatric Dentistry at the Medical College of Georgia.
Start regular tooth care when your baby’s first tooth comes in. Use a wet
washcloth or soft bristle brush to wipe the teeth, at least twice daily. Both
dentists and pediatricians advise using a rice-sized amount of fluoride-
containing toothpaste to cleanse the teeth. Yes, your baby will swallow it
and that’s okay.
Here is a key point: you absolutely need to clean your baby’s teeth
AFTER the last feeding of the night, before your baby goes to sleep. Yes,
that means you may be waking up a baby who has fallen asleep while
feeding. But if you don’t do this, you will be asking for cavities (also
known as NURSING CARIES).
Parents fall into the routine of feeding/nursing their babies to sleep (and
back to sleep throughout the night)—and then don’t know when to stop
doing it. If your baby is old enough to have teeth, I guarantee he is old
enough to fall asleep on his own and sleep through the night without a
feeding. The alternative is poor sleep habits, reliance upon sucking/eating to
fall asleep, and high dental bills. Remember, we’ll cover the sleep routine
issues in depth in Chapter 9, Sleep.
Fluoride is a whole topic unto itself. You’ll find that in Chapter 5,
Nutrition and Growth in the vitamin supplements section.
Q. When is the first trip to the dentist?
Both the American Academy of Pediatrics and the American Academy
of Pediatric Dentistry recommend a first dental visit at one year of age.
Which babies are at greatest risk for tooth problems? Those include kids:
Whose mothers have cavities.
With special medical needs.
With teeth, who fall asleep with a formula bottle/sleep with a formula
bottle. Or with teeth who breastfeed throughout the night (and don’t
brush after each nursing).
With plaque buildup on their teeth.

However, even if your baby doesn’t fall into a high-risk category, it is a

good idea for ALL kids to have an initial dental visit around their first
birthday so you can establish a “dental home.” You’ll then have a point
person if you have questions or a dental emergency. Your child can visit the
dentist every six months after that. While a professional cleaning may not
happen until your child is two years old, these early visits can provide
guidance and direction.
FYI: Tooth decay is contagious. Plaque is bacteria that can be passed
from person to person. So parents should NOT share food utensils or clean
pacifiers by using saliva (that’s gross if you think about it, anyway)! (AAP)
NUTRITION & GROWTH
 Chapter 5
"A baby is an inestimable blessing and bother."
~ Mark Twain

WHAT’S IN THIS CHAPTER

WHAT GROWTH CHARTS MEAN
HOW INFANTS GROW (HEIGHT, HEAD SIZE, WEIGHT)
TEETH
CALORIES & NUTRITION FOR THE FIRST YEAR
FEEDING SCHEDULES, OR LACK THEREOF
VITAMIN SUPPLEMENTS
OVEREATING, OBESITY, & THE BODY MASS INDEX
CALCIUM, FIBER, AND IRON
ONCE YOUR CHILD TURNS ONE

Welcome to the world of food. This section of Baby 411 is dedicated to

growth and nutrition—first, we’ll look at the general questions you might
have about your baby’s growth, like what those ominous-looking growth
charts really mean. We’ll also discuss HOW your baby will grow (height,
head size, weight), as well as the needed calorie and nutrition for the first
year. Should you put your baby on a feeding schedule? We’ll hit that hot-
button issue here, as well as discuss vitamin supplements, obesity and your
baby’s needs for calcium, fiber and iron.
The next two chapters (six and seven) will get into the nuts and bolts of
nutrition, as we discuss liquids (breast milk, formula, juice) and solids
(baby and table foods). But first things first—let’s talk about your baby’s
amazing growth!
Infant Growth

Q. At my baby’s well checks, my doctor charts her

growth on a chart. What’s this for?
Growth charts help your doctor follow the trends of your child’s growth.
Your baby’s height, weight, and head size are checked at every well child
visit. (Weight is usually checked at sick visits too, to assess the severity of
an illness—for example, dehydration—and in case medication needs to be
prescribed).
Most doctors use the World Health Organization (WHO) growth charts
for children under two years of age. The percentiles on the charts compare
your child to other children the same age and gender across the globe. For
example, a boy in the 75th percentile for height is taller than 75% of boys
his age.
It’s useful to ask which charts are being used, though. Some doctors use
the Centers for Disease Control infant growth charts, comparing your child
only to other kids in America.
What’s the difference? The WHO charts are based on how a breastfed
baby should grow, regardless of what country she lives in. Breastfed babies
gain slightly less weight than their formula-fed counterparts from four to six
months of life—and therefore may look like they are not thriving on the
CDC’s charts. Breastfed babies also weigh less than formula-fed babies at
their first birthdays. (Kim) See Appendix E to find the WHO growth charts.
The key issue: is your baby’s growth consistent? In other words, if your
child is at the 50th percentile for height at three months, he should roughly
be at the 50th percentile at six months. What if your child’s height and
weight percentiles are significantly different? We’ll address the issue with a
discussion of the Body Mass Index (BMI) later in this chapter in the section
on overeating, obesity, and the BMI. Also later: what if you child’s head
size is growing too fast or too slow? We’ll cover that too.

Q. How much weight can I expect my baby to gain in

his first year?
 Here are some general guidelines. Babies double their birth weight by
four to five months of age. They triple their birth weight by one year, and
quadruple their birth weight by age 2. After age 2, kids gain about four
pounds a year until they hit puberty.
For example: A seven-pound newborn should weigh about 14 pounds at
five months and 21 pounds at one year. (Behrman)

Q. How tall will my baby grow in his first year?

Your baby will grow ten inches in his first year (about an inch a month
for the first six months and 1/2 inch per month from seven to twelve
months). He’ll grow another four inches from age one to two. After that,
he’ll grow three inches a year from ages three to five, then two inches a
year until he hits his growth spurt at puberty (rule of thumb is 10-4-3-3-2
inches per year). For example: A 20-inch tall newborn should be about 30
inches tall at one year.

PREEMIES & CATCH-UP GROWTH

Babies born prematurely experience a phenomenon called catch-

up growth. Most preemies catch up to their peers by the age of two,
but some continue to play catch up until age seven. Your baby’s
measurements can be plotted on the full term baby growth chart both
by chronological age (determined by birth date) and by adjusted age
(determined by due date).
The head catches up the fastest, followed by weight, then height.
(Bernbaum) That’s why doctors continue to adjust for their age for 18
months for head size, 24 months for weight, and 40 months for
height.

Q. Can you predict how tall my baby will be?

For boys: Add five inches to Mom’s height and average that number
with Dad’s height.
 For girls: Subtract five inches from Dad’s height and average that
number with Mom’s height.
This number is your baby’s growth potential. Of course, some people
exceed their potentials and some people never reach their potentials.
The first fairly accurate height predictor is the measurement taken at age
two years. Kids have established their growth curves by then. A good rule
of thumb is that kids are half of their adult height at 24 to 30 months old.

Q. Why do you measure my baby’s head size?

Because your baby’s brain is also growing at a tremendous rate. Most of
this growth occurs in the first two years of life. His brain weight doubles,
just in the first six months. We want to make sure this is happening, and that
the skull is providing enough room for this to happen (see
CRANIOSYNOSTOSIS).
Some babies have huge heads (see MACROCEPHALY) and some babies
have tiny heads (see MICROCEPHALY). Most of the time, this is thanks to
their gene pool. The apple doesn’t fall far from the tree. A baby’s head size
percentile may be completely different than his height or weight percentiles
—and that’s okay.
The average newborn head size is 35 cm. It grows 12 cm. in the first
year, and then only 10 cm. more for an entire lifetime!

Q. My baby has a flat head. Will he need to wear a

helmet?
Unlikely.
Changes in infant sleep position recommendations have done wonders to
reduce the risk of sudden infant death syndrome (SIDS) by 50%. (See
Chapter 9, Sleep in the sleep safety tips section for more discussion of
SIDS.) However, many babies have flat heads (official name: POSITIONAL
PLAGIOCEPHALY) as a result of being placed to sleep on their backs. In
most cases, the head shape improves once kids begin to move and
reposition themselves during sleep. Helmets are recommended as one of a
few treatment options for severe flattening, and effective if used only
between four and 12 months of age. (AAP)
A recent study compared children at two years of age who had mild to
moderate flat heads as infants. Examiners could not tell the difference
between kids who wore helmets and those who did not. Bottom line: Save
your money and skip the helmet! (Van Wijk)
See the nearby section later in this chapter for more on flat heads and
tummy time.

Q. When does the soft spot (anterior fontanelle) close?

Anywhere between nine to 18 months. The anterior fontanelle gives the
brain the growing room it needs.
Pediatricians rely on that soft spot to provide clues for fluid status
(dehydration), infection (meningitis), and problems inside the skull (brain
tumors, hydrocephalus).

Q. When will my baby’s teeth come in?

Anytime between six and 12 months.
Teeth may erupt as early as two months, but that is a rare event. As
discussed in Chapter 4, teething is variable. A baby might have several
teeth at his one-year birthday, another may just have one. Don’t worry
either way.
As a rule, the first teeth to erupt are the bottom middle teeth (medial
incisors). After that, it’s anyone’s guess. There is no order to further
eruptions. Frequently, a baby’s one-year molars will come in before the
middle or eye teeth (incisors/canines).
By the way, once the teeth arrive, you need to clean them! See Chapter
4, Hygiene section on dental care for teeth cleaning tips and a handy visual
aid to explain which teeth are which.

Flat heads and tummy time!

 Why do some babies wear helmets? Why is it important for babies to
have tummy time? And what the heck is tummy time, anyway?
Before we answer that, here’s a quick 411 on your baby’s skull:
newborns have skull bones with soft tissue between them (sutures) and a
couple of bigger gaps or soft spots (anterior and posterior fontanelles). This
skull structure allows the baby’s head to squeeze through the birth canal and
the brain to grow rapidly in the first two years of life.
By the time the child is two years old, her skull has hardened and those
gaps and sutures have closed.
A newborn’s malleable skull can put her head at risk for some really odd
shapes after delivery. Later if a baby spends much time on her back (or in
one position), the skull may flatten. While most newborn heads will
eventually round out and look normal, here are some things to be watching
for:

Molding. Some newborns look like they have a “cone head” because the
skull compresses as it goes through the birth canal (more common in
vaginal deliveries than C-sections). Babies who have had vacuum- or
forceps-assisted deliveries may have pretty dramatic molding or even a
large bruise (CEPHALHEMATOMA) that can harden and leave a lump on the
skull for several weeks. These irregular head shapes are present at birth and
resolve by six to eight weeks of life.

Positional Plagiocephaly. Yes, we know this is a mouthful—it literally

means “oblique (flat) head.” A baby who spends significant time lying on
his back or leaning his head back (sleeping, sitting in a car seat or in an
infant swing) is at risk for a flat head. This odd head shape becomes
noticeable after eight weeks of life. In most cases, the flattening is mild or
moderate, and rounds out over the first year. You can try to avoid this
problem by following the tips at the end of this section.

Torticollis. A tightening, shortening, or bruising of a neck muscle when

baby’s head favors in one position for a long time. This becomes a vicious
cycle, because the baby then develops a preference for turning his head to
one particular side. The result? The skull flattens on one side and the facial
structure starts to look asymmetric. TORTICOLLIS can be present at birth or
begin during infancy. Aggressive neck stretching exercises are required to
fix this problem.

Craniosynostosis. This is a premature closure of one of the suture lines

that sits between the skull bones. Unlike some of these other problems,
CRANIOSYNOSTOSIS is not something that is preventable—it’s an
uncommon disorder that just happens to some kids. Early closure not only
causes a funny looking head shape, but also interferes with the brain’s
ability to grow. If untreated, these babies can be at risk for vision defects
and increased pressure within the skull. Surgery is required to fix this
problem.

Now you know how your newborn’s skull will change and what
problems to look for. But let’s look at the most common cause for head-
shape problems: sleep position.
Ever since safety advocates recommended infants sleep on their backs,
babies have spent an increasing amount of time in that position. Add in time
spent in car seats and swings—and you can understand why positional
plagiocephaly (flat head) is an increasing concern. Of course, there is a
simple answer: tummy time.
So, what is tummy time? Simply put, tummy time is an opportunity for
your baby to lie on his belly while awake and practice lifting up his head.
This will develop neck and other muscles for head control and rolling over.
Tummy time also keeps the pressure OFF the back of baby’s head by
altering his position.
Here are some simple guidelines for tummy time. Do tummy time
exercises as often as you do diaper changes. For babies under two months
of age, aim for one to two minutes about eight times daily. For older babies
(two months and up), gradually increase the length of time your baby is
doing his “cobra” or “upward facing dog” yoga poses. Stop when he tells
you he is no longer enjoying the experience.
What if your baby hates tummy time? One idea: have him lie on your
chest and he will work to lift up his head. Or get on the floor with baby so it
doesn’t seem so lonely down there. To help baby lift up his head, you can
use a rolled-up receiving blanket under the chest.
What else can you do to prevent a flat head?
 Alternate which direction you do diaper changes so your baby has to
turn his head both ways to look at you.
Alternate turning your baby’s head from left to right on his back when
he is sleeping.
Play “airplane” with your baby and let him lift his head to look at you.
What to do once your baby has a flat head or torticollis:

1.Aggressively work on neck stretching exercises at home. See

Chapter 14, Common Diseases, in the muscles/bones section for
specific advice on exercises you can do.
2.Hire a personal trainer (okay, really it’s a physical therapist) to help
with neck exercises.
3.Encourage your baby to spend more time holding his head up—
see the tummy time tips above.
4.Check in with your doctor every month so she can monitor your
baby’s progress.
5.If the head is significantly misshapen and not improving with
exercise, consult with a neurosurgeon or a craniofacial surgeon
and consider a helmet. Again, your doctor should be able to give
some guidance. (Nield, Persing)

Infant Calorie and Nutrition Needs

Q. How quickly will my newborn grow on a day-to-

day basis?
Faster than you want him to.
After you look at the following stats, you will never buy newborn
clothes as baby gifts again. You can also understand why babies need to eat
all the time. It takes a lot of caloric energy to grow that much.
On a day-to-day basis, here is what you can expect:
 Birth to four days old: A weight LOSS of 5-10%. As we discussed
earlier, babies are born with extra baggage for the trip out into the
world.
Four days to three months: A weight GAIN of about 2/3 to one ounce
a day (1/2 lb. a week). Note: newborns should be back to birth
weight by their second week doctor visit.
Three months to six months: A weight gain of about 1/2 to 2/3 ounce
a day (1/2 lb. every 2 weeks).
Six months to 12 months: A weight gain of about 1/4 to 1/2 ounce a
day (3/4 to 1 lb. per month).

Q. How many calories does my baby need to eat?

It depends on her age. Another factor: babies born very small . . . or very
big.
The calculations are listed on the next page, but please don’t get too
wound up about these numbers. Do NOT do calorie counts on your baby.
As you can see, your baby’s calorie needs will increase as she grows.
Real mom tip: baby’s appetite can vary from day to day. This advice also
applies to older children. Focus on what your child eats over the space of a
week, not every meal. Let’s put this in bold: Obsessing over every ounce of
milk/formula or spoonful of rice cereal isn’t healthy for you or your baby.
That said, here’s how many calories a baby typically needs to eat per day
(given your baby’s weight in kilograms):
Babies birth to two months consume 90-110 calories per kilogram in
24 hours.
Babies three to eight months consume 80-100 calories per kg in 24
hours.
Babies nine to 12 months need 80—90 calories per kg in 24 hours.

Don’t know your baby’s weight in kilos? To convert pounds to

kilograms, divide the weight in pounds by 2.2. For example, a baby
weighing seven pounds would weigh 3.2 kilograms.
 Now that we have all the formulas, let’s figure out how many calories
your average seven pound newborn will need each day to grow normally.
Realize this is a ballpark figure because each person has individual energy
(calorie) needs. Your little 3.2 kg bundle of joy needs between 288—384
calories per day (3.2 x 90 or 120). Breast milk and formula have 20 calories
per ounce. So divide 288 or 384 by 20 calories per ounce and you’ll find
that your baby needs to consume about 15 to 19 ounces a day. But, once
again, obsessing over every ounce will only give you an overwhelming
need for Zantac.
A word on preemies: Premature babies have higher calorie needs to
catch up on their growth. Some babies go home from the Neonatal Intensive
Care Unit (NICU) with a higher calorie diet requirement. This is achieved
with either a higher-calorie formula or a special human-milk fortifier that is
added to expressed (pumped) breast milk.
A word on big babies: The calorie calculations we’ve made here are
accurate for average sized babies. All babies gradually increase their daily
breast milk/formula intake and eventually max out at about 40 oz. a day.
Average-sized babies get to that point at four to six months of age. A ten-
pound newborn may reach that 40 oz. a day maximum before his friends do
and will just stick to that daily volume. We point this out so you don’t try to
give him 50 or 60 oz. at six months of age.

COMMON CONVERSIONS

For the mathematically challenged (that is, us writers) and for

those who have forgotten the metric system, here are the common
conversions you’ll need to digest this chapter:

cc (cubic centimeter) or ml (milliliter) are ways of measuring fluid

volumes.
1cc = 1ml
5cc or 5ml = 1 teaspoon
15cc or 15 ml = 1 tablespoon
3 teaspoons = 1 tablespoon
There are 30cc per ounce, or 2 tablespoons per ounce (oz).
 There are 16 ounces (oz) in 1 pound (lb).
There are 2.2 pounds in 1 kilogram (kg).

There will be a quiz on this next Tuesday.

Q. Can you show me how a baby’s calorie needs

change for the first year of life?
Okay, here is an example . . . but remember these are ballpark figures.
Fair warning: we get many emails from worried readers who think their
babies aren’t reaching these numbers. Again, there is no reason to obsess
over these figures.
So here are the numbers for a 7 lb. newborn: (AAP Committee on
Nutrition)

Insider Secret
A simpler (but less accurate calculation): Babies from two weeks to three
months of age need to eat approximately 2.5 oz. per pound of body weight.
(West)
BOTTOM LINE
Do NOT calculate your baby’s dietary needs at every moment. You will
drive yourself, your spouse (and your doctor) nuts. This is especially
challenging to do if you are breastfeeding and can’t see the volume. It’s just
helpful information to help you gauge things.

The Big Picture: Nutrition For The First Year

The details will become clearer to you as you read through the next
couple of chapters, but here is the big picture:

1.Babies need either formula or breast milk exclusively for the first
four to six months of life.
2.Some babies are ready to eat solid food (a.k.a. “complementary
food”) at four months old, and others aren’t. The right time to
start offering solid foods mostly depends on when a baby knows
what to do with food in his mouth. However, allergists,
nutritionists, and pediatricians all agree that there is no need to
start before four months of age. Breast milk and formula are the
main source of nutrition and solid food is complementary. (For
details see Chapter 7, Solids).
3.From six to nine months of age, a baby drinks less liquid nutrition
(breast milk or formula) as he eats more solid food nutrition.
4.From nine to twelve months of age, a baby usually eats three solid
meals a day and takes 20 to 30 oz of breast milk or formula.
5.After a year of age, a toddler can drink breast milk or whole or
2% milk, with a goal of 16 oz. or dairy serving equivalent a day.
Formula is no longer needed. The norm: three solid meals and one
to two snacks per day. Toddlers can continue breastfeeding, but
they need additional sources of nutrition.
 NEW PARENT 411: GROWTH SPURTS

Babies will have growth spurts and their appetites may seem
insatiable at times. These episodes usually occur at three weeks, six
weeks, and occasionally later in the first year. They may last a couple
of days or a week. If you are breastfeeding, do not be alarmed that
you can’t satisfy your baby. His appetite will ramp up your milk
supply.

Reality Check
When it’s your first baby, you can’t wait to start solid food. When it’s your
second or third child, you’ll avoid it as long as possible! Why? Solid food
becomes yet one more chore you have to do—and it’s really not that much
fun.
We’ll go into further detail on how liquid and solid nutrition divide up in
Chapter 6, Liquids and Chapter 7, Solids. But, below is the big picture.
Remember, these are average ranges. There’s no need to panic if your baby
isn’t right on the curve:
*Liquid volumes decrease as solid volumes increase.

See later in this chapter for information on calcium and dairy

requirements at one year of age. For a more detailed chart of liquids and
solids, see Chapter 7 in the section titled “The Big Picture on Liquids and
Solids.”

Reality Check
Babies have “off” days and growth spurts. So, your baby may not be as
predictable as you would like when it comes to meals. Occasionally, he will
be less interested in feedings. And sometimes, he will seem like he hasn’t
eaten in days.

Feeding Schedules

Q. I’ve heard about putting my newborn on a feeding

schedule. How do I do it?
You don’t. Your baby does it for you.
 The phrase “newborn feeding schedule” is an oxymoron. Newborns are
learning how life works outside the womb. Before birth, they were on a
24/7 feeding schedule. Now, your newborn will have to rely on her innate
sense of being hungry when her body needs energy. However, she will not
have a neat and tidy schedule.
Newborns need to eat about eight to 12 times in a 24-hour day. This may
be every 1 1/2 hours for a few cycles, then four hours later, then two hours,
etc. Somehow, in 24 hours, they do it. This is called “ad lib” or feeding on
demand. Ideally, parents (and their doctors) would like their baby to have
‘“cluster feeding’” of every 1 1/2 hours during the day and a nice four hour
stretch at night. But, short of divine intervention, there is little that can be
done to make this happen.
For parents of preemies: Premature babies really need those feedings
frequently. Their smaller tummies, and need for catch-up growth often
require feedings every two to three hours until they are at least four months
old. (That is, four months from the original due date, not the actual birth—
their so-called adjusted age).

BOTTOM LINE
Although newborns can’t be put on a schedule, by four months of age, your
baby WILL BE capable of regular feeding and sleeping patterns. Some
lucky moms and dads will have a baby that falls into a predictable
feeding/sleeping pattern by two months of age.

Q. My six-week-old seemed to have somewhat of a

feeding schedule . . . but now seems insatiable. Is my
milk drying up?
No. Babies often have growth spurts at three weeks and six weeks of
age. They will have feeding frenzies during those periods of time. As your
baby’s demands increase, so will your milk supply. (We have a
comprehensive breastfeeding chapter ahead in Chapter 6, Liquids.) If your
baby continues to act this way, it’s time to check in with your doc and make
sure you are making enough milk and your baby is appropriately gaining
weight.

Old Wives Tale

Adding rice cereal to formula or expressed breast milk will make your
baby sleep through the night.
The truth: Only if your baby has heartburn. Let’s think about this in a
scientific way. Formula has 20 calories per ounce. If your baby is taking a
six oz. bottle, he gets 120 calories. A teaspoon of rice cereal flakes has
about five calories. It’s not providing any calories to fill them up. But it is
heavier. If your baby has acid reflux, he will be happier but he still won’t
sleep through the night!

DR B’S OPINION: FEEDING

SCHEDULES?

The AAP advises parents that “newborns should be nursed

whenever they show signs of hunger, such as increased alertness or
activity, mouthing, or rooting . . . newborns should be nursed
approximately eight to 12 times every 24 hours until satiety.” This is
termed “ad lib” or “on demand” feedings. And that’s pretty much
the way it should be for the first eight weeks with your newborn.
Here’s the take-home message: lower your expectations. Yes,
your baby IS in charge of your house right now. That’ll change in
about 18 years. Or 26.
Special Concerns

Q. My 6 month old has dropped his weight percentiles

from 75% to 25% since his four-month visit. What
happened?
Did he start solid food? Solid foods contain significantly fewer calories
than formula or breast milk. When babies are given solid foods before their
milk, it reduces the amount of formula or breast milk they drink. Don’t get
carried away with feeding your baby solid foods until he can take two to
four ounces—not spoonfuls—of solid food at a sitting. What many parents
don’t realize is that your baby will tell you when he or she wants more. If
your little one is finished, you’ll know it. And until she’s asking for more,
don’t push the solid food. (We cover solid foods in-depth in Chapter 7.)
If your baby is exclusively breastfed, check out the World Health
Organization’s growth charts. Remember, if your baby’s doctor uses the
CDC’s growth charts, it may not reflect a breastfed baby’s growth curve
from four to six months. If your baby is tracking fine on WHO’s curves,
that’s all the reassurance you need (see Appendix E).

Q. My nine month old seems to be dropping on his

growth percentiles. Is he malnourished?
Probably not.
Babies these days are born much bigger than they used to be (good for
them, bad for Mom’s pelvis)—thanks to good prenatal care. But not all
babies turn out to be sumo wrestlers. Their genetic makeup (i.e. Mom and
Dad) determines their ultimate size. Big babies that have more average
sized parents start to plateau, showing their truer growth curves as they
approach a year of age.
Your doctor will check for iron deficiency anemia at this age, as this can
also be a cause of poor growth (a drop in growth percentiles). If your baby
is dropping off the growth charts, your doctor should perform a thorough
evaluation to figure out what’s going on.
Q. My baby has dropped off the growth charts for his
weight. What is wrong with him?
No, your baby hasn’t begun the South Beach Diet behind your back. The
official term for this problem is FAILURE TO THRIVE.
Babies whose weight percentiles start off fine, then plateau or fall below
the third percentile need to be evaluated. The causes are various and
include: poor feeding routines, incorrect formula preparation,
gastroesophageal reflux, malabsorption of food from intestinal problems,
kidney disease, metabolic disease, hypothyroidism, and anemia.
An extensive medical evaluation is usually performed, unless a cause is
found easily. If no cause is identified, a higher calorie diet is initiated and
baby’s weight is checked frequently.

Vitamin Supplements

Q. Does my baby need a Vitamin D supplement?

Probably. But bear with us—the answer is confusing.
Babies from 0-1 years of age need 400 IU (International Units) of
Vitamin D a day to prevent RICKETS, a bone malformation (see glossary).
Vitamin D may have other health benefits as well but the data on this is less
conclusive.
While Vitamin D is present in some foods (cod liver oil, salmon,
sardines, fortified milk), we get most of our Vitamin D from the sun’s rays.
Mother Nature planned on children producing Vitamin D in their skin after
sun exposure. She did not plan on the creation of sunblock that blocks UVB
rays—an essential component of Vitamin D synthesis. (Gartner, Taylor)
Because it is impossible to determine the amount of sunlight every baby
needs to make enough Vitamin D (skin color, sun block, and the your
home’s latitude complicate the equation), the American Academy of
Pediatrics and the National Institutes of Health recommend Vitamin D
supplements for all babies. (AAP Committee on Nutrition)
Before we list the specific guidelines, here are few comments:
 Breast milk is perfect nutrition with one caveat. Often, there is not
enough Vitamin D in breast milk for your baby’s growth (even if
mom is taking a Vitamin D supplement herself).
One formula, Enfamil Newborn formula (it has a big “N” on the label)
contains higher concentrations of Vitamin D, allowing a 0-3 month
old to get 400 IU of Vitamin D by drinking 27 oz/day.

Here are the Vitamin D supplement guidelines from the AAP. Vitamin D
supplements of 400 IU per day are recommended beginning after birth for:

1.Babies who are exclusively breastfed.

2.Babies who are primarily breastfed or exclusively formula fed and
drink less than 32 oz of standard infant formula daily.
3.Babies who drink less than 27 oz of Enfamil Newborn formula daily.
4.After twelve months of age, children and adults need 600 IU of
Vitamin D daily. Since that would require drinking SIX cups of
milk or consuming other Vitamin D rich foods (salmon, or a daily
dose of cod liver oil) on a daily basis, most people need to take a
Vitamin D supplement. Yes, that means you, too.

FYI: Babies who are at the greatest risk of Vitamin D deficiency rickets are
those with darkly pigmented skin living above latitude 40 degrees (that’s
Iowa and north). However, breastfed babies in Texas and Georgia have been
found to have rickets too.

Factoid: The peak incidence of rickets is between 3 and 18 months of age.

However, adequate daily Vitamin D intake may also play a role in
preventing autoimmune disease, some cancers, and Type 2 Diabetes later in
life, although the jury is still out on those health benefits. (Institute of
Medicine)

DR B’S OPINION: SUPPLEMENTS

 I recommend D-Vi-Sol (which contains Vitamin D only) because
it is sold everywhere. Yes, super-concentrated Vitamin D drops are
also available. BioGaia ProTectis is another option—this contains
both Vitamin D and probiotics. All these supplements are available
over the counter.

Q. Does my baby need an iron supplement?

There are a few kids who will need this.
Here’s the 411 on iron. Our bodies need iron to carry oxygen on red
blood cells. Iron deficiency causes ANEMIA (see glossary). Anemia causes
fatigue, poor weight gain, and poor intellectual functioning.
Newborns have a large iron bank, thanks to Mom. They fill up that bank
while in the womb during in the third trimester (which is one reason why
babies born prematurely are more prone to iron deficiency). As withdrawals
are made from the bank, the supply needs to be replenished via baby’s
nutritional intake. By six to nine months, the original iron stores are gone
and baby is on his own.
Formula-fed babies get an appropriate amount of iron in their iron-
fortified formula. However, nutrition experts caution that breastfed babies
need an additional source of iron at four months of age to prevent anemia.
(AAP Committee on Nutrition) Some breastfeeding experts disagree with
this position. We point this out because you may hear conflicting advice on
this topic.
Here are the latest AAP guidelines on iron:
Babies who are born full term and are fed with an iron-containing
formula do NOT need iron vitamin supplements. Babies should eat iron-
rich foods whenever they start solid foods. (See the list later in this chapter
in the “Calcium, Fiber, Zinc, and Iron” section for food ideas!)
Babies who are exclusively breastfed or primarily breastfed
(supplemented with only a small percentage of formula) have two options
beginning at four months of age. Option 1: They can start eating iron-rich
solid foods like pureed meats and fortified cereals daily. Option 2: They can
take a daily vitamin supplement such as Poly-Vi-Sol with Iron from four to
six months of age until they begin eating iron-rich solid food.
Babies who are born prematurely (under 37 weeks) DO need an iron
supplement (2mg/kg of weight—your baby’s doc can give you the dosing)
starting by one month of age. Breastfed preemies need that iron supplement
until they are weaned to formula or they begin eating iron-containing solid
foods . . . although some docs may recommend an iron supplement be
continued until age one.
Babies from 6-12 months of age should get about 11 mg per day of iron
in their diets. While there are several iron-containing foods, our bodies
absorb iron from meat food sources more readily than non-meat sources.
Toddlers from 1-3 years of age need 7 mg per day of iron in their diets.
(If you have a toddler who definitely does not eat iron-containing foods—
we know, toddlers can be picky—consider a vitamin supplement like Poly-
Vi-Sol with Iron.)
All children should be screened for iron deficiency anemia at 12 months
of age. Many docs screen their patients at either the nine-month or one-
year-old well child visit.) A child needs an iron supplement if he is anemic.

BOTTOM LINE
Many babies get the iron they need, but make a concerted effort to offer
iron rich foods once your baby starts eating solid foods. And if you have a
preemie or you are exclusively breastfeeding, be sure to ask your child’s
doc about iron supplements.
Now you can see one of the key reasons to start solid food at four to six
months of age: to get more iron into your baby’s diet. (Baker)
Helpful Hint
If your doctor prescribes an iron supplement for your baby, do not give it
with a dairy product (e.g. breast milk, formula, whole milk). The calcium
and iron compete for absorption in the digestive tract and will decrease the
amount of iron that the body gets.

Q. Does my baby need a multivitamin?

Babies do NOT need multivitamin if they born at full-term, are growing
appropriately on breast milk or formula and have a relatively “balanced”
diet once they start eating solid foods. So, no, we don’t routinely
recommend iron or multivitamins for all babies.

Q. Does my baby need DHA/fish oil supplements?

Docohexaenoic acid (DHA) is an Omega-3 fatty acid used in our bodies
to make nerve tissue, hormones, and cell membranes. Found in fish oil
among other foods, DHA promotes brain and vision development in
infancy. But are there lifelong health benefits to daily DHA intake?
Here’s a reality check: there is no long-term data that shows DHA has a
significant health impact. The most compelling studies, however, show
some protection against heart disease and high cholesterol.
Foods that contain DHA naturally are human breast milk, fatty fish
(salmon, herring, tuna, rainbow trout, whitefish), and organ meats. Most
commercial infant formulas contain DHA. Some foods, including
commercial baby foods, are now “fortified with DHA.”
But here’s the rub: the fortified foods do NOT have nearly the same
amount of DHA that you can find in fish. Example: a three-ounce serving
of Atlantic salmon has 1825 mg of DHA. An eight ounce cup of Horizon
Organic milk fortified with DHA has 30 mg.
 While there is no official recommendation about adding fish oil
supplements to your child’s diet, the AAP does recommend that nursing
moms have 200-300 mg of daily DHA. (AAP) FYI: Adults with heart
disease should have 1000mg of DHA per day. There are no such nutritional
guidelines for kids.
Bottom line: if you want your child to get DHA in his diet (beyond what
he gets in breast milk or formula), offer fish on a regular basis.

Q. I’ve heard about fluoride supplements. Does my

baby need this?
The answer is a riddle . . . wrapped in an enigma.
Fluoride prevents tooth decay. The process of adding fluoride to water
supplies that do not contain it naturally is one of the top public health
achievements of the twentieth century. Despite the overwhelming evidence
of benefit, there are a few vocal skeptics who think this is a government
conspiracy to hurt children. I’ll respectfully disagree on that one.
However, kids need the right amount of fluoride. Too little, and you risk
tooth decay. Too much, and you risk fluorosis (a permanent stain on tooth
enamel). Fluorosis occurs only in teeth that are developing under the gums
—the teeth are not at risk once they have erupted. So, the greatest risk of
fluorosis is in kids under three years of age.
So, how much fluoride the right amount? Fluoride is measured in parts
per million or “ppm.” The U.S. government says that the maximum fluoride
level in drinking water should be 0.7 ppm. Be aware that some communities
(particularly in Texas, Oklahoma, South Carolina and Virginia) have water
supplies with high levels of naturally occurring fluoride—above 2 ppm.
Some towns have 4 ppm or more of fluoride in their water, which is clearly
a concern. You can contact your local water department or public works
agency to find out the fluoride level in your local tap water.
Here’s the key point: babies under six months don’t need fluoride, babies
over six months do. Both breast and formula-fed babies should drink
fluoride-containing water on a daily basis starting at six months of life.
They need 0.25 mg fluoride a day. (Note: the dose for fluoride is in
milligrams; fluoride content of water is measured in ppm or parts per
million).
 So, exactly how much water should baby drink to get the recommended
0.25mg dose? Well, there’s no easy answer. That’s because your child gets
fluoride from sources other than drinking water. Fluoride is not only found
in your tap water, but also in foods you prepare with water, and
commercially produced beverages, etc. Since the American Dental
Association (ADA) doesn’t specify volumes, I’ll conservatively suggest
four to six ounces of fluoridated water a day.
Because striking the right balance for fluoride intake is key in babies, the
American Dental Association (ADA) has some very specific advice:

Breastfed babies. Babies who are breastfed for the first year of life
should drink fluoride-containing water (tap or bottled water that has 0.7
ppm fluoride) on a daily basis starting at six months of life.

Formula-fed babies. As you will read in the next chapter, there are three
general types of baby formula: ready-to-feed (no water needs to be added),
powder and liquid concentrate. For powder or liquid concentrate (which
you mix with water) the ADA recommends either using “low-fluoride”
water (less than 0.3ppm) or bottled water specifically labeled “purified,
demineralized, deionized, distilled or reverse osmosis filtered.” (ADA)
Reverse osmosis filters are home water treatment systems that remove
fluoride from your tap water.
BUT the ADA advises to offer drinking water with fluoride (0.7ppm)
once your baby is six months old. Yes, you read that correctly. Always
prepare formula with low-fluoride water for the entire first year, but offer
additional fluoride-containing water starting at six months of age.
FYI: Just to make your life difficult, bottled water companies are not
required by the government to label fluoride content. That’s why it’s easier
to go with the type of bottled water the ADA recommends.

All babies from 6 to 12 months old: Babies over six months of age need
0.25 mg fluoride a day (about four to six ounces a day of water that has
0.7ppm of fluoride) to get their daily recommended fluoride intake.

So, let’s sum this up for babies over six months of age:
 1.First: Call your local water supplier and find out how much
fluoride is in your water.
2.If you are breastfeeding or using ready-to-feed formula, your baby
should also drink fluoridated water daily after six months of age.
Again, the safe level is 0.7 ppm. There is no official
recommendation from the AAP or ADA on the amount of water a
baby should drink. Our rough guess: aim for four to six ounces a
day. If your tap water has the right amount, go for it. If not buy
nursery water or talk to your doctor about a fluoride supplement.
3.If you use powder/liquid concentrate formula: continue mixing it
with low/no fluoride water for the entire year.
4.Which children need a fluoride supplement? If your baby is over
six months of age, and is drinking water that contains LESS than
0.6ppm fluoride for whatever reason (reverse osmosis filtered tap
water, well water, etc.), your doctor or dentist may want to
prescribe a fluoride supplement. Be sure to ask about it! For yet
more details on fluoride supplements, see Appendix A,
“Medications.” And we’ll tackle other formula preparation details
in Chapter 6, Liquids.

Insider Tip
Once your baby has teeth, the ADA recommends using a rice-sized amount
of fluoride containing toothpaste to clean the teeth daily. Yes, your baby
will swallow the toothpaste since he will not know how to spit it out. That
may be enough daily fluoride to avoid an additional supplement! Ask your
baby’s doc for his or her opinion.

Q. I’ve heard that fluoride can cause cancer. Is this

true?
No. This and many other myths about fluoride, including adverse effects on
IQ, have been solidly debunked by numerous scientific studies. Just browse
the website, ILikeMyTeeth.org, to get the facts regarding fluoride safety
concerns. That website is the word of the American Academy of Pediatrics
and their message is clear: Life is better with teeth!
There have been debates about fluoride ever since communities began
adding it to their water supplies seventy years ago. Fluoride is very safe as
well as very effective in preventing cavities. The only problem with fluoride
is when a child gets way too much of it.

Overeating, Obesity, And The Body Mass Index

Q. I am concerned that I am overfeeding my baby. Is

that possible?
It is unlikely, but it can happen in rare cases.
Let’s look at this rationally. Most infants do not think, “I’m full, but that
dessert looks pretty good.” That is a learned behavior in our society. Most
infants self-regulate. In other words, they will eat until their tummies are
full and stop. If they do overindulge, they usually just throw up.
But, it is a good idea to learn your child’s cues. Some new parents think
their baby needs to eat every time he cries. This becomes a set up for
obesity.
Bottom line: your baby gets weighed in at every well child visit with his
doctor. That’s when you will see if your baby is eating enough or too much.

NEW PARENT 411: AVOIDING OBESITY

Set up the right routines while your baby is an infant and toddler.
Here are our tips:
 1.Keep your child physically active.
2.Make restaurant food a treat. Fast food should be a once a month
treat—not a weekly outing.
3.Offer appropriate serving sizes. Start with two tablespoons per
serving. Most older babies eat about 4-6 oz, three times a day
until their first birthdays. Offer seconds on fruit and vegetables.
4.Banish the “Clean Plate Club.” Don’t force your child to eat. Yes,
there are starving children in India, but they won’t be eating
your leftovers.
5.Make juice a low-priority item.
6.Keep the four C’s out of your pantry: cola, chips, cookies, and
candy. If you have to go out of the house to get these items,
they will truly be a treat.
7.Be a good role model. Your child is watching what you are eating.
8.No TV while food is being served. Watching the tube while you
eat encourages overeating. Don’t watch the news during dinner
—set the DVR and watch it after the kids go to bed.

One of the realities of being a parent is that you often end up

eating what your kids eat. That’s how you end up at the end of baby’s
first year still wearing those prenatal pounds. What to do? Change
your eating habits now and everyone in the family will benefit.
Next, buy healthy, yet good snacks: think portable fresh fruit,
veggie spreads/dips, yogurt, and whole grain cereals and bread
products. And if you are going to buy juice, stick with 100% juice
products. Read the package labels. You may be stunned at what you
discover. And be a good example to your kids. Don’t drink soda in
front of them day and night. Instead opt for milk or here’s a crazy
thought: water!
In the end, an outright ban on cookies, soda, chips and candy can
backfire. As we said earlier, these can be occasional treats.
Otherwise, you’re going to have a kid who sneaks out to a neighbors’
to indulge or spends his allowance on the sly to buy candy bars.
Q. Is it possible for my baby to be overweight? His
weight percentile is off the charts!
Yes, but that does not mean he needs to join Weight Watchers.
A landmark study found that 32% of American babies were already
overweight at nine months of age and 44% of those babies were still
overweight at age two. Boys and those of Latino heritage are most at risk.
FYI: overweight is defined as a Body Mass Index of at least 85th percentile
or more.
If your baby fits into this category, your baby’s healthcare provider may
chat with you about appropriate baby-sized serving sizes of solid foods,
daily intake of breast milk/formula, and discontinuing night-feedings if he
was born full-term and is over four to five months of age.

Q. Is there anything I can do while my baby is an

infant to prevent obesity later in life?
Yes. Here are three things you can do.

1 START A HEALTHY DIET AND LIFESTYLE

FOR YOU AND YOUR CHILD FROM DAY 1. Before
parenthood, maybe you didn’t work out as much as you should have . . . or
ate too much take-out food. It’s time to change those habits. Your baby
looks to you as a role model—so be a good one. He also looks to you to put
his food on the table for the next 18 years—so make it good, healthy food.

2 BREASTFEED FOR AT LEAST FOUR

MONTHS. Breastfeeding for at least the first four months lowers the
odds of childhood obesity. Breastfed babies (no matter when they begin
eating solid food) have only a one in 14 chance of being obese as a
preschooler.
3 START SOLID FOODS AT FOUR MONTHS OF
LIFE OR LATER. Introducing solid food at four to six months of
life seems to reduce childhood obesity rates. One study showed that
formula-fed babies who started solid food before four months of age had a
one in four chance of being obese at three years of age. Those who indulged
in solid food at four to five months of age had only one in 20 odds. (Huh)

FEEDBACK FROM THE REAL WORLD: AVOIDING THE

4 C’S

You’ve seen the statistics and you’re worried. You don’t want
your child to be one of them. We’re talking about overweight and
obese children. They are a statistic on the rise and if they start out
overweight, most likely they’ll be overweight adults. You’ve also
seen the incredible array of snack foods on the shelf at your local
grocery store. So it’s time to ask our experienced moms for tips on
keeping your baby off the junk and excited about healthy snacks.

1.It takes a family. Julie DeCamp Palmer of Seattle, WA spoke for

most of our readers when she said, “It takes the whole family
eating a healthy diet.” So lead by example and don’t stock the
four C’s (cola, chips, cookies, candy) in your home. For those
of us who want a little of the forbidden items ourselves, eat
them when your child is not around or when you’re out and
about without him.

2.Presentation is important. Healthy snacks can still be exciting

to a child when they are presented with enthusiasm. One
reader Tiffany Johnson from Vancouver, WA, who is also a
daycare provider noted that “children like anything that isn’t
called what it is . . . i.e. celery sticks with cream cheese and
raisins becomes much more appealing when you call it ants on
 a log. Cottage cheese with raw fruit or veggies is a hit when
you make it into a face and call it clown food.”

3.Moderation. Yes, an occasional cookie as a treat is just fine. In

fact, S. Von Lengerke had a great story about her own
childhood where the four C’s were completely banned: “I
believe everything in moderation is OK. I was raised in one of
those families where we could never have soda or sweets, so
my brother and I chose our friends based on their snacks. We
were chubby kids. I think having some access to sweets, rather
than forbidding them, makes them less of an allure to kids and
the children, in turn, will have a healthy regard for snacks.”

4.Go with the flow. “One item I think many parents forget is that
kids’ eating often ebbs and flows. Kids will be starving and eat
more than Dad at one meal and turn up their noses at even
favorite foods the next. It’s not easy, but we offer a variety of
healthy and favorite foods at meal- and snack-time and let the
kids decide if they are going to eat or not. We don’t take it
personally and trust that our children will eat when they are
hungry. Not always easy, but usually very successful.” –Wendy
Stough

When you find a great product, check to see if they have a web
site. We discovered that they are full of nutritional information, fun
games and even e-coupons for their products.

Reality Check
Could a viral infection lead to obesity? A recent study found that children
who had a previous infection with adenovirus strain 36 were often heavier
than those who had no antibodies to this virus. Unfortunately, there is
currently no way to prevent becoming infected with this virus. (Gabbert)
 See below for some astounding facts on the childhood obesity epidemic
and ways to prevent it.

The Rise In Childhood Obesity

The United States is super-sized, to paraphrase an article in U.S. News
and World Report. A startling fact: the number of overweight school-aged
children has doubled in the past 20 years.

Why? Here are some of the key reasons:

1.Lack of activity. Children are spending more time (about three hours
a day) watching TV and playing on computers and other screens
than ever before. Whatever happened to the good old days of
playing outside?
2.Eating out and take-out food. 34% of our calories are eaten outside
of the home. Restaurant food has more fat, salt, and sugar than
home prepared meals.
3.Larger serving sizes. Super-size servings have become the norm at
all types of restaurants, not just fast food outlets. This trend toward
giant portions has even crept onto our own dinner tables.
4.Too many sugar drinks. Although juice has some nutritional
benefits, it is also full of sugar. This adds extra calories to your
baby’s daily intake. (More on this in the Other Liquids section of
Chapter 6 Liquids.) Don’t let your child become a juice-a-holic.
Kids graduate from juice to soft drinks. Believe it or not, the
average teenage boy drinks three sodas a day.

Q. How can I find out if my child is overweight?

There is a calculation called the BODY MASS INDEX (BMI) that
compares your child’s height to his weight. The formula is applicable to
children ages 2-20 years of age. The ranges vary for gender and age
(because the BMI varies as kids grow).
Here’s the formula:
 For children, the risk for obesity is a BMI of 85-95%. An overweight
child has a BMI of 95% or higher. To check your child’s BMI, go to
http://bit.ly/bmicalculatortool.
The BMI range for ADULTS is based on the number derived from the
calculation above:

Healthy BMI 18-25

Overweight BMI 25-30
Obese BMI Greater than 30

For more information on body mass indexes for both children and adults,
check out the Centers for Disease Control’s website at:

cdc.gov/nccdphp/dnpa/growthcharts/bmi_tools.htm

Calcium, Fiber, Zinc, And Iron

Q. Are there any nutrients that children eat too little

of?
Calcium, fiber, zinc, and iron. Let’s take a look at each.

1 CALCIUM. Calcium is a key nutrient for healthy bones. The

requirements change as children grow. Babies from birth to 12 months get
enough calcium from breast milk or formula. For ages one to three years,
children need 500 milligrams per day (mg/day). Kids ages four to six need
800 mg/day. Kids ages seven to 14 need a whopping 1300 mg/day. If your
child has a milk intolerance or allergy, try calcium fortified orange juice,
broccoli, rhubarb, or tofu as alternative calcium sources. If you are looking
for a vitamin supplement that contains calcium, get one with Vitamin D
added (it helps the body absorb calcium better).

Calcium Content Of Foods

Food Calcium content (mg)

8 oz cup of milk 250 mg

1 slice of cheese 200 mg
1 cup of ice cream 175 mg
4 oz cup of yogurt 200 mg
3 oz salmon 200 mg
1/2 cup tofu 200 mg
1/2 cup white beans 80 mg
1/2 cup broccoli 30 mg
1/2 cup collards 130 mg
8 oz cup calcium fortified OJ 300 mg

Note: As you can see, milk is the most efficient way of getting calcium.
But don’t lose sleep if your child has a milk allergy. Calcium fortified
beverages have comparable absorption to dairy products and the calcium in
green leafy vegetables is absorbed better than milk (that is, if you can get
your kid to eat kale or collards).

2 FIBER. Not only does fiber make your child a regular guy or gal, it also
has potential benefits including reducing heart disease. So, make it a little
family project to increase everyone’s fiber intake.
The fiber requirement for children is calculated by: Age in years + 5 =
Number of fiber grams/day. Example: a two-year old needs seven grams of
fiber day. However, there are no established guidelines for children under
one year of age. So, you and your baby’s healthcare provider will have to
tinker with how much fiber to offer if your baby gets constipated! Adults
need 25—30 grams of fiber per day. The average American diet doesn’t
come anywhere close to our daily needs.
So, how do you get a baby to eat high fiber foods? Try whole grain
cereals and breads, prunes and other fruits, beans, and green leafy
vegetables. If you are laughing at the prospect of convincing your baby to
eat kale, see the section Solid Food Equals Solid Poop in Chapter 8, “The
Other End” for our tricks.

Reality Check
Many parents don’t realize that the source of fiber in many fruits is the skin,
which usually gets peeled off before a child gets to the fruit.

3 ZINC. Zinc is necessary for immune function, cell growth and repair.
Research shows kids who have high zinc levels also have fewer serious
respiratory infections. Babies from birth to six months need 2 mg per day
and babies from seven months to age three need 3 mg per day of zinc.
Zinc is in both breast milk and formula. However, babies need an
additional source of zinc in their food, starting around six months of age.
This is especially important for babies who were born prematurely and are
growing faster than their peers.
The best and most practical source for zinc is meat. Lentils are another
great option. Fortified cereals for infants also contain zinc, but this is less
effective (it is harder for the body to absorb this type of zinc). Less baby
friendly sources of zinc include oysters, beef liver, and crab.

4 IRON. We have already chatted about this one. It’s important for babies
six to 12 months old to have a daily intake (11 mg/day) for growth and
brain function.
Here are some good sources of iron:
 Meat, poultry, fish, bread, enriched pasta, dark green vegetables
(spinach, broccoli, kale), legumes (dried beans, soybeans, lentils), eggs,
nuts/seeds, peanut sauce and butter, dried fruits (raisins, etc)*, cereals
(infant as well as grown up breakfast cereals are iron fortified). Note:
Eating iron in combination with Vitamin C (orange juice, etc), helps the
body absorb iron.

*Because of risk of choking, hold off on these foods until after three years
of age.

Happy Birthday, You’re Turning One!

Yes, your child is turning one! How exciting, no? Remember that food
pyramid we learned about in science class? Yeah, well that doesn’t exist
anymore. The following servings should help you determine the proper diet
for your child. You can check out choosemyplate.gov for food guidelines
for kids ages two and older.

Food Guidelines for a One Year Old

The serving size is listed beside the food item.
The average calorie intake for a one year old is 900 calories. Two to three
year olds consume 1000-1400 calories a day

Breads/Grains 4-6 servings/day

Whole wheat bread 1/2 slice
Cooked cereal, rice, pasta 1/4 cup
Cold cereal 1/2 cup

Fruits/Vegetables 4 servings/day
(1 Vitamin A/ 1 Vitamin C)
Vitamin C
Citrus, berries, melons, 1/4 cup
Tomatoes, broccoli, potatoes, cauliflower

Vitamin A
Peaches, carrots, peas, 2 Tbsp
Green beans, melons, apricots
Other 2 Tbsp

Milk/Dairy 4 servings/day
Whole or 2% milk 1/2 cup
Cheese slice 1 slice (1 oz)
Yogurt 4 oz
Ice Cream 1/2 cup

Meat/Protein 2 servings/day
Beef, chicken fish, pork 2 Tbsp
Egg 1 egg
Beans 1/4 cup

Fats 3 servings/day
Butter, mayo, ranch dressing 1 tsp

Q. My one year old is on a hunger strike. Help!

Very few one year olds have a world cause they support that
passionately!
The toddler diet appears as your baby approaches one year old. The
typical toddler eats well once every three days or eats one good meal in 24
hours. The food that is loved for seven straight days will be refused shortly
thereafter. A good strategy is to offer three food choices in a meal. Pick one
that is sure to be a hit—the others are trial offerings. If your child refuses
everything, do not make another meal for him. Mealtime is over. Don’t
worry, your child will eat at the next opportunity.
All humans have both a hunger and thirst drive that compels us to fulfill
our calorie and fluid needs. Your toddler is regulating his food needs.
Embrace it.

Now that you have the low down on your baby’s nutrition, let’s get
specific: next up is a discussion of both liquids (breast milk, formula, milk)
and solid foods. We’ll start with the liquids.
LIQUIDS
Chapter 6
“In short, breastfeeding occurs above the eyebrows as much as or
more than it occurs in the mammary glands.”
~ Judithe A. Thompson

WHAT’S IN THIS CHAPTER

BREAST MILK
THE ADVANTAGES OF BREAST MILK
HOW LONG TO DO IT
WHY WOMEN STOP
GETTING STARTED
TROUBLESHOOTING
WHERE TO GET HELP
HOW TO PUMP AND STORE BREAST MILK
CONSIDERATIONS FOR MOM (DIET, GOING BACK TO WORK,
ETC.)
INTRODUCING A BOTTLE
SPECIAL SITUATIONS
WEANING

FORMULA
FORMULA OPTIONS
BOTTLE MANAGEMENT

OTHER LIQUIDS
WATER, JUICE, MILK
For the first four to six months of your baby’s life, you only have one
decision to make about her nutrition: breast milk or formula. You can
guarantee that decision won’t occur in a vacuum: friends, neighbors,
relatives and complete strangers at the grocery store will want to weigh in
on what’s “best.” But you are the only one who can make that decision for
your baby.
This chapter will offer you the pros and cons of both breast milk and
formula. We promise we won’t make judgments about your choice. But like
every medical organization on this planet, we agree that human breast milk
is the perfect nutrition for human babies. No matter how much formula
companies tinker with their products, formula will only be a close
approximation to the real thing. Breast milk has living ingredients
(including all those antibodies you’ve been making your entire life) . . . and
you just can’t package this stuff and sell it in the grocery store.
So, we will do our best to convince you to breastfeed and to stick with it
—with lots of tips and handholding along the way. However, we won’t
make you feel guilty if you decide on formula or can’t make a go of
breastfeeding. We just hope you give breastfeeding your best effort, because
any breast milk you feed your baby is a gift to her or him.
If you decide to go with infant formula or need to supplement your
breast milk supply, this chapter explains what you what you need to know
about formula options.
Besides breast milk and formula, you’ll be addressing the question of
what other liquids to serve your child. These include water, juice and cow’s
milk. We’ll discuss these other liquids in this chapter as well.

Breast Milk

Q. I have heard that breastfeeding is best for babies,

but what are the real advantages?
There are advantages for both baby and mom. Let’s take a look at each:
Breastfeeding Advantages for Baby:
Mother’s milk:
1.Has the ideal ingredients for a human body. Formula is an
approximation of the real thing. Breast milk is living food.
2.Carries the mother’s antibodies to protect baby from various
infections.
3.Reduces the severity of certain infections, like stomach viruses and
the common cold.
4.Is hypoallergenic. It is rare to be allergic to human milk.
5.Is brain food. Breast milk naturally contains nutrients (called DHA
and ARA) known to stimulate brain and vision development.
Interestingly, boys who have nursed for at least six months score
higher on standardized tests! (Oddy)
6.Reduces risk of obesity, diabetes, inflammatory bowel disease,
asthma, and some forms of cancer later in life.
7.Reduces a baby’s risk of Sudden Infant Death Syndrome (SIDS).
(Vennemann)

Breastfeeding Advantages for Mom:

1.It may be the easiest way to lose those pregnancy pounds and still
eat like you are a professional wrestler.
2.It is always ready to serve, at the perfect temperature.
3.It’s free. Formula can cost $1200 or more for the entire first year
of life.
4.It reduces a woman’s risk of breast cancer. Any amount or duration
of breastfeeding lowers your risk of developing breast cancer
before menopause. Currently, one in eight women will get breast
cancer.
5.It may reduce a woman’s risk of ovarian and endometrial cancer.
6.It may lower a woman’s risk of osteoporosis, diabetes, high blood
pressure, heart disease, and rheumatoid arthritis. You can lower
your risk of many of these disorders by nursing for at least a year
of your life (not necessarily with just one baby). You can lower
your risk of having a heart attack or stroke after menopause by
10% if you nurse for at least one month.
 7.It can be a form of birth control, but don’t rely on it exclusively
(unless you want a toddler and a newborn in the house!)
BOTTOM LINE: Breastfeeding is worth the effort it takes to learn how
to do it.

ENCOURAGING BREASTFEEDING

How can both doctors and parents ensure that breastfeeding is

successful? Here are the AAP’s guidelines:
Encourage “rooming-in” with your newborn at the hospital to
learn baby’s cues.
Trained caregivers should formally evaluate breastfeeding (latch,
position, etc) at least twice daily while newborns are at the
hospital. (If that doesn’t happen, speak up!)
Supplements (water, sugar water, formula) should not be given to
a breastfed newborn unless ordered by the baby’s doctor for a
medical reason.
Pacifiers are discouraged until breastfeeding is going well.
Breastfed babies should see their healthcare provider at three to
five days of life and again at two weeks of age to assess
breastfeeding.
“Complementary foods” (solid food) should be introduced from
four to six months of life. (Good luck convincing your mother
about this one!)
Babies should sleep in close proximity to their moms to encourage
breastfeeding. (Note the word choices here—the AAP is not
recommending a family bed).

Q. How long should I breastfeed my baby?

 The American Academy of Pediatrics recommends breastfeeding for at
least the first year of life. The latest statistics show that 79% of American
babies go home from the hospital breastfed. But only 49% are still breastfed
at six months of life. The numbers are even lower for babies who are
breastfed until one year of age. (CDC)

Q. If breast milk is recommended for the first year of

life, why do most American families stop before then?
That’s a great question. We’ll give you the big picture here and then
more details throughout this chapter.
Most women stop nursing because breastfeeding can be a real pain
(literally and figuratively) for the first couple of weeks. Some lack support
to overcome the initial challenges. Others stop when they return to work,
when they find it nearly impossible to balance their work-life and nursing-
life.
Here are the five key reasons why moms stop nursing before their baby’s
first birthday and our solutions:

1 IT HURTS. The Problem: Breastfeeding is a learned process. It’s not as

natural as you might think. Babies know how to suck, and Mom’s body
knows how to make milk. But the technique of getting the baby latched on
correctly requires a great deal of patience and sometimes four hands. Throw
in a hormonal roller coaster after delivery and you’ll understand why many
women give up. Then comes ENGORGEMENT. This is what happens when
the milk actually comes in. Your breasts may be more impressive than your
neighbor’s boob job. Your spouse will want to take pictures. You will wish
that it is a bad dream and hope that your old breasts will be back when you
wake up—engorgement often means tenderness, pain, sore nipples and
more.
 DR B’S OPINION: GRANDPARENTS
& BREASTFEEDING

There are some things about babies that will never change. But
there are many things we have learned in the past 20 or 30 years that
are different than what our parents were taught (like using car seats,
for instance). Learn grandparents’ trade secrets for soothing your
crying baby because they have been there and done that. Learn the
411 on current pediatric trends in this book.

THE FACTS OF LIFE—A.K.A. SCIENCE OF BREASTFEEDING

Keep in mind these four tips on the “science” of nursing your

baby:
Breast milk production is a supply and demand phenomenon.
Most women have no trouble making enough milk if the
demand is there. Nursing at least eight times in 24 hours
promotes a good supply.
Colostrum, the first milk, is all your baby needs for the first few
days of life. Mature milk, the high fat stuff, arrives when your
baby needs it—around the fourth day of life.
ALL babies are exhausted by the birth process and are not very
interested in eating for the first 48 hours. They latch on, get
cozy . . . and fall asleep after five minutes. This behavior will
change (at almost the same moment you leave the hospital!)
Babies are born with 10% extra baggage to carry them through the
first few days of life. They will lose 5-10% of their birth weight
—expect that. Do not think you are failing at breastfeeding
because your baby is losing weight.
4 YOU RETURN TO WORK. The Problem: Working moms, in general, have
trouble finding time to pump. To completely keep up with your baby’s
demands, you need to pump every three hours (nearly impossible, right?).
But remember, pumping some breast milk is better than none at all. This is
not an “all or nothing” situation.
The Solution: Figure out what works for you. Some moms can only
pump once while at work, and continue to nurse while at home. Your body
can adjust to many different feeding patterns . . . which means you can
continue some level of breastfeeding even after you head back to work.

5 YOUR BABY HAS A PROBLEM THAT MAKES BREASTFEEDING

DIFFICULT. The Problem: If your baby was born prematurely (before 37
weeks), has acid reflux (GERD), or a significant food allergy, it may be
even more challenging to breastfeed successfully.
The Solution: Get professional help from a lactation consultant and your
baby’s doctor regarding pumping, supplementing, or eliminating foods in
your own diet to accommodate for your baby’s dietary issues. See the
section on “Special Situations” later in this chapter for our tips.

Denise’s Opinion: Sometimes, the criticism you get about your decision
to breastfeed comes from unlikely sources. Exhibit 1: grandparents. Parents
from previous generations seldom breastfed their babies—it just wasn’t
fashionable. And the idea of baring your breast in front of them (especially
grandfathers) makes them squeamish to say the least. Here are some
suggestions for how to deal with their objections.

1.When in your own home, you have a right to nurse in your living
room. It’s your house, your rules. But your dad will probably
appreciate it if you either cover yourself with a shawl or warn him
before you whip out your breast.
2.At their house, be discreet. Try nursing in a bedroom if you know it
makes them uncomfortable.
 3.When they ask, “Why can’t we just give baby a bottle so we can
participate in feedings,” promise that they can when your baby’s
nursing is well established and you can pump a bottle or two.

When they ask you why you’re still nursing your baby at ten months,
calmly inform them that the American Academy of Pediatrics recommends
that babies breastfeed for at least a year of age.

DR B’S OPINION

“Despite all these challenges, it is well worth the

effort to make breastfeeding successful.
Breastfeeding is like running a race, with the
hardest hurdles up front. Many moms don’t
realize that they will be coasting the rest of the
way if they just make it past the first mile.”

BREASTFEEDING MOJO: LINDA’S TIPS

Before we delve into our breastfeeding tips, we’d like to give a

special shout out to a special expert here at Baby 411: Linda Hill.
Linda is a registered nurse and a certified lactation consultant
(IBCLC). Linda and Dr. Brown have worked together for over a
decade. We appreciate her sharing her thoughts and advice. Look for
“Linda’s Tips” throughout this chapter.
Q. If I have trouble breastfeeding, whom should I turn
to for help?
A poignant comment from one mom we interviewed: “If everyone would
just leave the baby and I alone, we could figure it out!” Truer words were
never spoken. However, if you are at wit’s end, utilize your pediatrician and
a lactation consultant. Lactation specialists (IBCLC’s) are medical
personnel certified to handle breastfeeding challenges. We suggest you ask
your obstetrician or pediatrician for a recommendation. Lactation
consultants who have an established relationship with your doctor are best.
It is helpful to have everyone working towards the same goal: your success!

Q. What do I need to know about my baby’s first few

days of breastfeeding?
Let’s break this down, day by day . . .
First Day of Life (0—24 hours old):
1.Nurse your baby for the first time within an hour or so of his birth. He
will be awake, alert, and interested.
2.At two hours of life, he will be exhausted and hard to arouse for
several (three to four) hours. Don’t get too worked up about trying
to nurse right now. Take a nap yourself. Or, place your newborn
skin to skin with you and relax together.
3.Frequency goal: six to eight feedings in the first 24 hours of life.
4.Your baby will probably fall asleep at the breast after a few minutes
of nursing. An acceptable feeding session for today is five to ten
minutes per breast.
Second Day of Life (24—48 hours old):
1.Today’s goal is working on your technique. It may take a second set
of hands to position the baby while you hold your breast. You will
fly solo eventually. See tips to survive the first two weeks later in
this chapter.
 2.Frequency goal: eight feedings in 24 hours. Do not let your baby
sleep more than three hours during the day or four hours at night or
you will have trouble meeting this goal.
3.Length of feedings goal: at least five to ten minutes per breast. Do not
take baby off the breast at ten minutes if he is still actively sucking.
4.If your nipples are cracked and bleeding, you need help with your
technique.
Third Day of Life (48—72 hours old):
1.Your baby is suddenly awake and sometimes, insatiable. As long as
your baby has lost less than 10% of his birth weight (and has no
other risk factors—see below), keep your chin up and resist the
temptation to supplement with formula. Your baby’s demand is
precisely what your body needs to create the supply of milk.
2.Make sure your technique is okay and you are comfortable when your
baby latches on.
3.Frequency goal: eight feedings in 24 hours (it should be an easy goal
to reach today!)
4.Length of feedings goal: at least ten minutes per breast.
5.You may feel that your baby is on your breast non-stop. If that is the
case and your nipples are sore, take a break if you have nursed for
more than 45 minutes. Let someone else have a chance to soothe
your baby. (Letting baby suck on someone’s finger may be
helpful.)

NEW PARENT 411: BREASTFEEDING LINGO

Breastfeeding has a language all its own. Here is a quick

overview:
Colostrum. The first milk that your breasts produce. Some women
start making (and leaking) it before the baby is even born. It is a
high-protein drink, filled with mom’s antibodies that boost the
 immunity of a newborn. It has fewer calories than mature milk
because of a lower fat content.
Mature Milk. The milk that arrives on the third or fourth day after
birth. It is about 50% fat.
Foremilk. The milk that comes out in the first several minutes of
feeding. In general, it contains slightly less fat. Babies who
“snack” end up getting mostly foremilk, leading to more
frequent feedings (and possibly, fussiness).
Hindmilk. The milk that comes out in the later part of a feeding. It
is slightly higher in fat than foremilk. Babies who drain a whole
breast in a feeding tend to be more satisfied, for good reason.
Let down. When your milk rushes into the milk ducts as your baby
suckles or as you pump. Most women feel this “let-down.”
Engorgement. In the first days when you make mature milk, your
breasts may feel full, tender, lumpy, and hard.
Plugged ducts. An area of the breast has obstructed milk flow,
creating a hard, tender lumpy area. These areas are at risk of
getting infected (mastitis—ouch!). See tips below for more info.
Inverted nipples. Your nipples have an indentation in the center. It
can make it more difficult for your baby to latch on.
Flat nipples. Your nipples are flush against your breast tissue.
Like inverted nipples, flat nipples can make it difficult for baby
to latch.
Breast shells. Plastic devices that pull out inverted nipples. They
can also be worn to protect sore nipples from rubbing against
your bra.
Nipple shields. Plastic devices that protect sore or cracked nipples.
These are also used for moms with flat or inverted nipples.
Unfortunately, they can sometimes limit the amount of milk that
flows to the baby’s mouth.
Lanolin. A thick emollient that helps heal cracked nipples. Brand
names: Lansinoh, Pur-lan. Available at breastfeeding boutiques
and even Wal-Mart.
 Compression. Squeezing breast tissue during nursing to improve
milk flow and encourage baby to drink. It can also be done
while pumping to express more milk.
Paced Bottle Feeding. Holding a baby upright and holding a
bottle of expressed breast milk/formula horizontally to simulate
a feeding session at the breast. This technique makes baby less
frustrated when he resumes nursing.

Fourth Day of Life (72—96 hours old):

1.Hello milk! There is usually little question of whether or not your
milk has arrived. How will you know? Your breasts will be much
larger, heavier, and tender. You should feel full before you nurse,
and softer after you nurse. You should also see milk when you burp
your baby (and sometimes when you shower). The change in your
baby’s poop will also tell you the milkman has arrived. See the
section Newborn Poop in Chapter 8 “The Other End” for more.
2.If your breasts are rock hard and your areola (the darker colored ring
around your nipple) are flattened against them, you are officially
engorged. This lasts for a day or two. See troubleshooting tips
below.
3.Frequency goal: eight feedings in 24 hours. Do not let your baby
sleep for more than 3.5 hours during the day or a four hour stretch
at night.
4.Length of feedings goal: at least ten to 15 minutes per breast. Once
your milk supply is well established (around four weeks of life),
some women prefer to nurse with one breast per feeding. For now,
use both at each feeding as it stimulates your milk production.
You should be on your way now. Your baby should be gaining about an
ounce a day.

NEW PARENT 411: ANXIETY AT CHECK OUT

 You will go home from the hospital with a shrinking baby and no
“mature” milk in your breasts. Understandably, this often creates
great anxiety for new parents. Your baby will do just fine with
colostrum as long as your breast milk comes in around the fourth day.
The circumstances that interfere with this perfect plan are:
1. Jaundice (elevated bilirubin).
2. Prematurity or small gestational age (small for dates).
3. Loss of more than 10% of birth weight.
4. Delay in milk’s arrival.
The AAP recommends follow-up appointments for babies at the
third to fifth day of life to make sure things are heading in the right
direction.
It’s a good idea to keep a breastfeeding diary (see our handy two
week survival guide earlier in Chapter 1) that tracks both feeding and
elimination for the first two weeks. Or try an app like Baby Connect
(baby-connect.com) for iPhone or Android. If the milk is going in, it
will come out the other end. If you are still uncertain of how things
are going, schedule an appointment!

Days 5—14
1.Breastfed newborns eat about every 2-3 hours (or 8-12 times) in a 24-
hour day. They may cluster feed as often as every 90 minutes
(that’s from the beginning of one feeding to the beginning of the
next). They usually eat about 2-3 ounces at each feeding.
2.Babies who try to nurse more frequently than every 90 minutes are
either nursing for comfort or not getting enough milk. So, if it has
been less than 90 minutes since the beginning of the last feeding,
try using your finger to let her suck. Your breasts will thank you.
3.If your baby is truly nursing non-stop, go get your baby weighed.
Make sure you have enough milk supply to meet your baby’s
demand.
4.On the other hand, do not let your baby go for more than 3.5 hours
during the day or more than 4 hours at night without nursing.
Frequent feedings improve your milk production and give your
baby what he needs to grow.
Two Weeks
If your full term baby is at or above birth weight at his check up, you
have my blessing to let your baby sleep as long as he wants at night.

The One Month Mark

Your baby should be more efficient at feeding sessions. And nursing is
(hopefully!) on auto-pilot.

See the section called The Big Picture: Breastfeeding for the First Year,
later in this chapter for a nice summary of what lies ahead this year.

TOP 10 SURVIVAL TIPS FOR THE FIRST TWO

WEEKS

And now, from the home office here in Austin, TX, our top 10 list of
advice for breastfeeding success in the first two weeks:

1.Make sure your baby is latched on to your areola and not just the
tip of your nipple.
2.If it hurts for more than a few seconds, take your baby off your
breast and reposition him. Do not be a martyr.
3.If the position you are using is not working, try another one. See
more tips on positions in this chapter.
4.Have a spouse or willing volunteer get the baby’s open mouth to
your breast while you hold your breast. Have this person pull
down your baby’s chin gently with their finger.
5.Ask for a nipple shield (a plastic covering with a hole) if your
nipples are too tender or cracked to nurse comfortably. This is a
controversial option because the volume of fluid coming to
baby is reduced. But it may make the difference for some
women if used for a day or two. If you choose this option,
schedule a follow-up appointment with a lactation consultant.
 6.One word: LANOLIN. Various brands of this ointment (such
as Lansinoh) are available. Any product with this active
ingredient provides comfort to healing nipples. (It’s also great
for baby’s bad diaper rashes.) If your nipples are really in dire
straits, you can buy Elastogel (a wound dressing) at your local
hospital pharmacy or from a lactation consultant. Your doctor
can also prescribe an antibiotic cream if necessary.
7.Use both breasts during each feeding to stimulate milk
production. Once your milk supply is established at four weeks,
it is fine to nurse on one breast per feeding if your baby
consistently refuses the second breast and is gaining weight.
One exception: veteran moms may have plenty of milk to
accomplish this sooner.
8.Sleep when your baby sleeps. Your baby should not sleep more
than a four-hour stretch in the first two weeks.
9.Don’t be afraid to ask for help.
10.Don’t give up. The first two weeks can be rough, but then it will
all be worth it!

Helpful Hints
When you are told that babies feed every two to three hours, time is
measured from the BEGINNING of one feeding until the beginning of the
next. If the feeding session itself lasts 45 minutes or an hour, that may leave
less than an hour before it’s time to nurse again.
Your goal is to nurse at least EIGHT TIMES a day. This may be every
two to three hours or it may be a series of cluster feedings every 90
minutes, followed by a four-hour stretch. As long as the number of feedings
add up to eight in a 24-hour period, it is fine.
Remember this word: COMPRESSION. Just because your baby is at the
breast, it does not mean he is drinking. If your baby seems to be doing more
sleeping than swallowing, try the following trick. Encircle your breast with
your hand and gently squeeze the breast tissue with your thumb. Do not
stroke or massage the tissue, just squeeze and hold it down briefly. It gets
the colostrum/milk flowing and will encourage your baby to have a drink.

Old Wives Tale

“My doctor told me I didn’t have enough milk.”
The truth: Thirty years ago, doctors thought breast milk was supposed to
come in immediately after birth—and hence when it didn’t appear in day
one or two, panic bells went off. We now know that it is Nature’s Way to
have colostrum first and mature milk later. This is one of the reasons why
our mothers did not breastfeed us.

BOTTOM LINE: Be prepared for the 72 hour Colostrum Zone. Your mature
milk will arrive soon enough.

RED FLAGS
Check in with your baby’s doctor if:
1.You don’t have a dramatic change in your breasts by the fifth day of life.
2.You don’t hear your baby swallowing (“cuh” sound) when he is at the
breast.
3.Your baby’s poops have not changed from black tar (meconium) to a
greenish-yellowish color by the fourth day.
4.Your baby does not have at least four wet diapers on the fourth day.
5.Your baby is sleepy and hard to arouse for feedings.
6.Your baby is nursing non-stop.
Q. Is it okay for me to take pain medication when I am
nursing?
Yes.
The medications that your OB prescribes for discomfort after delivery
are safe to take while you are breastfeeding. It’s true that a tiny amount of
these medicines end up in your breast milk, so it’s important to watch your
baby for extreme lethargy (for example, not waking up for feedings).
Whether you are nursing or not, you should wean off of narcotic pain
medications (Vicodin, Tylenol #3 with codeine) as soon as you feel better.

Breastfeeding positions
Cradle hold: Baby’s head rests on Mom’s forearm with his belly next to
Mom’s (that is, left arm holding baby for feeding at the left breast).

Football hold: Baby’s head rests on Mom’s hand with his body coming
underneath Mom’s armpit. (Good for after a C-section, large breasted
moms, preemies, and twins.)

Side-lying: Baby and Mom lie on their sides and face each other, tummy
to tummy. (Popular at night feedings) (Danner)
 Cross cradle hold (not pictured): The baby’s neck and upper back are
supported by the opposing hand (that is, left hand cradles the baby’s head to
the right breast and right hand holds right breast). This is a good position to
start with as it gives you more control. When the latch is comfortable, you
can switch to the cradle hold.

Linda’s Tips: Positioning

Mom should be comfortable with her arms and back supported.
Mom should not lean over the baby. Instead, use a breastfeeding
pillow—a firm pillow that wraps around Mom’s waist and
allows baby to rest supported. Linda’s favorite brand is called
(don’t laugh at the name) My Brest Friend because it provides
more support than the competing brands on the market.
Baby should directly face the breast without having to turn his
head.
Baby’s stomach should be pulled in close to Mom, tummy to
tummy. Using a footstool may be helpful to bring baby closer to
mom.
Baby’s ear, shoulder, and hip should be in a straight line.

The other critical issue is making sure your baby’s bottom lip latches
onto the pigmented area (areola) and not at the base of the nipple.

Linda’s Tips for a comfortable latch

Position your baby at the breast so that his nose is directly across
from your nipple.
Aim your nipple up with your thumb so that it is pointing to the
roof of his mouth when opened.
 Touch his lips with your breast and he will look up to the nipple as
he opens his mouth.
Have his bottom lip latch onto the pigmented tissue (areola)
beneath the nipple. Push your nipple into his mouth as you pull
him into you.
If it hurts more than 10-20 seconds beyond the initial latch, break
the suction seal (see below), reposition, and try again. DO NOT
NURSE IF IT HURTS BEYOND THE INITIAL LATCH. It’s
normal to feel a tugging sensation. It’s not normal to feel
pinching, burning, or stinging. You are not doing yourself or
your baby a favor by suffering. Pain means you don’t have a
good latch—or you are paying for previous damage you’ve
already done.
You should hear gulping (“cuh”) noises. Take your baby off if you
hear a clicking sound.
Signs of a bad latch: Your nipple looks like a tube of lipstick or
you see a white line across the nipple that eventually leads to
cracks, bleeds, and scabs.

Helpful Hint
To take your baby off of your nipple without causing excruciating pain,
place one of your fingers into the corner of his mouth and break the suction
seal. If the seal doesn’t break, slip your finger deeper into his mouth to relax
his jaw.

Insider Secret
A Canadian pediatrician/lactation consultant has created some extremely
informative (and free!) breastfeeding videos that are worth a look, whether
you are having trouble or not. Check them out at Breastfeeding Inc’s
website here: breastfeedinginc.ca.

Infant Feeding Behaviors

Newborns can be divided into five types of feeding styles. Identifying
what type your baby is may help you understand how to help him feed
better. The types listed below were characterized by a study done in the
1950’s, but are still relevant today:

1.The Barracuda. This little guy attacks the breast and gets down to
business. Mom’s nipples sometimes pay the price for this style in
the beginning weeks.
2.The Excited Ineffective. Yes, this is the baby who is so excited to eat
that he loses his latch. Calming, then reattempting to latch helps
until baby figures out the routine.
3.The Procrastinator. The baby who waits until the milk lets down to
bother with eating. There is no rush. Be patient and keep trying.
4.The Gourmet. She must mouth the nipple, have a taste test, then
begin the meal. Again, there is no need to rush. Let her do her
thing.
5.The Rester (similar to a cow who grazes). He takes his own sweet
time. He eats for a few minutes, rests, then continues. He will
eventually finish the meal and eat well but you can encourage him
by rubbing his back or head. (Barnes)

Q. Is it okay to supplement with formula until my

mature milk comes in?
Yes, it’s okay, but it’s usually not necessary.
Mother Nature has an elaborate plan for babies and breast milk.
Newborns arrive with some extra nutritional baggage to carry them through
the first few days of life. That’s good because they’d rather sleep than eat.
It’s also good because your body is making early milk (COLOSTRUM) that
is antibody-rich, but calorie-poor (it has fewer calories in it than mature
milk, which shows up around day three or four).
In fact, we pediatricians expect most newborns to lose about 10% of
their birth weight by the third or fourth day. That’s supposed to happen.
At about 48 hours of life (at precisely the moment most of you are
heading home from the hospital), your baby suddenly says, “Hey, I’m
starving, what have you got to eat around here?!”
He’ll act completely differently than his first two days and want to nurse
non-stop. That demand drives your milk supply up. Although that can be
pretty nerve-wracking for about 24 hours or so, it’s what gets your milk
production going.

BOTTOM LINE: You don’t need to tinker with Mother Nature’s grand
scheme by offering formula. Unless there is a medical reason to give
formula (see below), let nature take its course.

Top 6 reasons why you SHOULD supplement with

formula
Women who are certain they want to breastfeed are often devastated if
they need to temporarily supplement with formula.
The key point to remember: you are not a failure. And it isn’t the end of
the world. There are some key medical reasons why it’s necessary. And
offering formula for a short time won’t sabotage breastfeeding success.

1 PREMATURE NEWBORN. If your baby is born between 24 to 34 weeks

gestation, he probably won’t be able to breastfeed initially. Depending on
how premature your baby is, he might not even eat by mouth at first. You’ll
need to start pumping to stimulate your milk production. When your baby
can get his nutrition by mouth, he can either drink your pumped (expressed)
breast milk through a feeding tube or take it from a bottle. Most likely, he’ll
also need some formula made especially for premature babies to fulfill his
nutritional needs.
2 LATE PRETERM NEWBORN. Babies born between 34 to 36 6/7 weeks
gestation tend to be very sleepy, lazy, and inept at efficient suckling at the
breast. So, until your baby gets the hang of it, you may need to offer the
breast and then some pumped breast milk in a bottle after each nursing
session to fulfill his nutritional needs. If you don’t have enough milk,
formula will work. You can nurse exclusively once his skill and energy
level improves, he is gaining weight appropriately and you are making at
least 3 oz. of milk combined from both breasts for each feeding. This is
usually for a week or two, or until your baby reaches the day he was
supposed to deliver.

Linda’s Tip: In the first month, be sure to pump for ten minutes every time
you “top your baby off with a bottle.” This rule applies even if you already
breastfed and even if nothing is coming out. It’s very important for the
stimulation to equal the baby’s demand when you are establishing your milk
supply.

3 LOW BLOOD SUGAR (HYPOGLYCEMIA). Some newborns have trouble

maintaining an adequate blood sugar level. Low blood sugar can become a
vicious cycle. Babies with low blood sugars lack the energy to eat, which
leads to persistently low blood sugar. Besides its negative impact on
feeding, sustained low blood sugars can lead to brain injury and seizures.
Hence, the temporary solution is to offer supplemental formula in addition
to nursing until your baby maintains normal blood sugar levels. For a full
term baby, born between 37 to 40 weeks, this may be for a feeding or two,
or a day or two at most.

4 EXCESSIVE WEIGHT LOSS. A newborn that loses more than 10% of his
birth weight usually needs both breast milk and formula until he starts to
gain weight. As we mentioned earlier, it is normal and expected for your
baby to lose 10% of his weight at birth. But more than 10% means that your
baby is dehydrated. Dehydrated babies are not happy babies. They lack
energy to eat (another vicious cycle) and so they lose more weight, end up
with low blood sugar, and develop jaundice (more on this next). Don’t let
your baby become a martyr in the name of breastfeeding. If he is
dehydrated and your mature milk hasn’t arrived yet, supplement with
formula. It prevents him from having other medical issues. Remember, this
is temporary until your baby gains weight and your mature milk is plentiful
enough to feed him.

5 SIGNIFICANT JAUNDICE. Let’s talk about poop for a minute. Humans

clear out a waste product (called BILIRUBIN) in their poop. Bilirubin has a
yellow pigment to it. In the first few days of life, a newborn doesn’t clear
out much bilirubin because her liver (which breaks it down) doesn’t
function at 100% and she isn’t pooping very much (since she isn’t eating
much). As a result, all newborns temporarily collect some bilirubin in their
skin, causing a yellowish glow (called physiologic jaundice). This resolves
on its own around three to five days of life once they eat a lot, poop a lot,
and have fully functioning livers.
For a variety of reasons, some newborns get significantly jaundiced. If
there is more bilirubin than the skin can handle, it collects in the brain and
can cause permanent brain damage (called kernicterus). It goes without
saying that everyone wants to avoid this! There are several ways to prevent
kernicterus, but the first and simplest thing to do is to get a newborn to eat
and poop more. The more he eats, the more he poops, the more he gets rid
of his bilirubin load. For a breastfed baby, that means supplementing with
formula for a few days.
Once you see the poop turn from black to dark green to yellow (that
yellow pigmented bilirubin makes it change color) and your mature breast
milk is in, the bilirubin levels will drop and you’ll be able to resume nursing
exclusively.

6 MATERNAL REASON. Sometimes a mom intends to nurse, but

encounters a medical problem of her own that prevents her from doing so at
first. Those problems include: postpartum bleeding, high blood pressure,
etc. If this happens to you, don’t let it get you down. Nurse as much as your
OB doctor allows and let your baby have some formula until you have
recuperated. Your baby will be fine. You need to be healthy to be able to
make milk. If you can, pump to protect your milk supply.
 THE LOW DOWN ON BREAST PUMPS

You can rent a hospital grade pump, purchase an electric pump, or

purchase a manual pump.
A smart move: rent a pump when you go home from the hospital.
Renting lets you figure out whether you need a pump long term,
without making a serious financial commitment. Most hospitals offer
rentals or at least provide a list of medical supply companies in the
area that rent pumps.
Moms who are returning to work but still want to pump have two
options: rent a pump for an extended period of time or buy a pump.
Either way we recommend a professional-grade dual electric pump.
You can control the speed and pressure, which less expensive models
don’t allow. For working moms, efficiency is key. You can pump
both breasts simultaneously in 15 minutes. A Medela rental pump
will cost $45-75 per month to rent. It pumps 50 cycles per minute
(baby sucks about 60 times/minute) at a comfortable pressure.
You can purchase a professional grade equivalent pump (example:
Medela “Pump In Style”) for $250 to $300.
You might get a manual pump as a shower gift. This is convenient
for emergencies or travel. The mechanism is similar to operating a
bike pump. Your arm may get tired out long before your breasts have
emptied.
FYI: For an in-depth discussion on buying a breast pump
(including brand name reviews) as well as the best milk storage
options, check out our other book Baby Bargains (see back of this
book for details).
Insider Secret
Here is another important breastfeeding term: PACED BOTTLE
FEEDING. If you have to supplement with expressed breast milk or
formula, hold your baby in an upright position and hold the bottle in a
horizontal position. This position forces the baby to work a little bit to get
the milk, more like the flow at the breast. Most people instinctively recline
the baby and tilt the bottle, allowing the baby to chug the milk. If your baby
chugs breast milk or formula with a bottle, he is likely to become very
impatient when he goes back to the breast.

Top 3 reasons why women end up supplementing (but

don’t need to)
Exhaustion. Delivering a baby is an exhausting experience. After many
hours of labor, you’ll just want someone to tuck you in for a long night’s
sleep. No such luck for a breastfeeding mom. You might get about four to
five hours of sleep after delivery (the “honeymoon” period while your
exhausted newborn sleeps too). Then, the party is over. You’ll need to feed
your baby EIGHT times every 24 hours—yes, that’s every three hours on
average.
To get your milk production up to speed, you shouldn’t go any longer
than four hours between feedings. With that pace, it’s no wonder women
ask to let their baby camp out in the nursery and get a bottle of formula
while mom gets some shut-eye. If this is the deal breaker for whether or not
you will continue breastfeeding, okay, take a break. But we don’t
recommend it. Once you start on this road, you’re more likely to give up
nursing altogether. If you can get through these early days, we promise it
gets easier!

Pain. If you start off with poor technique, each breastfeeding session is
incredibly painful. The thought of bringing the baby to the breast can bring
some women to tears. Hopefully, our tips will prevent this situation from
happening. But if you find yourself in this place and need to take a break
from nursing for a few feedings or 24 hours until your nipples can heal, so
be it. You need to continue removing milk from your breasts for every
feeding, though. Pump and offer that expressed milk to your little one. You
can also temporarily use nipple shields while nursing. You are more likely
to continue nursing if you can forge ahead (with proper technique going
forward, of course).

Fear. Women mistakenly fear that their baby is not getting enough to eat
when they are producing early milk (COLOSTRUM). They see their baby
losing weight and get worried. Don’t worry! If your baby has no medical
issues and your pediatrician does not feel you need to supplement with
formula, you don’t need to supplement with formula! If you start
supplementing when you don’t need to, your baby will fill up. You need his
hunger drive to get your breast milk production going. Don’t mess with
Mother Nature.

Nursing: Concerns & Questions

At the two week mark, nursing should be fairly routine and comfortable
(if not, read the next section on troubleshooting). Take a look at the Big
Picture summary at the end of this section to see how your baby begins to
take larger quantities of breast milk at each feeding. But in general, expect
that your baby will continue to eat about every two to three hours during the
day and start eating less often (and sleeping more) at night after the first
two months of life. Here are some common breastfeeding concerns and
questions.

Q. Can my baby use a pacifier if I am nursing?

Yes. Babies are soothed by sucking. In the first two months of life,
sucking on a pacifier may be the only thing that reliably settles your baby.
Despite what you may hear, binkies and breastfeeding can mix.
Experts used to believe that pacifiers shortened the length of time that
moms continued to nurse. So it was almost taboo to offer a binky to a
breastfed baby. Research suggests otherwise. Pacifiers don’t make a baby or
mom stop breastfeeding. Parents who use a binky choose to discontinue
nursing for a variety of other reasons. (O’Connor)
In our opinion, breastfeeding and pacifiers are not mutually exclusive—
pacifiers are NOT evil. But it is wise to wait on introducing a pacifier until
your baby is a confident breastfeeder (between one and four weeks old)
because babies suck pacifiers differently than the breast. And we
recommend the “Soothie” brand (has a long nipple; web: soothie-
pacifier.com) as it is more similar to the human nipple than other brands. A
reasonable alternative to the pacifier is a parent’s finger. The other obvious
alternative is to offer your breast for comfort nursing. This may or may not
be for you.
Note: as we’ll discuss in the section on Sleep Safety Tips in Chapter 9,
Sleep, pacifiers have been shown to reduce the risk of SIDS in babies under
six months.

BOTTOM LINE
If you opt to use a pacifier, we suggest getting it out of your baby’s life by
six months of age when he no longer needs to be soothed by sucking. For
more information, see the section on Soothing a New Baby in Chapter 11,
“Discipline.”

INSIDER SECRETS: TOP 8 BREASTFEEDING

PROBLEMS . . . AND SOLUTIONS!

Sure, you know that breastfeeding is best for your baby . . . but if
something goes wrong? Don’t give up! Here are the top eight
breastfeeding problems and how to solve them.

PROBLEM SOLUTIONS

#1 Underproduction Discuss options to increase

milk production with healthcare
 Newborn: less than three provider
poops a day by Day 3 of life, After nursing, feed baby with
poop not yellow/seedy by Day expressed breast milk or
5 of life, less than six wet formula (see Paced Bottle
diapers a day by Day 4 of life, Feeding earlier in this chapter)
no weight gain by Day 5 of life, Check baby’s ability to get
birth weight not regained by milk at the breast (milk
Day 14. transfer) with a certified
Day 5-4 Months: weight gain lactation consultant.
less than 5 oz/week.
4 Months-1 Year: weight gain
less than 3 oz/week.

#2 Overproduction
Baby: coughs or chokes while Nurse on one breast per
nursing, excessive weight gain, feeding and return to that same
green frothy poops. breast if baby wants to nurse
Mom: always feels full, milk within two hours.
shoots out forcefully. Manually express or pump off
for a minute before having the
baby latch on (don’t overdo it,
or you will have even more milk
production!)
Lean back while nursing to
reduce the flow.

#3 Engorgement
Baby: has trouble latching on. Increase milk removal by
Mom: has severe fullness and nursing more often or pumping.
pain, nipples are flattened. Cold packs for 10-15 minutes
after feedings.
Ibuprofen.
Should get better in 1-2 days,
if not, visit a lactation
consultant.
#4 Nipple Pain
Mom: nipples/areola are red, Check baby’s mouth and chin
cracked or bleeding, look like a (tongue tie or a recessed chin
tube of lipstick after nursing, can cause a latch problem).
look blanched after nursing, or Have a lactation professional
have blebs (white cysts). assess how baby is latching on.
Have a lactation professional
assess mom for a nipple
infection.

#5 Nipple Bacterial Infection

Mom: nipples are cracked, Mom’s doctor can prescribe
painful during latching, an antibiotic cream until
draining pus or has golden nipples are healed.
crust.

#6 Plugged Duct
Mom: localized area of a Breastfeed frequently, always
breast is painful, red, and tender starting on the affected breast.
usually before nursing, Position baby with chin
decreased milk production, pointing towards the affected
fever free or temperature below area.
101.3F. Massage the area while
nursing or pumping. Apply heat
before and ice after feedings.
See a lactation consultant for
more help.

#7 Mastitis
Mom: Fever, body aches, Milk is safe to use. Nurse
redness or red streak on frequently on the affected
breast(s), decreased milk breast.
production Use a hot pack on the breast
for four minutes before each
feeding (if breast is not feeling
hot).
 Alternatively, if the breast
feels hot, use ice pack before
and after feedings.
Mom’s doctor can prescribe
an oral antibiotic that’s ok to
use while nursing.
Mom can take probiotics
while taking antibiotics to
prevent a yeast infection.

#8 Yeast infection
Baby: may be symptom free, Mom and baby should be
or may have white adherent treated for infection, even if
plaques on the tongue, inside of only one party has symptoms.
cheek, inner lip, and gum line. Baby: doctor can prescribe
Mom: may be symptom free oral antifungal medication.
or may have Mom: can use over-the-
sharp/shooting/burning pain counter antifungal cream on
while nursing, shiny/red areola, nipples or doctor can prescribe
cracked/ easily bleeding oral antifungal if pain is deep.
nipples, painful or itchy Take probiotic supplement.
nipples/breasts throughout the Sterilize all pacifiers,
day. teething toys, pump parts,
This chart is adapted with permission breast shells, bottle nipples
from Physician’s Breastfeeding Triage daily.
Tool Kit, developed by Diana West, Good hand washing before
IBCLC, for International Lactation
Consultant Association, Copyright
and after breastfeeding. (West)
2007.

Q. My baby prefers one of my breasts to the other. Is

that ok?
 Yes. Why does this happen? One of your breasts may produce more milk
than the other, flow differently or be easier to latch onto. And your baby
will figure that out and may develop a preference for the better-producing
breast. Some babies will even refuse the breast that has slower flow or less
volume.
If your baby doesn’t get too frustrated, offer the slower flow breast first
because he will nurse more aggressively at the beginning and that helps
increase your supply. When he becomes frustrated, switch to the other
breast. And try pumping the lower-producing breast after nursing to
improve production.
No worries if your baby completely refuses one breast. It’s possible to
make enough milk from one breast to completely satisfy your baby. (I’ve
even had a patient whose mom had a mastectomy and successfully nursed
on the remaining breast!)
Nutrition is not the issue. You will just start to look rather lopsided if you
nurse on only one side!

Q. My baby fills up after taking just one breast. Can I

nurse alternate breasts at each nursing session?
Yes. Once breastfeeding is well established and your milk supply is
stable, it’s fine to alternate breasts for each feeding. For first time moms,
that’s about 3-4 weeks after delivery. For seasoned moms, their milk supply
is fairly stable after two weeks.
Insider tip: some moms place a safety pin on the bra cup of the breast
they used at the last feeding. (Sleep deprivation takes a toll on the
memory!)

Q. I am exhausted after several weeks of every-two-

hour nursing sessions 24/7. Will I get more sleep if I
supplement with formula?
Nope. A recent study compared a mother’s level of sleep deprivation
(and ability to function) after living with a newborn (between 2—12 weeks
old) to what the baby ate—exclusively breast milk, exclusively formula, or
a combination of breast milk and formula. The answer? There was
absolutely no statistical difference . . . all the mothers were walking
zombies! (Montgomery-Downs)
Although what you feed your baby doesn’t make a bit of difference, you
are certainly entitled to a few hours of uninterrupted shut-eye for your
physical and mental health. After 2-4 weeks, you can pump (express) some
breast milk and let your partner take a turn doing an evening feeding.
Getting a four or five hour stretch of sleep will feel like an amazing night’s
sleep!

DR B’S OPINION

“Babies will get what they need from breast milk,

at the expense of Mom’s body. I recommend
continuing your prenatal vitamins if you are
nursing.”

Q. My four month old still nurses every two to three

hours at night. Is this really necessary or is it just a
habit?
Four-month old babies who were born full-term, don’t have acid reflux
(GERD), and are gaining weight appropriately should be able to sleep at
least six hours without needing to eat. Five-month olds can go at
least nine hours. And six-month olds can go up to twelvehours!
Bottom line: your baby should have at least one, long sleep stretch a
night. Then it may be mealtime every two to three hours after that. If he
awakens after six hours, asks to eat and actually EATS, then assume he is
hungry and continue to follow his cues.
But if he fusses and falls asleep at the breast without actually eating
much, that is your clue that he doesn’t really need to be fed. Next time just
try patting him back to sleep. That will help begin the process of
lengthening that “long stretch” of sleep.
However, even if your baby is sleeping longer, you may have to get up
and pump. Some moms need to pump after six hours, otherwise their milk
supply vanishes. Moms who struggle to make enough milk often have to
follow this rule: aim for at least six to eight stimulations a day (whether
pumping or breastfeeding) and take no longer than one six hour break of no
stimulation.

DIETARY RESTRICTIONS FOR CERTAIN CIRCUMSTANCES

Two and a half percent of all newborns have a hypersensitivity to

cow’s milk. Occasionally, babies with a milk allergy can have
problems if their breastfeeding moms have milk products in their diet
(see “I Give Up” story later in this chapter). For more information on
food allergies, see Chapter 7, Solid Nutrition. (Sampson)

Reality Check
Babies continue to eat about every two to three hours during the day for a
very long time. Even preschoolers eat three meals and two snacks a day
(eating about every three hours). Do not try to increase the time interval
between meals during the day—just aim for spacing them out at night.

Q. I need to leave my baby for a few days. Do you

have any tips?
 Leaving your nursing baby can be anxiety producing for both mom and
baby. Some ideas to make life easier are:
Start stockpiling expressed breast milk in the freezer a few weeks
before the trip.
Take an electric breast pump and a hand held one if you have a long
flight.
Offer breast milk in a bottle once daily before your travel begins.
Take a picture of baby with you to inspire you to let down.
Leave your slept-in nightie or another clothing item with your scent on
it for your baby.
Know that your baby will be just fine while you are away and happy to
see you when you return.

Linda’s tip: Fresh breast milk is always better for your baby than frozen.
Freezing/warming destroys certain properties in your milk like some
vitamins and antibodies. So, while this thawed breast milk is still better for
your baby than formula, it is better to pump for the next day’s supply and
only have an emergency stash of frozen milk in the freezer. If you are going
to be away from your baby for a few days, then stockpiling in the freezer is
the way to go!

Trouble Shooting
When breastfeeding goes wrong, these are the usual suspects:
Underproduction (low milk supply) or insufficient milk transfer to
the baby.
Overproduction.
Engorgement.
Nipple pain.
Nipple bacterial infection.
Plugged duct.
Mastitis.
 Yeast overgrowth/infection.
Here is our discussion on these problems and solutions in full detail. See
the handy summary table of survival tips earlier in this chapter.

1 UNDERPRODUCTION (LOW MILK SUPPLY) OR INSUFFICIENT MILK

TRANSFER TO THE BABY.

Q. My milk supply is low. Can I do anything to

improve my production?
Milk supply is based on demand. So if your baby is not stimulating you
enough (premature babies and late preterm infants are often at fault for
this), use a breast pump to rev up the supply. Pump a few minutes after each
feeding session.
And yes, some women do not make enough breast milk to feed their
baby. Here are some suggestions to pump up the volume:

1.Try pumping with a high-efficiency breast pump AFTER nursing

sessions. An empty breast signals the body to make more milk.
2.Try herbal supplements. Fenugreek (two dropperfuls of tincture, three
times daily) and blessed thistle (three pills, three times daily) or a
tincture called More Milk Plus. These appear to be safe and may
improve milk supply.
3.Try Reglan (metoclopramide). This medication requires a prescription
from your doctor and may have some undesirable side effects.
4.Eat and sleep more. Your milk production depends on you taking
good care of yourself.
5.Try eating a combo carbohydrate/protein snack just before or during
nursing. This increases your prolactin hormone level, which in
turn, increases milk supply.
 DR B’S OPINION: TRAINED NIGHT
FEEDERS

Some parents opt for a more relaxed approach to feedings and

schedules. Keep doing what you are doing if you enjoy night
nursing and do not need/desire a schedule. But, please know that if
your healthy, thriving baby is over six months of age and nursing
every two to three hours at night, he is officially a “trained night
feeder.” That behavior can be easily changed. Read Chapter 9, Sleep
so you can all get more sleep! I just want you to know what your
baby is capable of so you can make an informed decision.

Q. My pediatrician thinks there is a milk transfer

issue. What does this mean?
Simply put, you are making plenty of milk but the baby is not effectively
getting it from the breast. Sometimes the problem lies with the baby, and
not with the mother. This is called insufficient milk transfer. This may
happen with late preterm babies, babies with medical issues (for example:
heart, neurologic problems, etc.), and babies with mouth abnormalities like
a tongue-tie (see more on this below).
Milk transfer issues can also occur when mom uses a nipple shield as
some of the milk gets caught in the shield.
Depending on the problem, there are a variety of solutions. The key is to
protect mom’s milk supply (usually by pumping, expressing breast milk,
and giving it to the baby) until the milk transfer issue resolves.

2 OVERPRODUCTION.
Q. Holy cow! I have to change my shirt before I start
nursing! I have so much milk, what do I do?
Some women naturally make an overabundance of milk. We’re not
talking just in the first couple of weeks, when your supply and your baby’s
demand are trying to sync. We are talking several weeks down the road, you
still look like Dolly Parton, and your milk shoots out across the room. If
this describes your situation, your baby may be unhappy (and even upset).
He may feel like he’s treading water in the ocean with the excessive flow.
And as a result, he may choke, cough, and arch while nursing.
If you have this issue, try nursing at just one breast per feeding. Lean
back or lie flat while you nurse to slow down the velocity of that milk
stream!

Linda’s tip: Remove your baby from your breast after the first several
gulps and squeeze out the overflowing (or spraying) milk into a burp cloth.
Then put the baby back to the breast. Repeat with each let down or gulping
phase.

DR B’S OPINION: MEDICATIONS

AND BREASTFEEDING

Mothers frequently call me about medications they are taking

and if they are okay to use while breastfeeding. Although I sound
smart knowing all the answers on the phone, I find the answers in a
book called Medications and Mother’s Milk by Thomas Hale, Ph.D.
If you are planning on nursing for the long haul, or have a chronic
medical condition, it might be worth having this gem on your
bookshelf at home. (Find it at iBreastfeeding.com or 800-378-
1317.)
3 ENGORGEMENT.
Q. My breasts look like I have had implants and my
baby can’t get latched on. Help!
Welcome to engorgement. Don’t worry, this is only a two or three day
experience at most.
When your body first starts making milk, it sometimes gets carried away.
This also happens if your baby takes less volume or suddenly starts sleeping
through the night. Here are some ways to feel better:

1.Pump or manually express for a few minutes before getting baby

latched on. Your nipple will stand more upright, be soft, and
compressible.
2.Pump or manually express only to soften the breast. Pump off
after feedings only if your baby is unsuccessful in nursing.
Otherwise it can create an even greater supply of milk.
3.Wear a bra 24 hours a day for support. No underwires, ladies.
4.Take a hot shower and massage breasts to encourage let down.
5.Cabbage leaves. Yes, they can help. Try this: wear washed, chilled,
crushed cabbage leaves in your bra. Replace wilted leaves every
fifteen minutes for a total 45 minute experience, three times daily.
Reality check: your baby may refuse the breast due to the cabbage
flavor, so try to keep the cabbage away from your nipples.
6.Put a bag of frozen vegetables on your breasts for ten to 20 minutes
before nursing if your breasts are hard and not leaking. Some
women feel better using ice packs after nursing, too.
7.Encourage your baby to nurse at least ten minutes on each
breast. This is the time women usually get desperate and wake
their babies up to relieve their own discomfort.
8.Take some ibuprofen (Motrin). Yes, it’s safe to use while
breastfeeding. (Huggins)
4 NIPPLE PAIN.
Q. Ouch! My nipples hurt! Any suggestions?
There are several reasons why your nipples may hurt during or after
nursing. Solving this mystery, and fixing the problem will make
breastfeeding much more pleasant and enjoyable. And in turn, it will enable
you to successfully continue nursing!

Poor position. There are several positions that keep you and your baby
comfortable. If one is not working, try another one. See the
recommendations below and the graphics earlier in this chapter.

Poor latch. You should hear your baby swallowing/gulping. Clicking is

NOT a sound you should hear. Get your baby to open wide, with lips curled
out. Make sure his nose and chin are next to your breast. Don’t let go of
your breast until your baby is securely latched on. Poor latch leads to sore
nipples. If your nipple looks like a new tube of lipstick after nursing, you
have a problem (see picture). When your nipple returns from the lipstick
shape to the normal shape after a few minutes, you may see a bruised line
(called a compression stripe) down the center of your nipple. With
continued shallow latches, that bruise will turn into a more significant
injury, where the skin will start to split, bleed and scab. If all of this
describes your nipples, seek professional help, try different positions so that
the nipple isn’t always being injured in the same place, and start “moist
wound healing” to prevent scabbing (use lanolin and gel pads on your
nipples). Bottom line: cracks and open wounds are a dead giveaway for a
latch issue (ouch!)

Normal nipple
 Lipstick nipple

Houston, we have a nipple problem. Flat and inverted nipples pose a

challenge. The football hold may help get baby latched on. Stimulating
inverted nipples to stand out prior to nursing may help. Breast shells (see
Breastfeeding Lingo box earlier in this chapter) also help inverted nipples.
Lactation consultants are very helpful for this situation.

Mouth problem. Babies with tongue thrusting and tongue-tie can have
poor technique. See more about tongue-tie below. Babies who thrust their
tongues forward while nursing can be taught how to suck correctly (with a
lot of patience and professional help).

Tongue-tie. Sometimes a baby has a poor sucking technique because he

has a tongue-tie (ANKYLOGLOSSIA). This leads to cracked, painful nipples
in Mom and poor intake because baby has trouble compressing the nipple.
There are four types of tongue-tie. Two types (1 and 2) are usually
detected on the newborn exam because the tip of the tongue is forked and
the tongue cannot extend out. Type 3 (“anterior tongue tie”) is often missed
on exam because the tongue moves outward normally. For types 1, 2 and 3
experts agree that the tongue cannot reach the roof of the mouth, which is
an issue with breastfeeding as well as with speech later in life.
If you think this may be a problem, let your pediatrician know about it.
For an anterior tongue tie, the thin piece of tissue causing the problem can
be easily clipped before you leave the hospital or in an office setting in the
first couple of weeks of life. This procedure is called
a FRENULECTOMY. It takes just a minute or two to perform the
procedure and the improvement in latch is usually immediate.
So what is Type 4? Well, this is pretty controversial. Most pediatricians
and ear, nose, and throat experts think Type 4 does not exist. Some babies
just have very short tongues. Lactation consultants disagree. They feel that
some babies have Type 4, a “posterior tongue tie”, which limits tongue
mobility and interferes with nursing success. And yes, there are a handful of
practitioners (usually dentists) across the country, willing to perform a laser
procedure to cut into the muscle of the tongue in hopes of improving
suckling. The procedure is more involved and so is the recovery.
Consider using a nipple shield for your own protection until the tongue-
tie can be clipped. Getting the procedure done sooner rather than later
prevents your baby from developing bad sucking habits. If your lactation
consultant feels your baby has a posterior tongue tie, you’ll want to go over
the treatment options with your baby’s healthcare provider.
Factoid: Tongue-tie often runs in families.

FLAT AND INVERTED NIPPLES

When a woman gets physically cold, it’s normal for her nipples to
harden and stick out. If this doesn’t happen to you, you might have
flat or inverted nipples.
Flat nipples: Is your breast perfectly smooth? Try pinching the
pigmented area (AREOLA) just beneath the nipple to help your baby
find it. Avoid baby bottles and pacifiers in the beginning, as your
baby will prefer them since they are easier to latch on to.
Inverted nipples: Do you see an indentation in the center of your
nipple? Try pinching your nipple. Does it stick out or go in? If it goes
in, pull your nipple out before offering it to your baby. If it “hides,”
then you may want to wear nipple shells during your pregnancy. You
can also use a breast pump after you deliver to help bring out your
nipple. Nipple shields are useful if the baby can pull the nipple into
the shield.
 DR B’S OPINION: TONGUE TIES

For a posterior tongue tie, the risks of the procedure outweigh

the benefits. Some babies just have short tongues and will not be
able to successfully nurse at the breast. Thank goodness we have
bottles and breast pumps.

Q. My nipples are already cracked and it’s only my

second day of nursing! My nurse offered me some
nipple shields. Are these okay to use?
Yes, temporarily.
As we’ve discussed, a nipple shield is a piece of thin plastic that you
place on top of your nipple and surrounding tissue (AREOLA) while you
nurse. It has four holes that allow most of your breast milk to pass to your
baby. They can be a real lifesaver for you if your nipples/areolas are raw,
cracked, or bleeding because they keep your baby from being able to do any
more damage and give you some time to heal.
Another suggestion: Soothies by Lansinoh ($12-$17) are reusable gel
pads that provide a cooling sensation—a lifesaver for sore nipples!
Of course, these are only temporary solutions. The long-term goal is to
have good nursing technique so you don’t have repeated injuries!

Q. My nipples are really sore. What can I do to get

some relief?
Linda has several tips to help your nipples heal:
 Get out some shot glasses. While you might consider doing some tequila
shots to ease your pain, we have something else in mind. Place a
mixture of one teaspoon of Epsom salts to one cup water in the
glasses and soak your nipples in them twice daily for two to five
minutes.
Go topless. Let your nipples air dry for a few minutes twice a day. You
can also expose them to sunlight through a sunny window for
additional comfort.
Lube up. Before you nurse or pump, apply a tiny amount of pure lanolin
ointment or olive oil to the wound(s). The lubrication will protect the
tender skin from further insults.
Get rid of germs. After you nurse or pump, apply antibiotic cream—
either over the counter polysporin or prescription mupiricin
(Bactroban)—to the wound(s).
One word—Elastogel. These are basically bandaids for boobs. You can
buy these gel pads at your pharmacy. Place the gel pad over the
wounded area (and over the antibiotic cream if you are using it) after
you have nursed or pumped.
Pump it up (and out). If you are in complete agony, try pumping and
offering your milk through a bottle occasionally. But to maintain your
milk supply, you’ll need to pump each time your baby gets a bottle. If
you do bottle feed your nursing baby, keep the bottle in a horizontal
position so she has to work to get the milk like she does at the breast.

Linda’s Tip: Cracked Nipples. Your body can heal itself. Squeeze out
some breast milk and place it on your nipples after every feeding. And if
your nipples are painful from pumping, try putting some olive oil on them
beforehand.

5 NIPPLE BACTERIAL INFECTION. If your nipples are already cracked

and bleeding, you are at risk for getting a bacterial infection. If you notice
redness, draining pus, or golden crust, call your OB doc for a prescription
antibiotic cream.
6 PLUGGED DUCT. Equate this to a clogged pipe. The milk backs up and
causes a hard, lumpy, tender area. Massage these areas while you nurse. Use
moist heat before feedings and ice afterwards. Nurse or pump frequently (at
least every three hours). Beware of any redness on the skin or fever.
Plugged ducts are the precursor for a breast infection called mastitis (see
later in the chapter for more info).

Linda’s Tip: Try nursing your baby with his chin pointing to the plugged
duct—the suckling motion will massage the area and perhaps help unplug
the duct. You can also try using a homemade “castor oil pack.” Apply castor
oil to a clean dry cloth to make it saturated, but not dripping. Fold the cloth
to the size that will cover the plugged area. Apply plastic wrap over the
area, place a heating pad on low setting over the plastic wrap, and leave for
20 minutes. Repeat every 1-2 hours as needed. It is very helpful to nurse or
pump immediately after applying the castor oil pack. Just be sure to wash
the area thoroughly before nursing.

7 MASTITIS.
Q. So, what is mastitis?
A breast infection due to raw nipples and germs from your baby’s
mouth.
New mothers often have trouble with their baby’s latch initially, leading
to raw and cracked nipples. This lets baby’s mouth germs enter Mom’s
breast. Symptoms include fever, chills (like you have the flu),
pain/swelling/redness of the breast. Women are usually afflicted with this
one to four weeks after delivery.
Treatment requires antibiotics (you need to call your OB for this) and
continued elimination of breast milk from the breasts. Yes, you either need
to continue nursing or pumping through this unpleasant experience. Your
baby will not be harmed—it’s his germs that did this to you!
If you take antibiotics, we suggest you also take probiotics (also known
as acidophilus or lactobacillus). These are good germs (found naturally in
yogurt) that will help prevent you from getting a yeast infection on top of
everything else!

What causes mastitis?

1.Cracked nipples (mostly from poor latch technique)
2.Plugged milk ducts (from incomplete emptying at a feeding, tight
clothes)
3.Missed feedings (lack of nursing or pumping for several hours)
4.Stress and exhaustion
5.Rapid weaning (lack of nursing)

If you notice that you have a tender, painful area on your breast—do
something about it ASAP. Massage the area while you nurse or pump to
unclog the duct. Apply a warm compress to the area. Try the castor oil pack
as discussed earlier. Nurse or pump every two to three hours. And get some
sleep! (Lawrence) If your symptoms persist or worsen, call your OB.

8 YEAST OVERGROWTH/INFECTION
Q. My nipples are burning every time I nurse. Why?
This is likely to be a yeast infection.
Pediatricians try to stay out of Mom’s medical care, but parents often ask
their opinion. Yeast infections also come from your little one’s mouth.
Babies (who are toothless) have some bacteria in their mouths, but not
nearly as much as we do (because plaque goes along with teeth). Yeast likes
dark, warm, moist, low bacteria places. So, newborns often get yeast or
THRUSH infections in their mouths. It looks like curdled milk that can’t be
wiped off the gums, cheek lining, and roof of their mouth.
If your nipples burn or itch and you experience shooting pains every
time your baby nurses, check your baby’s mouth, and check with both your
obstetrician and pediatrician. A family practitioner should be able to handle
both of these problems.
 Your baby can get an antifungal mouthwash and you can get an
antifungal cream or oral medication.
There is evidence to show that the yeast clears more quickly if both
mother and baby are treated, even if only one party is showing symptoms of
infection. And some yeast infections get passed back and forth for what
seems like forever. If that is your situation, see below.

Linda’s Tips: Top 10 Tips to Beat Yeast

Wash hands with hot, soapy water and dry with paper towels before
and after nursing, toileting, and changing baby’s diaper.
Wash laundry in hottest water possible. Add a cup of white distilled
vinegar to final rinse.
If you have intercourse, use condoms to prevent cross-infection.
Sterilize all pacifiers, bottle nipples, pump flanges daily.
Do not freeze breast milk while being treated. But it is OK to nurse and
pump for daily use.
Change bra pads as soon as they become moist.
Wear a clean bra each day.
Eat yogurt/take probiotics daily.
Decrease your consumption of refined sugars. Increase your veggie
and garlic intake.
Wash nipples with a mixture of vinegar and water (1/4 cup vinegar to 1
cup water) after each feeding. Apply over-the-counter antifungal
cream (like clotrimazole) to your nipples afterwards. Gently wipe
off any excess prior to the next feeding.

Whew! That’s a lot of things that can go wrong! We sum up the Top 8
breastfeeding problems and solutions with the chart earlier in the chapter.

Breastfeeding Books
Among the best is The Nursing Mother’s Companion by Kathleen
Huggins, R.N. It will hold your hand and give you 25 different ways to
relieve engorgement. Also good: The Womanly Art of Breastfeeding by La
Leche League.

Expressing Milk
Q. Why do some women express their breast milk
(that is, pump)?
Many mothers pump to survive engorgement. You can pump off the
excess milk to get more comfortable and baby can have an easier time
getting latched on. For working moms, it’s essential to pump to maintain
breast milk supply. For stay-at-home moms, it allows you to escape your
house for a little while.

Q. How do I pump and store my milk?

Here’s what you need to know:
Wash your hands.
Clean all breast pump apparatus thoroughly.
Freshly pumped breast milk will last eight hours at room temperature
and 24 hours in a cooler with blue ice.
Use sterilized opaque plastic bottles (polypropylene) or
polyethylene disposable bags for collection of milk. See the Reality
Check below for a discussion of disposable bottle bags.
Fresh breast milk retains more of the antibodies and vitamins than
breast milk that has been frozen and then thawed/warmed. So limit
the amount of breast milk that is frozen and stored.
Remember to put a collection date on the bottles or bags! Use the
oldest milk first.
Yes, you can combine expressed milk from different pumping sessions
together in one container. Just keep it going for a full day, then
divide the milk up into individual servings.
 Start with three oz servings of milk to freeze. Store four to six oz
servings when your baby is three months old. Leave room in the
container; fluids expand when frozen.
Newly expressed breast milk can sit out at room temperature for up to
six to eight hours. So you can take freshly pumped milk with you
when you are out and about without keeping it on ice. (Human Milk
Banking Association of North America)

See the handy chart later in this section for details on how long expressed
milk can safely be refrigerated or frozen.

Reality Check
There is no perfect container in which to store breast milk. Plastic
disposable bottle bags are very convenient. You can pour the milk directly
into them and freeze. For use, immerse the bag in a bowl of warm water to
thaw it out. But many of those great antibodies in Mom’s milk stick to the
bags and don’t get to baby’s mouth. The bags are also more likely to spill or
tear.
Glass bottles are eco-friendly, but can potentially break.
Most lactation professionals prefer the soft polypropylene bottles
(frosted or colored plastic) for breast milk storage because the antibodies in
the breast milk won’t stick to these bottles as much—but know that some of
the rich fatty milk does get stuck. (Riordan)
Another reality check: Breast milk can be different colors (white, yellow,
blue, brown, black) and that’s okay. Once it is frozen, it can smell kind of
like soap. If it smells rancid, it has spoiled and needs to be tossed. If you
notice this rancid smell with freshly expressed milk, scald (not boil) your
freshly expressed milk, then quickly cool it and put it in the freezer. This
will prevent it from spoiling.

Q. How do I serve my expressed breast milk?

 Warmed and gently shaken. Some tips:

1.Thaw frozen milk in the refrigerator overnight.

2.Warm it up by placing the bottle into warm water.
3.Do not microwave it! It may lead to hot spots that can burn baby’s
mouth.
4.The milk will separate into water and fat. Mix the bottle up before
serving.
5.Once the milk has been thawed, it will last in the refrigerator for up to
24 hours.
6.Thawed (defrosted) milk is good for one hour at room temperature.

An unfinished (fresh, not defrosted) breast milk bottle can be placed

back in the refrigerator and used within four hours. It’s okay to reheat it.

To maintain the most nutritional value of expressed breast milk and offer
it safely, here is a chart with the optimal time frames for use. If a baby
drinks all breast milk from a bottle or if he is premature or immune
deficient, use milk within the “optimal” time frame. If your baby gets most
of his nutrition directly from the breast, then the longer time frame is
considered “acceptable”.
*Do not refreeze
(Source: Human Milk Banking Association of North America)

Reality Check
Good news: The Affordable Care Act requires insurance plans to cover the
costs of lactation services and breast pumps. Bad news: insurance
companies may have their own interpretation of these laws, only offering to
cover the cost of cheap, low-end breast pumps instead of higher quality
ones. Unfortunately, these low-end breast pumps don’t efficiently express
milk, making them virtually useless. Check with your insurer to get details
and read the fine print. At the very least, breast pumps and breastfeeding
supplies are currently tax deductible. Stay tuned for updates from the U.S.
Department of Health and Human Services at hrsa.gov/womensguidelines/.
Q. When can I introduce a bottle?
Ideally, introduce one bottle a day of expressed (pumped) breast milk at
two to four weeks of age. Why?
Dad gets involved.
Mom can go out to get her hair cut (remember you are nursing every 2-
3 hours).
Baby learns that food comes in different packages.

A common mistake is waiting until the end of maternity leave or when

you want a date with your spouse to try a bottle. Once a baby is in the
breast-only mode, he is less flexible about change.

DR B’S OPINION

“It is very healthy for your marriage to leave your

baby at home with a loving family member or
friend! I frequently prescribe this form of mental
health therapy to my families. Dinner or a movie
(you won’t have time for both) is much cheaper
than marital counseling.”

Linda’s Tip: Introducing a Bottle. Do paced bottle feedings. Keep the

bottle more horizontal, keeping the nipple half full of milk when you are
bottle feeding a breastfed baby. Using a “vented” bottle also helps. That
way, the baby has to actively remove milk from the bottle, just like at the
breast. Don’t let him chug it or he may not want to work at the breast. A
key tip: it is very important to maintain a bottle a day in your baby’s
routine, so that he doesn’t “forget” how to take a bottle. Many parents get
their babies to take a bottle but then don’t offer one for a couple of weeks.
Then, surprise, baby won’t accept a bottle anymore!

Q. My baby is refusing to take a bottle. Help!

Babies are smarter than you give them credit for. They can see and smell
Mom if she is anywhere in sight. Get out of the house and let someone else
feed your baby the bottle.
Babies have thirst and hunger drives. No matter how stubborn your baby
is, he will eventually accept a bottle of your breast milk if he is not given an
option.
This is not cruel or unusual punishment. It’s also a good excuse for you
to spend a day at the spa.

Considerations for Mom

Q. I have small breasts. Will I make enough milk?

Probably. Size doesn’t matter. It’s what’s inside that counts.
You should have enough milk if you have normal breast tissue (milk
ducts, nipples), make hormones that trigger milk production, and have
enough stimulation from your baby suckling or using a breast pump.

Q. I have very large breasts/nipples. Is this good for

nursing?
Sometimes yes, sometimes no.
If you have large, pendulous breasts, you may have more difficulty
getting your baby correctly latched. You may want to try the “football hold”
or lying on your side while nursing so you don’t have to hold up the weight
of your breast. Or, you can try a nursing pillow that supports both your
breast and your baby.
 If the entire dark pigmented area (AREOLA) including the nipple is so
large that your baby cannot latch on, you may need to pump until he and his
mouth get bigger.

Q. I’ve had a breast reduction. Will this be a problem?

Possibly.
Certain types of breast reduction surgery disrupt the milk duct super-
highway. This may mean you do not have enough milk to breastfeed
exclusively. You may not even make more than a drop or two at each
nursing session. In this scenario, formula feeding is the most reasonable
choice for your baby.
However, no one can predict whether you will be able to nurse or not
before you try. And even if you cannot nurse for the long haul, it’s great to
offer your first milk (COLOSTRUM) to your newborn. Work with a lactation
consultant to get help with your situation.

Q. I have implants. Can I still nurse?

Yes.
However, certain types of reconstructive surgery may interfere with your
ability to breastfeed exclusively. Get professional help from a lactation
consultant.

Q. I’ve heard I need to restrict my diet while I am

breastfeeding. Is this true?
Not really.
Human milk is remarkably uniform despite differences in women’s diets.
It is always a good idea to eat healthfully for both you and your baby,
though. There are actually very few restrictions. Here are the
recommendations, according to the Institute of Medicine:

1.Avoid diets that promise rapid weight loss.

 2.Eat a wide variety of foods including breads/grains, fruits, vegetables,
dairy products, meats or meat alternatives daily.
3.At least three servings of milk (dairy) products daily.* But see below
for details on milk protein allergies in babies.
4.Specifically eat Vitamin A rich foods: carrots, spinach, greens, sweet
potatoes, cantaloupe.
5.Drink water when you are thirsty.
6.Caffeine-containing products (cola, coffee) are suggested in
moderation (300mg or less per day). A standard 12 oz cup of
coffee has about 200mg of caffeine. The caffeine enters the breast
milk—so nurse first, and then have your coffee. Preterm babies and
newborns may metabolize caffeine at a slower pace and be a bit
more sensitive to it—so take that into consideration.
7.Avoid eating shark, swordfish, king mackerel, and tilefish because
they may contain high levels of methyl mercury which can
interfere with neurological development. (Suitor)
8.It’s okay to eat 12 ounces or less of shellfish, canned fish, small ocean
fish, or farm-raised fish (and less than six ounces of canned tuna)
per week. (Suitor)

*If you drink cow’s milk or eat dairy products, some of the cow milk
protein ends up in your human breast milk. And some babies who are
sensitive to this protein end up extremely gassy and fussy. Babies with true
milk protein allergies who are consistently exposed to cow’s milk protein
end up having blood-streaked or mucousy/stringy poop, or diarrhea. Hint: if
your baby’s poop looks like snot, let your doctor know.
If your baby has a true milk protein allergy, you’ll have to cut out ALL
milk and dairy products from your diet (more on this below). If your baby
just seems sensitive, you can try eating dairy products that have been
cooked or fermented (yogurt, cheese) and avoiding milk for the first six
months of breastfeeding. Why? Milk contains unprocessed cow milk
protein, which seems to be more problematic for allergic babies than protein
that’s been processed in other dairy products.
For more details on food allergies in general, flip over to the section on
food allergies in Chapter 7, Solids.
Feedback from the Real World: “I Give Up”
One of our readers sent us a note, in desperation, regarding her baby’s
problems. The mom had been exclusively breastfeeding her baby. She
wrote, “it breaks my heart to hear her scream all the time . . . to have your
child be so obviously unhappy and/or in pain all the time is the worst
feeling in the world . . . I think it’s time for me to give up (breastfeeding)
because nothing else I’ve tried seems to work.” A milk protein allergy was
ultimately diagnosed.
Our response: You are not alone. Babies who suffer from this problem
leave both baby and parents in misery. But do not fear—your child will not
be like this forever. Some babies outgrow this problem by six months of
age, and over 80% outgrow it by age five. Babies who are breastfed and
have a milk protein allergy can still have problems because mom’s
milk/dairy intake can end up in the breast milk. If you want to continue
breastfeeding, you need to avoid ALL products containing milk or dairy.
There are often hidden dairy sources, so it’s not only the obvious dairy
products you need to avoid. Check out the web site FoodAllergy.org for
more information.
When your doctor gives you the green light to reintroduce dairy into
your diet how will you accomplish this? After all, you don’t want to start
drinking a half-gallon of milk a day with extra-cheese pizzas and such. Here
is a reasonable approach to introducing dairy gradually:
Step 1: Start with small amounts of hard cheeses (cheddar, Swiss) or
yogurt for the first week.
Step 2: If baby does well, try soft cheeses (gouda, cottage, cream,
American) for week two.
Step 3: If baby does well, try butter, ice cream, and cooked dairy
products for week three.
Step 4: If baby does well, have a glass of milk.

Of course, if your baby shows allergy symptoms again, it’s back to the
dairy free diet for you.
Old Wives Tale
You need to drink excessive amounts of water when you are nursing.
The Truth: Your body will increase its thirst drive to accommodate for
your fluid needs. You don’t need to go overboard.
FYI: Your daily caloric needs will be higher if you are breastfeeding.
The average recommended daily allowance for non-pregnant women is
2100 calories. With breastfeeding, the recommendation is 2700 calories.
(Lawrence) Don’t bother counting calories, though, unless you are losing
too much weight or having a problem producing enough milk.

Old Wives Tale

You need to avoid gassy foods like beans because they will make the
baby gassy.
The truth: You may want to avoid gassy foods because other people
might not want to be around you. Your baby is unaffected by this food
choice.

Q. Is there any truth that some foods in my diet will

make my baby fussy?
Yes, but there is no reason to restrict your diet unless you identify a
problem. Foods that might cause a problem: cabbage, turnips, broccoli,
rhubarb, apricots, prunes, melons, and peaches. (Lawrence)

Linda’s Tip: Funky food, fussy baby? Is your baby fussy because of
something you ate before nursing? Remember it takes anywhere from four
to 24 hours to notice the effect. So if your baby is acting unusually fussy,
think about what you ate in the past day. Since the oils from the foods you
eat transfer into breast milk, your baby may not like the “taste” of
something you ate.

Factoid: If you are nursing, don’t smoke. (We don’t recommend it for
formula-fed babies either, by the way). Besides the health reasons, you
won’t get much sleep. Nicotine passes into breast milk and nicotine exposed
babies sleep about 30% less than their non-exposed friends. If you want
more sleep, quit smoking! That’s just one of the many good reasons to kick
the habit.

Q. Should I take DHA (Omega 3 fatty acids)

supplements while I am nursing?
Yes. DHA is an essential fatty acid found in fish oils. DHA is found in
breast milk, but the amount varies depending on the nursing mother’s diet.
DHA is known to promote brain and vision development in infants.
Because the FDA has issued warnings about limiting fish consumption
(tuna, mackerel, shark, swordfish, tilefish), nursing moms may be getting
less fish oil in their diet. The American Academy of Pediatrics currently
recommends that nursing moms take 200—300 mg a day of DHA
supplements.

Q. Can I eat sushi while I am nursing?

Yes. Just be aware that consumption of raw fish (whether you are
nursing or not) carries a slight risk of food-borne infection. And the FDA
recommends that you eat less than 6 oz a week of tuna. So, order less toro
and more unagi.

Q. Can I eat peanuts and peanut butter while I am

nursing?
Yes! With the increase in people with peanut allergies, there has been
quite a bit of research on this subject. A landmark study in the New England
Journal of Medicine (NEJM) looked at the diets of breastfeeding women
and later development of food allergies in infants. The results: there was no
association or prevention of peanut allergy even if mom avoided these
foods in her diet. And more recent studies have found the same results.
(Sicherer)

Q. Can I drink any alcoholic beverages while I am

nursing?
Yes, in limited amounts.
Alcohol enters the bloodstream and the breast milk anywhere from 30-90
minutes after ingestion. The levels in the milk drop quickly. Each
individual’s metabolism is slightly different. So, a good rule of thumb is to
avoid nursing for at least two hours after drinking. And don’t nurse if you
feel tipsy!
I’d suggest you limit your intake to one alcoholic beverage, sporadically,
if you are nursing.

Old Wives Tale

Drinking alcohol improves your milk supply.
The truth: Drinking alcohol may help relax an over-stressed mother, but
it does not improve breast milk volumes or let-down reflexes.

Q. Are there any medications to avoid while I am

nursing?
Yes, lots of them.
The short answer to this question is, always inform your doctor that you
are breastfeeding. That way, a medication choice for you can be made
safely. You can always call your child’s doctor, or your pharmacist to
double check.
 See Appendix A, “Medications” for more information.

Q. I love exercising. Any problems with that while I

am breastfeeding?
If you exercise vigorously then nurse, your milk may have a sour taste
that your baby may not like. Exercise produces lactic acid in your body,
which goes into your breast milk. It’s not harmful, it just tastes funny. There
have also been anecdotal reports of infant fussiness up to six hours after
Mom’s exercise/nursing session. Here are some suggestions:
Pump or express for a minute or two before nursing.
If your baby gives you a strange look, use some stored breast milk for
that feeding!

Reality Check
While we are on the subject of sour tasting milk . . . your breast milk
may change flavors during your period (if you have one). And it may not be
a flavor your baby likes, according to lactation expert Dr. Ruth Lawrence.

Q. I am going back to work after my maternity leave.

How am I going to make this breastfeeding thing
work?
Setting aside time, having a progressive workplace, and being
committed.
Some women are able to go back to work AND provide breast milk to
feed their babies. It may take some trial and error to figure out what works
for you, but here are some ideas.
 1.Leave for work a little early and pump BEFORE you start working.
Or, nurse before childcare/work.
2.Invest in a high-powered, double pump. You can successfully pump
in 15 minutes with one of these models.
3.Let your boss/co-workers know of your intentions. You may be
surprised at how understanding people are.
4.Think about where you will be able to pump and how often.
5.Think about where you will store your expressed milk until you get
home. It can sit in a cooler with ice packs if you don’t have access
to a refrigerator.
6.Start stockpiling expressed milk BEFORE maternity leave is over.
See “Linda’s tip” regarding stockpiling earlier in this chapter.
7.Be prepared for being exhausted the first few weeks. It does get
better.

If you don’t have enough breast milk for the whole time you are away,
supplementing with formula is okay. Your baby will benefit from any milk
you can provide. Every ounce counts!

Reality Check
The percentage of fat, protein, and sugar in breast milk not only varies
from the beginning let down (foremilk) to the latter part (hindmilk) of the
nursing session, but also in the time of day. If you notice your baby seems
more satisfied with your evening nursing sessions more than morning ones,
it may be because your breast milk has more fat in it during that time of
day!

Q. I have a fever, can I still nurse?

Absolutely!
 Your body is producing antibodies to whatever infection your body is
fighting. Those antibodies are going directly to your baby. If you have a
cold or upper respiratory infection, not breathing on your baby would be
helpful!
Contact your doctor (obstetrician, preferably) if you have a fever shortly
after the birth of your baby. You could have a bladder infection, womb
infection, or mastitis.

Special situations

Q. I am adopting a baby. I have heard that I can take

a medicine to stimulate my milk supply. Is this true?
Yes. There is a medication called metoclopramide (the brand name is
Reglan) that helps some women produce milk. This is also used for women
who have trouble producing enough milk for their babies. While there are
natural remedies to stimulate milk production, there is no scientific data on
how effective these are. A good web source for info on this topic is
AskLenore.info.

Q. I am unable to breastfeed, but I want my baby to

receive breast milk. Can I buy breast milk?
Yes. There are several programs across the country called Mother’s Milk
Banks that sell breast milk, primarily to ill, premature babies. The donors
are rigorously tested to be certain they are free of infectious diseases like
Hepatitis B and HIV. And the breast milk is pasteurized. If a bank has
excess supply, they will sell it to healthy newborns. It’s quite pricey ($4.25
per oz). Check with your area hospital’s lactation services or visit the
Human Milk Banking Association of North America’s website at
hmbana.org.
On the flip side, if you have more milk than your freezer can handle,
consider making a donation!
Reality Check
Certified milk banks check donors and their milk rigorously for infection
before the milk is sold. It is becoming trendy for moms to purchase breast
milk from neighbors, friends, and even wet nurses via the Internet. Let the
buyer beware—this is probably not the safest idea for your baby.

Q. I have twins and want to breastfeed. How do I

make it work?
The key is getting both babies fed at the same time. Otherwise, it will be
a challenge to get any sleep. Start this routine from day one and you will
have more success.
When it comes to multiples, you will do a little more scheduling and a
little less feeding “on demand.” If you are able to get some hired or
volunteered help around the house, things may be less chaotic for you.
The football hold and/or the cradle hold work well for simultaneous
feeding sessions. It’s probably wise not to have one breast exclusively
designated for one baby. That way, they will accept either breast in the long
run. And, just in case one breast produces more milk than the other, one
baby won’t get short-changed.

Q. I have a baby who was born prematurely. Anything

special I need to know about breastfeeding?
Yes—it’s even more important to breastfeed these little ones. Here are
some special considerations:

1.Many premature babies get tired easily while nursing. If you no

longer hear your baby swallowing, take him off the breast and burp
him. Then return to feeding.
2.Many premature babies have poor technique (sucking, latching). Get
professional help (from a lactation consultant) if you are having
trouble.
3.You may be supplementing with formula or expressed breast milk for
a while. Don’t give up.
4.Rent a hospital grade pump for the first month because you will need
to pump eight times daily to protect your milk supply until your
baby is feeding well at the breast. A rental pump is the fastest,
easiest option when pumping this often.
5.Weigh your baby once or twice weekly to make sure he is gaining,
ideally, an ounce a day. Eventually you can stop doing this—check
with your doctor. You can usually stop the weekly weight checks
when you reach your baby’s actual due date.
6.The football hold works well for little preemies. That way you have
better control of positioning and latch.
7.Give baby skin to skin time. This stimulates your milk production
(and promotes bonding!)
8.Most babies born 37 weeks gestation or younger do better at the
breast with a nipple shield, as this helps stimulate their sucking
reflex.
9.Because it is often difficult to tell if your baby is actually eating at the
breast versus pacifying, it is helpful to do the following:

Limit breastfeeding to about ten minutes per side in the beginning

weeks when your baby is falling asleep at the breast.
Pump for ten minutes after all daytime feedings and at least once
during the night
Supplement the baby with 15-30 ml (1/2 to 1 ounce) of expressed
breast milk after breastfeeding to guarantee he is getting
enough calories.
10.When you are supplementing, you may notice that your baby is
getting lazier at the breast in anticipation of taking the easier bottle.
If that is the case, then supplement BEFORE offering the breast.
 As your premature baby gets closer to his real due date, he will have
more energy and be able to stay awake longer. At that point, you can start
experimenting with getting him off of the nipple shield and taking away the
supplemental feedings and pumpings.

Q. My baby was born at 35 1/2 weeks gestation.

Should I treat him like a full-term baby when it comes
to breastfeeding?
No. You have a “late preterm infant” who may have more difficulty with
nursing because he may not have the skills or the energy to suck effectively.
Here are some specific tips to make breastfeeding successful:
Aim for at least eight feedings a day.
Wake your baby up if: he doesn’t wake on his own, it has been more
than three hours between feedings during the day, or four hours at
night until he reaches his real due date.
Feeding time should be 40 minutes, tops. After that, your baby will be
exhausted.
Use a nipple shield if your baby has a poor latch—most late preterm
infants do!
Use a “supplemental nursing system” to offer expressed milk or
formula while your baby is at your breast. You can use a tube with a
bottle reservoir that attaches to either your nipple or your finger.
Offer 5-10 ml (1-2 tsp) per feed on Day 1, 10-20 ml (1/2 oz) per
feed on Day 2, and 20-30 ml (up to one oz) per feed on Day 3. The
nurses or lactation consultant at the hospital can show you how to
use these supplemental nursing systems.
Pump after each feeding to stimulate your milk production, because
your newborn won’t.
Have a lactation consultant check to make sure your milk is
successfully being transferred to your baby when he is at the breast.

Don’t be discouraged. Do weight checks every week until your baby

reaches his actual due date.
Reality Check
American Red Cross makes an infant scale that is accurate, user friendly,
and moderately priced at Walmart or Amazon.com for about $50. Here is
one, for example: http://j.mp/scaleredcross

Q. I have a baby with acid reflux (GERD). Is there

anything differently I should do when I am nursing?
We’ll tackle gastroesophageal reflux (GERD) in depth in Chapter 8, The
Other End. But yes, nursing a reflux baby presents special challenges.
First problem: Positioning. Reflux babies do better when they are more
upright with feedings. Unless you are a Cirque de Soleil performer, it’s
physically impossible to nurse your baby upright. However, if you keep him
at a 45-degree angle with his bottom down more towards your lap, he may
fare better. Also, avoid the side-lying position.
Next problem: what do you do when you’ve just completed a nursing
session, your baby spits it all back at you, and then wants to eat again? You
won’t have much milk left at your breast to offer. But you can still put him
back to the breast. Why? Breast milk is made as your baby sucks. And that
richer, heavier hindmilk he’s drinking is more likely to stay down.
If that doesn’t work, you may have to offer a bottle stashed away in your
freezer. Breastfeeding moms quickly realize they need to have a stash of
expressed milk, just in case the entire feeding comes back up.
Other breastfeeding moms offer expressed milk in a bottle (instead of
direct nursing at the breast) for one or more feedings. This enables you to
feed your baby in an upright position as well as to thicken up your breast
milk. (Thicker, heavier milk may be beneficial in keeping the milk down in
the stomach where it belongs.) One idea: it’s okay to add rice cereal to your
expressed milk, but it loses its thickness quickly. Why? Live enzymes in
breast milk will break the cereal down before your baby has a chance to to
finish drinking it.
 Here are the take-home tips for nursing a baby with acid reflux:
Read your baby’s cues and adjust his feedings accordingly.
Burp him more frequently.
Don’t sit him up to burp—that creates too much pressure on his
tummy.
Let him rest between breasts.
Keep him upright for 30 minutes after feedings.
Make sure your “let down” of milk isn’t too fast, causing him to gulp
down a lot of air as he nurses.

Weaning

Q. When should I wean my baby off of breast milk?

When one or both of you is ready.
The American Academy of Pediatrics recommends breastfeeding for at
least a year, with the addition of “complementary” solid food by six
months. Hopefully, both you and your baby will enjoy nursing for at least
that long. Some nursing teams (mother and baby) opt to continue even after
one year.
So, the right time to wean is when one or both of you thinks it is time to
stop. That time may be when your baby refuses the breast, when you decide
you want your body to yourself, or when your ten-year-old asks for your
breast by name. It is really a personal decision.

Reality Check
Americans tend to nurse their babies for less time than many other
cultures. In some cultures, women nurse one child until the next one arrives.
These same women have lower rates of breast cancer. Food for thought.
Q. I am planning to wean my baby. How do I do it?
Slowly and methodically.
If you stop breastfeeding abruptly, your body will be unhappy with you.
Milk ducts get clogged (and infected). With that said, here is a typical
strategy:

1.Create a timetable for the projected target date of nursing completion.

2.Eliminate one nursing session every 3-4 days, 2-3 weeks before your
target date. The length of time for the entire weaning process
depends on how many times a day you are currently nursing.
3.If you are weaning prior to one year of age, replace that feeding with
either previously expressed breast milk or formula.
4.Eliminate the first morning and last evening feeding at the end of the
weaning process.
5.Once you have completely stopped nursing, you may continue to leak
milk for a week or two.
6.Wear an old bra (non-nursing), even though it is a little binding.
7.If your breasts feel so full that they are going to explode, pump or
manually express just enough milk to get comfortable.
8.Taking pseudoephedrine (Sudafed) during the day, diphenhydramine
(Benadryl) at night, and/or drinking three cups/day of sage tea may
also help.

Q. I want to continue breastfeeding, but my nine-

month old seems to be weaning himself. Is that okay?
Yes, but you may gently encourage him to continue. Babies go on strike
(from formula or bottles, too) for various reasons.
Some babies get distracted during feeding sessions when they realize
the world is pretty interesting. Nurse in a boring, dark, quiet place.
Or nurse while he is sleeping.
Some babies don’t want to suck if they are teething. Try using
acetaminophen to relieve teething discomfort.
 Ear infections and nasal congestion can also discourage a baby from
nursing. Check in with your doctor.

If none of the advice above helps, transition to formula in a bottle or a

cup (depending on your baby’s age and skills). Transition to whole milk if
your baby is over a year of age. (Lawrence)

Linda’s tip: You will need to protect your milk supply during this time of
breast refusal by pumping and offering your milk in a bottle or cup. Try to
get your baby back to the breast by offering it when she is asleep or drowsy.
Don’t let the breast become a battleground. These strikes can last up to a
week sometimes. Be patient. Skin-to-skin time in the bathtub together can
often work wonders!

Q. If I stop breastfeeding before my baby is one year

old, what do I offer him instead?
Commercial-brand formula is the acceptable substitute for breast milk in
the first year of life.
Note: cow’s milk, soymilk, goat’s milk, and rice milk are NOT
substitutes for breast milk in the first year of life.

The Big Picture: Breastfeeding for the First Year

Okay, let’s sum up this breastfeeding section with an overview of

nursing for your baby’s first year:

Birth to 2 weeks: (15-24 ounces/day)

Breastfed newborns tend to eat every two or three hours. That adds up to
eight to 12 times in a 24-hour day. They may cluster feed as frequently as
every 1 1/2 hours (that’s from the beginning of one feeding to the beginning
of the next). If you are expressing breast milk and feeding via a bottle, your
baby will probably take two or three ounces at a feeding.
Babies who try to nurse more frequently than every 90 minutes are
usually nursing for comfort.
 Babies have no other way of consoling themselves. They can’t just pull
it together and settle down. Sucking is extremely soothing. So, if it has been
less than 90 minutes since the beginning of the last feeding, try using your
finger to let him suck. Your breasts will thank you. Note: If your baby is
truly nursing non-stop, have your baby weighed to ensure proper weight
gain. Make sure you have enough milk supply.
On the flip side, your baby may take a four-hour stretch before feeding
again. In the first two weeks of life, do not let your baby go more than four
hours without feeding. Why?
Breast milk is a supply and demand phenomenon. To get your supply
established, the demand must be there.
Your breasts will feel like they are going to explode. If that four-hour
stretch is during daylight hours, you are in for a long night of cluster
feedings.

2 weeks to 2 months: (17-32 ounces/day)

Once your baby is two weeks old, you can relax a bit. Your milk supply
will be better established and your baby will have regained his birth weight.
If he sleeps through the night, let him! You may need to pump to get
comfortable during the night, but don’t wake a sleeping baby. By the way,
this is unlikely to happen. If it does, don’t tell your friends about it. They
will hate you.
This feeding “pattern” goes on for at least the first two months of life.
While this seems a bit erratic, it is normal for a newborn to be irregular with
her feeding (and sleep patterns).

2 to 4 months: (21-40 ounces/day)

Your baby will start to have some regularity! He will have more
predictable wakeful periods and sleep periods. Hopefully, you will be down
to one or two night feedings. If you are returning to work and pumping,
plan on four ounces per feeding at two months of age and up to eight
ounces per feeding at four months. Babies usually max out at 40 oz per day
at four months of age.

4 to 6 months: (25-40 ounces/day)

 You can look forward to five or six breast feedings a day. You should be
able to get an evening stretch of six hours without nursing. Six hours is
considered “sleeping through the night”, although this is probably not your
definition.
You may begin offering complementary solid food between 4-6 months
of age. While there are some differing opinions, the American Academy of
Pediatrics recommends your exclusively breastfed baby receive an iron
supplement from 4-6 months if you wait to offer infant iron-fortified cereal
until six months of age.
Initially, solid food is dessert. Your baby needs the same volume of
breast milk until he takes large volumes of solid foods.

6 to 9 months: (28-36 ounces/day)

Your baby will nurse four or five times per day. You should be done with
night feedings. If you are not, do some problem solving with your doctor.
You may enjoy those cuddly moments nursing in the middle of the night,
but these are not a necessity. Your baby is comforted and used to feeding at
night. Frequently, so is Mommy. If both of you are enjoying this situation,
keep doing it. If one of you (Mom) is not enjoying it and wants more sleep,
read Chapter 9, Sleep.
Solid foods should be in full swing at this point (see the next chapter on
solid nutrition). You’ll probably see your baby eat more and drink less
between 7-9 months of age.

9 to 12 months: (20-30 ounces/day)

Babies are well into solid foods and start to wean—that is, their volume
and frequency of nursing decline. Your baby may nurse three or four times
per day.
By one year of age, babies wean to 16 to 24 oz per day. At this point,
you deserve a gold medal of honor. If you and baby are ready, you can stop
breastfeeding.
We recommend switching to whole or 2% milk with Vitamin D added at
one year of age. The goal is two cups of milk per day (or dairy serving
equivalents). Remember, breast milk is low in Vitamin D and iron. So, if
you want to go beyond a year of nursing, find other nutritional sources for
these nutrients.
 Now that you’ve learned all you wanted to know about breastfeeding,
let’s talk about formula.

Formula

Q. Is it okay to feed formula to my newborn?

Yes.
Although it is wonderful to breastfeed, it is also acceptable to feed your
baby infant formula for the first year of life. Here are the key advantages to
formula:
It’s about as close as it gets to human milk. Formulas are specially
prepared to contain the appropriate amount of fat, protein,
carbohydrates, and other nutrients that growing babies need.
It’s convenient. You can take a formula bottle anywhere you go. Just
keep it cool and then find a place to warm it when it is time to use.
(It’s less convenient at 2am when your baby is screaming while you
frantically have to warm up a bottle.)
It isn’t mom-dependent. Yes, any willing and able-bodied person can
feed a baby a bottle of formula anytime during the day or night.
There are options. While not all babies can tolerate cow’s milk-based
formula, there are several alternatives for babies with food allergies.
But formula is also very expensive. Expect to pay $550+ for a year if
your baby tolerates the least expensive cow’s milk based powered
formula (that’s a generic brand formula bought in bulk from a
warehouse club). Name brand powered formula is about $1200 a
year. Hypoallergenic formula could run $2000 to $6000 or more.
 DR B’S OPINION

“Although we encourage you to breastfeed your

baby for obvious benefits, your baby will be fine if
he is formula fed.”

Q. I have chosen to feed my baby formula. What

formula do you recommend?
The cheapest cow’s milk based formula with iron you can find. Get a
warehouse club membership now, if you don’t have one already. In general,
the cheapest formula is the generic or store brand sold at discount stores
like Wal-Mart, Target, Costco or Sam’s Club. Buy in bulk (the bigger the
container, the better) to get the maximum savings.
Here is an overview of these products. Dr. Lewis First, Chief of
Pediatrics at the University of Vermont, deserves credit for the explanations
below. He classifies formula into three categories: Coke, Diet Coke, and
Caffeine Free Diet Coke. We’ll also provide you the brand names for each
type in the following list:

Coke = Cow’s Milk Based Formula with iron. This is the formula
tolerated by most babies and recommended first by most doctors.
Name brands include: Enfamil Premium (Newborn and Infant), Similac
Advance, Gerber Good Start (Gentle), Earth’s Best. There are also generic
or store brand cow’s milk formulas found at Wal-Mart, Target, and your
grocery store.

Diet Coke = Soy Protein Formula with iron. Some doctors recommend
soy protein formula for babies who seem intolerant to cow’s milk formula.
(Note: this intolerance is NOT an allergy to milk protein, which is
addressed with the formula type discussed next). “Intolerance” is a vague
term for extremely gassy babies, or those who throw up more formula than
they keep down. About 25% of American babies are fed soy formula. Soy
formula is also an option for parents looking for a vegetarian-based
alternative to cow’s milk-based formula.
Name brands include: Enfamil Prosobee, Similac Soy Isomil, Gerber
Good Start Soy. As you might guess, there are also generic/store brand soy
formulas sold at Target and Wal-Mart as well.

Caffeine Free Diet Coke = Extensively hydrolyzed casein protein

formula with iron. The Dom Perignon of formulas, these are for babies with
a MILK PROTEIN ALLERGY, not merely an intolerance to regular milk-
based formula. Babies who are allergic to cow’s milk protein have diarrhea
with blood and/or mucous in their poop. Occasionally, babies with milk
protein allergy also have a soy protein allergy. Some babies need this
formula for the entire first year—but, based on a family history of food
allergies and the severity of the baby’s reaction to milk protein, your doctor
may attempt a trial of soy formula before one year.
Name brands include: Enfamil Nutramigen, Similac Alimentum.

FYI: Babies with the most severe cow’s milk protein allergy may not
even tolerate the hydrolyzed casein protein formulas. They need amino
acid-based formulas that are completely milk protein free and of course,
even more expensive! Name brands include Neocate Infant, Elecare infant,
or Enfamil Puramino. (All are sold online or can be special ordered.)

Special formulas are expensive. Some insurance companies will partially

cover the cost for “medical foods,” so be sure to inquire about it.

DR B’S OPINION

“If you think Coke and Pepsi have an intense

rivalry, check out the competition between
formula companies. Despite the hype and spin,
the products are basically equivalent in each
category.”

Helpful Hint
Do not switch formulas without asking your doctor. Most babies who are
gassy and fussy will be gassy and fussy for the first three months of life no
matter what they are eating.

BOTTOM LINE
 All marketed formulas are tested extensively and required by law (Infant
Formula Act 1986) to contain minimum levels of 29 different nutrients.

WHAT ARE DHA AND ARA? LIPIDS?

DHA stands for Docosahexaenoic Acid. ARA stands for

Arachidonic Acid. DHA and ARA are also called “lipids.” Walk into
your grocery store and you’ll see lots of formula cans hyping their
added lipids. So, what is this stuff? Lipids (DHA/ARA) are
polyunsaturated fats that occur naturally in breast milk. They are also
found in fish oils, egg yolks, and algae/fungal oil.
There has been a fair amount of research done on these fatty acids
because they are present in nerve tissue and the eyes. Some studies
show improved vision and scoring on infant developmental testing
when babies have DHA and ARA in their diets. (Chandran)
Both the major brand-name formulas and generic versions have
lipids. That’s a good thing because a baby’s formula should be as
close to breast milk as possible.

Soy Formula
Considering soy formula? The American Academy of Pediatrics (AAP)
recommends soy formula for the following reasons:
Full term babies who are not breastfeeding and whose parents want a
vegetarian alternative to cow’s milk-based formula. Soy formula is
considered a safe alternative.
Full term babies with galactosemia or hereditary lactase deficiency.
Full term babies with documented (diagnosed) transient lactase
deficiency.
Babies with documented (diagnosed) IgE-mediated allergy to cow’s
milk.

The AAP does NOT recommend soy formula for:

Preterm infants with birth weights less than 1800g (4 lbs).
 Prevention of colic or allergy.
Infants with cow’s milk protein-induced enterocolitis/enteropathy (i.e.
food allergy causing blood in stool). (AAP Committee on Nutrition)

Q. I am primarily breastfeeding, but will need to

supplement with formula once I return to work. Any
advantage to buying the formulas especially designed
“for supplementation”?
In our opinion, no. Enfamil first came up with this idea and competitors
Similac and Gerber soon followed with formula “designed for
supplementation.”
There are very few, if any, differences between the product specifically
labeled for supplementation and the standard cow’s milk infant formula
made by the same manufacturer.
For instance, Enfamil has three different formulas (or at least three
different names for formulas) designed for newborns—Enfamil Newborn,
Enfamil Infant, and Enfamil for Supplementation. Both the Enfamil
Newborn and Enfamil Supplementation formulas contain slightly higher
amounts of Vitamin D (400 IU in 27 oz of formula) compared to the
Enfamil Infant (400 IU in 32 oz of formula). The Enfamil Infant and
Enfamil Supplementation formulas have the same milk protein ratios (see
more on this below) as breast milk. The Enfamil Newborn formula has a
slightly different ratio. That’s it. Three different labels, but they are pretty
much the same product.
So, we would suggest using the regular infant formula and calling it a
day.

Q. What are “comfort proteins” and “gentle

formulas”? Should I believe claims that some formulas
are easier to digest?
The cynic in us says: beware of marketing ploys! But there are some
minor differences among formula brands. The Infant Formula Act requires
a standard AMOUNT of protein in formula, but the TYPE of protein (the
whey to casein ratio) can vary a great deal. Whey and casein are two types
of protein found in milk. (Whey is acid soluble, casein is not).
Human milk has a whey to casein ratio of 60:40. Cow’s milk has a ratio
of 18:82. Because of the casein, cow’s milk is much harder for a human
baby to digest. Cow’s milk based formula makers alter the ratios so the
product is more easily digested. Most Enfamil and generic products have a
60:40 ratio. Similac has a 48:52 ratio. The entire Gerber Good Start product
line is 100% whey, and the whey is pre-digested (partially hydrolyzed).
Enfamil’s “Gentlease” and Wal-Mart’s Parent’s Choice “Gentle”
formulas contain partially digested whey protein in the 60:40 ratio with
reduced levels of lactose (milk sugar). Similac Total Comfort also touts
partially broken down milk protein for easier digestion.
Do any of these formulas actually make babies happier? If you have a
baby who tends to have more solid stools and seems to struggle with
pooping, it is worth giving these formulas a try.

DIFFERENCES BETWEEN BREAST MILK & FORMULA

To understand the differences, you need a brief chemistry lesson

here. Milk contains fat, protein, and sugar. Use the following table as
a reference:
Special notes:
1. Human milk has lactose sugar.
2. Soy formulas replace cow protein with soy protein and are lactose
free.
3. Protein Hydrolysate formulas are hypoallergenic because the
protein is pre-digested.
4. All formulas in the table contain the recommended daily iron
requirement for babies. Avoid low-iron versions of formula unless
specifically directed by your doctor.
5. Note that 50% of the calorie intake comes from fat.
6. All formula companies have added very long chain
polyunsaturated fatty acid derivatives of Omega-3 and Omega-6
(DHA and ARA). These are present in breast milk and some studies
suggest they promote vision/brain development. (For more on this
topic, see DHA nearby).
 Q. So which is better, cow’s milk formula or soy
formula?
The consensus here: cow’s milk. Why? Cow’s milk-based formula is a
better source of protein than soy, according to research studies. But neither
is without controversy . . . see Chapter 15, The Environment and Your Baby
for details.

Q. I have seen other formulas on the shelf at the

grocery store. What are they used for?
These would be classified as the “gourmet formulas.” Most are made for
babies with particular problems. A few are made as optional products,
which are not based on a medical necessity. See the following section for
more on gourmet formulas.

The Gourmet Formulas

1. Lactose Free Formula
Lactose intolerance occurs in older children and adults. Babies are rarely
born with this problem. Lactose intolerance can occur temporarily after an
infant has a stomach virus. Some stomach viruses break down the human
enzyme “lactase” which digests the lactose sugar, creating a temporary
intolerance. This can go on for one to six weeks after the virus.
When babies are allergic to formula, it is usually the milk protein that is
the problem, as it is the most allergenic part of the food. It is rare for a baby
to have a problem with the milk sugar (lactose). Human milk has lactose in
it and it is perfect nutrition.

FORMULA FOR PREEMIES

There are higher-calorie formulas made especially for babies who

are born before 34 weeks gestation or less than four pounds. These
formulas have more calories, more protein, more calcium, and more
 phosphorous than standard formulas. Some babies will switch to
standard formula, but the premature formulas can be used for a whole
year if necessary for growth. (AAP Committee on Nutrition)

2. Similac Expert Care for Diarrhea

This delicacy is made for babies who are experiencing a stomach virus.
Not only has the lactose sugar and cow’s milk protein been removed, but 6
grams of fiber are added per liter of formula. You’re thinking, why give
fiber to a child with the runs? Believe it or not, fiber actually bulks up
watery stools. This formula can be used for the duration of a stomach bug to
cut down on the water loss that occurs with intestinal infections.

3. Enfamil NEWBORN
Enfamil “NEWBORN” is the same product as the Enfamil “Infant”
formula except it has a higher amount of Vitamin D per serving. By using
this special newborn formula, a baby gets the appropriate daily dose of 400
IU of Vitamin D by drinking just 27 oz/day. Babies need to drink at least 32
oz/day of the standard Enfamil Infant formula (or any other brand of infant
formula) to get the adequate amount of Vitamin D.
Note: even with this higher Vitamin D formula, your baby will still need
a Vitamin D supplement until about three months of age.
So, here are your options: either buy this special newborn formula (and
the company hooks you into buying Enfamil products going forward) or
give your newborn a daily Vitamin D supplement until he drinks at least 32
oz per day if he uses any standard kind of formula. The latter is much less
expensive.

4. Enfamil AR / Similac for Spit-Up

All babies spit up a little. But babies who suffer from heartburn (a.k.a.
gastoesophageal reflux or GERD) spit up a lot or are very uncomfortable at
meal time. Thickening the formula can help keep it from coming back up.
So pediatricians often recommend parents add a teaspoon of rice cereal to
each bottle to make the formula heavier. After trying this at home, however,
I can tell you that the formula gets clumpy and it requires minor surgery on
the rubber nipple to get it out of the bottle. No fun.
 Enfamil AR or Similac for Spit-Up solves this problem by adding rice
starch to their regular cow’s milk formula. This is much easier to use,
reducing your frustration. You will still need to use bottle nipples with a
larger hole to get the formula to flow, however.
It is an old wives’ tale that adding rice cereal will make your baby sleep
through the night. But those old wives would be correct if they are speaking
about babies with reflux.

5. Organic Formulas
These are the certified “antibiotic, pesticide, and growth hormone free”
products on the market. Brands include: Earth’s Best, Similac Advance
Organic, Parent’s Choice and the Honest Co. Are these organic formulas
worth the hefty price tag? It’s your call. The good news: stores like Wal-
Mart now sell generic organic formula at lower prices.

6. Formula with probiotics

Gerber Good Start brand is the only formula that contains active living
bacteria cultures like the stuff found in yogurt. Good Start Protect has
Bifidobacterium lactis, a “good germ” similar to what resides in the guts of
babies who are breastfed. Good Start Soothe contains Lactobacillus reuteri
(L reuteri), the probiotic shown to reduce symptoms of colic. The potential
benefits include fewer illnesses, less severity/frequency of diarrhea, and
yes, maybe less colic. And there do not seem to be any significant risks
with this type of formula. (Weizman)
Are the health benefits worth the added cost? Maybe, but only time and
more research will tell. A cheaper option: Buy a L reuteri probiotic
supplement and toss it into whatever your baby is eating once a day. (see
Appendix B, Alternative Medications, for details)
FYI: If you use a probiotic-enhanced formula, be sure to mix it with
water less than 100 degrees or you will kill all those little good germs!

7. Formula with prebiotics

Similac Advance, Enfamil Premium and Enfamil Newborn, and Gerber
Goodstart tout that their formulas contain “prebiotics.” Found naturally in
human breast milk, prebiotics feed good germs in the gut. Hence, probiotics
(see above) are good bacteria, while prebiotics are food for good bacteria.
Prebiotics may aid in digestion, boost immunity to disease, and reduce
allergies— but most of the research on these benefits is only in its infancy.

8. Older baby and toddler formulas

According to formula companies, toddler formulas are designed for older
babies who are eating solid foods. This product contains more calcium than
standard infant formula. The pitch: babies over nine months have a higher
calcium requirement than younger infants.
The issue: companies are trying to hook parents with “next step” or
follow-up formula for 9-24 month olds and “toddler formulas” designed for
one to three year olds. The formulas, with added vitamins, are pitched to
parents as an allegedly better substitute for cow’s milk.
Is any of this necessary? We say no. Follow-up and toddler formulas are
generally a waste of money. The calcium content of standard infant
formulas is appropriate for birth to 12 months of age. After one year of age,
a baby can drink whole or 2% milk—and milk is 85% cheaper than toddler
formula! The American Academy of Pediatrics Committee on Nutrition
concurs. They do not recommend using toddler or follow-up formulas for
healthy children who have low risk of nutritional deficiency. (Georgieff)

Q. I’ve heard commercially prepared infant formula

contains a ton of artificial ingredients. What do you
think of making our own formula? I’ve seen recipes on
mommy blogs.
No, we discourage DIY formula. We, too, have also seen these recipes
circulating around the blogosphere, along with warnings not to tell your
child’s pediatrician that you are doing it.
Simply put, moms who came along before us tried to create a breast milk
alternative in their kitchens—it worked out okay for some babies, and was
an epic fail for others. Pediatricians want their little patients to get the exact
combination of nutrients they need to thrive and grow. That is why we
prefer products that are regulated to ensure that happens.
If you are trying to save money, then buy generic infant formula. If you
are seeking a GMO-free, organic, corn syrup-free product, then opt for
buying an organic infant formula like Earth’s Best or the Baby's Only.

Q. Do you have a preference for powder, concentrate,

or ready-to-feed?
As we mentioned above, we pointed out the cheapest option formula is
powder. But is it best for baby? The answer: it’s complicated. And cost isn’t
the only factor to consider.
The American Dental Association suggests using ready-to-feed formula
to avoid excess fluoride intake (see discussion of this in the previous
chapter). Or if you choose powder or liquid concentrate formula, the ADA
recommends mixing it with purified, demineralized, deionized, distilled, or
reverse osmosis filtered water.
Powdered formulas are heat-treated but cannot be commercially
sterilized like ready-to-feed formula. Thus, powdered formulas contain low
levels of microorganisms. One particular germ, Enterobacter sakazakii, can
cause serious infections in babies who are low birth weight, born
prematurely, or immune compromised. (Centers for Disease Control) That’s
why we recommend boiling bottled water before mixing with
poweredformula.
Given those concerns we STILL recommend powder formula as the best
option for baby. But we do so with the following caveats:

1.Mix powder formula with purified, demineralized, deionized,

distilled, or reverse osmosis filtered water that is boiled (the water
must be over 158 degrees to kill the germs). It’s okay to use your
own tap water if you have a reverse osmosis filter, or it contains
less than 0.3 ppm of fluoride—ask your local water department for
details.
2.Cool or chill the prepared formula slightly before giving it to your
baby (test it on your inner wrist to check the temperature).
3.Use the prepared formula within 24 hours of preparation.
4.Toss any unused formula after a feeding.
5.Don’t use a blender to prepare it—blenders can harbor bacteria.
 6.Refrigerate any bottled water after opening it to prevent germs
growing in the water.
7.Don’t use powder formula if your baby was low birth weight,
premature, or is immune compromised.

It’s perfectly fine to use liquid concentrate or ready-to-feed formulas, but

they are significantly more expensive.
FYI: the nutrients are the same for all types of formula!

Old Wives Tale

The ready to feed formula is easier to digest.
The Truth: The ready to feed is convenient, a little thicker, and a lot
more expensive. All products are digested exactly the same way.

Q. Do I need to sterilize the bottles, boil water, or use

bottled water to mix the formula?
No, maybe, and yes.
You don’t need to sterilize bottles. Yes, we do suggest a run through the
dishwasher when you first open the packages. Thereafter, you can clean
bottles with warm, soapy water. That’s clean enough.
You don’t need to boil the water you use to mix liquid-concentrate
formula because the American water supply is pretty clean. You DO need to
boil the water you use to mix powder formula (see the previous question).
Note: if you have well water, you need to get your water tested before your
baby arrives to make sure it isn’t contaminated.
Yes, we do recommend bottled water to mix powdered formula—see the
above discussion in the previous question for more details. We also
discussed this issue (fluoride and formula) in the previous chapter, Chapter
5, Nutrition.
Helpful Hint
Look at the mixing instructions on the formula can. Powder usually
requires one scoop per two ounces of water. Liquid concentrate is one
ounce of formula per one ounce of water. Ready-to-feed is ready to go
(DON’T ADD WATER). This may seem obvious to you. But if you screw
up, your baby gets either half of the calories he needs or rocket fuel.
My mother-in-law (who was a very bright woman) mistakenly bought
ready-to-feed formula for her third baby (my future husband) and added
water because she thought she had purchased concentrate. Her astute
pediatrician identified the problem at the baby’s two-week well check when
he wasn’t gaining weight. Sure, this baby ended up nearly six feet tall as an
adult, but we figure he could have topped Shaq’s height if this mistake was
caught earlier.

Q. Which bottles/nipples do you recommend?

Walk into any baby store and you’ll see the Wall of Bottles—a mind-
numbing array of baby bottles and nipples, each claiming to be the best
choice for your newborn. While we review baby bottles in depth in our
other book, Baby Bargains, here is a quick primer.
Bottles come in several different types: glass, plastic and polycarbonate.
Any type is fine.
Which nipples are best? Lactation consultants we’ve interviewed seem
to like the Avent nipples best. They believe there is less nipple confusion
when alternating between breast and bottle. Note: There are newborn
nipples (low flow), older baby nipples (higher flow), and cross cut nipples
(highest flow). You can switch to the older baby nipples at four months. The
cross cut nipples are better for babies with reflux who drink thickened
formula.
Reality Check
Feeder bottles (solid food dispensers) are unnecessary. Your baby needs
to learn how to eat, not drink his solid food. (See the next chapter for more).

Q. How much and how often do I feed my baby?

For the first few days of life, a newborn might take an ounce or two
every few hours. After the first few days, offer him three ounces in a bottle
and see what he does with it. From day three to two weeks old, babies
usually eat about 2-3 ounces every 3-4 hours. They gradually want more to
eat over the next several weeks. But as you might guess by the standard
bottle size, babies eventually max out at eight ounces per feeding.
How will you know when your baby wants more to drink than what you
have offered? Easy. He will finish off what you gave him and look for
more! And the beauty of babies is that most of them just eat what they need
to and then stop when they are full. So if you follow your baby’s lead, he
will probably eat just the right amount.
Using the “Big Picture” guidelines below, you will have a decent idea of
how much and how often you can expect your baby to drink.

The Big Picture: Formula Feeding for the First Year

Birth to 2 weeks: (15-24 oz)

Newborns tend to eat two to three ounces every three to four hours. For
the first two weeks, wake your baby if it has been more than four hours
since the last feeding. Once baby has regained birth weight, he can sleep as
much as he wants (good luck)!

2 weeks to 2 months: (17-32 oz)

 You will see a gradual increase in volumes at feedings. By two months,
babies usually take around four ounces per feeding, about every three hours.

2 to 4 months: (21-40 oz)

Your baby will eat six to eight ounces per feeding, and max out at about
40 oz per day at about four months of age.
When the volumes go up, the number of daily feedings go down. So, a
baby who chugs eight ounces at a feeding can eat five times a day and sleep
through the night. Parents often ask if they can space out the frequency of
daytime feedings. NO! Use common sense here—if your baby eats every
two to three hours during the day, you will all be sleeping at night. (Get
used to it. This frequency of meals continues into preschool, when kids still
eat three meals and two snacks a day.)
Babies who take smaller volumes at each feeding will need to eat more
often. These tend to be babies who suffer from heartburn (GERD). We’ll
have more on this in Chapter 8, The Other End.

4 to 6 months: (25-40 oz)

Babies continue to take a ballpark of 40 oz per day of formula. Even if
you begin offering your baby a nibble or two of solid food, there should be
no reduction in the volume of formula. Initially, you should view
complementary solid food as dessert.

6 to 9 months: (28-36 oz)

You’ll be going full speed ahead on solid food. Your baby will start to
wean—decreasing volumes of formula as his intake of calories from solid
food increases. By seven to nine months, you will see this start to happen.

9 to 12 months: (20-30 oz)

Your baby will decrease drinking formula to a minimum of 24 oz per
day. At one year of age, your baby will usually drink three 8 oz bottles. This
will then be replaced by whole or 2% milk that is Vitamin D fortified. The
goal is 16 oz a day (which is two cups a day) of milk. The equivalent in
dairy products is also fine.
 It’s time to kick the bottle habit at a year. Don’t get stuck here. You don’t
have a baby anymore. You have a toddler. If you want a baby in your house,
go have another one. Yes, your child will be quite capable of drinking via a
cup or a cup with a straw. He will not go thirsty.

Other Liquids

Q. Does my baby need any water?

Not until six months of age.
The reason: your baby is already getting water. It’s naturally in breast
milk and added to prepared formula. Your baby gets plenty of water. After
six months of age, your baby should start to drink some water every day.
How much? Even though there is no official guideline, we think four to six
ounces of water a day is adequate.
No matter what other liquid babies are drinking or how it is prepared
(breast milk, ready-to-feed formula, or powder/liquid concentrate formula),
babies over six months of age should all drink some fluoride containing
water (0.7ppm) on a daily basis. Again, four to six ounces a day is our best
estimate on what is needed.
If your baby has no source of fluoride-containing water in his diet for
whatever the reason (using fluoride-free bottled water, reverse osmosis
filtered tap water, etc), then you should discuss getting a fluoride
supplement with your doctor or dentist. For details on this whole fluoride
issue, check out the section on Vitamin Supplements in Chapter 5,
Nutrition.

Reality Check
Bottled water is not any safer than tap. A Dutch study compared bottled
water from 16 countries. Of these samples, 37% were contaminated with
bacteria and 4% were contaminated with fungus! Hence, for older children,
tap water is preferred, since it usually contains fluoride. The only reason
that we recommend using distilled bottled water to prepare formula is to
ensure your infant doesn’t get too much fluoride.

DR B’S OPINION: SIPPY CUPS

Yes, I know they are popular: the no-spill sippy cup. I have never
been a fan of these because the sucking mechanism to get the fluid
out is similar to a bottle. Dentists dislike sippy cups because the
flow of liquid heads straight to the back of the top front teeth. In
short, sippy cups can promote tooth decay.
I’d prefer to have your baby drinking from a straw if he hasn’t
quite mastered the art of drinking from a cup. Another cool option:
The Reflo drinking cup (reflo.net) which controls the flow of the
liquid and reduces the mess while a child is learning how to hold
and tilt a cup.

Q. When can I give my baby juice?

What’s the rush?
Pediatricians, as a general rule, are not very enthusiastic about juice.
Sorry, juice producers of America. Here are the reasons:

1.Juice provides little nutrition. Vitamin C has to be added to many

juices to give them any nutritive value. Otherwise, juice is just a
form of liquid sugar.
2.Juice is filling, which decreases a child’s appetite for more nutritious
foods.
3.Drinking juice throughout the day (especially in a bottle) causes sugar
buildup on the teeth. This, in turn, creates high dental bills.
4.A sugar-loaded diet causes diarrhea.
BOTTOM LINE: Children with poor weight gain, chronic diarrhea, or rotten
teeth often are juice-a-holics. The American Academy of Pediatrics
recommends no more than six oz of juice a day for 1-6 year olds

DR B’S OPINION

“If you are going to offer juice, do it after six

months of age. Offer no more than six ounces per
day. Diluting it half and half with water is even
better. I also suggest introducing juice in a cup
not a bottle.”

Helpful Hint
A sneaky way to get those vegetables in: drink them. Although we aren’t
big fans of juice, combination carrot-orange juice is a tasty option most
kiddos like. And it’s an excellent source of Vitamin A and C. Get your
juicer or blender out and make some tasty veggie drinks for you and your
child. Save money, be healthy.

Q. When can my baby drink from a cup?

You can try introducing a cup any time after six months of age, but there
is certainly no rush.
Your long-term goal is to have your baby drinking from a cup at his first
birthday. Most babies get the hang of it by 12 months.
Reality Check
Once your baby has teeth, you need to wipe them or brush them after
the last feeding (before bedtime). Your baby shouldn’t be falling asleep
while he is eating by the time he has teeth anyway. (See Chapter 9, Sleep
for details.)

Q. When and how do I switch to cow’s milk?

At one year of age, cold turkey.
Your baby still needs a high fat diet because his brain development is on
overdrive. The American Academy of Pediatrics recommends whole or 2%
milk until two years of age. Previously, it was recommended that all
children drink whole milk until age two. But the guidelines recently
changed because many toddlers already eat a high-fat diet and obesity
begins early in life. You and your child’s doctor can decide whether whole
or 2% is best for him, depending on your family history and your child’s
growth. (American Heart Association)
After the second birthday, your child should drink what the rest of the
family is drinking. This should be skim milk (nonfat or 1%) for everyone.
The fat will clog your baby’s arteries just like it clogs ours.

Q. What do you think of alternative dairy products

compared to cow’s milk?
While some products have nearly the same calories as whole milk, less
of those calories come from fat (and 12 to 24 month olds still need more fat
than you do). Whole cow’s milk is the preferred dairy beverage because it
contains almost half of its calories from fat, 35% of your child’s daily
calcium requirement, and 20% of your child’s Vitamin D needs per cup.
Other products have trouble measuring up to that. If you select an
alternative beverage, just be sure your child gets his fat, calcium, and
Vitamin D needs met elsewhere in his diet. Here is a comparison:

2% or “reduced fat” cow’s milk contains 2% fat and about 120 calories per
8 oz serving.

DR B’S OPINION: ALTERNATIVE

MILKS

From 12 to 24 months of age, your child needs some dietary fat

to build a healthy brain and calcium and Vitamin D to build healthy
bones. I really don’t care what your child eats or drinks to get those
needs met. So if you or your child has some issue with cow’s milk,
choose an alternative milk . . . but compare labels to make sure it
includes those nutrients.
Q. What do you think of organic milk?
It’s expensive.
Some families prefer to buy organic, pesticide free products. Others
don’t. There is no public health group that recommends the use of organic
milk over non-organic cow’s milk. Some parents have concerns about
bovine growth hormone in “regular” milk causing precocious puberty.
Currently, medical evidence is lacking to support this claim. It’s your call.
While organic milk is fine, we don’t recommend raw or unpasteurized
milk. We discuss the hazards of raw milk in Chapter 13, Infections.

Q. I’ve heard that goat’s milk is healthier than cow’s

milk. Is this true?
No. When it comes to nutrients, cow’s milk is about the same as goat’s
milk. Goat’s milk contains slightly more fat, and slightly less sugar (lactose)
but that’s about it. While many crunchy websites like Mother Earth News
and Natural Society tout goat superiority, there is a lack of evidence to
support these claims.
It’s totally fine if you prefer pasteurized goat’s milk over cow’s milk. We
do not recommend that you buy a goat to provide fresh milk for your family
(check your local zoning ordinances first!).

Q. Is it okay to use formula after a year of age?

It is not the appropriate diet for a child over age one. For babies who are
failing to thrive, your doctor might recommend a dietary supplement (such
as Pediasure, Carnation Instant Breakfast). Using formula for convenience
when you are out and about isn’t harmful, but is unnecessary. Using
formula for nutrition is a waste of money.

Now that you’re an expert at liquids, let’s move on to a topic that truly
indicates your baby is growing up: eating solid food! Up next, your guide to
solid foods, food allergies and more.
SOLIDS
 Chapter 7
"Raising kids is part joy and part guerrilla warfare."
~ Ed Asner

WHAT’S IN THIS CHAPTER

HOW TO TELL IF YOUR BABY IS READY TO EAT SOLID FOOD
WHAT IS RICE CEREAL?
GETTING STARTED: FIRST FOODS
MAKING YOUR OWN FOOD
FOOD ALLERGY SPECIAL SECTION
SIX MONTHS AND BEYOND
THE BIG PICTURE—HOW MUCH TO OFFER AND WHEN
FOOD LABELING

This is the chapter you have been waiting for! After months of feeding your
baby a liquid diet, you’re looking forward to those photos with peas all over
your baby’s cute little face.
You are welcome to read this chapter at any time, but know that solid
food doesn’t enter the picture until your baby is four to six months old.
Note: Although it’s fine to try a limited amount of solid food between four
and six months, breast milk or formula is the mainstay of nutrition.
When your baby is taking larger amounts of solid foods (six to nine
months of age), solid food will start to replace some of the nutrients that
liquid nutrition offers.
Before we get going, we need to tell you a little secret. There is nothing
special about baby food. In fact, we are on a mission to banish “Baby Food”
from the dictionary. We want your baby to eat Food . . . basically, the food
you are eating. So when you see Food in this chapter with a capital F, that’s
what we mean.
Prepared commercial baby food is not in any way superior to the food
you prepare in your home. It is just ready-made like a frozen pizza at the
grocery store. Sure, it is convenient to pack up a jarred food or squeeze
pouch when you are on the go or bringing meals to childcare, but we are
hopeful that this chapter will help you make Food that is just as easy and
portable.
We also want you to view your child’s experience with solid food like
any other developmental milestone. You give him the opportunity, and he
will master it when he is ready. Despite what all your family and friends
will tell you, there are very few rules about introducing Food.
Here are five simple rules:

1.Let your baby try any food (except for raw, uncooked honey)*. In
fact, we encourage introduction of high allergy foods starting at six
months of age.
2.Offer one new single ingredient food every few days (to identify a
food allergy or intolerance). Once several single ingredients are in
the diet, try combo dishes like pumpkin pancakes or lasagna.
3.Use your seasonings and spices to flavor food. Just keep salt to a
minimum for everyone’s health.
4.Prioritize iron-containing foods. Your baby needs an additional
dietary source of iron in his diet, beyond his breast milk or
formula.
5.Eating is a developmental milestone. Your baby will start out eating
very little solid food until he figures out how to move food around
in his mouth, chew, and swallow. Most babies figure this out by
eight to nine months of age. At that point, aim for three solid meals
a day and your baby will cut back on liquid food intake on his own.
*Raw honey carries a risk of botulism for babies under one year of age.
Pretty easy, right? We will go into greater detail in this chapter, but
really, this is not rocket science.
When to Start Solid Foods

Q. My mother wants to feed my two-month-old solid

foods. I’ve heard this is a bad idea. Help!
Your mother will tell you that she fed you rice cereal at two months of
age and you did fine. Here is your ammunition to keep the baby spoon out
of Grandma’s hands:

1 STARTING SOLID FOODS WILL NOT MAKE YOUR BABY SLEEP

THROUGH THE NIGHT. Most babies start sleeping through the night by four
months of age. It is not because their tummies are full of rice cereal, but
because they are developmentally able to by that age.

2 INTRODUCING SOLID FOODS BEFORE FOUR MONTHS OF AGE CAN

LEAD TO OBESITY. New research suggests that a parent who jumps
headfirst into solid foods is more likely to misinterpret a baby’s fussiness
for being hungry—and overfeed her. (Huh) Babies who begin eating solid
food before four months of age have a one in four chance of obesity later in
life. Babies who start between four and six months of age have a one in 20
chance.

3 INTRODUCING SOME SOLID FOODS BEFORE FOUR MONTHS OF AGE

CAN LEAD TO DIABETES. Recent studies suggest that babies who first eat
wheat or barley (gluten-containing grains) before four months of age or
after seven months of age can develop an inappropriate autoimmune
response that leads to Type 1 Diabetes. (Snell-Bergeon)

4 SOLID FOOD DOES NOT PROVIDE ANY NECESSARY NUTRIENTS FOR

AN INFANT UNDER FOUR MONTHS OF AGE. Breast milk and formula are
the only items that should be on the menu for babies from birth to at least
four months. These products contain 50% fat and thus, are loaded with
calories (20 calories per oz). So unless you are serving lard for dinner, you
will never get that many calories in solid food! Breast milk and formula
also contain all the essential nutrients a young infant needs (with the
exception of Vitamin D—see Chapter 5, Growth and Nutrition for the
discussion on that issue).

5 TELL GRANDMA THAT YOUR DOCTOR TOLD YOU NOT TO START

SOLIDS UNTIL FOUR TO SIX MONTHS OF AGE. Use your doctor as an
excuse any time. We don’t mind.

PREEMIES & SOLID FOOD

Because eating solid food requires a certain level

of oral motor skill, many premature babies are not
ready to eat solid food until their adjusted age
(based on due date) is at least four to six months
old. Also, preemies tend to need lots of extra
calories for catch up growth. Liquid nutrition is a
much better source for calories than solid food.

Q. My baby is four months old now. Is he ready to eat

solid foods?
It depends. The advice on this topic can be confusing, but experts at the
AAP and the National Institute of Allergy and Infectious Diseases
recommend starting solid food sometime between four and six months of
age when a baby shows signs of readiness. (NIAID)
But you may hear contradictory advice—even the AAP doesn’t agree
with itself on when to start solid foods. While the AAP Nutrition
Committee says go for it, the AAP Breastfeeding Committee says wait to
start solids until six months if your baby is breastfed (because it promotes
continued breastfeeding).
Your baby is ready when he knows what to do with food on his tongue
(ORAL MOTOR SKILLS). Some babies are ready at four months; some aren’t
ready until six months. Your baby will tell you if he is ready. Let him sit at
the dinner table with you and join the mealtime experience. If he watches
every bite you are taking, let him have a bite, too. (Anything in the single
ingredient category of fruit, vegetable, grain, or meat is fine for a baby from
4-6 months of age. After six months of age, everything else is fair game,
too. See our suggested food list in this chapter.) If he swallows it, he’s
ready. If he spits it back out at you (called tongue thrusting), try again
another day. But being at the table at mealtime is a good social experience
to start now—even if no food is eaten! Again, the take home message: there
is no hurry to start solids. Any solid food consumed before six months of
age is mostly for fun, anyway.

BOTTOM LINE: There is a great deal of variability amongst babies (and

their doctors) about when they are ready to eat solid food. Anywhere
between four to six months is fine. But remember, this isn’t a race. Don’t
rush. And once you get the green light to start solids, remember they are
“complementary foods,” not the main source of your baby’s nutrition.
Breast milk/formula is still the priority.

Reality Check
One-third of parents do not listen to the pediatrician’s advice and start
feeding babies solid food before four months of age. The reasons are
unclear. Perhaps it’s a pushy grandparent or the myth that solid food will
help a baby sleep through the night. Whatever the case may be, please wait
until your baby is at least four months of age. Trust us.

How to Start Solid Foods

Q. I have some friends who recommend baby-led
weaning. What is it, exactly?
This is a great question because learning how to feed your child is just as
important as learning what to feed your child.
Baby-led weaning advocates suggest that babies who are six months of
age and older do not need pureed food and do not need to be spoon-fed.
Their position: the whole point of eating solid food is learning how to gnaw,
chew, and swallow. Babies can be given bite-sized pieces of food, such as
broccoli, cucumber sticks, bananas, or a soft chicken leg. Advocates admit
that most babies will do more exploration than eating initially and that
gagging (not choking) does occur. The argument: bypassing baby food
purees and parental control of feeding simplifies the process and reduces
food battles later on.
We agree with many of these principles. We want your baby to eat Food.
We want your baby to be an adventurous eater. And we’d like to minimize
the high chair battlefield over eating a spoonful of pureed peas. However,
there are two concerns with this feeding method:
Babies over six months of age need a dietary source of iron beyond
breast milk or formula. If you rely on your baby to eat enough iron-
containing foods on her own, she may become anemic by nine to twelve
months of age. That’s because babies will not master self-feeding for
several months.
There will be gagging. Nothing ruins a perfectly good meal more than a
baby who gags and vomits at the dinner table. If a solid-food novice eats a
big chunk of food, it may come right back out. It’s true that gagging is no
big deal, but accidental choking is also possible—and calling 911 during
dinner is a real buzzkill!
Bottom line: Spoon-feeding your baby some pureed foods at the
beginning is fine. It is particularly important to offer iron-containing foods
like soft meats, beans, or fortified cereals. At the same time, you can let
your baby try soft pieces of food and put him in charge. If you prefer the
more traditional way to introduce solid food, advance from purees, to
chunky texture, and then bite-sized pieces over 2-3 months. The take home
message: find a feeding method that works for you and your little one.
Getting started: First Foods
Before we get rolling, let’s answer that age-old question: IN WHAT
ORDER do you introduce these foods?
The answer: there is no right or wrong answer. There are only two rules:

1.Offer single-ingredient foods first and then begin mixing them

together.
2.Prioritize iron-containing solid foods. According to the American
Academy of Pediatrics, “no comprehensive research has been
conducted on which specific complementary foods [solids] to
provide or in which order.” (AAP Committee on Nutrition) And, as
we will discuss in detail later in the chapter, experts now
recommend introducing high allergy foods starting at six months of
age.
Now, if you stroll down the baby food aisle at the grocery store, this is
what you will see: Stage 1 or “First” foods are pureed, single-ingredient
foods in 2 oz. serving sizes. Stage 2 foods are chunkier textured foods or
combination ingredient meals in 4 oz. serving sizes. Stage 3 foods are full
meals (such as turkey rice dinner) in 5-6 oz. serving sizes.
We point this out so you can understand this old way of introducing solid
food. Stage 1 foods are suitable for babies from four to six months of age
because they are single ingredient foods in the smallest serving sizes. Any
“stage” food is fine at six months of age as long as your baby has eaten the
individual ingredients in combination meals.

Reality Check
Commercially prepared baby food is nothing special, plus it is five times
more expensive than cooking the same food at home.

Q. What is the first solid food I should offer?

 Warning: controversial content ahead.
Despite what you may hear, rice cereal does NOT have to be the first
solid food your baby eats. In fact, some experts suggest meat as your baby’s
first food. Why? Because the two key nutrients your baby needs from solid
food are iron and zinc. Meat contains both nutrients in abundance . . . plus
iron and zinc in meat are better absorbed by the body than in iron-fortified
infant cereal. Clearly, your baby isn’t ready for a steak, but you can puree
meat into the texture of Spam or a nice pate.
If you prefer to go the traditional route, any fortified infant cereal (rice,
barley, oatmeal) is a good choice for most babies. It’s easy to prepare, a
decent source of iron and zinc, and almost no one is allergic to it.
The American Academy of Pediatrics Nutrition Committee recommends
iron-fortified infant cereals and pureed meats as good first foods. (AAP
Committee on Nutrition)

Reality Check
If your family maintains a vegan or vegetarian diet, you do not HAVE to
offer meat to your baby at all. There are dietary alternatives to meet your
baby’s/growing child’s nutritional needs. If you plan on feeding your baby a
purely vegan diet, chat with the pediatrician about potential vitamin
supplements for iron, zinc, calcium, Vitamin B 12, and Vitamin D.s

BOOKMARK THIS PAGE! BABY FOOD BY STAGE

Fruits and Vegetables, Single Ingredient “1st Foods”

Applesauce
Apricots
Asparagus
Avocados
 Bananas
Broccoli
Carrots—cooked, pureed
Green beans
Guava
Mashed potatoes
Mango
Melons
Nectarines
Papaya
Peaches
Peas
Pears
Plums
Prunes
Pumpkin
Squash
Sweet potatoes

Fruits and Vegetables, more interesting textures

Bell peppers
Blueberries
Grapefruit
Kale and other greens
Kiwi
Oranges
Pineapple
Rhubarb—cooked
Spinach—cooked
Strawberries
Tomatoes

Dairy, Single Ingredient “1st Foods”

Whole milk yogurt
Soft cheeses (cream cheese, sour cream)
Dairy, More interesting textures
Cottage cheese
Shredded cheese

Dairy, Combination foods

Yogurt and fruit smoothies
Mac & cheese (made with real cheese!)

Grains, Single Ingredient “1st Foods”

Iron-fortified infant cereal
Rice, Barley, Oatmeal, Wheat
Millet cereal
Quinoa cereal

Grains, More interesting textures

Cheerios/Oatios or generic
Corn tortillas
Oat bran cereal
Pasta such as wagon wheels
Puffed kashi
Rice cakes

Grains, Combination foods

Cornbread
Enchiladas
Grits
Lasagna
Oat bran muffins
Polenta
Quinoa salad
Whole grain pancakes
Whole grain waffles

Meats, Beans, Legumes, Single Ingredient “1st Foods”

Beans: red, kidney, white, black-eyed, navy, etc
Beef; Chicken; Lamb; Pork;
 Turkey
Lentils; Split peas
Tofu
Garbanzo beans

Meats, Beans, Legumes, More interesting textures & higher allergy

foods
Edamame; Egg; Fish
Peanut sauce, cashew/almond
butter*

Meats, Beans, Legumes, Combination foods

Chicken salad
Egg salad
Falafel
Hummus

*Whole nuts are a choking hazard for kids under age three.

Q. What is rice cereal?

Rice cereal for babies is packaged in a box as dry flakes and sold in the
baby food aisle. The brand doesn’t matter, as long as it is labeled iron-
fortified infant cereal.Mix it with either expressed breast milk or formula—
otherwise it tastes like cardboard. (Truth be told, even when you doctor it
up, it still tastes like cardboard!) Make sure the cereal is pretty watery—not
the thick texture you would eat. Make about two tablespoons worth. If that
isn’t enough, you can always make more.

Helpful Hint
You may want to experiment with tastier cereals (oatmeal, barley, and other
grains). These grain cereals also offer another advantage: FIBER. Rice
cereal contains no fiber . . . therefore, if your baby eats a fair amount of it,
he may become constipated.

Q. Does rice cereal contain arsenic?

Yes, arsenic has been found in baby rice cereal, as well as in brown and
white rice and other rice-containing products like rice milk and rice cakes.
For details, check out Chapter 15, Environmental Health. In a nutshell, we
think rice cereal for infants is safe.

Q. How should I give my baby his first solid meal?

Offer it as a snack after your baby has had breast milk or formula. If you
try to feed him solid food when he is hungry, he will only become impatient
and frustrated. By six months of age, your baby could probably win a
chugging contest with the speed he guzzles down 160 calories (eight ounces
of liquid).
High chairs are a convenient way to let your baby have a seat at the
kitchen table. Let him join you at mealtime, and offer a few bites (or
spoonfuls) at a time. FYI: If your baby cannot sit upright and hold his head
and neck up, he is not ready to eat solid food! (Our sister publication, Baby
Bargains, has recommendations for high chairs at
highchairs.babybargains.com).
If you are spoon-feeding him, he will tell you when he is no longer
interested in eating by turning away or blowing raspberries at you. Do not
force him to eat. This is meant to be fun, not nutrition.
For babies who are six months of age an up: if you are aiming for self-
feeding, offer a few soft sticks or pieces of food (think banana or avocado)
on his tray and let him experiment/play with it.
With either method, prepare for a mess—on your baby, high chair, and
kitchen floor.
Q. What other foods should I offer first?
Remember, there are no rules on which “order” to progress through these
foods.
Iron-fortified single grain infant cereals and single ingredient foods are
sensible first foods to introduce because they are soft (or can be pureed) and
the least allergenic. Other easy first foods include carrots, sweet potatoes,
mashed potatoes, squash, green beans, peas, bananas, peaches, pears,
plums, applesauce, lamb, turkey, chicken, pork, pureed beans, and whole
milk yogurt. (If your baby has been diagnosed with a cow’s milk protein
allergy, ask your baby’s doc first before offering her yogurt!)
See the earlier box on first foods. Make sure to offer each new food
individually before combining them.

Q. How often do I introduce a new food?

Introduce one new food by itself every three to four days. You are
introducing foods slowly because you are looking to see if your baby has
any food allergies (see a discussion on this topic later in this chapter). The
AAP recommends no more than three new foods per week.

Q. How often do I feed my baby solid foods?

Here is a ballpark figure: one solid meal daily at four through six
months, two at seven months, and three solid meals daily by eight to nine
months.
Start with one feeding a day and work up to three feedings a day (by
nine months old).
Until about eight to nine months, always feed your baby his breast milk
or formula first. Then offer solid food as a between meal snack. Remember,
until your baby eats a large amount of solid food (we are talking about at
least 12 oz of solid food daily), his primary source of nutrition is still breast
milk or formula. When your baby is only eating one kind of solid food, a
single feeding of solid food per day is fine. When he has a repertoire of
foods, you can feed him three times a day. Regardless, he can definitely sit
in his high chair at family mealtimes and be a part of the experience.

Reality Check
To give you some perspective: rice cereal has 60 calories per 1/4 cup (5
calories per tsp) and a jar (2 1/2 oz) of “Stage 1” carrots has 25 calories.
Your baby would need to eat almost 3/4 cup of cereal or six whole jars of
carrots to replace one bottle or breastfeeding session. You’ll be lucky if
your baby eats two tablespoons of cereal or 1/2 jar (1 oz) of carrots in a
feeding session in his first weeks of starting solids.

Old Wives Tale

Introducing fruits before vegetables will give your baby a sweet tooth.
The truth: Your baby will either like vegetables or not. The order of
introduction has nothing to do with it. When your baby is a toddler, he
won’t eat anything.

Q. My baby started solids and now his skin is turning

yellow—HELP!
You are what you eat!
Babies are often first introduced to a series of yellow vegetables (carrots,
squash, sweet potatoes). All of these vegetables are rich in Vitamin A
(carotene). This vitamin has a pigment that can collect harmlessly on the
skin producing a condition called CAROTINEMIA. The difference between
this condition and jaundice (high bilirubin level) is that jaundiced babies
have a yellowing in the whites of their eyes. Sweet potato lovers don’t have
that. See Baby411.com (click on “Bonus Material”) for a great picture.

Q. Can I make my own baby food?

 Absolutely. But there is that phrase we hate, “baby food.” We want you
to offer Food from your table! That way, your baby will get used to your
cooking! Yes, you can use seasonings, herbs, and spices. Just limit the
amount of salt, and use iodized salt if you must add it. It’s not that hard.
Of course, this assumes that you and your partner are preparing home-
cooked meals for your family. When we refer to Food, we are not talking
about a Big Mac and a side of fries. If you were a take-out/eat-out couple
before you had a baby, now is the time to rethink mealtime . . . and get
cooking.
Trust me, I’d never make it on “Top Chef” but even I could make food
for my kids. Here’s the secret: take the food that you are eating and mash it
up into a texture your baby can handle. That’s it. And it doesn’t take that
much time . . . you just need a blender or food processor. If you are on the
go, pick up a cheap handheld baby food grinder or mill for about $10.
Feeding your baby gets even easier as she expands her repertoire of
foods and figures out how to manage different textures and pieces of food.
When your baby begins to work on self-feeding (at six months of age or
older), cut up soft food into thin sticks or small pieces that her tiny fingers
and hands can grasp.

Reality Check: Table salt vs fancy salt

Our bodies need iodine, a mineral that makes thyroid hormone. Iodine is
found naturally in fish, kelp, and dairy products. Prior to 1924, many people
developed goiters from iodine deficiency. An easy solution: salt
manufacturers added iodine to standard table salt (hence the term
“iodized”). But thanks to our diets and love of fancy salt, there is a modern-
day resurgence of iodine deficiency. Sea salt and kosher salt do not contain
iodine. Opt for table salt if you are going to add a little to your home-
cooking.
Q. Is baby food in squeezable packages safer or more
healthy?
Baby food is baby food—regardless of the packaging. But, squeezies are
extremely popular with parents and kids on-the-go. Because babies and
older kids can suck the pureed solid food directly out of the package, they
don’t require parental assistance. A parent can hand a squeezie to a hungry
child sitting in the back seat of a car and keep on driving through rush hour
traffic. And, some parents report that pureed veggies are the only kind their
kids will eat. So where’s the downside, right?
For babies, learning how to eat foods of different textures is important.
So, while squeezies are certainly a convenient option, they should not be
the only way you introduce solid foods to your fledgling eater. They also
cost significantly more than jarred baby food (which already rivals a three
star Michelin restaurant’s prices in cost per ounce).
As for safety and health questions, makers of squeezable packages point
out the containers are BPA-free (more on this controversy in Chapter 15,
The Environment and Your Baby.) From a nutrition standpoint, baby food
in squeezable packges is the same as that in jars.
Bottom line: squeezable baby food is fine when used in moderation.

DR B’S OPINION: BABY FOOD

COOKBOOKS

I bought a baby food cookbook for my husband, our chef, when

our first child was born. (Being in the kitchen actually makes me
nervous!) The recipes amused him. The recipe for carrots was:
1. Steam carrots. 2. Puree. 3. Serve.
My advice—don’t bother buying a baby food cookbook. Just use
a food processor or blender and puree your home cooking. You can
pour the food into ice cube trays (perfect serving size) and freeze
them. It’s easy to thaw out and serve.
Q. Is it ever a good idea to pre-chew food for my
baby?
Um, no. Celebrity Alicia Silverstone was captured on video doing that,
but remember she starred in Clueless.
Seriously, yes, some cultures practice “premastication,” but there is no
need to take the health risk in the modern age of utensils and food blenders.
Mixing baby food with an adult’s saliva increases the chance of spreading
germs that can lead to infection, as well as germs that can lead to cavities.

Q. What do you think of organic baby food?

It’s a lifestyle choice.
As we have discussed, some parents make this a priority. Others don’t.
What does the science show? We will save that discussion for Chapter 15,
The Environment and Your Baby.
If you do opt for going organic, we advise you to prepare your own food
from organic fruits and vegetables rather than to buy commercially prepared
organic baby food, which is very expensive.
If you do buy prepared baby food, know that all the conventional brands
(not just organic) make their Stage 1 foods preservative- and additive-free.
The Stage 2 and 3 foods do add other ingredients, so you may want to
check the packaging.
We’ll delve into what we know about food-borne environmental
exposures in Chapter 15, The Environment and Your Baby.

BEHIND THE SCENES: WHAT IS “ORGANIC”?

 The USDA regulates the labeling of all of these “natural”
products so that people know how natural a product really is. Organic
products are meats, poultry, eggs, and dairy products made from
animals that did not receive antibiotics or growth hormones or fruits
and vegetables grown without pesticides or petroleum based
fertilizers. Organic farms are certified by a government inspector.
Here are the rules:
100% Organic must have a USDA seal on it.
Organic is made of 95% to 100% organic ingredients.
Made with Organic Ingredients is made of at least 70% organic
ingredients.

Special Section: Food Allergies

Q. How do I know if my baby has a food allergy?

Look for an impressive rash, profuse vomiting, horrible diarrhea, or
blood/mucous in poop (the poop looks stringy, like snot from the nose).
Allergic reactions are not subtle. If your baby has a few dots of a rash or
a diaper rash, it’s not because of the food you just introduced.
Most allergic responses occur within minutes or at most four hours after
an exposure. (Although it’s quite rare, some serious reactions can occur up
to three days after an exposure.) (Sampson) A chemical in the body called
HISTAMINE is released in massive quantities with an allergic reaction.
Histamine can cause a tingling or itchy mouth, mouth or lip swelling,
shortness of breath, and dramatic diarrhea. You may also see hives (raised
borders of red plaques that look like mosquito bites with circles around
them). See our web site at Baby411.com (click on “Bonus Material”) for a
picture.
The extreme scenario is called an ANAPHYLACTIC REACTION. This is
when loss of consciousness and airway swelling occurs—obviously, this is
life threatening and you need to call 911. This is very unlikely to ever
happen, particularly with a Stage 1 food—they are extremely well tolerated.
 Infants who are more at risk for food allergies are those with parents who
are very allergic. These babies’ risk of having a food allergy may be as high
as 20%. A baby whose sibling has a peanut allergy has a seven-times
greater risk of having a food allergy. Compare that to the general
population, which has about a 2% risk of food allergies. Children who have
asthma have a higher risk of having a more serious allergic reaction if they
have a food allergy.

Reality Check
Acidic foods such as berries, lemons, grapefruit, oranges, and tomatoes can
cause redness or even hives when it touches the skin. This is NOT an
allergic reaction. Just wipe the food residue off your baby’s cheeks and chin
if this response occurs.

DR B’S OPINION: PICKY-EATER

TODDLERS

After years of watching babies grow up to be picky-eater

toddlers, I can tell you those who acquire a taste for mom or dad’s
cooking early on, eat a broader range of healthy food in the toddler
and preschool years. If you were a couple who usually ate out or
ordered take-out in your pre-baby years, now is the time to make a
permanent change in your food lifestyle. As I alluded to in Chapter
5, Nutrition, it really does take a family to eat healthy.

Q. What is food intolerance?

 This term refers to an adverse reaction to a food or food product, not an
allergic response.
Allergic reactions produce histamine. Food intolerances do not. If a baby
has intolerance to a food, he might have stomach cramps or bloating. You’ll
probably avoid that food in the future, but he’ll never have a life-
threatening (anaphylactic) reaction if he is exposed to it.
(Example: An adult with lactose intolerance has gas or diarrhea when he
drinks milk, but doesn’t get hives).

Q. What foods are more likely to cause food allergies?

1.PEANUTS/Peanut Butter. We’ll discuss this in detail next.
2.Egg whites. (the white part—egg protein is the problem)
3.Shellfish (crab, lobster, shrimp, scallops, oysters).
4.Fish.
5.Tree nuts (walnuts, cashews, etc).
6.Wheat.
7.Cow’s milk.
8.Soy.
9.Citrus fruits, berries.
10.Cocoa.
11.Sesame seeds are rapidly emerging as a new top food allergy.

Food Allergies Stats

2.5% of newborns have a cow’s milk allergy. 80% outgrow it by age
five.
1.5% of children are allergic to eggs. 80% outgrow it by age ten.
0.8% of children are allergic to peanuts, but of those with the allergy,
only 20% will outgrow it.
Most food allergies occur in the first three years of life (8% of all
children).
Only 2% of adults have a food allergy, and of those, 50% are allergic to
either peanuts or tree nuts. (Sampson, AAP)
Q. Can my baby have a cow’s milk protein allergy if I
am breastfeeding?
Yes. Food proteins are passed into mom’s breast milk, and cow’s milk
protein is no exception.
Babies with a milk protein allergy may have blood streaked poops,
diarrhea, and poor growth. If your baby is fed a cow’s milk-based formula,
this allergy may pop up in the first few weeks of life. In breastfed babies, it
may not be a problem at all. Or, it may take a few months to become
apparent because there is less exposure to the cow’s milk protein.
If you are nursing and your baby is diagnosed with a cow’s milk protein
allergy, you will need to eliminate ALL dairy from your diet. That means
no milk or dairy products—no cream in your coffee, no parmesan cheese
sprinkled on your spaghetti, etc. We discussed this in Chapter 6, Liquids.
And yes, your baby may not get her doctor’s blessing to eat dairy solid
food products like yogurt or cheese until she outgrows the allergy.

FOOD ALLERGIES AND ECZEMA

Food allergies are one of the key precipitating factors for eczema.
37% of kids with severe eczema have a food allergy. The eczema
improves when the food offender is eliminated from the diet. The
vast majority of food offenders are the top 8 foods on the list earlier.
(Eigenmann)

Q. My baby was diagnosed with a cow’s milk

protein allergy. I am nursing and I’ve removed all milk
and dairy products from my diet. But he is still having
blood in his poop. Am I doing something wrong?
No, you are probably doing everything right. It takes at least six to eight
weeks for the irritated, inflamed gut/rectum to heal. So, even if your baby is
not ingesting any more milk protein, it can take time to see the results in his
poop. The good news: most parents report that the baby seems happier and
less uncomfortable after the dietary changes occur. Babies with persistent
bleeding should see a pediatric gastroenterologist (a specialist in childhood
intestinal disorders).
Food allergy testing is usually not helpful in situations where the baby is
only having bloody or mucousy poop. Most babies will not have positive
allergy tests. But their symptoms gradually improve when their diet
changes. (Ruffner MA)

HIDDEN SOURCES FOR DANGEROUS FOODS

If you have a food allergic child, the world can be a scary place.
Are you aware of how peanuts and other potential food allergy
dangers are hidden in other products? Candy and cookies, as well as
fresh baked goods, are a flash point—undeclared soy, wheat, nuts,
and eggs are common in baked goods. Today most processed foods
are required to list allergy facts, but some products still are not
covered by these laws.
And let’s talk about restaurants. Unfortunately, there is no law
requiring restaurants to disclose the use of allergenic foods as
ingredients. As a parent, you have to take charge: inform the waiter
of your preference to avoid peanuts (or a child’s allergy) and ask
what dishes are a problem. If you get a blank stare in return, ask to
see the manager. Ditto for quick-serve restaurants.
Watch out for stealth uses of allergenic foods like peanuts—for
example, some Chinese restaurants seal their egg roll wrappers with
peanut butter!
Now, we’re not trying to make you overly paranoid here. But as a
parent, you have to be vigilant—especially when your child goes
over to friends’ or relatives’ homes. If in doubt, speak up and don’t
forget to warn all your friends and relatives every time you drop off
your child. In fact, it may be a good idea to get a MedicAlert bracelet
 for your child when he gets older. It reminds him of his allergy as
well as the adults he’s with for the day. For more information, check
out the web. Food Allergy Network’s website (FoodAllergy.org) has
a brochure you can download called “Preventing or Delaying the
Onset of Food Allergies in Infants.” It also provides an FAQ, alerts
and school resources.

Reality Check
Many babies with a cow’s milk protein allergy also are allergic to soy
protein. Studies report that up to 40% of babies are allergic to both proteins.
Milk from other mammals (like goat’s milk) can also be problematic for
these babies. Nursing moms often opt for rice milk or coconut milk in their
diets.

Q. So when can I feed my child a peanut butter and

jelly sandwich?
Okay, let’s talk peanuts and peanut butter.
Here’s the scary fact about peanut allergy: it can be life threatening.
That’s right, some kids with a peanut allergy can die from ingesting less
than one peanut. Another scary fact: only 20% of kids who have peanut
allergy will outgrow it!
So here is the latest advice on babies and food allergies. The American
Academy of Pediatrics and the National Institute on Allergy and Infectious
Diseases both recommend you offer solid food (including high-allergy
ones) at four months of age and beyond. This includes children who are
born to families who have a history of food allergies.
Yes, you read that correctly. Experts believe exposure to high allergy
foods early in life may be protective instead of sensitizing! This reverses
the advice of years past, when doctors urged parents to hold off introducing
high-allergy foods until later.
For example, a study on peanut allergies in the November 2008 Journal
of Allergy and Clinical Immunology found that Israeli children who got
their first taste of peanuts between eight and 14 months of age were LESS
likely to have a peanut allergy than their British peers who didn’t start
eating peanut products until after 14 months. In fact, the British kids were
TEN times more likely to have peanut allergies! (Du Toit)
A quick caveat here: eating whole peanuts are a no-no until after age
three because they are a choking hazard. Raw honey is off limits until one
year of age due to a risk of botulism. (AAP Committee on Nutrition,
NIAID.)

BOTTOM LINE
Although we don’t suggest offering peanut butter as the first food out of the
gate, you can and should offer those high allergy foods before your baby’s
first birthday. (Practically speaking, peanut butter is pretty tough to swallow
for a young child so a nice peanut sauce is a safer bet.) If your baby has
eczema, wheezes, or has a milk protein allergy, you should definitely chat
with your baby’s doctor before offering those high allergy foods.

Reality Check
Do people with food allergies have other allergy problems? Sometimes. The
most common allergy pair is eczema and a food allergy. In fact, eczema can
be aggravated by a food allergy. The most serious combination is asthma
plus a food allergy. Those children are more likely to have a scary
respiratory emergency (wheezing/anaphylaxis) with an allergic reaction to a
food, because that is the way their body responds to an allergen. That
doesn’t happen to everyone, mind you. However, kids with these combo
allergies need to be particularly careful to avoid allergenic food(s).

CELIAC DISEASE: ON THE RISE

Celiac Disease, a disorder caused by an abnormal immune

response to a protein found in certain grains called gluten, used to be
rare. Today 1% of the U.S. population has Celiac.
Here is what you need to know. People with celiac disease have
an unfortunate combination of genetics (predisposition that is passed
down from family) and exposure to gluten. The exposure leads to
injury of the intestinal lining and then, difficulty with digestion
(malabsorption). The result: chronic diarrhea, failure to thrive,
vomiting, and bloating to name a few symptoms. But, some people
have no or subtle symptoms while their guts are being irritated.
Wheat, barley, and rye grains all contain gluten protein. And,
there are a variety of other gluten-containing foods that might
surprise you—who knew Communion wafers could be a problem?
See the list below for more problematic foods.
As babies start to eat cereal grains (wheat, barley, and rye), Celiac
Disease can become apparent. More subtle symptoms include trouble
gaining weight or anemia.
If you have a family member with this disorder, or notice a
change in your baby after introducing these foods, check in with your
baby’s doctor. Children with Down syndrome, diabetes, and other
genetic syndromes are also at risk and should be tested if they have
worrisome symptoms. The first thing to do is a couple of blood tests
(IgA endomysial antibody and IgA antitissue transglutamate) after a
child is on a gluten-containing diet for at least two to four weeks. If
the blood tests are abnormal, a biopsy of the small intestine (done via
an outpatient procedure) confirms the diagnosis.
Recent research shows the ideal time to introduce gluten-
containing foods is between four and seven months of age.
Introducing gluten-containing food before or after this time frame
actually increases the risk of developing celiac disease!
 Gluten-containing foods:
Always contains gluten
Wheat (einkorn, durum, faro, graham, kamut, semolina, spelt),
rye, barley, malt, malt flavoring, malt extract derived from barley,
malt vinegar, triticale

May contain gluten

Breading, brewer’s yeast, broth, bouillion, brown rice syrup, cake
frosting, candy, coating mixes, Communion wafers, certain
condiments, croutons, dates rolled in oat flour, drink mixes, flavored
teas and coffees, flour/cereal products, gravies, imitation bacon,
imitation seafood, licorice, marinades, matzah/matzah meal, some
medications, some oats, panko, pasta, processed lunch meats, rice
pilaf, roux, some salad dressings, some sauces and spreads, some
seasonings, seasoned chips/nuts/seeds, self-basting poultry, smoke
flavoring, soup stock, soy sauce (often made with soy and wheat),
stuffing for poultry, some nutritional supplements. (Hill)

Feedback from the Real World: Ben’s Story

Want to hear something really scary? How about the story of Ben, (Denise’s
son), and how we discovered his life threatening peanut allergy. When Ben
was one year of age, we decided we could add peanut butter into his life.
Being a confessed peanut nut (I’ve searched the Southern U.S. for the best
peanut butter pie–haven’t found it yet but I’m still looking), we thought this
would be a tasty addition to his diet. Besides we had no history of severe
food allergies in our families.
Shazam! He immediately swelled up like a tomato. This was our first
experience with an allergic reaction. Hives hit him like a ton of bricks. We
practically threw him in the car and raced down the mountain (yes, we did
live in the mountains at the time) to the doctor’s office. There we were
informed that he was allergic to peanuts. After treating the hives, the doctor
mentioned that this would probably be allergic for life and the next time
could be life-threatening anaphylaxis (after eating one peanut he could stop
breathing and die). We next visited with an allergist who confirmed the
diagnosis with a “peanut challenge” test.
So what now? Well, we see the allergist once a year. And we have to
carry an epinephrine injectable pen with us everywhere we go. In fact, there
is an Epi-Pen at school, at Nanna’s, at our house and in my purse. We had to
teach Ben to read labels on food, never share at school and never, ever take
food samples without first checking with us (Sam’s Club is a nightmare
sometimes!). It’s no wonder a recent study showed that kids with a peanut
allergy suffer from more stress than kids with diabetes.
The good news: scientists are working on a form of oral immunotherapy,
using the same strategy as allergy shots for seasonal pollen allergies. Food
allergic patients would take increasing amounts of the food substance they
are allergic to on a regular basis. This therapy, however, is still several years
away from being reality.

Helpful Hints
1. If your baby does have a food allergy, get educated about hidden
sources of the problem food.
2. Know how to read an ingredient label. Products containing milk include:
casein, sodium caseinate, whey, or lactoglobulin.
3. Be a detective. Deli slicers are often contaminated with milk because
both cheese and lunchmeat are sliced on the same machine. Many candies
without peanuts are processed in the same location as those with peanuts.

Q. What is the best way to prevent food allergies?

Breastfeed for at least four months. Since human milk is made for
human babies, it is the least likely to be problematic.
Is there any benefit to a breastfeeding mom avoiding high allergy foods
in her diet? No. A fair amount of research has been done on nursing
mothers eliminating highly allergenic foods from their diets to prevent
“sensitizing” their infants. It is true that the breakdown products of foods
mom eats end up in her breast milk. However, this exposure does not put a
baby at any greater risk of developing a food allergy. A nursing mom only
needs to limit her diet if a problem is identified.

Q. Okay, so when can I try these high allergy foods

with my baby?
Again, your baby can try any solid food, even the high allergy ones
(eggs, fish, peanut containing products) after four months of age. However,
we would advise starting with less allergenic foods first, and then
attempting the riskier ones. Offer a small amount in the comfort of your
own home (not at childcare or at a restaurant!) Then, let your baby eat
larger quantities of that food daily for the next few days. (Fleisher DM)

New Parent 411

I had one mom bring in a jar of peanut butter in at her baby’s well check so
her baby could try it in front of me. You do not have to be that anxious
about it! If you want to be uber-cautious, offer these foods during daylight
hours and have an antihistamine (Benadryl, Zyrtec, etc) nearby.

Reality Check
The recommendations for starting highly allergenic foods represent a
MAJOR change from past years’ advice on this topic. So have a discussion
with your child’s doctor if you have questions or concerns. It is particularly
important to talk to your doc if your baby already has eczema, wheezing, or
a milk protein allergy.
Q. What is a good reference if my baby does develop a
food allergy?
Check out the Food Allergy Network at www.foodallergy.org. Or call,
(800) 929-4040.

Q. How are people tested for a food allergy?

There are four basic ways to test for a food allergy, but be aware that
there is no perfect science:

1 ELIMINATION DIET. Eliminate the food from the diet for three to six
weeks; see if there is an improvement in symptoms (i.e. eczema, diarrhea,
etc).

2 SKIN TESTING. Skin prick tests detect a true allergic response (see IgE
below) to a food. If skin testing shows an allergic response, RAST testing
can be done for confirmation.

3 CAP-RAST TEST. Blood test detects an elevation of the body’s IgE

antibodies (an allergic response chemical). RAST testing is useful because
it can identify some food allergies. However, not all food allergies cause an
elevation of IgE levels. In English: a positive test is useful. A negative test
does not rule out a food allergy. The newer CAP-RAST tests have been
shown to be 95% predictive in food allergies for milk, eggs, peanuts, and
fish.

4 FOOD CHALLENGE. When a person is known to be allergic to a certain

food, periodic (annual) RAST testing may show a decrease in allergy
response levels. A person can try a certain food again in a controlled
medical setting to see if he is still allergic to a particular food. (This does
not mean at your kitchen table). (Sampson)
Q. Can you outgrow a food allergy?
Most kids outgrow food allergies to milk, eggs, soy, and wheat by the
time they are five years old. Over 50% of kids will outgrow their food
allergies by the age of one. The foods that tend to be lifelong problems are
peanuts, tree nuts, fish, and shellfish. (Wood)

Q. Are there any other foods my baby shouldn’t eat?

Yes. Here are three:
Honey: Wait on honey until your child is one year old. Honey contains
clostridium botulinum spores that can cause botulism in an infant.
(Infants’ digestive systems are relatively sterile compared to ours
and can’t kill the spores).
Choking Hazards: Raw carrots, celery, popcorn, potato chips, nuts,
hard candy, hard meat, fruits with seeds, raisins, hotdogs, and grapes
(unless cut lengthwise). Wait on these foods until your child is really
good at chewing (two to three years).
Artificial sweeteners: There is no official party line on this one, but
there is no reason to offer these products to babies.

Six months and beyond

Q. My baby is six months old now. What can he eat?

Start with the low allergy, single ingredient “first foods” and then
advance to higher allergy options and combo plates.
If your child is doing well, expand his diet. You will work your way
through the different food groups and textures, while increasing the volume
of food as your baby demands it. Traditionally, we have advised going from
pureed to chunky (think apple sauce or guacamole) to bite-sized pieces or
“finger foods” (see the question below). But it is fine to let your baby
experiment with soft pieces or thin slices of foods at the same time you are
feeding him purees and see what he does. He may or may not like certain
textures initially, but keep offering them. No pressure.
Now is the time to start good eating habits, and give your baby a feeling
that mealtime is enjoyable. (That means, don’t worry about making a mess.)
Solid foods should still be a supplement and not replacement of calories.
Your baby will tell you he is done by turning his head, spitting out his food,
and/or throwing it on the floor.
So, if the food on your plate looks good to your baby, let him try it. This
includes a variety of safe ethnic foods. Don’t worry about herbs and spices
you use in seasoning—just limit adding salt or sugar. Your baby needs to
get used to your methods of food preparation.
See our handy list earlier in this chapter for fun food ideas.

Q. My baby is nine months old. What can he eat now?

Almost anything. This includes “finger foods.”
Your baby is ready to feed himself when he uses his index finger and
thumb to grasp things, otherwise known as the pincer grasp. Finger foods
include: Cheerios, pieces of banana, pieces of pears or peaches, avocados,
mashed beans, shredded cheese, whole wheat toast, boneless fish, wagon
wheel pasta, pancakes, graham or whole grain crackers, falafel, and ground
or shredded meats. And you thought solids were messy before . . . do not
make a big deal out of it—just clean it up. Kids sense frustration and will
have mealtime anxiety if you make it an issue. Your child can be toothless
and enjoy solid and finger foods. They can gum just about anything.
As far as amounts, your baby should be taking enough solid food at a
sitting to cut back on the volume of liquid nutrition. Aim for three solid
meals per day (six to 14 ounces of solid food). See the “Big Picture” table
at the end of this chapter.

Feedback from the Real World: Multiples

Cutting the finger foods ahead of time reduced my stress.
 Patience is not exactly a baby or toddler’s strong suit! Less fussing and
crying made mealtime a little more enjoyable for me.—Agustina, mom of
twins Gael and Malena

Helpful Hint
Now is a good time to take that CPR class you have been meaning to take.
It’s unlikely you will ever need to utilize your skills, but it’s always good to
be prepared.

Q. My nine month old refuses any food that has a

texture to it. Help!
This is called TEXTURE AVERSION.
Some babies prefer smooth, pureed foods well into their second year of
life. If he is otherwise developing normally, I’d consider your baby a little
eccentric, but normal.
Babies with texture aversions, adverse reactions to sensory stimulation,
and developmental delays may be worth talking to your doctor about (see
PERVASIVE DEVELOPMENTAL DISORDER, SENSORY PROCESSING
DISORDER).

Q. My one year old refuses to let me feed her, but can’t

use utensils yet. Any ideas?
Try letting her dip foods. Yogurt, applesauce, guacamole, hummus, and
beans will stick easily to a cracker that your baby can lick off.
Remember, getting your toddler to eat anything is a real challenge.

Q. What are the food expectations for a one-year old?

 To join the family at the dinner table, and eat what the family is eating.
The goal is for your child to graduate to Food (what you eat) at one year
of age. He should eat three meals and two snacks per day. He should drink
whole or 2% milk (16 oz or dairy serving equivalent), juice (less than six oz
per day), and water out of a cup. Say goodbye to bottles.

Q. Is it okay for my baby to eat fish?

Yes. The few restrictions are: shark, swordfish, king mackerel, and
tilefish. These fish contain high levels of mercury, so the Food and Drug
Administration has recommended that these be avoided for young children.
It is also recommended to contact your local health department about any
warnings on fish caught in area lakes. Canned tuna is okay in small
amounts (less than six ounces/week).

The Big Picture For Liquid And Solid Nutrition

*Solid nutrition from 4-6 months depends on your baby’s readiness.

Key Points To Remember:

For perspective: Prepared baby food jars: Stage 1 = 2 oz. serving.

Stage 2 = 4 oz. serving. Stage 3 = 5-6 oz. serving.
For more perspective: Remember that breast milk and formula have 20
calories per ounce. Your baby gets 160 calories when he drinks 8 oz.
When he eats 2.5 oz of pureed carrots, he gets only 25 calories.
Do not reduce the amount of liquid nutrition until your baby eats
enough solid food to replace the calories. This gradual taper begins
somewhere between six and nine months. This is when a solid meal
is at least a four to six ounce serving.
Every baby is different!
THE OTHER END
 Chapter 8
"Gil, why are you standing there?” “I’m waiting for her head to spin
around.”
~ Parenthood

WHAT’S IN THIS CHAPTER

NORMAL NEWBORN POOP
THE TOP 5 WORRISOME POOPS
TRADE SECRETS FOR CONSTIPATION RELIEF
FUN FIBER FOODS
SPIT UP, REGURGITATION, AND VOMIT
WHAT IS GASTROESOPHAGEAL REFLUX (GER)?
TOP 5 WORRIES ABOUT VOMIT
URINE AND BLADDER INFECTIONS
BURPING, HICCUPS, AND GAS

This chapter addresses a subject taboo at most dinner tables. We are going
to have a candid discussion about poop (as well as gas, burps, pee and spit
up, too). Why spend a whole chapter on poop? Let’s be honest—you’ll have
LOTS of questions about this subject. And you’ll be looking at lots of it
too! The average baby goes through 2300 diaper changes in the first year
alone.
Parents have concerns because baby poop does not look like theirs. If it
does, your baby has a problem. And as you might imagine, changing at least
eight diapers a day also results in a pre-occupation with diaper contents.
Before we go too far, it’s a good idea to go over the terminology we’ll be
using in this chapter:
 Stool. Digested food garbage that is eliminated through the anus. Stool
also has bacteria germs in it (these germs help us digest our food).
Just so we’re on the same page—it’s also known as poo, poop, feces,
caca, Number 2, bowel movement . . . for this book, we will use the
term POOP.
Urine. The garbage that the kidneys clean out of the bloodstream that
is eliminated through the urethra (the hole in the penis or the hole
above the vagina). Urine is sterile (germ free). Otherwise known as
pee, pee-pee, wee-wee, wet diapers, urinating . . . for this book, we
will use the term PEE.
Gas. The air inside the intestines that is a by-product of the food transit
through it. When babies eat 24 hours a day, their intestines move 24
hours a day, and make a whole lot of gas. The gas slows down when
the intestinal transit slows down, around six weeks.
Burps. The air that gets swallowed comes back out of the esophagus.
Because babies exclusively suck and swallow their nutrition for the
first four months of life, burping feels good after a big meal. Some
babies suck very aggressively and ingest a large air bubble. When
this air bubble comes up, often so does the whole meal.
Hiccups. This is caused by a muscle spasm of the diaphragm (the
muscle that divides the chest and abdomen). All babies have some
hiccups. This sometimes is a sign of sensory overload (i.e. over
stimulation). There is nothing wrong with your baby. You may just
want to soothe him.

Newborn Poop

Q. What should my newborn’s poop look like?

Black tar.
In the first 24 hours of life, your baby should pass a poop called
MECONIUM. This has the color and texture of black tar. It looks like this
because the baby has swallowed some blood while inside the womb. The
black tar contains some digested blood. (Good to remember if you ever see
poop that looks like this again from your baby or a family member).
As your baby starts to eat breast milk or formula, the poop will change
color and texture. This happens on about the fourth day of life. (Remember,
they don’t eat much the first few days.)

Q. My newborn is breastfed. What should his poop

look like?
Grey Poupon (or crab mustard, as my Baltimore friends would say).
Breast milk poop is very watery. In fact, many parents worry that their
baby is having diarrhea if they have never changed a breastfed baby’s diaper
before. It’s watery because the breast milk is so easily digested, it goes right
through the intestines and leaves very little solid garbage to be pooped out.
Parents often wonder how they will know when their baby is having
diarrhea. The answer is the frequency of poop increases. Breastfed babies
often poop with every feeding for the first six weeks of life. Some babies
will poop less frequently than that, sometimes only once every few days. Do
not worry unless the consistency of the poop looks like yours.
The color is often yellow. But, any shade of yellow, green or brown is
okay. Florescent green is okay too.

DR B’S OPINION: GREEN POOP

AND FOREMILK?

Some mothers hear that green poop is a sign that their baby is
only getting the foremilk and not the richer hindmilk. (For a
discussion of foremilk and hindmilk, see Chapter 6, Liquids). While
this may be true, a better way to tell if a baby is getting hindmilk is
to look at the feeding patterns and growth charts, not the poop color.
Babies who get foremilk only tend to be snackers who eat frequently
 (they don’t fill up as well). They also gain less weight if they miss
out on the fatty hindmilk.

Q. My newborn is formula fed. What should his poop

look like?
Strained peas.
Formula poops tend to be greener than breast milk poop. But, as we
mentioned, any shade of yellow, green or brown is okay.
Formula poops are also thicker and pastier than breast milk poop. It takes
longer to digest formula in the intestines, so more water is absorbed before
the “final product” comes out.

Q. How often do formula fed babies poop?

Formula fed babies poop less often because the “transit time” through the
intestines is longer. These babies may poop three or four times per day or
once every couple of days. The frequency slows down even more at six
weeks of life.

RED FLAGS: Worrisome Poop

If you see/note any of these, call your doctor immediately:

1.Your baby doesn’t poop in the first 24 hours of life (see MECONIUM
PLUG OR ILEUS).
2.Your baby’s poops look bloody, tarry, or mixed with mucous (see
BLOOD IN STOOL)
3.Your baby’s poop looks like yours. (see CONSTIPATION)
4.Your baby has a stomachache and poop that looks like grape jelly (see
INTUSSUSCEPTION)
 5.Your baby’s frequency of poop increases two or three fold (see
DIARRHEA/GASTROENTERITIS)

Q. My baby grunts and his face turns red when he

poops. Is this normal?
Yes.
Try lying down and pooping some time. See what your face looks like.
This does NOT mean your child is constipated. There is actually a term for
this phenomenon—The Grunting Baby Syndrome.

Q. My three-week-old usually poops with every

feeding. Now, he hasn’t gone in 24 hours. Is he
constipated?
No.
Please read this carefully. Constipation is diagnosed by the FIRMNESS
of the poop, NOT THE FREQUENCY (or infrequency) of pooping.
Concerned parents often think their baby is constipated when they are not.
Newborns to six week olds usually poop several times a day. Occasionally,
though, they may take a day off. That’s when you call the doctor in a state
of panic. The answer is, “Be prepared for the Mother Load.” Some babies
may poop once or twice a week. That’s fine, as long as it is soft when it
comes out.
Your baby is constipated when the poop looks like logs, rock balls,
marbles, or deer pellets. See below for tricks of the trade for relieving
constipation.

Trade Secrets For Relieving Constipation

1 RECTAL THERMOMETER TRICK. If your baby is straining and not

having any success, insert a rectal thermometer in his anus for about a
minute. Trust me—this is the most dispensed phone advice by any
pediatrician’s office. You can read the exact details on how to insert a rectal
thermometer in Chapter 15, First Aid. This usually provides the inspiration
your baby needs to get moving. (And no, they don’t mind having it done
like you would!)

2 PRUNE JUICE COCKTAIL. If your baby is regularly irregular, he may

need some extra fiber to move things along. Try one teaspoon of prune
juice per feeding (mixed in formula or given separately to breastfed babies)
until you get the desired consistency of poop. You can adjust the volume to
what your baby needs (that is, anywhere from one to five teaspoons a day).
Prune juice has both fiber and sorbitol (sugar) that pull water into the poop
to make it softer. Hint: Buy store brand prune juice—not the stuff in the
baby food section. “Baby” prune juice is mixed with apple juice and is very
expensive by comparison.

3 KARO COCKTAIL. Some pediatricians recommend using karo syrup

instead of prune juice to pull water into the stool. I don’t use it because
there are some anecdotal reports of botulism spores in karo syrup (similar to
the concerns we discussed about honey in the feeding chapter).

4 WASH IT OUT. Sometimes, babies need drink a little water to soften up

the poop. I wouldn’t offer more than an ounce or two, though, to an infant
under six months of age.

5 GLYCERINE BULLET. For immediate relief, use a glycerine suppository

to get dramatic results. These suppositories can be purchased without a
prescription at the grocery store or pharmacy. Frequently, the label will read
“infant” suppository. The suppository looks like a bullet made of soap.
Insert it directly into the anus. It dissolves as you push it in. Be prepared for
the fireworks.

If these tricks don’t work, call your doctor. Pediatricians always have a
few more tricks like this up their sleeves!

Q. My six-week old breastfed baby used to poop at

every feeding. Now she only goes once a day. Should I
be worried?
 No. This is normal and you should be thankful.
Babies are born with intestines that work 24/7. They work that way to
keep the nutritional juices flowing. By six weeks of age, things start to slow
down. This is called slower intestinal transit time. Mature breast milk is also
mostly digested, so there is very little garbage to eliminate.
As long as the poop is soft, your baby is fine. So be grateful you have
fewer diaper changes!

New Parent 411

We said it before and let’s say it again: babies poop less often after six
weeks of life!

Solid Food Equals Solid Poop: Older Babies

Q. My five month old started rice cereal and now she

is constipated. Help!
Rice cereal has this effect on some babies. Offer only one feeding a day
of rice cereal and introduce higher fiber cereals and foods sooner rather than
later. Try offering some pureed prunes or pureed beans (that is, refried
beans). That should help move things along! See below for more fun fiber
foods.

Q. How much fiber does my child need to eat?

The equation is Age in Years + 5 = Total daily fiber requirement (in
grams)
This equation doesn’t apply for babies under a year of age. Breast milk
contains no dietary fiber, thus there are no requirements for babies from
birth to six months. From six to twelve months, fiber is introduced in the
diet via solid foods. The daily needs varies from baby to baby and there are
no established guidelines. But studies have shown that children who are
constipated eat significantly less fiber than their “regular” peers. (McClung)

Reality Check
You, Mom and Dad, need 25 to 30 grams of fiber per day no matter how old
you are. Most Americans do not eat enough fiber. The way to get your child
to eat fiber is for you to have it in the house and eat it yourself. If you don’t
realize this yet, your baby is watching every move you make!

Q. Which foods are high in fiber and more

importantly, which ones will my child eat?
This is my favorite fiber food list. Some foods will be off limits under a
year of age and are designated with an asterisk (*)–these are choking
hazards. Kids usually find the bread/grain category the most appealing.
Take careful note of serving sizes. The sizes listed below are sometimes
more than even a one year old will eat.
(I like wheat germ because you can sneak it into food and your child might
not even notice)

Fruit (raw)
Note: The peel is often the part of the fruit that contains the fiber. Since
most kids hate the peels, the fiber ends up in the compost pile and not in
your child.
Q. Now that my nine month old eats a large amount of
solid food, what should his poop look like?
Soft and solid.
The more your baby eats like you do, the more his poop will look like
yours. It should always be easy for your baby to pass. It has a cow patty
appearance when your baby sits on it after he poops.
By the way, some foods don’t get completely digested as they pass
through the intestines. It’s normal to recognize last night’s corn, carrots, etc.
in your child’s poop.

RED FLAGS: Worrisome Poops For Older Babies

1.Streaks of blood. If the streak is on a hard, firm poop, it’s probably
due to a tear in the anus as the poop was passed. It’s worth
checking out, though.
2.Streaks of blood/mucous. This is more concerning for infection,
particularly if poop is loose/diarrhea. Be prepared for a homework
assignment (providing your doctor with a fresh poop specimen).
This can also be a sign of a food allergy, especially if the poop
looks slimy and stringy like snot from the nose. Sorry to gross you
out.
3.Clay (white) colored poop. The official name is ACHOLIC STOOL.
This can occur in conjunction with a stomach virus. But inform
your baby’s doctor.
4.Looks like meconium again. Black, tarry poop can be a sign of
bleeding in the upper part of the intestinal tract (because the blood
has had time to get digested). This may indicate irritation and
inflammation in the intestines. Your doctor will do a test to check
for blood in the poop.
5.Grape Jelly poop. The doctor term for this is actually “currant jelly
stool.” This is a medical emergency. It is a worrisome sign of
INTUSSUSCEPTION where the intestines have kinked.
6.Bulky, REALLY stinky, greasy, floating poops. This may indicate
difficulty with absorption (see MALABSORPTION).
Helpful Hint
Pepto Bismol makes poop look black like meconium. Pepto Bismol is not
currently recommended for infants. Just thought you’d be interested for
your own sake.

Q. My baby just had a BLUE poop. Help!

Your baby is not an alien. It’s either natural or artificial food coloring.
To the best of my knowledge, blue poop is never a sign of illness. Blue
colored kid juices (Hi-C) and kid yogurts are often the culprits.
Beets cause a dramatic red hue in both poop and pee.

Q. I am interested in toilet training my baby. Is it too

early to think about this now?
Yes, in our opinion. Your baby will be in diapers for a long time.
Being toilet trained is a developmental milestone, just like learning to
talk and walk. Milestones can be encouraged, but the child has to achieve it
on his own. Your child needs to be able to sense the urge to pee and poop
(not just after he has gone). His only incentive to be toilet trained is the
desire to be clean (regardless of how many toys you buy him). If he runs
around in a poopie diaper and could care less, he is miles away from this
milestone.
Girls usually train around 2 1/2 years of age. Boys train around 3 or 3 1/2
years. There is no need to purchase a potty seat any time soon. All it will do
is collect dust in your bathroom. Good news: we cover this topic in depth in
the sequel to this book, Toddler 411 (see back of this book for details).
We should note there is another school of thought on this topic:
Elimination Communication (EC). Proponents say babies give subtle clues
that they need to poop or pee and it is up to the parent to respond to those
cues. These babies go diaper-less, and parents put them on the pot every
time they think their kid needs to go. If you want to learn more about this
method, check out DiaperFreeBaby.org. We admit our skepticism about EC
—it seems that the parent is potty-trained, not the child.
Spit Up, Regurgitation, And Vomit

Q. My newborn spits up all the time. Should I be

worried?
No. Most babies spit up after meals. They are born with a loose muscle
between the esophagus (swallowing tube) and the stomach. This muscle,
called the lower esophageal sphincter (see picture at right), will tighten up
by about six months of age. Until then, liquids travel down into the
stomach. Then some will return into the esophagus and mouth. By
definition, most babies have GASTROESOPHAGEAL REFLUX (ACID
REFLUX OR GER). They spit up effortlessly and with small volumes.

GER is not a problem (other than forcing you to spot treat all the
shoulders on your shirts). According to Dr. R. Jeff Zwiener, Medical
Director of Pediatric Gastroenterology at Dell Children’s Medical Center of
Central Texas, GER only becomes a problem called GASTROESOPHAGEAL
REFLUX DISEASE (GERD) if it leads to these unpleasant consequences:

irritation of the esophagus (esophagitis), making babies irritable, fussy,

or refuse to eat.
respiratory/airway problems that make babies wheeze, gag, choke, or
have trouble breathing.
RED FLAGS: When to worry about acid reflux
1.If your baby spits up large volumes consistently, he won’t gain weight
(see GERD TREATMENT).
2.If your baby cries or arches after feeding, with or without spitting up.
The stomach acid is irritating his esophagus (See GERD
TREATMENT).
3.If your baby has Exorcist-style, projectile vomiting after every meal,
call your doctor immediately (see PYLORIC STENOSIS).

Q. My baby is four-months old now and is spitting up

more than he did when he was younger. Should I be
worried?
No.
It takes about six months for the sphincter muscle to tighten up. As your
baby takes larger volumes of breast milk/formula, larger volumes will come
up. Hence, it gives the appearance that your baby’s reflux is getting worse
instead of better. The spit up is usually at an all-time high around four
months of age.

Q. Okay, my baby is nine-months old and still spitting

up. Should I be worried?
No. You’re just at the end of the bell curve. Many babies graduate from
spitting up by six months, but there are a few stragglers. Almost all babies
stop spitting up by one year of age.
Reality Check
No, it’s not just your baby who is an Olympic-caliber spitter. Consider this:
Of all babies 0-3 months of age, 50% spit up.
Of all babies 4-5 months of age, 67% spit up.
Of all babies 6-7 months of age, 21% still spit up.
By 12 months of age, less than 5% of babies are still spitting up. (Edmunds)

Q. How can I tell if my baby is suffering from

acid/gastroesophageal reflux?
Everyone is usually miserable from this. Your doctor can help you make
the diagnosis on this one.
This is usually the problem behind fussy, “colicky” infants. Most parents
are convinced that their infant either has horrible gas pains, a milk allergy,
or colic. They also think that they are inadequate as parents because their
baby is always fussy and they haven’t figured out how to make her feel
better. Some adventurous parents will unsuccessfully try Mylicon drops (an
over-the-counter medicine which makes big gas bubbles into little gas
bubbles), switching formulas, or eliminating dairy from breastfeeding
Mom’s diet before scheduling an appointment with their doctor.
How do we make the diagnosis? We look at the time the fussiness
occurs, and what seems to make it worse. The first rule: babies with reflux
don’t always spit up—(spitters are really easy to diagnose). Some babies
experience heartburn when the stomach acid comes up into the esophagus
with the milk. If it doesn’t make it all the way up to the mouth, you won’t
see it. Babies with heartburn often cry during and shortly after feedings.
They can also cry when lying down (for example, on the changing table)
because this allows the acid to come up. They may try to arch their backs or
thrust their heads back to alleviate the pain. This happens around the clock,
making a very unhappy baby.
Colic is ruled out by the frequency of the behaviors. Babies with colic
are also unhappy. However, they are only unhappy for three hours a day
(say, around 5 pm to 8 pm). Colic starts at three weeks of age and lasts until
three months of age. If your baby has been fussy since two weeks of age
and is always fussy, it’s probably not colic and most likely acid reflux. (See
Chapter 11, Discipline and Temperament for more about colic).
Milk allergy or intolerance is ruled out by exploring some details about
baby’s poop. A true milk allergy causes mucous and/or blood in loose poop,
really horrible eczema, or worse—hives or immediate vomiting. If you have
a fussy baby with normal poop, the food is unlikely to be the problem. A
therapeutic trial of changing formula or Mom’s dairy elimination will not
improve a reflux baby’s symptoms.

TRICKS OF THE TRADE TO TREAT ACID

REFLUX

If your baby is uncomfortable from the heartburn associated with

acid reflux, or is not gaining weight, there are many options to reduce
the severity of the symptoms. Start by using the following tricks at
home. If that doesn’t work, consider a medication (which will require
a prescription).

1. Keep your baby upright for 20 minutes after feedings. This lets
the food travel out of the stomach into the small intestine before
moving baby around.

2. Let your baby plan his mealtimes. Babies often figure this out
themselves. They have more discomfort with large meals, so they
learn to become snackers. It’s not great for parents’ schedules, but is
more comfortable for baby.

3. Have your baby sleep in an inclined position. Keeping the head

upright 30 degrees keeps food going downwards instead of upwards.
How? One solution is a Tucker Sling (tuckersling.com) which allows
your baby to be inclined safely and securely for sleep. While some
babies under three months do well in their car seats, some reflux
babies actually have more problems because they slump down,
increasing the pressure on their bellies. For infants over three months
of age, you can prop up the crib mattress with a purchased wedge or
pillow UNDER the mattress. It’s not terribly effective, though,
because many babies roll all over their crib.

4. For formula fed or expressed breast milk babies: thicken it up.

Thicker milk is heavier and stays down better. If you formula feed:
add one teaspoon of rice cereal to each four oz bottle of formula (or
use Enfamil AR or Similac with added rice starch—see Chapter 6,
Liquids). FYI: The rice cereal trick doesn’t work well with breast
milk since the enzymes in breast milk break it down before the baby
has a chance to drink it.

5. Medications. Babies use the same antacids as adults. Many

products are over the counter for adults, but are by prescription-only
for kids. Some products are not approved by the FDA for use in
children, but are routinely used by both pediatric gastroenterologists
and pediatricians. Although a 2011 review of the scientific literature
questioned the effectiveness of proton pump inhibitors (or “PPI’s”)
for infants with GERD, most docs will try these meds to see if they
work. (van der Pol) The options are listed below. (For details, see
Appendix A on medications.):

Histamine 2 Receptor Antagonists: Zantac (Ranitidine), Axid

(Nizatidine)
Proton Pump Inhibitors (PPI’s): Prilosec, Zegerid (Omeprazole),
Prevacid (Lansoprazole)

If you reach the point that your baby needs medication, he likely
has a pretty irritated esophagus lining from constant stomach acid
burns. The medication prevents further insults, but it takes at least a
week for the irritation to heal. So, don’t expect a miraculous change
in your baby’s behavior after just one dose of medicine. Give the
medicine for a week to see if it is working.
Helpful hints: The medication is dosed based on your baby’s
weight. In some cases, if your baby gains a pound or two, he may no
longer be getting a therapeutic dose of his meds. Remind your doctor
 to recalculate his dose every month or so. And medications like
Prilosec that have to be specially mixed (compounded) may separate
after a couple of weeks. Get a two-week supply and refill it
frequently.
Parents are often leery of giving medication on a daily basis to
their babies. Understandable. However, these medications are safe to
use daily, as a general rule. One rare adverse effect is the potential for
an intestinal infection called C. difficile. Be sure to contact your
baby’s doctor if he develops bloody diarrhea while taking the
medication. Once your baby outgrows the problem (about six months
old), the medicine is no longer needed.

Q. Can’t we just do a test to look for acid reflux?

Yes, tests are available. Here’s an overview:
An Upper GI or “barium swallow imaging study” (see Appendix C, Lab
Work and Tests) can be done to rule out other problems that cause
regurgitation. If the baby happens to reflux while the test is being done, you
have an answer. But having a “normal” barium swallow can simply mean
your refluxing baby didn’t do it during the test.
An esophageal pH probe can be inserted through the baby’s nose to his
esophagus and acid levels can be monitored for 24 hours. While the test is
about 70% accurate, performing the test on all babies is impractical for
obvious reasons—keeping this lovely tube in a baby’s nose for a day is no
fun, nor is the time baby isn’t allowed to eat (several hours).
Then, there’s always the option of doing an endoscopy. That involves
anesthesia—a tube with a camera at the end of it that is inserted through the
baby’s mouth and throat to look at the esophagus. Biopsies (tissue samples)
can also be taken at the same time to make the diagnosis. This test is 100%
accurate, but very expensive.
Given the unpleasant and imperfect nature of these tests, most doctors
rely on a simple examination of baby (and parent reports) to make an acid
reflux diagnosis.

What’s your baby’s I-GERQ score?

 Here’s a free and painless way to assess for possible reflux disease
(GERD) in your baby. It’s called the I-GERQ-R score. If your baby
experiences many of these symptoms, she may be suffering from at least
mild heartburn.
This quiz is pretty good at screening for babies who have troublesome
heartburn. But it’s not 100% accurate and some normal, healthy babies who
“fail” the test do not need treatment.
Take the quiz and get your baby doctor’s opinion on the problems she is
experiencing. Her doc may suggest following her for worsening symptoms,
additional testing, or treatment. (Orenstein)
The test is on the follows.

(I-GERQ-R; Author I-GERQ, Susan Orenstein, MD, © 2004, University of

Pittsburgh) To be filled out by primary caregiver of baby. Please read each
of the questions carefully, answer to the best of your ability, and do not skip
questions. There are no right or wrong answers.

This copyright in this form is owned by the University of Pittsburgh and

may be reprinted without charge only for non-commercial research and
educational purposes. You may not make changes or modifications of this
form without prior written permission from the University of Pittsburgh. If
you would like to use this instrument for commercial purposes or for
commercially sponsored research, please contact the Office of Technology
Management at the University of Pittsburgh at 412-648-2206 for licensing
information Copyright 2004, University of Pittsburgh. All rights reserved.
Developed by Susan Orenstein MD.

DR B’S OPINION: GERD . . . AND

PATIENCE
 Having a baby with GERD can be miserable for everyone.
Feeling helpless and sleep deprived (thanks to the symptoms
worsening when reclined) makes any parent rethink the number of
kids they want to have. These are normal feelings. I promise it gets
better with time. Patience is key. And call on friends and family for
help.
If your baby is not improving while taking medication, contact
your baby’s doctor.

Infant Gastroesophageal Reflux

Questionnaire
1.During the past week, how often did the baby usually spit-up (anything
coming out of the mouth) during a 24-hour period?
Less than once / 1 to 3 times /4 to 6 times /More than 6 times

2.During the past week, how much did the baby usually spit-up (anything
coming out of the mouth) during a typical episode?
Did not spit up
Less than 1 tablespoonful
1 tablespoonful to 2 ounces
More than 2 ounces to half the feeding
More than half the feeding

3.During the past week, how often did spitting up (anything coming out of
the mouth) seem to be uncomfortable for the baby, for example,
crying, fussing, irritability, etc.?
Never / Rarely/ Sometimes Often /Always

4.During the past week, how often did the baby refuse a feeding even
when hungry?
Never / Rarely/ Sometimes Often /Always
5.During the past week, how often did the baby stop eating soon after
starting even when hungry?
Never / Rarely/ Sometimes Often /Always

6.During the past week, did the baby cry a lot during or within 1 hour
after feedings?
Never / Rarely/ Sometimes Often /Always

7.During the past week, did the baby cry or fuss more than usual?
Never / Rarely/ Sometimes Often /Always

8.During the past week, on average how long did the baby cry or fuss
during a 24 hour period?
Less than 10 minutes
10 minutes to 1 hour
More than 1 hour but less than 3 hours
3 or more hours

9.During the past week, how often did the baby have hiccups?
Never / Rarely/ Sometimes Often /Always

10.During the past week, how often did the baby have episodes of arching
back?
Never / Rarely/ Sometimes Often /Always

11.During the past week, has the baby stopped breathing while awake or
struggled to breathe?
No / Yes

12.During the past week, has the baby turned blue or purple?
No / Yes

13.Overall, how would you rate the severity of your baby’s

Gastroesophageal Reflux Disease (GERD) symptoms during the past
 week?
No symptoms
Very mild
Mild
Moderate
Severe
Very severe

Again, if you have concerns, fill out the quiz and ask your baby’s doctor to
evaluate your child for possible heartburn or GERD.

BOTTOM LINE
Most babies outgrow their symptoms of acid reflux when the esophagus
muscle tightens up (around six months of age). A few babies will continue
to have problems up to their first birthdays. Babies who suffer with daily
reflux symptoms from 6-12 months of age are more likely to have feeding
problems in their second year of life (even if the reflux is gone). (Nelson)

Reality Check
Your baby does not have acid reflux because your Great Uncle Harry has
acid reflux. Nor will your baby develop a hiatal hernia because of acid
reflux. However, there are a few babies with GERD who grow up to be
adults with GERD.
Insider Tip: Acid Reflux
. . . a reason for wheezin’
Some babies with acid reflux have respiratory symptoms such as chronic
cough and wheezing. This happens because the milk is coming up and
irritating the baby’s airway. Again, even babies with severe reflux may not
be spitting up large volumes of milk. If a baby is having this much trouble
with reflux, doctors are pretty aggressive about a treatment plan (for good
reason!).
The flip side: if your baby wheezes and a diagnosis of asthma is being
considered, get him evaluated for acid reflux (GERD)—that may be the
reason he wheezes.

Q. Occasionally, my baby will throw up his whole

feeding. Should I worry?
No.
When babies eat aggressively, they suck in a lot of air. When that big air
bubble comes back up with burping, often the whole feeding does too.
Unlike adults, babies often throw up and then want to eat again.
The only time to worry is when the whole feeding gets thrown up at
every feeding. This is a red flag for PYLORIC STENOSIS (see picture at
right). This is a medical emergency caused by a narrowing of the muscle
between the stomach and small intestine (called the pyloric sphincter). It
usually occurs at six to eight weeks of age because the muscle seems to
narrow over time.
RED FLAGS: Vomiting
1. Vomiting bile. Bile is a fluorescent green/yellow color that can indicate a
blockage in the intestines. It is especially worrisome if associated with
stomachache or a bloated looking tummy, or fever. Call your doctor ASAP.

2.Vomiting blood or “coffee grounds.” In newborns, blood in baby’s

spit up is often from Mommy’s cracked and bleeding nipples.
Beyond that time, blood in vomit warrants a call to the doctor.
Blood that has been partially digested by the stomach looks like
coffee grounds when it is thrown up. Both of these symptoms can
be caused by bleeding in the esophagus or stomach.

3.Vomiting repeatedly over six hours. Excessive vomiting can be

caused by stomach viruses (see GASTROENTERITIS), food
poisoning (see BACTERIAL ENTERITIS), or an intestinal blockage
(see ACUTE ABDOMEN). Most of the time, it’s a stomach virus. It’s
time to check in with your doctor after six hours because your baby
can get dehydrated.

4.Vomiting associated with fever and irritability. This is how

meningitis presents in a baby. Babies have a unique “window” to
the brain with their soft spot (fontanelle) on their heads. A full,
 bulging soft spot occurs with meningitis. Call your doctor
immediately.

5.Morning vomiting. Babies don’t get morning sickness. It’s incredibly

rare, but vomiting exclusively in the morning is a symptom of
increased pressure in the skull. This can be caused by abnormal
fluid collections or a mass (i.e. HYDROCEPHALUS, BRAIN
TUMOR). Both of these abnormalities cause a full, bulging soft spot
(fontanelle). This definitely needs to be checked out.

Q. What should I feed/let my baby drink while he is

vomiting?
Nothing.
When your baby is actively vomiting, give him nothing to eat or drink
unless you want to see it come right back out.
Wait until it has been at least an hour since the last vomit to test the
waters. Start with Pedialyte or a generic brand oral rehydration solution sold
at most grocery stores and pharmacies (or see the recipe to make your own
in Appendix B).
This is basically Gatorade made specifically for babies. Give one
teaspoon every five minutes. Don’t let your baby chug as much as he wants.
He will be very thirsty. If he takes a full bottle worth on an unsettled
stomach, it’s destined to be thrown up. He’ll get about two ounces an hour
for the first couple of hours. If the Pedialyte test fails (more vomiting
occurs), call your doctor.
Once the Pedialyte stays down, resume formula or breast milk.

Q. What are the signs of dehydration?

Lethargy, dry skin and lips, sunken soft spot (fontanelle), and peeing less
often (less than three wet diapers in 24 hours—or no wet diaper in eight
hours).
Another measure is weight loss, which is checked in the doctor’s office.
If your child is vomiting and/or having diarrhea, start tallying how many
wet diapers your baby is having. Your doctor will ask you that question
when you call or come in for an appointment. For more info, check out
Chapter 15, “First Aid.”

Pee/Urine

Q. My newborn urinated only once in his first day of

life. Is this normal?
Yes.
All you can expect is one wet diaper on baby’s first day. We just want to
know that the pipes are working. Your baby might pee twice on his second
day of life. The wet diapers will start to accumulate once your baby is
drinking more. By day four of life, you should get at least four wet diapers.
This should reassure you that your baby is getting something to drink when
you are breastfeeding.

Q. These diapers are so absorbent, how can I tell if my

baby has urinated?
Put a tissue in the diaper and you can see the pee.
In the first week of life, keep track of wet diapers. This information is
also useful if your baby is vomiting and has diarrhea.
Another hint: diapers with pee in them feel heavier than dry ones.

Q. My newborn looks like he has blood in his pee.

What is it?
Take a closer look. Does it look like brick dust? Is it powdery and on the
surface of the diaper?
If the answer is yes to these questions, it’s not blood. These are URIC
ACID CRYSTALS. When newborns are a little dehydrated (in the initial 10%
weight loss mode), the pee is more concentrated and less watery. This
causes one of the ingredients of pee, uric acid, to separate out. That’s what
you are seeing. Uric acid crystals are nothing to worry about if it is just one
newborn diaper. Call your doctor if this is persistent or you see it in an older
baby. For a picture of this, see Baby411.com/bonus (click on Visual
Library).

Q. My newborn looks like she has blood in her diaper.

What is it?
This is the equivalent of a menstrual period. It’s not in the pee.
Baby girls’ bodies respond to their mother’s hormones. There is
frequently some bleeding and vaginal discharge in the first few weeks of
life. This is normal.

Q. I’ve heard that baby girls are prone to bladder

infections. How can I prevent them?
Good hygiene.
A brief anatomy lesson here. Girls have a very short tube (urethra) that
attaches the bladder to the outside. The urethral opening sits just above the
vagina. Just below the vagina is the anus. Remember that poop has bacteria
in it and urine is sterile. If the poop ends up in the nooks and crannies
surrounding the urethra, the bacteria (usually E.coli) can climb into the
urethra and grow in the bladder causing a bladder infection. Girls in diapers
are particularly prone to infections. The best ways to prevent infection are:
Change a baby girl’s poop diaper ASAP.
Wipe “front to back.” Dads—this means start cleaning your daughter
at the urethra and wipe downwards to the anus. Never go the other
direction! Gently separate the labia and be sure to clean well in
there.

Boys rarely get bladder infections because the urethral tube is much
longer from the bladder to the opening (the urethra tube is inside the penis
and the opening is at the tip). It’s much harder for those bugs to travel that
far.

Q. How do you diagnose a bladder infection in a baby?

Foul smelling urine, cloudy urine, and particularly, fever in a baby with
no obvious symptoms (i.e. no runny nose, cough, or diarrhea).
This is one of the top reasons why we want to hear from you if your baby
under three months of age has a fever. Untreated bladder infections can
quickly lead to kidney infections (and even meningitis) in infants under six
months of age.
If your baby is in diapers, and has a fever with no obvious symptoms,
your doctor will need a urine sample to look for infection.

Q. Are some babies more prone to bladder infections

than others?
Yes. Although most bladder infections occur due to poor hygiene (poopie
diapers) and bad luck, about 30-45% of all children who have a bladder
infection have a rare abnormality of the urinary system that causes urine to
flow backwards into the kidneys. This is called VESICOURETERAL REFLUX
(VUR). See pictures at right.

Normal urine flow.

 Vesicoureteral reflux.

There are five grades of VUR, with Grades 4 and 5 being the most
severe. Kids with the most severe VUR are at the greatest risk of kidney
infection and permanent damage. The good news: most children with VUR
outgrow this disorder by age seven—even 70% of kids with Grade 3 VUR
will outgrow it.
However, those with Grade 4 or 5 are the least likely to outgrow VUR
and may need surgery to correct the problem.
Because of the potential for permanent kidney damage, pediatricians
have always been cautious about little ones who have bladder infections.
Historically, any child with his or her first bladder infection before
reaching puberty would have been tested for VUR. That testing involved an
ultrasound of the kidneys (easy and relatively cheap) and either a Voiding
Cystourethrogram “VCUG” or a radionuclude DMSA scan (more involved
and expensive). See Appendix C, Labs and Tests for details on these studies.
If the child was diagnosed with VUR, she was prescribed a low-dose
antibiotic to take at bedtime to prevent future infections. This antibiotic was
taken every night until she outgrew her VUR (monitored by repeating these
fun imaging studies annually.)
Recently, this evaluation and preventative antibiotic treatment for kids
with VUR has come under fire. Evidence shows that kids with severe VUR
will likely be sicker, and have their first urinary tract infection before being
potty trained. So, is it worth the time, money, and discomfort of the
procedure to test every child with their first bladder infection? And should
all babies who have VUR be on a nightly dose of antibiotics until they
outgrow the condition? Even children who have mild to moderate (Grade 1-
3) VUR may never have another infection and may not end up with kidney
damage anyway.
 The American Academy of Pediatrics updated their position on this issue
in 2011, but not all urologists agree with their advice.
Here is what all experts can agree on: any infant under two months of
age with a bladder infection needs to be tested for this abnormality. Other
children at high-risk for having VUR should be tested. That includes those
with: more than one bladder infection, a bladder infection with bloodstream
infection, poor urine stream, a bladder infection with unusual bacteria,
abnormal urinary tract on prenatal ultrasound, or continued symptoms after
being on antibiotics over three days.
Here is the summary of recommendations for who should get tested for
VUR:
All children under two months of age who have a fever with a bladder
infection.
Kids ages two to 24 months old with more than one bladder infection
with a fever.
Children whose infections do not clear up quickly. (Finnell)

And newborns who have abnormalities detected on a prenatal ultrasound

(Grade 3-4 hydronephrosis, hydroureter, abnormal bladder) should have a
VCUG screening test for reflux shortly after birth. (AUA 2010)

Reality Check
There is a 60% chance of a child having vesicoureteral reflux if a parent has
the disorder. There is a 30% chance of having VUR if a brother or sister has
the disorder. (AUA 1996)
Siblings (or offspring) of affected children may be screened as well. The
American Urology Association says that healthcare providers may opt to
screen healthy siblings of children with reflux via a kidney (renal)
ultrasound. Then a VCUG test should be performed if an abnormality is
detected on the kidney ultrasound. It’s also an option to just observe siblings
and then promptly evaluate these kids if they have a bladder infection. The
same logic applies to offspring of adults who had reflux in childhood.
BOTTOM LINE
Your doctor may want to screen your child for VUR, even if she doesn’t fall
into the high-risk category. There is no harm in following the precautionary
principle. (AUA 2010)

Burping

Q. Do you have any tips on burping my baby? I spend

20 minutes trying to burp him and nothing happens.
It’s either going to happen or it won’t. It’s not your technique or patience
that does the trick.
Burps are the result of swallowed air during feedings. Once your baby is
an efficient eater (by four months old), he’s also likely to be an efficient
burper.
For the first few months of life, stop in mid-feed to burp your baby.
There are basically three techniques.

1.Baby is upright on your shoulder, and you rub upwards on her back.
2.Baby is sitting in your lap, upright, and you rub upwards on her back.
3.Baby is lying face down on your lap, and you rub upwards on her
back.

If it has been more than ten minutes, the burp ain’t happening on your
watch. Unfortunately, your baby may sleep for 20 minutes, then wake
himself up when he burps. Welcome to parenthood. Just do what you can.

DR B’S OPINION
 “Note that the burping technique involves
rubbing. I watched my brother burp his twins
once and considered reporting him to child
protective services. Patting and hitting aren’t
really necessary!”

Hiccups

Parents ask a lot of questions about hiccups. Here is what you need to
know:

1.Hiccups don’t hurt.

2.Don’t worry about hiccups—doctors don’t.
3.Only excessive hiccupping is associated with acid reflux (GERD).

Gas

A nice way to exit this chapter.

Q. My baby has more gas than me. Should I be

worried?
No.
Your baby has more gas because he sucks in a lot of air and because his
intestines are on high alert 24 hours a day.
Most of the time, babies don’t really care that they have gas. And don’t
be embarrassed, it’s the only time in your child’s life when people will think
it’s cute when he toots.
 NEW PARENT 411: HELPING YOUR BABY PASS GAS

Here are three tips from seasoned parents:

1. Infant massage. This is a comforting way to help your baby relax.

Pressing gently on baby’s belly sometimes gets the gas out.

2. Warm bath. This also works by relaxing your baby.

3. Mylicon (simethicone) drops. This over the counter medication is

safe for babies, including newborns. It makes big gas bubbles into
little gas bubbles. Some parents swear by it, others see absolutely no
difference in their baby’s demeanor. Gripe water, a combo of ginger
and fennel, is also a popular remedy. Using daily probiotics such
as Lactobacillus reuteri, is another option.

Q. What can I do about my baby’s gas? Are Mylicon

drops okay to use?
Not much, and sure, it won’t hurt.
Gas is one of the biggest obsessions of newborn parents. Some parents
believe it is the root of all evil . . . the reason that the baby is
unhappy . . . the reason why nobody is sleeping. The truth is—IT’S NOT
THE GAS. But, if you feel compelled to do something (which is a common
feeling of all parents), it’s okay to try those Mylicon (simethicone) drops.
See above for gas tips. If you have a baby who was born full-term, it is also
okay to try some daily probiotics as a digestive aid. See Appendix A,
Medications for more information on probiotics such as Lactobacillus
reuteri.
The good news; the gassy phase will pass by age two or three months.
Q. I’m breastfeeding. Will eliminating high fiber foods
from my diet fix my baby’s gas problem?
No, but it will give you, Mom, a constipation problem.
This is rarely the cause of baby’s gas. You can try an elimination diet, but
it’s usually not the problem.

Q. My baby is colicky. Is it because of gas?

No. Gas gets a bad rap.
See Chapter 11, Discipline and Temperament, for information on colic.
Eliminating gas won’t solve your colic problem.
BABY
411
 Section 3

Sleep, Development & Discipline

SLEEPING LIKE A BABY
 Chapter 9
“Whoever coined the phrase,
‘sleeps like a baby’ never slept
with one!”
~ Anonymous

WHAT’S IN THIS CHAPTER

THE SCIENCE OF SLEEP
NEWBORN SLEEP ISSUES
SLEEP SAFETY TIPS
DECIDING ON YOUR FAMILY’S SLEEP ROUTINE (FAMILY BED VS.
SOLITARY SLEEP)
SETTING UP GOOD HABITS
UNDOING BAD HABITS
TOP 10 MISTAKES PARENTS MAKE
THE SLEEP GURUS
NAPS
SPECIAL SITUATIONS—MULTIPLES AND PREEMIES

Who needs sleep?

well you’re never gonna
get it

Who needs sleep?

tell me what’s that for

Who needs sleep?

be happy with what
you’re getting
There’s a guy who’s been
awake since
the Second World War
—Barenaked Ladies

New (and veteran) parents struggle with their baby’s sleep habits—it’s a fact
of life. Everyone warned you about it, but you weren’t buying it. At first, the
excitement of being a parent gives you the momentum to make it through the
first few weeks of sleep deprivation. Then, the novelty begins to wear off.
You are exhausted and desperate for a good night’s sleep. You’ll ask friends
and relatives for tricks that worked for their babies. It’s no wonder that
books on infant sleep are a booming section at Amazon.
If you are reading this chapter before your baby is born, good for you.
You will be prepared for what lies ahead. If you are already in the desperate
category—don’t worry—we can help you, too.
Before we give you all of our sage advice on this subject, it is essential
that you understand the science of sleep. Knowing the basics will help you
appreciate the advice and avoid the common mistakes parents make.

The Science Of Sleep

Q. Do newborns have the same sleep patterns that

adults do?
NO. That’s why you cannot expect them to sleep like we do. Here are
four important concepts you need to understand:

1 TYPES OF SLEEP. There are two basic types of sleep: REM and Non-
REM. REM stands for Rapid Eye Movement. Here are the differences
between the two.
 Newborns spend 50-80% of their sleep in REM sleep while adults spend
only 25% of their sleep in REM. The result: babies are very active when
they are asleep. Your baby will be noisy and moving around, but he is not
awake.

BOTTOM LINE: Your baby’s sleep activity and noises do not mean you need
to feed or help him.

2 SLEEP CYCLES. Humans go through a series of sleep cycles throughout

an evening’s rest. Adults tend to bunch all the Non-REM cycles first, and
then go through REM cycles. Babies do more flip-flopping of Non-REM and
REM cycles. Each sleep cycle has a beginning and an end, where a person
goes from light sleep to deep to light again, before entering the next cycle.
Humans recheck their environments and body comfort at that time. At the
end of each sleep cycle, a partial wakening occurs. Babies may whimper or
briefly cry out during this time.

BOTTOM LINE: Leave your baby alone when he has a partial wakening. He
will enter into his next sleep cycle if you leave him alone. If you intervene,
you will wake him up. As the saying goes, let sleeping babies lie.

3 LENGTH OF CYCLES. The average adult sleep cycle lasts 90 minutes.

The average newborn sleep cycle lasts 60 minutes.

BOTTOM LINE: Your baby has shorter sleep cycles than you. It can take
several months until he has mature sleep patterns like an older child.

4 CIRCADIAN RHYTHM. The human body has a biological clock that

registers 24.5 to 25 hours in a day. This is called a circadian rhythm. It is
affected by both light exposure and a body chemical called melatonin.
Babies follow their mother’s circadian rhythm in the womb probably
because of melatonin levels. Once outside the womb, they have exposure to
light and must form their own circadian rhythm.

BOTTOM LINE: It takes several weeks for a baby to get their circadian
rhythm sorted out. If you lived in the dark for nine months, you’d probably
be a little confused too.

Newborn Sleep Issues

Q. Okay, now I understand why my newborn has

erratic sleep patterns. But, how can I get my baby to
sleep at night instead of during the day?
This is called Day-Night Reversal. It usually takes three or four weeks to
resolve.
The best way to help your baby through this is to stimulate him during the
day and keep things low key at night. Talk to your baby during daylight
hours and encourage any wakeful periods he has. At night, do your feeding
routine with little interaction. Only turn the lights on if you have a poopy
diaper to clean. If your baby decides he wants to have a slumber party, he
can party (coo, grunt, etc) on his own. You don’t have to be by his side to
entertain him.
These nocturnal habits usually resolve by three to four weeks of age. See
“Sleep Tips” below in this chapter for more advice on the first couple weeks
of life.

Q. How much should a newborn sleep?

About 14 to 18 hours total a day.
But here’s the cruel part: most newborns will not sleep more than four
hours at a stretch. They need to eat frequently and their little bodies know it.
 Check out the table in the Setting Up Good Habits section later in this
chapter to get an idea of how sleep changes through the first year of life.

BOTTOM LINE: Most newborns have six or seven stretches of sleep every
24 hours. Feedings occur in between these stretches.

Helpful Hints
Three Sleep Tips for the First Two Weeks of life
Wake your newborn up if he has slept longer than three hours during
the day. When your baby has day-night reversals, he may have his one long
stretch of sleep in the middle of the day. Discourage this! Otherwise, you
will be in for a long night of cluster feedings.

Do not let your newborn sleep more than four hours straight during the
night. He needs nutrition to grow. He also needs to stimulate your milk
supply to come in if you are breastfeeding. Once he has regained his birth
weight and your doc gives you her blessing, you can let the baby sleep at
night (he won’t, but it’s fine if he does).

Your job is to sleep when baby sleeps. Become nocturnal. Don’t even
think about doing laundry when your baby crashes in the afternoon. Go to
bed!

Q. When can I expect to sleep through the night?

Now that you are an expert in “sleep-ology,” you can appreciate the
following fact: it takes (on average) 17 weeks of life for an infant to develop
mature sleep patterns. Yep, that’s about four months. Think about that for a
moment.
The definition of “sleeping through the night” is six hours of
uninterrupted sleep. That will feel like a great night’s sleep by the time you
get there! (Kleitman)
 FYI: Even parents with school-aged kids will be awakened by middle-of-
the-night announcements (“I just had a nightmare, Mom” . . . you get the
picture). The concept of “sleeping through the night” is only a fuzzy and
abstract concept that exists for childless couples.

BOTTOM LINE
There is a popular baby sleep book entitled Twelve Hours’ Sleep by Twelve
Weeks Old. If the author were honest, it would be really entitled Six Hours
by Seventeen Weeks. Of course, then no one would buy it! Bottom line:
Don’t fall for the marketing hype of sleep books that promise the Holy Grail
for sleep-deprived parents.

Old Wives Tale

Giving your baby rice cereal helps him sleep through the night earlier.
The truth: Food has nothing to do with it.

Q. My friend says that their baby slept through the

night at four weeks of age! That’s not fair! How can this
be?
Odds are, your friends are exaggerating—or will soon be proved wrong
when their baby reverts back to a normal sleep pattern (that is, waking up
during the night). Sure, lightning sometimes strikes and a one month old will
sleep through the night . . . for one night. Or even a month. But then, as we’ll
discuss later, she may relapse into waking up during the nighttime.
Another explanation for these wild claims: dads. When we hear about a
baby that miraculously slept through the night from birth, this claim usually
comes from the proud new dad. Of course, the baby wasn’t sleeping but
daddy was—mom still had to get up several times a night!
By the way, some babies will sleep up to 12 hours a night as early as two
months of age, but it’s not the norm. If your baby is a terrific sleeper, don’t
brag about it—you’ll jinx yourself for the next baby!

DR B’S OPINION

“If your full term, healthy baby is still not sleeping

six hours straight by six months of age, you need
help. Read the section ‘Undoing Bad Habits’ later
in this chapter.”

Q. How do I get my newborn to fall asleep? He seems

to have trouble relaxing.
It would be nice to have the baby who awakens to feed and then goes
right back to sleep. More likely, you have the baby who eats and then fusses
until you help him return to the Land of Nod.
After you and your baby get to know each other better, you will figure out
what helps him settle down.
Newborns are born with immature nervous systems. That means, they
don’t have the ability to pull it together, relax, and fall asleep. The most
reliable way babies know how to settle down is to suck. See the box nearby
for our Newborn Sleep Tips.
 NEW PARENT 411: TOP 5 TIPS FOR GETTING A
NEWBORN TO SLEEP

1.Suck to soothe. If you are so inclined, your breast may become the
human pacifier. If this approach is not for you, use your finger or
a pacifier in your baby’s mouth to encourage sucking. This is fine
for the first few months of life (more on pacifiers later in this
chapter).
2.Move around. Rocking, swaying, and bouncing (you will have the
veteran-parent-bop down quickly) are effective.
3.Sing, in or out of tune.
4.Snug as a bug. Swaddling, sleeping in a bassinet, or even sleeping
in a car seat may do the trick.
5.Go for a car ride.

Q. How long should my newborn sleep in a bassinet?

Two or three months max.
You are not setting up any permanent habits the first two months of life.
Babies become aware of their surroundings around three to four months of
age. That’s when you need to set up a permanent routine.
For now, newborns prefer to be snug. They like to sleep in bassinets or
cradles (example: Halo Bassinest Swivel Sleeper) until they decide they
want to stretch out. I recommend transitioning over to where you want your
baby ultimately to sleep around three months of age. Another factor: some
playpens with a bassinet insert have weight limits that are usually exceeded
by two or three months of age.
FYI: Newborns never sleep for more than a few hours at a time. Hence,
sleeping or napping for a short time in a car seat is fine. However, once baby
starts sleeping for longer stretches (and wants to stretch out!), move him out
of these contraptions and into a crib.
Old Wives Tale
Too much holding and rocking will spoil your baby.
The truth: You cannot spoil a newborn. Remember, babies don’t have the
ability to settle on their own. Do what it takes to get your baby to sleep.
However, you need to grow as your baby does. Your six-month-old will be
quite capable of settling down on his own.

Reality Check
Many babies will sweat while they are asleep. Don’t be alarmed if your baby
awakens in a pool of water (well, you might want to check the diaper, too).

Q. My baby will only sleep on me. If I put him down

anywhere (bassinet, etc.) he wakes right up. What do I
do?
Remember, babies are not born with self-soothing skills. They are used to
being snug, warm, and next to your heartbeat. While you can simulate that
environment (you can even buy a device that makes heartbeat noises), your
baby may still do his best sleeping when he is skin to skin with you.
During the day, it’s fairly easy to do this. Wear your baby in a front
carrier (example: the ERGObaby 360°). Just continue your daily activities
with your baby in tow.
During the night, it’s a bit more of a challenge. You’ll need to come up
with a safe way for both of you to get some sleep. One solution: the Halo
Bassinest Swivel Sleeper. That way, each of you will sleep in your own
space, but you can swivel the Bassinest for easy access to baby.
 You are not setting up any bad habits. By two or three months, your baby
will want to stretch out and won’t need to be carried continuously. You’re
welcome to continue using a carrier as long as you’d like for transportation,
but we’d suggest discontinuing its use as a sleep aid at three months.

Q. How do sleep patterns and needs change as baby

grows?
Check out this information as well as the handy sleep requirements chart
nearby for details. Remember, these are general guidelines. No need to freak
out if your baby doesn’t follow these numbers to a tee!

Sleep requirements, birth to 2 years (in hours)

 Birth to two months. Newborns sleep 14-18 hours a day. They have day-
night reversals, and rarely sleep for more than a four-hour stretch at a time.
Yes, you have our blessing to do whatever it takes to get your baby to fall
asleep and stay asleep, as long as it is safe. Swaddling, rocking, nursing to
sleep, wearing your baby in a front carrier, going for a car ride, using a
pacifier, etc. You are not spoiling your baby or setting up any permanent bad
habits. Remember: your baby does not have the neurologic maturity to pull it
together, relax, and fall asleep on his own yet.

Two to four months. On average, babies sleep 12-14 hours a day. They
are usually taking three naps per day. Babies who prefer catnapping may
take four shorter naps. If you are lucky, your baby may sleep for a six-hour
stretch at night. It is still too early to train your baby to sleep. Your goal: set
up healthy sleep routines. We’ll have more on this subject later in the
chapter.

Four to six months. The average four to six month old sleeps a total of
11.5-13.5 hours a day, with two naps included. Your baby should be sleeping
AT LEAST six hours at night. Some babies will sleep up to 12 hours at
night. Yes, everyone in the house should be getting sleep by now . . . but if
this is not happening, you need help. Do not be convinced that your baby
NEEDS to be up at night. In fact, everyone will be happier if your child is
sleeping at night. Sometimes parents aid and abet their baby’s bad sleep
behaviors. We’ll discuss the reasons why babies this age continue to wake at
night later in this chapter.

Six to 12 months. On average, these babies sleep 11—13.5 hours per day,
with two naps included. Many babies sleep ten to 12 hours straight at night.
Yes, your prayers were answered! If your baby is still waking up for night
feedings or comfort, you need help. See “Undoing Bad Habits” later in this
chapter.

Feedback from the Real World: Multiples

Keeping your sanity with one newborn’s erratic sleep habits is difficult
enough. Imagine the juggling act when you have two (or more) newborns!
You can’t control or force them to sleep, but you can encourage them to eat
(sometimes!) and that helps synchronize their sleep. Here’s what worked for
us: wake the sleeping baby for a feeding within 30 minutes of the first baby
waking up. Feeding twins at the same time gives you more time to rest
between feedings especially in the beginning when feedings are so close
together.
—Agustina, mom of Gael and Malena, 18 months

Sleep Safety Tips

Q. I’ve heard about sudden infant death syndrome

(SIDS). What is the official recommendation about
infant sleep position?
The “Back to Sleep” Campaign is promoted by the American Academy of
Pediatrics and various other health organizations. The official
recommendation is that babies sleep on their backs from birth to at least six
months of age to reduce the risk of SIDS (90% of SIDS cases occur in
babies under six months old).
Our own parents put us on our bellies to sleep. Any grandparent will tell
you that a baby sleeps better on her tummy. They are right. However,
numerous studies have proven that this sleep position significantly increases
the risk of sudden infant death. It seems to be caused by the infant
smothering herself—a pocket of carbon dioxide forms around the baby’s
face when she is face down in a mattress or soft bedding. Babies don’t have
the neck muscles to move their heads and, sadly, that’s how some SIDS
deaths occur.
Before the Back to Sleep Campaign began in 1992, 5000 babies died per
year in the U.S. from SIDS. Today, that number is down by over 50%. Let’s
take a look at a graph that shows how the SIDS rate plummeted as parents
stopped putting baby to sleep on their stomach:
US SIDS rate versus the % of babies sleeping on their
stomach

Source: Contemporary Pediatrics, Vol 17, No. 9

Q. Are there any other known risk factors for SIDS?

Yes. Here are the top six:

1 ROOM TEMPERATURE. Stuffy rooms with poor ventilation are a SIDS

risk. The cooler the room, the better. SIDS occurs more frequently in the
winter months when babies are bundled and the heat is on. Believe it or not,
the recommended “safe” room temperature to reduce SIDS risk is 68
degrees. And a fan in the baby’s room can also reduce the SIDS risk.
(Coleman-Phox)

MEMO TO GRANDPARENTS: BACK TO SLEEP

Here’s a scary fact: babies who are used to sleeping on their backs
and are placed on their sides (and roll over) or stomachs to sleep have
 a significantly greater risk of SIDS than those babies who are used to
sleeping on their tummies.
The message: make sure that your childcare provider or occasional
grandparent-as-babysitter puts your baby on his back to sleep. They
may have missed the memo on the Back-To-Sleep Campaign!

2 SOFT BEDDING. All those beautiful bedding sets need to stay out of the
crib. Heavy quilts, pillows, bumper pads, and blankets cause the ambient
temperature of the crib to go up. Babies can also smother themselves in soft
bedding. All your baby’s crib needs is a sheet and mattress.

3 SMOKING. Babies whose parents smoke have a higher risk of SIDS. So,
if you can’t do it for yourself, stop smoking for the most important thing in
your world.

4 ETHNICITY. Native Americans and African Americans have a much

higher risk of SIDS than other babies. New research suggests a genetic
defect may be passed on in certain ethnic groups.

5 FAMILY HISTORY. There may be a higher incidence of SIDS when a

previous family member has had it.

6 BIOCHEMICAL ABNORMALITY. Recent studies point to a deficiency in

serotonin (a neurotransmitter necessary for a baby’s arousal system) as a
reason why some babies do not wake up during life-threatening situations
(like when they’re sleeping face down and not getting enough oxygen.) This
is a major medical breakthrough, but there’s no practical way of testing
babies for this disorder right now. (Paterson, Duncan)
Obviously, there are risk factors on this list that you cannot control. But
try to avoid the ones you can—like bedding, sleep position, and smoking.
New Parent 411: Sleeping on the sofa is risky business.
Over the past decade, sofa sleeping led to over 10% of sleep-related infant
deaths in the U.S. Soft sofa cushions can enable a baby to roll to the back of
the couch and get stuck. And babies who nap with a snoozing parent can roll
off the parent’s chest (and couch), leading to injury, entrapment, and
suffocation. (Rechtman LR)

Reality Check: Pacifiers Reduce SIDS Risk

Believe it or not, there is substantial evidence to show that pacifiers actually
reduce the risk of SIDS. It is unclear why, though. It may be that the pacifier
keeps a baby’s airway open. Or, sucking on a pacifier prevents a baby from
forgetting to breathe. FYI: 90% of SIDS cases occur between one and six
months of life. (AAP SIDS Task Force) For a quick look at the latest
recommendations to avoid SIDS, see the Top Ten Take-Home Messages on
Sleep Safety later in this chapter.

Helpful Hints
What should you do with that baby quilt you got as a gift? Use it as a
wall hanging. Or buy a special quilt rack for your baby’s nursery. You can
always use it on the floor as baby gets older. Put a few toys out and
encourage some supervised tummy time. Another alternative: some crib
bedding makers are substituting lighter-weight blankets for thick quilts in
their sets.
 Don’t borrow a crib or use a hand-me-down. Over two million cribs have
been recalled in recent years for safety hazards. As a result, the federal
government rolled out tough, new crib safety standards a few years ago. The
take home-message: we strongly recommend buying a new crib for your
baby instead of using a hand-me-down or that garage-sale find.

Q. What bedding items are acceptable to place in the

crib?
A fitted sheet over a mattress is all you need. We like to call it the Naked
Crib. See nearby picture for an example.
What about blankets? While it is acceptable to swaddle a newborn to
eight-week old baby in a receiving blanket, we discourage any other loose
blankets for babies under a year of age.

A baby can just sleep in a sleeper or be swaddled. Or consider a

“wearable blanket” (an example is the SleepSack from HALO Innovations,
halosleep.com). These provide warmth but cut the SIDS risk, as babies can’t
crawl under them or become entrapped. Again, the key goal here is to not
over-heat your baby—putting your child in a wearable blanket and cranking
up the thermostat is a no-no.
What about crib bumpers? Safety experts, including the American
Academy of Pediatrics, discourage using them. The risk of SIDS with crib
bumpers is greater than the protection bumpers offer from minor injury.
(Thach) And, no, you don’t need a mesh crib bumper to keep a baby’s arm
or leg from getting stuck between the crib rails. The risk of a trapped limb in
the crib slats is minor compared to SIDS.
Save your money, skip the bumper.

Reality Check
Another item you DON’T need: a sleep positioner—a device pitched to
parents as a way to keep their baby sleeping on their back. Sleep positioners
have been responsible for 12 U.S. infant deaths over the past 13 years, due to
suffocation or the baby rolling onto his belly. Both the American Academy
of Pediatrics and the Consumer Products Safety Commission advise against
their use.

Q. I’ve heard that standard crib mattresses are a risk

for SIDS and organic mattresses are safer. Is this true?
Short answer: no. Evidence-based medicine says conventional crib
mattresses are not a significant risk factor for SIDS. And buying an organic
mattress is not going to prevent SIDS. We’ll delve into this debate a bit more
in Chapter 16, The Environment and Your Baby.

HOW TO SWADDLE A BABY—AKA BABY BURRITO WRAP

And now, the seven steps to swaddling your baby:

1.Take a square receiving blanket and turn it diamond shaped on a flat

surface.
2.Take the top corner and fold it towards the center of the blanket. You
now have a horizontal line at the top.
3.Place your baby on the blanket with his neck at the level on the
horizontal line.
 4.Bring the bottom corner up to the baby’s belly button.
5.Bring one side corner over the baby and fold over the other side of
the belly.
6.Bring the other side corner over the baby and fold over on the other
side. Voila!
7.Remember to keep the legs loosely wrapped to allow the hips to
develop normally.

Q. Is it okay to swaddle a baby in his crib?

Yes, with a few caveats. You need to know how to swaddle and know
when to stop.
Your friendly nurses from the hospital probably taught you the “burrito
wrap” technique of swaddling your baby. If not, see the box nearby. It’s fine
to wrap your baby’s arms snugly but leave the legs loose enough for him to
move them around. Experts advise this technique to possibly prevent hip
dislocation from spending hours positioned like a mummy. A good tip if
Baby Houdini lives with you: The Miracle Blanket ($30;
miracleblanket.com). This is one blanket your baby will not be able to
squirm out of.
Newborns like to be snug for the first six to eight weeks of life. Think
about it. They are used to being in a confined space. Swaddling works well-,
until baby wants and needs to stretch out. But, after eight weeks, ditch the
swaddling trick. It is important for a baby to move and turn during sleep—
otherwise you will end up with a flat-headed baby.

Q. Okay, I put my baby on his back to sleep. What do I

do if he rolls over?
Let him sleep!
Your baby probably won’t figure out how to roll over until he is at least
four months old. Once he starts, you can’t stop him. The next morning, you
will find him in a completely different position than the way you left him!
 If it makes you feel any better, once babies are good at clearing their nose
and mouth by turning their heads, the risk of SIDS is lower.

Q. I’m concerned my baby might choke if he sleeps on

his back. Should I be?
No.
Babies have a gag reflex that protects their airway when they vomit (all
humans do). There is no increased choking risk.
As a side note, babies with gastroesophageal reflux do better with their
heads elevated 30 degrees (about the angle of an infant car seat). They
experience less heartburn that way. (That’s the way I sleep, too, after
overindulging on Tex-Mex food). Reflux babies often prefer their car seats
or hanging out in the popular Fisher Price Rock ’N’ Play for the first several
weeks of life.

Q. Can I cheat, and let my baby sleep on his side?

We can’t recommend it. Babies who sleep on their sides may accidentally
roll onto their tummies. And babies who are not used to being tummy
sleepers have an 18 fold increased risk of SIDS if they end up sleeping that
way.

Q. Can I buy one of those breathing motion detectors

and let my baby sleep on his stomach?
These products are not worth the expense—a gadget can’t prevent SIDS.
It leads to more parent anxiety and disrupted sleep when the alarm goes off
accidentally. The motion detectors you buy at the store are not the same as
“apnea monitors” that some premature infants use after they are sent home
from the hospital.
Wearable baby health monitors will probably improve over the coming
years. But right now, they are still a work in progress and largely
unnecessary. Example: the Owlet Smart Sock (owletcare.com) is a sock that
monitors your baby’s breathing and sends updates to your smartphone. At
$250, you’re better off depositing that money in a college fund than this
sock.

Q. My baby has a flat head and a bald spot on the back

of her head from this sleep position. Is this permanent?
No. This is called POSITIONAL PLAGIOCEPHALY and most kids do not
need helmets to fix the problem. As your baby starts to roll over, the head
shape will round out. All babies lose their hair around four months, and then
grow new hair in.
You can help with the head shape issue by scheduling daily tummy time.
This also promotes neck and back muscle strength. And, it helps them learn
how to roll over. (It’s easier to roll from stomach to back than the reverse).
For details on tummy time and positional plagiocephaly, see the section on
Flat Heads and Tummy Time in Chapter 5, Nutrition & Growth.

Q. Is there any risk to having a family bed?

When it comes to infants, the answer is yes. Babies who sleep in a family
bed are at greater risk of SIDS and Sudden Unexplained Infant Death
(SUID) The family bed increases the risk of smothering and entrapment,
both of which can be fatal. Waterbeds, comforters, pillows, and exhausted or
intoxicated parents in the family bed are suffocation hazards. That is why the
American Academy of Pediatrics supports room sharing, but NOT bed
sharing for infants.
However, toddlers (older than one year) can safely sleep in a shared
family bed if this is your preference.
For room sharing and safe infant sleeping, try these two tricks:
Use a bassinet (example: the Halo Bassinest Swivel Sleeper).
Move the crib next to your bed.
BOTTOM LINE
Here are the latest American Academy of Pediatrics recommendations to
prevent SIDS:

1 NO TO SIDE SLEEPING. Babies who sleep on their sides are more likely
to roll onto their tummies and increase their risk of SIDS. And infants who
are back sleepers that sleep on their tummies increase their SIDS risk by 18
times.

2 NO TO BED SHARING. The risk of smothering or entrapping an infant is

greater when parents and baby share a bed.

3 YES TO ROOM SHARING. The AAP encourages room sharing to support

breastfeeding and reduce SIDS risk.

4 YES TO PACIFIERS. For unknown reasons, the binky is protective. Just

know when to start (after breastfeeding is well established) and when to stop
(when the risk of SIDS is over) using it.

Top Ten Take-Home Messages on Sleep Safety

1.Put your baby to bed on his back.
2.Keep soft bedding out of the crib.
3.Keep the room temperature cool (68 degrees).
4.Keep the room well ventilated. Consider using a fan.
5.Don’t over bundle your baby with too many clothes. Swaddling in one
light blanket is okay. No need for a hat or cap.
6.No smoking.
7.Use a crib made after 2012 (when new safety rules took effect).
 8.Buy a new, firm crib mattress.
9.Make sure the mattress fits into the crib snugly, without gaps.
10.Lower the mattress height to the lowest level before your baby starts
to pull on the railings to stand up.

Deciding On The Family’s Sleep Routine: a.k.a. The

Family Bed vs. Solitary Sleep Debate

This debate is worthy of an introduction before we get to the details.

Where your baby sleeps is completely your decision. We are not making any
judgments on parenting styles (that means you, Attachment Parents.)
Here are two things you need to know:

1.The American Academy of Pediatrics endorses room sharing—but not

bed sharing—as a way to promote safe sleep and successful
breastfeeding.
2.Attachment Parenting International states that paying attention to a
baby’s needs at night is the priority, not the sleep location.

We’ll give you the information to make an educated decision about what
is best for you, with your baby’s health and wellness in mind.
Your options:
The Family Bed (Co-sleeping): Parents and children sleep together in
the same bed.
Solitary Sleep: Each child sleeps separately in his own sleep space
(crib, bassinet, or cradle).
The Desperation Move: Parents prefer that their baby sleep in his own
bed, but end up having him in their bed out of sheer exhaustion and
frustration with their inability to get their baby to sleep in his crib.
(See undoing bad habits section later in this chapter.)

Q. What are the advantages of a family bed?

 Convenience is a big advantage. And many parents who practice
attachment parenting view the family bed as a way to maintain secure
parent-child bonds and work the nighttime parenting shift.
For a breastfed newborn, it’s very easy to eat at night. As soon as he stirs,
his mother is there for him. This is also convenient for Mom, who might fall
asleep shortly after (or during!) those middle-of-the-night feeds. Recent data
suggest that co-sleeping babies nurse more frequently and take larger
volumes of breast milk at night than their solitary sleeping peers.
Many parents choose this option simply because it feels good to snuggle
up with their baby.
Just a bit of trivia: in the U.S., 12.8% of infants regularly sleep in a
family bed. And it’s hard to know how accurate that figure is, as some folks
may not admit to sleeping in a family bed when surveyed.

Q. What are the disadvantages of the family bed?

Potential for SIDS and SUID (Sudden Unexplained Infant Death).
The American Academy of Pediatrics policy position warns against
family bed sharing with infants due to the increased risk of death. They
strongly encourage infants to have their own sleep space.
Solitary sleep advocates argue that co-sleeping families get poor sleep
and prolong the time before a baby starts sleeping through the night. They
also feel that co-sleeping interferes with a baby’s ability to become an
independent being.

BOTTOM LINE
An eighteen-year study on parent-child bed sharing
A landmark study evaluated children who slept in a family bed as infants
and young children and compared them to their solitary sleeping peers.
These children were studied from birth through age 18 years. The data
showed that co-sleeping had no statistically significant problems or benefits.
(Okami)
Q. What are the advantages of solitary sleep?
Safer sleep for babies. And, better quality sleep for parents and children.
Bed sharing for infants, in short, is risky business. And as stated above,
breastfed babies who co-sleep are up more often at night to feed.

DR B’S OPINION

“Having a well-adjusted and happy child has

nothing to do with where he sleeps!”

Q. What are the disadvantages of solitary sleep?

Consistency is required.
A baby who is used to sleeping alone in his own bed may have more
sleep disruptions when families travel or sleep away from their home. It also
requires taking a portable crib on trips or making arrangements to borrow
one at your destination.
Babies who sleep alone need a consistent sleep ritual to wind down.

Q. With all of these night feedings, my baby ends up

falling asleep on me. Will this be a problem in the
future?
For the first two months, do anything that is safe for your baby and buys
you some sleep.
Babies are very malleable for the first two to three months of life. You are
not setting yourself up for having long-term sleep problems. If your baby
nurses and falls asleep on you, just try to peel him off of you and put him
into his bassinet afterwards.
However, your goal should be to have a consistent sleep routine by four
months of age.

Setting Up Good Habits (Two to Four Months)

Note: as we discuss the steps to establishing good sleep routines, these

are general age ranges for healthy, thriving babies. Babies who are born
prematurely or those with medical problems (such as failure to thrive or acid
reflux) may go through these sleep milestones a little later.
For the first two months of life, when it comes to you and your baby’s
sleep, you gotta do what you gotta do—nursing, rocking, infant swing, a car
ride, etc. You know the drill.
Guess what? Your baby is now nearly four months old. It’s time to stop
those old habits.
Why? Your baby is becoming more aware of her environment. She will
respond better when things are predictable, anticipating what is next. She
will also start to form sleep associations. That means your baby will rely on
certain routines to fall asleep. Those routines are the good sleep habits you
want to keep. And now is the time to punt the bad habits. Think about it—
you really don’t want to be rocking your five-year-old to sleep every night,
do you?
For the nitty gritty on forming good sleep habits, check out our Ten
Commandments for establishing a sleep routine in the box nearby.

Q. When can I start to schedule my baby’s naps and

bedtime?
Between two and four months of age, your baby will start to have some
regular sleep and feeding patterns (finally). Keep a sleep/feeding diary for a
week and you’ll know your baby’s preferences.
Then you can put your baby down for naps and bedtime before she shows
you that she is tired (cranky, rubbing eyes—you’ve seen it all before). The
key word in that previous sentence is BEFORE. Once you see those sleepy
signs, she is actually overtired.
Start your wind down routine before that happens by aiming for
nap/bedtime about 20 minutes earlier than what your sleep diary shows. Not
only will you have some idea how to schedule your day, but you’ll give your
baby the best shot at falling asleep on her own.
You’re in the driver’s seat now and can put your baby on a schedule she
already likes—yes, YOU have the power!

Q. My three month old only falls asleep while feeding.

How do we change that habit?
You will be walking a fine line between two and four months of age. Your
goal is to separate the eating experience from the sleeping experience. Your
baby may not need to eat to fall asleep, but you won’t know until you try!
And if you fail the first time, try again the next week. Your baby is maturing
at the speed of light. At this stage, a week older is a week smarter.
In the middle of the night when you hear your baby cry . . . walk, don’t
run, to your baby’s bedside. She might just go back to sleep without your
intervention.
You can also try soothing your baby without offering food if you have
frequent night wakenings. Your baby may not need to eat every time and is
just relying on you to help him get back to sleep. If you are breastfeeding, let
Dad try to be the soother. There will be less expectation of food if he shows
up. But if it has been more than four hours or so since the last feeding, you
will probably have a hungry baby on your hands who needs to eat.

INSIDER SECRETS: TOP 10 COMMANDMENTS

FOR ESTABLISHING A SLEEP ROUTINE (2 TO 4 MONTH
OLDS)
1 TEACH YOUR BABY TO FALL ASLEEP ON HIS OWN. Remember
those sleep cycles? The cycle consists of light to heavy to light arousal
before entering the next cycle. At the end of each cycle, humans
recheck their environment and change body position (move a pillow
or blanket, roll over). By three to four months of age, your infant will
be aware of his world. If he falls asleep on a parent’s shoulder and
gets moved to a crib, or falls asleep when he is drinking or sucking a
pacifier, that is what he will be expecting when he arouses at the end
of his sleep cycle. Translation: be careful of sleep “crutches” like the
pacifier. Put your child in a crib or bassinet when he is sleepy . . . but
before he falls asleep. If the child always falls asleep on your
shoulder, he will expect to see that shoulder at the end of every sleep
cycle.

2 BE CONSISTENT. KIDS DO BEST WITH ROUTINES. Predictable is

comfortable. You will learn that rapid transitions and unexpected
activities promote anxiety and outbursts in your child (see Chapter 11
Discipline & Temperament for details). Have a routine for both nap
and bedtime and stick with it by the age of four months.

3 YOUR CHILD SHOULD ALWAYS SLEEP IN THE SAME PLACE FOR

NAPS AND NIGHTTIME. That’s not the car seat or the infant swing
anymore. Reality check: yes, every now and again your child may fall
asleep in a car seat, especially after a long trip on the weekend for
example. That’s OK on an occasional basis. But when you are at
home, keep the sleep place the same.

4 NAP TIME AND BEDTIME SHOULD BE APPROXIMATELY THE

SAME TIME EVERY DAY. That goes for vacations, visits to relatives,
etc.

5 ALWAYS FOLLOW YOUR SLEEP RITUAL. Bath, feeding, (teeth

brushing), story-time, songs, prayers . . . you might do the abbreviated
 version of a book or song if it has been a long day, but still do it.

6 START YOUR SLEEP RITUAL BEFORE YOUR CHILD IS TIRED.

Don’t wait for the yawns and eye-rubbing to begin the routine.

7 EARLY TO BED, LATE TO RISE. Sounds like it wouldn’t work this

way, but it does. Babies actually sleep better when they go to sleep
early. An “overtired” baby does not sleep longer —so, you are not
buying time to sleep in by putting your baby down later in the
evening. Trust me on this one.

8 GET RID OF THE PACIFIER BY FOUR TO SIX MONTHS OF AGE.

Your baby is very aware of his world. If he falls asleep with a pacifier
in his mouth, he will cry when it falls out. At 3am. And 5am.

9 BABIES NEED REFRESHER COURSES ON SLEEP ETIQUETTE

AFTER TRAVEL, ILLNESS, OR TEETHING. When consistency is
broken, it takes a few days to get back on track. If you don’t remind
your baby of what to do, he will remain on a disrupted sleep schedule.

10 DON’T TREAT YOUR FOUR MONTH OLD LIKE A

NEWBORN. Your baby will take advantage of your naiveté. Many
four month olds are capable of falling asleep on their own if given the
opportunity to do so.

The Big Transition: (Four to Five months)

Q. My four month old still needs help falling asleep.

What do I do?
 You can gradually cut the virtual umbilical cord. Your goal is for your
baby to fall asleep on her own—without feeding or rocking her to sleep.
Now that she is four months old, set up a consistent sleep ritual. If she
falls asleep during the feeding, wake her up before putting her in bed so she
is aware of where she is going. You are creating a healthy bedtime ritual—
and one that lets your baby be in charge of falling asleep.
Give her at least ten minutes to try to fall asleep on her own. Yes, she may
protest (code word for cry) and that is okay. She is learning how to self-
soothe. If she cannot fall asleep, go back in and do as little as possible to
relax her. Try patting, singing to her, and cuddling her for a few MINUTES
(not hours). Rocking her until she is dead weight on your shoulder or nursing
her to sleep is the last resort.
The exact method of transitioning to a better sleep pattern varies for each
baby. Basically, you do as little as possible and give your baby more time to
work things out on her own. Thirty minutes is a reasonable amount of time
by five months of age.
If your healthy, thriving baby still does not fall asleep on her own by five
months, you can use the “progressive waiting” or “rapid extinction” methods
so she can figure out how to self-soothe (more info later in this chapter). The
same rules apply for frequent night wakenings.
Consistency is key. Do the same ritual for both nap and bedtime.

DR B’S OPINION: FOUR MONTH

OLDS AND SLEEP

Your four-month old baby is aware of his surroundings. If he falls

asleep in your arms and you sneak him into bed, he will awaken at
the end of his sleep cycle (every 90 minutes) looking for comfort. If
your child is awake when you leave the room, he will fall asleep
alone and content. You’ll hear him on your baby monitor discussing
his day with inanimate objects. Your baby is growing up—realize
and adapt to this!
Q. I’ve heard babies are more likely to sleep through
the night if their tummies are full. What do you think of
“dream feeds”?
For newborns, feeding and sleep patterns are intimately related. Babies
under two months of age need to eat frequently, usually every two to three
hours day or night. That means they can’t sleep very long because they get
hungry. Babies start to stretch out feedings at night (and give parents a small
break) at two to four months.

DR B’S OPINION: IS CRYING IT

OUT CRUEL?

I encourage you to give your baby a chance to fall asleep on her

own. Obviously, you have to do what you feel comfortable
with . . . but it is not cruel or inappropriate (from a child
development perspective) to give a healthy baby the freedom to self-
soothe from four to six months of age. Otherwise, I’d never advise it!
Yes, there are parenting circles that vehemently oppose this sleep
training approach. They like to cite research that it causes permanent
emotional damage to the child. I’m here to say that is absolutely
untrue. In fact, a recent study looked at five-year-old children who
went through sleep training as babies and guess what? They were
completely normal, well-adjusted kiddos. (Price)

However, as babies get older, their ability to sleep through the night has
more to do with their brains than their guts. Your healthy, growing four
month old is capable of sleeping at least six hours without needing to eat.
Don’t let her fool you. The key to Mr. Sandman’s house resides in your
ability to teach your baby self-soothing skills . . . not stuffing her full of
milk.
 For a full-term, healthy thriving baby (who doesn’t have acid reflux), here
are some helpful feeding parameters:
Four month olds: Can sleep SIX hours without needing to eat.
Five month olds: Can sleep NINE hours without needing to eat.
Six month olds: Can sleep TWELVE hours without needing to eat.

Some parents will try to feed a sleeping baby (a.k.a. Dream Feed) before
they go to bed, hoping to catch that six-hour stretch during the hours they
want to actually sleep. For example, instead of your baby fasting from 8 pm
—2 am, he fasts from 11 pm—5 am. While this sounds great in theory, I am
not a big fan of this strategy. I think it sets up a habit of feeding a child when
he isn’t hungry, and it in no way guarantees you’ll sleep until 5 am. Second
problem: cavities. Many parents continue night feedings long after their
baby has teeth (around six months of age). Unless you plan on brushing your
child’s teeth after that dream feed, you will be paying for your dentist’s kids
to go to college.
If your baby learns how to soothe himself, you’ll have better odds of
sleeping through the night.

Undoing Bad Habits (Five to 12 months and beyond):

Solving the Sleep Problems

If you have a healthy baby who is still not sleeping at least six hours a
night, or you are bringing your child to bed with you out of desperation (and
not choice), this section is for you. Admitting you have a problem is the first
step! Don’t say we didn’t warn you: if you set up healthy sleep routines up
front, you won’t have to endure the (often) highly emotional experience of
sleep training.
The International Pediatric Sleep Education Task Force found that 25% of
ALL parents report problems with their baby’s sleep patterns . . . no matter
what country they live in. You are not alone. (Touchette)
 DR B’S OPINION: SLEEP STATS TO
KNOW

These stats are based upon my 20 years of experience working

with babies of all shapes and sizes:
At least 50% of healthy four month olds can fall asleep on their
own.
At least 75% of healthy five month olds can fall asleep on their
own.
100% of healthy six month olds can fall asleep on their own.

Behind the Scenes

Is there a correlation between parents’ behavior and infant’s sleep?
A recent Canadian study showed that many infant sleep disorders were
based on parents’ excessive intervention in comforting them to sleep. These
parent behaviors with their five month olds included:

1. Putting a baby in bed after he was asleep.

2. Remaining in the room until the baby was asleep.
3. Taking the baby out of his bed to comfort him.
4. Parent feelings of inadequacy.

A significant percentage of these babies continued to have sleep problems

well into their third year of life.
BOTTOM LINE: Don’t just wait for your baby to outgrow his sleep issues—it
may be a long time waiting. And the issues may belong to the parent and not
the baby. (Willinger)

New Parent 411

I’ve had parents resort to some pretty crazy strategies in the name of sleep.
One mom admitted to sleeping with her baby in the crib. Another mom
turned her blow dryer on for an hour every night as a form of white noise.
Both agreed to share their stories to protect our readers from making the
same mistakes!

Q. My baby started sleeping through the night at three

months old. She is five months old now and waking up
in the middle of the night again. Help!
Babies who are early to start sleeping through the night (less than three
months old) frequently start up again when they become aware of their
surroundings.
These are babies who never needed the sleep rituals before. They just fell
asleep eating and were placed into bed. Now, they are alert little beings and
need to learn how to fall asleep on their own.
When your former perfect baby starts having night wakenings, it will be
at the end of a sleep cycle (a multiple of 90 minutes after bedtime). That’s
when you know your baby’s current sleep routine has backfired. Start using
a sleep ritual that lets your baby fall asleep on his own.

Continued here
 DR B’S OPINION: BEEN THERE,
DONE THAT

I am a parent. I have walked in your shoes. I know that irrational

thoughts seem rational at 3 am. It SEEMS EASIER to just bring your baby
in bed with you or nurse them to sleep. But it is not the right answer
anymore.
Once you are on the other side (sleeping through the night), you’ll say,
“What was I thinking?” I am happier and so are my children when we have
all slept at night.

THE TOP TEN MISTAKES PARENTS MAKE WITH

INFANT SLEEP ROUTINES

1. Sneaking baby into bed. Your baby falls asleep in your arms, and
then you sneak him into his crib. Compare this to the following
scenario, courtesy of acclaimed sleep expert Dr Ferber. You fall asleep
on the couch in front of the TV. Your spouse picks you up and carries
you into your bed. When you wake up in your own bed, you are
disoriented and alarmed. Your baby feels the same way—and hence,
wakes up and wants your arms back!

2. Falling asleep while eating. Your baby falls asleep when he is

drinking (breast or bottle). When he stirs, he is in a different place and
not eating anymore.

3. Falling asleep with a pacifier. Here is the comparison, again credit

to Dr Ferber: You fall asleep with your head on your pillow. In the
middle of the night, your spouse steals your pillow. When you wake
up, you are confused and probably annoyed. (Ferber)

4. The Trained Night Feeder. Your baby gets used to eating a snack
or a meal in the middle of the night, so he continues to be hungry at
that time. Equate this to working the nightshift and having your lunch
break at 3 am. Yes, your body will work up an appetite if you are used
to it. Stop eating at 3 am, and your body will no longer be hungry.
Parents frequently continue these feedings well beyond six months of
life because they don’t know any better and their babies continue to
demand it.

5. Inconsistent schedules. Babies are creatures of habit. Adjust your

schedule as much as possible around your baby’s. Don’t change your
baby’s bedtime because you got home late from work and missed
spending time with him. Pushing back your baby’s bedtime for selfish
reasons is always a recipe for disaster. Tomorrow is another day.

6. Missed naps. The better your baby sleeps during the day, the better
he will sleep at night. Being overtired actually creates sleep
disturbances. So, don’t run errands when it is your baby’s naptime.

7. Late to bed equals EARLY to rise. This is really true, even though
you would think the opposite. As we’ve said, overtired babies sleep
poorly.

8. Interventions at partial wakenings. Just because your baby stirs at

night, does not mean he needs your help. We all stir at the end of each
sleep cycle (every 90 minutes). If you go in “to help,” you will wake
your baby up. If these partial wakenings are waking you up, turn off
the baby monitor. If your baby really needs you, you will hear him. As
Dr. B’s husband would say, “Everyone sleeps better with the monitor
off!”

9. Bringing baby into bed when you don’t want him there. Babies get
used to routines. If you consistently bring your baby into your own
bed when he cries, this is what he will expect. He will continue to cry
 until he gets what he wants. If the expectation is not there, the
behavior won’t exist. Make a plan between BOTH parents and STICK
WITH IT.

10. Not letting your baby learn how to self-soothe. The ability to
soothe one’s self is a learned skill. This skill can be mastered by six
months of age, if your baby is given the opportunity. Yes, both thumb
sucking and comfort objects (see below) are acceptable. Those Old
Wives are correct about “spoiling” if you coddle your older baby.

Q. My baby uses a pacifier to fall asleep. When

should we stop offering it?
We’ll discuss the Great Binky Debate in the section on Soothing a New
Baby in Chapter 11, Discipline and Temperament. But when it comes to
healthy sleep routines, we suggest saying goodbye to the binky by six
months of age.
In the first two or three months of life, babies have very few ways to
soothe themselves. Parents usually figure out within the first few days of
bringing their baby home that a pacifier buys everyone some sleep. This
approach is fine for the first few months.
BUT, do not use a pacifier beyond six months of life. Trust me. This is
the time when you need to set up the routines you plan to keep. What if
someone stole your pillow while your were sleeping? If the pacifier falls out
in the middle of the night, your baby will be looking for it.
You don’t want to have a baby who is capable of sleeping through the
night waking because the pacifier is out. If the pacifier isn’t there to begin
with, he won’t be looking for it.

Helpful Hints
Don’t place dozens of pacifiers in your baby’s crib so he can find one
on his own.
 Don’t go in every 90 minutes to put a pacifier back into your baby’s
mouth.
Don’t buy a glow-in-the-dark pacifier so your baby can find it at night. I
promise that your six-month-old can fall asleep without the pacifier.
Don’t get stuck treating your older baby like a newborn!

Q. My eight month old can only fall asleep

nursing/taking a bottle. When will he outgrow this?
Your baby has been capable of it since four or five months of age. But he
will continue to do it much longer if you let him. Feeding has become his
crutch to fall asleep.
Again, for the first two months of life, anything goes. The optimal time to
change this behavior for a full-term, healthy baby is around four months. But
if you missed the window of opportunity, it’s not too late. Babies are
resilient and adaptable. If he falls asleep while feeding, wake him up just
enough so he knows he is getting into bed and you are leaving the room. Be
prepared for some protesting the next few nights, but he will adjust soon.
It’s much easier to change these behaviors now. Your child isn’t going to
wake up one morning and move on from this routine—you need to actively
change it. (I once consulted with a family whose five YEAR old still drank
milk to fall asleep every night. Don’t let this be your kid!)

Q. Are comfort objects okay to put in the crib?

Yes, at one year of age.
Comfort objects are also called transitional objects because they help a
baby transition from needing their parents 24/7.
You can offer a comfort object during the day at any point, but it’s safest
to use—a little blanket or small stuffed animal that can go to bed with your
baby, starting at one year of age. Remember, SIDS occurs in babies under
age one. Just make sure the comfort item you select is small/light enough
that it is not a smothering or suffocation hazard.
Q. My nine month old still has a middle of the night
feeding. Is there something wrong with him?
He is a trained night feeder. There is nothing wrong with him. You’ve just
allowed him to get part of his nutritional needs met during the night beyond
when he needs them. Healthy, full term babies are all capable of fasting for
up to 12 hours at night by six months of age. As long as your baby is
growing well, read on.*
Stop the night feeding and he will stop being hungry. That’s easy to say,
right? Offer water at 3 am and see what happens. It’s likely to be rejected the
first night. And yes, your child will protest. The second night, offer water
again. The protesting will be less lengthy. By the third night, your baby
won’t bother to wake up.
*Some babies nurse all night long because mom’s milk supply has
diminished and they are truly hungry. If this is a possibility, it is best to visit
the doc and do a weight check before making any interventions.

Reality Check
It’s likely that your nine-month old has at least one tooth.
Therefore, offering milk at night without brushing his teeth afterwards
may be a set up for cavities (milk has sugar in it). Be honest—you aren’t
getting out the toothbrush at 3 am after your child has crashed on your
shoulder. The answer: STOP THE NIGHT FEEDING.

Q. What sets off disrupted sleep patterns?

Travel, teething, and illness. Any change in routine will disrupt a child’s
perfect sleep pattern.
Q. How do I get my baby back on track after a
disrupted sleep schedule starts?
A quick refresher course in the preferable, normal sleep routine is helpful.
It may take just one or two nights, but be consistent with the routine you
want to re-establish. Let him fall asleep on his own. Do not offer an
additional night feeding. Do not bring him into your bed if he usually sleeps
in his crib.
If you continue to intervene (a.k.a resorting to whatever it takes to get
everyone back to sleep), your baby will demand his new “normal” routine.
And trust me, these disrupted and sleepless nights are not what you or your
child wants in the long run. As a doc, I am very comfortable recommending
either “progressive waiting” (a.k.a. Ferberizing) or “rapid extinction”
depending on how you feel about it. More on this below.

Q. My nine month old sleeps through the night, but she

likes to start her day at 5 am. Can we change that?
You can adjust it somewhat, but some kids are early risers. Some tips:
First, pick a reasonable time to start the day–like 6 AM (sorry about
that!). When you hear your little one making noise at 5AM, wait until 5:15
or 5:20 before going to her. The next morning, wait until 5:45. By the third
morning, you can begin the day at 6 AM.
Next, try to put her down a little earlier at night. Early to bed often means
late to rise-the opposite of what you might think.
Finally, try putting a few board books in her crib. She can look at them
for a while until the sun comes up. Some babies will decide to play, others
will go back to sleep. But let her decide what to do. Your presence signals
the beginning of the day.

Helpful Hint
A baby’s bedtime usually falls between 7pm and 8:30pm. Just because your
baby or toddler is bouncing around the living room doesn’t mean he isn’t
tired. Don’t fall for this trick! Wired = tired.

Q. There are so many books written about infant sleep.

What do you think about them?
The market has spoken: babies and their parents are desperate for a good
night’s sleep! If you are looking for more information, there are a few books
that are worth reading.
Here are our opinions of the leading sleep authors and their books. You
are welcome to read all of them and decide for yourself what works for you
and your family. And, if you are a co-sleeping, attachment parent family, you
can just skip right past this section of the chapter. First, the nearby table
sums up the background and theory of each guru. Then below we offer a
more detailed description of each.

1 SOLVE YOUR CHILD’S SLEEP PROBLEMS, FERBER. Theory:

“What parents view as abnormal wakenings in the night are actually normal.
What they do to treat the ‘abnormal’ wakenings—namely going in to help
their child go back to sleep—is actually causing the disturbance.”
For the first four months of life, parents need to create positive sleep
associations, routines, and rituals. If your baby is not sleeping through the
night (six hours of uninterrupted sleep) by five or six months of age, it is
time to train or un-train (break bad habits) your baby to stop the night
wakenings.
Note: Babies under four months of age are not neurologically mature
enough to settle and console themselves. This method is not intended for that
age group.

Ferber Method, in a nutshell:

1.Do not let your baby fall asleep feeding, rocking, or being stroked by
you.
2.Provide the identical sleep ritual (books, songs, cuddling) at nap and
bedtime.
 3.Have your baby sleep in the same place for naps and bedtime.
4.Avoid sleep crutche. (i.e. pacifiers).
5.Put your baby down relaxed, but not asleep.
6.Progressive waiting. If your baby protests, you make a brief
appearance at increasing intervals (add five minutes each time) to
reassure your baby that you have not abandoned him. This is NOT
intended to console your baby. In fact, he will yell louder.
Eventually your baby falls asleep on his own.

Pros: This method works! And it works quickly—usually in three or four

nights. Dr. Ferber is truly one of the world’s experts on sleep disorders in
children. His book thoroughly explains the science of sleep at a level that
parents can understand. He explains his method clearly with good detail and
examples.
This book also addresses the gamut of all childhood sleep disorders, not
just infant sleep problems. It is an excellent reference for night terrors, bed-
wetting, sleep walking, etc.

Cons: Yes, your child will cry. Yes, the first night will be ugly. The second
night is less ugly. The third night is manageable. The fourth night, your baby
has a smile on his face and so do you. Your baby will be fine. Parents are
always guilt-ridden when they hear their baby crying. More on this later.
As in every method, there are occasional setbacks. Illness, teething, and
travel create sleep disturbances. Kids need an occasional refresher course
(shorter than the initial training) to return to the normal routine!
Grade: A

Table: Sleep Gurus Compared

Reality Check
There is no one-size-fits-all approach to infant sleep training. But babies
thrive on consistency and routines. And, setting up good sleep habits up
front prevents sleep problems down the road.
2 HEALTHY SLEEP HABITS, HAPPY CHILD, WEISSBLUTH.
Theory: Good sleep is critical to good behavior and functioning. Overtired
children have a lower frustration tolerance (short fuses), more behavior
problems, and more difficulty falling asleep. Parents, with good intentions,
perpetuate their child’s poor sleep habits unintentionally with their actions.
Common pitfalls are thoroughly explained.

Weissbluth Method, in a nutshell:

1.Set an earlier bedtime to get baby down BEFORE he is overtired. This
may limit the evening playtime after a working parent comes home,
but makes for a happier child.
2.Naptime should be preserved at all costs.
3.Let your baby learn the process of falling asleep by letting him do it
on his own.
4.Rapid extinction. If your baby is already in a vicious cycle of being
overtired, end this cycle abruptly by letting him cry until he falls
asleep on his own (after four months of age). This strategy is called
the “Let Cry” Plan, and it takes one night to accomplish.
5.Weissbluth offers the “Maybe Cry” and the “No Cry” Plans which are
more gradual approaches for parents who can’t handle crying.

Pros: This method works quickly—in one or two nights. Dr. Weissbluth
provides an understandable, in-depth discussion of sleep physiology. He
teaches you how to set up healthy sleep habits so you won’t have to resort to
breaking bad habits down the line.
The author provides true stories that will hit home with many of the
parents that read this book. There is even a chapter written by a psychiatrist
that is very insightful about parenting styles and how these styles impact a
child’s sleep routine.

Cons: Breaking the vicious cycle can be one very long night of crying (both
on the part of the baby and the parent). Many parents don’t have the stamina
to let their child cry for more than 15 minutes, even if it is in their child’s
best interest. (See why parents can’t let their child cry later in this chapter).
In Weissbluth’s defense, he expands his alternatives to letting the child cry
for those parents in his latest edition.
Grade: A

PROGRESSIVE WAITING OR RAPID EXTINCTION?

Let’s break this down so you understand how to implement these

techniques in the real world. Both progressive waiting and rapid
extinction work. It just depends on your tolerance level. Will you
suffer in small doses over a period of nights (progressive
waiting) . . . or suffer one long sleepless night (rapid extinction). Note:
the parent is the one in agony. Your child is going to be just fine.

Progressive Waiting (a.k.a. Ferberizing)

1.Get your child relaxed, put him in his crib, and say goodnight.
2.Your child will start complaining.
3.On night one: Wait three minutes before returning to the nursery.
4.When you enter the nursery, make your response short and sweet (no
more than 60 seconds). Tell your child you love him and say
goodnight. Do NOT pick him up, rock him, or feed him. Leave
the room. The purpose is for you to see that your baby is just fine
and for your baby to know you have not gone to Brazil.
5.Your baby cries louder. (No surprise here.)
6.Wait five minutes before returning.
7.Repeat step 4.
8.Your baby sounds possessed. (They usually get louder once you
leave).
9.Wait ten minutes before returning.
10.Repeat step 4.
11.Wait ten minutes before returning (this continues for the rest of the
night).

This process requires your baby to do the work to fall asleep (yes,
he is quite capable). The first night will be very difficult to tolerate.
 Don’t back down once you have committed to this plan. When
your baby wakes up the next morning, he will be happy to see you.
The second night is much easier. The night’s events will last half as
long as the first night.
The third night may last only ten minutes. By the fourth night,
your baby will have adjusted to his new sleep schedule.

Rapid Extinction
Get your child relaxed, put him in his crib, and say goodnight.

If you are looking for steps #2 or #3, you won’t find them. Yes,
this is one long night. But guess what? Your baby will figure it out
and move on to a new, healthier sleep routine of falling asleep and
staying asleep.

Some final thoughts:

1.These techniques only work when your baby is neurologically
mature enough to settle on his own—five or six months old. If
you set up healthy sleep routines in the first place, you won’t have
to break the bad ones.
2.I always recommend doing this over a weekend. Otherwise, you will
be cursing me the next day at work.
3.You can’t give in or give up once you start.

3 SLEEPING THROUGH THE NIGHT, MINDELL. Theory: Ditto

Ferber and Weissbluth, sprinkled with a bit more reality.

Mindell Method, in a nutshell:

“All you want is that golden moment when your child falls asleep
independently. How you get there doesn’t really matter.”
1.Set up a sleep routine and be consistent about it.
2.Allow your child to fall asleep on his own.
3.Check on your baby as frequently or infrequently as you and your
baby can tolerate.
 4.Resist the temptation to resort to past sleep crutches at the beginning
of the night (like rocking or nursing to sleep) once you’ve started to
let your baby self soothe. It’s okay to do whatever it takes (rocking,
nursing to sleep) in the middle of the night until the sleep training
process is complete.

Pros: Mindell’s method gives a bit more wiggle room for parents who are
squeamish about the whole crying thing. However, her take home message is
essentially the same. As she says, “Setting limits for your child is part of
being a good parent . . . it’s a tough job, so don’t feel guilty when your child
doesn’t like what you just told him to do.” Her writing style is warm and
engaging. It’s the easiest to read, and thus, probably my favorite of the sleep
books.

Cons: Mindell gives the green light to prolonged pacifier use (up to age
four!) and dream-feeds. Since I don’t really care for either of these sleep
crutches, we’ll have to agree to disagree on these points.
Grade: A

4 THE BABY BOOK, SEARS. Theory: Babies need positive sleep

associations. To Dr. Sears, this means your baby should be skin to skin with
you during sleep. Dr. Sears once said in a Child magazine interview (1998),
“Why would a parent want to put her child in a box with bars in a dark room
all by herself?”

Method: The family bed fosters attachment parenting. There is no reason to

force your baby to sleep through the night or discontinue night feedings.

Pros: Many cultures use the family bed. If this is your plan, this is the
guidebook. Attachment parenting, for those who desire it, is rewarding for
both parents and baby.

Cons: As discussed earlier, there are safety concerns for babies who sleep in
a family bed. Co-sleeping should also be a choice both parents vote for.
Sometimes, only one parent is in favor of the family bed (the mother). Dad
agrees to the family bed because his wife is exhausted from the frequency of
having to get up for breastfeeding sessions. Eventually, Dad moves out to the
couch or the spare bedroom to get some sleep.
Our opinion: we know that there is no one-size-fits-all approach to infant
sleep training. We don’t have a problem with attachment parenting advice,
but the way the Sears’ present their method as the preferred way to have
happy well-adjusted child. We think parenting should be guilt-free.
Grade: B-

5 THE NO CRY SLEEP SOLUTION, PANTLEY. Theory: Babies

develop associations with sleep that become a crutch (co-sleeping, feeding to
fall asleep). Pantley says breaking these bad habits by letting the baby cry is
insensitive and cruel. The focus is on establishing good routines and earlier
bedtimes before missing the window of opportunity.

Method: Author provides 20 ideas that promote good sleep associations and
routines. She tested her method on 60 families with infants.

Pros: Some families just can’t listen to their baby crying. This book
provides some ideas for establishing sleep rituals.
We agree with many of the author’s comments on establishing sleep
routines, although none of them are unique to her book. She does a nice job
of addressing how to transition a co-sleeping child to his own bed.
She suggests that parents compile data on their own child and then make
a personal plan for addressing their child’s sleep disturbances.

Cons: Author admits that following her approach may take up to eight weeks
to be successful. Perhaps a prescription for Prozac could be included for the
parents when they buy her book. Most sleep-deprived parents are at the end
of their rope at week ONE!
Ms. Pantley focuses on families who choose attachment parenting and the
family bed. Her answer to reducing night feedings is to pretend to be asleep
—not very realistic.
Grade: C
6 ON BECOMING BABYWISE, EZZO AND BUCKNAM. Theory:
Parents mistakenly create a high need baby by having a “child-centered
universe”—only the child’s needs are prioritized. According to the authors,
parents who feed their babies “on demand” create this flawed system. The
result? Exhausted parents and breastfeeding failure.
As an alternative, the authors promote a family-centered lifestyle where
the needs of the family are the priority. The parent makes the schedule
(known as “parent directed feedings” or PDF). The parent is the one who
initiates feedings, wake time, and naptime for the baby—which need to occur
in that exact order. The authors emphasize the importance of starting this
routine in the first days of life. The first edition of this book was extremely
rigid in scheduling a newborn’s feedings.
The most recent edition of Babywise (5th editon, 2012) is more flexible
and attempts to move away a bit from fixed hyper-scheduling. The authors
tell parents to look at the newborn’s hunger cues and the clock, and then
assess whether or not it is time for the baby to eat. Hence, your baby doesn’t
need to nurse every 20 minutes, and if he does, he may not be getting
enough breast milk. We agree with this. The 2012 edition offers tips on
breastfeeding challenges and includes healthy baby growth charts. And, the
authors discourage letting babies under four weeks of age go any longer than
four to five hours between a feeding. The memo to parents: do not deprive
your baby of food in an attempt to get him to sleep through the night.
The whole premise here is that good sleep patterns arise from good
feeding patterns. The order should be eat-awake-sleep, not awake-eat-sleep.
Babywise recommends putting your newborn into bed awake from day one.

Babywise Method, in a nutshell:

1.From birth to eight weeks of age, feed the baby every 2-3 hours. That
is timed from the beginning of one feeding until the beginning of
the next. Aim for a full feeding, not a snack.
2.Aim for a “first morning feeding” by eight weeks, which regulates the
day and night’s sleep schedule. If the baby awakens before the
scheduled “first morning feeding,” wait to see if he will fall back
asleep without feeding.
3.Naptime is scheduled for the last one to one and 1/2 hours of each eat-
awake-sleep cycle. Put your newborn down awake. Fussing or
 crying for 15-20 minutes is acceptable in the settling down process.
4.Stretch out feeding schedules after eight to twelve weeks. Sleep
clusters will expand because the baby has been trained since day
one.
5.There will be situations where you will have to deviate from routine.

Pros: According to the authors, 95-97% of their babies are sleeping through
the night at 12 weeks of age. (Babies who were born prematurely and those
with acid reflux take longer.) They offer up results of their own study of 520
babies (which does not appear to be published in a peer reviewed medical
journal). One message we like: the importance of nurturing the family
relationship.

Cons: The first edition of this book was so contrary to mainstream pediatric
practice that the American Academy of Pediatrics issued a rare alert about
this book.
However, the kinder, more flexible 5th edition is much more in line with
what the AAP recommends for feedings.
The biggest red flag: the idea of leaving a newborn to settle on his own
for 15-20 minutes is anathema to most pediatricians (and parents). Newborns
are incapable of self-soothing. You can’t ignore them and let them cry it out
eight times a day. For that reason alone, I can’t recommend this book.
Grade: F

Q. I tried letting my child “cry it out” and it didn’t

work. Help!
There are a couple of reasons why attempts at sleep training fail:

1. A determined child.
2. A tired parent.

Let’s tackle the child issue first. Yes, some babies protest more than
others. It is completely normal for a child to push back when he is asked to
change and try something new.
 Most babies will cry for 45 minutes and then fall asleep. A few, really
vocal ones, may go on for an hour or two. Most babies will adapt to self-
soothing after a few nights. A few, really determined ones, may protest for a
week or more.
We understand that if you are living with the vocal, determined baby that
you will only have so much will power to follow through with this self-
soothing, baby-in-charge-of-falling-asleep game plan. If this is your
situation, it’s okay to go in for a brief intervention. Do some snuggling or
singing but don’t completely rock your baby to sleep . . . because then you
just taught your baby that a long tirade achieves the objective: a parent’s
shoulder to fall asleep on.
Note: although most babies adapt very quickly, there are a handful of kids
who may not be ready for this approach quite yet. For those babies, take a
complete break from sleep training and try again in a few weeks.
Now, let’s talk about you. Most parents are unsuccessful because they are
either too exhausted or don’t feel right about letting their baby cry. We know
it can be nerve-wracking.
Here is my pep talk to give you the incentive to persevere.

1.What you are doing currently is not working.

2.Nothing is medically wrong with your child.
3.Nothing will happen to your child if he cries.
4.Your child will not hate you or feel you have abandoned him. Your
baby will be HAPPY to see you the next morning and you’ll be
happier to see him.

Feedback from the Real World: Multiples

One parent wrote of her nine-month-old twins:

“You’ll be interested to know that they slept through after the second
night. I guess they were as ready as I was.”

Here’s another reader comment from a mom of twins:

 “‘Crying it Out’ is a frightening term to most parents. But truth be told,
fear is often times worse than the actual event itself. It was such an
intimidating undertaking for us, but once we started, it only took two nights
before they learned how to self-soothe. And contrary to what you might
think, the crying twin rarely awakens the other twin. They have been
sleeping through the night since six months for 12+ hours a night!”
—Agustina, mom to twins Gael and Malena

Q. I know I am being a wimp, but I don’t think I can

listen to my baby cry.
Be strong. You can do it.
As a baby sleep consultation expert, here is my perspective. Yes, your
baby is mad that he is not getting his way. You will see a lot of this behavior
in the years to come (a preview of the toddler and teenage years)! Remember
when you were 16 and your parents didn’t let you borrow the car? Did you
still love them? Your child will still love you, even when you set limits on
his behaviors (including sleep).
I know, easy for us to say. But as moms, we’ve been there and know what
you are going through. Follow the advice in this chapter and you can do it.

FIVE REASONS PARENTS CAN’T LISTEN TO THEIR BABY CRY

1.You feel like you are helpless and not “doing anything” for your
baby (not true).
2.You are a working parent and feel guilty (don’t).
3.You think you will cause your baby to have long-term emotional
scars (you won’t).
4.You think you are an inadequate parent if you can’t get your baby to
settle down (you aren’t).
5.You think something must be wrong with your baby (probably not).
 DR B’S OPINION: WHICH SLEEP
METHOD IS BEST?

By far, my patients’ families have had the most success with

progressive waiting or rapid extinction (the methods found in Ferber,
Weissbluth, and Mindell’s books). Which works better for the
individual child depends on the parents’ ability to cope. Some
parents prefer to go into the nursery to check on their baby. Others
prefer to avoid seeing the drama unfold. Either way, the baby learns
to self-soothe. If you have a video baby monitor, you may be more
willing to wait it out outside the nursery.
Yes, your baby will probably (okay, almost definitely) cry. If you
avoid our “top ten mistakes” and follow through with your plan, the
crying is a one night to one week (at most) experience. Your baby is
resilient and has the wings to fly. Give her the chance to use them!
For parents who “just can’t let their baby cry,” I offer these words
from Dr. Weissbluth: “Have the courage to do what is best for the
child.”
As Dr. Mindell points out in her sleep book, sleep training will
NOT a) cause your child harm, b) affect your child’s attachment to
you or c) make your child emotionally scarred for life. In fact,
studies have shown that kids who sleep well are well adjusted and
have fewer behavior problems than kids who are up several times a
night. Studies have also found that “young children are more
securely attached to their parents following sleep training.” (Mindell)
Anti-CIO (Cry It Out) activists claim that infant crying causes
elevated stress hormone (cortisol) levels and permanent damage.
However, the studies that critics refer to were NOT done on the
impact of sleep training techniques. Those studies looked at babies
who cry all the time (not just at bedtime) beyond three months of life
to detect early signs of neurological or developmental delays. (Rao,
Stifter)
 According to Dr. Mindell, “The positive results of weeks and
months of a good night’s sleep clearly outweigh a few nights of sleep
training. Not only are babies happier and more alert during the day
after a good night’s sleep, but moms and dads are also better parents
when they get the sleep they need.”
I’d argue that a few nights of crying is insignificant compared to
MONTHS (or, gulp, years!!) of disrupted sleep. That, I believe, takes
a huge toll on growth, development, and parent-child relationships.

Feedback from the Real World

From Helen G. in Austin, TX: “If you are really bothered by letting your
baby cry without seeing what is going on, buy a video baby monitor. That
way you will know if there is a serious problem (his leg is stuck between the
crib slats) . . . or if he is just testing you.”

So now that we’ve picked apart all of the sleep gurus, it’s our turn to
summarize our approach to sleep. Yes, it’s the BABY 411 SLEEP PLAN.
Drum roll please . . . we’ve cleverly used the acronym S.L.E.E.P. (Heck, you
all are so exhausted, it would be hard to remember otherwise!)

S Set up a sleep routine. Babies and kids thrive on consistency. Follow the
SAME routine at naps and bedtime. Make it short and sweet. Example: one
book, one song, one minute of rocking, bed.

L Less is more. The less you intervene, the more everyone sleeps. Babies
who learn to self-soothe won’t need you to help them fall asleep or go back
to sleep after every sleep cycle.

E Empower the child. Babies (by four to six months) are capable of going
to sleep, and falling back asleep on their own . . . if you let them!
E Earlier bedtime. Babies who are overtired have more trouble falling
asleep. The earlier they go to bed, the better and longer they sleep.

P Plan together and stick to it. Make a plan with your spouse that you
BOTH agree to follow. And then don’t cave at 3am. If you need to do a sleep
“intervention,” start it over a weekend so no one has any excuses.

Feedback from the Real World

“Consistency is key. Keep your bedtime wind-down routine simple, and one
that works for both you and your partner. Don’t lock yourself into an
elaborate ritual that you will later regret!”
—Agustina, mom to twins Gael and Malena

Nap Schedules

Q. How much should my baby be napping?

Here’s the timeline:
Birth to two months: three to four naps per day (mostly waking up to
eat and going back to sleep)
Two to four months: Three or four naps per day
Four to six months: Two or three naps per day
Six to 12 months: Two naps per day

Babies usually cut back to one afternoon nap a day shortly after their one-
year birthdays. Some will keep that nap until kindergarten. Most (like my
own kids) give it up by three years old.

Q. When will my baby be on a nap schedule?

 By four months, maybe earlier. Follow your baby’s lead.
At two months of age, you will have more predictability in your lives.
Your goal, at this point is to start having a schedule by four months of age.
You follow your baby’s plan and work around it. In general, babies are
awake for a couple of hours and then it’s time for a nap.
Naptime can begin within 30-45 minutes of your daily goal. But try as
much as you can to be consistent. Overtired babies are not exactly the life of
the party. Things happen and delays sometimes are unavoidable. Just be
prepared . . . you will pay for it!
Remember, from birth to two months, anything goes. If your baby falls
asleep in the car, that’s fine. This is a popular parent trick. But by four
months, avoid it.
Put your baby down awake and follow your same sleep routine as at
bedtime. View naptime as your baby’s downtime. If he chooses to talk for 30
minutes instead of sleep, so be it.
By six months, you should have the nap thing down. If you don’t, it’s
time for an intervention. The only difference with naps versus night sleep is
that if your intervention goes on for more than an hour, that is the end of
naptime. As a result, you may have a baby who is not actually sleeping
during naptime for a few days.

Q. How long are naps supposed to be?

Thirty minutes to three hours.
It depends on the child. By four months of age, your baby should have
two to four naps per day. The more naps, the shorter they all are in duration.
Once she is down to a couple of naps a day, one is likely to be a morning
catnap and the afternoon nap may be a three-hour marathon.
By a year of age (12-21 months), the morning nap is lost, and your baby
will probably take a 90-minute to three-hour afternoon siesta.

Q. My baby never naps at daycare and comes home

cranky. Help!
Some babies just don’t do well with group naptime. They prefer solitude.
 See if your daycare center is willing to put your baby in a private area to
take his naps. If this is not a possibility, you may need to rethink your
childcare options or aim for a very early bedtime.

Q. My nine month old talks and plays during his

second nap of the day and rarely falls asleep. Is it time
to cut that nap out?
It’s reasonable for naptime to last one hour. What your baby chooses to
do with it is up to her. She is having downtime (and likely, so are you). She
may look at books, talk to her dolls, or complain. But she still needs that
opportunity to rest or sleep. The second nap is usually dropped around 12-21
months.

Q. I have an older child that is in school. My baby’s

naptime falls right at the time I pick him up from
school. He either misses his nap or falls asleep in the
car, only to be awakened when we get home.
Naps are an important part of your baby’s schedule. Enough that it is
worth looking into carpool options. Perhaps you could drive in the morning
and a friend could pick your child up from school. Don’t sacrifice that nap if
you can help it.

Q. My baby takes a late afternoon nap and then wants

to stay up all night. I don’t. What should I do?
It’s wise to end that afternoon nap by 4 pm or 5 pm at the latest.
Otherwise, your baby won’t be tired enough to go to sleep at a reasonable
hour. Try putting your baby down for the last nap of the day by 1pm or 2 pm.
If your baby plays in his crib for an hour and then finally falls asleep, you
will probably need to wake him up to stick to the game plan.
Beyond The First Year

Q. How long will my baby sleep in his crib before

graduating to a big bed?
As long as he still likes it.
That can be as old as three years of age. We don’t recommend toddler
beds or convertible beds because they are a waste of money. When your
child starts trying to climb out of his crib, take the mattress out and put it on
the floor. Put up a safety gate in front of his doorway. That way, he’ll have
free reign of his room, but not the whole house.

Q. We have a one year old and are expecting again.

Should I take the older baby out of the crib when the
new one arrives?
No.
A bassinet will buy you a couple of months with the newborn. Then, see
if the older child still likes his crib. If the answer is yes, borrow or buy a crib
for the younger baby until the older one graduates. We do suggest a new
mattress for each baby.
Otherwise, you are asking to have a toddler roaming free around your
house at night.

Q. Can we use a small travel pillow in the crib?

After a year of age, it’s okay.

Special Situations

Q. I have twins. Is it okay to let them share a crib?

 Yes. Until they start waking each other up.
For the first two months, both babies will sleep snugly and not get in each
other’s way. After two months, it’s probably wise to give them the space
they need to move around—that means two cribs. It’s fine to have them
share a room.

Q. Do you have any recommendations for how to get

both babies to sleep through the night?
The answer is the same as for single babies. Set up the right routines and
rituals.
The only difference is with feeding times. See Chapter 6, Liquids for how
to coordinate night feedings with multiples.

Q. I have a baby who was born prematurely. Will it

take longer for him to sleep through the night?
Yes. It may be as long as 17 weeks beyond your baby’s due date, not his
birth date.
Premature babies are neurologically immature. They also need more
calories for “catch up growth.” Night feedings will be necessary for a longer
period of time than full term babies need.

Q. My baby has acid reflux (GERD). Will this make

any difference in his ability to sleep through the night?
Yep. Babies with reflux take longer to sleep through the night for a few
reasons. For starters, their heartburn symptoms are worse at night when they
are lying down. You can’t really blame them for having trouble falling
asleep. If your baby is taking medication to control the symptoms, be sure he
hasn’t outgrown his dose of medication (get the dose re-calculated by your
doctor every month). You don’t want your child lying there in misery.
And crying can make the acid reflux worse. So it’s probably not the best
idea to let your baby cry it out for an hour. It’s okay for five or ten minutes,
but not for the duration an otherwise healthy baby would cry. The good
news: most kids outgrow reflux by six months of age. Get the green light
from your doc or gastroenterologist, and then proceed with your sleep plan.

BOTTOM LINE
Some final thoughts: the National Sleep Foundation found that infants and
young children are not getting enough sleep (and neither are their parents—
but you already knew that). Tired kids are not only cranky, but they are less
interested in learning new information. Make sure both you and your baby
get enough sleep!
DEVELOPMENT
 Chapter 10
“I have found the best way to give advice to your children is to find out
what they want and then advise them to do it.”
∼ Harry S Truman

WHAT’S IN THIS CHAPTER

WHAT DOES DEVELOPMENT MEAN?
HOW DO I KNOW MY BABY IS DEVELOPING NORMALLY?
WHAT IS THE DENVER DEVELOPMENTAL CHECKLIST?
FAILING MILESTONES AND EARLY CHILDHOOD INTERVENTION
AUTISM
INTELLECTUAL (COGNITIVE) DEVELOPMENT
SOCIAL & EMOTIONAL DEVELOPMENT
FOSTERING DEVELOPMENT
KEEPING KIDS SAFE WHILE THEY EXPLORE
DEVELOPMENTALLY APPROPRIATE TOYS AND BOOKS

“There should be a warning label in bold at the beginning of this chapter:

‘Caution: all overachievers and/or first-time parents. Your baby may not
develop at the same rate as we have listed in this chapter as normal. You
should neither jump off a bridge nor sign your child up for Sylvan Learning
Center. These are just averages.’”
—Adventures in the Life of NGL, blogger and fan of Baby 411
Okay, you’ve heard the conversations on the playground: “Janey was
walking at only ten months.” “Well, my little Henry was saying his first
words at four months.” You know—competition starts early. Now if you’re
pregnant as you read this you’re probably wondering when they should start
walking and talking. If you have a child already, you may be one of those
quiet moms who doesn’t join in the above boasting conversation. But, you
may still be wondering if your baby is behind. That’s what this chapter is
here to tell you.
When can your child roll over, when should he, and when is he
developmentally delayed? And what is important to worry about and bring
up to your doctor during well check visits? This chapter provides the key to
understanding how your child’s brain works. Knowing what to expect will
help you know how to respond to your child’s needs as he is growing. This is
required reading before you get to the next chapter, “Discipline and
Temperament.” We’ll refer back to this stuff, so don’t jump ahead.
Your first lesson: DO NOT COMPARE YOUR BABY TO OTHER
CHILDREN. We know, you just can’t help it. You watch other kids in
playgroups, at the park, and in your own family and then look at your baby.
Don’t do it. Every child reaches her developmental milestones at her own
pace. Yes, there is a certain timeline to reach these milestones, but there is a
broad range of “normal.”

Q. What does development mean?

The way a child evolves in muscle skills (large and small muscles),
language skills, social and personality skills, and intelligence. This is
different from the term “growth” which refers to physical body changes.
We’ll define some key terms on this topic next.

1. Gross Motor Development. This refers to using large muscle groups to

function (i.e. arms, legs, torso). Milestones: rolling, sitting, crawling,
climbing, walking, running, throwing, and kicking a ball. FYI: Gross motor
development is mastered in a “Head, shoulders, knees, and toes” direction.
Remember these milestones by the numbers 3-6-9-12:
Three-month-olds have achieved head control. (no more head bobs)
 Six-month-olds have shoulder and trunk support. (rolling over, sitting
up)
Nine-month-olds have knee control and can stand up holding on, and
walk with support.
12-month-olds have control of their feet and toes, standing alone and
taking steps.

2. Fine Motor Development. This skill involves using small muscle groups
to function (i.e. fingers). Milestones: batting with hands, grabbing, picking up
objects, feeding oneself, holding food utensils, holding writing utensils,
coloring, and writing.

3. Oral Motor Development. The ability to use mouth and tongue muscles.
Milestones: swallowing, chewing, and talking. Newborns only have the
ability to suck, swallow, and cry.

4. Language Development. This refers to the ability to communicate with

others. The prerequisites for language development are oral motor
development and the ability to hear and process language (see receptive
language skills below). Milestones: cooing, babbling, stringing sounds
together, imitating noises, and using words purposefully. There are two
different areas of language development:
Receptive language skills. The “input” that babies get in the form of
words is understood long before they start talking. Babies can follow
directions (if they are in the mood) before they say any words.
Expressive language skills. This is language “output.” When people
refer to a child having language delays, it is usually an expressive
language delay (i.e. they aren’t talking yet). If there is a concern for
an expressive language delay, your doctor should always check to be
sure there is not a receptive language delay, too (a hearing problem,
or an AUDITORY PROCESSING DISORDER).

5. Social-Emotional Development. This is how a child adapts to his world.

Milestones: smiles responsively, knows parents, asks to be held, laughs,
imitates, plays peek-a-boo, anxiety towards strangers, anxiety from being
separated from loved ones, seeks independence.
 Social skills are a learned process. And, parents are the most important
role models for a child. Children interact in social situations quite differently
at different ages.

6. Cognitive (Intellectual Development). This refers to how a child figures

out his world. Babies are like big sponges. They absorb vast quantities of
information on a daily basis and learn how to decipher it all. And you
thought your learning curve was steep with this new parent experience.
Imagine what your baby’s brain is going through!
Milestones: follows people and objects in field of vision, expresses needs,
explores toys, prefers routines, knows how to get people’s attention,
understands cause-and-effect (that is, banging this toy makes noise), object
permanence (things still exist even if not in view), remembers frequent
visitors, limited problem solving skills.

Q. How do I know that my baby is developing

normally?
You visit your pediatrician or family doctor for well baby checks. Or
schedule a special appointment to address any developmental concerns you
might have.
Many parents think that well baby checks are “just for shots.” They’re not.
At every well baby check, your doctor will ask a series of questions to be
sure your baby is developing all five types of skills at an appropriate pace.
Docs don’t usually ask developmental questions at sick visits because those
are “problem-focused” appointments.
If a delay in any of the developmental areas is detected, it may be
followed for a period of time to see if your baby “catches up” or a referral
may be made to a specialist in that particular field.
This is an extremely important part of both the parent and doctor’s job
description. If you have concerns about your child’s development, don’t be
shy about it. There is never a downside to getting your concerns checked out.
Early intervention makes the greatest impact in lifelong outcomes. For
more on this, see the section “Learn the Signs. Act Early.”
Q. I’ve heard the term “developmental milestones.”
What does it mean?
These are individual skills that your baby progressively masters as he
matures.
The series of questions your pediatrician asks are based on expected
milestones at specific ages. Some babies will show off and demonstrate their
new tricks in the office. In most cases, however, doctors rely on your
descriptions for the rest. Remember, there is a range of time for when
milestones are achieved.

Q. Can I have a milestone checklist so I can follow

along?
Yes. The Denver Developmental Checklist is considered the gold standard
to assess milestones. We have included the test items in a box below.
Remember, no obsessing over this list. Do not tape it to your baby’s crib
and check off his accomplishments. This is by no means a perfect test, but it
is a helpful guide for doctors to screen for developmental delays.
There is a very low criterion to “pass” a test so that children with normal
skills are not falsely considered delayed. In light of this, if a child does “fail”
a test on the Denver Checklist, it is quite likely he has a developmental delay
in a certain area. In such a case, the doctor will investigate this further either
in her office or via referral to a developmental specialist.

BOOKMARK THIS PAGE! THE BABY 411 ALL-IN-ONE

Developmental checklists are designed to identify developmental

delays in infants and young children. In general, the areas are divided
into the following categories:
Gross motor skills (large muscle groups)
Fine motor skills (small muscle groups)
 Language including all forms of communication (indicating wants,
facial expressions, understanding language, and vocalization)
Personality/intellectual development

Because children accomplish these milestones at a range of ages,

mastery of a particular milestone will vary over a period of time (i.e.
walking may be mastered between 9-15 months of age). The cutoff for
‘normal’ is at the level where over 90% of children have achieved a
milestone at a particular age.
For babies born prematurely (if your child was born before 36
weeks gestation and your child is under 2 years old): Subtract the
number of months missed in pregnancy from the baby’s current age
and check at the adjusted age.

Gross Motor: Age achieved:

Lifts head 0 to 2 months
Holds head steady 1.5 to 4 months
Pushes chest up while lying on 2 to 4 months
stomach
Rolls over 2 to 4.5 months*
No head lag when pulled to sitting 3.5 to 6 months
position
Bears weight on legs when held in 3 to 7.5 months
standing position
Sits alone 5 to 8 months
Stands holding on to something 5 to 10 months
Pulls self up to standing position 6 to 10 months
Gets to sitting position independently 6 to 11 months
Walks holding on to furniture 7.5 to 12.5 months
(“cruises”)
Stands alone briefly 9 to 13 months
Stands alone 9.5 to 14 months
Walks alone 11 to 14.5 months

*Note: Rolling over is a less reliable milestone now that babies spend
most of their time on their backs with the anti-SIDs campaign.
*Note: Crawling is not listed on the developmental checklist because
many children skip crawling and are developmentally normal.

Fine Motor: Age achieved:

Brings hands together 1.5 to 3.5 months
Grasps objects 2.5 to 4.5 months
Reaches for objects 3 to 5 months
Transfers objects hand to hand 4.5 to 7.5 months
Grabs objects with whole hand 5 to 8 months
(“rakes”)
Able to feed self a cracker 4.5 to 8 months
Grabs object between thumb and 7 to 10.5 months
finger (“crude pincer grasp”)
Bangs objects together 7 to 12 months
Mastery of pincer grasp (“fine 9 to 14 months
pincer”)
Drinks from a cup 10 to 16.5 months

Language/Communication: Age achieved:

Eyes focus on objects in front of 0 to 1.5 months*
them
Eyes follow objects to the sides 0 to 2.5 months*
Baby regards person’s face 0 to 1 month*
Baby smiles in response to person 0 to 2 months*
smiling at them (“social smile”)
Responds to loud noise 0 to 1.5 months
Makes happy noises 0 to 2 months
Laughs 1.5 to 3.5 months
Makes squealing noises 1.5 to 4.5 months
Baby smiles without prompting 1.5 to 5 months
Turns to someone’s voice 3.5 to 8.5 months
Says “dada” or “mama” but doesn’t 6 to 10 months
mean it
Imitates speech noises (baby 6 to 11.5 months
talk/jabber)
Says Dada or Mama and means it 9.5 to 13.5 months
Indicates wants non-verbally (“point 10.5 to 14.5 months
& grunt”)
Says 3 or more words besides 11.5 to 20.5 months
Mama/Dada

*Note: A newborn’s vision is 20/200. They can only see about 8 to 12

inches in front of their faces. So, to test these items, you need to be very
close to your baby’s face.

Personality/Intellectual Age achieved:

development
Plays peek a boo 6 to 9.5 months
Looks for hidden object 5 to 8 months
Initial shyness with strangers 5.5 to 10 months
(“stranger anxiety”)
Plays pat a cake 7 to 13 months
Plays ball with someone 9.5 to 16 months
Putting it all together

Here are the questions your baby’s doctor will ask you at each well check
during the first year. Complete these checklists ahead of time if you want to
make sure your baby is tracking where he should be (or if you want to look
really smart!).
If you answer YES to more than one of these autism screening questions,
please be sure to inform your doctor.

Q. What is the significance if my child fails in his

milestones?
Maybe something, maybe nothing.
This is a non-committal answer, but it is the truth. Some children will
have an isolated delay in one particular developmental area (that is, just
motor skills, just expressive language skills, etc.). With a little help and
encouragement, these kids catch up to their peers and you might never notice
a problem later on. For others, it may always be an issue. For instance, a
child with gross motor delays may grow up to be a non-athletic kid. A child
with expressive language delays may turn out to have a learning disability.
Both of these children might also be a varsity football player or the
valedictorian. It just might take a little more work for that kid to succeed in
those areas.
 The children we are most concerned about are those with delays across the
board, termed “global developmental delays.” These children are more at risk
to never catch up to their peers. There is a range from mild to severely
affected children. Doctors evaluate these children for genetic and metabolic
(the way the body breaks down certain chemicals) defects when they are
diagnosed.

Autism Spectrum Disorders

Q. I’ve heard a lot about autism in the news. What is it,

and when do I worry?
AUTISM SPECTRUM DISORDERS (ASD) are a collection of several
disorders that cause children to have three abnormal areas in common: social
and communication skills, and repetitive/restrictive behaviors. Previously,
specialists used the terms PERVASIVE DEVELOPMENTAL DISORDERS
(PDD), PERVASIVE DEVELOPMENTAL DISORDER, NOT OTHERWISE
SPECIFIED (PDD-NOS), and ASPERGER’S SYNDROME separately to describe
people who fell onto the autism spectrum. Without question, there is a very
broad range of severity within ASD. A child may have normal intelligence
and language, but be socially awkward and have panic attacks if his
sandwich is cut in triangles instead of squares. Or a child may appear out of
touch with reality and spend his entire day rocking and flapping his hands.
Both children have autism. And that is why the newest psychiatric diagnostic
bible (DSM-5) eliminates these other diagnostic terms and gives everyone on
the spectrum the same diagnosis—autism.
As you might suspect, children with severe problems are diagnosed much
earlier than kids who can communicate but have trouble with social skills.
Children are usually diagnosed by 18-24 months of age when language
delays are obvious. Many mildly affected children may not be diagnosed
until preschool (or sometimes even later!)However, clues to the diagnosis
appear long before that time. Some early clues include: not smiling back at
people, poor eye contact, not imitating, not gesturing (waving bye-bye), not
responding to being called by name, and not trying to
communicate/connect/engage with other people by one year of age.
 There are also some unusual behaviors. Cuddling may not be soothing. In
fact, a child with autism may get very upset by being touched. Bright lights
and noises often bother them. Because they are bugged by the outside world,
they may turn inwards and find comfort in repetitive behaviors (rocking,
head banging, spinning). Children with autism may have little interest in
playing with toys. Or they may play in an odd way—such as using a phone
as a comfort object.

BOTTOM LINE: Children with autism have autism long before their first
birthdays, even though their “official” diagnosis usually occurs in their
second year of life. Remember this fact when we discuss the now debunked
measles (MMR) vaccine controversy. (see Chapter 12, “Vaccines” for
details).

LEARN THE SIGNS, ACT EARLY.

The Centers for Disease Control recently launched a campaign

called “Learn the Signs. Act Early.” It empowers parents with
information on what is normal child development and what isn’t. The
key point: early diagnosis and intensive therapy leads to the best
developmental outcome for the child. Kids who get help before age
three (and earlier is even better) have the best chance of overcoming
developmental challenges. You can access their info at
www.cdc.gov/actearly or at 1-800-CDC-INFO.

Q. My baby bangs his head frequently. Does he have

autism?
No. Many babies have behaviors that they perform repeatedly. The
repetition is soothing for them. It becomes a red flag (see below) when the
behavior goes on all day long and replaces meaningful play. And with
autism, there are other also other atypical behaviors (lack of social skills,
poor language, etc.). By the way, babies have the same self-preservation
instincts that we do, so they really won’t hurt themselves by head banging.

RED FLAGS for Autism

Although autism is usually diagnosed by age two or so, clues are apparent
much earlier. Here are some things to be watching for by a child’s first
birthday.
Lack of eye contact. Babies should make eye contact (and smile back at
you) by two months of age.
Failure to respond to name by first birthday.
Constant repetitive behaviors (hand flapping, etc).
Preference for unusual comfort objects (that is, not a doll or blanket).
Lack of symbolic play or imitation—pretending to talk on the phone or
use the TV remote.
No babbling by first birthday.
No gesturing by first birthday.
Lack of social skills. Babies should try to engage and get some-one’s
attention.

WHERE TO GET HELP

Head Start and Early Head Start programs: ehsnrc.org

Parent training: patnc.org
Early Intervention for children birth to three years:
nectas.unc.edu
Insider Tip: Testing
All children who are being evaluated for autism should have chromosome
testing done (karyotyping). A small percentage of kids with ASD have a
chromosomal abnormality called Fragile X Syndrome. Other, less common
chromosome abnormalities have also been linked to autism. Knowing that
your child has Fragile X or another genetic defect may be useful someday if
targeted gene therapy becomes a reality.

Q. Is there a test for autism?

There’s currently no blood test or imaging study that detects autism. An
autism diagnosis is based on the symptoms that a child displays (and lack of
findings/results that would suggest a different diagnosis). However, testing
for chromosome defects or metabolic disorders may be useful if there are
other family members who have autism or the child’s physical examination is
concerning. Doing a blood lead test is helpful if a child has had a significant
environmental exposure. (Kids with lead poisoning don’t really have autism,
but their bizarre behavior may be misdiagnosed as autism.)
What is NOT useful? Tests that look for heavy metal exposure in the
hair/urine/poop, food allergy tests that look at “IgG” levels, or any
“alternative lab” where you get your child’s test results back on a pretty, four-
color grid.
Your pediatrician can do an assessment in her office. If autism is
suspected, your child’s doctor can make a referral to a developmental
pediatrician or multidisciplinary assessment program.
The American Academy of Pediatrics has an extensive Autism Toolkit to
help educate families. You can ask your doctor for these materials or go
online to aap.org for more information.

Q. I have a friend whose child has autism. She said he

was “perfectly normal” until he was about 18 months
old. Does this happen?
There are a small minority of children with autism who have completely
normal milestones and then regress, which is known as “late onset autism.”
These children most likely have a distinct genetic abnormality that turns on
or off without any trigger.
However, for most kids with autism, parents and doctors just miss (or
dismiss) the early signs in the first year of life and the child’s atypical
development only becomes apparent at 18 months.
Doctors rely heavily on parents to point out concerns. And parents
(especially first timers) don’t know what is normal and what isn’t.
One of my patient’s mothers told me that she only realized how unusual
her son’s development was after she watched her second child, without
autism, breeze through her milestones. Even the most vocal autism activist
mom of all, Jenny McCarthy agrees. Her son was five months old when he
first smiled at her (that’s abnormal), when all of her friend’s babies smiled at
two months of age (that’s normal).
Some parents report that their child with autism spoke a few words and
then “lost” the ability to say them. If you delve a bit deeper, the child may
have randomly said a few things, but was not consistently using words like
“juice” or “no” to communicate his needs.
There is growing research in language development that looks at brain
anatomy. Primitive brain parts control early language development from birth
to 18 months. At 18 to 24 months, the mature brain parts turn on and
language takes off. With children who have autism, mature language does not
take off. But from a parent’s perspective, it may look like a loss of skills.
And again, children with subtle atypical behaviors may be harder to
diagnose early on. Reviewing home movies of a child once the diagnosis is
made often shows that early signs are overlooked. (Maestro)

OLD WIVES TALE

The MMR Vaccine causes autism.
False. See Chapter 12, Vaccines, for an expanded discussion!
Q. Okay, so what causes autism?
The million-dollar question.
In the 1980’s, one in 10,000 kids were diagnosed with autism. Today,
about one in 68 American eight-year-olds have some form of autism. Boys
outnumber girls four to one. The U.S. is not the only country seeing this
trend. It is increasingly diagnosed worldwide.
For starters, is it really an epidemic? Or are more people being diagnosed?
Many children who were diagnosed with mental retardation thirty years ago
are children who are diagnosed with classic autism today. And mildly
disabled kids with autism today are children who never would have had a
diagnosis thirty years ago. Those verbal, but socially awkward, children
account for the majority of new autism cases.
So what are the hotbeds of research into the causes of autism?
1 GENETICS. There’s no question that genetics play a role. Autism runs in
families. I have a family in my practice and all four children have a diagnosis
on the autism spectrum.
Studying twins is an obvious way to detect genetic disorders. If one
identical twin has autism, up to 90% of the time, so will the other twin. To
date, studies suggest there is more than just one “autism gene”—there appear
to be several.
Children with autism have several different abnormalities with their DNA.
However the X chromosome is one of interest because of the high prevalence
of boys with autism. (Jamain)
Fragile X Syndrome, which is a known genetic cause of autism, also
points to a defective X chromosome in autism spectrum disorders. And Rett
Syndrome, which is a disorder causing developmental regression and autistic
behaviors in girls, is caused by a defective MECP2 gene located on the X
chromosome. (Chahrour)
We also know that kids with autism and defects on Chromosome 11 have
dysfunctional “neurexin 1 protein.” Researchers are looking into how this
defective protein affects fetal and infant brain growth.
Finding these specific genetic defects may help in genetic counseling as
well as therapies in the future. Animal studies are already underway for
targeted genetic therapy in both Fragile X and Rett Syndrome.
2 ABNORMAL BRAIN GROWTH. Children with autism spectrum disorders
have problems with brain growth. Babies are born with immature brains that
grow rapidly and make nerve connections called synapses . . . like an
information superhighway. In the normally growing brain, some branches of
this superhighway get “pruned.” In the autistic brain, this pruning process
seems to be defective. This may explain why babies who are autistic have
abnormally rapid head growth under one year of age. No one has yet figured
out what causes that defective nerve growth. Of note, boys with autism have
higher levels of hormones (insulin-like growth factor) which may contribute
to their larger head size, weight, and body mass index. (Mills)

3 ENVIRONMENTAL TRIGGERS. Is there some environmental exposure that

sets off abnormal brain development in a genetically predisposed baby?
Maybe. And that exposure may happen at or shortly after conception, before
a mother even knows she is pregnant. The embryo has a critical period of
brain development at 20-24 days after conception. That is when the
developing brain is most sensitive to injury. Studies done by the
Environmental Working Group have detected over 280 environmental toxins
in umbilical cord blood, so clearly pregnant moms are exposed to a variety of
toxins—could one of these be the autism trigger? We don’t know.
Viral infections during pregnancy may also be a key environmental trigger
that causes abnormal genes in the fetus. Those infections include rubella,
CMV, and influenza (yes, “the flu”). (Fatemi) Having prolonged fevers
during pregnancy also seems to be a risk factor. (Atladottir)
Researchers are also exploring whether or not air pollution exposure
during fetal development and the first year of life is a possible autism trigger.
(Volk)
What about vaccines as an environmental trigger? Researchers and
scientists have taken a long, hard look at vaccines—and there is conclusive
evidence that vaccine exposure is NOT the turn-on switch for autism. (AAP)
Flip over to Chapter 12, Vaccines for an extended discussion.
The bottom line: there’s evidence that newborns who are later diagnosed
with autism already have abnormal levels of certain proteins in their brains.
So, whatever the trigger is (if there is one), it has been fired before the baby
even enters the world.
4 PREMATURITY. A developing brain is quite vulnerable. Premature, very
low birth-weight babies (under three pounds) have a 25% chance of
developing an autism spectrum disorder. (Limperopoulos)

5 OLDER PARENTS. Another possible reason for the increase of autism: the
trend of parents having babies at a later age. Moms who conceive after the
age of 40 have a 30% increased risk of having a child with autism. Dads who
conceive after the age of 40 have a 50% increased risk of having an autistic
child. (Croen) Scientists speculate that an older dad’s sperm may have
defective genetic material, possibly altered by environmental toxins. Dads
who are 20 years old at conception pass on 25 different gene mutations. Dads
who are 40 at conception pass on 65 genetic mutations.

6 CLOSELY SPACED PREGNANCIES. A 2011 study compared children who

were conceived at least three years after their sibling was born, to closer
spaced pregnancies and found that babies conceived less than 12 months
after the birth of the first-born child were THREE times more likely to be
diagnosed with autism spectrum disorder. Babies conceived from 12 to 23
months after the birth of the first-born child had almost two times the risk of
autism. And, even babies conceived 23-35 months after the first-born child
had a slightly greater risk of autism.
Unfortunately, researchers have no idea why the odds are greater when the
spacing between pregnancies is shorter. Perhaps it’s because a woman’s
nutritional stores have not had enough time to be replenished. Or maybe
women who have put off parenthood until later in life have more closely
spaced babies—and parental age itself is a risk factor for having a child with
an autism spectrum disorder.
Thus study alone should not necessarily influence your decision on how
long to wait between pregnancies. However, the current recommendation
from the Centers for Disease Control is to wait at least 18-23 months
between pregnancies for a mother and baby’s optimal health. (Cheslack-
Postava)

7 OBESITY. Researchers at UC Davis and Vanderbilt medical school

published a 2012 study that found women who were obese (Body Mass
Index of 30 or greater) at the beginning of their pregnancies were more likely
to have a child diagnosed with autism. Perhaps the altered metabolism affects
the intrauterine environment, and thus affects the intricate process of fetal
brain development. More research is definitely needed in this area.
(Krakowiak)

8 FOLIC ACID DEFICIENCY. A 2013 Norwegian study showed that women

who took folic acid (or prenatal vitamins) at least four to eight weeks before
becoming pregnant lowered the risk of having a child with an autism
spectrum disorder by 40%. We’ve known for a long time that folic acid is
clearly necessary for proper brain and nervous system development
(deficiencies in pregnancy cause spina bifida). So, it isn’t a crazy stretch to
think this nutritional deficiency in pregnancy could also lead to autism.
(Suren)

FYI: On our web page, we have a graphic that helps put things in
perspective (go to http://j.mp/autismrisks). On the left side is the number of
newspaper articles that mention certain factors that might cause autism. On
the right side are “actual risks” for autism, based on scientific papers. The
message: there has been much press attention to autism risk factors that
aren’t supported by scientific research. Conversely, there are some autism
risk factors that have received scant press coverage. Example: having a
sibling who is a science or engineering major in college increases the risk of
having autism by 200%. Bottom line: heredity (genetic makeup) has the
greatest impact on whether a child will have autism.

Follow our website at Baby411.com for new information on this topic.

Q. My child has autism. What therapy do you

recommend?
The first place to start with is your child’s medical provider. He/she can
help with both diagnosis and referrals locally in your community. National
resources to help you get started include:
The Centers for Disease Control: cdc.gov/ActEarly
American Academy of Pediatrics: aap.org
Early, intensive therapy with developmental specialists is key. Please
beware of unproven (and possibly dangerous) therapies that promise a cure
for autism. We realize that parents will do anything to help their kids. But we
also know that leaves them prey for unscrupulous folks selling snake oil.

Other developmental differences

Q. My baby has Down syndrome. What steps do I take

to get help for him?
Down syndrome is the most common of all the known chromosome
abnormalities that cause intellectual disability. So it’s important to get your
baby hooked up with developmental specialists from the start. The AAP
recommends that kids with Down syndrome receive early intervention
services from 0—3 years of age. That’s good news because it means most
insurance companies will foot the bill for it!
Down syndrome also causes other potential health problems that need to
be assessed. Most large pediatric hospitals and academic centers offer a
Down syndrome clinic where an affected child can see all his specialists on
the same day (convenient, one-stop shopping!)
Here is a checklist for the health issues associated with Down syndrome:
Growth: Assess at regular well child visit intervals.
Sleep: Evaluate for sleep apnea (snoring, restless sleep) beginning at 1
year of age.
Thyroid screening: Assess as part of newborn metabolic screening,
recheck at 6 months of age, 1 year of age, and then annually.
Hearing screen: Formally assess in newborn period, recheck at five
years of age, 13 years of age, and then annually. Referral to specialist
between 1—2 years of age. Assess for frequent ear infections.
Vision screen: Referral to specialist by six months of age. Formally
assess as needed until 13 years of age, and then annually.
Heart defect screening: Heart ultrasound (echocardiogram) performed
at prenatal visit. Referral to specialist for periodic assessment in
teenage years and adulthood.
Blood count: Newborns need a complete blood count, recheck annually
between 13—21 years of age.
 Celiac disease screening: Perform at two years of age. Repeat
assessment if symptoms of gluten intolerance develop.
Periodontal disease screening: Referral to dentist for regular dental
visits every six months.
Neck/spine stability screen: Assessment by neurologic exam, and
possibly a screening x-ray. (AAP)
For more information and parent resources on Down syndrome, check out
the Association for Children with Down syndrome at acds.org.

Q. If my child has a developmental delay, where can I

get help?
Want to use a service that makes house calls?
Most states offer an early childhood intervention (ECI) program—Google
your state name and “early child intervention” to find a local agency. Your
child’s development will be screened over the phone. If he qualifies as
having a delay, a specially trained physical therapist (large muscles),
occupational therapist (small muscles), or speech therapist (language, mouth
skills) will show up at your doorstep and do a formal assessment. If help is
needed, regular therapy will be scheduled.
Like most government programs, needs often exceed resources of early
intervention agencies. Our advice: be a strong advocate for your child. ECI is
a great program in theory, but your child may need more intensive services
than what the program can offer. If your child qualifies for speech therapy
once a month but really needs it once a week, speak up or seek alternative
programs.
Besides ECI, another option is to get a referral from your pediatrician to a
private specialist in your area. Easter Seals also has a national program that
provides services based on ability to pay. Contact them at easter-seals.org or
at (800)-221-6827.
Denise’s opinion: We’ve all been at the park and noticed a child who
seems to be “hyper” or “slow” or “aggressive” or non-communicative. But
no matter how tempting it is, keep your opinions to yourself. Besides,
behavior problems on the playground probably have more to do with kids
who are tired or hungry than with some kind of serious brain dysfunction.
 As the parent of a learning disabled child, I can tell you that no outsider
would have known he was anything but normal until he got closer to school
age. And kids who seem to have delays and problems often sort them out and
have no issues by the time they reach kindergarten.
But if you notice your child doesn’t seem to be keeping up with other kids
his age physically or socially, be sure to bring it up to your doctor at the next
well visit. If you don’t say anything, your doctor may not notice subtle signs
in a ten or 15-minute visit.

Feedback from the Real World

Special babies, Extraordinary Parents: Meredith’s Story
“When we first learned of Meredith’s diagnosis (developmental delays)
our first worry was that there would be nobody to take care of her in the
future when we were gone. We now realize that dwelling on that is giving up
any hope for the present. When Meredith was finally able to throw a ball, we
celebrated all the years in therapy that got her to that moment. When she was
able to catch the ball, we marveled that it happened the very next day.”—
Sarah B. and Jim H., parents of Meredith (diagnosis: agenesis of the corpus
callosum).

Q. My baby was born prematurely. Does the same

developmental checklist apply to him?
Yes, but not at first.
Your baby’s chronological age will be adjusted by subtracting the number
of weeks born prematurely. So, the expectations will be lower initially. Your
baby’s “age” won’t need to be corrected once he is 2 1/2 or 3 years old.
FYI: Because very low birth weight babies (under three pounds) are at
greatest risk of developmental delays, they should have a formal
developmental screening (in a developmental assessment program or Early
Childhood Intervention) at nine to 15 months corrected age, and again at 21-
30 months corrected age.
 Babies who are born between 32 to under 37 weeks are at higher risk for
having learning issues (particularly reading skills) than babies born full term.
So, even if your kiddo was a “late preterm infant,” he should still be followed
closely for developmental delays. (Chyi)

Now that we’ve talked about general developmental milestones and

delays, we want to explain a bit about intellectual development and
social/emotional development. We’ll explore theories from two prominent
doctors with their thoughts on the stages your child will go through
throughout his life.

How Your Baby Learns

Ever wonder how your baby learns all the amazing things she does? How
does she go from being a little lump at birth to a smiling, talking, walking
dreamboat by her first birthday? Dr. Jean Piaget, the father of the major
accepted theory for cognitive (intellectual) development, believes that a
child’s brain processes and understands information in different ways at
different ages. As a parent, it’s helpful to know what “stage” of brain
development your child is at, because your child’s reasoning will be different
than yours. And if you are educated about those differences, hopefully, you’ll
be less perplexed and frustrated by them.
So here is the big picture, stage by stage:

Sensorimotor: Age birth to two years

Babies learn by hearing, feeling, tasting, smelling, moving, and
manipulating (that is, using their Five Senses). Babies are EGOCENTRIC. In
their minds, the world revolves around them. They continue to think this way
until about age six or seven years old (although you might think that some
adults haven’t outgrown this stage yet!).
Birth to one month: A newborn comes equipped with immature reflexes
(sucking, rooting, grasping). He will learn how to use and coordinate them.
Newborns have no concept of “self.”
 One to four months: Babies realize that they have body parts, and can
control them. If you see your baby staring at his hand, it’s because he has
discovered it.
Four to eight months: Babies are more interested in the world. They
realize their actions can make other people do things. They start to
manipulate objects and explore with their mouths. But, people and things
don’t exist unless they are within a baby’s visual field. They do well with
routines and predictable events with their limited memory banks.
Eight to 12 months: Babies grasp the concept of object permanence. A
baby realizes that a person still exists even when he leaves a room. The same
goes for toys, food, etc. A baby this age has a limited repertoire of techniques
to explore a new situation. He uses his memory of what worked in the past to
approach something unfamiliar.
12 to 18 months: Toddlers have more sophisticated approaches to problem
solving (although it won’t feel that way to their parents). They experiment
systematically. Toddlers go through a trial and error method of attack. Things
are explored more with hands than with mouths. They CAN follow
directions. (It’s a matter of whether or not they CHOOSE to).
18 to 24 months: As these kids approach two years of age, they can do
“trial and error” in their minds, and figure out the solution to a problem (i.e.
simple puzzles). They will figure out language, and start to pretend.

Pre-Operational: Age two to seven years

Kids have the concept of symbols representing things (i.e. language,
pretend play). Their level of reasoning is based on their viewpoint. They are
not capable of taking someone else’s perspective. They have primitive logical
thinking. For example, a full juice cup will look like it has more in it than a
half-full water glass.

Concrete Operational: Age seven to eleven years

Kids this age can think logically, order and classify items, compare, and
sequence information. But, everything is black and white—there is no gray
zone.

Formal Operational: Age 12 to Adulthood

This is the age of abstract reasoning— when a child can “think outside of
the box.” A teenager can take a hypothetical situation and reason it out.
(Brainerd)

Your Baby’s Social and Emotional Growth

As one of the most influential psychologists of the 20th century, Erik

Erikson continues to influence our view of social and emotional development
today. His theory suggests that personality development rests on how a
person deals with a series of stages in his life. A person’s sense of identity
depends on the outcome of eight crises or conflicts. If a person does not
successfully resolve a particular conflict, the unresolved issue persists in later
life.
People can also regress to prior stages during times of stress (that is, a
four-year-old returns to the Terrible Two’s when a baby sister is born).
Again, the big picture. . . .

Trust vs. Mistrust: Birth to 18 months

Infants learn to trust their parents. They learn that their needs are met.
Babies who do not get appropriate care have a sense of distrust and
apprehension around others.

Autonomy vs. Doubt: 18 months to three years

Children are seeking independence and are trying to gain confidence in
their abilities. This happens while parents are trying to set limits on
inappropriate behaviors. (This meeting of the minds is also known as the
Terrible Two’s). Children need some autonomy to rely on their own skill, or
else they will begin to doubt themselves.
Initiative vs. Guilt: Three to six years
Children thrive on decision-making and accomplishments. If parents do
not support these experiences, the child feels guilty for trying to be
independent.

Industry vs. Inferiority: Six to 12 years

Children gain confidence in their skills and want to learn. With failure or
lack of support, children feel inferior to others.

Identity vs. Role Confusion: 12 to 18 years

Simply put, teens either figure out who they are and what they want (sense
of self) or they are confused and reliant on their peers. (Harder)

Now you know the theories behind how babies develop. So you’re
probably wondering how to put them to work. This is the section for you.
Here we’re going to discuss how to foster appropriate development for each
age and stage. Keep in mind the idea is not to “train” your child to be the
next Beethoven, Mary Cassat or Bill Gates.

Birth to Two Months of Age

Q. So what is a general idea of how my baby will

develop in the first two months?
Here is a thumbnail sketch.
You may think that your newborn spends his whole life eating and
sleeping, but he is actually learning a great deal. Babies are born with an
immature nervous system (brain, spinal cord, nerves). So, most of what you
see develop is not dramatic in the first two months of life. Instead,
development is happening with a baby’s neurological system. Milestones:
 Newborn reflexes. Babies suck and turn their head instinctively when
you rub their cheeks. They will also grasp anything placed in the
hands. If you gently drop their heads back, they will flail their arms
out and open their eyes. These reflexes should go away by six
months of age.
Motor skills. Babies are born with poor head and neck stability. Over
the first two months of life, they gain better head control. They
should move both arms and legs equally well. A dominant side or
hand preference is NOT normal.
Vision. Newborns have 20/200 vision. They are not blind. But, they can
only see clearly about eight to ten inches in front of them. Putting
your face right up to theirs is very entertaining for them. Babies like
contrasts (hence, all of the black and white toys at trendy baby
stores). By the time your baby is two months old, he will be able to
see one to two feet in front of him. He should also be able to fix his
eyes on an object and follow it side to side.
Hearing. Newborns are born with normal hearing. They startle to loud
noises. Babies recognize their parents’ voices. They have heard you
inside the womb.
Social. Newborns are interested in your face. By two months of age, if
you smile at your baby, he will smile back (called a social smile).
Under six weeks of age, any smiling is a mere coincidence, or gas.
Language. Initially, babies cry to express all of their needs. As they
approach two months, babies will start to “coo” (ooo and ah noises).
They may even start to laugh and squeal.

Q. What kind of developmental stimulation should I

provide my birth to two month old?
Give them lots of time with you. Here is a breakdown:

1. Sensorimotor:
 Give your baby interesting things to follow with her eyes (your face,
colorful toy).
Listen to music; play with rattles, music boxes.
Let your baby touch different objects (your face, your hair, the dog).
Give your baby short bursts (five minutes) of time on her tummy (a.k.a.
Tummy Time) to work on shoulder and stomach muscles. Not only
does it strengthen neck and shoulder muscles, it also prevents the flat
head issues we discussed earlier in the book (POSITIONAL
PLAGIOCEPHALY). Many babies hate tummy time at first because
it’s a lot of work for them! The earlier and more often you do it, the
more comfortable they get with tummy time. Get down on the floor
with her and give her some encouragement (and entertainment).

2. Language:
Start a reading ritual. Set aside reading time EVERY day until your
child packs up and goes to college. There is a great deal of research
that proves infants who are read to at early ages have stronger
language and cognitive skills than their peers.
Infants respond best to rhymes and good illustrations. See the end of
this chapter for a list of good books for kids age birth to one.

3. Social:
Spend time talking and smiling at your baby.

Q. My newborn does not have good head control yet. Is

it okay to use an infant baby carrier?
Yes. Holding your baby in your arms 24/7 gets old quickly. Carriers
provide enough head support and allow you to use two hands to get
something done. See our sister site, Carriers.BabyBargains.com, for
suggestions.

Q. My two month old’s eyes cross frequently. Should I

worry?
 No. A baby’s eye muscles are weak initially and frequently are not in sync
with each other.
Doctors start testing for lazy eye muscles (see AMBLYOPIA) from six to
nine months of age. If you notice that one eye turns in, turns out, or only one
eye has a “red eye” effect in photographs, let your doctor know. Note: a two
month old can follow your face as you move it in front of him. A three month
old can follow it for a full 180 degrees.

Old Wives Tale

Letting an infant bear weight on his legs will make him bowlegged.
The truth: Babies like to bear weight on their feet with your support. It’s
fun—and it won’t make them bowlegged.

Two to Four Months of Age

Q. What milestones should I expect my two to four

month old to achieve?
Gross Motor. Your baby should have good head control by three
months of age. If you lift his body from a lying position, his head
should come up at the same time and not lag behind. He may or may
not roll over. By four months old, he should bear weight on his legs
if you stand him up. Most babies can lift their heads up when lying
on their stomachs.
Fine Motor. Your baby will start to realize that his hands are useful. At
first he will bat at objects, then start to grab successfully around four
months. (This is when moms usually stop wearing hoop earrings and
pull their hair back). Your baby should also be able to bring his
hands together.
Language. Babies are really experimenting with their voices at this
age. They will move on from cooing to laughing and squealing. They
 may start to “blow raspberries” (spray saliva). This is particularly
fun at mealtime. They also experiment with the volume of their
voice.
Vision. Your baby’s vision improves to about 20/40 by four months of
age. So he will be able to see you across the room.
Social/Personality. Your baby will try to imitate social contact with
you. Smiling, tickling, and laughing are very entertaining for your
baby.

Q. What developmental stimulation can I provide for

my two to four month old?
Motor. Give your baby more tummy time (five to ten minutes) several
times a day. He will let you know when it’s time to turn over.
Activity gyms are fun because they can start to bat and grab at the
objects.
Language/Social. Keep that reading ritual going. When you are out and
about, talk to your baby. He is your companion, so treat him like one.
Tell him where you are going and what you are doing. You may feel
silly telling him what you are putting in your grocery cart, but all
those vocabulary words will be recorded in his growing brain.

Reality Check: The Value of Talk Time

A recent study looked at three-month-old babies’ brain activity in response to
hearing simple phrases. Guess what? Their little brains lit up when they
heard phrases they had heard before! While you may not hear your baby talk
back to you for a while, there is a lot going on in there. This study validates
the importance of talking to your baby early in life. (Dehaene-Lambertz)
While it may seem awkward conversing with your baby during a Costco
outing, keep it up. These seemingly insignificant moments are actually pretty
significant.

Four to Six Months of Age

Q. What developmental milestones will I see with my

four to six month old?
Gross Motor. Your baby will sit up with your assistance, then “tripod
sit” with his hands supporting him between his legs. Eventually, he
will sit up without support.
Fine Motor. Your baby has mastered grabbing. He will start to use his
fingers more than just his hands. He will “rake” objects to get them
into the palm of his hand by six months. He will also start to transfer
objects from one hand to the other by six months old.
Oral Motor. Your baby will figure out how to maneuver his tongue to
swallow solid food by six months of age (see Chapter 7, Solids).
This is one of several reasons why it is not recommended to offer
solid food before this age.
Language. Your baby will start making the first recognizable sounds of
language. Consonant sounds usually progress from B’s to D’s to M’s.
This means, you’ll first hear “ba-ba” then “da-da” then “ma-ma”.
The “Ba-Ba” occurs around six months of age. Your baby should
also turn to you when you are talking to him by six months.
Social/Cognitive. Your baby is very aware of his surroundings. He
knows his family and friends. He knows his room and his crib. Four
month olds already thrive on the routine and the expected. But even
at six months of age, your baby will not have the concept of “object
permanence.” So, if you leave the room or a toy leaves his sight, it
no longer exists.
 NEW PARENT 411: READING PROGRAMS

Reach Out and Read (reachoutandread.org) is a national program

that encourages 15-20 minutes a day of reading to young children. In
participating doctors’ offices, books are given free of charge at well
child visits from infancy to five years of age. This allows parents to
build a developmentally-appropriate reading library in their homes.
You can also seek out local libraries and national bookstore chains
that offer free story times for both infants and toddlers.
The benefits of reading to children at an early age are clear. Set
aside special time everyday for reading with your little one!

Q. My six-month-old is sitting up but he never rolled

over. Should I be worried?
No. Welcome to the anti-SIDS generation.
It is easier to roll from tummy to back, than from back to tummy. Babies
of our generation spend significantly less time on their tummies because of
the “Back to Sleep” campaign to prevent Sudden Infant Death Syndrome. As
a result, babies these days often master rolling over about the same time as
sitting up (or skip rolling over entirely). Rolling over used to be a four-month
milestone. Sitting up is a six-month milestone.

Q. What can I do to foster my four to six month old’s

development?
Gross Motor. Because babies of this age group aren’t quite sitting alone
yet, the stationary Exersaucer toys are great. They give babies a
sense of independence, and free up their hands to play. However, we
don’t recommend using them for more than ten or 15 minutes at a
time. Some studies have shown that babies who can’t see their feet
and legs because of the trays on these toys can have delays in
 walking. Also, be sure to give babies lots of floor time to work on
rolling and balancing.
Fine Motor. Give your baby large plastic or plush toys to grab,
manipulate, and mouth. Yes, mouth is used as a verb here.
Everything your baby examines will go into his mouth to test out.
Toys that make noise are fun. The plush caterpillars that have
different sounding objects in each segment are popular.
Language. You know the drill by now. Read to your child on a daily
basis. Use board books and those designed for tub time (that is,
they’re waterproof)—these give your child a tactile experience as
well. But, for safety reasons, no chewing on vinyl books.
Social/Personality. Babies are keenly aware of facial expressions. Get
a cheap plastic mirror for hours of fun—your baby will sit there and
stare at himself.

RED FLAG: AVOID WALKERS

The American Academy of Pediatrics strongly discourages the use

of walkers. Canada banned walkers over a decade ago. Why? Babies
drive these things without taking a driver’s ed course. Walkers allow
babies to get places that their knees or feet would never take them.
This sometimes means falling down a flight of stairs.
New walkers now have some safety devices built in meant to keep
them from falling down stairs. Because of the newer safety
requirements, there has been a marked decline in the number of
injuries caused by walkers.
Even with the new safety standards, pediatricians see numerous
head injuries every year as a result of walkers. Even if a child doesn’t
fall down the stairs, she can still run into low tables and chairs and
knock items off tables (like hot drinks and glass vases, for example).
And older, used walkers without the new safety devices are definitely
death traps.
Six to Nine Months of Age

Q. What are your expectations for a six to nine month

old?
Gross Motor. The main milestone over these three months is
locomotion. Your baby will figure out how to get where he wants to
go. That may be achieved by rolling, crawling, or “cruising”
(walking while holding onto furniture). Some babies skip crawling.
Because of this, if you look at the Denver Developmental Checklist,
you’ll notice that crawling isn’t listed. Meanwhile, your baby should
also be able to get from lying down to sitting, and from sitting to
standing up (holding on to something).
Fine Motor. Your baby will refine his reaching and grabbing skills. The
crude “raking” will change to a “pincer grasp” (picking things up
between index finger and thumb). Things like lint and dirt on the
floor will suddenly become very interesting. This correlates with the
ability to self-feed (see finger foods in Chapter 7, “Solids”).
Oral Motor. Your baby should be able to maneuver his tongue and
chew food with teeth (or gums).
Language. Your baby should be progressing into the D’s and M’s. We
expect a nine month old to say “Dada” and “Mama”, but don’t
expect them to know the meaning of those words until about 14
months. Everything you are saying is recorded in your little one’s big
brain. His receptive language is quite good (that is, he understands
what you are saying). Your nine month old understands the word,
“No.” Whether he chooses to respond to it is another story.
Cognitive/Social. Ah, the light has turned on. Somewhere between six
and nine months, your baby will have achieved “object
permanence.” This is a MAJOR concept. He realizes that people and
things still exist, even if he can’t see them anymore. So, if you leave
 the room, he will look for you. This, understandably, creates some
anxiety (see “separation anxiety” in the next chapter).
More social issues. Another concept that arises is stranger anxiety. Not
only will your baby want to know your every move, but he won’t
want to hang out with anyone but you. Don’t get too frustrated.
When your baby is so independent that he wants nothing to do with
you, you will look back fondly at these days. Your baby also is
picking up social cues. He will smile to engage others. He might
wave bye-bye by nine months of age. He also is starting to figure out
how to express his needs non-verbally. Finally, your baby will start
testing the limits of his world. At nine months old, your real
parenting job begins. You need to set limits on your baby’s behaviors
STARTING NOW (see Chapter 11, Discipline).
Vision. Your baby’s vision is 20/20 by six months of age.

Old Wives Tale

A baby who skips crawling and walks first won’t be able to do higher
math.
The truth: Where did this one come from? I crawled before I walked and
still couldn’t figure out calculus—so there. It has no bearing on intelligence.

Q. What developmental stimulation can I provide for

my six to nine month old?
Gross Motor. Provide a SAFE environment for your baby to move
around in (see safety tips later in this chapter). Your house is now his
playground.
Fine Motor. Provide SAFE toys for your baby to feel, touch, maneuver,
and taste. Babies explore with their hands first, then their mouths. If
you are buying toys, pick ones that make sounds or lights when
 manipulated. Before you rush to Toys R Us, look around your
kitchen. Old measuring cups, Tupperware, seasoning bottles (sealed
shut), pots, pans, and wooden spatulas are often a hit with this age
group. If you actually venture to a restaurant, those individually
wrapped crackers are a real crowd pleaser until your meal arrives.
Language. Do you have a Barnes & Noble Member Card or Amazon
Prime? Now would be a good time to take the plunge—reading
books to your baby is key to language development. Use your local
library as your baby gets older, but for now buy some cardboard
books (called board books) of your own. Your baby’s library will
double as his teething toys.
Even More Language. When you speak to your baby, use single words
and short phrases. Otherwise, you will sound like the teacher in the
Peanuts cartoon to him. Your baby will start to show you what he
wants. Instead of saying, “Oh, do you want the rubber ducky?” say,
“Duck?” That will teach him the vocabulary word he is looking for.
The same language rules apply for discipline. Instead of saying, “Oh,
no, Honey, don’t bite Mommy’s shoulder!” say, “No biting.” (Yes,
there is more coming on this in the next chapter).
Social/Personality. Your baby is a social being and is very responsive
to family members. Your baby will imitate the way you respond to
situations. He follows your lead. Be a good role model. Since your
baby now has object permanence, playing peek-a-boo is fun. It’s also
fun to hide toys under a blanket and let your baby look for them.
How easy it is to amuse a child this age!

DR B’S OPINION: BABY SIGN

LANGUAGE

We know that children are capable of understanding language and

communicating non-verbally long before they are able to speak. So,
teaching an older baby or toddler hand gestures to communicate
 makes sense. And there is scientific proof that signing is beneficial.
One study found that infants and toddlers that were “sign talkers”
spoke earlier and performed slightly higher on IQ tests at age eight
that their non-signing friends. (Brenner)
While your baby may only learn a few signs, sitting down with
your child to learn any new skill has its merits. You don’t need to buy
a book to learn sign language. You can create the hand gestures on
your own (check out Meet the Fockers on Netflix sometime). If you
choose not to teach your child sign language, do not fear . . . your
child will master the universal “point and grunt” skill to tell you what
he wants.

Nine to Twelve Months of Age

Q. What are the developmental milestones for a nine to

12 month old?
Gross Motor. Your baby should definitely have his sea legs. He should
be able to stand holding on to someone’s hand or a piece of furniture.
He probably will be able to pull up to stand and get back down to a
sitting position. One day, you’ll go into the nursery and be shocked
to find your baby standing up in his crib grinning at you. Your baby
may or may not be taking his first steps at his birthday party. It’s still
within developmental limits to be walking by 15 months old.
Fine Motor. Your baby should be good at picking up small items. He
will also start banging objects together. Babies this age get really
good at pointing.
Oral Motor. Your baby should learn how to drink liquids from a cup.
Ideally, she will be able to drink from a real cup, but most parents
seem to prefer the no-spill sippy variety. Drinking from a straw is
also something that works well for a child this age. By one year of
 age, your baby should graduate from a bottle to a cup (see Chapter 6,
Liquids for details).
Social/Personality. As your baby approaches his birthday, he will be
very good at expressing his needs non-verbally. There is a universal
“point and grunt” that babies around the world know how to do. As
his expressive language improves, there will be less frustration due
to communication barriers.
Anxiety. Separation anxiety peaks at nine to 12 months, then again at
15 to 18 months. Remember that anxiety stems from the fear that
you are leaving permanently. Ease these fears by kissing your baby
goodbye and telling him when you will be back. Keep it short and
sweet, and make your exit.
Language. From nine to 12 months, your baby may start to say
“Mama” and “Dada” and mean it. He may also say a word or two
(but it’s more likely to happen if you have a girl). Regardless of sex,
your baby will speak with great confidence in some foreign
language. If you listen to him (via monitor) in his crib at night, you
should hear a whole monologue going on. This singsong intonation
of speech is called “jabbering.” Even though there aren’t any
vocabulary words, you know your baby has been listening to you.

Babies start to imitate their parents’ activities. You may catch him
pretending to dust and sweep. You may have a cleaning buddy!
Your baby will make it clear that she wants to be in charge and
independent (in simple terms, it’s her way or the highway). It is important to
begin discipline and setting limits.
Your child will have conflicting moods. He may happily leave you behind,
but then call for your help. Your availability as a consultant teaches your
child to turn to adults for problem solving. Your child’s sense of self (ego) is
developing. Praising your child for small accomplishments gives him
confidence.

Q. My one year old son isn’t talking yet. All of the girls
in his playgroup are yakking up a storm. Should I be
worried?
Girls are talkers. Boys are walkers.
There is no question that girls learn language skills more quickly than
boys. And once we start talking, you can’t shut us up! Boys tend to reach
motor milestones more quickly than girls—hence the roughhousing and
athletic skills that you see later on. It’s very interesting to watch. Clearly,
parents have some hand in the way children develop along gender lines, but a
lot of it is pre-determined.
However, if your one year old son or daughter has no signs of non-verbal
communication skills (babbling, pointing/grunting), it’s time to get it checked
out.

Q. We speak two languages in our house. Will our child

learn both?
Yes. She will have excellent receptive language skills in both languages
(that is, she’ll understand both) long before she speaks either language.

NEW PARENT 411: CAR SEATS & HEAD

CONTROL

Children should be at least two years of age to sit forward-facing in

a car seat. Why? A child under two lacks neck support to avoid injury
in a car accident when forward-facing. Hence, rear-facing is safer.
That’s the official advice from the American Academy of Pediatrics—
a child should ride rear-facing until age two. The good news: most car
seats (both infant and convertible) work rear-facing to 30 or 40 lbs.

Q. What can I do to foster my baby’s development

from nine to 12 months?
 Gross Motor. Offer a wide-open space for your child to roam. Start
playing with a ball. Toys that can be pushed are fun for babies who
are walking (lawn mower, grocery cart, baby buggy).
Fine Motor. Play pat-a-cake. Offer toys that your baby can bang
together. It’s also fun to get “cause and effect” toys (your baby
pushes a button that causes a toy to move or make a noise; Jack-in-
the-Box). Now is the time to buy “the classics.” These toys are called
stacking cups (plastic cups of various sizes) and shape sorters
(cylinder with plastic shapes and matching holes in the top). Toys
that can be filled and dumped are also entertaining.
Social. Let your child participate in activities of daily living. While you
are cooking dinner, let your baby “cook” his own meal on the floor
with old pots and pans. While you are cleaning up, give him a towel,
too. Start reviewing body parts with your child as a part of his
vocabulary. You can also begin giving jobs to your baby. He should
be able to follow one-step directions (such as “Bring me the ball.”)
Language. Books, books, and more books. Picture books with a single
picture and word on each page encourage vocabulary words.
Remember to converse with your child as your companion. Continue
to identify items in single words and short phrases. Singing songs
helps with language skills, and helps pass the time in traffic. Your
baby doesn’t mind if you can’t carry a tune.

If you’re looking for a great resource on the best toys to buy for your
child, check out the Oppenheimer Toy Portfolio (web: toyportfolio.com). The
book and accompanying web site rate and review toys, books, videos,
software and music for kids. You can find age appropriate toys that are
geared toward stimulating your child’s development.
Don’t forget friends’ toys. When you take your child to another kid’s
house for a play date, they get exposed to a whole other set of toys. Some
parents even get together and toy swap so their kids get different toys but
don’t have to spend oodles of money on them.
Feedback from the Real World: Multiples
“Don’t buy two of everything! Twins learn to share early on. Instead, have a
few different options and swap them around to keep them entertained.”—
Agustina, mom of Gael and Malena.

Q. When should I buy shoes for my baby?

When he is a good walker.
There is no medical reason to wear shoes. Most babies use their toes to
grasp the floor when they are trying to walk. For this reason, we encourage
your baby to travel the house in bare feet. If you are out in public, by all
means, put shoes on your child. You don’t need to buy expensive shoes. But,
it is a good idea to get your child’s foot measured when you buy that first
pair of shoes to ensure proper fit.
The hottest trend: Robeez. These are soft leather moccasins meant for
protection and flexibility. Did we mention, pricey? Does your baby NEED
these shoes? No. They are not a medical miracle. But they are a nice
alternative to socks if your child will be exiting his stroller on your travels.

Helpful Hints
Take a CPR course and have any caregivers who are taking care of
your child take one, also. The biggest potential problem for a child
after nine months is choking. Kids this age do not get the famous
Heimlich maneuver— they get back blows to force out the foreign
object. You’ll want to find out how to perform this if you don’t know
already.
Have Poison Control’s phone number by your kitchen phone. The
national number is: 1-800-222-1222. You can find your local Poison
 Control number from the American Association of Poison Control
Centers’ web site at aapcc.org. Always call poison control first if
your child has ingested something. FYI: It is no longer
recommended to have syrup of Ipecac in your medicine cabinet. Not
all toxic chemicals should be removed by vomiting because they can
burn the esophagus and mouth when coming back up.

Q. Where can I get information about toy safety? I

have heard about baby product recalls.
Check out the U.S. Consumer Product Safety Commission Hotline on the
web at cpsc.gov or toll free at 1-800-638-2772.

Q. When can my baby start watching TV?

I’m so glad you asked! As one of the authors of the 2011 American
Academy of Pediatrics policy statement on media use in kids under age two,
I can answer this question and explain the rationale behind it.
The short answer: the AAP discourages passive media programs viewed
on all screens (TV, DVD’s, smartphones, tablets, etc.) for kids under two
years of age. (AAP) Note: the AAP’s advice is specific to passive screen
time, where a child is simply viewing a show. There is currently no official
AAP position on apps or computer games, where a child is engaging in
activity (interactive media).
Once children turn two, the AAP recommends limiting total recreational
screen time to two hours a day. (AAP) Despite that recommendation, 90% of
kids under age two watch TV every day and 26% even have a TV in their
bedrooms. (Kaiser Family Foundation)
Why are the experts so negative on TV? What’s the harm, you say? Sure,
we know that a 30-minute kiddie show might buy you time to take a much-
needed shower. And don’t “educational” shows help kids learn?
Here’s why TV and other forms of passive media is bad for babies under
age two:
1 WATCHING A SHOW ON A SCREEN IS A LOW ENERGY ACTIVITY. If a
screen is turned on, your child is sitting down (unless you are doing an
aerobics video). The average school age child has three to eight hours of
daily screen time.. Yep, that’s a third of a day sitting on their butts. Do you
want to start this couch-potato habit in infancy?

2 IT’S ONLY EDUCATIONAL WHEN YOU CAN UNDERSTAND IT. Studies

have shown that educational programming is beneficial for kids . . . BUT
only for children who understand the content. The magic age to understand
TV is two years old. While there are some very bright 18 month olds who
“get it,” the majority of kids don’t, and thus do not gain any knowledge by
watching. It gets lost in translation. The reality: those baby videos that claim
developmental stimulation have no data to back up those claims (heck, why
spend money doing a study when the product sells like hotcakes). Bottom
line: even Sesame Street, which is an educational show, is not appropriate for
your baby to watch. (Anderson)

3 SCREEN TIME DISPLACES OTHER ACTIVITIES. The time kids are

watching screens is time they are not spending with their family, engaging in
conversation, playing with someone, or playing independently. These are
important activities for kids of all ages. (Vandewater) That is the harm of TV
for babies. We know you can’t sit down and play with your child 24/7. But
realize that independent or solo play is a valuable use of your child’s time.
That is how kids fine-tune skills that they need in this world (like problem-
solving or using their imagination).

4 SCREEN TIME INTERFERES WITH TALK TIME. If a parent and child are
in the same room (even if both are working on individual tasks) and screens
are off, a parent is more likely to chat with a child. That “Talk Time” is a
necessary part of learning language and social skills. When screens are on,
parents talk time goes down by 85%.
5 MANY PROGRAMS ARE INAPPROPRIATE FOR CHILDREN. For instance,
the evening news can be very graphic and disturbing (and don’t think your
baby/child isn’t watching because it’s “your” show). Even children’s
programs can be problematic. Have you watched a cartoon lately? The
average cartoon has 20 violent scenes per hour. The violence that occurs does
have an impact. Studies have shown a direct influence on children’s
behaviors after watching cartoons. (AAP)

So, here are some suggestions:

After your child turns two or older, limit your child’s screen time (a
daily limit is good). Have house rules and stick to them.
Content matters. Any PBS show is usually a good bet. Cartoon
Network shows require a parent preview. Yes, that means sitting
down and watching without your child to see if that show is
appropriate. You can also cheat and go to commonsensemedia.org to
get expert and parent reviews of programs.
Co-viewing matters. Participate WITH your child. Watch shows or play
apps/games together. Talk about it.
Keep screens out of your child’s bedroom. Let’s get real here—your
kids will learn how to master just about any screen you put in front
of them . . . probably better than you. So, any screen that lives in a
child’s room gives your little one free access without supervision.
Bad idea.
No screens at meal times—no exception for kids’ shows OR the news
or checking your Facebook page. This not only interferes with
important time together as a family, but it also encourages people to
continue eating after they are full.

BOTTOM LINE
Many baby videos and websites have clever marketing pitches—watch THIS
video and your child will be smarter! Stronger! Wealthier!
The truth: your baby will be smarter if you sit down for 15 minutes and
play with him—no screen time required. Children learn much better when
they are actively participating in a learning activity. No kiddie program will
make your child an Einstein or a Mozart.

Reality Check: Distracted Parenting

Have a media management plan for everyone in your family—that includes
YOU. Screen time is distracting for parents. That all-important “talk time”
gets reduced when a parent is watching her own adult show or even has the
TV on in the background while preparing dinner. And even if the show on
the screen is intended for grown-ups, a child playing in the same room will
look up at the screen about every 20 seconds and be less attentive to his play.
Just turn it off and watch your shows later.
And don’t get us started on parents who check email, latest stock quotes,
or Facebook posts on smartphones while their little ones play on the
playground, or worse, in the pool. Turn it off!

Q. But I just need 15 minutes to take a shower or

prepare dinner. Is a little screen time okay to entertain
my child?
We hear you—as parents of four children ourselves, we know there are
times you just want to take a shower. Or cook dinner. Yes, this means taking
your attention away from your child.
But what is your child to do during this brief period of time? We know the
simple answer is to turn on a kid TV show or DVD as a babysitter. While
there are no studies that suggest this will leave a permanent scar on your
child, here is an alternative:
It’s called independent play. Crazy, eh?
 Yes, you have our blessing to let your child find something to do with his
time! And yes, it stimulates your child’s creativity and problem solving
skills. He can be sitting in the bathroom while you take a shower. Or on the
floor in the kitchen with some age-appropriate toys (plastic bowls and
wooden spoons do nicely).
We’d argue this is time well spent. Our kids have become the Entertained
Generation—if they aren’t plugged in, they’re bored. The take home
message: you do NOT have to entertain or find entertainment for your child
24/7. Let them play on their own.

Q. What about iPads and educational apps? Are these

ok?
Great question. The AAP has no official recommendation on interactive
media and young children—yet. AAP policies are based on scientific
evidence and in this case, science lags far behind the pace of technology.
Our advice: the answer depends on how much you trust your baby with an
expensive piece of equipment (does AppleCare cover drool damage?) and
how you decide to manage your family’s media time. Trust us, once the cat is
out of the bag, your child will be as addicted to it as you are.
There are some great interactive apps that let kids test cause and effect,
learn vocabulary words, and practice problem-solving skills. Just know that
an app can never replace some toys. There is real value in figuring out how
to take two blocks in your hands and stack them up on top of each other so
they don’t fall over. You can’t do that on an iPad. Remember that young
children are tactile learners and need to experience real people and real
things—not just virtual ones.

Q. What do you think of “Mommy and Me” and other

community programs for babies?
For babies, these are a mixed bag. For the most part, Mommy gets more
out of these programs than babies less than one year of age. Look for
programs that focus on singing, story time, and finger plays. The more motor
oriented programs (Gymboree, Little Gym) are more appropriate for toddlers
(over one year in age). One tip: watch a class or two before you sign up so
you aren’t wasting your time.

Q. Should my baby take an infant swim class?

Sure. It can be a fun way to bond with your baby and get out of the house.
And it may actually help prevent a drowning.
Recent research suggests that swim classes may be an important part of
drowning prevention—which is why the American Academy of Pediatrics
now recommends beginning swim lessons when a child shows signs of
interest and developmental readiness. Children ages 1-4 who have had some
formal swimming instruction are less likely to drown.
The other keys to prevention include pool fencing, adult supervision (and
we really mean supervision—without distraction), and a CPR-trained parent
or caregiver sitting poolside. (Brenner) For more water safety information,
check out colinshope.org, an advocacy group founded by a family who lost
their son, Colin, in a drowning accident at a community pool. Not only is it
chock full of useful information, it’s near and dear to my heart because Colin
was my patient.
Many community pools offer “parent and me” classes. Check with a local
office of the Red Cross or your city’s parks and rec department for more info.

NEW PARENT 411: FINDING THE BEST TOYS

The best place to find great toys are to look in your own home. Old
bowls, wooden spoons, measuring cups, and Tupperware can entertain
a child more than you think.
But, if you are in the market for toys, it is worth doing a little
research. The Oppenheimer Toy Portfolio is a great resource. Visit
their website at toyportfolio.com.
Reality Check
By swimming instruction, we are NOT endorsing the Infant Swimming
Resource (ISR) programs where babies are repeatedly immersed in water
until they learn to roll to their backs and float. Look for Red Cross approved
lessons.

Q. What books do you recommend if I want to learn

more about child development?
Touchpoints by Dr. T. Berry Brazelton. He has a beautiful style to
approaching development, developmental stimulation, and the challenges
within these topics. Brazelton has a “cup is half full” way of viewing your
child’s struggles with growth and independence.

NEW PARENT 411: TOP 14 SAFETY TIPS

Now is the time to make your home safe. Put this one on the
Honey-Do List.
Children start to explore their world as a natural part of their
development. Make their world safer so they can accomplish their
goals. Here are the Top Safety Tips:

1.Safety gates need to be at the top and bottom of the stairs. The best
and safest option is to permanently install gates (instead of using
pressure gates).
2.Electrical outlets need to have plastic safety covers.
3.Get down on the floor and look at the world through your child’s
eyes. Electrical cords and telephone cords need to be moved
 behind furniture.
4.Toxic cleaning products in lower cabinets need to be moved.
5.Cabinet locks on cabinets with knives, glass containers, and china.
6.Coffee tables and fireplace hearths with corners need safety
bumpers.
7.Anchor bookshelves to the wall.
8.Get toilet lid locks so your baby cannot fall in.
9.Set your hot water heater to 120 degrees or less.
10.Get cord shorteners or wall brackets to avoid dangling drapery
cords.
11.Remove any toys hanging over the crib by the time your baby is
five months old.
12.Keep medicine out of reach. Be especially watchful of
grandparents who come to visit. They are more likely to a) be
taking a medication and b) be leaving it out on a bathroom
counter.
13.If you drop something, pick it up. Otherwise, your baby will do it
for you and stick it into his mouth.
14.If you are a gun owner (remember I live in Texas, y’all), lock ‘em
up. Guns should never be accessible to children. Store
ammunition elsewhere and lock it up, too.

BOTTOM LINE
The most critical developmental stimulation for your baby is the time you
spend with him. You don’t need to buy expensive toys or park him in front of
“developmentally appropriate” DVD’s. Nor do you need to enroll your baby
in a special preschool program. We’ll discuss preschool at length in
our Toddler 411 book (see the back of this book for details). For now, just
concentrate on spending time with your baby.
Q. Can you give me some ideas for age appropriate toys
for babies?
Here are some guidelines:

Infants birth to six months:

Look for: bright primary color, clear lines, features, human faces
Fine Motor (manipulatives): soft blocks, rattles, squeeze toys, keys on a
ring, activity gyms.
Other sensory activities: Tape recordings of you singing or reading a
story, music boxes, mobiles, mirrors, hand held puppets

Infants six to 12 months:

Look for: things safe to go in the mouth, things to stack, pour, dump,
things to push, turn, or press, things to open and shut
Gross Motor Play (large muscles): Push toys, Low climbing platform
Fine Motor: soft blocks, easy puzzles, squeeze-squeaky toys, pop-up
boxes, containers to empty and fill, nesting cups, water toys
Other sensory: music boxes, songs, tapes, tapes of you

This list is derived from The Consumer Products Safety Commission

guide called Which Toys for Which Child: A Consumer’s Guide for Selecting
Suitable Toys, Ages Birth Through Five. Check out their website at cpsc.gov
for your own copy.

Recommended books for birth to age one

We suggest buying the board book versions if you can find them. Not only
will your baby enjoy listening to the stories, but he’ll want to help turn the
pages. He’s also likely to use them as a teething toy at some point (as we
discussed earlier). If you want the books to have a decent lifespan, go
cardboard.
Here are some favorite titles:

Margaret Wise Brown: Good Night Moon, Runaway Bunny

Eric Carle: The Very Busy Spider, The Very Hungry Caterpillar
Eric Hill: Where’s Spot?
Bill Martin, Jr.: Brown Bear, Brown Bear, What Do You See?
Golden Books: Pat The Bunny, The Pokey Little Puppy
Nancy White Carlstrom: Jesse Bears’ Yum Yum Crumble
Dr. Seuss: Mr. Brown Can Moo! Can You?
Sandra Boynton: Barnyard Dance!
Tedd Arnold: Five Ugly Monsters
Jan Pienkowski: Little Monsters, Oh My a Fly!
Paul Strickland: Dinosaur Roar!
Stephen Losordo: Cow Moo Me
Adam Rubin: Dragons Love Tacos
DISCIPLINE &
TEMPERAMENT
 Chapter 11
“Any child can tell you that the sole purpose of a middle name is so he
can tell when he’s in trouble.”
~ Dennis Fakes

WHAT’S IN THIS CHAPTER

FIGURING OUT YOUR BABY’S TEMPERAMENT
THE HIGH MAINTENANCE BABY
TIPS FOR SOOTHING THE SAVAGE BEAST
PACIFIERS
COLIC
INFANT MASSAGE
TIPS ON PLANTING THE SEEDS OF DISCIPLINE
SEPARATION ANXIETY
MASTURBATION
THUMBSUCKING
BITING AND BEING BITTEN

Every parent will go through it. You can see it coming. Your son snuck out
last night to hang with his buddies after you explicitly told him he couldn’t.
So he’s grounded. You took the car keys. He has to bum a ride to school or,
worse, take the bus. Maybe you remember when you did exactly that or
something like it.
Okay, so you don’t have to worry about this scenario yet, but you do
need to set up the foundation for what seems like a lifetime of discipline.
And now that you know all about child development, you can take all that
knowledge and apply it to guiding your child’s behaviors today and into the
future.
But before we get to discipline, we’ll need to discuss temperament. Call
it the “getting to know the real you” section of the book. Once you figure
out your little angel’s temperament, you can tailor your discipline issues to
fit him like a glove. Or at least that’s the theory.
Believe it or not, your baby’s doctor may be a good resource to help you
sort through these issues. If she doesn’t have all of the answers, she can
point you in the right direction to get the answers.
Temperament and discipline issues are the toughest part of your job
description. Here is a general list of what you will be facing this first year:

AGE FUN CHALLENGE

0-3 months Learning your baby’s temperament
Colic
3-4 months Night feeding/sleep issues
9 months Separation anxiety
Stranger anxiety
Night wakenings
Limit setting
12 months Aggressive behaviors (biting, hitting)
(Harriett Lane Handbook)

Temperament: Getting to know YOUR baby

Every baby is different. We know that’s not news to you. No matter how
much advice you get, or how many books you read, no one can tell you
what YOUR child’s emotional needs will be. You will realize when you
have a crying baby on your hands that you’d better figure out your child
ASAP . . . or check into the nearest mental health facility.
Q. What are the typical temperaments of babies?
Landmark research done in the 1970’s described the three main types of
temperaments. Every child doesn’t fit into only one category all the time,
but here are the groups:

1 EASY CHILD. Surprisingly, 40% of kids fit in this category. These babies
have regular eating, sleeping, and elimination habits. They are usually
happy and easy going. They are interested in exploring new things and
don’t mind change.

2 DIFFICULT CHILD. Only 10% of kids fit in this category. These babies
have more irregular eating, sleeping, and elimination schedules. They have
trouble with change, transitions, and new experiences. These babies are
intense.

3 SLOW TO WARM UP CHILD. About 15% of kids fit here. These kids are
also difficult because it takes them a while to adjust to change in
environment or care provider. They hide in their shells when they encounter
a new situation.

4 THE REST. Thirty-five percent of kids don’t fit into any of the above
categories and have “mixed” temperaments. (Thomas)

BOTTOM LINE
Figuring out what type of baby you have will help you to anticipate how
your child will react to certain situations. Plus, you’ll have a better idea how
to make his world (and yours) a better place. For example, a difficult baby
needs extra time getting into his car seat without a fight. Plan extra time in
your schedule for coaxing if you have some place you need to be.
 Real world parent story: It always amazes us to watch our child-less
friends decide to go somewhere (like a restaurant). They just pick up their
keys, lock the door and poof! They’re gone. For parents of children, it is a
20 (or 30 or 40) minute odyssey that first involves finding shoes/socks,
coats, toys, books, etc. Then someone has to have a diaper change. It then
takes more time to buckle in the car seat, only to discover a child has
forgotten their toy and then the process repeats. As a parent, outings require
the pre-planning that usually goes into staging a small-scale military
invasion—remembering to bring that diaper bag (honey, do we have any
wipes?), wallet, purse, keys . . . as well as your sanity. Then add in a
“difficult” baby and you may as well just stay home.

DR B’S OPINION

“View your baby’s temperament . . . as a cake

mold. While you can’t break the mold, you can
control how the cake is baked. How you interact
with your baby can positively impact his future!”

Q. When will I be able to figure out my child’s

temperament?
By the time a baby turns one, most parents have his number—you know
what kind of child you have on your hands.
Of course, some temperaments are more difficult to live with than others.
But all have their strengths. When you are feeling frustrated with your baby,
think about how successful he will be in the future with those traits!
Here are seven questions to help you understand your child’s
temperament:
 1.Adaptability: How does your baby respond to change or new
situations?
2.Regularity: Does your baby follow a schedule with sleep and
mealtimes?
3.Mood: Is your baby’s attitude positive or negative about life?
4.Persistence: Does your baby persist at activities or give up easily?
5.Sensitivity: Is your baby sensitive or oblivious to environmental
changes (like noises, smells, tastes, lights)?
6.Intensity: Is your baby laid back or intense?
7.Energy: Is your baby energetic or quiet? (Kurcinka)

Q. As a doc, what is your view of infant temperament?

There are high-maintenance babies and low-maintenance babies. If you
are blessed with a high maintenance baby, recruit family and friends to help
out.
High-maintenance babies require more physical and emotional strength
from their parents. These babies get walked around, rocked, and soothed
more than their low maintenance friends. Parents of these babies are
exhausted and frequently at wits end. They have irrational thoughts about
giving their baby up for adoption. Don’t worry—you are not alone.
Low-maintenance babies need little intervention, and therefore need
little discussion here.

Q. Can you predict a child’s future personality based

on their temperament as an infant?
Yes.
Elements of a child’s temperament will persist through a lifetime.
However, all humans adapt to succeed in the face of life’s challenges. The
way you respond to your child has a tremendous impact on your child’s
personality. It’s that heredity vs. environment thing—both have an influence
on behavior.
Q. I have an extremely active baby. Can you tell if he
has Attention Deficit Disorder (ADD)?
No.
Attention Deficit Disorder is a diagnosis based on the shortened attention
span of a child compared to peers his age. All babies under one year of age
have fleeting abilities to pay attention to anything for very long. It’s
virtually impossible to make a diagnosis of ADD in a child less than three
years of age.
Will your very active baby ultimately have ADD? Only time will tell. As
we discussed in the previous chapter, armchair quarterbacks (namely, other
parents at your local park) may be quick to offer a diagnosis for your child
on this subject. Don’t listen to them!

Q. Why is my baby crying?

Because he can’t talk. The average baby cries one to four hours a day.
If you had no other way of communicating you’d be crying, too. Babies
are trying to tell you something when they cry. It’s your job to play
detective and figure out what it is. Yes, there are certain types of cries (I’m
hungry, tired, in pain), and that will give you some clues. The truth is, when
you spend 24 hours a day with your crying baby, you will get each other
figured out—we have no doubt about it. Welcome to Hell Week—you are
about to be initiated as a parent.
Read the next box for a reasonable cry management approach.

Reality Check
A recent study done at a clinic for babies with colic showed that two-thirds
of the babies referred actually had gastroesophageal reflux (that is,
heartburn). (High)
BOTTOM LINE
The mistake most parents make is that they give their newborn more credit
than they deserve. Newborns have simple needs.
They don’t cry because you are a bad parent, because they are lonely, or
because you have gone back to work and they are mad at you.
Most of the time, your baby just can’t pull it together to fall asleep and
needs some soothing. Depending on your baby’s temperament, that may
mean a little—or a lot—of soothing.

NEW PARENT 411 : THE 3 RULES OF CRY

MANAGEMENT

Rule #1: DON’T PANIC—the most important advice!

Rule #2: Go through your baby’s To Do List. Is your baby crying

because she:
Needs to eat?
Needs a diaper change?
Is overtired and having trouble falling asleep?
Is a high-maintenance baby and doesn’t know what she wants?
Rule #3: Rule out medical causes if crying persists over two hours
straight. A good rule of thumb is that medical reasons for crying are
generally not fixed by holding and rocking your baby. For example,
your baby may be saying:
I’m having heartburn. (This is probably the most common medical
reason—see GASTROESOPHAGEAL REFLUX DISEASE).
I have colic. I do this every night. (See later in the chapter for
more discussion on colic.)
 I have a fever. (If your baby is under three months old, call your
doctor ASAP.)
I have gas, constipation, or milk intolerance (Memo to new
parents: usually this is NOT the cause, but every parent is
convinced that this is the problem).
I have a really serious medical problem (also rare, but that’s why
you should call your doctor).

Old Wives Tale

Picking your newborn up every time he cries will spoil him.
The truth: Your newborn does not have a neurological maturity to relax
and settle down on his own. You need to do the work to comfort him—
given his age. From birth to two months, you do whatever it takes. There is
no such thing as spoiling a newborn. As babies reach four to six months of
age, they become more capable of self-soothing. Wait to see if your baby
can settle on her own before intervening.

Top Ten Tricks for Soothing a New Baby (under three

months of age)

1 LET YOUR BABY SUCK ON YOUR FINGER. Sucking is incredibly

soothing for newborns. Pacifiers are okay, too. (More on this below).

2 DO THE BABY BURRITO WRAP. Swaddle your baby in a receiving

blanket. They are used to being snug in the womb, without limbs flailing
around. See the How to Swaddle a Baby box in Chapter 9, Sleep for a how-
to lesson.
3 ROCKING. Either sitting in that expensive rocking chair you bought, or
walking around and gently swaying baby back and forth in your arms.
(Much as YOU would like to be sitting in that chair, babies often prefer you
to walk around.) Singing or humming is also helpful.

4 GO FOR A WALK IN THE STROLLER. A change of scenery often helps

baby and parent.

5 GO FOR A CAR RIDE. When parents call me about prolonged (over two
hours straight) crying, I tell them to go for a car ride. If a few trips around
the block don’t make the crying stop, I’ll tell them to keep on driving to the
nearest emergency room.

6 USE A VIBRATING INFANT SEAT OR INFANT SWING.

7 TAKE A TRIP TO THE LAUNDRY ROOM. Put your baby in his car seat
and place on top of the dryer. Turn on the dryer. Vibration is particularly
helpful for colicky babies. Don’t leave your child unattended, however.

8 GIVE YOUR BABY A BATH.

9 TRY SOME INFANT MASSAGE (see later in this chapter for more info).
10 PUT YOUR BABY IN BED AND LEAVE HIM ALONE. If you have tried
everything and now you are crying, too, it’s time to let your baby cry it out.
They are truly exhausted at this point and will fall asleep on their own.
Feedback from the Real World: Multiples
“My twin stroller turned out to be my best friend, both indoors and
outdoors. I used it whenever my two hands weren’t enough. If necessary, I
could simultaneously bottlefeed them in the stroller. During bath time it was
the best way I found to focus all my attention on the one in the water and
know that the other one was safe and secure in the stroller next to me. It
was also my crutch anytime they were crying in unison. I would strap them
in and do laps around my kitchen and living room which calmed them every
time!”—Agustina, mom to twins Gael and Malena

The Great Binky Debate

Q. Is it okay to use a pacifier?

Sucking is soothing. And it is one of the few skills a newborn possesses.
That’s why pacifiers and thumb sucking are such popular pastimes for the
diaper-clad set.
Yes, by four to six months of age, babies have other ways to calm
themselves. And by the time babies reach their first birthdays, they are
more than developmentally ready to lose the binky and move on. But do
they need to? And, is there any harm in clinging to the pacifier after a
birthday or two (or more)?
We’ve all seen binky-addicted preschoolers. Case in point: years ago,
then five-year old Suri Cruise graced the tabloids with a binky in her mouth
(which sadly clashed with her Dolce&Gabbana handbag).
So let’s tackle the Great Binky Debate! Where do the experts weigh in?
Pediatricians, lactation consultants, speech pathologists, and orthodontists
all have their own opinions.
The American Academy of Pediatrics states that pacifiers offer some
protection against Sudden Infant Death Syndrome, which occurs
exclusively in babies under one year of age (90% of cases occur in babies
less than six months of age). That’s all the AAP says on the matter.
However, pacifiers are a known risk factor for ear infections. They are
also a sleep crutch, requiring a parent to repeatedly return to the crib-side
for re-insertion when the child pops it out of his mouth. For those reasons,
many pediatricians advise kicking the pacifier habit sooner rather than later.
The International Lactation Consultant Association (ILCA) has no
official position. Although many lactation experts feel that pacifiers
sabotage breastfeeding success, research shows that pacifiers don’t have an
impact—that is, when a family is motivated to breastfeed. (Jaafar)
Do pacifiers cause speech impediments? The research is inconclusive,
according to Shelley Solka, MS, CCC-SLP, an Austin-based speech
language pathologist. “Pacifier-using children plug themselves up and don’t
have a chance to use their words,” she said. “Instead they point and grunt to
communicate. Speech starts developing earlier than parents think and if a
child is using the pacifier, they may not experiment with sounds and putting
sounds together to make words.” Her perspective: with respect to speech
development, it’s best to get rid of the binky in infancy.
Perhaps the greatest concern about pacifiers is their potential impact on a
child’s teeth and mouth structure. You’d think the major orthodontic
organization in the country would have something to say on the matter, but
they don’t. So, we asked Randy Kunik, DDS, an orthodontist in Austin, TX,
for his advice on binkies as well as thumb sucking. Here are his answers:

Q. Is there any harm in letting my child use a pacifier

beyond a year of age?
Dr. K: As long as parents use a “Nuk” style pacifier after a year of age
and the baby is not turning it upside down, there is no significant dental
issue in using them until 24 months of age. It’s rare to see any long term
consequences if discontinued before then.

Q. How old is “too old” for a binky?

 Dr. K: From a purely dental standpoint, any child over 24 months is too
old for a pacifier. Kids who use pacifiers between two and three years of
age risk having additional nasty habits such as tongue thrusting or lip
sucking. These habits can adversely alter the growth of the mouth and teeth,
which makes future orthodontic treatment more complex. It may take
longer to correct the problems and may be difficult to maintain permanent
results.

DR B’S OPINION

“I cringe when I see a three-year-old walking

around the mall with a pacifier in his mouth. In
fact, my husband gets great joy in pointing these
kids out to me to see my reaction.”

Q. Are there any other dental risks?

Dr. K: Yes. Pacifiers are germ-laden. The bacteria S mutans can be
present on a pacifier and increase the risk of caries (dental
decay) . . . especially if a parent licks the binky after it drops on the floor.
(Yuck, right? It’s gross but many parents use this “cleaning” tactic.)

Q. What do you say to parents who say, “My child

might need braces even if he doesn’t use a pacifier”?
Dr. K: Well, it’s true that your child may need braces anyway. But long-
term binky users or thumb suckers (and the associated habits of tongue
thrusting and lip sucking) can create some really challenging orthodontic
problems, particularly in people who have longer, less round facial
structures. Those cases require oral surgery for optimal results. Bottom line:
prolonged binky use or thumb sucking may be the tipping point that results
in oral surgery and not just braces if a child is already genetically
predisposed to having tooth misalignment.

Q. Which is worse? Pacifiers or thumb sucking?

Dr. K: Pacifiers (beyond three years of age) cause more orthodontic
damage, but truthfully, it is much easier to break a pacifier habit than a
thumb sucking habit. Thumb sucking pushes the erupting permanent teeth
outwards, increasing the risk of injury. And, if the finger or thumb isn’t
clean, thumb or finger sucking increases the risk of bacterial and fungal
infections.

Q. How old is “too old” for thumb sucking?”

Dr. K: From an orthodontist’s perspective, a child needs to stop by
kindergarten. By age six, there is a much greater risk of significant and
complex orthodontic problems.

BOTTOM LINE: The longer the pacifier remains in your baby’s world, the
harder it will be to kick the habit. Babies adjust very quickly to life without
a pacifier and forget about it within a day or two.

Linda’s tip
If you are breastfeeding, it’s probably wise to wait until things are going
well (at least four to seven days) to introduce a pacifier. That way your baby
learns good sucking etiquette at your breast first.
Another concern: WHICH pacifier to use. A newborn who uses an
“orthodontic” pacifier (such as “Nuk” brand) may suckle (or bite!) at
mom’s breast the same way, leaving her mom with some very sore and
cracked nipples. I recommend “Soothie” brand pacifiers (soothie-
pacifier.com) for newborns since they’re shaped like the human nipple—
lowering the odds of gnarly nipples! Orthodontic pacifiers are fine for a
seasoned breastfeeding team.

DR B’S OPINION: PACIFIERS

Pacifiers are okay to use for babies under six months of age, at
most, a year. After one year of age, there are absolutely no medical
or developmental benefits—only risks. While it’s not a dental issue
before age two, binkies can lead to ear infections and interfere with
a good night’s sleep for everyone in the house.

Colic

Q. What is colic, anyway?

It’s the “C word” in new parent circles. But what is it, exactly? Colic is
known as the Rule of Three’s. It starts around three weeks of age. The baby
cries for about three hours straight from about 5—8 PM every night
(otherwise known as the “UN-happy hour”). And it lasts until the baby is
three months old. About 15% of all babies are afflicted with this malady.

Q. What causes colic?

Although scientists have been studying colic for years, no one knows
exactly what causes it. Many experts think the problem is due to immaturity
of the gastrointestinal or digestive system. So over the years, doctors have
tried treating it with medications to reduce gas, relax the intestinal muscles,
or cause sedation. None of these medications really help. The best treatment
for colic is time. . . . all babies eventually outgrow colic.
Some babies who seem “colicky” actually have a medical diagnosis. So
it is important to check in with your baby’s doctor if you’ve got a
chronically fussy baby on your hands. Some babies have heartburn
(gastroesophageal reflux disease or GERD). Those babies are usually
miserable all day and night or around feedings—not just for a three-hour
period everyday. Other babies may have a cow’s milk protein allergy and
don’t start to show signs of discomfort until several weeks of being exposed
to the milk protein going through mom’s breast milk or in standard cow’s
milk-based formula.

Insider Tip
The difference between a baby with colic and one with heart-burn
(gastroesophageal reflux, GERD) is that colicky babies act this way for
specific periods during the day. Babies with heart-burn do it all day long.

Q. My baby has colic. Help!

We know you want to do something. As parents, we are compelled to
help our babies feel better even when the doc tells us there is no treatment
but time. After browsing the net, you’ll no doubt find many colic treatments
that make miraculous (and unregulated) claims.
My advice before starting any treatment is to ask yourself this question:
Am I treating my child to make myself feel better (because I feel I am doing
something), or does the therapy really work?

Q. Do any alternative therapies for colic really work?

Maybe, but more research is needed to prove it.
 While there are over 1700 studies in the medical literature looking at
colic, fewer than ten studies were well designed. And, only two treatments
had more than one single study showing beneficial results to treat colic.
(Perry)
Therapies included spinal manipulation, massage therapy, reflexology,
herbal remedies (chamomile, fennel, licorice, vervain, mint tea or fennel
seed extract), sugar solutions, and probiotics. Of those, the most effective
therapies were fennel-containing remedies, sugar solutions, and probiotics.
Fennel may relax the gut and increase the gut’s motility. Sugar solutions
may have a pain-relieving effect. And probiotics may kick-start a colicky
baby’s (presumably) immature gut.
All of these remedies deserve more study.

Q. Is it worth it to try probiotics for my colicky baby?

Yes! Sold in capsules or powder, probiotics are the good germs in your
body that help improve intestinal function. Babies are born germ-free and
then acquire good germs in the gut to help digest food (you have millions in
your adult gut as you read this).
One of the first studies published on colic and probiotics compared 90
exclusively breastfed babies with colic. Half received over-the-counter gas
drops (simethicone) and the other half got one capsule a day of a probiotic
containing the germ Lactobacillus reuteri (commonly known as L. reuteri).
(Savino)
The results? Pretty darn impressive . . . the gas drops group saw a 7%
reduction in crying. The probiotics group had a 95% reduction in crying.
No, that isn’t a typo. Babies who cried two to three hours a day were crying
less than an hour after one month of treatment.
Several studies have shown similar results. While we won’t promise that
it will cure your baby’s colic, probiotics are certainly less expensive than
hiring a babysitter every night for two months!
The product I recommend for my patients is a powder form of L. reuteri
from Nature’s Way. The dose is a half-teaspoon a day, immersed in a few
drops of water (or mixed in expressed breast milk or formula). BioGaia
ProTectis is another good option.
Q. Do you have any other tips to help us survive the
next 10 weeks of colic?
We know it is a nerve-wracking experience. So, here are a few tips to
help you keep your sanity:
1. Recruit loving friends and family to come over from 5 to 8 pm a
night or two a week. You leave.
2. If #1 isn’t an option, put your baby in his crib and step outside for a
few moments.
3. Put your baby in a sling or carrier and run the vacuum cleaner. You
probably haven’t had a chance to clean the house in a while
anyway. We’re not being cruel, just realistic here.
4. Seek professional help for yourself if you can’t take it anymore—this
is not a sign of weakness or poor parenting skills.
5. For those parents who are really desperate, and will spend any
amount of money to stop the crying, there is a product called
“Sleep Tight” which attaches to the baby’s crib to simulate the
vibration and noise of a car going 55mph. For a mere $140, it can
be yours. Check out www.colic.com or call 1-800-NO COLIC.
Another idea: those vibrating bouncer seats ($30 to $40) have been
the saviors of more than one parent of a colicky baby.

Tips and tricks for dealing with colic could fill an entire book—and, in
fact, one doctor has already written an excellent book on this. Dr. Harvey
Karp, a retired pediatrician in Santa Monica, CA, has developed a terrific
method for soothing colicky babies. HisHappiest Baby on the Block book
(Bantam, $13.95) focuses on five steps to mimic the baby’s experience in
the uterus: swaddling, side/stomach position, shhh sounds, swinging and
sucking. We highly recommend Karp’s book.

DR B’S OPINION: GRIPE WATER &

COLIC
 Based on limited evidence of safety and effectiveness, I
recommend trying “gripe water” (a combination of ginger and
fennel) or a daily dose of L. reuteri probiotics to combat colic. Both
products are available in pharmacies and online. I don’t make any
promises, though.

Reality Checks
A common parent thought is, “I can’t listen to my baby cry.” That is
exactly the way nature intended it to be. All animals have a certain noise
that is disturbing to their elders and that prompts them to take action. As a
doctor, I listen to children cry all day long in my office and completely tune
it out. When I get home and my own children cry, it drives me nuts. Parents
(including me!) need to learn to take their own emotions out of the picture.
View crying as a form of self-expression and it won’t raise your blood
pressure. Remember this rule: Most of the time, YOUR CHILD IS FINE.

Parents at the end of their rope need to walk away from their baby.
NEVER SHAKE a baby. Babies who are colicky or high maintenance have
a significantly higher risk of being abused. A baby’s brain is very fragile. If
he is shaken, the motion can lead to blindness, brain damage, or death.

Q. When should I encourage my baby to have a

favorite toy?
The official term is transitional object. You can introduce it starting at
six months of age, but it is safest to keep it out of the crib until a year of
age.
 Remember that object permanence concept from Chapter 10,
Development? Babies start to realize that parents still exist when they leave
their viewing field between six and 12 months of age. The transitional
object or toy is the friend that travels with your child when you aren’t there.
They are making an emotional “transition” to seeking an alternative source
of comfort. The object may be a doll, blanket, or even a piece of parent’s
clothing.
Your child will likely have his comfort object for a while. He will give it
up before going to his first slumber party (age seven to eight years is
normal).

Helpful Hint
Try to pick a transitional object you don’t mind carrying around
everywhere. One of my patients clung to his mother’s satin nightie. Another
important point: buy EXTRA objects. Once your child has a favorite
“lovie” (such as a stuffed animal or blanket), be sure to buy extra identical
ones. Odds are, the lovie will get lost or destroyed—and that isn’t a pretty
scene. Having back-ups is important for everyone’s sanity. Also: be careful
when you attempt to wash a lovie—a much-loved stuffed animal can easily
fall apart in a washing machine. Hand washing or using the delicate cycle
(and not drying) is important.

Q. What do you think about infant massage?

Everyone benefits from a massage.
The power of touch has known therapeutic value. Not only are babies
soothed, but parents are too. Learning infant massage teaches parents how
to feel more comfortable holding and handling their babies.
Infant massage classes are very popular. Check with your local hospital
or parenting magazine for information in your area.
 DR B’S OPINION

“Spouse massages are also very important. Often

our energies get focused on the baby and our
spouses get treated like chopped liver.”

If you’ve ever seen those kids who seem to have their parents wrapped
around their little finger (think Veruca Salt from Charlie and the Chocolate
Factory), you know you want to avoid that fate. But how can you prevent
that future behavior in your cute little baby? Even though you now know
how your baby’s brain works, you still may not have all the right answers in
every discipline situation. Why? Because your child is really smart and has
figured YOU out. So let’s move on to setting up a good discipline
foundation that can hopefully take you through the tougher times to come.

Planting The Seeds Of Discipline

Q. At what age should I start to discipline my baby?

By nine months of age.
Planting the seeds of discipline is CRITICAL. From birth to eight
months, your parenting job is easy. It is physically exhausting but doesn’t
require too many mental strategies to succeed. At about nine months old,
you will start playing chess with your child and will continue to play for a
lifetime. Here are the rules of the game:
Discipline is the process of teaching your child to be an independent
being. Your job is to give your child a SUPER-EGO. This is a Freudian term
that refers to self-control and self-regulation—a person’s internal control
that limits inappropriate behavior from occurring. In other words, your
discipline implants a device in your child’s hard drive that he will carry
with him wherever he goes. That way, your child will do the right thing
even when you aren’t around.
Let’s review your child’s development. A nine to 12 month old is
exploring, not purposefully destroying, his environment (your house). He
uses his memory of what has worked before to approach the unfamiliar, so
everything ultimately ends up in his mouth (and hence, a safety hazard). He
has figured out how to get other people to repeat behaviors (if you scream
when he bites you, he will bite you again). He is egocentric—the world
revolves around him (how could a phone call be more important than him?)
He wants independence, but doesn’t quite have the motor skills to
accomplish his goals (refusing to let you feed him). He has developed a
sense of trust with his parents and caretakers. He doesn’t want anyone to
leave him, even to go to the bathroom (separation anxiety). Are we having
fun yet?
When the baby I just described is your baby, it’s time to get to work.

BOTTOM LINE
Consistency is the key to making a discipline plan work. If there is an adult
who ignores a behavior that other adults reprimand, the behavior will
continue to occur.

Q. What should be included in our House Rules?

Anything dangerous or potentially painful to the child or others.
These are behaviors that are never acceptable. These include pulling on
cords, touching the stove, putting fingers in electrical outlets, turning on
bathtub water, biting, hitting the dog and so on. Look around your house
and add to your list.

Q. What is a discipline management plan?

 How adult caretakers will respond to inappropriate behaviors.
Everyone has his or her own style. Most parents will think back to their
own parents’ approach and remember what worked. You and your partner
need to come up with a uniform strategy that both of you feel comfortable
enforcing.

NEW PARENT 411: PLANTING THE SEEDS OF

DISCIPLINE

1.Make your house kid safe, so you don’t have to say “No” to
everything your child touches.
2.Make up a set of “House Rules” that all caretakers enforce.
3.Make up a discipline management plan with consequences—
again, that all caretakers enforce.
4.Know that your nine-month old understands the word “no”, but
wants to be sure you really mean it. Yep, this is “testing limits.”

Remember, you are planting the seeds of discipline. Don’t expect

a tree to grow overnight. You won’t see your child’s behavior change
immediately. It takes months (and sometimes years!) to see the fruits
of your labor. Be calm and consistent.

Q. Do you think it’s okay to spank my child?

No.
We never recommend using physical force to punish a child. Your child
learns from you. If you are violent when you are angry, your child will be
that way, too. We know that your first reaction when your child hits you is
to hit back—DON’T. You’re older than your child remember?
BOTTOM LINE: The goal of discipline is to teach. If you want a well-
behaved child, you need to be well behaved as their role model.

Q. At what age does the Terrible Two’s start? My one

year old is already acting terrible.
The Terrible Two’s is a misnomer. It actually starts when your child
declares independence from you. This behavior starts around 12 to 18
months and lasts until age three or four.
My advice is to have a glass of wine at dinner for the next two years.
Just kidding—sort of. My other advice is to give your child the opportunity
to feel like he is in control of his world. You are really in charge, but he
doesn’t need to be reminded of that 24 hours a day. When there is an
opportunity for him to choose something, let him (picking out a snack, a toy
to play with, etc.). Also, don’t bother to discipline for minor infractions. It’s
not worth it and limits the amount of conflicts that arise.

Q. What is a temper tantrum and how should I

respond to it?
A physical release of anger. You need to let it happen.
Tantrums are frequently seen in toddlers, but some kids like to start
early. When your child is at the end of his rope, he may have an emotional
breakdown. This involves kicking, screaming, crying, and flailing around
on the floor.
Your job is to give him a safe place to have it out. Do not respond to
your child while he is in the midst of this performance. When he is done,
you can scoop him up and discuss things.
Just for fun, as parents, we also like to rank our children’s temper
tantrums much in the way scientists score hurricanes. There are Category 1
and 2 fits, which like minor hurricanes involve a minimal amount of
damage. Then there are the serious tantrums—up to and including the big
ones we like to call Category 5.
Once we took our two year old to a train show, something he absolutely
loved. Until it was time to go. They were closing it down and turning out
the lights (we had been there for an hour or more). Suddenly, our son
launched into the most amazing Category 5 tantrum—a one-hour
screamfest. You just had to marvel at the intensity of it all. Of course, at the
time, we wanted to give back our parent license and go into the Federal
Parent Witness Protection Program.

Reality Check
A word of caution: If you give in to a situation when your child has a
tantrum, you have just taught him that a tantrum is an effective way to get
what he wants. Be strong!

11 TIPS FOR DEVELOPING A DISCIPLINE STYLE

1 AVOID AS MANY CONFLICTS AS POSSIBLE. Make your house kid

safe. Don’t push your child past his threshold. For example: running
too many errands, missing naptime, waiting forever at a restaurant.
For eating out, we have a ten-minute rule—if the wait is over ten
minutes, it’s time to go elsewhere. Obviously, eating early is a good
way to avoid lengthy waits for a table.

2 ANTICIPATE CONFLICTS. If you see your child heading towards

the stereo, move him elsewhere or offer him a toy. Obviously, parents
develop a sixth sense for this—soon, you’ll be able to scan a room
and predict the future (that is, zeroing in on your baby’s next
conflict).
3 ANTICIPATE ATTENTION-SEEKING BEHAVIOR. Be prepared for
trouble when your attention is turned elsewhere. If your child gets
into trouble when you are cooking dinner, let him “cook” on the
kitchen floor.

4 PICK YOUR BATTLES. Saying “No” twenty times a day loses its
effectiveness. Believe it or not, I had a parent tell me her child
thought his name was “No.” Categorize behaviors into major errors,
minor ones, and those too insignificant to bother with. Minor
infractions are negotiable with an older child.

5 ACT IMMEDIATELY. Discipline when the behavior occurs, not

after the fact. Otherwise, your child won’t remember what he is
getting in trouble for. Never say: “Just wait till your father/mother
gets home!”

6 MAKE YOUR COMMENTS SHORT AND SWEET. Speak in short

sentences such as “No hitting.” This is much more effective than,
“Johnny, you know it’s not nice to hit the dog.” Believe us, you lost
Johnny right after “you know.”

7 FOCUS ON THE BEHAVIOR, NOT THE CHILD. Be sure to state that

a particular behavior is bad. NEVER tell your child that HE is bad.

8 REMIND YOUR CHILD THAT YOU LOVE HER OR HIM. Always

end your intervention with a positive comment. It reinforces the
reason that you are teaching her how to behave.

9 USE AGE-APPROPRIATE AND TEMPERAMENT-APPROPRIATE

DISCIPLINE TECHNIQUES. You need to adapt to your baby and find a
discipline style that works well with your individual child. What
works at nine months might not work when your child is two. He’s
had time to figure out your strategy!

10 DON’T YELL. It’s not the volume of your voice, but the tone
that gets your point across. Remember The Godfather? He never
 needed to yell. Some of the most effective discipline we’ve ever seen
has been whispered.

11 CATCH YOUR CHILD “BEING GOOD.” Praise for good behavior

is so important and helps encourage more of it. Think of it as
fertilizer for her conscience.

Q. What sets off a temper tantrum?

Anything and nothing.
Look at your child’s world through your child’s eyes. He has poor
language skills and can’t tell his parents everything he needs and wants. He
hasn’t mastered all his motor skills to accomplish certain tasks. He isn’t
sure where his activity boundaries are and is told “no” numerous times a
day. Add in an egocentric perspective that Mom and Dad can read his mind
(if he thinks it, everyone must know what he is thinking). Finish with the
unattainable goal of complete independence.
Being tired, bored, and hungry are also contributors to ugly behavior.
So, when you pick out the wrong pajamas at bedtime and your child
explodes, don’t think it’s just the P.J.’s.

Special Situations: Tips & Tricks

Q. How do I deal with separation anxiety? Can I just

sneak out of sight?
Before, you could leave the room and your baby might not have cared.
Now, if you leave the room, he wants to know where you’re going. This is
about the time you will keep your bathroom door open so your baby does
not panic every time you answer nature’s call. (That bathroom door often
remains open for the next several years. I have to remind myself when we
have company to close mine. But I digress). It is CRITICAL that you tell
your baby where you are going. You will think it is better to “sneak out” of
the house when you leave, so your baby doesn’t cry. But, you are NOT
helping your baby with his anxiety—you only make it worse. He doesn’t
know if you are leaving for a minute or for a lifetime. If your baby is
prepared for your departure, he will protest for a few minutes and then
move on.

Q. My child freaks out with strangers. How do I make

him more comfortable?
Be patient. All babies, but especially the slow-to-warm-up ones, are
afraid of strangers. They need some time to check out these people and
make sure they are okay. And “strangers” to a baby might include a
grandparent who lives out of town.
To help the situation, let your baby watch this person before handing him
over. Then, stay in your child’s view for a while after the hand off.
It’s probably a good idea to have consistent caregivers while your child
is in his stranger anxiety mode (nine to 15 months).

Q. My baby is playing with his genitals. How do I

make him stop?
He is normal and you don’t need to stop him.
The official term is MASTURBATION. It is amazing how quickly babies
find these body parts, and yes, it does feel good to touch them. P.S.
Erections are also normal.
For now, there is little you can do to limit this behavior. As your child
gets older (18 months) you can start explaining to him that it’s okay to
touch down there, but only when he is at home/in his room. This is a good
segue into a discussion that no one else touches or looks down there except
for Mom, Dad, and Doctor.
Masturbation is in the same category of self-soothing behaviors as thumb
sucking. You won’t be able to eliminate these behaviors, but you can limit
where and when they are occurring.
Reality Check
Boys aren’t the only ones exploring their pleasure zones. I had a female
patient who would ride the high chairs at restaurants. Needless to say, her
parents didn’t take her out to eat much.

Q. My nine-month old enjoys having food fights in our

kitchen. Help!
A budding John Belushi. Children start to play with their food when they
are no longer eating it. When the food starts to fly, mealtime is over. Your
child will quickly learn that he is excused from the dinner table when more
food ends up on the floor than in his mouth.

Q. My one year old sucks his thumb. How can I stop

it?
You can’t. The thumb goes everywhere your child does. This is another
self-soothing activity. As your child gets to be around 18 months, you can
reason with him about where it is appropriate to thumb suck (in his
bedroom) and where it is not (out in public). This will limit the behavior to
certain times when your child needs to have some down time. Check out
our other book, Toddler 411, for ways to end a preschooler’s thumb sucking
habit.

Q. My child holds his breath when he gets angry.

What do I do?
Nothing. At worst, he will faint. It is human nature not to inflict harm on
oneself. If your child holds his breath long enough, he will lose
consciousness and start breathing spontaneously. This sounds really cruel,
but a breath-holding spell is potent ammunition for a little kid to get his
way. If you want to win the battle, you can’t give in.
Note: If your child has numerous breath-holding spells, check in with
your doctor. Occasionally, this can be related to iron deficiency anemia.

Q. My child is biting me. What do I do?

Don’t bite back. And whatever you do, don’t scream.
When babies are teething, they often start to gnaw on whatever is
available. This may be a parent’s shoulder or Mom’s nipple (OUCH!). It’s
not malicious. But, if you respond dramatically, it will encourage your baby
to bite again.
Your response: Take your baby off your body and place him on the floor.
Calmly and sternly say, “No biting.” Do not pay any attention to your baby
for one minute. Your baby yearns for your attention so this is a good
punishment. Lick your wounds later, out of sight from your baby.
It may take 20-30 times before your baby gets the message, but he will.

Q. My child is biting/being bitten at daycare. What do

I do?
Talk to the daycare director and do an observation in the classroom.
There is a biter or hitter in every room. A good childcare program will
be constantly watching the children and be able to prevent Dracula, Jr. from
successfully drawing blood from another child.

Reality Check
My son’s kindergarten teacher had a wonderful motto. “If I’m doing my
job, I don’t have to discipline these kids.” The point is, children who have
the opportunity to bite or hit are those that aren’t being watched closely
enough by an adult caregiver. If your child is biting, do an observation in
the classroom.

Q. We are traveling with our baby. Do you have any

tips?
For starters, lower your expectations. Then you can be pleasantly
surprised when things go smoothly. How your baby does with a travel
adventure depends on his temperament.
Regardless of the mode of travel, bring a “goodie” bag packed with old
favorites and new toys/books to explore. Remember the New Toy Rule:
whipping out a special new toy your child has never seen before can
provide a valuable distraction. It still works on our babies and one of them
is in middle school now. If your baby likes music, take an iPod with some
fun songs.
And try to travel at off-peak times—traffic delays and delayed flights
make the experience that much more challenging. Here are our tips:

Get a seat for your baby, if possible. The National Transportation

Safety Board recommends that kids under age two be restrained in their
own seats while in the air, but the FAA does not require it. Check to see
if your airline will discount that seat—it’s rare but worth a try.

Feed baby on takeoff and landing. Babies don’t know that yawning
will equalize pressure in their ears as cabin pressure changes. Drinking
works the same way as yawning.

What about drugs? Parents often ask about giving Benadryl

(diphenhydramine) to make their babies sleep through the flight. If your
baby is under six months old or your flight is less than six hours long, I
don’t suggest it. If you are taking an international flight, it is a
consideration but check with your doctor first.

Can my baby fly with a cold or ear infection? Yes. For either issue,
using decongestant nose spray (see Appendix A, “Medications”) before
 takeoff reduces nasal secretions and makes cabin pressure changes less
unpleasant (see Chapter 13, “Infections” for more info).

Finally, here’s when you know you’re getting through to your kids: My
four-year-old was watching a football game on TV with my husband. One
of the teams called time out. My daughter astutely asked, “Daddy, why is
the team in Time Out?”
BABY
411
 Section 4

Sickness & How to Avoid it!

VACCINATIONS
 Chapter 12
“It’s a small world after all.”
~Walt Disney

WHAT’S IN THIS CHAPTER

THE TOP 15 VACCINE QUESTIONS
THE VACCINATION SCHEDULE
VACCINE PREVENTABLE DISEASES
OPTIONAL VACCINES
CONTROVERSIES AND MISCONCEPTIONS
-MMR AND AUTISM
-ROTAVIRUS
-THIMEROSAL
-VACCINE SHORTAGES
-ALUMINUM
WHERE TO GET MORE INFORMATION

It’s time to jump right into a hot topic you’ll find in parent circles—vaccines.
Nothing seems to stir the blood these days more than a good ol’ fashion
debate on vaccinating your child. And after the 2015 measles outbreak at
Disneyland, the silent majority of parents who believe in vaccinations are far
from silent.
A head’s up: since there is so much misinformation out there on vaccines,
you need to be armed with detailed, accurate information. And like the rest of
this book, that is what you will get in this chapter. The information we
provide is based on scientific evidence and solid peer-reviewed research.
Remember our mantra: show us the science! Your child is too precious to
make such important decisions on anything less. This chapter is not based on
personal anecdotes, conspiracy theories, “research” done in people’s
basements (we are not kidding), or the crusades of B-list celebrities.
However, before we get to our take on this debate, let’s go back in time a
bit. Well, more than a bit. How did the human race survive when other early
humans didn’t? Yes, making tools and efficiently finding food played a big
role.
But here’s another key element: we built civilizations. And we developed a
sense of responsibility . . . to ourselves and to our society.
Every time we respond to a tragedy in our nation—whether it be 9/11,
Hurricane Sandy, or the Boston Marathon bombing—we are reminded of how
we are not just individuals living in our own little worlds. It’s part of our civic
duty to lend a hand and take care of our neighbors.
So, what’s this pontificating have to do with vaccines? Again, it is our
responsibility to work together as a community . . . this time, the subject isn’t
terrorism or storms, but something that can be just as terrifying: infectious
diseases.
Consider a bit of history: in the 1890’s, people would have seven or eight
children in their families and only half of them would survive childhood. Just
go to an old graveyard some time and look at the ages listed on the
headstones. Many of the diseases that killed those children are now prevented
by vaccination. It’s a fact: vaccinations have increased the life expectancy of
our nation’s children. That’s why our grandparents and parents embraced
vaccines.
Here’s a crucial point: the key to a vaccine’s success is that everyone in the
community gets vaccinated. Vaccines won’t work if a large number of folks
just choose to opt out of the system and their responsibility. Germs are rather
simple creatures . . . they just look for a new person to infect. They don’t play
politics.
Please keep this in mind as you read about vaccinations. Your decision
(and every other parent’s decision) affects your child. And society as a whole.

Reality Check
The concept of “public health” has been around since antiquity. Obviously,
rulers had a vested interest in keeping their subjects healthy so they had a
society to rule. Through the years, governments have been responsible for
managing numerous programs. The most important advances in public health
have been vaccination programs, water purification, and waste
disposal/sanitation systems. The only way for public health to work, though,
is for all members of the community to follow the same rules.

OUTBREAK: IT COULD HAPPEN TODAY

Let’s get even more serious here. European settlers who came to the
New World had a very effective (yet unintentional) way of clearing
locals off the land they intended to settle. They brought their germs
from the Old World and infected Native Americans. In some cases,
entire groups of native peoples were wiped out by disease. Why? They
had no immunity.
Fast forward to the present day. One obvious real-world example:
swine flu (H1N1). Here’s a new virus that in a matter of weeks spread
around the world and killed thousands. Thanks to today’s modern air
travel system, a bug can go from a regional problem to a worldwide
epidemic in a blink of an eye. Swine flu, like many of the diseases we
vaccinate for, is a VIRUS. Besides a vaccine, there is little we can do to
stop the spread of infection—despite our scientifically advanced world.
(Fenn)

Q. Who came up with the idea of vaccinations in the

first place?
It took centuries of observation as well as trial and error. (And sometimes,
error meant death.) The first real step was describing the disease, in this case,
smallpox. Smallpox was a deadly disease that, historically, wiped out entire
civilizations. The earliest descriptions can be found as far back as the ninth
and tenth centuries among Turks. In fact, “inoculation” or the infecting of a
person with the disease in hopes of introducing a mild form and then creating
immunity was practiced first in Asia. In the 1700’s an English aristocrat, Lady
Mary Wortly Montagu, was living in Constantinople and learned of the
practice of inoculation (known then as variolation). She had her son
inoculated and subsequently, brought the practice back to England.
At about the same time, an English country doctor, Edward Jenner, made
an interesting connection: milkmaids who had been exposed to cowpox (a
common disease in cattle at the time) never seemed to get smallpox infections
during epidemics. He began to study the idea that vaccinating humans with
cowpox virus would make them immune to smallpox. In 1798 he published a
paper on his idea and called it “Vaccination.” Not to say, by the way, that Dr.
Jenner’s idea was accepted with completely open arms. In the nineteenth
century there did emerge a group opposed to vaccination led by Mary C.
Hume. See, even the anti-vaccination lobby has been around a long time! Of
course, in those days, you could be prosecuted for refusing to vaccinate.
(UCLA)
People were inoculated with a small amount of cowpox virus on their arm.
It caused a localized infection at that site (hence, the scar that we forty-
somethings and above bear). And true to Dr. Jenner’s hypothesis, it provided
protection against smallpox disease. In 1972, the United States stopped
vaccinating against smallpox because it was no longer a threat to the
population. In 1977, the last case of smallpox occurred in Somalia. In 1980,
the World Health Organization declared the world free of smallpox, thanks to
a global effort to immunize all children.
The success of the smallpox vaccine and other scientific discoveries led to
the evolution of many vaccines. These new, safer vaccines are extremely
effective in preventing diseases and epidemics that our grandparents and
parents can still remember.

DR B’S OPINION: TODAY’S

PARADOX—ARE VACCINES TOO
SUCCESSFUL?
 Vaccinations are one of the greatest achievements in medical
history. They have significantly decreased infant and childhood
mortality. Yet, amazingly, doctors have to convince some of today’s
parents that immunizing their child is extremely important, not
“optional.”
Most parents have not spent a night in a pediatric intensive care
unit with a child who has HIB meningitis, watched a child gasping for
breath with whooping cough, or seen a child die with a Strep infection
as a complication of chickenpox. I have. Sadly, every pediatrician has
had one of these experiences and has known that the child’s illness or
death could have been prevented by vaccination. I don’t want your
child to be that child. And I refuse to let a child become a statistic
because of online myths or fear mongering.
That’s the bitter irony of today’s vaccine “debate.” As a vaccinated
society, we’ve made diseases like measles so rare that parents have no
idea today how devastating it was and still can be.

Q. Why do you care whether I vaccinate my child or

not?
For starters, I want your baby to be protected.
But I also want you to realize that the decision to vaccinate your child
impacts the health of other children in the community. Choosing NOT to
vaccinate your child is choosing to put your child AND your community’s
children at risk. As a parent, you want to make the right choices for your child
to protect them. I want you to ask questions. I want you to be informed. And I
want you to get your child vaccinated. YOUR decision impacts ALL children.
Why?
There are two critical points for vaccination to work:

1.You need to be vaccinated.

2.Your neighbor needs to be vaccinated.

This concept is called herd immunity. And yes, you are a member of a
herd. When 90-95% of “the herd” is protected, it is nearly impossible for a
germ to cause an epidemic. Think of germs as rain. Vaccination is a raincoat.
Even with a raincoat on, you can still get wet. You need an umbrella, too. The
umbrella is “herd immunity.” Those who don’t vaccinate expect someone to
share their umbrella when it rains. But society can only buy umbrellas
TOGETHER. And raincoats aren’t made for newborns—they need umbrellas!
As comedian Jon Stewart once put it, herd immunity is like a zombie
movie. You are in an isolated farmhouse and the occupants rely on each other
to board up their windows to keep the zombies (germs) out. The zombies get
in when some lady from Marin County decides not to board up her windows
because she read an article on a wellness blog about the potential health risks
of boarding up windows. You can guess what happens!
Some parenting decisions have little or no impact on the community at
large. Deciding whether or not your child eats organic baby food, goes to
preschool, or sleeps in a family bed is entirely up to you—your decision only
affects your child.
However, your decision whether or not to vaccinate your child
affects all our kids. If you are a parent who is considering delaying or
skipping vaccinations altogether, please realize the impact of your decision.
If more than 10% of American parents choose to “opt out” of vaccines,
there’s no question that our entire country will see these horrible diseases of
bygone days return. Fortunately, very few parents decide to do this (see the
stats below).
What is most concerning today is that there are pockets of under-
vaccinated children. Birds of a feather flock together. Like-minded parents
who don’t vaccinate their kids tend to live in the same community and send
their kids to the same schools. With lower immunization rates, there is no
herd immunity. We have these “Ground Zero” areas to thank for recent
measles and whooping cough outbreaks. (Omer)

FIVE BIGGEST MISCONCEPTIONS ABOUT VACCINES

Pop online to any of the anti-vaccine web sites out there today and
you’ll find a plethora of misconceptions, untruths and worse about
vaccines. Here are the top five we hear most often:

1.Diseases disappeared before vaccines were introduced. No!

2.Vaccines cause illness and death. Reactions are very rare.
3.Vaccine preventable diseases are rare. No!
 4.Too many vaccines, given too soon overload the immune system.
No!
5.There is a government conspiracy to inject autism-causing agents
into our children. (The Jenny McCarthy movement.) Dr.
Strangelove, check your messages!

SOURCE: CDC AND DR. BROWN’S PATIENTS.

Reality Check: The good news

While parents are asking more questions, they are still choosing to vaccinate
their kids. The most recent CDC survey (2013) showed 99.3% of U.S.
children aged 19 to 35 months are being vaccinated. Yes, 99.3%. Despite all
the media stories on vaccine “controversy,” only a tiny fraction of parents—
less than 1%— are choosing to forgo vaccinations.

The Top 15 Vaccine Questions

1 WHAT ARE VACCINES? Vaccines are materials that are given to a person to
protect them from disease (that is, provide immunity). The word vaccine is
derived from “vaccinia” (cowpox virus), which was used to create the first
vaccine in history (smallpox).
Modern medicine has created many vaccines. Vaccines PREVENT viral
and bacteria infections that used to cause serious illness and death.

SEVEN TRUTHS ABOUT VACCINES

Let’s contrast those misconceptions about vaccines with these

truths:
 1.Vaccines save lives. They have single-handedly reduced infant
mortality rates.
2.Lower immunization rates mean higher disease & mortality rates.
3.Misinformation is everywhere—online, media, and playgroups.
4.The decision NOT to vaccinate is a decision to accept the
consequences of the disease.
5.The decision NOT to vaccinate is a decision to put your community
at risk for epidemics.
6.Like any medication, vaccines are not 100% risk-free.
7.Your parents/grandparents respect vaccines because they have seen
these diseases.

2 HOW DO VACCINES WORK? Here is your microbiology lesson for today.

Your immune system is your body’s defense against foreign invaders (viruses,
bacteria, parasites). Vaccines prepare your body to recognize foreigners
without getting infected. A vaccine revs up your immune system to make
antibodies (smart bombs with memory) for the signature of a particular germ.
So, if your body sees the real germ, voila! You already know how to fight it
off.
There are three types of vaccinations: inactivated, live attenuated, and
inactivated bacterial toxins.
Inactivated vaccines do not contain any living germs. An immune
response forms against either a dead germ, part of the germ
(recombinant DNA), or a protein or sugar marker that sits on the outer
layer of the germ (its signature). Very cool. These vaccines are safe to
give to immune-compromised people. The only down side is that
several doses of the vaccine are needed to provide full, lifelong
protection against disease. Some of these types of vaccines include:
Flu, Hepatitis A & B, HIB, Pertussis (whooping cough), Inactivated
Polio, Prevnar.
Live attenuated vaccines are weak forms of the germs that cause
infection. An immune response occurs just as if your body had the
infection. So one or two doses of vaccine gives you lifelong
protection. These vaccines are not given to immune compromised
people because they can make them sick. Examples include: MMR,
 Oral Polio, Smallpox, Tuberculosis, Varicella (chickenpox),
Rotavirus.
Toxoids (inactivated bacterial toxins) are vaccines that create a defense
against the toxin (poison) that a bacteria germ makes. Examples of
toxoid vaccines include: Diphtheria, Tetanus.

DR B’S OPINION

“I vaccinated my own kids to protect them. I

wouldn’t do anything differently for your kids. I
consider my patients to be my own children. I
would not sleep at night if I knew they were not
protected against preventable disease.”

3 WHAT ARE THE DISEASES WE ARE PROTECTED AGAINST WITH

VACCINATION? Good question. You are probably unfamiliar with most of
these diseases since we don’t see them much anymore in the U.S. After you
read about these diseases later in this chapter, thank your parents for
immunizing you.
As you read through the vaccination schedule, note that some diseases are
viruses. Antibiotics kill bacteria only. Doctors have no medications to cure the
viral infections. See section on “vaccine specifics” for details on all of these
diseases and the vaccines.
Doubt the effectiveness of vaccines? Just take a look at the sharp decline of
illness and death rates from these diseases over the past 100 years. Here is the
link if you want to check it out: http://j.mp/declineindeaths
Rather amazing, no? Diseases that used to kill thousands (if not hundreds
of thousands) now only harm a handful of people—thanks to vaccines.
4 HOW ARE VACCINES TESTED TO MAKE SURE THEY’RE SAFE? Vaccines
are researched extensively for an average of 15 years before being approved
for use.
A pharmaceutical company conducts medical research trials in a series of
stages. Once safety is proven, the vaccine is tested in several thousand
volunteers to make sure the vaccine actually works. These volunteers are
followed for at least one year to be sure that no serious side effects occur.
Nothing in this world is 100% foolproof, including vaccine science. But
the research trials that occur before licensing are very rigid. If you think there
are a lot of vaccines on the market, imagine how many didn’t make it through
the research phase of development.
The Food and Drug Administration (FDA) governs this whole process.
The FDA is the watchdog for any medication that is sold over-the-counter or
by prescription. There are extremely high standards that must be met before
any product is allowed for human use.
After a vaccine is approved for use, long-term follow-up studies are done
to assess for side effects, adverse reactions, and potency over a lifetime.

Reality Check
Given the FDA’s mixed track record, you may be skeptical about trusting the
government when it comes to vaccine safety. But in truth, the system is in
place to protect consumers. Although conspiracy theorists might disagree, the
FDA really is on our side.
To improve drug and vaccine safety, the Institute of Medicine has called
for an overhaul of how the FDA works—in the future, the FDA will do more
ongoing safety reviews of medicines and make all clinical study results
public. This should help boost public confidence in the FDA and vaccine
safety.

5 WHY IS MY CHILD GETTING MORE SHOTS THAN I DID? Simple answer:

we’ve been successful inventing vaccines to fight more diseases. It’s one of
the important advances in modern medicine—vaccines prevent disease, injury
and death. More vaccines are a good thing!
An important point: many of the vaccine preventable diseases are viruses.
These viral infections cannot be treated with medicine once an infection
occurs (for example, Hepatitis B).
Vaccines that protect against bacterial diseases are often serious ones, and
resistant to many antibiotics (for example, Prevnar).
And even though the number of shots has gone up, the total load on the
immune system has gone down. Today’s vaccines are smarter and better
engineered than the shots from a few decades ago.
In fact, the total number of immunologic agents in the entire childhood
vaccination series today is less than what was in just two vaccines in 1980!
Our children are getting smarter, safer vaccines today and better protection
than we ever got as kids.

6 ARE WE GIVING TOO MANY SHOTS, TOO SOON? This is a false mantra of
the anti-vaccine crowd: they say babies are receiving too many shots
(compared to say, 1980) and too soon (infants can’t handle all these shots,
they say).
So, let’s look at this scientifically. On any given day, your baby is exposed
to literally thousands of germs (it doesn’t matter how spotless your house is).
Exposing your child to five to eight different germs in the form of vaccines is
a spit in the bucket.
Young children have better immune responses to vaccines than adults and
older children. So they will form adequate immune responses to various
vaccines simultaneously. (This is studied extensively before a vaccine is
licensed). Even if your baby got 11 shots at the same time, he would only
need to use about 0.1% of his immune system to respond to them. (Offit)
Giving several vaccines at once does not damage, weaken, or overload the
immune system. Vaccines boost the immune system.
Also, the diseases that the vaccines protect against are the most severe in
infants and young children. Your doctor wants to get those vaccinations in as
safely and effectively as possible. That’s why the timing is so important (and
why a staggered or delayed vaccination schedule is a bad idea—more on that
in the controversies section of this chapter.)
Q. Can’t you just give one big shot that has all the
vaccines in it?
Medical science is working on it!
There have been a few combination vaccines licensed for use. The largest
combination vaccines are Pediarix (DTaP, IPV, Hepatitis B) and Pentacel
(DtaP, IPV, HIB). The reason there isn’t just one big shot is that some
vaccines are ineffective when they are sitting together in a solution. Your
baby may still need more than one shot, but if your doctor uses a combo
vaccine at least it will be fewer shots than if they are all administered
separately.
More combination vaccines are on the horizon.

REASONS NOT TO VACCINATE

There are very specific medical reasons to discontinue or hold off on

certain vaccinations:

1.An immune-compromised patient or family member.

2.Had disease (for example, if you’ve had chicken pox, you don’t
need the vaccine).
3.Encephalitis or degenerative brain disorder.
4.Allergy to vaccine or an additive in vaccine.

If your baby has a food allergy to eggs or gelatin, or an allergy to

antibiotics (such as Neomycin, Streptomycin, Polymyxin B), notify
your doctor before any vaccinations are given. Several vaccines are
grown in chick embryo cells and therefore contain a small amount of
egg protein: flu vaccine (Flushield, Fluzone, Fluvirin), MMR, rabies
(RabAvert), and yellow fever vaccine (YF-VAX). The MMR vaccine
also includes gelatin.
Rabies, MMR, Chickenpox and Polio vaccines include several
different kinds of antibiotics to prevent contamination of the vaccine
itself. Check with your doctor if your child is allergic to any antibiotics.
(Schuval)
 While there is a scant amount of egg protein in the MMR vaccine, it
is still safe to give to a person with an egg allergy in your pediatrician’s
office. (Pickering) And, although the flu vaccine contains trace
amounts of egg protein, it is also still possible for some egg-allergic
people to get it. Patients should consult their allergist for testing and
administration.

Helpful Hints
Top Five Tips to Make Shots Less Painful
Distraction. Blow in your child’s face, or pull out a new toy.
A spoonful of sugar. Put a little sugar water on a nipple or pacifier. It is
a known pain reliever (analgesic).
Acetaminophen (Tylenol). It’s a great pain medicine. Be sure to check
with your doctor for the correct dose for your baby’s weight.
Remember, for your baby’s immune system to respond optimally to
his shots, wait at least four hours after the shots to give a dose of
acetaminophen.
Numb it. There is a prescription anesthetic cream called EMLA that can
be applied one hour before shots are administered. The downsides: a)
Pain is not just from the needle going through the skin but also from
the fluid injected into muscle. b) You may not know where to place
the cream.
Freeze it. There is a cold “vapocoolant” spray that can be placed on the
skin just before the injections. A few doctors use it. It works slightly
better than the distraction technique. (Reis)

7 WHAT GROUP MAKES DECISIONS ABOUT VACCINATIONS FOR

CHILDREN? There are four governing panels of experts in infectious diseases
that make recommendations for vaccinations. These smart folks include:
American Academy of Pediatrics (AAP), American Academy of Family
Physicians (AAFP), Advisory Committee on Immunization Practices (ACIP),
and the Centers for Disease Control (CDC). Because there are several groups
involved in this effort, there is some variability in vaccination schedule
recommendations.

8 MY BABY HAS A COLD. SHOULD I HOLD OFF ON VACCINATIONS? No!

This is a common misconception of parents. Even if your baby has a minor
illness, he can still get his shots. We cannot stress how important it is to get
your child vaccinated in a timely manner. So don’t let a sniffle or two make
you reschedule an office visit for shots. Your child can also get his shots even
if he is on antibiotics.

9 CAN I CHOOSE NOT TO VACCINATE MY CHILD? Yes, but we wouldn’t

advise it. Choosing not to vaccinate is not a risk-free choice. It’s choosing to
expose your child to potentially serious infection. It’s also choosing to expose
other children in your community to serious, preventable diseases. And if you
think your child will be safe because everyone else vaccinates his or her kids,
you’d be wrong (and very selfish, we might add). You can also choose not to
stop at a stop sign, but we wouldn’t advise it!

Reality Check
Vaccine requirements for school entry vary by state. There is no one
consistent policy. All 50 states allow vaccine exemptions for medical reasons,
48 states allow exemptions for religious reasons and about 21 states allow
exemptions for philosophical reasons. (Johns Hopkins Hospital) After the
2015 measles outbreak, several state legislatures are reconsidering their
existing laws for vaccine exemptions. Limiting the exemptions improves
vaccination rates and thus, protects more children.

10 I’VE HEARD THAT GETTING A DISEASE PROVIDES IMMUNITY

FOREVER AND VACCINATIONS MIGHT NOT PROVIDE LIFELONG
PROTECTION. WOULDN’T IT BE BETTER TO GET THE DISEASE? ISN’T
THAT A MORE “NATURAL” WAY OF CREATING IMMUNITY?
No.
The diseases we prevent by vaccination are not minor illnesses (this
includes chickenpox). For instance, would you rather have your child get
meningitis and die or get the vaccine? Getting chickenpox or any other
disease the “natural way” is a much greater health risk without any significant
benefit. And just think of the discomfort, pain and perhaps serious injury that
come with getting any of these diseases.
It is true that some vaccinations require a booster dose to keep antibody
levels high. That is why we need a tetanus booster every ten years.

11 WHAT WOULD HAPPEN IF WE STOPPED USING VACCINATIONS? That’s

an easy one. The diseases would come back.
Vaccinations keep us from getting sick from these infections. But, all of the
infections we protect against are alive and well in our world. As of today, the
only disease we have completely eliminated is smallpox. And when it was
eliminated, we stopped vaccinating for it.
Anyway, it’s a simple fact: when immunization rates drop, epidemics
occur. Just look at states with lower immunization rates—their rates of
pertussis (whooping cough) are twice the number seen in states with higher
percentages of immunization rates. Children whose parents opt out of
vaccines face a 23 times greater risk of getting whooping cough. (O’Brien) In
the 2015 measles outbreak, most cases occurred in communities with measles
immunization rates below 80%.

Reality Check
In 1990, low immunization rates led to a measles epidemic of 55,000 cases
and over 100 preventable deaths in the U.S. The U.S. saw a measles epidemic
again in 2008—over 90% of these cases were unvaccinated children, two-
thirds of which were by parental choice. But a few of the cases were infants
who were too young to be vaccinated (and exposed to an infected child in the
doctor’s waiting room). You would think we would have learned our lesson,
but 2015 was another banner year for measles. This serves as a reminder that
vaccine-preventable diseases have not disappeared.

12 WHAT ARE THE TYPICAL SIDE EFFECTS OF VACCINATION? Fever,

fussiness, redness or lump at the site of the injection.
Inactivated vaccines cause an immediate immune response. The body
mounts a response to the foreign invader as if it were being infected. The
result, typically, is a fever within 24 hours of vaccination. Babies sometimes
feel like they are coming down with a cold or flu (body aches, pains). Some
babies prefer to sleep through the experience; some choose to tell you how
they feel (fussiness, crying). All of these symptoms resolve within 24 to 48
hours of vaccination.
Live attenuated vaccines (MMR, Varicella) cause a delayed immune
response. This occurs one to four weeks after the vaccination is given. Long
after the doctor’s visit, your child may wake up one morning and have a fever.
This may be accompanied by a rash that looks like measles (pimples) or
chickenpox (clear, fluid filled pimples). The rash can sometimes be dramatic.
Both the fever and the rash tell you that your baby is forming an immune
response to the vaccination. Babies are not contagious and aren’t too bothered
by the rash. You don’t need to call your doctor. This reaction is expected.
Redness at the injection site is common. In particular, the fifth booster dose
of the DTaP (at ages four or five years) can cause a pretty dramatic area of
redness. No worries. We do get quite a few phone calls about it, though! A
firm lump may develop at the injection site if some of the fat in the arm/leg
gets nicked as the needle goes into the muscle. This is called FAT NECROSIS.
It usually goes away within six to eight weeks. It doesn’t hurt.

RED FLAG
If your baby has a fever more than 72 hours after being vaccinated, it’s not
from the vaccination. You need to call your doctor. The only exceptions are
the MMR and chickenpox vaccines, which typically cause a fever one to four
weeks afterwards.
Reality Check
To help reduce fever and discomfort from shots, it’s okay to give your baby
acetaminophen (Tylenol) as long as you wait at least four hours after
vaccinations are given. The dose is not listed on the package. It says to
“consult a doctor.” That’s because doctors don’t want you giving this
medicine to a baby three months or younger with a fever without checking in
first. Other than with shots, you need to call your doctor about fevers in this
age group—see the section on fevers in Chapter 15, “First Aid” chapter.

13 WHAT ARE THE WORST REACTIONS TO VACCINATION? These are

called adverse reactions. This is the equivalent of an allergic reaction to a
medication—and fortunately, they are all quite rare. With each generation of
newer vaccinations, the risk of serious reactions is almost eliminated. Adverse
reactions include:

1.Death.
2.Anaphylactic reaction.
3.Encephalitis.
4.Fever related seizure (convulsions).

Both the CDC and FDA keep close tabs on adverse reactions to vaccines
via a Vaccine Adverse Event Reporting System (VAERS). Both doctors and
patient families may submit a VAERS form if any adverse reaction occurs.
Keep in mind that medical illness reports do not prove an association of a
particular illness with a specific vaccination. The job of both the CDC and
FDA is to review each report that occurs and see if there is a pattern of
subsequent illness after vaccination. VAERS data is publicly available at
vaers.hhs.gov. To report a possible reaction, you can download a form at the
same site. There is also a Clinical Immunization Safety Assessment Network
comprised of six U.S. academic medical centers that evaluates adverse
reactions to vaccines (vaccinesafety.net).
 While we would be remiss if we didn’t tell you that vaccinations have
some risks associated with them, we want you to remember that the risk of
adverse reaction is significantly lower than leaving your baby unprotected.
In 1988, recognizing that there are rare, serious reactions that occur as a
result of vaccinating children, the U.S. Department of Health and Human
Services created the Vaccine Injury Compensation Program. This program
attempts to determine whether adverse reactions from vaccines are
responsible for injuries or death and then to provide the victim with
compensation. Since 1988 there have been about 15,000 claimants.
Considering there are four million babies born each year and most have been
vaccinated, the odds of an injury are staggeringly tiny.
Another statistic to mull over: 1.9 billion doses of vaccine were given in
the U.S. from 1991 to 2001. Only 2,281 cases of allergic reactions were
reported. (Zeiger) (Compare that statistic to one in 50 adults who have a food
allergy!)
We agree that an adverse reaction only has to happen to one child for it to
be heartbreaking. But if we look at the big picture, we can point to the
millions of children who might have experienced illness, chronic disability,
and death if diseases like smallpox or polio were not controlled by
vaccinations.

RED FLAGS
Call the doctor if your baby does the following after a vaccination:
1.Inconsolable crying over three hours.
2.Fever over 105 degrees.
3.Seizure activity.
4.Extreme lethargy.

Q. How do I know that the CDC and FDA are on “our”

side?
 Ah, the government conspiracy theory—the belief by some that the
government is part of a vast conspiracy to hurt children with bad
vaccines . . . and enrich pharmaceutical makers who make vaccines.
Yes, years ago, some members of vaccine advisory committees had ties
with vaccine producers. These people were invited to the table because they
brought a wealth of knowledge with them (example: vaccine research
scientists).
Today, no one working for the vaccine watchdogs (CDC, FDA, AAP,
ACIP, or AAFP) receives any grant or research money from pharmaceutical
companies. So there is no real or perceived financial incentive to allow a bad
vaccine to stay on the market. If there is concern about a vaccine, it will be
pulled from the market immediately (see the example of the rotavirus vaccine
later in this chapter).
To further ensure unbiased recommendations, the National Immunization
Program (NIP) and the Vaccine Injury Compensation Program (VICP) parted
ways in 2005 so there would be no perceived “conflict of interest.”
Here is another consideration: why would these groups want our nation’s
children to suffer chronic illness, pain, or even death? Think about it. It is in
nobody’s interest to increase infant morbidity and mortality rates.

14 WHO KEEPS A RECORD OF MY CHILD’S VACCINATIONS? You and your

doctor. Your doctor keeps a record of vaccinations in your child’s records.
And some states have an immunization registry that also keeps records of
vaccinations.
But ultimately, YOU need to have a copy of these in your personal medical
record file. You will need proof of vaccinations for many things. Any
childcare or school program requires this information. Summer camps and
athletic programs want the records too. If your child becomes a healthcare
professional, joins the military, or is a food handler, he will also need this
information.

Helpful Hint
It’s a good idea to have a medical passport for your child. This should include
an immunization record, growth chart, list of medical problems, list of
surgeries, drug allergies, and name and dosage of any medications that are
used regularly (such as asthma medicine). Some medical practices now offer a
patient portal that allows you to keep track of your own records. If so, we
encourage you to take advantage of it!

Q. How do I know when my child needs booster shots?

Your doctor will remind you at each well child visit.
We wish pediatricians were more like dentists or veterinarians, who long
ago figured out how to send out reminders of needed visits. Sadly, only a
minority of pediatric practices have electronic reminder or recall systems.
Most do not usually send out reminder cards to let you know your child is due
for shots. What most practices do is provide the schedule in an information
packet at your child’s first visit. Your doctor will tell you at each well check
when to return. This system works pretty well unless you start missing well-
child visits. Then your child gets behind on his vaccination series. You can try
to catch your child up on shots when he is in for a sick visit if this happens.

Reality Check
Wanted: a national immunization registry.
There is no uniform system of tracking immunization status and sending
reminder cards to patients’ families. One solution: a national immunization
registry. Advocates of this plan feel it will improve our country’s
immunization rates. Those opposed to the plan think it invades personal
privacy and creates a government health care tracking system. So, like most
governmental decisions, it may take years to resolve.

15 WHAT VACCINES ARE REQUIRED AND WHICH ONES ARE OPTIONAL?

The answer varies state to state. It also varies depending on the frequency of
disease in particular counties within a state. We have provided a table of the
most recent requirements in the U.S. on our web site Baby411.com (click on
“Bonus Material”).

Q. Can I take my baby out before she gets her first set
of shots?
Yes, just be smart about it.
Pediatricians usually recommend limiting human contact with babies under
four weeks of life. Why? Because if your newborn gets any fever (of 100.4 or
greater), that is an automatic ticket to the hospital for two days (see Chapter
15, First Aid for details). Even if your baby has the cold that the rest of the
household has, we still need to rule out a serious infection. That said, you
aren’t quarantined, but use discretion when planning your outings. In cold and
flu season, avoid crowded places for the first three months of life.
With respect to an unvaccinated baby, the biggest threat these days is
whooping cough. Whooping cough is spread by cough and sneeze droplets of
an infected person. Babies get a series of four shots over the first two years of
life to protect them from whooping cough. To keep everyone inside that long
is crazy! But being cautious until she gets her first shot at two months isn’t a
bad idea.

Q. I have a friend who does not vaccinate her child. Is it

okay for our babies to play together?
Awkward, right? Well, the most politically correct thing to do would be
cancel a playdate when either child is ill. This is not a foolproof solution,
however. A person with measles, for instance, is contagious for three to four
days before the rash erupts.
If you want to make a statement (and potentially lose the friendship), be
honest and explain to her that you feel uncomfortable with your kids being
together—it may give her pause to consider her choices.

Vaccination Schedule
 The schedule for vaccinations is below. For details on these specific
vaccines, see the next section. Note: If you want to know what shots your
baby is due for, use the CDC’s free Immunization Scheduler. Go to:
www2a.cdc.gov/nip/kidstuff/newscheduler_le/and just type in your baby’s
birth date!

VACCINATION SCHEDULE

Disease And Vaccine Specifics

Let’s talk specifics—here is a breakdown of the vaccines and the diseases

they are designed to stop. View our website at Baby411.com for a visual
library of these diseases (click on “Bonus Material”).

Diphtheria, Tetanus, Pertussis

 Diphtheria: This is a bacteria that causes a serious throat infection. It
invades the tonsils, kills the tissue, and creates a thick pus lining that can
block off the airway. It also produces a toxin that enters the blood and injures
the heart, kidneys, and nerves. It is spread by respiratory droplets (coughs and
sneezes). There is a 10% mortality rate from infection, even today. Before the
vaccine, up to 20,000 Americans died per year.

Tetanus: This is a bacteria that causes wound infections. It is not

contagious person to person. Tetanus bacteria produce spores that are found in
the soil and dust around the world. These are resilient little germs, so we will
never eliminate them. Tetanus spores can enter open wounds (especially
puncture wounds, animal bites, and umbilical cord stumps) and make a toxin
that attacks nerves. The affected nerves cause muscles to spasm (called
“tetany”). These spasms prevent breathing and swallowing (lockjaw). There is
a 30% mortality rate from infection.

Pertussis (Whooping Cough): This bacteria causes irritation and

inflammation of the throat. This swelling prevents mucous from being
coughed up and creates a blocked airway, particularly for those with the
smallest airways (infants). Pertussis infection initially looks like the common
cold. Over time, infected people have coughing fits or spasms. As a person
tries to get a breath in, he makes a characteristic “whoop.” Infants, who have
smaller airways, are unable to breathe at all. So instead of whooping, they
stop breathing and their faces turn red or purple. Children often throw up
during a coughing fit. In Asia, this illness is known as the “100 Day Cough.”
The infection is spread by respiratory droplets. Prior to vaccine development,
there were 200,000 cases a year in the U.S. There were 10,000 deaths
annually, mostly in infants. In 2010, there were over 21,000 cases reported in
the U.S. and 26 deaths. Over 75% of the hospitalizations were in infants under
six months of age and most of the deaths were in babies.
If you want to know what whooping cough sounds like, check out this
website: vaccineinformation.org/video/pertussis.asp

DTaP: The vaccine

This is the vaccine that protects against Diphtheria, Tetanus, and Pertussis
(whooping cough).
 The combination vaccine has been around since the 1940’s. The original
vaccine (DTP) was called a “whole cell” vaccine because the vaccine was
derived from a whole dead whooping cough germ. This vaccine was effective,
but caused a significant number of high fevers and convulsions. A newer,
safer formulation (called the “acellular” vaccine or DTaP vaccine) came out
in 1991. The immune response is formed to a piece of the bacteria (its
signature).
The primary vaccination series is five total doses. The primary doses are
given at two, four, and six months of life. The fourth and fifth booster doses
(given to toddlers and before kindergarten) are more likely to cause a fever or
redness at the injection site because our bodies recognize it and have an
immune response ready to go. After the fifth dose of DTaP, a single Tdap
booster is given to 11-12 year olds and anyone else who has never received it.
And as of 2012, pregnant women should get Tdap with each pregnancy to
protect herself and her baby. The tetanus and diphtheria booster (Td) is then
given every ten years.
Here is the tricky thing about pertussis protection—it is short lived,
whether you endure the actual disease or get the vaccine. Immunity wears off
after about five years. That leaves susceptible teens and adults as reservoirs of
infection to expose infants who aren’t fully protected yet. So it’s important for
moms, dads, and other adult caretakers (under age 65) to get their Tdap
vaccine!

Q. Is it true that whooping cough epidemics still occur?

Yes. In fact, whooping cough is alive and well. In 2012, there were almost
42,000 cases—11% of which were in Washington state (a hub of anti-vaccine
sentiment). Most troubling of all, babies still die from this disease.
Here are some things you should know:

1.Whooping cough epidemics occur about every three to four years.

2.Immunity to whooping cough wanes in teens and adults despite
vaccination during childhood. The good news: since 2005, a
whooping cough vaccine for teens and adults is available. The bad
news: only 8% of American adults have gotten their booster shot!
3.Many cases of whooping cough are undiagnosed and untreated in older
people. Have you ever had a cough that just “hung on” for several
 weeks? You may have had whooping cough and not known it.
4.Dropping immunization rates allow the disease to spread quickly
through a community.
5.Infants are given their first whooping cough (pertussis) vaccination at
two months of age. But, they don’t have effective protection against
the disease until they have received three doses of the vaccine (at six
months of life). Yes, it is the youngest children who are the most
susceptible and unfortunately, they also have the highest risk of
serious illness and death.

BOTTOM LINE: If you or anyone in the family has a chronic cough, get it
checked out. It’s important for you and your baby. And please get your baby
vaccinated.

Polio

This virus attacks the spinal cord and brain. It has particular affinity for the
nerves that control leg muscles and the diaphragm muscle (that helps you
breathe). Polio infections leave people paralyzed, or needing a machine to
breathe for them. Prior to our modern day ventilators, people survived the
illness by living in iron lung machines. The virus spreads through the stool of
infected people. This was a common summertime epidemic, and whole
households would get the infection. Before the vaccine, there were 20,000
cases of paralysis per year in the U.S. Since 1979, there have been no cases of
naturally occurring polio infection in the U.S. We still give the polio vaccine
because the infection is an airplane flight away.
The top three countries where polio is still endemic are: Nigeria, Pakistan,
and Afghanistan. There has been an extraordinary effort to eradicate the
disease, like smallpox. Seeing what countries are involved, you can
understand why this is such a challenge! While this may happen in our
lifetime, polio is still a threat.

Polio: the Vaccine

In the U.S., we give the inactivated form of the vaccine (a shot). The
vaccine that was given from 1963-1996 was a live vaccine (a drink) that
carried a small risk of acquiring vaccine-associated polio disease.
 There were a few cases annually of vaccine associated polio disease when
the live (oral) vaccine was used. In 1997, doctors switched to an all-
inactivated vaccination series (IPV; that is, not live). IPV does not cause polio
disease.
Polio vaccine is a four-dose series. The first doses are given at two and
four months of age. The third dose is given at 6-18 months. The final dose is
given before entering kindergarten.

Haemophilus Influenza B (Hib)

This is a bacteria that causes a potentially fatal throat swelling

(epiglottitis) and MENINGITIS (infection of the brain lining). Despite the
name, there is no relationship to influenza, the flu virus—yes, we realize that
is confusing. HIB is spread by respiratory droplets (sneezing, coughing). Prior
to vaccine development, there were 20,000 cases of HIB infection annually in
the U.S. and 500 deaths. Most infections occurred in children less than five
years old. Survivors of meningitis may be permanently deaf, blind, or
intellectually disabled. About 5% of children with HIB infections die, and
20% suffer permanent disability.

HIB: The vaccine

The development of the HIB vaccine is a true success story of modern-day
medicine. The vaccine was licensed in 1985. By 1992, HIB infections were
virtually eliminated (less than 200 cases per year). Doctors who were in
training or practice prior to 1992 literally watched this disease disappear.
Younger doctors have never seen a case of HIB in their careers!
The HIB vaccine can be given either individually (in three or four doses)
or in a combination product. Children form a good immunity with either of
these products.
According to the CDC immunization schedule, babies complete a primary
series of vaccinations for HIB at two, four, and six months of age. A HIB
booster dose is given to toddlers at 12-15 months.

Measles, Mumps, Rubella

 Measles: This is a virus that infects the entire body. Infected people start out
with cold symptoms and pink eye. It causes a dramatic head-to-toe rash, then
the infection spreads to other organ systems. These include the intestines
(diarrhea), lungs (pneumonia), and brain (encephalitis). The highest rate of
these complications is in children under age five.
The virus is highly contagious and is spread through respiratory droplets
(coughs and sneezes). The virus is so hearty, it can remain alive and infectious
in the air and on surfaces for up to two hours.
Measles was as common as chickenpox used to be. Before the measles
vaccine, there were an amazing four million cases per year and 500 deaths
per year in the U.S. Today, measles is more common in other countries
(particularly England, Germany, Austria, Italy, Australia, Switzerland, Israel,
China), and international travel easily brings it to America. Twelve children
recently adopted from China had measles infections when they landed on U.S.
soil.
2015 saw one of the largest U.S. measles outbreaks that began with an
unvaccinated, measles-infected person visiting a mecca for children
worldwide—Disneyland. Other visitors and Disney employees contracted the
illness from this incidental exposure. At the time of this writing, there have
been over 170 cases in 17 states, and 30% of patients had to be hospitalized
for complications. This story captured the media’s attention for several weeks
—Hollywood could not have written a better script! It served as a chilling
reminder that unvaccinated people do not wear nametags and may
unknowingly spread potentially fatal diseases. It truly is a small world after
all.
Another outbreak in 2008 also was a superb example of how easily
measles can spread in an undervaccinated community. It all started when one
of those children (a seven year old boy from San Diego), returned from a trip
to Switzerland with measles. He went on to infect his unvaccinated siblings
and classmates. He also infected infants (who were too young to be
vaccinated), whose only mistake was to be in a doctor’s waiting room on the
wrong day. Some children were hospitalized, fortunately none died. 91%
percent of the children who contracted measles in this outbreak were
unvaccinated by parent choice.
Great Britain (which does not have a mandatory-for-school vaccination
program) had a more substantial outbreak in 2008—1348 cases and one death,
compared to 56 cases in 1998. Why such a rise? Immunization rates at the
time, were only about 80% for the MMR shot on that side of the pond. Not
coincidently, Britain was the epicenter for the MMR vaccine controversy,
which first erupted in 1998—more on that later in this chapter (see
controversies).

DR B’S OPINION

Even today, there is no treatment for measles. If you’d rather let

your child get the measles than give them the shot to prevent it,
you’ve never seen measles!

Mumps: This is a virus that attacks the salivary glands. Mumps infect the
glands located along the jaw line and causes a marked swelling. It also infects
other body parts that swell up, including the testicles, ovaries, and brain.
Mumps attacks the brain (meningitis) about 15% of the time. It can cause
deafness and intellectual disability in survivors. Like measles, mumps is
spread through respiratory droplets. Before the mumps vaccine was developed,
there were up to 200,000 cases per year. We usually see fewer than 600 cases
a year in the U.S.

Rubella (GERMAN MEASLES): This is a highly contagious virus that causes

mild infection in children, but fatal or disabling infection in unborn fetuses.
Rubella spreads through respiratory droplets and causes a runny nose, swollen
glands, and a rash in children. If a pregnant woman gets rubella, the fetus can
die in the womb (miscarriage) or be born with severe intellectual disability,
deafness, or blindness (called congenital rubella syndrome). An epidemic in
1964 (prior to the rubella vaccine) affected 20,000 babies. The good news:
the CDC took rubella off the U.S. disease “threat list” in 2005 because only
nine cases were reported in 2004. Three cases were reported in the U.S. in
2012. We need to continue vaccinating since this disease is not eliminated
worldwide.

MMR: the vaccine

 The vaccines for measles, mumps and rubella are given together as the
MMR vaccine. In the past, these vaccines were also manufactured separately.
Since 2009, the only vaccine product on the market is the combination MMR
vaccine.
Because the MMR vaccine is a live-attenuated vaccine, your child may
develop a rash that looks like measles (red pimples) and/or a fever, one to four
weeks after being vaccinated. There are two shots in the MMR vaccination
series. The first dose is given at 12-15 months of age. A booster dose is given
before entering kindergarten.
About 90-95% of people mount a lifelong immune response to the first
dose of the vaccine. The second dose is given to protect 5-10% of people who
did not mount a great response with the first dose. That said, the second dose
of MMR vaccine can be given just four weeks after the first dose in times of
an outbreak.
The MMR vaccine can also be given to infants from 6-11 months of age if
they will be visiting a country where measles is more prevalent. Even with the
U.S. 2015 measles outbreak, there is no official recommendation to give the
MMR vaccine prior to one year of age. Why? The vaccine is less effective for
infants. But if there is an increased risk of exposure, some protection is better
than no protection. Any MMR vaccine given prior to one year of age does not
count as part of the two dose series.

Hepatitis A

This virus attacks the liver. And there is a vaccine to prevent it. It’s spread
through infected poop, contaminated water and food. It spreads rapidly in
childcare centers due to all the kids in diapers. Fortunately, children infected
with Hepatitis A have a relatively minor illness. Some children don’t even
have symptoms. Adults, however, get very sick. Prior to the Hepatitis A
vaccine, there were over 100,000 cases per year in the U.S.

Hepatitis A: the vaccine

The Hepatitis A vaccine was approved in 1995 and became part of the
routine childhood immunization series in 2005. Vaccinating toddlers against
Hepatitis A not only protects them but also prevents the spread of the disease
to others in childcare centers. The vaccine is very effective: Israel has seen a
98.5% reduction in disease since they began Hepatitis A universal
vaccination.
Kids get the vaccine starting at age one. It is a series of two doses given at
least six months apart.

Hepatitis B

This is another virus that attacks the liver. There are various types of
Hepatitis. The most noteworthy are A, B, and C. Each type of virus is spread
differently. Hepatitis B is spread through blood and body fluid (saliva, vaginal
discharge, and semen) contact. It is extremely contagious. Yes, it is spread
primarily by sexual contact and by exposure in the healthcare field. However,
children are most at risk of exposure to Hepatitis B during birth if their
mother has the disease.
The infection causes skin to turn yellow because the liver is unable to
metabolize bilirubin as it should (see earlier in this book for a discussion of
bilirubin). It causes stomach upset and lack of appetite. Some people with
Hepatitis B recover quickly, while others die. Others have a chronic infection
that goes on for 20 years until they die. And some people become carriers of
the disease once they survive the infection.
Don’t think of this disease as one that only happens to IV drug users or
people with several sex partners. Of people who get Hepatitis B, 16% have
neither of these risk factors.

Reality Check
There are over 1 million Hepatitis B carriers walking around the U.S.
If this isn’t enough to convince you to protect your child, Hepatitis B also
is a known cause of liver cancer. Yes, the Hepatitis B vaccine is the first
cancer vaccine. Before the vaccine became part of the childhood
immunization series in 1991, 30,000 children were infected with Hepatitis B
annually in the U.S.
Hepatitis B: The vaccine
Giving the vaccine as a part of the childhood immunization program
ensures that your child gets immunized and has lifelong protection. Babies
born to mothers who have Hepatitis B need to get the vaccination and
immuneglobulin shot within 12 hours of birth to prevent infection. If they
don’t get these shots, newborns who get infected by their moms have a 90%
chance of getting Hepatitis B.
The Hepatitis B vaccine is a three-dose series. The first dose is routinely
given before hospital discharge. The second dose is given one or two months
later. The third dose is given six to 18 months after the first dose.

Varicella (Chickenpox)

This is a virus familiar to most of us. Before routine use of chickenpox

vaccine in 1995, about four million people got chickenpox every year in the
U.S. Some of you reading this book probably remember having this illness.
What most of you don’t know is that chickenpox also led to 10,000
hospitalizations and 100 deaths annually.
The varicella virus spreads by respiratory droplets and by the fluid found
in the skin lesions. It is incredibly contagious. The virus attacks the whole
body via the bloodstream. Infected people feel tired and run a fever, then
break out in classic clear fluid-filled blisters that arrive in clusters. The
average number of skin lesions is 350. Does it make you feel itchy just
thinking about it? People are contagious for seven days, on average.
The virus itself can cause pneumonia and encephalitis. Even more
problematic is that Strep bacteria have a field day with the open wounds when
the blisters pop. These secondary infections can be deadly.
The vaccine has prevented 95% of severe chickenpox infections. And in
kids under nine years of age, death from chickenpox is down by a whopping
90%. And vaccinated people who get chickenpox despite the vaccine have a
very mild illness (less than 50 pox; occasional fever; lasts for just a few days).

Varicella (Chickenpox): The vaccine

The varicella vaccine is a live-attenuated vaccine. Hence, it contains a
weakened form of the germ that causes chickenpox. As a result, some
children will get a rash that looks like chickenpox one to four weeks after
being vaccinated.
Some parents wonder if a recently vaccinated child can spread chickenpox
to someone else (particularly someone who has an immune deficiency). Since
the chickenpox vaccine came out in 1995, several million people have been
vaccinated. There have been three documented cases of vaccine-associated
chickenpox. Yup, three. The risk is so low that even if your child develops a
rash after his shot, he can still attend daycare. (Pickering)
There is a small risk of getting shingles (reactivated chickenpox) later in
life. Evidence suggests that you are more likely to get shingles if you get the
actual disease than if you have been vaccinated.
Parents also wonder if the vaccine will provide lifelong protection. While
we don’t have an entire generation’s worth of data, we do have data on people
who participated in the original studies of this vaccine dating back to 1975—
and yes, those people have shown good immunity.

DR B’S OPINION: CHICKENPOX

CAN BE DEADLY

During my residency, I cared for a seven-year-old patient with

chickenpox who came to our emergency room with a secondary Strep
infection—she died two hours later. That experience has left an
impact on me. When parents perceive that chickenpox is just a minor
illness, I tell them that story. Attending a “chickenpox party” to
knowingly give your child this illness is not a sign of being an
empowered parent. It’s a sign of ignorance.

The American Academy of Pediatrics and Centers for Disease Control

recommend two doses of vaccine for the most complete protection. The first
dose is given at 12-15 months and the booster dose is given at 4-6 years, in
preparation for kindergarten.
 Can older children get the chickenpox vaccine? Yes, the varicella vaccine
should be given to anyone over a year of age who has never had chickenpox.

Strep Pneumoniae

This is a bacteria that is in the Strep family. It is not the Strep that causes
Strep throat. It’s a distant cousin. This bacteria causes meningitis, pneumonia,
blood infections (sepsis), sinus infections, and ear infections. The Prevnar
vaccine protects against the top 13 strains of Strep pneumoniae (there are 90
total) that cause serious infection.
Respiratory droplets spread the bacteria. Once the bugs get in, they head
for the respiratory system (ears, sinuses, lungs) or the brain. They travel via
the blood en route to these places. Infected people run a high fever when the
bacteria are in the bloodstream. Fortunately, many infections are treated
before meningitis occurs. Prior to the Prevnar vaccine, there were over
16,000 cases of serious Strep pneumoniae infections a year in American
children under age five. In babies, Strep pneumoniae is the #1 cause of
bacterial meningitis. The highest risk groups for serious infection are infants
and the elderly.
There are antibiotics to treat Strep pneumoniae, however, doctors are
seeing more drug-resistant strains. It’s survival of the fittest for germs—and
these germs are some of the smartest around. Twenty percent of the Strep
pneumoniae strains in the vaccine are resistant to Penicillin. Ten percent are
resistant to three OR MORE types of antibiotics. Daycare children are at
higher risk for Strep pneumoniae infection, particularly the drug-resistant
strains.

Strep pneumoniae (Prevnar or PCV 13): The vaccine

Prevnar is recommended as part of the routine immunization schedule by
the American Academy of Pediatrics. There has been an 87% reduction in
serious Strep pneumoniae disease (meningitis, blood and pneumonia
infections) since the immunization program began in 2000. Interestingly, we
have also seen a 50% reduction in pneumonia in the elderly since there is less
Strep out there.
Prevnar is a four dose series. The first three doses are given at two, four,
and six months of age. A booster dose is given at 12-15 months.
Rotavirus

Rotavirus is a virus that comes to visit every winter.

Doctors always know rotavirus has arrived in a community. The littlest
patients come into the office with so much watery diarrhea that parents cannot
keep up with diaper changes. The vomiting part is pretty miserable, too.
Because there is so much water lost in the poop, infants are at high risk of
becoming dehydrated.
Before widespread vaccine use in 2006, Rotavirus infection caused about
50,000 hospitalizations of young American children every winter. There were
also about 30 deaths per year in the U.S. from rotavirus. Worldwide, rotavirus
kills 440,000 kids every year.
You can see why docs have long wanted a vaccine for this disease!
Looking at data on diarrhea season (that’s a fun job, eh), it’s clear that
rotavirus vaccine has made a significant impact in reducing the number and
severity of cases. (CDC)

Rotavirus: The vaccine

The FDA approved the rotavirus vaccine (called Rotateq) in February
2006. It’s a live, attenuated vaccine given in the form of oral drops at two,
four, and six months of age. Rotarix, another FDA approved rotavirus
vaccine, is a two-dose oral drops series.
The most common side effect of the rotavirus vaccine is mild diarrhea
within a week. Past rotavirus vaccines had a very rare, nasty side effect:
bowel obstruction (intussusception); see the controversies section later in this
chapter. However, since the vaccine came out, tens of millions of doses been
given worldwide and results are promising—the risk of bowel obstruction is
no greater in vaccinated babies than in the general population. Nonetheless,
parents should be looking out for severe abdominal pain/irritability or blood
in the poop/grape jelly poop after vaccination.
One word of caution: rotavirus vaccine is a live vaccine. Babies cannot
receive the vaccine if they have a rare immune disorder called Severe
Combined Immune Deficiency (SCID). And if any caretaker is immune-
compromised (for example, on chemotherapy) there is a theoretical risk of an
adult getting the disease from exposure to the vaccinated baby’s stool. About
9% of babies will shed the weakened virus in their poop four to six days after
the first dose of the vaccine. Less than 0.3% shed it after the second or third
doses. Let your doc know and you can discuss your individual situation.

Influenza (Flu)

This is another virus we see every winter. It is an infection that attacks the
respiratory tract. Worse than the common cold, flu causes higher fevers, body
aches, headaches, and a crummy feeling in general. The runny nose and
cough arrive later and last longer than a typical cold. Secondary bacterial
infections (ear infections, sinus infections, pneumonia) occur more often with
the flu than with your garden-variety cold virus.
Besides being generally unpleasant to endure, the flu can be deadly. The
highest risk groups for serious health complications from the flu are children
under two years of age and adults over age 65.

Influenza: The vaccine

The only state that requires flu vaccine for school is New Jersey. Yep, you
can’t go to school in New Jersey without proof of being vaccinated against
the flu. While that sounds draconian, keep in mind that school-aged kids are
often ground zero for a flu epidemic—while they are at low risk of suffering
severe health complications, school-aged kids are most likely to spread the flu
to others in the community who ARE at risk.
The Centers for Disease Control’s latest recommendations for “Who
should get flu vaccine?” are: EVERYONE who is six months old and up. But,
here are the people who are most at risk:

1.50-years or older.
2.Immune-compromised (weak immune systems)
3.Suffering from chronic illness (asthma, heart disease, diabetes), age six
months old or older.
4.Health care workers.
5.Pregnant women during flu season (November-March).
6.Children ages six months old to 18 years old.
7.Household contacts and caretakers of any child aged birth to five years.
 The flu vaccine currently used for kids under two years of age is an
inactivated vaccine, in the form of a shot. They won’t get the flu from it. It
provides immunity two weeks after getting the vaccine. The vaccine is
effective for one year. The particular influenza virus strains that show up
every year is different, so we have to get vaccinated for the new bugs in town
each autumn.
Kids under nine years of age who get the flu vaccine for the first time need
two doses given one month apart. One cautionary note: children with egg
allergies should first consult their doctor about the flu vaccine.
Currently, there is only one flu vaccine that is “preservative free” and
allowed for use in infants as young as six months old. It’s called Fluzone
(Aventis Pasteur). The other flu vaccines contain a trace amount of thimerosal
(0.025 milligrams per dose). However, the acceptable limit of exposure is
over 12 times this dose (0.2-0.4mg). See the section “Controversies” later in
this chapter for more information on thimerosal.

Insider Secret
There is a live inactivated flu vaccine nasal spray called Flumist, currently
FDA approved for healthy children ages two years and up . . . to age 49 (in
case you are squeamish about shots and wanted to know your options). The
nasal spray vaccine provides comparable protection to the injectable one—
and it doesn’t hurt. Flumist is produced in single-use nasal syringes. No
preservatives are necessary (hence, Flumist is thimerosal-free).

Reality check
Every spring, the World Health Organization determines the three or four
strains of influenza virus that are most likely to show up in the Northern
hemisphere in the upcoming winter flu season (based on those circulating in
the Southern hemisphere). So each year, the seasonal flu vaccine protects
against three or four different types of flu. That’s why the flu vaccine is
slightly different every year.

Q. I’m pregnant. Is it safe for me to get the flu vaccine?

YES! And, it will protect both you and your unborn baby.
The flu shot (not the nasal spray) is FDA approved for pregnant women
during ANY trimester of pregnancy.
A pregnant woman is at greater risk of complications from the flu because
her body is in a functionally immune-compromised state (which allows her
body to let a fetus with foreign DNA grow inside of her). So protection via
vaccination is pretty important.
Moms-to-be who get their flu vaccine also protect their babies, once they
are born. In fact, newborns and infants whose moms got flu vaccine during
pregnancy have a 40% lower chance of being hospitalized for flu. (Eick)

Smallpox

Q. Will my baby get the smallpox vaccine?

No. The World Health Organization declared the world “smallpox-free” in
1980 (a major accomplishment). We no longer vaccinate for this disease.
Currently, there is no plan to resume smallpox vaccination.

Insider Secret
There are three vaccines that protect against different causes of bacterial
meningitis: Prevnar/PCV 13 (13 strains of Strep pneumonia), HIB
(Haemophilus influenzae B), and MCV 4 (4 strains of Neisseria
meningitides). Babies receive Prevnar and HIB vaccines as part of the routine
immunization series. Preteens (11-12 year olds) routinely receive MCV 4, but
babies with compromised immune systems can also get this vaccine starting
at nine months of age.

Controversies

Let’s face it, controversy drives TV ratings and web traffic. No one is
interested in hearing about things that work as they should—and vaccines are
a good example. Vaccines have been a hot topic for the last decade or so.
Unfortunately, rare adverse events and theoretical concerns tend to make
more headlines than the remarkable success story of vaccinations. These
problems are then seized on by vaccine opponents and spread online through
the web like a, well, virus.
So, let’s address this head on. Here are the controversies you might hear
about with vaccines:

Does MMR Cause Autism?

Q. I’ve heard that the MMR vaccine might cause
autism. Is this true?
No.
Parents also hear that vaccinations cause multiple sclerosis, diabetes,
asthma, and SIDS. None of these are caused by vaccination. The government
operates a safety monitoring system (VAERS, FDA, CDC)—watching for any
possible adverse effects from vaccines. No one wants to increase autism rates.
One small case report of only eight patients in 1998 led a research group to
feel that the combination MMR vaccine might cause autism. (Wakefield) But,
don’t try to find the article online because the journal that published the
article later retracted it when a former member of the research lab revealed
that the data reported in the study was fabricated! (Newsweek.com) Twelve
years later, the lead author lost his license to practice medicine in England and
was accused of fraud. The whole thing was a hoax.
Before this came to light, several reputable scientists tried to replicate the
findings of this now discredited researcher. No one ever could—and know we
know why!
 Unfortunately, frightened parents chose to skip the MMR vaccine and
measles epidemics occurred both in England and the U.S. as a result of these
unfounded claims.
Bottom line: Don’t base health decisions for your child on one research
study or what the media reports! Talk to your child’s doctor about any vaccine
safety concerns.

DR B’S OPINION: MMR & AUTISM

I follow the developmental milestones of all my patients carefully.

I have concerns for autism long before a patient turns a year of age.
But I keep these concerns to myself because many of these worrisome
children ultimately catch up developmentally. It is only when I am
sure of the diagnosis do I sit down with my families to discuss these
lifelong developmental disorders.
I have never had a developmentally normal patient come in for his
one year well check, get his MMR vaccine, and come back at his 15-
month checkup as an autistic child. The 15-month-old who is autistic
is a child I was worried about long before the one-year well check.
In another study, doctors noticed the same results. Developmental
specialists viewed footage of children’s first birthday parties (who had
not received the MMR vaccine yet). The specialists accurately
identified the children who were later diagnosed with autism.

Q. If the MMR vaccine doesn’t cause autism, why is the

diagnosis made around the same time as the
vaccination?
One of the criteria used to make a diagnosis of autism is a language delay.
Because children do not have significant expressive language under a year of
age, doctors have to wait until 15 to 18 months to confirm a language delay
and make the diagnosis. That’s about the same time as the MMR vaccination,
which leads some parents to wonder about autism and vaccination.

DR B’S OPINION: IS IT TIME TO

MOVE ON?

Vaccines have received intense scrutiny over the past seventeen

years in the search for a cause of autism. The best scientific minds,
worldwide, have looked for a link and none has been found. Many
autism researchers have moved on to look for more promising leads.
Some families, however, have not moved on and want more research
dollars earmarked for this debunked theory. So, yes, you will continue
to here about this controversy and we want you to realize that a)
science has devoted much brainpower, time and money to this concern
and has concluded there is no link and b) many families with a child
who has autism do not feel that vaccines have anything to do with
their child’s disorder. Here are some noteworthy comments:

“The question has been asked and answered and it’s time to move
on . . . we need to be able to say, ‘Yes, we are now satisfied that the
earth is round.’ . . . we need to listen to experts and not actresses. The
media culture, feeling compelled to give both sides of an argument
has lent a legitimacy to the anti-vaccine movement that is very over-
weighted. They’re a small number of people with very loud voices.
The vast majority of parents of children with autism are very
supportive of the importance of vaccines. . . . the media need to show
both sides to make it look like both sides are equal. One side is backed
by evidence, one side is not.”
Alison Singer, Founder and President of the Autism Science
Foundation and mother of a child with autism spectrum disorder

“It would be nice if autism advocacy organizations actually

advocated for children with autism . . . Instead, they are anti-vaccine
 organizations, and the fact of the matter is vaccines have nothing to do
with autism . . . it’s high time that these organizations stopped
deluding people into thinking that vaccines do have something to do
with autism and started focusing on the real causes of autism.”
Paul Offit, M.D. Director of the Vaccine Education Center,
Children’s Hospital of Philadelphia

Rotavirus
Q. I’ve heard about a vaccine that was taken off the
market. What was the problem with it? It makes me
nervous about other new vaccines.
The original rotavirus vaccine was approved in August 1998 after a study
was done on 10,000 individuals. It looked like a safe vaccine. That vaccine
was then given to 1.5 million children over a period of nine months. During
this time, there were 15 reports of bowel obstruction (intussusception) that
occurred within a week of being vaccinated. There were no deaths. The CDC
immediately pulled the vaccine off the market and initiated an investigation.
Although this was certainly a setback for new vaccinations, it proves that
the adverse events reporting system (VAERS) works. Modifications have
been made to the license process as a result of the rotavirus vaccine. This was
the first vaccine recall in over 20 years.
As we mentioned earlier in the chapter, a newer rotavirus vaccine debuted
in 2006—it was studied in 70,000 infants in Latin America and Europe before
getting the nod by the FDA. After several years of use, this vaccine has
clearly proven to be very safe. But given the history of the previous rotavirus
vaccine, the FDA still closely monitors for any cases of bowel obstruction.

The Thimerosal (Mercury) Controversy

Q. I’ve heard there is mercury preservative in the
vaccines. Is this true?
Not anymore. It was removed from all required childhood vaccines by
2001. This deserves repeating: YOUR baby will not be getting required
vaccines that contain mercury (thimerosal) as a preservative.
Despite the fact that vaccines have been mercury preservative-free for over
a decade now, speculation persists about vaccines previously containing
mercury and links to autism. This speculation continues even after the
Institute of Medicine published a conclusive report in 2004 negating any
association between vaccines and autism. (The IOM spent four years studying
both the mercury question and the MMR combo vaccine question and
published a series of eight reports on the subject).
Because of ongoing concerns, we present to you: more than you ever
wanted to know about thimerosal!

BOTTOM LINE: Thimerosal will remain on blogs and anti-vaccine websites

forever, but the preservative does not remain in any of the required childhood
vaccines that YOUR baby will get.

Q. I heard that I should still ask my doctor if the

vaccines for my baby are thimerosal-free. What do you
suggest?
We think you should ask as many questions as you need to feel
comfortable. Remember that since 2001, the entire childhood vaccine series
went thimerosal (mercury) preservative-free. If your doctor has a 2001
vintage vaccine vial sitting on the shelf (which would be long expired by
now), I’d have bigger concerns about your doc than his vaccine supply.
Here are the specific rules regarding thimerosal use in vaccines: the FDA
requires manufacturers of routine childhood immunizations to no longer use
thimerosal as a preservative. This rule does NOT apply to flu vaccine because
(technically) this vaccination is optional (except in New Jersey) and not
“routine.”
Why does flu vaccine need thimerosal or any other preservative? First,
understand the flu vaccine is reformulated every year to reflect the anticipated
flu strains. Since millions of doses of flu vaccine are needed every year, the
most efficient way to produce the shot is in multi-dose vials, which require a
preservative.
Hence, some flu shots (not the flu nasal spray) contain the preservative
thimerosal. However, there are single-dose preparations of flu vaccine that are
mercury preservative-free. These can be given to young children and pregnant
women. Ask your doctor for a thimerosal-free flu vaccine if you are
concerned.
Even though thimerosal is safe, it would be ideal for all flu vaccines to be
thimerosal preservative-free—this would put any concerns to rest. However,
the manufacturing process just isn’t there yet.
What about other vaccines? Do they contain thimerosal? There are four
vaccines that use thimerosal in the production process—but it is extracted
before the final product is bottled. As such, these vaccines must list that
TRACE amounts of thimerosal (less than 0.003mg) may exist in the vaccine.
There is probably little or no thimerosal in the finished product, but the
manufacturer must declare it.
We have no concerns about these vaccines, but if you are completely
freaked out about the thimerosal thing (despite the proof that they are safe),
there are other alternatives to these specific vaccines made without any
thimerosal:
Tripedia (one brand of DTaP),
Pediarix (one brand combo of DTaP/HepB/IPV),
Trihibit (DTaP/HIB),
Engerix-B (one brand of Hep B).

The FDA has a chart online that tracks any thimerosal content in
vaccines:vaccinesafety.edu/thi-table.htm We have a link to the chart on our
web site Baby411.com(click on Links).
FYI: many vaccines such as the combination measles, mumps, and rubella
vaccine (MMR,) never used thimerosal in the production process or as a
preservative.

THIMEROSAL 411

Preservatives and stabilizers are used in vaccines so that the

vaccinations remain potent and uncontaminated. A popular preservative
used to be a chemical called thimerosal, which contained trace amounts
of ethylmercury. Thimerosal use began in the 1940’s.
A quick chemistry lesson: Certain compounds have completely
different properties even though they may be related. For instance, take
the alcohol family. Methanol is anti-freeze; ethanol is a Bud Light.
Keep this in mind when we discuss mercury. We are all exposed to
small amounts of mercury. The type of mercury that has raised health
concerns is called methylmercury. High concentrations of
methylmercury can be found in tuna, swordfish and shark from
contaminated waters. The information known about mercury poisoning
comes from unfortunate communities that have experienced it.
Example: there is a large amount of data from the Faroe Islands, near
Iceland. The people there would eat whale blubber contaminated with
toxic levels of methylmercury and polychlorinated biphenyls (PCBs).
Children, especially those exposed as fetuses during their mother’s
pregnancy, seemed to have lower scores on memory, attention, and
language tests than their unexposed peers. (They were not diagnosed
with autism or Attention Deficit Disorder, however.) (AAP Technical
Report)
Chronic exposure to liquid methylmercury causes Mad Hatter’s
Disease, named for hat makers who used liquid mercury in the hat-
making process. The disease consists of psychiatric problems,
insomnia, poor memory, sweating, tremors, and red palms. Chronic
mercury poisoning also impairs kidney function.
Methylmercury is a small molecule that can get into the brain—it
takes almost two months to break down in the body. Ethylmercury (the
type of mercury that was previously used as a vaccine preservative) is a
large molecule that cannot enter the brain and is rapidly eliminated
from the body within a week.
Because of the increased number of vaccinations that children get,
the potential cumulative exposure to mercury became a concern in
1999.
There are three federal groups that set standards for acceptable daily
mercury exposure (Environmental Protection Agency, Food and Drug
Administration, Agency for Toxic Substances and Disease Registry).
When the exposure was calculated, the cumulative dose was higher
than acceptable levels set by the EPA only (the other groups’ standards
were higher). The Food and Drug Administration mandated the
 removal of thimerosal (ethylmercury) at that time for concerns
extrapolated from data on methylmercury.
Vaccines still contain other preservatives (more on this in the
additives section later in this chapter).

Reality Check
Worried about the mercury preservative (thimerosal) in your child’s flu
vaccine? Consider this: there is five times more mercury in a tuna fish
sandwich, than in a thimerosal preservative flu vaccine. (EPA) And the type
of mercury (methylmercury) found in tuna is the one that has health concerns.
Also: a baby who is exclusively breastfed for six months of life consumes
about 0.36 mg of methylmercury from breast milk. That’s 15 times the
quantity of mercury in one flu vaccine!
Bottom line: as a doc, I am much more concerned about your baby’s
mercury exposure from the environment than what’s in a flu shot. Here’s a
look at the numbers:

Q. Does thimerosal cause autism?

No. The Institute of Medicine reached this conclusion in 2004. What proof
do we have?
Thimerosal has been removed from vaccines since 2001, but the rates of
autism are still skyrocketing. A 2008 survey of autism rates in California
confirms that mercury is essentially out and autism rates are still going up. If
thimerosal was the cause and it was removed from vaccines since 2001,
autism rates would be going down by now. Why? Because autism spectrum
disorders are usually diagnosed by three years of age. By now, any reduction
in autism should have been obvious if thimerosal caused the disorder.
(Schechte)

1.Mercury preservatives were removed from vaccines in Denmark in

1992. Canada and the European Union followed suit shortly
thereafter. However, their autism rates are going up too.
3.Mad Hatter’s Disease (mercury poisoning) and autism are very different
disorders. See chart below.
4.A study of 100,000 kids in England compared those receiving
thimerosal containing vaccines to those who did not. The ones who
had the t-free shots had HIGHER rates of autism. (Communicable
Disease Surveillance Center)
5.A 2007 study showed that children between seven and ten years of age
who got those mercury containing vaccines (before 2001) have no
significant differences in tests of attention and processing
information. Although the study did not look specifically at autism, it
showed that mercury preservatives did not make much of an impact
on brain functions in general. A follow up study that specifically
addresses autism is now underway. (Thompson)
Did thimerosal cause autism? Notice the differences between autism and
mercury poisoning (Nelson):
 DR B’S OPINION

“We have spent a lot of money studying vaccines.

Now let’s spend our research dollars on finding a
cause for autism.

A colleague of mine, Dr. Jill Nichols, said it

best: ‘This is not the case of two sides to every story.
It is a case of fact vs. opinion.’”

Q. Are there other additives in the vaccines?

Yes. And you should know about them.
As we have already discussed, vaccines contain the active ingredients that
provide immunity. But there are inactive ingredients that improve potency and
prevent contamination. Below is a list of additives and why they are there.
These products are present in trace amounts and none have been proven
harmful in animals or humans. (Offit)
Preservatives: Prevent vaccine contamination with germs (bacteria,
fungus). Example: 2-phenoxyethanol, phenol, (thimerosal, prior to
2001).
Adjuvants: Improve potency/immune response. Example: aluminum
salts.
Additives: Prevent vaccine deterioration and sticking to the side of the
vial. Examples: Gelatin, Albumin, Sucrose, Lactose, MSG, glycine.
Residuals: Remains of vaccine production process. Examples:
Formaldehyde, Antibiotics (Neomycin), Egg Protein, Yeast Protein.
 See our web site (Baby411.com, click on “Bonus Material”) for a list of
ingredients for the routine childhood vaccination series.

Reality Check
If vaccines contain ingredients like aluminum or formaldehyde, wouldn’t it be
better if vaccine makers got rid of these additives? Shouldn’t vaccines be
“greener”?
This is a red herring argument against vaccines—current vaccines are safe,
even with tiny/trace amounts of preservatives or additives like aluminum.
And your baby is exposed to many of these ingredients every day . . . simply
by eating or breathing.

Q. Why is formaldehyde in vaccines?

Small amounts of formaldehyde are used to sterilize the vaccine fluid so
your child doesn’t get something like flesh-eating Strep bacteria when he gets
his shots.
We know when you think of formaldehyde, that ever-present smell wafting
from the anatomy lab in high school comes to mind. But what you probably
don’t know is that formaldehyde is also a naturally occurring substance in
your body. And if you use baby shampoo, paper towels or mascara, or have
carpeting in your home, you’ve been exposed to formaldehyde. The small
amount used in vaccines is not a health concern. (Dept of Health and Human
Services)

Q. Is it true that anti-freeze is used in vaccines?

No.
There is a chemical used in some vaccines (called polyethylene glycol) that
is also found in antifreeze, as well as toothpaste, lubricant eyedrops and
various skin care creams. Polyethylene glycol is used in the production
process to purify vaccines (it is used in one flu vaccine, among others).
 DR B’S OPINION: ASK YOUR DOC
ABOUT HER KIDS

As parents, our job is to protect our kids as best we can. I get it. I
am a parent, too. And I certainly understand, after browsing the
internet and hearing parent chatter, that you may have more questions
and concerns about vaccinations.
At the end of the day, you’ve got to put your trust in someone to
help guide you in some of those decisions. I hope you and your baby’s
pediatrician have a good relationship and this person can answer
questions that concern you on any topic. Our job is to advocate for
and protect your child. If I ever had any doubt about vaccines, or
anything else that might harm your child, I guarantee that I would be
the first to stop doing it. I treat my patients like my own children. So I
suggest asking your doctor the most important question you can ask
regarding vaccines: Did you (or would you) vaccinate your own
children?
I vaccinated both my children, and would do it again without
hesitation.

Q. Is it safer to delay vaccines or use an alternative

vaccination schedule?
Easy answer: no.
The CDC publishes a recommended vaccine schedule for American
children. Many, many doctors, scientists, and researchers work together with
the CDC to decide what is the best timing to give shots. The goal: protect
babies as soon as it is safe and effective to do so. This schedule was not
created out of thin air.
Between anti-vaccine activists shouting “too many shots, too soon” and Dr.
Bob Sears hawking his book, new parents wonder if it would somehow be
safer to wait on shots altogether or stagger them out on “Dr Bob’s schedule.”
Here’s a nasty little truth about alternative vaccination schedules: they are
all fantasy. There is absolutely no research that says delaying certain shots is
safer. Dr Bob is making up “Dr Bob’s Schedule” all by himself. He even
admits that. In an interview with ¡Village, he commented, “My schedule
doesn’t have any research behind it. No one has ever studied a big group of
kids using my schedule to determine if it’s safe or if it has any benefits.”
A 2010 study actually did study children whose vaccinations were delayed
and found there was absolutely no difference in their development to children
who’d received their shots on time. (Smith) A 2013 study showed further
evidence that giving numerous shots at the same time and giving the
recommended vaccination schedule has no impact on a child’s risk of autism.
(DeStefano)
I’d much rather follow a schedule that has been extensively researched for
both safety and effectiveness by experts in the field of infectious diseases.
What we do know about alternative vaccination schedules is that delaying
shots is playing Russian Roulette with your child. The simple truth is that you
are leaving your child unprotected, at a time when she is the most vulnerable.
We realize that parents who choose to delay or opt out on vaccines are not
bad parents. They are scared parents. What we are trying to help you realize is
that the fear you should have is for the diseases that vaccines prevent. If you
are on the fence about vaccinations, please take the time to research the
diseases—see earlier in this chapter for details.

Q. If I want to do a staggered vaccination schedule, how

should I do it?
I suggest setting up a consultation with your own pediatrician to discuss
what both of you feel comfortable with doing. Remember, the ultimate goal is
to have your child vaccinated in a timely manner.
With the 2015 measles outbreak on everyone’s minds, more pediatricians
are increasingly adamant about protecting their littlest patients. Many refuse
to deviate from the recommended schedule just to appease a nervous parent. It
may be difficult to find a board-certified pediatrician willing to modify or
delay shots. It’s our job to protect kids. Following the recommended schedule
is the best way to do that.
Q. Didn’t the government concede that vaccines caused
a child’s autism?
During the equivalent of a class action lawsuit against the government
(called the “Omnibus Autism Proceedings”), one child, Hannah Poling,
received a monetary settlement. The court did not hear her case. Hannah’s
case was being reviewed to serve as one of the test cases for a suit to represent
5000 families who believe vaccines caused their child’s autism. During the
review process, it was determined that Poling did not represent a test case
because she had a rare, underlying genetic mitochondrial disorder that caused
her deterioration and autism. For rare kids like her, any stress could have
caused her to deteriorate. This is the equivalent of being born with an
aneurysm, a ticking time bomb that could go off at any moment. Although she
was not diagnosed prior to being vaccinated, experts recommend that even
children with known mitochondrial disorders still be vaccinated.
Bottom line: the government did NOT concede that vaccines cause autism
in the Poling case.

ALUMINUM 411

Now that the mercury (thimerosal) saga is coming to an end, anti-

vaccine crusaders have come up with a new bad guy: aluminum. Yes,
trace amounts of aluminum salts are used in some childhood vaccines.
Here’s all you need to know (and more) about aluminum. Bottom line:
we are not worried about it. Here’s the 411:

Aluminum is everywhere. It’s one of the most common metals in

our earth’s crust. So it is naturally present in our water, soil, and even in
the air. Fruits, vegetables, nuts, flour, cereal, dairy products, and yes,
even baby formula and breast milk . . . all contain some aluminum. Do
you wear antiperspirant? It’s in there, too. To avoid aluminum
exposure, you’d have to quit wearing antiperspirant . . . and basically
leave the planet.
 Why is aluminum used in vaccines? Aluminum enhances the
immune system’s response to the vaccine. It’s been used safely for
several decades. By using aluminum salts, some inactivated vaccines
require fewer booster shots for the body to mount an adequate immune
response.

Are there any health concerns with aluminum in vaccines? No.

There is significantly less aluminum in vaccines than what babies are
exposed to in the environment. Both the National Vaccine Program
Office and the World Health Organization have determined that the
aluminum content in the childhood vaccination series is safe. Humans
rapidly eliminate aluminum salts from the body. The small amount of
aluminum that accumulates in human brains (about 50-100 mcg in an
adult brain) comes from food sources. (Mitkus)

Does aluminum poisoning cause autism? No. People with

aluminum poisoning have bone problems (osteomalacia) and anemia,
as well as neurologic issues. These include memory loss, fatigue,
depression, behavioral changes, and learning impairment. Aluminum
has also been proposed as the cause of Alzheimer’s Disease. To date,
however, there is little evidence that aluminum causes that disorder.
(Dept of Health and Human Services)

How much aluminum is in vaccines? Very little. If your baby

follows the standard immunization schedule, he is exposed to about
four to six mg of aluminum at six months of life. By comparison, he’s
also exposed to 10 mg of aluminum if he is breastfed, 40 mg if he is
fed cow’s milk-based formula, or 120 mg if he is fed soy formula.
None of these are very large amounts, by the way. To put things in
perspective, there’s about 200mg of aluminum in a standard antacid
tablet. In fact, the average adult ingests seven to nine mg of aluminum
everyday. Here’s a look at how much aluminum is in breast
milk/formula, compared to vaccines:

Amount of aluminum exposure (milligrams per liter) (Vaccine

Education Center)
 AMOUNT OF ALUMINUM
Breast milk 0.01—0.05 mg/L
Cow’s milk based infant formula 0.06—0.15 mg/L
Soy based infant formula 0.46—0.93mg/L
Prevnar vaccine 0.125 mg/dose
DTaP vaccine 0.17—0.625 mg/dose
HIB vaccine 0.225 mg/dose
Hep A vaccine 0.225—0.25 mg/dose
Hep B vaccine 0.25—0.5 mg/dose
DTaP/IPV/HIB vaccine 1.5 mg/dose

Is it a good idea to space out vaccinations that contain aluminum

salts? No. Since aluminum-containing vaccines do not cause any health
risk, separating or spacing out these vaccines has no benefit. In fact,
there is a risk to spacing out the vaccines—your baby will go
unprotected against real vaccine-preventable disease.

Vaccine Shortage
Q. I’ve heard there is a vaccine shortage. Is this true,
and why did this happen?
Yes, our country has experienced shortages in many of the childhood
vaccinations. Most vaccines are available now, though.
One reason for vaccine shortages: there are fewer vaccine makers than in
years past. Now that you have read about all the controversies with vaccines,
would you want to be a vaccine manufacturer? There used to be 15
pharmaceutical companies that made vaccinations. Now there are only four.
When the others left the market, the remaining companies were forced to
increase production for the needs of our entire country.
Helpful Hints
Where to get more information
Our advice: don’t type in “vaccinations” in a Google search.
You will end up with inaccurate information from concerned groups who
do a great job of creating parental anxiety. The following sites will provide
accurate information:
CDC’s National Immunization Program
cdc.gov/nip, (800) 232-2522
American Academy of Pediatrics: aap.org, (800) 433-9016
Immunization Action Coalition immunize.org
Vaccine Education Center, Children’s Hospital of Philadelphia
vaccine.chop.edu
Here is an excellent reference book written for parents: Vaccines and Your
Child: Separating Fact from Fiction. Offit, P. and Moser C. New York:
Columbia University Press. 2011.

Feedback from the Real World

Vaccination Revealed, by Ginny Butler, Pregnancy and Newborn magazine
March 2009:
“We live in an Information Age. We mothers can become experts in digital
photography, gourmet cooking and up-to-the-minute runway fashion, merely
by spending some time online. However, when we’re making decisions that
may be critical to our children’s health and our communities’ stability,
obtaining correct information is vital.”

Ryan’s Story
Frankie Milley, a founder of Meningitis Angels (meningitis-angels.org),
offered up this heartbreaking story about vaccines:
 On June 22, 1998, a vaccine preventable disease called Meningococcal
meningitis took the life of my only child, my son, Ryan. Thousands of children
will develop meningitis each year and many will die. But death isn’t the only
outcome: children who survive are often left with limb amputations, organ
damage, and the list goes on.
The two types of meningitis that are most common are meningococcal and
pneumococcal (Strep pneumoniae). There are vaccines for both.
This vaccine preventable disease took away my identity, my right to ever be
the parent at a wedding, to hold a grandchild, and to have the comfort of a
child in my old age. We must work together in the United States to protect our
children from epidemics which other parts of the world see everyday. Because
epidemics are a plane ride away. And vaccinations save lives.

Yes, vaccines prevent sickness—but you can’t be vaccinated against every

infection. Up next, the infection hit parade, including a special focus on ear
infections, when your child can go back to day care and more!
COMMON INFECTIONS
 Chapter 13
“A family is a unit composed not only of children but of men, women,
an occasional animal, and the common cold.”
~ Ogden Nash (1902-1971)

WHAT’S IN THIS CHAPTER

WHAT ARE VIRUSES?
WHAT ARE BACTERIA?
ANTIBIOTIC RESISTANCE
WHAT YOU ALWAYS WANTED TO KNOW ABOUT THE COMMON
COLD
WHEN YOUR CHILD CAN RETURN TO CHILDCARE OR
PLAYGROUP
GERM HIT PARADE
SPECIAL FEATURE—EAR INFECTIONS

This chapter answers that age-old parent question: “So, when can my child
go back to child care/playgroup?” Yes, it’s time to take a look at the germs
that like to invade us. Infectious diseases are a large part of pediatrics.
Adults have their share of infections, but the numbers pale in comparison to
kids (a.k.a. human culture dishes). FYI: diseases that are not caused by
infections are covered in the next chapter, Common Diseases.
Common infections are usually caused by one of two things—viruses
and bacteria. We’ll cover both in this chapter.
Most infections that your child will get are viruses. These are infections
that go away on their own, without medication. One of the advantages of
being a pediatrician is that in the case of viruses we do nothing, and our
patients usually get better! Many parents don’t understand what viruses are
and feel compelled to DO SOMETHING. It often takes more time to
explain to a parent that their child will get better without a prescription,
than it takes to diagnose the ailment.
You will be an honorary microbiologist after reading this chapter. It will
prepare you for the numerous infections coming your way. We’ll go over
viruses and bacterium since those are the biggies. Fungi, mites, lice, and
parasites are discussed in “Things that make you itch just thinking about
them” in this chapter. Fun, no?

Q. What is a virus?
These are tiny germs that need our body cells (called the “host”) to
survive and prosper. Viruses are like little copy machines. Their genetic
coding allows the virus to reproduce quickly in the host.
Most viruses enter our bodies, reproduce for a few days, then leave to
infect someone else. Examples include the cold virus and hand/foot/mouth
diseases (see the table at the end of this section for a complete run-down of
viruses with their common and scientific names). A few viruses like to stick
around, lie dormant, and then reactivate to torture us again, such as herpes
and chickenpox. Rarely, a virus kills their host—one example is HIV.
Here’s some cocktail party trivia for you: according to the International
Committee on Taxonomy of Viruses (7th Report, 2000), there are more than
1550 virus species, divided into 56 families. Within each family, there are
sometimes thousands of relatives for each virus. These identified viruses are
just a small portion of what is actually out in the world.

Q. Where do viruses live when they aren’t infecting

someone?
Viruses can be airborne or live on surfaces for a period of hours to days.
Germs live on surfaces called FOMITES. Fomites include door handles,
grocery carts, gas pumps, changing tables, shared toys, etc. In other words,
there is a “biofilm” that is living on items that you and your child touch
every day.
BOTTOM LINE: Your mother was right—WASH YOUR HANDS!

Q. Is antibacterial soap a good defense against

infections?
Yes, but let’s talk about the ingredients and then you can decide if you
want to use them. Antibacterial soaps contain an effective antiseptic
chemical called triclosan. (Hospitals used triclosan-containing hand
cleansers for decades before they popped up in household products and
hand gels.) Experts are increasingly concerned that widespread use of
triclosan may lead to antibiotic-resistant super germs. There are also
possible health risks regarding exposure and the body’s hormone regulation.
According to the Centers for Disease Control, triclosan is present in the
urine of 75% of Americans over the age of five. Scary, no?
Then, there are alcohol-based hand sanitizers, which are also effective in
keeping germs at bay. Hand sanitizers that use at least 60% alcohol as the
active ingredient are a convenient alternative to soap and water if hands are
not full of dirt. The only controversy related to these popular hand gels is
that some products contain far less than 60% alcohol—which means they
won’t work.
As you might guess, we have mixed feelings about antibacterial soap.
Are they “too much of a good thing?” We certainly do not want to help
create new breeds of bacteria that are harder to kill.
Ultimately, the decision is up to you. We suggest using 60% alcohol-
based hand sanitizer for when you are out and about or at the diaper
changing table. But in most other circumstances regular soap will do just
fine.
Denise’s opinion: On a personal note, we have found that in the Fields’
household, antibacterial soap aggravates our chronic dry skin (we live in a
very arid climate) and eczema. We stick to regular Dove soap and wash
frequently. Also those alcohol based hand sanitizers like Purell are very
painful if you have cracks from eczema. We avoid them as well.
 NEW PARENT 411: WHY EVERYONE IN THE HOUSE
GETS SICK WHEN A CHILD HAS A VIRAL ILLNESS

Everyone gets sick because of what families do in their own

homes. We hug, kiss, share drinks, touch door handles, touch hand
towels, etc. We also wash our hands less in our homes than when we
are out in public.
BOTTOM LINE: Think twice before you decide to finish what is
left over on your child’s plate. Is that half-eaten chicken nugget really
worth it?

Q. Do we pass viral infections back and forth in our

house?
No. Once everyone is infected, everyone is immune to that particular
germ.

Q. Why is my child always getting sick?

Because he is being exposed to infectious germs he has no immunity to.
There are literally millions of germs out there. Every time your child
gets an infection, he creates antibodies to a specific bug. But until your
child has a large immune memory in his body’s “hard drive,” he will get
almost every illness that comes down the pike. Most infections are spread
through respiratory droplets (snot and cough secretions), saliva, and poop.
Babies don’t have good manners. They cough and sneeze on each other.
They also explore toys in their mouths, leaving the germs behind for
someone else.
Reality Check
Babies begin to get sick when they start venturing out in the world. Here are
some astounding statistics:
The average number of viral infections per year for kids under age five
is EIGHT. Yes, you read that right.
Each illness lasts seven to ten days.
Most infections occur between October and April.
That’s 80 days of illness packed into six months of the year.

BOTTOM LINE: That’s right, expect an infection every other week in the
winter. And that’s just the AVERAGE. If you win the sick kid lotto, you
could be in for more. Astounding, eh?

Q. Why is my second child sicker than my first?

Because your older child is bringing home infections to share.
Firstborns often live in a bubble for their first year of life (unless they are
in childcare). Second babies don’t have that luxury. They get carted around
to big brother or sister’s activities. And big bro/sis share whatever
infections they have acquired with the little ones. So, it is natural for a
second child to get more illnesses earlier in life than the first.

Q. Why do we only see the flu virus in the wintertime?

Viruses prefer certain times of year to attack.
When a virus arrives in a community, it spreads in an epidemic fashion
for a period of weeks, then disappears. Doctors know what virus has arrived
because every patient has the same illness for a few weeks. Yep, it’s a fact
of life—viruses are always coming to town, it’s just a matter of when they
arrive every year. Here are the seasonal patterns of viral epidemics:
Summer: Coxsackievirus (hand/foot/mouth), Enteroviruses (stomach, skin,
respiratory, eye)
Fall: Parainfluenza (croup), Rhinovirus (common cold)
Winter: Influenza (the flu), Rotavirus (stomach virus), RSV (bronchiolitis)
Spring: Parainfluenza again, Varicella (chickenpox)

What causes these seasonal patterns? There are various factors that
influence the annual epidemics of these viruses. Scientists have been
studying this for years. It seems to be a combination of atmospheric
conditions and host (that’s us) behaviors that lead to the perfect conditions
for a virus to attack. Interestingly, viruses can be found infecting people in
their “off-season,” but not at epidemic levels. (Dowell)

Q. How do viruses cause infection?

Remember, viruses need us to survive. They jump at the chance to enter
any body orifice (eyes, nose, mouth, anus, vagina, urethra). Most often,
they are spread via the nose or through cough droplets, saliva, poop, or
sexual relations.
Garden-variety viruses enter our body, replicate, and leave. This makes it
hard to detect a virus or use a medicine to stop a viral infection—by the
time you realize you have been attacked by a virus, the virus itself may
have moved on.
The symptoms we experience are due to our immune response to the
infection. For example, the common cold virus (rhinovirus) attacks the
nose. Our immune system sends white blood cells there to fight the
infection. The result of the bug/white blood cell battle is mucous
production.
Once we have symptoms, the virus has already replicated numerous
times in our body. It’s usually too late to do anything. Fortunately, most
viral infections are not serious and our bodies recover from the invasion.

BOTTOM LINE: Think of a virus as a speedboat. It zips in and out of our

body.
Q. How do doctors know that a child has a viral
infection?
Your baby’s doctor will make a diagnosis based on symptoms (the
problems/complaints you describe) and the signs of infection (the abnormal
findings on physical examination). Most experienced physicians are able to
accurately make the diagnosis of a typical viral infection on this
information alone.

Q. Are there any tests that can detect a viral infection?

There are a few special tests for certain viral infections, but most tests
look for signs of a bacterial infection.
The problem with viruses is that they are extremely small. We can’t see
them with a regular microscope. And often, the virus is already out of the
body so it can’t be caught. The few tests we have available for specific viral
infections usually look for an immune response to a particular virus
(antibody levels). There are a few rapid lab tests for influenza virus (“the
flu”), Epstein-Barr virus (“mono”), viral respiratory infections like RSV,
and viral diarrheal infections like rotavirus. And occasionally, some viruses
like herpes, can be caught growing in a culture specimen.
But most of the time, your doctor can’t just do a blood test to see if your
baby has a virus. If a complete blood count is done on a child with a viral
infection, the results are usually normal. The white blood cell count does
not rise in response to a virus. In fact, some viruses cause a decrease in the
number of cells that fight infection (termed viral bone marrow
suppression). Influenza is classic for causing a low white blood cell count.
White blood cells can be further differentiated by their shape under a
microscope. The types of white blood cells that mount an immune attack to
viruses are predominantly lymphocytes. Seeing a high number of
lymphocytes is one of the only useful bits of information in a blood count to
diagnose a viral infection.
BOTTOM LINE
Lab work and x-rays are rarely necessary to diagnose a run-of-the-mill virus
in your baby. If a child does not improve as expected, though, doctors need
you to call or follow up to explore things further.

Q. Are there any anti-viral medications?

Yes. There are a few available. But all of these medicines must be given
within the first 24 to 48 hours of symptoms because they act by inhibiting
the replication of the virus. It is useless to take an anti-viral medicine more
than three days into a viral illness.
For most viruses, there is no anti-viral medication available to clear the
infection. The ones that ARE available include:
1.Tamiflu (Oseltamivir) for Influenza A and B
2.Symmetrel (Amantadine) for Influenza A
3.Flumadine (Rimantadine) for Influenza A
3.Zovirax (Acyclovir) for chickenpox, shingles, or Herpes virus
4.AZT, Abacavir for HIV infections
5.Formvirisen for CMV eye infections

Q. How long do most viral infections last?

You can expect a typical virus to cause symptoms for seven to 14 days.
Usually a fever is present for the first two to four days of illness. While
there is a fever, your child is contagious. The virus is actively
growing/replicating. The fever stops when the virus stops replicating. But
our bodies will feel the impact of the infection for about a week.

Q. Is there any way to prevent a viral infection?

 Yes—with vaccination.
We are fortunate to have vaccinations to prevent some of the most
serious viral infections known to civilization: smallpox, polio, Hepatitis A,
Hepatitis B, measles, mumps, rubella, Rotavirus, chickenpox and Human
Papilloma Virus (HPV).

The Common Cold

Q. What is the common cold?

Answer: a viral infection usually caused by our friend, rhinovirus
(“rhino” is the Latin word for nose.)
Here is what you need to know:
1.The virus enters the host body through the nose and goes to work.
2.Fever and body aches occur when the virus starts reproducing.
3.Snot (mucous production), cough, with or without sore throat follows.
4.Symptoms last for up to 14 days, with day three or four being the
worst.
5.The snot can change from clear to green and still be just the same old
virus (not a sinus infection, which we’ll discuss later in this
chapter).

So, how long with cold and flu symptoms last?

Source: Dr. S. Michael Marcy & Kaiser Permanente from data presented in
JAMA

DR B’S OPINION: COLD MEDS

AND INFANTS

The Food and Drug Administration prohibits the sale of over-

the-counter cough and cold meds for kids under age four. I never
recommended them anyway. Infants under six months of age can
have a paradoxical reaction to antihistamines (instead of sedating a
baby, these medicines can leave your child wired). The
decongestants used in most of these medicines can act similarly to
caffeine. I personally would rather deal with a snotty sleeping baby
than a snotty awake baby.
Q. How is the common cold diagnosed and treated?
A cold virus or upper respiratory infection is diagnosed based on the
symptoms that the patient has. There is currently no test for it.
For babies, the best treatment is to use saline nose drops as much as
needed. Saline is salt water. (See home remedies in Medications, Appendix
A.) A mist or two in each nostril before feedings and bed helps loosen the
mucous and often makes babies sneeze. The beauty of saline is that it is safe
and nearly impossible to overdose on it!
Remember, antibiotics will not cure a cold.

Top Remedies to Treat a Cold

Saline nose drops.
Running a humidifier in baby’s room to help loosen the mucous.
Having baby sleep in car seat or with head of mattress elevated (place a
pillow or wedge under the mattress).

Reality Check
There are over 100 rhinoviruses. Once your child has a rhinovirus infection,
he is immune to that one. But there are 99 more that he isn’t immune to. Get
the picture?

Q. I can feel a rattling in my baby’s chest. Are you

sure the infection isn’t in his lungs?
Yes. It’s air moving through snot that you hear and feel. See transmitted
upper airway noise info in the section on breathing problems in Chapter 15,
First Aid.
Q. How long is a baby contagious with a cold virus?
In general, the first three days of illness.
With viruses in general, people are contagious while they have a fever.
The infection is spread via hand-to-hand contact with snot (mucous). It is
also spread from cough and sneeze droplets.

Q. When my baby has a cold, he has a runny nose for

almost two weeks. I’m afraid to take him back to
playgroup because the other moms seem upset. When
is he no longer contagious?
With the common cold virus or upper respiratory infection, the virus is
spread in the first three or four days of illness (usually when kids have a
fever). After that, it’s just snot. You can return to playgroup.

DR B’S OPINION: VAPO-RUBS

Some parents love to use this stuff. But here’s what you need to
know: it is not approved for use in children under two years of age.
Camphor, one of the active ingredients, gets absorbed through the
skin and can potentially cause seizures in babies. See Appendix B
Alternative Medicine for information on menthols/peppermint oil.

HUMIDIFIERS & VAPORIZERS: COLD VS WARM MIST

DEBATE

A humidifier and vaporizer both do the same thing—they add

humidity to dry air. Vaporizers have a place to add medicine to the
 mist but this feature is rarely used today. Kids who have asthma and
need breathing treatments have a high-tech machine called a
nebulizer.
Warm mist humidifiers are unnecessary and they make the
nursery feel like the Bahamas. There is also a risk of an older baby
burning his hand on a warm mist machine.
BOTTOM LINE: Buy a cheap, cool-mist humidifier. It loosens up
mucous so babies can sleep when they have a cold. Just be sure to
clean it every few days.
For a discussion of which humidifier models are best, ratings and
buying advice, see the web site for our other book Baby Bargains
(BabyBargains.com).

Q. My baby has swollen glands. What is that?

Lymph nodes. Our bodies have chains of lymph nodes that look like a
string of pearls. These chains are located throughout the body, but mostly in
the neck, armpits, and groin. Each area works to protect a particular body
area. For instance, the neck nodes are dedicated to the head, ears, nose, and
throat. These tiny glands are jam packed with the cells that fight off
infection. When there is an active infection in the body, these glands rise to
the occasion, swelling to several times their normal size. They can be tender
and can remain enlarged for up to six weeks after the infection is gone.
Swollen lymph nodes point us in the direction of where an infection is
located.

Q. What is the significance of green snot? I always

thought that it meant a bacterial infection.
Bacterial sinus infections cause green nasal secretions, but green snot
alone does not diagnose sinusitis. The nasal secretions are a result of our
immune system (white blood cells) fighting with either a virus or bacteria.
The discoloration tells us that the battle has been going on for a while.
The difference between a cold and a sinus infection

The common cold causes a short lived fever with several days of snot. A
sinus infection causes prolonged fever and prolonged snot.
The change from clear secretions to yellow/green secretions WHEN
ACCOMPANIED by fever, headache, fussiness, or prolonged symptoms
(over two weeks of illness) is suspicious for a bacterial sinus infection.

Bacteria

Q. What are bacteria?

These are much larger germs than viruses. These bugs can live on their
own without a host. Most bacteria do not cause illness, and live in harmony
with us. Some bacteria cause infection only in susceptible humans (those
that are “immune compromised”), or when they end up in places they don’t
belong (e.g. intestinal bacteria in the urinary tract causes a bladder
infection). And there are only a few bacteria that live to hurt us.

Q. I have heard about “good bacteria.” What are

they?
 The bacteria that live in and on our bodies are called normal flora.
These bacteria live on our skin, and in our mouths, nostrils, vagina, and
intestines. Babies are born relatively sterile (bacteria free). But it only takes
a day or two in the real world to become colonized with bacteria. Here are
the typical bacteria that are in you and your baby’s body:
Skin bacteria: Staph and Strep
Nostril bacteria: Staph and Strep
Gut bacteria: Lactobacillus and E coli, among many others
Vagina and gut bacteria: Group B Strep
Mouth bacteria: too numerous to mention here

Q. How do bacteria cause infection?

They enter through any body opening under favorable conditions. These
conditions include open wounds, mucous in the nose from viral infection,
fluid in Eustachian tubes with a common cold virus, poop and bacteria
pushed into the urethra/bladder opening. Other bacteria get in via
respiratory secretions, saliva, or sexual activity.
Then they grow and fester in our bodies. Unlike viruses, they like to
stick around.
Bacteria either invade our body tissues or produce a toxin (poison) that
injures our bodies. Each bug has a particular body part they prefer to hang
out in (throat, intestine, bladder, eye, etc)

Q. I have heard the term “secondary bacterial

infection.” What does it mean?
Bacteria often capitalize on a person who already has an active viral
infection.
The viral infection is the primary infection. The bacteria that come in
later are termed secondary infections. This is an important concept to
understand why a) you are at risk for bacterial infections when you have a
cold or flu, b) you don’t often get bacterial infections when you are well,
and c) why many bacterial infections are not contagious to others.
BOTTOM LINE: Think of bacteria as tugboats. They are slower moving than
viruses. Their lack of speed and tendency to stick around make them
susceptible to antibiotics.

Old Wives Tales

Going out in the rain causes pneumonia. False!
The truth: Having a viral infection (cold or flu virus) predisposes a person
to getting a secondary bacterial infection (pneumonia is a bacterial infection
in the lungs). The weather has nothing to do with it.

The wind or ceiling fans cause ear infections. False!

The truth: If your baby has a cold (or any viral infection), she is more
susceptible to getting an ear infection (or another bacterial infection). Like
the old wives tale about the rain and pneumonia, the wind has nothing to do
with ear infections.

Q. Are bacterial infections contagious?

It depends on the bug and the host.
Not all bacteria jump from person to person. Some just set up shop in
one body and grow until they are killed off.
And some bacteria will only cause infection in people who are
susceptible (either because they already have a viral infection or their
immune systems are compromised—such as premature infants, the elderly,
people on chemotherapy, AIDS patients).
As a general rule, assume your child is contagious if he has a fever. The
fever tells you that the body’s immune system is actively fighting the bug.
But your doctor can tell you if the particular bacterial infection is
contagious to others (or read the final section of this chapter) For example,
Strep throat (Group A Strep) infection IS contagious. An ear infection
caused by Strep pneumoniae is NOT contagious.
 HOW A DOC CAN TELL A BACTERIAL INFECTION
FROM A VIRUS

1.Your child is sicker. Bacterial infections, in general, make people

sicker than viruses.
2.Your child’s fever lasts longer than four days. Viral illnesses
usually cause fever for three to four days maximum (except
influenza which last up to a week).
3.Your child’s fever is really high (over 105). Viruses cause high
fevers, too. But there is a greater chance it’s a bacterial
infection when you could fry an egg on your child’s back.
4.Your child has a localized area of infection. Bacteria pick a
body part to live in. The most common bacterial infections in
childhood include: ear, sinus, throat, eye, lung, bladder/kidney,
lymph node, intestine, blood, or the brain.
5.YOUR CHILD HAS ABNORMAL LAB WORK. If there is not an
obvious source of infection on examination, and he looks really
sick with or without prolonged or high fever, some tests will be
done. A complete blood count shows an elevation of the cells
that fight infection (total white blood cell count over 15,000,
and a high percentage of NEUTROPHILS—see lab section in
Appendix C for details). Or, white blood cells in urine, spinal
fluid, etc. indicate that infection is there (white blood cells are
never found in normal urine or spinal fluid).

DR B’S OPINION
 “If you can get a child over three months old to smile at you, he
isn’t that sick. There is a scientific study that has proven this. In
practice, I can tell you it’s true.”

Q. Can you find out which bacterium is causing an

infection?
Yes.
Because bacteria don’t leave the body, doctors can potentially catch the
bacteria and identify them under a microscope or grow them on a culture
plate. Blood, urine, stool, spinal fluid, eye discharge, ear discharge, throat
pus, sputum (mucous coughed up), and vaginal discharge to name a few,
can be examined. Bacteria living in our bodies can grow on a culture plate
in about 48 hours.
The only problem is that we can’t always get a specimen from the
location of the infection (like an ear infection). Fortunately, a limited
number of bacteria cause certain infections. Once the source of the infection
is identified (eye, ear, sinus, lung, etc.), doctors have a pretty good idea
which bacterium is wreaking havoc.

Q. How do doctors know which antibiotic will kill a

bacterial infection?
Doctors select an antibiotic that kills the bacteria most likely causing the
infection. Antibiotics are not all the same. They are each potent against
specific families of bacteria. (See Appendix A, Medications.)
If bacteria grow on a culture plate (from an available specimen), doctors
get exact information for antibiotic selection. The growing bacteria are
placed on several “sensitivity” plates. These plates contain a growth
medium and an antibiotic. If the bacteria can’t grow on a particular
antibiotic plate, the right medication to keep the infection from growing in
the body is found.
Antibiotic Resistance
Q. I’ve heard a lot about drug resistant
bacteria/antibiotic resistance. What is it?
Darwin’s Survival of the Fittest.
Bacteria adapt to survive. There is a constant challenge to create more
anti-microbials (antibiotics) to kill off the smart drug-resistant bugs.
Many people don’t understand the concept of antibiotic resistance. They
think that a person who is taking antibiotics will develop a drug resistance.
Drug resistance refers to the bugs. When so many antibiotics are being used
in the community, the bugs know our ammunition. Those that survive are
drug resistant. The idea is that we can’t overuse our weapons—otherwise
we will be left with no defense. We need to use our antibiotic weapons
judiciously.

Reality Check
Penicillin resistant strains of bacteria, particularly one called Strep
pneumoniae (see Prevnar in the last chapter on vaccines) began emerging in
1991. Now 20% of Strep pneumoniae strains are resistant to Penicillin and
10% are resistant to at least three types of antibiotics. Strep pneumoniae
cause five to seven million ear infections annually.

Q. What can be done to stop drug-resistant bacteria?

Give the Prevnar vaccine to children at high risk of getting Strep
pneumoniae infection (children under age five).
Use a higher dose of the first-line antibiotic (amoxicillin).
Save the big gun, broader spectrum antibiotics for persistent
infections.
Only use antibiotics when it is really necessary.
Q. When should antibiotics NOT be prescribed?
1.The common cold or “upper respiratory infection.”
2.A sore throat caused by a virus (as opposed to Strep throat which is
caused by a bacteria).
3.Green snot (see the common cold section earlier in this chapter).
4.Because someone else in the house is on antibiotics.

The abuse of antibiotics

Here are a couple of startling stats: In 1980, U.S. healthcare providers
wrote four million prescriptions for amoxicillin (a popular antibiotic) for
children. By 2010, that number jumped to 18 million.
In fact, amoxicillin was the most prescribed medication to kids under age
two. And except for albuterol (a medication for wheezing), three other
antibiotics—azithromycin, amoxicillin-clavulanate, and cefdinir—rounded
out the top five list of medications prescribed to young children. (Chai)
It is clear that doctors over-prescribe antibiotics. Want to know the
number one reason doctors site for over-prescribing? Parent expectation
that an antibiotic will be prescribed!
Truth be told, it’s not just the parents’ fault. One study showed that
doctors often misperceive what a parent expects at an office visit (and try to
satisfy them). (Mangione-Smith)

DR B’S OPINION: CAN WE TALK?

Parents and doctors need to communicate better. If a bacterial

infection is diagnosed, an antibiotic is in order. Viruses are not
cured by antibiotics.
Doctors need to do a better job of explaining viruses. Parents
need to do a better job of accepting the fact that their child will get
 better on his own. And this may mean missing work to take care of
a sick child. A miracle “pill” isn’t always available to restore your
child to perfect health in mere hours!

Old Wives Tale

I am on an antibiotic for an upper respiratory infection. My child is
sick, too. He needs antibiotics.
The truth: Not everyone with a cold develops a sinus infection. That is
probably why you are taking an antibiotic. Your child should be checked for
a secondary bacterial infection if he has a fever, crankiness, or prolonged
symptoms (beyond ten to 14 days). It was common 15 to 20 years ago that
if one person in a house had a Strep infection, then doctors prescribed
antibiotics for the ENTIRE family. Now, we realize that is NOT the answer.
Giving antibiotics to healthy folks only strengthens the bugs’ resistance to
drugs.

When can Johnny go back to childcare/playgroup?

KEY—Rx: prescription medicine; OTC: over-the-counter medicine.
(Donowitz)

Putting it all together . . .

Now you know the usual suspects. Here is how doctors put it all
together. When a child has a fever, your doctor looks for infection. (There
are other causes for fever, but infection tops the list). The symptoms IN
ADDITION TO the fever are what lead to the diagnosis. (Vomiting,
diarrhea, cough, runny nose, decreased appetite, rash . . .) The constellation
of symptoms and findings on physical examination are often enough
information to make the call. Lab work and x-rays are sometimes needed to
help figure out the source of infection.
Viral infections for the most part do not require any medication and are
fought off by our body’s immune systems. Bacteria, fungi, mites, and
parasites respond to medication, which helps eliminate the infection. The
medication selection is often based on the usual suspects for a particular
illness. If an infection doesn’t clear up or the patient is pretty sick, cultures
can help identify the particular bug and the right medication.
Bacterial infections are frequently secondary infections that capitalize on
a weakened immune system that is fighting a virus (ear infections, sinus
infections/adenoiditis, pneumonia). Doctors worry about secondary
infections when a child with a viral infection suddenly gets worse (i.e. new
fever, new green snot, new irritability, new respiratory distress).

NEW PARENT 411: ANTIBIOTICS

Just because YOU are on an antibiotic, does not mean your child
needs to be on one. Whole families can get infected with a virus. But not
everyone gets a secondary bacterial infection from the virus. Remember
that secondary infections are not contagious. So, even if you now have a
sinus infection, your baby most likely will still have just a cold.

Viral Infections

And now, for your listening pleasure, the viral hit parade! In just a bit,
we’ll have a special section on ear infections. But first, here’s an overview
of the viral infections that most impact babies:

1. Respiratory Viruses

The Flu (Influenza)

Disease: Respiratory illness caused by either Influenza A or B. A different
strain causes epidemics every year. Influenza causes more severe
respiratory illness than the common cold. There is a higher risk of
 secondary bacterial infections in infants, people with chronic lung
disease, or other chronic diseases.
Symptoms: High fever, body aches, and chills. Then runny nose, cough and
sore throat.
Diagnosis: Based on symptoms. White blood cell count is low (less than
4,000) with mostly lymphocytes. Rapid flu assay is available, but it is
only about 50% accurate in identifying the flu.
Treatment: An anti-viral medication can be given to babies over two weeks
old if diagnosis is made within 48 hours of becoming ill.
Contagious: From 24 hours before symptoms start, and while person has
symptoms. Spread via respiratory droplets, fomites.
Incubation period: 1-3 days after exposure
Season: Winter
Prevention: Annual flu vaccine offered each fall season. Recommended for
everyone, starting at six months of age. (Pickering)

Bronchiolitis (RSV)
Disease: RSV stands for Respiratory Syncytial Virus. (Or, as one of my
patient’s dads says, “Really Sucky Virus”.) It can infect anyone, but
causes more severe illness in infants, especially babies born
prematurely. As opposed to the common cold or upper respiratory
infection, RSV attacks the tiny branches of the lower lung airways
(bronchioles). Swollen bronchioles make the air flow turbulent through
them, creating a wheeze with inspiration, similar to the mechanism of
asthma. RSV infection can be serious enough to require hospitalization.
Symptoms: Fever, runny nose, breathing faster than normal and wheeze, but
no “distress.” Infants and premature babies may have more “respiratory
distress” (see glossary). About 30% of children who wheeze with an
RSV infection will have asthma. The cause is debatable. Does the RSV
infection causes long term damage to the airways, predisposing to
asthma; or are the kids who wheeze with RSV really asthmatics with
sensitive airways? Regardless, damage to the bronchioles from RSV
takes a long time to heal. Symptoms can go on for weeks.
Diagnosis: Based on symptoms. A rapid assay test is available, but it is not
always performed. Testing is only useful if it will affect treatment
 decisions.
Treatment: Some kids respond to asthma medication (Albuterol) via a
nebulizer machine to aerosolize the medication. Some kids need oxygen,
which requires hospitalization.
Contagious: 3 to 8 days, but sometimes up to 3 weeks. Spread by fomites
(biofilm), respiratory droplets.
Incubation period: 2 to 8 days.
Season: Winter, early spring
Prevention: For children under 12 months of age who were born
prematurely (less than 29 weeks gestation), those born less than 32
weeks of age who have chronic lung disease, and those with significant
heart disease or severe immune system defects, RSV-Antibody
(Synagis) provides immunity for one month. The medication is a shot
given monthly through RSV season. (It’s about $1000 a shot, and the
series is usually six injections). (See Appendix A “Medications” for
details on Synagis.) (Pickering)

Croup
Disease: A viral infection that attacks the voice box area. The smaller the
child, the smaller the airway tube, the more problematic when the
airway is swollen.
Symptoms: Fever. Cough is a classic “bark”, like a seal. Always worse at
night when lying down. This is a three night illness. With babies,
significant swelling can occur. A squeal is heard. Persistent squealing
(stridor) more than five to ten minutes is a medical emergency. Adults
with croup have laryngitis instead of a bark because adults’ airway tubes
are larger.
Diagnosis: The bark is usually enough to prove it. A neck x-ray is
occasionally done to identify the swollen area.
Treatment: Turn on the shower in a closed bathroom. The steam works well.
Humidifier in room. For more severe cases, steroids (taken by mouth or
a shot) help reduce the airway swelling. A breathing treatment (racemic
epinephrine) also relaxes the airway for kids with stridor.
Contagious: 4 to 7 days. Spread via direct contact, fomites, respiratory
droplets.
Incubation period: 2 to 6 days.
Season: Fall. (Pickering)

2. Mouth And Tonsil Viruses

Hand-Foot-and-Mouth (Coxsackievirus)
Disease: A virus that causes ulcers in the back of the mouth, and sometimes
a rash on the palms, soles, and around the anus.
Symptoms: Fever, lack of interest in eating. Rash can be flat red dots or
raised like pimples. Ulcers in the back of mouth.
Diagnosis: The ulcers in the back of the mouth are classic. No diagnostic
testing is done. See Rash-o-Rama on Baby411.com for a picture.
Treatment: Avoid citrus and salt. Acetaminophen (Tylenol) or Ibuprofen
(Advil) for discomfort. Make up a concoction of
liquid Benadryl and Maalox (1 tsp of each), then give about 0.8 ml of
the mixture before feedings. This coats the ulcers.
Contagious: Up to 7 days. Spread through saliva, poop, and fomites.
Incubation period: 3 to 6 days.
Season: Summer, fall. (Pickering)

Oral Herpes Stomatitis

Disease: Viral infection caused by HSV Type 1. (Type 2 is genital herpes—
a completely different infection). Once a person is infected, the HSV-1
lies dormant for life and can re-activate as a cold sore. Cold sores appear
on the outer lip and last for a week. Cold sores spread HSV-1 to others.
The worst case scenario is a newborn who contracts HSV infection
(75% of these are from genital herpes type 2, but 25% are HSV-1).
These babies are at high risk of getting an infection of the brain
(ENCEPHALITIS) from HSV.
Symptoms: Fever over 102 for a week. VERY poor fluid and food intake (at
risk of dehydration). Numerous ulcers in mouth, gums, tongue called
GINGIVOSTOMATITIS. The pain is so severe, some children avoid
swallowing their saliva. These kids feel awful.
Diagnosis: Can be made just by looking at the mouth lesions (very
impressive looking). Can also be grown (takes 3 days) in a culture by
taking a specimen from the ulcer base. It’s not always cultured because
by the time the culture grows out, it’s too late to treat the infection.
Treatment: FLUIDS. Acyclovir, an antiviral, is used if the diagnosis is made
within 48 hours. Gingivostomatitis is usually diagnosed too late (after
two days of illness) to use an antiviral medication. Cold sores can be
treated with anti-virals.
Contagious: VERY! For 7 days. Spread via saliva and direct contact with
the lesions.
Incubation period: 2 to 14 days.
Season: Year round.
Prevention: Avoid contact with child if someone has an active cold sore.
(Pickering)

Reality Check
If Great Aunt Suzy has a cold sore, kindly ask her not to hold your
newborn. If you have a cold sore, don’t touch your lips and don’t kiss your
family members.

3. Viral Sore Throat

Disease: A viral infection that causes the tonsils to be swollen. Caused by
many different viruses. Adenovirus often causes pink eye (viral
conjunctivitis), runny nose, and ear infections in addition to a sore
throat.
Symptoms: Fever, decreased appetite, redness or pus (white patches) on
tonsils.
Diagnosis: Based on age group and associated symptoms. No lab test. Strep
test rarely done because it is rare for babies under age two. It is
extremely rare for babies under age two to get Strep (bacterial) throat.
Treatment: To treat the symptoms only. Acetaminophen (Tylenol) or
Ibuprofen (Advil), lots to drink.
Contagious: While child has a fever. Spread by direct contact, respiratory
droplets, fomites.
Incubation period: 2 to 14 days.
Season: Winter, spring, summer. (Pickering)

4. Gastrointestinal Viruses
There are many types of viruses that are known collectively as the
“stomach virus.” They are all treated the same way—lots of fluids to
prevent dehydration. Stomach viruses come every winter. You’ve been
warned.

Viral gastroenteritis (Rotavirus)

Disease: Rotavirus enters the stomach and intestines. Prior to 2006, almost
all kids got this infection by three years old. (And people can get it more
than once). The kids at greatest risk are infants. They lose so much
water in the diarrhea that it’s hard to keep the fluid intake greater than
the losses. That’s why some babies get admitted to the hospital for IV
fluids.
Symptoms: Fever, vomiting, and extremely watery diarrhea (often more
than 20 times a day). This lasts for about a week.
Diagnosis: Usually obvious by the volume of diarrhea! Assay test is
available.
Treatment: Lots of fluids. See Diarrhea section in Chapter 15, First Aid.
Contagious: VERY. FOR THE WHOLE TIME YOUR CHILD HAS
DIARRHEA. Spread via contact with infected poop, fomites. Spreads
like wildfire through childcare centers and households.
Incubation period: 1 to 3 days.
Season: Winter (starts southwest and moves northeast every year—the
opposite of birds)
Prevention: Rotavirus vaccine, given at two months of age, with one or two
doses to complete the series.
Viral gastroenteritis (Norovirus)
Disease: Another common stomach virus that prefers group settings like
cruise ships, nursing homes, and child care centers. The cause of up to
30% of all gastroenteritis in the U.S.
Symptoms: Nausea, vomiting, abdominal cramps, non-bloody diarrhea,
occasionally fever.
Diagnosis: Health department does testing when there are a large number of
people affected in an outbreak.
Treatment: Lots of fluids. See Diarrhea section in Chapter 15, First Aid.
Contagious: VERY. FOR THE WHOLE TIME YOUR CHILD HAS
DIARRHEA. May return to childcare when symptom free for 48 hours.
Spread via contact with infected food, water, poop, fomites
(contaminated surfaces), and person-to-person contact.
Incubation period: 12 to 48 hours.
Prevention: Good hand washing with soap and water for at least 20
seconds. Alcohol based hand sanitizers are not an acceptable substitute
for this resilient little virus. (MMWR)

5. Viral Exanthems (viruses that cause rashes)

See rashes section in Chapter 15, First Aid for more info on treatment.

Roseola (Herpes virus 6)

Disease: A virus that the entire world population over one year of age has
had. Because it is a Herpes virus (this is NOT genital herpes HSV-2), it
stays in our bodies forever. We all shed this virus in saliva and
respiratory droplets daily. Mom’s antibodies (immunity) are passed to
baby and provide protection against illness for 9 to 12 months. When
immunity wanes, babies get this infection. The only time you see a
roseola “epidemic” is if you hang out with a bunch of one year olds.
Symptoms: Fever over 102 for about four days with no other signs of
infection. Kids are usually in good spirits. When the fever breaks, the
rash comes out. The rash can be subtle or dramatic. It is mostly flat,
 with some raised areas. Red, blotchy. On chest, back, arms. Not itchy,
goes away within hours to a few days.
Diagnosis: Obvious after the rash comes out. The fever often prompts lab
work (CBC, urinalysis) to prove that there is not a bacteria causing the
fever.
Treatment: None. Acetaminophen (Tylenol) or Ibuprofen (Advil) for the
fever.
Contagious: We are all contagious because we shed the virus for a lifetime
once we are infected.
Incubation period: Ten days.
Season: When is your baby’s first birthday?

Chickenpox (Varicella)
Disease: Caused by Varicella-Zoster virus, another type of Herpes virus.
Like all Herpes viruses, it lies dormant forever in previously infected
people. Because chickenpox can cause serious infection and death,
vaccination became the standard of care in 1995. The vaccine is given to
all children at one year of age and anyone (including adults) who has
never had chickenpox. The vaccine is not 100% effective in preventing
infection. But people who get infection despite vaccination have a very
mild form of the disease. Babies under three months of age are usually
protected via Mom’s immunity (as long as she had chickenpox). Both
immunized and infected kids can get Zoster (shingles) infection later in
life (reactivation of Varicella). Shingles infects only one group of nerves
(called a dermatome). A group of lesions come up in one patch. These
blisters are more painful than itchy. They contain the virus and are
contagious.
Symptoms: A full blown case causes fever, body aches, and a rash of tiny
fluid filled blisters (called VESICLES) that appear in crops. New crops
come up over a period of 3 to 4 days. The average number of pox is 350.
Very itchy. Secondary Strep skin infections can occur. Watch for red
areas surrounding pox, or a new fever after the initial fever breaks.
Diagnosis: Classic rash. Virus (found in vesicle fluid) will grow in culture
in 2 to 3 days.
Treatment: Acyclovir, an anti-viral, can be given within 48 hours of illness.
It will shorten the course of illness by a couple of days and reduces the
total number of lesions (not dramatically though)
Contagious: VERY. FOR ONE WEEK. Child is contagious for 24 hours
before the rash comes out and until all lesions (which contain the virus)
are crusted over. Spread via respiratory droplets and direct contact.
Incubation period: 10 to 21 days. If you know when your child has been
exposed, look for infection 10 days later and for the next 11 days. If you
make it out of that window, you are safe.
Season: Winter, early spring
Prevention: Vaccination.

Slapped Cheek (Parvovirus)

Disease: Also known as FIFTH DISEASE or ERYTHEMA INFECTIOSUM.
Occurs more in school age children. Questions arise more with exposure
in pregnancy than anything else. The biggest problem with this infection
is that it can cause miscarriage. If a pregnant woman (usually in the first
20 weeks) is not immune to Parvovirus and gets the infection, her fetus
is at risk. Unfortunately, by the time we know a child has had Parvovirus
(i.e. the rash appears), he has already exposed everyone. Note: If you are
pregnant and have been exposed to any child with parvovirus, notify
your obstetrician.
Symptoms: Mild or even undetectable when a child is contagious. Low
fever, body aches, or headache. Ten days after the infection is gone, a
classic rash erupts. The red cheeks look as if someone slapped them plus
a lacy, mostly flat, red rash on chest, arms, and legs. The rash can last
several weeks. When older kids and adults get infected, they may get
joint pains that last for weeks.
Diagnosis: Easy once the rash has erupted. Antibody levels can be checked
for evidence of recent infection.
Treatment: None.
Contagious: Hard to know when contagious because often there are no
symptoms. Spread via respiratory droplets, blood products.
Incubation period: 4 to 21 days.
Season: Winter, spring.
Reality Check
Beware of mosquitoes. There were over 2100 cases of West Nile Virus
(WNV) reported in 2014, and 60% of these patients developed viral
encephalitis. Before you pack your bags to Antarctica (the only place in the
world that is mosquito-free), know that very few mosquitoes carry WNV
and 70-80% of people with WNV infection experience no symptoms at all.
Just remember the 3 D’s of prevention:
Drain any standing water near your home.
Dawn and dusk are peak mosquito feeding hours. Stay indoors.
Defend and protect your family with DEET or Picaridin-based insect
repellants. (CDC)

Bacterial Infections

1. Sinus Infections
Disease: Caused by the same bacteria that cause ear infections. Sinus
infections are a secondary bacterial infection after a person has a
common cold or flu. The virus sets up fluid in the sinus cavities behind
the cheeks and above the eyes. More common in older children.
Symptoms: Prolonged runny nose over 14 days. New onset of discolored
nasal secretions (snot) after 10 to 14 days of illness. New fever.
Nighttime cough.
Diagnosis: Mostly by examination. Occasionally sinus x-ray is helpful.
Treatment: Same antibiotic choices as for ear infections, but often needs
longer course.
Contagious: No.

2. Lung Infections (pneumonia)

Disease: Lung tissue inflammation that can be caused by bacteria or a virus.
Bacterial pneumonia is a secondary infection after a viral illness (cold or
flu).
Symptoms: High fever, wet cough, respiratory distress, vomiting. Child is
getting worse instead of better with an illness, or new fever after initial
fever resolved from an upper respiratory infection.
Diagnosis: Abnormal lung exam, chest x-ray, elevated white blood cell
count
Treatment: Antibiotics. Rarely hospital admission—for labored breathing,
need for oxygen.
Contagious: Depends on the bug.

3. Skin Infection (Impetigo and cellulitis)

Disease: Skin infection caused by bacteria that normally live on the skin
that get under the skin. Bacteria capitalize on open wounds (bug bites,
raw nostrils, burns).
Symptoms: Wound gets red with a golden, crusty, weeping discharge over it
with impetigo. The skin is red, warm, and tender with cellulitis.
Diagnosis: Based on symptoms. Bugs can also grow in a culture if drainage
from wound is obtained.
Treatment: Impetigo can be treated with prescription antibiotic cream.
Extensive impetigo and cellulitis are treated with antibiotics given by
mouth.
Contagious: Impetigo—yes. Spread by direct contact with wound. Not
contagious after 24 hours of antibiotic therapy. Cellulitis is not
contagious.
Incubation period: 7 to 10 days.
Season: Year round.
Special alert: Drug-resistant Staph infection. “MRSA” (Methicillin
Resistant Staph Aureus) is a bacterial skin infection that is a real
problem to treat.
Disease: Skin infection caused by Staph (bacteria) that is resistant to several
antibiotics and can spread through the whole household.
Symptoms: Infections look like spider bites, boils, or red, tender areas.
Diagnosis: Suspicious looking lesions can be lanced to drain as well as
obtain culture to check for the germ and its susceptibility to antibiotics.
Treatment: Topical or oral antibiotics, IV antibiotics for serious infections.
People who are carriers (not infected) may harbor MRSA in their noses.
They can be treated with topical antibiotics to the nose.
Contagious: Yes. Spread via carriers of MRSA, or those infected with it
spread to another person’s skin.
Prevention: Wash hands thoroughly with soap and water or alcohol based
hand sanitizer. Keep cuts/scrapes clean and covered with a bandage until
healed. Avoid contact with other people’s wounds or bandages. Do not
share personal items like towels, washcloths. (CDC)
Season: Year round.

4. Eye Infections “Pink Eye” (Bacterial conjunctivitis)

Disease: Infection of the eye lining. Can be caused by either viruses or
bacteria. Bacterial infections usually cause yellow or green eye
discharge. Viral infections usually cause watery eye discharge. One
bacteria, Haemophilus influenza, causes pink eye, sinus infections, and
ear infections at the same time. About 30% of babies under age two with
bacterial pink eye will also have an ear infection to go with it.
Symptoms: Red, itchy eyes with discolored thick fluid draining or matting
the eyes shut.
Diagnosis: Based on exam. Occasionally, a culture is done of the fluid.
Treatment: Antibiotic eye drops if infection is bacterial. No treatment for
viral pink eye.
Contagious: VERY. Spread by direct contact with eye discharge. Use
separate hand towels.
Incubation period: Varies. For viral pink eye, 2 to 14 days.
Season: Year round.

5. Food Poisoning (E. coli, Salmonella, Shigella, and

others)
Disease: Bacterial infection spread through contaminated food (and
infected people’s mouths and poop). Salmonella bacteria is the most
common cause of food poisoning (80% of the time). E. coli Type 0157:
H7, although less common, can be particularly serious. This bug
releases a toxin/poison that causes HEMOLYTIC UREMIC SYNDROME
(HUS). HUS causes severe anemia, low platelet count, and kidney
failure. It is a reversible condition, but can be fatal. These kids are really
sick with abdominal distention, pain, bloody diarrhea, and PETECHIAE.
E. coli 0157 comes from cow and deer poop. Ground meat can have
bacterial contamination throughout. Because of that, the meat needs to
be cooked thoroughly to kill any of these bugs. Whole muscle cuts are
only contaminated on the surface of the meat, which are always cooked
well. (The poop gets spread to the meat during hide removal or
evisceration). (Pickering)
Symptoms: Vomiting, diarrhea mixed with blood or mucous. Fever. Body
aches. Abdominal pain.
Diagnosis: Stool culture, blood and white blood cells in poop, some blood
test abnormalities.
Treatment: FLUIDS to avoid dehydration. Some bacterial infections need
antibiotics to clear. Some bacterial infections should NOT be treated
with antibiotics as it causes the person to remain a “carrier” of the
infection.
Contagious: Spread through contaminated food/water (poultry,
undercooked eggs, alfalfa sprouts, unpasteurized milk, undercooked
hamburgers), breast milk, fomites (e.g. raw meat on countertop), direct
contact with infected poop, saliva. Salmonella is also spread via pet
iguanas and turtles, who are carriers. People, especially infants, who get
Salmonella will often remain carriers for months after the infection.
Incubation Period: Varies on the bug, usually 6 to 72 hours.
Season: Year round.
Prevention: Never eat a hamburger that can moo back at you (it needs to be
well done). Avoid fresh fruit/vegetables and water when traveling to
developing countries. Drink only pasteurized milk and apple cider. Be
careful in the kitchen. Food preparation should be separated from baby
products (bottles, nipples, etc.). Avoid pet iguanas or turtles.
BOTTOM LINE
Yes, we know it is trendy in some circles to drink unpasteurized or raw
milk. People who prefer this product believe that the pasteurization process
takes out some of the “natural” ingredients . . . like bacteria that can cause
serious illness or death. Please purchase pasteurized milk and dairy
products!

Reality Check
There was an E. coli outbreak a few years ago blamed on petting zoo
exposure. Kids touched animals that had rolled around in cow manure. The
kids later touched their mouths with their contaminated hands. Note: wash
your child’s hands thoroughly after going to a petting zoo.

6. Bladder Infections or Urinary Tract Infections (E.

coli and others)
Disease: A bacterial infection caused by intestinal bacteria that get into the
bladder. Bacteria (e.g. E. coli) routinely come out in our poop. They
only cause infection when they creep into our bladders. Babies who are
in diapers are susceptible to bladder infections (especially girls) because
the poop collects where the opening to the bladder sits (urethra). Some
babies are prone to bladder infections because of an abnormality called
VESICOURETERAL REFLUX.
Symptoms: Fever, fussy mood, lack of other symptoms to explain fever
Diagnosis: Abnormal urinalysis, urine culture grows bacteria. Certain
children with bladder infections have an evaluation done of their urinary
tract system to rule out abnormality.
Treatment: Depends on the age and severity of infection. Babies under three
months of age are hospitalized because of a higher risk of kidney
infection and meningitis from infection.
Contagious: No.
Prevention: Clean poopie diapers as soon as possible. Wipe girls front to
back.

7. Meningitis
Disease: Inflammation of the tissues that line the brain. This can be caused
by viruses or bacteria. Bacterial meningitis is a life threatening illness.
There are different bacteria that cause meningitis in various age groups.
Meningitis can be caused by more than one type of bacteria. The top
two that you need to know about are discussed below:

Group B Strep
Disease: With a newborn, the bacteria you will hear the most about is
Group B Strep. This bacteria is normal flora in the intestines, bladder,
and the vagina of mothers. It uniquely causes infection in newborns as
they pass through the birth canal. Pregnant women are routinely
screened at 35 to 37 weeks to check for the presence of Group B Strep
(GBS). If Mom is a carrier, she is given IV antibiotics during labor to
suppress the growth of this bacteria. If Mom goes into labor before 37
weeks, has broken her water more than 18 hours, or has a fever greater
than 100.4, she also gets IV antibiotics because of the risk of Group B
Strep infection. (Women who have planned C-sections don’t have to
worry about this stuff.) Doctors watch all newborns closely, but those
with GBS-positive Moms get watched even more closely. A standard
protocol is to get a complete blood count and blood culture on a
newborn if Mom is GBS-positive and didn’t get pretreated with
antibiotics (i.e. a quick labor), baby is born less than 35 weeks gestation,
or if a baby starts misbehaving (temperature instability, respiratory
distress). There is also potential for a late onset GBS infection up to
three months after delivery.
Diagnosis: Bacteria can be seen in blood or spinal fluid under a microscope
(see Gram stain in lab section). Blood or spinal fluid cultures give the
definitive answer in 2 to 3 days.
Treatment: IV antibiotics. Penicillin works well.
Contagious: Spread via birth canal.
Incubation period: 0-3 months.
Season: N/A.
Prevention: Prophylactic antibiotics to Mom while in labor.

Strep pneumoniae
Disease: This type of Strep is also known as pneumococcus (very
confusing). This bacteria has been the top cause of bacterial meningitis
in infants. (It also causes ear infections, blood infections, sinus
infections and pneumonia). Strep pneumoniae has developed resistance
to many antibiotics. This is why the Prevnar vaccine (for Strep
pneumoniae) was a welcome arrival back in 2000. Since then, we have
seen an 87% disease reduction in bloodstream (bacteremia) infections
and meningitis.
Symptoms: High fevers (usually more than 103), without obvious symptoms,
irritability. If the infection is caught early while it is in the blood,
treatment prevents travel to the brain (meningitis).
Diagnosis: Blood infections (bacteremia) by an elevated white blood cell
count over 15,000 (often over 20,000) and a blood culture which may
grow the bug. Meningitis is diagnosed by an abnormal spinal fluid
(white blood cells in it) and a culture that grows bacteria.
Treatment: Blood infections get treated with an antibiotic shot initially, then
oral antibiotics. Meningitis requires IV antibiotics and hospitalization.
Contagious: Spread by respiratory droplets. Strep pneumoniae lives
everywhere. Some people are carriers. Children get infected when they
already have a viral upper respiratory infection.
Incubation period: 1 to 3 days.
Season: Winter mostly.
Prevention: Prevnar (PCV-13 strains) vaccine for infants and children under
five who are high risk. There is also a Pneumococcus vaccine (23
strains) for high risk children and elderly people. High risk: sickle cell
 disease, children with no spleen, kidney disease, immune compromised,
HIV. (Pickering)

Things That Make You Itch Just Thinking About Them

Note: We will also discuss some of these lovely germs in Chapter 15,
First Aid in the section on rashes. Go to our online Rash-o-Rama at
Baby411.com (click bonus material) to see pictures.

Fungal Infections
Disease: Fungi are plant relatives (yeast, mold) that don’t need light to live.
Fungi prefer places where there is little competition (i.e. low bacteria
levels). And, some fungi thrive on people whose defenses are down (i.e.
immune compromised). We get infected in the following ways:

1.Fungus infestation. These are the accidental tourists. These fungi thrive
on our skin, but don’t go any deeper than that (RINGWORM,
ATHLETE’S FOOT, JOCK ITCH). They are passed from person to
person, or via a pet. These fungi just happen to be at the right place at
the right time.

2.Opportunistic infection. These fungi grow when other factors alter our
body defenses to fungi. Infants are susceptible to fungal infections
(THRUSH, YEAST DIAPER RASH) because their bodies are relatively
free of bacteria flora. Kids are also at risk for yeast diaper rash after
having a course of antibiotics because the antibiotic not only kills the
bad bacteria, but also the good normal flora. Other fungal opportunities
include people on chronic steroids or with diabetes.

3.Invasive infection. This virtually never happens to normal, healthy

people. A fungus invades the blood or lungs after its spores are inhaled.

Diagnosis:
Ringworm. Classic circular area with raised red border, and central scale.
Fungus visible under microscope. Culture will grow in 2 to 3 weeks.
Ringworm of scalp. Patch of hair loss with overlying scale, or dots of hair
loss with stubs of broken hair, or big ugly pus pockets (kerion) in the
scalp. More in African American kids (fungus likes the hair texture).
Culture grows in 2 to 3 weeks.
Thrush. Classic white plaques on a red base in the cheeks, gums, tongue.
Looks like milk you can’t wipe off. Diagnosis based on examination.
Yeast diaper rash. Raw meat red area with satellite pimply dots. Won’t
improve with Desitin. Found often when thrush is present in the mouth.

Treatment:
Ringworm. Anti-fungal cream for 2 to 4 weeks.
Ringworm of scalp. Anti-fungal medicine by mouth for 1-2 months (cream
won’t kill it). The fungus imbeds in the hair follicle and is very hardy.
We see some drug resistant strains.
Thrush. Anti-fungal mouthwash for 1 to 2 weeks. Sterilize all nipples,
pacifiers.
Yeast diaper rash. Anti-fungal cream for 1 to 2 weeks.
Contagious: Until treated for 24 hours with anti-fungal medicine.
Ringworm. Direct contact with infected person or animal (itchy dogs).
Fomites too.
Ringworm of scalp. Direct contact with combs, hairbrushes, bed sheets.
Thrush. Direct contact with infant’s mouth (spreads to Mom’s nipples).
Yeast diaper rash. Opportunistic infection. Not particularly contagious.
(Pickering)

Scabies (Mite Infection)

Disease: An infestation caused by mites, tiny bugs that are somewhere
between parasites and ticks. The female scabies mite burrows into our
skin and lays her eggs. She lays 200 eggs in eight weeks. When the eggs
hatch, the babies burrow into our skin and start eating. This is the
ITCHIEST rash ever. Even after treatment, people are itchy for weeks
afterwards.
Symptoms: The mites usually burrow between our fingers, elbow creases,
armpits, belly button area, and genitals. In infected kids under two years
old, they prefer the neck, palms, and soles. What you will see is a streak
made out of tiny bumps—they start out gray, but are usually red by the
time a person seeks medical attention.
Diagnosis: If the rash is classic, diagnosis is made on examination alone.
For unclear cases, a scraping of a burrow can be done. It may reveal the
mite, mite egg, or mite poop under the microscope.
Treatment: A scabicidal body wash (Elimite-5% Permethrin) is available by
prescription. ALL FAMILY MEMBERS GET TREATED. Clothing and
bedding used for four days before treatment need to be washed and
dried on the hot cycle. Disinfecting the house is a waste of time.
Contagious: Until treated with Elimite. Spread by direct contact, especially
by holding hands. Co-sleeping is also an easy way for the whole family
to get infected with scabies. Mites cannot survive off of humans for
more than 24 hours.
Incubation period: 4 to 6 weeks.

More mite facts:

Chiggers are mites who like pores and hair follicles of people. These are
self-limited infestations, but are also very itchy.
Dust mites do not cause infection. They feed off of the dead skin that we
slough off on a daily basis. Some people are allergic to dust mite poop
and have chronic nasal congestion as a result of it (see environmental
allergies). (Pickering)

Lice
Disease: Infestation by a human louse. Head lice enjoy feeding on us via
human hair. They don’t have wings. They migrate from one head to the
next by crawling over. They can’t survive away from hair for more than
24 hours. The adult females lay eggs in the hair shafts (less than 1/4 inch
from the scalp). Adults live about one month. The eggs become thriving
nymphs in about one week. Head lice prefer the straighter hair of
Caucasian people. Outbreaks happen more in school age children, but
younger kids can acquire lice at childcare centers.
Symptoms: Itchy scalp, white flakes that are firmly adherent to the hair
shaft.
Diagnosis: Adult lice are brown and visible with the naked eye—but they
move quickly. The diagnosis is made most often by finding white nits
(empty eggshells). Nits stick firmly to the hair shaft close to the scalp.
Dandruff is rubbed off easily, nits are not.
Treatment: An over-the-counter shampoo called Nix (1% permethrin) kills
adult lice and the eggs. Two treatments, one week apart (to kill any baby
lice that survived the first round). Since the nits are empty eggshells,
removing them is more of a cosmetic issue than a therapeutic one. The
phrase “nit-picking” comes from the tedious task of removing the sticky
nits that are close to the scalp. Many little lice are resistant to current
over-the-counter treatment.
Contagious: Until treated. “No-nit” policies in childcare facilities are not
necessary.
Incubation period: 6 to 10 days.

Creative treatment for resistant head lice: If living adult lice are found
(not nits), then re-treatment is in order. The list of alternatives include
prescription 5% Permethrin (Elimite), Malathion (a pesticide), Bactrim
(an antibiotic), Ulesfia (benzyl alcohol), Sklice (ivermectin), and
products that smother the lice (Vaseline, olive oil, mayonnaise). A
combination of tea tree oil, eucalyptus oil, and olive oil (1 teaspoon of
each mixed together) applied to the scalp may also prove effective for
kids over age three.

For more information on lice: www.headlice.org

Pinworms
Disease: Pinworms live in our intestines and lay eggs on the outside of the
anus. Infection is spread when worm-ridden Johnny scratches his
bottom and plays in the sandbox. Suzie plays in the sandbox later and
picks up the eggs on her fingers. Her fingers go in her mouth, and voila!
Suzie has pinworms too!
Symptoms: The female pinworm comes out to the anus at night and lays her
eggs. This causes a symptom called pruritus ani (Latin for “itchy
tushie”). Itchy vagina also happens from pinworms.
Diagnosis: Often based on symptoms alone. Parents can go on a worm
hunt. The female comes out of the anus about two hours after a child is
sleeping. Put clear Scotch tape on a toothpick and obtain a specimen.
Treatment: Two doses of over the counter Pin-X, given two weeks apart.
Alternative: prescription strength Vermox (Latin for “worm-out”) can be
made by a compounding pharmacy. Doctors often treat the whole
family. Bathing in morning helps remove the eggs.
Contagious: Until treated. Infected people often re-infect themselves by
scratching their anus and ingesting more eggs.
Incubation period: 1 to 2 months (egg is ingested, then matures into an
adult egg-laying female in 1 to 2 months). (CDC)

Parasites
Another stomach infection is called Giardia. This is a parasite spread via
water. Yes, this includes swimming pools, hot tubs, and area lakes.
Someone with the infection who is swimming in the water can share it. It
frequently haunts childcare centers. Prolonged or foul-smelling diarrhea
deserves to be tested for parasites.

Special Feature: Ear Infections

Is your child earning frequent flier miles at the doctor’s office? Are you
exhausted by the constant ear infections your poor baby has had to endure?
Then this section is for you.

Q. Why is my baby prone to getting ear infections?

Thanks to your baby’s facial structure, her Eustachian tubes are not
working right. The Eustachian tubes equalize pressure changes in the ear
and clear the fluid created from infection or allergies. Babies are born with
round heads to get through the birth canal. As a result, the Eustachian tubes
(connection between the ears and the back of the nose) lie horizontally in
kids until three years old. This keeps the tubes from draining effectively. As
a child grows, his head and face elongate. The Eustachian tubes ultimately
slant downwards (and work better).
When a child gets a cold or upper respiratory infection, the virus causes
the lining of the Eustachian tubes to swell, making the tubes even more
inefficient. Bacteria like to grow if the fluid sits there long enough. The
body’s immune response to the bacteria creates pus, and that is the
definition of a middle ear infection (ACUTE OTITIS MEDIA). Older children
and adults rarely get ear infections because their Eustachian tubes drain
more effectively.

Your Baby’s Ear, in a nutshell

Notes:
1. The ear is divided into three parts—the inner, middle, and outer areas.
2. The Eustachian tubes attach to the middle part of the ear.
3. The eardrum (tympanic membrane) is a piece of tissue that separates the
middle and outer ear.
4. The eardrum protects the delicate middle ear bones and nerves.
Ear Infection Facts
By the age of three, 75% of all children have had at least one ear
infection.
40% of all antibiotics prescribed for children are for ear infections.
The peak age of ear infections is six to 18 months of age.
90% of ear infections are caused by bacteria; 10% by viruses.

Q. What is the difference between an ear infection

and swimmer’s ear?
An “ear infection” generally refers to a middle ear infection (ACUTE
OTITIS MEDIA). The pus/infection sits behind the eardrum (see diagram on
the previous page). A “swimmer’s ear” (OTITIS EXTERNA) refers to an
infection of the skin lining the outer ear (the canal where Q-tips don’t
belong!).

Middle Ear Infection (Acute Otitis Media)

A normal looking eardrum is grayish and translucent. The bones that
control hearing (the ones you learned about in junior high science class) are
visible behind it. An infected eardrum has pus behind it and is swollen and
red. The pus and swelling obscure the view of the middle ear. Think of the
infection as being a zit. It has to drain before it gets better. It can either
rupture the eardrum and drain (undesirable) or drain down the Eustachian
tube (desirable). The use of antibiotics taken by mouth clears the pus and
decreases the chance of the zit bursting (PERFORATED EARDRUM, see
more on the next page).

TOP 7 RISK FACTORS FOR EAR INFECTIONS

Parents often ask if there is anything that can be done to prevent

an ear infection from happening. Here are the risk factors:
 1.The common cold/upper respiratory infection. By definition,
fluid must be present in the Eustachian tubes to allow bacteria
to grow. Having a cold is the perfect set up for fluid
accumulation in the sinuses and Eustachian tubes.

2.Daycare. Children get more cold viruses when they are around
other kids. Naturally, kids in daycare will get more colds, thus
more ear infections. And the bacteria that live there are more
likely to be drug resistant bacteria.

3.Second hand smoke. Smoke is irritating to the whole respiratory

tract, from the nose down to the lungs. Irritation of the
Eustachian tubes causes swelling of the tissues and
inefficiency in clearing fluid.

4.Pacifier use. Constant sucking seems to create a backup of fluid

in the back of the throat and Eustachian tubes.

5.Bottle propping. Babies who lie down and hold their own
bottles allow fluid from the back of the throat to end up in the
Eustachian tubes. The fluid is a set up for infection.

6.Native American. The facial structure of this ethnic group

predisposes them to Eustachian tube dysfunction.

7.Cleft lip/palate. This facial structure predisposes them to

Eustachian tube dysfunction.

If you’re looking for more information on common ear, nose and

throat problems in childhood, check out the web site of the American
Academy of Otolaryngology Head and Neck Surgery at
EntNet.org/kidsent.

Swimmer’s Ear (External Otitis)

 This is a skin infection caused by either pooled water that collects in the
ear canal of kids who swim under water or skin irritation from being
scratched (from a Q-tip). Both situations allow bacteria to penetrate the skin
and cause infection. Swimmer’s ear causes extreme pain with touch or
movement of the outer ear (the part you can see). There is swelling, redness,
and sometimes debris in the canal. The eardrum is normal. These infections
usually clear up with antibiotic eardrops.

Q. My baby’s eardrum popped! Will he have

permanent hearing damage?
No. Perforated eardrums heal like a piece of skin that has been cut.
Remember the zit analogy? The eardrum is under pressure with all that
pus behind it. When the pimple pops, it lets the pus drain out. The
perforation hole is usually small and not completely ruptured. The ear feels
better if this happens. The infection still needs to be treated, though. The
doctor may prescribe antibiotic drops and oral antibiotics if this occurs. It
should heal up without any long-term consequences as long as the infection
is treated.

Q. Will my child get an ear infection from lying in

bath water?
No.
Bath water is fairly clean and very little collects in the outer ear canal.
But it’s a good idea to wipe the water out of the ears. It’s not a major player
in causing swimmer’s ear. And it has absolutely nothing to do with middle
ear infections (which happen on the other side of the eardrum).

NEW PARENT 411: EAR TREATMENT

GUIDELINES
 The American Academy of Pediatrics revised their treatment
guidelines for ear infections in 2013. Here’s a look at the rules:
Infants under six months of age with acute middle ear infections
will still get treated with antibiotics. They are more likely to suffer
complications from ear infections. But, providers should adhere to
strict guidelines for what constitutes an acute ear infection.
Kids ages six months to two years with clear cut infections are
also treated, but when the diagnosis is in question, a wait and see
approach is in order. Your doctor may ask you to return for a follow-
up visit or have you fill a prescription in a couple of days if your
child’s symptoms don’t improve.
The guidelines attempt to limit antibiotic use in kids with mild to
moderate symptoms and avoid use when the diagnosis itself is in
question (not all ear infections are so black and white).
Ask your doctor for her opinion about this issue. Record her
thoughts here:

Q. My child was just in the doctor’s office two days

ago. Now he has an ear infection. Didn’t the doctor see
it then?
Back to the zit thing. Ears can go from normal to bulging with pus in a
matter of hours.

Q. Can I buy one of those ear scopes (otoscope) and

examine my own child’s ears?
Sure. For $80, you can buy an iPhone Oto HOME app/scope
(cellscope.com) to examine your child’s ears in the comfort of your own
living room. But you might not know what you are looking at.
An acute middle ear infection may present itself in one of several ways.
The obvious bulging red ear is one you’d be able to diagnose. But not all of
them look like that. Some infections are more subtle. It doesn’t just take the
light of an otoscope to make the diagnosis. It takes the experience of
looking at thousands of ears for comparison.
Don’t be disappointed if you buy an otoscope, feel sure that you have
diagnosed an ear infection, and find that your pediatrician has a different
opinion.

Q. I’ve heard that not all ear infections require

antibiotics to go away. Do we have to treat every ear
infection with antibiotics?
Not all middle ear infections require antibiotics.
A small percentage (10%) of ear infections are caused by viruses. And
up to 60% of bacterial ear infections will clear on their own without any
consequences. However, bacterial ear infections clear more quickly with
antibiotics.
A 2011 study in the New England Journal of Medicine looked at the
standard recommendations for treating ear infections in children ages six to
23 months of age. Their conclusion: little kids feel better faster when they
are treated with antibiotics. (Hoberman)
That said, the American Academy of Pediatrics came out with its own
guidelines in 2013 regarding treatment of ear infections. Their message to
healthcare providers: be judicious about diagnosing ear infections based on
stricter criteria and only treat true infections. Their message to parents: be
patient. Every illness does not improve with antibiotics.
And for kids over age two, a provider might diagnose an ear infection
and send a child home without a prescription. She might tell the parent to
give the child a pain medication and come back the next day for a re-check.
If the ear looks worse or unchanged, she prescribes antibiotics. If the ear is
improved, no therapy is required.
 DR B’S OPINION

“I always pick the least potent antibiotic that will

work in a given situation. The only way to have
the ‘big gun’ when you need it is to avoid using it
when you don’t need it.”

Q. What happened in the days before antibiotics

when children had ear infections?
Some children did just fine. Others did not.
Untreated bacterial infections can lead to hearing loss (from chronic
fluid accumulation, chronic infection, and chronic ear drum perforations),
mastoiditis (infection invades the skull bone), and brain
abscesses/meningitis (infection extends to brain and spinal fluid). In the old
days before antibiotics, 80% of ear infections would go away on their own.
But the last 20% of ear infections that were untreated led to these
significant complications. (Rosenfeld)

Q. What antibiotics are typically used to treat ear

infections?
The right drug for the bug.
The most common bacteria that cause middle ear infections are:
Strep pneumoniae (now less common thanks to Prevnar vaccine).
Moraxella
 H. Influenza non-typable (a cause of pink eye with an ear infection)
Group A Strep

There are basically four antibiotic classes that kill all of these bugs. As a
general rule, doctors prescribe amoxicillin (in the Penicillin class) as their
first choice. It is a broad-spectrum antibiotic that is well tolerated by most
kids, has been around for a long time, and is relatively inexpensive (about
$10 for generic). It works about 85% of the time, depending on the amount
of drug resistant bacteria living in your neighborhood. That’s a pretty good
track record.
If it has been less than 30 days since a previous ear infection, doctors
may select a different class of antibiotics because the bacteria may be
resistant to the amoxicillin (that is, the same bug may have grown back
after being off medication).
If there is pink eye associated with an ear infection, there is a good
chance that H. influenza is the bug. This bug is resistant to amoxicillin
about 50% of the time (again, depending on your neighborhood). So, a
doctor may choose a different antibiotic in this situation.

Q. My child was on amoxicillin before and it never

works.
Your child is not resistant to amoxicillin—the bacterium he is being
infected with is resistant. Children in daycare settings tend to have more ear
and sinus infections with drug-resistant bacteria. That does not mean that
amoxicillin will never work. For instance, Group A Strep (which causes
Strep throat) is almost always cured with amoxicillin.

Q. My child is pulling on his ears. Should I be

worried about an ear infection?
No. It’s not a reliable indicator.
Parents frequently rely on ear pulling as a sign of an ear infection. There
was an excellent study done on this suspicious behavior that showed ear
pulling predicted ear infections only 5% of the time; 95% of the time,
babies pull on their ears because they can! (Baker)

Q. Why do I have to bring my child back for an “ear

check” after he has been treated?
Because infants can’t tell you that their ears are better.
The antibiotic prescribed should kill the bacteria. But there are smart,
resistant bugs that will survive. That’s one reason why the doctor wants to
see your child back two to three weeks after the diagnosis.
The other reason is that residual sterile fluid (SEROUS OTITIS MEDIA)
can remain for a long time after the bacteria is gone. This is basically pus
that is dissolved, but not dried up. The fluid is not infected, but can create
two problems:
It puts a child at risk for getting another middle ear infection down the
road.
It inhibits sound waves from getting through the middle ear
(CONDUCTIVE HEARING LOSS). It’s like walking around with
earplugs in all day long. Chronic fluid (more than three months
duration) is a problem for a child who is trying to learn his native
language (EXPRESSIVE LANGUAGE DELAYS).

Q. My child feels better after just a couple of days

taking amoxicillin for his ear infection. Why do we
have to continue the medicine for ten days?
Antibiotics start to clear an infection within 48-72 hours. However, it can
take five to ten days to kill off all of the bacteria. Stopping an antibiotic
early allows a germ to re-grow and cause infection (and pain) to return.
Doctors are trying to shorten the course of antibiotics because of the
growing number of antibiotic resistant bacteria. If your doctor prescribes a
shorter course (five days) of medicine, be sure to follow up with an
appointment to make sure the infection has cleared.
 RESIDUAL EAR FLUID

The pus from the ear infection gradually dissolves and gets
reabsorbed by the body. The name for this sterile (bug-free) fluid is
called SEROUS FLUID or serous otitis. 70% of children will still have
serous fluid two weeks after an ear infection. Up to 40% of kids will
still have serous fluid one month later, and 10% have fluid three
months after infection. (Peter)
The serous fluid does NOT need to be treated with antibiotics to
clear up. However, kids with residual fluid need to be re-evaluated to
make sure the fluid goes away. As mentioned earlier, chronic fluid in
the ears interferes with language development (in the short term).
If a child has chronic fluid in the ears, over three months duration,
an Ear/Nose/Throat specialist may want to drain the fluid by popping
the eardrum with a needle. Frequently, if the drum is popped, a PE
tube is inserted to prevent further accumulations of fluid.

Q. We are flying with our baby tomorrow and he was

just diagnosed with an ear infection. Should we cancel
our trip?
No. Go have fun.
As anyone who’s traveled on a plane knows, the pressurized air in the
cabin requires you to “clear” your ears (by chewing gum, yawning, etc).
Babies have the same needs—their middle ear must accommodate to the
pressure change. When a child has an acute ear infection, pus fills in the
middle ear space and the eardrum cannot move. The ear won’t hurt. In fact,
the pressure change might make the drum pop to release the pressure (and
that’s okay—see perforated eardrum earlier in this chapter).
It is more problematic when an ear infection is starting to clear up. Then
there is both air (normal) and fluid (not normal) in the middle ear. The
eardrum will try to accommodate to the pressure change and will be only
partially successful. This HURTS. Don’t cancel your trip; just be prepared
for some discomfort on take off and landing. Nursing, feeding your child a
bottle or sucking on a pacifier can help relieve the pressure.

Q. How many ear infections are too many?

Great question. For this answer, we’ve recruited Dr. Brown’s husband,
Mr. Dr. Brown (an Ear, Nose, and Throat specialist) for some advice:
“Most kids outgrow the problem of ear infections by about three years of
age. (See earlier for information on why this is). So theoretically, we can all
wait until your child turns three. But there are some important
considerations that compel doctors to take a more active approach.” Here
are some key questions:

1. How many courses of antibiotics are too many? Antibiotics can

have unpleasant side effects like diarrhea and yeast infections.
Being on antibiotics frequently leaves a child susceptible to
bacteria that are smarter (the drug-resistant strains) and allows
bacteria in the community to see our weapons. From an economic
standpoint, every ear infection costs parents a visit to the
pediatrician, missed work, and another round of antibiotics.
2. How old is the child? If a child is in the midst of language
acquisition (nine months to age two), it’s critical for him to hear
what people are saying to him. Otherwise, the infections can
contribute to short-term expressive language delays. In the long
run, these kids do catch up and have normal language skills.
3. How miserable is the child? Ear infections hurt. That leads to
disrupted sleep for the whole family. This important point tends to
get overlooked by both parents and doctors.
 DR B’S OPINION: WHEN TO CALL
IN AN ENT

Here is how I would approach making a referral to an

Ear/Nose/Throat (ENT) Specialist for a child with recurrent ear
infections (other than the “too many” criteria above).
Scenario 1: If a child already has had three ear infections by
Thanksgiving, that doesn’t bode well for the rest of the season (cold
and flu season will continue through March). Refer now to an ENT.
Scenario 2: If a child gets ear infections sporadically through the
winter and gets his fourth infection in April, wait and see if the ear
infections stop as the season ends.
Scenario 3: If a child gets two ear infections during the summer
months and a third in September, the child gets one more chance
before referring. But I prepare the family for the possibility.

Reality Check
It’s important to look at what is in the best interest of the child. There is
some variability amongst doctors, but a reasonable answer to what is “too
many” is the following:
Four infections in the peak (winter) season
Three infections in the off peak (summer) season
Three months of persistent residual fluid (serous otitis media)
Three back-to-back courses of antibiotics for the same ear infection.
 Too many ear infections buy your child a trip to see the Ear, Nose, and
Throat specialist. These doctors assist in decision making for children with
recurrent ear infections. If necessary, they can place pressure equalization
tubes in the eardrum to reduce the number of ear infections (we’ll discuss
this more in detail later in this chapter).
Ear infections occur mostly in cold and flu season. (Remember, bacteria
are secondary infections for a child with fluid in his ears already). So, it’s
expected that more infections will happen then. Kids who get middle ear
infections in the off-season are time bombs for the winter.

Q. How can I prevent ear infections from happening?

There are a few things you can do:

1. Feed your baby in an upright position. Milk can get into the
Eustachian tubes if a baby is lying horizontally while eating.
2. Avoid pacifiers after six months of age. There is some good data to
suggest this is a risk factor for ear infections. (Post)
3. Don’t smoke. Smoking is a respiratory irritant—both to the smoker
and his family. It causes swelling of the Eustachian tubes, which
can lead to infection.
4. Infection control during the cold and flu season. Good hand-
washing and flu shots for the family are helpful. The Prevnar
vaccine for your child helps limit some (not all) infections.
5. Reconsider your childcare options. There is no question that
children in daycare settings get more infections (and with drug-
resistant bugs). When families have reached the end of their ropes,
doctors may discuss this subject.

Q. Can we just start an antibiotic when my child has a

cold? What about preventative antibiotics through the
winter months?
 Doctors used both of these methods in the past. And to a certain degree,
they worked. However, the price paid is too great. This approach created
drug-resistant bacteria.

Q. Can I prevent an ear infection from happening by

using a decongestant or antihistamine to dry up all that
snot?
No.
You would think that if you got rid of the fluid, the ear infection could be
prevented. This idea was studied about 30 years ago and it didn’t prevent
ear infections. There is a reason it doesn’t work. When there is infection,
the Eustachian tubes are full of fluid and get swollen. This prevents them
from draining effectively.

Q. What are “tubes”?

The official term is Pressure Equalization (PE) Tube.
The alternative to antibiotics for recurrent ear infections is to insert PE
tubes into the eardrums. These tubes are the length of a pencil point and the
diameter of angel hair pasta (i.e. really small). The procedure is relatively
simple. An ENT Specialist makes a tiny hole in the eardrum, cleans out any
fluid/pus, and inserts the tube. The tube falls out on its own after a lifespan
of 6-18 months. The eardrum heals beautifully 99% of the time.
Children have this procedure done in a day-surgery facility. They do
require anesthesia, but don’t require an IV, breathing tube, or ventilator.
Why anesthesia? It’s helpful not to have a squirming child when someone is
poking a hole into the eardrum. The procedure takes about five minutes.
Kids are usually back to themselves again later that day.
Many parents are incredibly fearful of having PE tubes placed. They are
afraid of the procedure, the anesthesia, or the risk of having an opening in
the eardrum (you have to keep water out of the ear). Most of these concerns
should be clearly addressed by your ENT doctor.
Helpful Hints: Understanding PE Tubes
Think of PE tube placement as a procedure and not surgery. I think the
word surgery really freaks people out.
This is a simple, quick procedure. For adults, it could be performed in
an office setting.
The risk of anesthesia is no greater than the risk of all the antibiotics
your child has been taking.
You’ll no longer need to see the pediatrician every week. My frequent
fliers stop visiting my office after they have PE tubes placed. I
always enjoy seeing my patients, but I see some kids too often.

BOTTOM LINE
As a general rule, PE tubes are a life changing experience for the whole
family. Even the most anxious parents report how “easy” the experience is,
how much better their child feels, and wonder why they waited so long to
do it. I’ve never had a family tell me they regretted the decision to get
tubes!

THE INFECTION HIT PARADE: VIRUSES AND BACTERIA

So, let’s sum up this chapter. Here is a list of the top infections, as
caused by viruses and bacteria:

Viruses That Cause Infection

Here is a list of the most common VIRUSES that cause infection in
babies ages birth to age one.

Viral Respiratory Infections

1. The Common Cold or upper respiratory infection (Rhinovirus)
2. The Flu (Influenza)
3. Bronchiolitis (RSV)
4. Croup (numerous viruses)

Viral Mouth And Tonsil Infections

1. Hand-Foot-and-Mouth (Coxsackievirus)
2. Herpes Stomatitis (Herpes Type-1)
3. Sore throat virus (Adenovirus)

Gastrointestinal Viruses
1. Stomach virus, or “stomach flu” (Rotavirus, Norovirus)

Viral Exanthems (Viruses That Cause Skin Rashes)

1. Roseola (Herpesvirus-6)
2. Chickenpox (Varicella)
3. Slapped Cheek or Fifth Disease (Parvovirus)

Bacteria That Cause Infection

Here are some of the bacterial infections in babies birth to age one.
For details, please see earlier in the chapter.

1. Ear Infections (Strep pneumoniae, H. Influenza, and others)

2. Sinus Infections (Strep pneumoniae H. Influenza, and others)
3. Eye Infections (H. Influenza, Strep pneumoniae, and others)
4. Throat Infections (Group A Strep)
5. Lung Infections (Strep pneumoniae, Staph, and others)
6. Food Poisoning (E. Coli, Salmonella)
7. Bladder Infections (E. Coli, and others)
8. Meningitis (Group B Strep, Strep pneumoniae)
 9. Skin infections (Staph, MRSA, Strep)

Things That Make You Itch Just Thinking About

Them
1. Fungus: Ringworm, Thrush, Yeast diaper rash
2. Mites: Scabies, Lice
3. Parasites: Giardia
4. Worms: Pinworms

Whew! That was a load of viruses and bacteria. Now, it’s on to other
medical problems that are NOT caused by infectious bugs. The next chapter
explores the most common diseases that affect babies.
COMMON DISEASES
 Chapter 14
“Sooner or later we all quote our mothers.”

~ Bern Williams

WHAT’S IN THIS CHAPTER

EYES: LAZY EYE
LUNGS: ASTHMA, BRONCHIOLITIS
HEART: MURMURS
BLOOD: ANEMIA, SICKLE CELL DISEASE, IRON DEFICIENCY,
LEAD EXPOSURE
SKIN: ECZEMA
MUSCLES/BONES: INTOEING, BOWED LEGS, FLAT FEET,
TORTICOLLIS, HIP DYSPLASIA
ENDOCRINE: DIABETES
ALLERGIES: SEASONAL, ENVIRONMENTAL
GENITALS: PENILE, LABIAL ADHESIONS
WHAT’S THAT SMELL? UNUSUAL ODORS

This chapter is devoted to the most common medical problems in infants

ages birth to one. Some topics have been discussed in other chapters. (See
the index if you can’t find the disease you are looking for in this chapter).
The common thread of these medical problems is that they are not caused by
an infectious bug.
We’ve organized this discussion by body system—first up, it’s the eyes.
Eyes

Q. I’m worried my baby has a lazy eye. How do you

check for that?
By examining the eyes every time you visit your doctor.
Under three months of age, babies can looked cross-eyed occasionally.
The muscles of both eyes aren’t working together yet.
After three months, both eyes should move together. There are two
medical reasons for why they don’t:

1. Strabismus. The muscles that move the eye are weak.

2. Amblyopia. The eye itself is weak or injured.

Often a parent will notice this at home. Doctors check by covering up one
eye and checking that the other eye can focus on an object. A child looks
away or tries to remove the examiner’s hand when the unaffected eye is
covered. Cool new trend: high-tech vision screening devices. These gadgets
can detect vision problems—even in squirming toddlers. While the
American Academy of Pediatrics supports early vision screening, major
insurance plans have not embraced this technology yet. In other words, you
may need to pay out of pocket for it. Our advice: it’s worth it.
Children who fail a screening test should see an eye specialist
(ophthalmologist). If a lazy eye goes untreated, permanent problems can
occur. Eye doctors prefer to assess these problems before three years of age.

Helpful Hint
There is a benign condition called PSEUDOSTRABISMUS where kids just
have narrowly set eyes. This is not a medical problem.
RED FLAG
If your child has a dramatic new problem with an eye turning in, go see your
doctor ASAP. This can be a sign of a brain tumor. Don’t panic yet, just get it
checked out.

Lungs

Q. What is asthma?
In short, it’s like hay fever in the lungs.
Asthma is a process of swelling, muscle tightening, obstruction,
destruction, and mucous production in the big and little airways of the lungs.
This chain of events occurs due to a revved up immunologic/allergic
response to infections, allergies, weather, and emotions.
The narrowed airways interfere with the air exchange (getting clean air in
and dirty air out) that occurs with each breath. As a result, children are “air
hungry.” Their bodies try to get more air in by breathing fast and pulling the
rib muscles in when breathing. The characteristic wheeze comes from air
traveling through a narrowed passageway.
Asthma attacks (termed exacerbations) occur intermittently depending on
what a child is hypersensitive to. Often, kids with asthma have flare ups with
upper respiratory infections. This makes for a very long, bad winter.

Q. How do you diagnose asthma?

Asthma is a diagnosis made by physical examination.
If a child is caught wheezing three or more times in his life, he carries a
diagnosis of asthma. The first and second time a child wheezes, it might be
bad luck. The third time, it’s a trend.
 There are reasons other than asthma that make children wheeze. Babies
can get RSV bronchiolitis (see more below) or another infection that results
in wheezing. Older babies can get a raisin (or other small object) stuck in
their airway and wheeze, too.
Your doctor can get a chest x-ray to rule out an infection or a foreign
body in the airway. Blood tests aren’t particularly helpful. Probably the best
information to confirm a diagnosis is a child’s response to asthma
medication. If their lungs clear up with asthma medication, they likely have
the diagnosis.

Q. My doctor said my child has “Reactive Airway

Disease.” Is that asthma?
Basically, yes. It’s just a nicer term to use for a younger child who has not
been diagnosed asthmatic.
Doctors tend to hedge on the diagnosis of asthma in a child before the
first birthday. Some infants get hit really hard with an RSV infection and
wheeze for what seems like months. By definition, they have airways that
are “reacting” to infection—by getting swollen and full of mucous.
Still other babies with severe acid reflux (GERD) will wheeze when the
airway gets irritated. This type of wheezing resolves when they outgrow
their reflux.
Doctors use this term for little ones who haven’t proven themselves to be
true asthmatics yet.

Q. My husband had asthma as a child. What are the

chances that my baby will have it?
There is definitely a genetic predisposition to asthma and other allergic
disorders. There is probably a 25% chance your child will have asthma. That
means there is a 75% chance he won’t. Given the odds, it doesn’t pay to
worry.
Q. My baby had RSV bronchiolitis this winter. What
are the chances that he will have asthma?
Thirty to forty percent.
It is true that kids who wheeze with RSV tend to wheeze again (asthma)
in their lifetimes. This is a chicken or the egg dilemma. We just don’t know
which came first.
Interestingly, not all kids who get RSV wheeze. And of the kids who do
wheeze with RSV, not all of them respond to asthma medication. So, there
may be just a subset of kids who would have wheezed anyway who have
trouble with RSV infection. See the RSV section in Chapter 13, Infections,
for more details.

Q. Are there any other factors that cause asthma?

Besides genetics, there’s nothing else that is solidly proven to predispose
a child to asthma. However, a few interesting studies have recently been
published on this subject. Research suggests babies who are born four
months before peak cold and flu season seem to be at higher risk of
developing asthma later in life. One study points to RSV, while others point
to the common cold (rhinoviruses) as the culprits. (Stein)
Other studies have found correlations with using the European equivalent
of acetaminophen (Tylenol) in babies or exposure in the womb and
development of allergies and asthma later in life. None of these studies
prove that acetaminophen causes asthma. It’s an age-old rule of science:
correlation does not prove causation. (Beasley, Allmers, Persky, Bakkeheim)
But, considering that several studies have found similar results, it makes
sense for babies and pregnant women to only take acetaminophen when they
absolutely need it.
There is one major risk factor that is totally preventable, though:
smoking. If you can’t quit for your own health, hopefully your child’s health
and wellbeing can motivate you.

Q. How do you treat asthma?

 For immediate rescue: A BRONCHODILATOR (albuterol) very quickly
relaxes the airways. This is usually inhaled via an inhaler device or a
nebulizer machine (a souped-up vaporizer). For infants, the nebulizer
provides the most immediate, effective relief. This medication can be given
for prolonged periods in an office or emergency room setting. It can be
administered every four to six hours at home.

For prevention of attacks: Kids who wheeze more than twice a week or
one night a month need a medication to keep their asthma in check.
Persistent symptoms mean chronic destruction to the lungs, which we now
know, can be permanent. An INHALED STEROID (Budesonide/Pulmicort) is
administered via nebulizer daily for these high-risk kids. (Expert Panel
Report II) Children with severe, persistent wheezing may need a round of
steroids given by mouth. Other oral medications, called Singulair and
Cromolyn, are also used to prevent flare-ups (See Appendix A, Common
Medications for more info.)

Asthma is categorized by the severity of symptoms into Intermittent,

Mild Persistent, Moderate Persistent, and Severe Persistent. The National
Asthma Education and Prevention Program revised their guidelines in 2007
to standardize asthma treatment. The treatment plans are divided by the
severity of the symptom categories. See below:
 Steps with severe persistent asthma:
1. Medium-dose inhaled steroid or
2. Step 1 plus long-acting rescue or Singulair
3. High dose inhaled steroid plus long-acting rescue or Singulair
4. Step 3 plus oral steroids (National Institutes of Health)

Reality Check
Most insurance plans cover the cost of a nebulizer machine for a patient who
needs one. They know it’s less expensive to buy a $100 machine than to pay
for an ER visit or hospitalization.

Q. What are the chances my child will outgrow

asthma?
 50/50.
Those odds aren’t bad for a chronic illness. Unfortunately, no one can
predict if and when your child will outgrow it. As a general rule, kids who
have asthma before the age of five tend to outgrow it. Children who are
diagnosed with asthma when they are older are more likely to have it in
adulthood. (Behrman)

Q. What are the long-term consequences of asthma?

Asthma can cause permanent airway damage. This is a recent discovery
in the medical world.
Kids who have occasional asthma flare-ups do fine in the long term. If a
child has chronic wheezing, normal parts of the lung can be damaged—and
don’t recover. So, doctors are more aggressive about treatment for a child
with persistent symptoms. Chronic obstructed airways also decrease the
amount of oxygen getting to the body on a daily basis.

Q. My child has eczema. My doctor told me he has a

higher risk of developing asthma. Why?
Because allergic diseases can occur as a group. This particular problem is
called ATOPY.
Atopy or atopic disease refers to a classic triad of asthma, eczema, and
seasonal allergies. Of the kids who have eczema, 30% get either asthma or
seasonal allergies (but 70% won’t get either). (Behrman)

Q. My child wheezes. Could he have Cystic Fibrosis?

Yes, but it is very unlikely. Cystic Fibrosis is a genetically inherited
disorder that affects one in 1600 children. It causes an abnormality in body
cells that impair absorption of chloride. The result of this is that the lungs
pull in too much sodium. Normal airway secretions get thick and don’t
move. Chronic lung infections develop. Other body systems are affected by
this cell abnormality, particularly the intestines, pancreas, and reproductive
system.
 If your baby wheezes chronically, and especially if he is having trouble
gaining weight, a screening test for cystic fibrosis may be in order. A simple
assessment of a baby’s sweat will give the answer. (Behrman)

Heart

Q. What is a heart murmur?

A murmur is an extra noise that is heard when your doctor listens to the
heartbeat with a stethoscope. The normal heartbeat is actually a series of
sounds best described as “lub-dub.” A murmur is an extra noise that may
sound like rushing water (“p-ssh”) or a squeak (“eek”). The quality, duration,
and location of that noise help your doctor determine what is producing it.
If the cause isn’t obvious by simply listening, your doctor may
recommend that a heart specialist (pediatric cardiologist) see the baby. Tests,
such as an electrocardiogram (EKG) or echocardiogram (“echo” or
ultrasound examination of the heart), may be recommended to gain
additional information about your baby’s heart.

Q. My doctor heard an “innocent” heart murmur in

my baby. Should I be worried?
No.
We recruited one of our favorite pediatric cardiologists, Karen L. Wright,
M.D., to field this one. She says, “An innocent murmur is the sound of
normal blood flow passing through the heart chambers and blood vessels.
These sounds are commonly heard in infants, and are no cause for alarm. If
your baby is doing well and an innocent murmur is detected, your baby’s doc
will let you know and make a note to check on this during future visits. If
there is any concern, or reassurance is needed, your baby’s doctor can
arrange for you to see a pediatric cardiologist.”
Q. My baby has a heart murmur and is going to see a
specialist. Should I be worried?
Be appropriately concerned, but not alarmed. Most heart murmurs are
innocent (see above) and are not a problem.

Normal heart

Doctors err on the side of checking things out to be sure everything is

okay. The term for a murmur caused by a defect in the heart is a
PATHOLOGIC MURMUR. Most pathologic murmurs are caused by a problem
with the way the heart developed before a baby was born (CONGENITAL
HEART DISEASE). A congenital heart defect occurs in about one in 100
newborns.

VSD

According to Dr. Wright, “The vast majority of those defects are pretty
mild, and do not significantly interfere with a child’s life. In fact, some of
these defects truly go away on their own. A common type of congenital heart
defect is a hole between the pumping chambers of the heart, called a
VENTRICULAR SEPTAL DEFECT (VSD). Most of these holes are small, and
will often close as the baby’s heart grows.”
 Other, less common defects may require either a procedure or surgery to
correct. These defects are beyond the scope of this book. But if you are
looking for more information, check out
cincinnatichildrens.org/heartcenter/encyclopedia

Q. Are there other types of heart problems seen in

babies?
SUPRAVENTRICULAR TACHYCARDIA (SVT) is an abnormally fast heart
rhythm and it can make babies pretty ill. Fortunately, it’s rare.
A baby’s normal heart rate is already fast (up to 180 beats/minute), so it
can be difficult to tell what is too fast. But if a baby is unusually fussy,
feeding poorly, or breathing rapidly, SVT is one thing to think about. Get it
checked out by your doc.

Blood

Q. What is anemia?
Let’s discuss what red blood cells are first.
Red blood cells (which come from bone marrow) carry oxygen to our
body tissues and remove carbon dioxide. Hemoglobin is the name of the
protein that performs this function in each red blood cell. The key ingredient
of hemoglobin is iron.
“Anemia” means there are not enough red blood cells circulating in the
bloodstream. The causes of anemia are either excessive destruction or
inadequate production of red blood cells.
Examples of excessive destruction of red blood cells include:
More blood is being lost than made (such as menstruating women).
Abnormal red blood cells are made and destroyed (such as sickle cell
disease).
Examples of inadequate production of red blood cells include:
 Bone marrow production slows (such as bone marrow suppression by
virus).
Iron deficiency limits production due to lack of a key ingredient (that is,
iron-deficiency anemia).
Lead poisoning (technically, this is competition for iron’s place in the
red blood cell).
Poor nutritional intake of key vitamins like B12/Folate.

The number one cause of anemia in childhood is iron deficiency. Kids

who are severely anemic are pale and fatigue easily. Anemia sometimes
presents with odd symptoms, like breath-holding.

Q. My baby had an abnormal newborn screen. We

found out he has “sickle cell trait.” What does that
mean?
Let’s be geneticists for a moment. Babies get one set of genes/DNA from
Mom, and one set from Dad. Some diseases require one defective gene to
affect someone (AUTOSOMAL DOMINANT). Some diseases require both
genes to be abnormal to manifest themselves (AUTOSOMAL RECESSIVE).
Sickle cell disease is an autosomal recessive disease. People with one
defective gene and one normal gene are called carriers. They carry the trait
(gene) for the disease but are not affected by it. About 8% of the African-
American population are sickle cell carriers.
Both sickle cell trait and disease can be detected by that first newborn
blood test sent to the state laboratory (see Newborn Screening Tests in
Chapter 1). It’s detected by the type of protein chain that makes up red blood
cells.
This is only a problem when your child gets married. If he marries a
woman who also has sickle cell trait, his children are at a high risk for
having sickle cell disease. (Behrman)

Q. My baby has sickle cell disease. Can you explain

what that means and what I should worry about?
 Sickle cell disease is caused by abnormal protein (hemoglobin) in red
blood cells. This protein causes the red blood cell shape to be deformed.
Instead of an oval shaped cell, these cells look like half moons (like the
“sickle” on the old Soviet Union flag).
Sickle cells die more quickly, have trouble carrying oxygen, and clog up
blood vessels. This blood vessel clogging kills the tissues that the blood
vessel supplies (muscle, bones, spleen, lung, kidney, intestine).
The consequences in infancy and early childhood are the following:

1.Chronic Anemia: This shows up by age three months. Folate

supplements are given to promote red blood cell formation.
2.Dactylitis: Infants get hand and foot swelling from clogged blood
vessels.
3.Non-functional spleen: The spleen filters red blood cells as well as
white blood cells (infection fighters). Because of the spleen’s job, it
takes the greatest hit as far as clogged vessels. We can’t rely on the
spleen being a functional organ in a child with sickle cell disease.
This leaves children prone to infection, particularly with Strep
pneumoniae and H. influenza bacteria. These kids need Prevnar
vaccine, flu vaccine, and the Pneumonia (pneumococcal) vaccine
that elderly people get.
4.Failure to thrive: Because of a chronic lack of oxygen to the tissues,
these children are shorter and smaller than their peers.

There are a variety of medical problems associated with sickle cell

disease as a child gets older. For more information, see sicklecelldisease.org.

Q. My nine month old had a routine blood test

performed. He has iron-deficiency anemia. What did I
do wrong?
You probably haven’t done anything wrong.
However, there are some parent mistakes that can cause this problem:
1.Exclusively breastfeeding without introducing cereal after six months
of age.
 2.Replacing breast milk or iron-containing formula with regular
cow’s milk before the first birthday.

Q. How is iron deficiency anemia treated?

With a high iron diet and an iron supplement (we discuss this in detail in
Chapter 7, Solids).
If your child is diagnosed with iron-deficiency anemia, your doctor will
prescribe an iron supplement. Don’t try to treat anemia by yourself without
professional help. Why? Because iron, in high doses, can be toxic.
As a result, although vitamins containing iron are available without a
prescription, the infant drops are located at the pharmacist’s counter. The
pharmacist dispenses these medications so he can counsel you on the correct
dosage.
Also: there is a difference between the recommend daily allowance for
iron (maintenance iron dosage) and the dose required for replacement
therapy for those with low iron stores (iron-deficiency anemia). Doctors
usually treat a child with iron-replacement therapy and then recheck their
blood counts in three months.

Helpful Hints
Getting your child to take his iron supplement.
Iron supplements universally taste bad. The brand name products taste a
little better. Icar and Feostat brands taste best.
It’s okay to mix the medicine in juice. Just make sure your child drinks
all the juice. Vitamin C actually helps the iron get absorbed into the
bloodstream.
DO NOT MIX WITH MILK. The calcium in milk competes with iron
and can block absorption.
Iron can cause a temporary gray/brown stain on the teeth. You can use
baking soda on a toothbrush to remove it.
 Iron can make poop look black. It’s not blood. Don’t worry.

Q. We live in an old house. I’m worried about lead

exposure. When should I get my child tested?
The appropriate time to get tested depends on when your child becomes
mobile.
Most children who have lead poisoning live in homes built before 1978.
These older homes have lead paint and lead pipes. Chipping paint is a very
popular item for kids to pick up and eat. There is also lead in the soil
surrounding these homes.
Screening for lead exposure is usually performed at nine to 12 months of
age. In high-risk areas (urban, older homes), all children have a blood test
done routinely. In low risk areas, doctors will screen with a risk-factor
question list. If there is a possible exposure, a blood test is performed.
For more information, check out the Environmental Protection Agency’s
website at epa.gov/lead/index.html or call the National Lead Information
Center (NLIC) at 800-424-5323.
While the Environmental Protection Agency recommends consumers turn
to professionals to have their homes tested for lead, there are also a number
of home tests available on the market. For under $10, you can purchase a
lead test kit that includes swabs with a chemical that changes colors when it
comes in contact with lead. Unfortunately, the accuracy of these tests has not
been proven independently. And each $10 test kit only tests one area in your
home (hence, you will end up buying several test kits.) If you’re looking for
a reputable professional testing lab in your state, check out the EPA’s website
at epa.gov/lead. Once you contact a certification officer in your state, he will
be able to provide a list of certified labs.

Feedback from the Real World

I cared for a family who carefully de-leaded their home built in 1910 before
moving in with their young children. Unfortunately, a central air
conditioning unit was installed AFTER the move and it spewed old dust
from the attic into all of the children’s rooms. The children required
medication to remove the lead from their bloodstreams. They are all doing
fine now.

Skin

Q. What is eczema?
This falls into the allergic disease category. Eczema is a broad term to
describe dry, scaly, itchy skin that appears in patches. It is often referred to
as “the itch that rashes.” In other words, kids have particularly sensitive,
itchy skin. The itching is what produces the rash that you see.
The sensitive skin flares up with dryness, exposure to perfumes/dyes, or
allergies to metals/plants.
The rash appears in different places depending on the age of the child.
Younger kids tend to get it on their elbows, knees, and face. Older kids get it
in their elbow and knee creases. We have more on managing eczema in
Chapter 4, Hygiene and below.

LIVING WITH ECZEMA: 7 TIPS & TRICKS

As a parent of a child with severe eczema, we’ve been there, done

that. Here are our tips:

1. Moisturizing soap: The cheapest in this category is good

old Dove soap. Other options are Cetaphil, Aveeno, and Neutrogena.
Avoid alcohol-based hand gels—they sting cracked skin.
2. Avoid perfumes and dyes: If it smells good, don’t use it on your
child. That goes for laundry detergent too. Use All Free and Clear or
an equivalent product.
 3. The thicker and greasier the moisturizing cream, the better: My
personal favorite is Creamy Vaseline. Eucerin cream, Aveeno, CeraVe,
and Cetaphil are also popular choices among dermatologists. You
need to lube your child up several times a day. As soon as you get
your child out of the bathtub, apply the moisturizer (I’m serious—
have the tube ready).
4. Apply 1% hydrocortisone cream to really red areas twice daily:
1% hydrocortisone cream is a low-potency steroid cream available
without a prescription. It is very safe to use on a daily basis when
flare-ups occur.
5. Give a sedating antihistamine like diphenhydramine (Benadryl) at
bedtime, for babies over six months: it will help reduce the amount of
scratching that goes on when you aren’t watching your child.
6. No bubble bath—most contain dyes and perfumes that can
aggravate eczema. Instead, consider oatmeal bath treatments
(Aveeno makes one). If you bathe your child every night, do it in
lukewarm water. Consider bathing every other night in winter. The
combination of frequent baths and dry heated air can cause flare-ups.
7. IF YOU HAVE TRIED ALL OF THIS AND YOUR CHILD IS STILL
MISERABLE, IT’S TIME TO CHECK IN WITH YOUR PEDIATRICIAN.
They can recommend prescription products that are safe and effective.
Don’t hesitate to see a dermatologist if you and your pediatrician can’t
keep your baby’s eczema under control.

Q. How do you get rid of eczema?

It’s a long battle. In fact, it’s a more realistic goal to keep it under control
than to get rid of it.
The key to managing eczema is to keep the skin moist. Eczema always
flares up in the wintertime because of cold, dry air.

Q. My baby has severe eczema. Should I be worried

about using steroids all the time to treat eczema?
 No, these are not the dangerous steroids that some professional athletes
use. Topical steroids are extremely good anti-inflammatory medicines. They
act by reducing the irritation of the skin, thereby reducing the itching. Long-
term use (for months or years), especially with high potency products, can
cause unwanted side effects.
It’s always a good idea to use the lowest potency steroid creams and
ointments for the least amount of time. Doctors move up on the strength
level until they find one that works, and taper back down when the eczema
improves. Ointments work best, followed by creams and lotions. High
potency steroids should not be used on the face. And always use the product
as prescribed. More is not better.
There is another alternative to topical steroids (approved for use in kids
over age two) called immunoregulators. They are sold under the brand
names Elidel and Protopic. They are an alternative for short-term or
intermittent use to treat eczema. Because any medication has potential
adverse effects, ask your doctor his/her opinion.
There is also a class of medications that are called emollients. They act by
repairing the skin’s top layer and reducing inflammation and itching. For
details, see Appendix A.
Finally, you may want to consider food allergy testing. You may improve
the skin by eliminating an allergenic food.

Q. Is there a link between eczema and asthma?

Yes, for some people.
Eczema is an allergic disorder. About 70% of kids who have eczema have
a parent, brother or sister who has some type of allergy (hay fever/seasonal
allergies, eczema, asthma).
About 30% of kids with eczema will have the classic triad of ATOPY
(eczema, seasonal allergies, and asthma). But 70% of kids have eczema
without any other type of allergic disease. (Behrman)
It’s just something to pay particular attention to.

Q. Will my baby outgrow eczema?

 Chances are, yes.
About 70% of kids will outgrow eczema. But no one can predict if and
when your child will outgrow it. Chances are better if your child gets eczema
as a baby. Kids who get eczema later in life have a greater chance of having
it into adulthood.

Muscles/Bones

Q. My baby’s feet turn in. Will he need to wear special

shoes or a brace?
No.
The official term for this is called INTOEING. This is very common and
usually corrects itself as your child becomes a good walker.

Old Wives Tale

Pigeon toed children need to wear corrective shoes.
The truth: It was trendy 30 to 40 years ago to have kids wear corrective
shoes or braces (for example Forrest Gump) if they turned their feet in while
walking. Since then, doctors discovered feet get better whether a child wears
this apparatus or not—so why put a child through the trauma of special
shoes or braces.

Q. My one year old is bow-legged. Will he always walk

like this?
No.
Kids have some trouble finding their center of gravity. When they first
start walking, they bend their knees to support their body weight. As they get
older, they often go the opposite direction and look knock-kneed. It’s
nothing to worry about unless one leg is misshapen or both legs look
severely deformed.

Q. My baby seems to have flat feet. My husband has

flat feet, too. Do we need to see a podiatrist?
Your child can thank your husband for his feet. And no, you don’t need to
see a podiatrist yet.
The term “flat feet” refers to a lack of a natural arch in the bones of the
feet. Some flat feet are flexible (the arch is seen when standing on tip-toe)
and some are rigid (always flat). The feet that are always flat can cause some
discomfort when kids become teenagers and adults. But placing a shoe insert
(ORTHOTIC) into a toddler’s shoes is not going to change the results down
the line. The American Academy of Pediatrics feels orthotics are not
necessary for kids with flat feet.

Q. My doctor says my baby has TORTICOLLIS. What is it

and what do I do about it?
Here we go with the Latin again. This term literally means “twisted
neck.” It is caused by a tightening of a neck muscle
(STERNOCLEIDOMASTOID MUSCLE) on one side of the neck. This neck
muscle tightening occurs while the baby is still in the womb. The fetus may
get stuck in one position for several weeks, forcing the baby’s head to tilt
towards the shoulder.

The muscle tightening gets worse after birth if babies sleep in the same
position all the time. You may notice that your baby prefers to turn or tilt his
head to one side. Babies who are at greater risk for this are boys, large birth
weight babies, twins/multiples, breech, moms with uterus abnormalities, and
first pregnancies. (Stellwagen)
If your child has torticollis, his head and neck movements will be limited.
And if you don’t actively do something about it, his head and facial shape
may be affected. See the next box for home exercises to work on. Do the
exercises at each diaper change, if you can.
Here are a few other practical tips (warning: your baby will not like any
of them) (Barrow Neurological Institute):
Place your baby to sleep on alternating ends of her crib.
Place your baby’s head on alternate ends of the changing table.
Put toys on the side of the stroller/swing/crib where your baby’s neck
rotation is most limited. This forces him to work to see those toys.
When carrying your baby, alternate which hip or arm used.
Try to interact with your baby on the side where his neck movement is
limited.
Tummy time. Tummy time. And more tummy time.

If you do not see improvement in six to eight weeks, it’s time to call in a
physical therapist to help you.
Physical therapy is very effective in treating more severe cases of
torticollis. For the few kids who fail that intervention, BOTOX injections
and minimally invasive endoscopic surgery have both been used to release
the affected muscle.

EXERCISES FOR TORTICOLLIS

Here are two exercises you can do at home to fix this problem.
It’s easiest to remember if you do the exercises after each daytime
diaper change. Your baby will respond best if he has a full tummy and
is relaxed. You can do the exercises on the changing table or on your
lap.
 1.Tilt the head, ear to shoulder, stabilizing the chest with one
hand. Hold for 10 seconds and repeat on the other side. Repeat
three times on each side.

2.Turn the baby’s head, chin to shoulder, while stabilizing the

chest with one hand. Hold for 10 seconds. Then repeat in the
other direction and hold for 10 seconds. Repeat three times on
each side. (Stellwagen)

Q. My baby girl was born breech and the doctor wants

to do a special test on her hips. Should I worry?
No, but you should do the test. The concern: developmental dysplasia
(dislocation) of the hips or DDH. In some babies, the hip joint forms
abnormally and so the top of the thighbone does not stay in the joint. The
result is that the bone is either loose or entirely out of the joint. The
dislocation may be apparent at birth, or be identified as the joint loosens with
time and activity.
There are certain babies who are at increased risk of this deformity: girls
who are born in a breech presentation have the highest risk. First-born
children and those with a family history of hip dysplasia are also at risk.
If DDH is diagnosed in infancy (the earlier the better), it is fairly easy to
treat and correct. If DDH is not diagnosed or not treated, it can cause joint
pain and arthritis. That’s why pediatricians carefully examine a baby’s hips
and order a simple ultrasound test on babies who are born breech, who have
a family history of DDH, or who have a concerning hip examination.
Radiologists suggest doing a hip ultrasound at four weeks of life for these
babies. A follow up x-ray of the hips may be in order at six months of life
for some at-risk babies.

Reality Check
Notify your baby’s doctor if your baby:
Has uneven leg creases on the thighs.
Has legs that are a different length.
Seems to use one leg less than the other.
Limps or waddles when walking.

FYI: Experts are increasingly concerned that tightly wrapping a baby’s

legs while swaddling (aka the baby burrito wrap) may increase the risk of
DDH. So it’s a good idea to leave some wiggle room for the legs. Allow the
legs to bend up and out at the hips.

Endocrine
Q. Diabetes runs in my family. How can I get my baby
tested for it?
Let’s discuss diabetes first.
Diabetes mellitus is a chronic disease due to impaired sugar metabolism.
There are two types (Type 1 and Type 2). They are divided by the cause of
the disorder and the treatment. Although both can be inherited diseases,
Type 2 tends to “run in families” more often.
Here is a brief explanation of the malfunction:
Since a person with diabetes doesn’t breakdown sugar properly, the sugar
ends up in vast quantities in the bloodstream. The body tries to eliminate the
sugar by filtering it through the kidneys and into the urine. The sugar pulls
excessive amounts of water with it into the urine. The result?
Elevated blood sugar level.
Excessive urination (with sugar found in the urine).
Excessive thirst to keep up with fluid loss in the urine.
Weight loss (from poor metabolism and fluid losses).

Type 1 Diabetes is also known as Juvenile Diabetes, or Insulin Dependent

Diabetes. This is an autoimmune disease—that means the cells in the
pancreas that make insulin get killed off by a person’s own body. Insulin is
the chemical in our body that metabolizes sugars.
There are some genes that have been identified in people with Type 1
diabetes and genetic defects can be passed on to offspring. Treatment is life-
long with insulin injections and dietary modifications. Onset of Type 1
Diabetes is usually around school age (six to seven years old). It is
extraordinarily rare to be diagnosed with diabetes while a child is still in
diapers.
Type 2 Diabetes is also known as Adult Onset Diabetes. This type of
diabetes is caused by the body’s impaired response to insulin—this
impairment is related to obesity.
As you can tell by the name, this USED to be an adult disease.
Unfortunately, there is a virtual “epidemic” today of Type 2 Diabetes in
preteens and teens. Children at risk are obese (defined as a Body Mass Index
greater than 85%—see Chapter 5, Nutrition and Growth for details on the
BMI) as well as other family members with Type 2 diabetes. Treatment
includes dietary modifications and medications taken by mouth. FYI: There
is a higher risk of developing this disorder among African-Americans,
Hispanics, and Native Americans. (Behrman)
Interestingly, there seems to be an increased risk of developing diabetes if
babies are exposed to wheat and barley before four months or after six
months of age. The theory is that introducing these foods too early or too
late can trigger an autoimmune response that damages the body’s insulin-
making islet cells. (Snell-Bergeon)

BOTTOM LINE
Diabetes is not a disorder of infancy. But, offering wheat and barley between
four and six months of age may prevent diabetes later on.
If you have a family history of diabetes it’s a good idea to watch your
child’s growth. Eating a healthy diet and avoiding obesity is even more
important in your family.
As your child gets older, a screening test for diabetes can be done by
obtaining a urine and blood sample.
For more information, check out this web site: diabetes.org.

Allergies

Q. My husband and I both have seasonal allergies.

What are the chances that our baby will have allergies?
50%.
For each parent who has allergies, a child has a 25% risk of developing
them himself. This refers to seasonal allergies, asthma and eczema. Some
doctors might also put food allergies on this list, too. The earliest
manifestations of an allergic child are eczema and food allergies. Asthma is
usually diagnosed after a year of age. Seasonal allergies come even later.
Reality Check
The hereditary patterns of allergies do not apply to drug allergies. Just
because you have an allergy to Penicillin doesn’t mean your child will have
one too.

Q. My baby seems to have a runny nose all of the time.

Does he have seasonal allergies?
No.
Allergies (“hay fever”) that cause a runny nose can be divided into
perennial (all year long) or seasonal categories.
Perennial allergies. These are year round allergies caused by
something a child is exposed to on a daily basis. This is something
inside your house, not outside your house. The most common causes
are dust mites or cat dander. Molds are found both inside and outside
the house year round.
Seasonal allergies. These are allergies caused by something that’s in
the air outside of your house. These pollens include weeds, trees, and
grasses that come in seasonal patterns. Most children under one year
of age do not get seasonal allergies. Allergies, by definition, are a
body’s hyper-response to an allergen they have seen before. In the
first year of life, a child has never seen these pollens before so there
is no response.

BOTTOM LINE
Newborns do not have seasonal allergies when they are congested for the
first six weeks of life. Nor does a nine month old have a ragweed allergy.
 Most of the time, a chronic runny nose is caused by one viral upper
respiratory infection after another. Although there are conflicting viewpoints,
some doctors feel that perennial allergies or food allergies may cause a
chronic runny nose year round in kids under age two.

Allergies over the years

FELINES ARE OUR FRIENDS

Although most people have heard that having a cat causes

allergies, recent research shows that early exposure (first year of life)
to cats and dogs may actually prevent allergies. Kids who grow up on
farms have significantly less problems with allergies, presumably due
to their constant exposure to animals and the germs they carry.
Helpful hint
For perennial allergies (for example, dust mites), allergists often recommend
plastic bedding covers, air filters, etc. These products are available through
medical supply companies. Check out the following resources for a product
catalog: National Allergy Supply, Inc. (800-522-1448, web: natlallergy.com)
or Allergy Asthma Technology Ltd. (800-621-5545, web:
allergyasthmatech.com).

Genitals

Q. My son is circumcised, but he doesn’t look

circumcised anymore. What do I do?
See Chapter 4, Hygiene for a frank discussion on PENILE ADHESIONS.
Some parents will comment that they see a white blister (called a bleb) on
the skin, or a red swollen area, or that the penis just doesn’t look right. These
are usually all the same problem. The white blister is dead skin that has
collected and is allowing the skin to stick together. The red swollen area may
be the penis trying to unstick on its own. The penis doesn’t look right
because you can no longer see the helmet part.
Q. The skin of my daughter’s genitals is sticking
together. My doctor said not to worry about it . . . but I
am worried.
Don’t worry. This is a common problem called LABIAL ADHESIONS. The
labia and vaginal areas stay lubricated and open when estrogen is being
produced. Young women produce estrogen when they start menstruating. So
pre-pubertal girls are prone to labial adhesions until they go through puberty.
The only time this is a problem is when the labia are so fused together
that the urethral opening is blocked too (that’s where the urine comes out).
See the nearby graphic to understand what we’re talking about.
Labial adhesions are treated by using a prescription estrogen cream twice
daily on the area for a couple of weeks. After that, apply petroleum jelly
(Vaseline) on a daily basis to keep the area moist and open. Very rarely, a
surgical procedure is necessary to open the area.

What’s that smell?

Have you ever gone to a wine tasting and tried to describe the “nose” of a
wine? When babies smell unusual, parents go to great lengths to come up
with adjectives to explain the odor to their doctor.
We hesitate to explain this category of disorders in a chapter entitled
“Common” diseases. But there are some very rare metabolic disorders that
are associated with unusual body odors. It is important that you are aware of
them, and seek medical care if you notice any of the following smells:
Body odors: Barn-like, mousy, musty, horsey, wolf-like, sweaty socks,
cheesy.
Breath odors: fruity/sweet, fishy, ammonia-like, clover, musty fish,
raw liver, foul.
Urine (pee) odors: mousy, musty, horsey, wolf-like, barn-like, maple
syrup, caramel, boiled Chinese Herbal medicine, yeast, celery, malt,
brewery, sweaty feet/socks, ripe cheese, tomcat urine, dead fish,
cabbage.
Stool (poop) odors: foul, vile. (Fleisher)

Note that other problems may cause you to turn your nose: poisonings
and infections.

BOTTOM LINE: Bad odors are worth checking out.

Now that you’ve been briefed on the most common diseases that affect
children, let’s talk the environment. The next chapter covers top
environmental health concerns, including food, water, air quality and more.
THE ENVIRONMENT AND
YOUR BABY
 Chapter 15

WHAT’S IN THIS CHAPTER

TOP HEALTH CONCERNS
FOOD: FORMULA, HIGH FRUCTOSE CORN SYRUP AND MORE
FISH
WATER
HOME: BPA, PHTHALATES, LEAD
FORMALDEHYDE
RADON
CRIB MATTRESSES
AIR QUALITY: INDOORS AND OUT
28 TIPS TO REDUCING ECO-HAZARDS

Before having a baby, you might have given only a passing thought or two
about how the environment affects your health. Like many things in your
life, however, a baby changes everything . . . including your perspective on
this topic.
Whether you are a card-carrying member of the Sierra Club or just an
occasional Whole Foods shopper, going green is now mainstream. Heck,
when even Wal-Mart has an organic produce aisle, you know things have
changed.
Just because folks are paying more attention to the environment doesn’t
change the rather stark facts about eco hazards: babies born today are
exposed to more environmental pollutants than any previous generation in
history. And babies are more susceptible than adults to adverse health
effects from these pollutants.
 Eighty thousand chemicals have been used in commerce since the
1960’s. Three thousand are used in high volume production of consumer
products and foodstuffs. Most of these chemicals were invented in the past
30 to 40 years. MANY of them have never been tested for their effect on
your health.
Even more scary: we don’t know basic toxic info on more than HALF of
these chemicals . . . and even less is known about how these chemicals
affect the development of young children. (Goldman) The American
Academy of Pediatrics issued an ultimatum in 2011: revamp the Toxic
Substance Control Act of 1976 to protect pregnant women and children
who are particularly vulnerable to the affects of toxic chemical exposure.
(AAP Council on Environmental Health) We are still waiting for our
government to respond . . . until then, figuring out what may have real
health concerns and how to reduce or limit our exposure is mission critical
for researchers.
Warning: This chapter may be hazardous to your mental health.
Environmental health is an emerging science. Many factors contribute to
certain diseases . . . so we cannot necessarily say exposure to pollutant X
causes disease Y. There are also more questions than answers, and more
shades of grey than pure black and white. As you know, we are fairly non-
alarmist folks who make recommendations based on solid scientific
evidence. However, when solid science is lacking, it’s more challenging to
offer advice.
Bottom line: we’ll try not to freak you out.
What’s important is that you weigh the evidence (or lack thereof) so you
can make a more educated decision if you are concerned about reducing
your child’s exposure to environmental hazards.
Our key goal: this chapter should help you consider the HEALTH risks
of various eco decisions (Organic versus regular milk? Should I get my
home radon tested?). Of course, many of these decisions have other
environmental factors (sustainability, etc.)—we’ll leave that discussion to
the numerous other books and web sites out there dedicated to living a
green life.
So, let’s get rolling. We have divided this chapter into four sections:
food, water, home and air (indoors and out). First, let’s talk about why
babies are vulnerable to eco toxins.
Q. Why are children vulnerable to environmental
toxins?
Babies and children are not little adults—their growing bodies work
differently. And while they may live in the same macro-environment as
their parents, they live in a completely different micro-environment (that is,
the carpeted floor of a home in Hometown, USA). This can make a
significant impact on what environmental hazards babies are exposed to on
a daily basis.
Here are the top nine reasons why the environment can be hazardous to
your baby’s health:

1.Breathing: Babies breathe at faster rates than adults, so they take in

more air. They also breathe lower to the ground where chemical
matter settles.
2.Fluid intake: For their body weight, babies drink the adult equivalent
of 1.75 gallons of fluid a day.
3.Food intake: For their body weight, babies eat three times more food
than adults.
4.Oral exploration: Babies stick stuff in their mouths—and it’s not
always food. So they are at risk of ingesting pollutants, like lead in
the soil.
5.Gut absorption: To add insult to injury, a baby’s gut absorbs more
toxins than an adult’s. Case in point: lead. A baby’s gut absorbs
50% of lead that’s been ingested, whereas the adult gut only
absorbs about 10%.
6.Surface area: Compared to adults, babies have twice the surface area
per pound to absorb chemicals.
7.Location: Babies spend many more hours on the floor, grass,
carpeting, and wood decking. These offer more opportunities for
exposure where chemical matter settles.
8.Developing bodies: Embryos, fetuses, babies, and young children are
uniquely sensitive to environmental exposures that can
permanently interfere with how organs and body systems develop.
 9.Lifetime burden: Babies born today have a longer lifespan, giving
them a longer opportunity for adverse health effects from
exposures to arise. (AAP)

Q. Where are these pollutants?

Well, they are lurking everywhere. That’s encouraging, huh? Sometimes
we think ignorance may be bliss. But seriously, it’s important to know
where the greatest potential health hazards lie, so you can limit your baby’s
exposure where possible in a practical way.
Food: Additives, antibiotics, hormones, arsenic, methylmercury,
PCB’s.
Water: Lead, methylmercury, industrial chemicals.
Home: phthalates, bisphenol-A (BPA), lead, arsenic, flame retardant.
Air: Radon, carbon monoxide, second hand smoke, radio
frequency/electromagnetic fields, industrial chemicals.

Q. What damage can they do?

Some exposures have very defined health risks. Others are a bit murkier,
or have only been proven to have adverse effects in animal studies—not
humans. Environmental health is a very young scientific field. Compared to
other fields, scientists have only just started to look at the effects of natural
and man-made environmental exposures. And while some health risks are
obvious (for example, smoking increases your risk of lung cancer) there are
very few long-term studies that have been able to tease out one individual
exposure as a direct cause of one particular disease.
Here is how the major categories of health risks are divided:
Carcinogens: These agents are known to cause cancer. (Examples:
arsenic, tobacco, solvents like benzene).
Mutagens: These agents increase the rate of change (“mutation”) in
genetic material. This can lead to defective cells and cancer.
(Example: ionizing radiation).
 Teratogens: These agents alter a fetus during development in the
womb. Abnormalities are present at birth. (Example: alcohol).
Neurotoxins: These agents damage or interfere with nerve/brain
function. (Example: lead, methylmercury, Polychlorinated
Biphenyls or PCB’s, organophosphate pesticides). The scary part:
there is a spectrum of neurotoxicity. Severely affected people will
have obvious symptoms. Those with lower amounts of exposure
may have more subtle symptoms such as a shorter attention span or
slightly lower IQ.
Endocrine disruptors: These agents mimic the body’s natural
chemical messengers (hormones) and can potentially interfere with
body responses in the reproductive system and thyroid gland.
(Example: phytoestrogen).
Irritants and allergens: These agents cause allergic responses in the
airway and/or the skin. (example: Volatile Organic Compounds or
VOC’s).

Q. What are the top health concerns?

Certain disease rates are on the rise. While we can’t blame the
environment for everything, these diseases are currently hotbeds of research
for the possibility of environmental triggers. These include:
Asthma.
Leukemia.
Male reproductive system problems such as testicular cancer in
Caucasian men (up 60% in the past 30 years), hypospadias
(abnormal penis development has doubled in the past 30 years), and
falling sperm counts.
Neurodevelopmental disabilities such as dyslexia, ADHD, and
Autism Spectrum Disorders.
Obesity.
 THE TOP TOXINS

Industrial chemicals
Toxins: polychlorinated biphenyls (PCB’s), dioxin, solvents.
Source: industrial waste.
Exposure: prenatal, breast milk, seafood, air.
Health Risk: lower IQ, lower developmental scores, endocrine
disruptor.

Pesticides
Toxins: organophosphate, organochlorine, pyrethroids,
carbamates, boric acid, copper chromium arsenate (CCA), N,N-
idethylm-toluamide (DEET).
Source: pesticides, insecticides.
Exposure: food, household exposure, water, air.
Health Risk: nausea, vomiting, muscle weakness, allergic
reaction, neurotoxin, carcinogen, endocrine disruptor.

Metals
Toxins: arsenic, cadmium, lead, manganese, methylmercury.
Source: contaminated water from industrial waste, old homes
with lead paint.
Exposure: food, water, blinds, treated wood, imported pottery,
toys/jewelry, lead pipes.
Health Risk: anemia, learning problems, kidney problems, lower
IQ, carcinogen.

Volatile Organic Compounds (VOC’s)

Toxins: benzene, xylene, styrene, formaldehyde, aliphatic and
aromatic hydrocarbons.
Source: household products, air pollution.
 Exposure: rug/oven cleaners, paints, lacquers, paint strippers, dry
cleaning.
Health Risk: nasal congestion, eye irritation, headache, nausea,
vomiting, possible carcinogen. (AAP)

Q. If I can’t avoid these pollutants, how much

exposure is acceptable and how much is “too much”?
Unfortunately, the threshold of “acceptable limits” of exposure changes
as more research is done. For instance, 40 years ago experts used to think
that some lead exposure (levels under 40 mcg/dl) was perfectly safe. We
now know that any level of lead exposure can have subtle, but permanent
effects on the brain. (Canfield) And for some pollutants, it also depends on
when the exposure occurs.

Food: Additives, Contaminants, Facts and Fables

Formula

Q. Does soy formula cause man boobs or ADD?

Soy formula has been through some controversies. Some researchers
think soy formula may interfere with reproductive or immune functions
when given in high doses to infants. Why? Soy formula contains
phytoestrogens, which is a plant version of estrogen. While this chemical
has been shown to lower the risk of certain cancers in adults, it is unclear
what effect it has on infants. However, there is NO proof that soy formula is
harmful to babies. In 2006, the Center for Evaluation of Risks to Human
Reproduction reviewed all the concerns regarding soy formula. One
committee member said it best, “After 40 years of soy exposure we haven’t
seen a blip on the radar screen. Right now, we don’t have a problem.” (Wall
Street Journal)
As for soy formula and Attention Deficit Disorder, this fear stems from a
study that purported to show a link between one ingredient in soy formula
(manganese) and neurological disorders like ADD. But let’s take a closer
look at that study. Researchers fed baby rats extremely high doses of
manganese—some 38 times greater than the level found in formulas.
Surprise! These toxic doses caused developmental problems in the rats. The
bottom line: Soy formula has been around for over 40 years and is
considered acceptable by both the AAP and the Food and Drug
Administration. If you give toxic doses of anything to rats (or people), bad
things happen to them! (Tran)

Breast milk contaminants

Q. I’ve heard there is rocket fuel in breast milk. Is it

true? Is it dangerous?
Perchlorate is an industrial pollutant, a byproduct of weapons, rocket and
fireworks production. Twenty states around the country (especially those
with military production facilities that made Cold-War era missiles and
rockets) have significant perchlorate pollution in local groundwater and
wells.
The health concern for babies: perchlorate exposure can interfere with
proper function of the thyroid gland. That in turn can lead to growth and
brain development problems.
Perchlorate has been found in more than just water—it’s also been
detected in cow’s milk-based formula and, yes, even breast milk. That’s
because the chemical has crept into the food supply chain.
So, what can you do to avoid perchlorate exposure? The answer: not
much.
There is currently no federal legislation that requires states to test their
water and ensure tolerable levels of perchlorate. That’s because the EPA
found that most water supplies do not have high levels of perchlorate.
However, individual states do have some regulations for perchlorate—
check with your local state or water district for details.
The hard truth: human breast milk also contains many other
environmental contaminants. No, it is not practical to test your milk for
these chemicals. And yes, it is still the healthiest form of food for your
baby! The benefits far outweigh the risks. And remember that the
alternative, infant formula, has a small amount of perchlorate too.

Organic Food

Q. Which fruits and vegetables contain the most

pesticides?
The Environmental Working Group (ewg.org or foodnews.org) has
compiled the “dirty dozen” list of produce that contains the highest
pesticide load. If you have an organic food budget (let’s face it, going
organic is very expensive), these would be the top organic foods worth the
splurge.
Here is the list, in order of the most to least contaminated:

#1 Peach
#2 Apple
#3 Sweet bell pepper
#4 Celery
#5 Nectarine
#6 Strawberries
#7 Cherries
#8 Kale
#9 Lettuce
#10 Imported grapes
#11 Carrot
#12 Pear
 Want to see the entire list of 47 produce items? Go to foodnews.org. You
can sign up for a free iPhone app or PDF of the Shopper’s Guide to
Pesticides and take it shopping with you.

Reality Check
It is widely accepted knowledge that children are more sensitive than adults
to many pollutants. When it comes to pesticides, children are about ten
times more sensitive. (AAP) The question that remains is if the pesticide
exposure in foods has significant adverse health effects. At the moment,
there is no major evidence of that. (Forman)

SIX WAYS TO REDUCE PESTICIDE EXPOSURE FROM

FOODS

Don’t want to spend your entire paycheck on organic groceries?

Here are some tips to reducing pesticide exposure:

1.Scrub produce with a brush under running water to get rid of any
obvious residue.
2.Peel whatever produce you can. (FYI: this often removes the fiber
benefit, though).
3.Don’t eat the outer leaves of leafy vegetables (e.g. lettuce, kale).
4.Grow your own garden and don’t use pesticides.
5.If you are buying imported produce, only purchase produce that
can be peeled.
6.Buy produce that is in season. (AAP)

Unfortunately, that doesn’t eliminate all the pesticides, but it

helps.
Q. Is it worth it to buy organic formula, milk and
dairy products?
Organic milk and dairy products claim to be free of pesticides,
antibiotics, and hormones. But organic milk can cost almost twice the price.
Is it worth the cost? As we’ve already discussed, children today are exposed
to more environmental pollutants than past generations. Is it worth it to
limit these exposures when it comes to milk?
First, let’s discuss the three questionable ingredients consumers are
concerned about in their milk and dairy products:
Pesticides: Pesticides are in both water and soil. So there will be some
in just about anything our children eat or drink (including breast
milk and yes, organic products). Organic milk promises to be
chemical free, but because chemicals remain in the soil for so long,
even organic milk may contain pesticides. Organic farmers may
also use organic pesticides. Bottom line: compared to say, apples,
the pesticide residue in all milk products is rather low.
Antibiotics: All milk products are screened for antibiotic residues. If
residue is detected (which happens in about 1 in 1000 tankers of
milk), the milk is rejected for sale. Hence, conventional milk
should also be antibiotic-free. Our concern here: even though the
finished product is antibiotic-free, antibiotic use in livestock is
contributing to antibiotic resistance. Doctors have tried to limit
antibiotic overuse in humans; it is time to reduce use in animals
too. Your grocery store purchases drive the marketplace. Bottom
line: while there is probably no antibiotic residue in milk, buying
organic milk encourages milk manufacturers to avoid using
antibiotics.
Hormones: Even in “juiced” cows, all milk has about the same
composition (see below for more discussion on bovine growth
hormone.).

So, is organic worth almost twice the price? If you look strictly at health
risks, organic milk doesn’t have much advantage over conventional milk
(with the possible exception of the antibiotic issue discussed above).
 To us, the main argument for choosing organic when it comes to
formula, milk, and dairy products is this: when it comes to young children,
dairy is their biggest food group. If you are going to spend your organic
dollars somewhere, this would be the most cost-efficient for the volume
your child consumes.

Q. Is it worth it to buy organic baby food?

There are three choices here: buy organic jarred baby food, conventional
jarred baby food or make your own.
The argument for making your own is simple: it is easy to do and costs
less than the jarred stuff. Plus your applesauce will just be applesauce (no
additives, sugar, etc).
But is using conventional jarred baby food hazardous to your baby’s
health? No. Processed food (including jarred baby food) is actually subject
to stricter federal regulation than fresh produce. So, jarred baby food should
have less pesticide residue than what you might find in the regular
(conventional) produce aisle. And some baby food manufacturers make
their products pesticide-free even if they are not labeled as “organic.” (AAP)
Bottom line: there isn’t much difference between regular and organic
baby food. If you decide to go organic, we advise you make your own
baby’s Food using organic fruits and vegetables (see the discussion earlier
for the fruit that’s most likely to have pesticide residue).

Q. Should I buy organic meat?

There are plenty of reasons to choose organic meat, but the key health
issue is antibiotics.
Antibiotics are given to healthy animals to prevent disease and improve
growth. In fact, at least 40% of the antibiotics used in the United States are
used in animals that are destined to become our next meal. Antibiotics used
in the food industry are indirectly a problem for humans because they allow
antibiotic resistant bacteria to evolve.
So while there is no direct health hazard from eating conventional meat,
there is an indirect health risk. If you want to buy antibiotic-free meat
simply on principle, look for meat labeled USDA Organic.

Q. I’ve heard rice cereal contains arsenic and it’s

dangerous. True?
Yes, arsenic has been found in baby rice cereal, as well as in brown and
white rice and other rice-containing products like rice milk and rice cakes.
Inorganic arsenic is a potentially harmful chemical that is all over our
universe, thanks to natural causes (like being part of the earth’s crust) as
well as human causes (like burning coal). Because of its ubiquitous nature,
it is in our air, water, and soil . . . and thus in our food supply. The arsenic
levels in a particular food can vary widely, depending on its origin.
Inorganic arsenic is known to cause cancer. It’s also possible that fetuses
and young children who are exposed to arsenic may have lower IQ scores.
(Centers for Disease Control)
However, the Food and Drug Administration has not advised people to
change their diets at this point. The FDA is looking into this further and
then will provide recommendations. You can keep tabs on them here:
fda.gov/forconsumers/consumerupdates/ucm319827.htm
Bottom line: Like all environmental health issues, it’s wise to limit
exposures whenever possible. It’s fine to give your baby products made out
of rice. But, providing a varied diet consisting of other grains will reduce
his arsenic intake.

RBGH
Q. Will my baby go through puberty early if she has
milk or yogurt with bovine growth hormone?
No.
Some dairy farmers give bovine growth hormone to lactating cows to
increase their milk production. There are no direct associations to early
puberty or cancer. All cows, in fact, make this hormone naturally. Even
though these cows are “juiced,” the composition of conventional milk vs.
organic milk is almost the same. Pasteurization destroys 90% of the bovine
growth hormone. Additionally, bovine growth hormone is species-specific.
So even if there is some bovine growth hormone in commercial milk, it
does not affect humans. (Forman)
Despite the lack of scientific evidence, consumer demand drives retail
decisions. Wal-Mart, Kroger, and Safeway brands are now all synthetic
bovine growth hormone-free. And Starbuck’s only uses hormone-free dairy
products at their stores.

Reality Check
Northern American girls have had earlier menstrual cycles since 1840 when
nutrition improved. Some experts think early puberty these days is due to
the obesity epidemic—which turns on hormones earlier than it should. So,
if milk is to blame at all, it’s because kids over age two are drinking whole
or 2% when they should be drinking skim! Also: puberty standards have
also changed over the years in the US to compensate for African American
girls who do tend to go through puberty earlier than Caucasians.

Q. Is it safe for my baby to eat genetically-modified

foods?
This is a hot topic in parenting circles. A quick primer on GMO’s:
humans have been genetically modifying foods since the beginning of time.
As technology has advanced, scientists have been able to splice genes of
seeds to make plants resistant to drought, disease and so on. This has
provided an abundance of food at a very low cost. That’s the good news.
Opponents of genetically modified foods (GMO’s), however are concerned
with the potential long-term health impacts of GMO foods and want
mandatory labeling of GMOs in foods. The battle over “Frankenfoods”
rages on.
So what does the science say? The FDA and the American Cancer
Society both say there are no concerns about potential health risks from
bioengineered foods. Meanwhile, baby food companies like Gerber are
responding to consumer concerns by only using non-genetically modified
ingredients. Whole Foods plans to label all genetically-modified products in
their stores by 2018.
Here’s our take: so far, there is no science to support fears that GMO’s
are dangerous. No child has become sick from eating baby food made from
genetically modified organisms. So avoiding GMO foods is a personal
preference—if you go this route, look for “non-GMO” or “100% certified
organic.”

Nitrates

Q. I’ve heard it’s not safe to make your own baby food
out of carrots, beets, and spinach. Is this true?
No, that is false.
It is safe to make your own baby food out of root and leafy vegetables.
Just don’t offer those food items to babies under three months of age
because their guts are too immature to appropriately breakdown a chemical
called nitrates. (This should be a non-issue, because we don’t recommend
starting solid food until at least four to six months of age).
Nitrates are the product of nitrogen fertilizer and animal waste
breakdown that ends up in our water supply and soil. Nitrates aren’t toxic,
but the bacteria in a baby’s gut converts them to nitrites, which can be a
health hazard. Nitrites interfere with the oxygen carrying capacity of red
blood cells, and can cause Blue Baby Syndrome
(METHEMOGLOBINEMIA).
Bottom line: You can make your own baby’s Food out of beets, broccoli,
cabbage, carrots, and spinach as long as your baby is at least four months
old.
FYI: If you have well water and a septic system, be sure to get it tested
for nitrates. You don’t want to give this to a baby under three months of age
for the same reasons outlined above!
High fructose corn syrup

Q. Is high fructose corn syrup safe?

Yes, it’s safe.
High fructose corn syrup (HFCS) is found in many processed foods,
from soda to pancake syrup. Over the years, HFCS has replaced many other
types of sugar in foods for one simple reason: it’s cheap.
At the same time, however, concerns have been raised about HFCS: is it
contributing to our nation’s obesity epidemic?
Here’s the latest science: high fructose corn syrup does not cause obesity
or any other malady.
However, like natural sugar, you should limit how much HFCS you offer
to your baby. And since HFCS is found mostly in processed foods, it is
more nutritious to stick with fresh foods for overall health reasons.

Reality Check
A recent study found that countries with HFCS-containing food supplies
have 20% higher rates of Type 2 Diabetes. In short, processed-food-loving
Americans have the highest rates of Type 2 Diabetes. It’s not necessarily the
HCFS that is the problem, but the types of diets that are rich in HCFS.

Q. Does high fructose corn syrup (HFCS) cause

autism?
No.
This novel theory sprung from the blogosphere in 2009. Some autism
advocates claim HFCS is contaminated during the manufacturing process
with mercury. While it is true that some food makers use strong chemicals
to clean equipment, that doesn’t mean HFCS is contaminated with mercury
or any other chemical. And, no, mercury poisoning does not cause autism
either!

Artificial sweeteners

Q. Do artificial sweeteners cause cancer?

No. The U.S. National Toxicology Program says that consumption of
Splenda, Nutrasweet, Equal, and Saccharin has no increased risk of cancer.
Saccharin can cause bladder stones that lead to cancer in rats, but not in
humans.

Food coloring

Q. Does food coloring cause Attention Deficit

Disorder?
Several years ago, scientists looked at a possible link between food
coloring and attention problems. The “Feingold Hypothesis” failed to pan
out and the theory basically died. In 2007, researchers resuscitated this
theory in a study published in the journal Lancet. Children who drank
beverages with red or yellow dye, or sodium benzoate (a common
preservative) had more hyperactive behavior than their peers. Kids who
drank sugary drinks had no change in their behavior, by the way.
The FDA looked at this question a few years ago and did not find an
association between artificial food coloring (AFC) and ADHD, but noted
that a small number of children are intolerant to AFC and exhibit behavioral
changes. We don’t recommend changing your life on the basis of one study,
but it’s not a bad idea to limit processed foods (which usually contain food
coloring and preservatives).

Grilling
Q. Is it okay for my baby to eat grilled foods? Does
BBQ cause cancer?
Cooking foods quickly at high temperatures—by grilling, frying, or
broiling—produce heterocyclic amines (HCA). HCA’s are on the National
Institutes of Health’s list of chemicals “reasonably anticipated to be
carcinogens.”
However, we believe it is okay to enjoy BBQ in moderation. Here are a
couple of tips:
Certain foods produce more HCA’s than others. Chicken produces the
most, hamburgers the least.
Fat drippings on the grill create (warning: big chemical word ahead)
polycyclic aromatic hydrocarbons (PAH). These are also
carcinogens. Charred meat has more PAH’s . . . so, it’s wise to limit
fat drippings and scrape off any charring.

Sodium nitrate

Q. I’ve heard that lunchmeats and hot dogs processed

with nitrites/nitrates are dangerous. Is it worth it to
buy preservative-free meats?
Sodium nitrite keeps you from getting botulism from a frankfurter or
other processed meats like lunch meat, bacon, ham, and smoked fish. It also
makes the meat look more appetizing (otherwise your hotdog would look
sickly grey).
The health concern: nitrites can convert to nitrosamines, which are
known animal carcinogens (but only potentially carcinogenic in humans).
U.S. food manufacturers now add ascorbic acid or erythorbic acid to nitrite-
containing meat products, which prevents that chemical conversion to
nitrosamines. So the health concern is much lower now than twenty years
ago.
 However, processed meats like hot dogs and lunchmeats contain more
salt (and often more fat) than unprocessed, preservative-free products. For
that reason alone, we recommend limiting them in your baby’s diet. (CSPI)

Fish

Q. I’ve heard there is mercury in certain types of

seafood. How can I reduce my baby’s exposure?
Yes, fish can absorb methylmercury from coal-fired power plant waste
that ends up in nearby rivers, lakes, and oceans. And excessive
methylmercury intake during brain development of a fetus or young child
can lead to language, attention, and memory problems. In addition to
methylmercury, seafood can also be contaminated with polychlorinated
biphenyls (PCB’s).
However, fish is also a very healthy food choice and contains Omega 3
Fatty acids that promote brain development.
So, how do you avoid toxins in fish? Stick with the safest fish and avoid
risky varieties:

Safest fish:
Butterfish, catfish, domestic crab, crawfish, shrimp, fresh or canned
salmon, pollock, tilapia, whitefish.
Freshwater trout.

Risky fish:
Freshwater fish (with the exception of trout) are more likely exposed
to industrial waste products.
Predators (shark, swordfish, tuna, king mackerel, tilefish) who live a
long time build up methylmercury.
Fatty fish (mackerel, carp, catfish, lake trout) are more likely to
contain PCB’s.
 If you are really interested, you can see how much methylmercury is in
fish at this website: cfsan.fda.gov (click on seafood). And if you want a
handy wallet card to take to the grocery store with you, check this out:
nrdc.org/health/effects/mercury/walletcard.PDF
Here are some specific recommendations on fish for both your baby and
you if you are breastfeeding:
Completely avoid eating shark, swordfish, mackerel, and tilefish.
Eat less than 12 ounces a week of shellfish, canned fish, small ocean
fish, or farm-raised fish.
Eat six ounces or less a week of white albacore tuna. Canned light
tuna, and specifically Carvalho Fisheries and King of the Sea are
lower in methylmercury.
Eat six ounces or less of local fish if you are unsure of local water
contamination. (FDA)

Home

Water

Q. Is it worth it to get a water filtration system?

It depends on the type of system. Those little filters that attach to faucets
aren’t going to do very much. Tap filters may remove lead and other toxins,
but not excessive fluoride. And if you don’t take care of them properly and
replace the carbon filters regularly, bacteria will end up growing in the
filters.
Our advice: It’s cheaper to merely run your tap water for two minutes in
the morning before you use it—that flushes any lead out.
Reverse osmosis filters do remove both toxins and fluoride—but these
are much more expensive and need to be installed house-wide.
Here’s our recommendation: get your community’s water quality report
(most are posted online on water company home pages). If your community
has a serious problem with contamination, then a whole-house reverse
osmosis filter would be a useful investment. The same is true if you are
relying on well water: get it tested and treat it if necessary.

Bisphenol-A (BPA)

Q. Are plastic baby bottles safe? Do I still need to

worry about BPA?
Prior to 2009, all the best-selling clear, hard plastic baby bottles were
made of polycarbonate, which contained a chemical called Bisphenol A
(BPA). It is the BPA that makes the hard, clear plastic bottles . . . well, hard
and clear. BPA is also used in the linings of cans for liquid foods (more on
that later).
BPA’s chemical bond with polycarbonate breaks down over time,
especially with repeated washing or heating of the bottle. As a result, BPA
leaches out of the plastic and ends up in the liquid—that is, the breast milk
or formula.
BPA is an endocrine disruptor. It can mimic the natural female sex
hormone, estradiol. While most data about BPA comes from animal
research, these studies show even low level exposure of BPA may be linked
to everything from early puberty and breast cancer, to attention and
developmental problems.
We don’t know all the answers about BPA—the research is evolving.
But, the FDA banned BPA in baby bottles and sippy cups in 2012 over
potential health concerns. When you go bottle shopping today, the plastic
bottles you see in major chain stores are all BPA-free. As long as you don’t
use hand-me-down baby bottles, you should be in the clear.

Q. How do you lower your exposure to BPA?

The National Toxicology Program has these recommendations to reduce
BPA exposure:
 Avoid plastic containers with #7 on the bottom (some—but not all—
that have a #7 recycling number may have BPA).
If you own polycarbonate plastic containers, do not wash them in the
dishwasher with harsh detergents.
Do not microwave polycarbonate plastic food containers. BPA may
break down from repeated use at high temperatures.
Eat less canned food. Opt for fresh or frozen foods.
Use glass, porcelain, or stainless steel containers, particularly for hot
food or liquids.

Phthalates

Q. There’s buzz about other harmful plastics. What

should I know to protect my baby?
The other big plastic issue you should be aware of: phthalates.
Phthalates are plasticizers that make plastic soft and durable. The health
concern? Phthalates are considered endocrine disruptors (weak estrogens
and androgen-blockers) and animal carcinogens. While there is much
controversy about phthalates, there is still no scientific consensus that they
are dangerous to humans.
Phthalates are used just about everywhere. For example, you’ll find them
in plastic cooking wrap, plastic food packaging, baby shampoos, diaper rash
creams, and toys. Phthalates can be both ingested and absorbed through the
skin. Babies have been found to eliminate the breakdown products of
phthalates in their urine.
The good news: both the U.S. and Canada require toys and products that
are intended for use in the mouth (pacifiers, teething toys, bottles) to be
phthalate-free. And newer U.S federal legislation has tighter restrictions on
phthalate use.
The Consumer Product Safety Commission is in charge of enforcing this
ban, and for the record, do not find a significant health risk to young
children. According to the CPSC, a child would have to suck/mouth a
phthalate-containing toy for at least 75 minutes a day to have any
significant health consequences.
Our advice: If you want to reduce phthalate exposure, use a napkin or
paper towel when you heat food in the microwave and do not use second-
hand soft plastic toys.

Lead

Q. Is it safe to decorate with holiday/Christmas lights?

Yes.
Readers have asked about this after seeing holiday lights sold in the state
of California plastered with a warning label about lead. So is the lead in
holiday lights dangerous? And why is it there in the first place?
Lead is used in the manufacturing process of holiday lights to stabilize
the plastic bulbs (so the plastic doesn’t burn and set your tree on fire). The
lead acts as a flame retardant—which is a good idea.
Bottom line: unless your baby is eating or chewing on holiday lights, she
is NOT in any danger of lead poisoning.

Q. Because of the lead toy scare, I am hesitant to buy

toys for my baby. How can I be sure they are lead-free?
In response to the Toxic Toy Fiasco of 2007, Congress passed a
Consumer Product Safety Improvement Act. This law requires toys and
products intended for use by children under 12 years of age to contain less
than 0.009% lead. The law also requires testing for lead and other heavy
metals.
New children’s products (including toys) made after February 2009 are
required to be certified to meet this new standard—this includes both
American made and imported items.
The best course: buy NEW toys, certified to meet the current standards.
All toys sold in major chain stores would qualify. Avoid hand-me-downs
from friends, relatives or older siblings.
Q. Are there any other sources of lead exposure I
should know about?
Yes.
Here’s a surprise: your garden hose most likely contains lead. Lead is
used to stabilize the hose material (which is made of polyvinyl chloride).
If water has been standing for a while in the hose, the lead concentration
in the water is higher. If you are filling up a baby pool in your backyard
with that garden hose, you should let the water run for a minute before you
start filling. Yes, your baby will probably play and drink that water. If you
are in the market to buy a new garden hose, buy one that is labeled “safe for
drinking”.
We discuss lead exposure in old homes in Chapter 14, Diseases.

Formaldehyde

Q. I saw a news story about formaldehyde in baby

shampoo and other hygiene products. Are these safe
for my baby?
Yes.
In very small amounts, formaldehyde is not considered a health hazard.
For example, it is used in mascara, paper towels, and carpeting. There is
also a trace amount in some vaccines.
Concerns about formaldehyde in baby care products arose after a 2009
study by the Campaign for Safe Cosmetics, an environmental advocacy
group. The study found that half of the baby products tested (shampoo,
soaps, lotions, diaper wipes) contained some formaldehyde.
We should note that none of these products intentionally add
formaldehyde. The chemical is a byproduct of the production process.
Among the more ironic findings: the product that had the most
formaldehyde was Huggies Naturally Refreshing Cucumber & Green Tea
Baby Wash!
 Bottom line: this is not a serious health risk.

Cleaning products

Q. Are cleaning products safe to use?

Home cleaning products have been scrutinized in recent years, as an
entire industry has grown around eco alternatives to conventional cleaning
chemicals.
So is there a health risk here? Well, if your baby accidentally inhales,
drinks, or bathes in a cleaning product, that’s a real problem. Yes, they are
toxic and, in some poisoning situations, fatal.
As for other potential health hazards from everyday, appropriate
use . . . that’s a bit more difficult to say. At this point, there’s no scientific
evidence linking everyday use with health problems.
If you’d prefer to go the green route, check out web sites like
EarthEasy.com for extensive lists of eco alternatives and homemade recipes
for cleaning products.
Want to know what’s in your common household cleaning products?
Check out the National Library of Medicine’s website at hpd.nlm.nih.gov
for details.

Carpeting

Q. Is it safe to install new carpeting in our home?

New carpeting, as well as the padding and adhesive that goes with it, can
release Volatile Organic Compounds (VOC’s). VOC’s can irritate eyes,
nose and/or throats as well as cause coughing or trouble breathing.
Also: carpeting is a nice place for pesticide residue, molds, and dust
mites to settle. This is the same place your baby will be crawling and rolling
for several hours a day. Our advice: considering putting down a playmat or
washable area rug over the carpeting in rooms where baby plays.
Q. Is it safe to get my carpets cleaned?
You may have heard the claim that carpet cleaners causes Kawasaki
Disease (KD; an immune disorder that causes blood vessel swelling).
However, scientific evidence suggests that an infectious agent causes KD,
not carpet cleaning.
Although carpet cleaners do not cause KD, it’s still a good idea to wait
until your carpets are completely dry before your baby plays there. You may
also want to use a no or low solvent cleaner.

Pesticides

Q. Is it safe to use pesticides in our home?

Here is what we know for certain, according to the Centers for Disease
Control: “Home pesticide use overall has been linked to childhood cancers
such as soft tissue sarcomas, leukemias, and cancer of the brain.” Some
studies have specifically linked organophosphate pesticides to lymphoma
and leukemia, but the study results are controversial and inconclusive.
(CDC)
We’ve got some tips to reduce your child’s exposure: If you have to use
pesticides, set traps or treat the outside of the house first. This should be
done BEFORE use of any an indoor insecticide spray or “bombs.” The
pesticide residue will collect on upholstery, rugs, carpeting, and even
stuffed animals. And only treat for pests when there is a problem. Skip
scheduled or routine pesticide applications.
It’s also a good idea to avoid doing routine pesticide treatments on your
lawn—only treat your lawn when there is a problem.

Q. Is it safe to use insect repellent on our baby?

Yes, we cover this answer in detail in Chapter 4, Hygiene.
Radon

Q. Should I have my home tested for radon?

Yes.
Radon is an odorless, colorless, tasteless radioactive gas formed from the
decay of naturally occurring uranium in the earth’s rocks, soil, and water.
Radon gets into homes from cracked foundations, granite walls, and porous
cinderblocks. Exposure is usually more of a problem in homes with
basements.
Because radon exposure is a known carcinogen, you should get your
home tested. For more info, check out the Environmental Protection
Agency’s website at epa.gov/radon or call 800-767-7236. (AAP)

Crib mattresses

Q. Are organic crib mattresses safer than traditional

mattresses?
In short, no.
Yes, conventional crib mattresses do utilize synthetic ingredients such as
polyurethane foam, polyvinyl chloride (aka vinyl), phthalates, and flame
retardants.
Rumors have circulated the Internet for years that sleeping on a
conventional crib mattress was related to Sudden Infant Death Syndrome
(SIDS). The theory: inhaling all the fumes from a traditional mattress
caused SIDS. Scientific research has debunked this theory: SIDS is NOT
caused by foam or coil crib mattresses.
However, we understand why parents would want to limit exposure to
these chemicals—and let’s face it, your baby will spend a good amount of
time on his mattress.
An entire alternative crib mattress industry has sprung up in recent years
to fill this demand—companies are now selling “organic” mattresses filled
with soy-based foam, latex, coir (coconut husks) and more. Most of these
mattresses are covered with organic cotton covers or food-grade
polyethylene plastic. And, of course, these mattresses are much more
expensive than traditional crib mattresses: $300 to $600, compared to
conventional mattresses that start at $100.
One major negative to some organic mattresses: some have covers that
are NOT waterproof. As you probably can guess, diapers leak, babies spit
up (and more) in their crib. A waterproof cover is critical to keep bacteria
from growing inside the mattress. Hence some folks buy an all-organic
mattress but then use a waterproof protector that contains many of the same
“bad” chemicals they were trying to avoid in the first place.
So where’s the science that says organic is better for mattresses? There
isn’t much. Most of the “proof” circulating around the web comes from a
company in New Zealand, which is selling its own special mattress cover
which it claims protects against SIDS.
Our opinion: we don’t think an organic mattress is going to reduce the
risk of SIDS. If you buy an organic mattress and don’t have a waterproof
cover, the occasional pee that escapes the diaper will enter your organic
mattress and leave a nice nesting ground for bacteria. (Sherburn)
Bottom line—here’s what we’d recommend:
Get a mattress with a vinyl cover that is triple-laminated (basically
thicker). The cover should be listed as waterproof, not just water
resistant.
Use a waterproof pad over the mattress. Some “sheet savers”
(Ultimate Crib Sheet) have waterproof backing that would provide
extra protection to keep liquid out of the mattress.
Don’t use a hand-me-down mattress, since it might have not been
water-protected.
Consider changing out the mattress with each child (new baby, new
mattress). No matter how hard you try, some leakage might happen.
If you want to limit chemical exposure, look for mattresses that are
GREENGUARD certified. These mattresses are tested to meet
strict standards for low chemical emissions.
Q. Is it safe to have a sandbox for my baby?
Here’s the health concern for sandboxes: synthetically-made play sand
can contain asbestos-like fibers. Asbestos is a known carcinogen (exposure
can cause cancer later in life). Real sand from the beach is fine.
Except for the state of California, manufacturers do not have to list
whether or not the sand is real or synthetic, and whether or not it is
asbestos-free. Our advice: buy only natural river, beach, or silica-based
products for your baby’s sandbox. If you know where the sand is coming
from, go for it. (AAP)

Q. Are chlorine-free diapers any safer for my baby?

There are no adverse health effects from conventional disposable diapers
that contain chlorine. Deciding whether or not to buy chlorine-free diapers
is more of an eco decision than a health one.

Air: indoors and out

Carbon monoxide

Q. Should I install a carbon monoxide detector?

Yes.
Carbon monoxide poisoning can be quite serious. It’s health effects can
range from headaches and dizziness to coma and even death. People are
exposed to carbon monoxide from woodstoves, fireplaces, charcoal grills,
poorly ventilated combustion appliances, motor vehicle exhaust, and
tobacco smoke. (AAP)
Bottom line: it’s wise to have a detector in your home, since carbon
monoxide is odorless and invisible. Be sure to get one that is UL certified.
Good brands include American Sensors and Kiddie; check
ConsumerReports.org for the latest ratings.
Tobacco smoke

Q. If I smoke outside the house, my baby will not be

exposed to secondhand smoke, right?
Wrong. Sorry to ruin the fantasy here but . . . your baby is very likely to
be a secondhand smoker unless you wear a towel over your head and
clothing while you are smoking outside. The smoke is pervasive and will
settle on your hair and clothing. Once you re-enter your house and pick
your baby up onto your chest or shoulder, your baby will be breathing in the
particulate matter from the smoke.
Besides the obvious long-term health hazards to a child, the immediate
health consequence is often wheezing. Babies and young children exposed
to tobacco smoke are more likely to have symptoms of asthma.

Factoid: Poor air quality has a direct link to asthma. Air pollution can cause
new cases of asthma—and can trigger symptoms in people with existing
asthma. Clearly, there is a genetic susceptibility (that is, you have a greater
chance of having asthma if other family members have asthma/allergic
disorders). But environmental pollutants don’t help.

Electric and magnetic fields

Q. I worry about exposing my baby to electric and

magnetic fields. Should I worry?
Electro magnetic fields (EMF’s) are invisible lines of force created by
electric charges. Power lines, electric appliances, cell phones (and towers),
the earth’s magnetic field, and even humans, emit these EMF’s.
Low frequency fields don’t have enough energy to cause damage to you
or your baby’s DNA or body organs. (NIH) Hence, your hair dryer, coffee
maker, and microwave are probably safe. But researchers continue to look
at possible connections between EMF’s (including cell phone use) and brain
tumors and certain types of leukemia. At this time, many experts believe
that cell phones do not emit enough energy to damage human DNA. The
greatest concern is the distance of the body organ (example, the brain) from
the EMF source (say, the cell phone).
One suggestion to avoid EMF exposure via cell phones: use a hands-free
device or Face Time grandma instead (assuming she is tech-savvy!) It’s not
a bad idea for you to do this as well. (American Cancer Society)

Ionizing Radiation

Q. My baby hit his head and the ER doc wants to do a

head CT scan. Is there a health risk from the
radiation?
Short answer: yes.
Long answer: While the risks from ionizing radiation are low, we know
that children are more radiosensitive than adults. Studies show that a child
who has two to three head CT scans has a three times greater risk of
developing a brain tumor later in life.
Clearly, doctors should only recommend an imaging study that involves
ionizing radiation when it is absolutely necessary. And they should lower
the radiation settings or opt for non-radiation imaging (ultrasound, MRI
scans) if possible. In this scenario, the head CT scan is the right thing to do
if your child has sustained a significant head injury or has an abnormal
neurologic examination.

28 tips for reducing eco hazards

We know that going green can sometimes be impractical and costly.

Here are some easy, common sense things you can do to reduce your
family’s exposures to environmental pollutants.
1 HAVE FORCED AIR FURNACES, FUEL-BURNING APPLIANCES (gas
water heaters, stoves, clothes dryers) PERIODICALLY CHECKED by a
professional as the manufacturer recommends.

2 PILOT LIGHTS PRODUCE CARBON MONOXIDE SO MAKE SURE THEY

ARE WORKING PROPERLY.

3 DON’T USE GAS STOVE TOPS OR OVENS AS A HEAT SOURCE.

4 VENTILATE SPACE HEATERS PROPERLY.
5 DON’T USE HIBACHIS OR BBQ GRILLS INDOORS.
6 DON’T LEAVE A CAR RUNNING IN THE GARAGE, even when the door is
open.

7 LIMIT THE AMOUNT THAT YOUR BABY TALKS/LISTENS DIRECTLY ON

YOUR CELL PHONE.

8 LIMIT THE TIME/INCREASE THE DISTANCE BETWEEN YOUR BABY

AND SMALL APPLIANCES.

9 IF YOU HAVE TO USE PESTICIDES, set traps or treat the outside of the
house instead of using an indoor insecticide spray or “bomb” indoors. The
pesticide residue will collect on upholstery, rugs, carpeting, and even
stuffed animals.
10 TREAT FOR PESTS ONLY WHEN THERE IS A PROBLEM. Skip
scheduled or routine pesticide applications in your home and on your lawn.

11 SCRUB PRODUCE WITH A BRUSH under running water to get rid of

any obvious residue.

12 PEEL WHATEVER PRODUCE YOU CAN. (FYI: this often removes the
fiber benefit, though).

13 DON’T EAT THE OUTER LEAVES OF LEAFY VEGETABLES (for

example, lettuce, kale).

14 GROW YOUR OWN LITTLE GARDEN, AND DON’T USE PESTICIDES.

15 IF YOU ARE BUYING IMPORTED PRODUCE, ONLY PURCHASE
PRODUCE THAT CAN BE PEELED.

16 BUY PRODUCE THAT’S IN SEASON.

17 COMPLETELY AVOID EATING SHARK, SWORDFISH, MACKEREL,
AND TILEFISH.

18 EAT LESS THAN 12 OUNCES A WEEK of shellfish, canned fish, small

ocean fish, or farm-raised fish.

19 EAT SIX OUNCES OR LESS A WEEK OF WHITE ALBACORE TUNA.

Canned light tuna, and specifically Carvalho Fisheries and King of the Sea
are lower in methylmercury.
20 EAT SIX OUNCES OR LESS OF LOCAL FISH if your community’s
fishing advisories are unknown.

21 AVOID PLASTIC CONTAINERS WITH #7 ON THE BOTTOM (some—

but not all—that have a #7 recycling number may have BPA)

22 IF YOU OWN POLYCARBONATE PLASTIC CONTAINERS, DO NOT

WASH THEM IN THE DISHWASHER WITH HARSH DETERGENTS.

23 DO NOT MICROWAVE POLYCARBONATE PLASTIC FOOD

CONTAINERS. BPA may break down from repeated use at high
temperatures.

24 EAT LESS CANNED FOOD. Opt for fresh or frozen foods.

25 USE GLASS, PORCELAIN, OR STAINLESS STEEL CONTAINERS,
particularly for hot food or liquids.

26 CONSIDER USING MORE ECO-FRIENDLY CLEANERS.

27 RUN YOUR TAP WATER FOR A COUPLE OF MINUTES IN THE
MORNING BEFORE USING IT.

28 DON’T SMOKE.
Here are some useful websites if you are looking for additional info:
Environmental Health and Toxicology of the National Library of
Medicine www.sis.nlm.nih.gov/enviro.html
 Household Products Database householdproducts.nlm.nih.gov

We dedicate this chapter to Michael Shannon, M.D., FAAP. Thank you

for your sage advice and guidance. You are missed.
BABY
411
 Section 5

First Aid
Top 12 Problems & Solutions
FIRST AID
PROBLEMS & SOLUTIONS
 Chapter 16
“It's no longer a question of staying healthy. It’s a question of finding a
sickness you like.”
~ Jackie Mason

WHAT’S IN THIS CHAPTER

1. YOUR FIRST AID KIT
2. TAKING VITAL SIGNS
3. THE TOP 12 PROBLEMS & SOLUTIONS
ABDOMINAL PAIN
ALLERGIC REACTION
BLEEDING AND BRUISING
BREATHING PROBLEMS (RESPIRATORY DISTRESS)
BURNS
DIARRHEA AND VOMITING
FEVER
POISONING
RASHES
SEIZURES
DOES IT NEED STITCHES?
TRAUMA (ACCIDENTAL INJURY)

Are you afraid your pediatrician will fire you for calling too much?
Although doctors entertain this thought occasionally, we never act on it
(well, almost never). Phone calls are a part of the job. Most phone calls
come from new parents. You are not alone.
 The purpose of this chapter is to help you troubleshoot the most common
problems you will encounter on the front line of your baby’s medical care.
It should help you determine when to call the doctor. It also prepares you
for what the doctor will ask when you call.
This chapter does not replace the need to check in with your doctor. Pick
up the phone if you are worried. But being educated helps you worry less
and trust your instincts more.

Helpful Hints
On Call Etiquette
How can you make the most of a call to your baby’s doctor? As a doctor
who has spent one third of her life on call, here are some important points
to consider:

1 THE ON-CALL DOCTOR IS NOT IN THE OFFICE. Doctors leave the office
at the end of the workday and carry a cell phone for after hours calls.
Doctors also go to sleep. (It’s often disrupted sleep—but we try). If you call
about your child’s diaper rash at 2 am, the doctor won’t be as perky as when
you call during office hours. (FYI: Some offices utilize nurse call centers to
handle minor middle-of-the-night questions and save the more pressing
emergencies for the physicians.)

2 TELL THE ON-CALL DOCTOR ABOUT PAST MEDICAL PROBLEMS. Most

pediatric and family doctor practices have SEVERAL doctors on staff.
After hours, there is usually one doctor (who picks the short straw) that is
on-call. This may or may NOT be your regular doctor. As a result, the on-
call doctor may not know your child. If the practice has an electronic health
record and the on-call doc can access it from home, then he might be able to
see your child’s chart. But, as a general rule, assume that he doesn’t. (Nurse
call centers don’t have access to your child’s chart either.) Explain any
previous medical problems, surgeries, or hospitalizations. It might have a
bearing on the particular problem at hand.

3 TELL THE ON-CALL DOCTOR ABOUT ALLERGIES TO MEDICATIONS. If

your child has an allergic reaction to a medication, put it in YOUR family
medical records. Don’t rely on an on-call doctor or your pharmacy to know
this information.
“The pink medicine” or “some antibiotic” is not adequate. Most doctors
inquire about drug allergies before any medicine is prescribed—but we
appreciate it if you tell us.

4 HAVE A PHARMACY PHONE NUMBER READY. Yes, many docs have

smartphones and can Google a pharmacy phone number—but it is helpful if
you have your preferred pharmacy phone number available for us. Often,
there is more than one Walgreen’s on a major street, so being as specific as
possible is helpful. That way, I can call in your prescription after I talk with
you.

5 DON’T CALL FOR REFILLS, REFERRALS, OR APPOINTMENTS AFTER

HOURS. Universal doctor rule—we don’t do these things without patient
charts or schedules available. Medical emergencies are the only exception
to this rule.

6 DON’T LEAVE YOUR HOUSE OR GET ON THE PHONE AFTER PAGING

US. Believe it or not, this happens. If it’s truly an emergency, keep your
phone line clear or your cell phone within reach. During cold and flu
season, it may take a while for the doctor to return your call (the on-call
doctor may get several calls per hour). But we appreciate it if we can get
through to you when we call you back.

7 DON’T USE CALLER ID TO CALL THE ON-CALL DOCTOR BACK WITH

ANOTHER QUESTION. Okay, for the doctor, this is just creepy. If you call
back through the appropriate answering service or voicemail system, you
will always get your call returned. There is a protocol for a reason, folks—
there is often a queue of patients who may need callbacks. If your caller ID
shows the doctor’s home or cell phone number, don’t use it.

8 DON’T EXPECT OR DEMAND THAT ANTIBIOTICS BE PRESCRIBED

OVER THE PHONE. There is a good reason why antibiotics aren’t available
over the counter. A child needs to be seen to make a diagnosis of a bacterial
infection. Remember the drug-resistant bacteria problem. (This is
mentioned in Chapter 13, Infections). Doctors usually prescribe “supportive
relief” (such as acetaminophen (Tylenol)) until your child can be evaluated.

9 IF YOU HAVE A QUESTION ABOUT A MEDICATION, HAVE THE BOTTLE

IN HAND WHEN YOU CALL. Just common sense here. We will probably ask
you to read the information on the bottle to us.

Q. What should I have in our first aid kit at home?

Here is your grocery list:

Band-Aids (lots of them—they become badges of courage)

sterile, non-stick dressing and tape
“butterfly” bandages or thin adhesive strips
Ace wrap
a roll of gauze dressing
rectal thermometer
petroleum jelly
acetaminophen (Tylenol)
ibuprofen (Motrin, Advil)
antibiotic ointment
diphenhydramine liquid (Benadryl)
saline nose drops (home made or store bought)
decongestant nose spray (Afrin)
 1% hydrocortisone cream
A list of emergency phone numbers, including the National Poison
Control Center (800-222-1222) or your local poison control number.
baking soda
tweezers
measuring spoon, cup or dropper; you’ll want one with cc/ml
measurements for those tiny infant doses. (See Chapter 5, Nutrition &
Growth for a list of common measurements)

Q. Should I take a CPR course?

Yes!
Learn how to handle emergencies before they happen. Even if you can’t
remember exactly what to do, you will be more prepared to take action if
something bad happens.
It’s also helpful to learn how to take your child’s vital signs. This
information is very useful for when you call your doctor for advice.

Q. How do I take my child’s vital signs?

Vital signs include the heart rate (pulse), respiratory rate (breaths per
minute), temperature, and blood pressure. The only thing you cannot do at
home is the blood pressure.

1.Temperature: Know how to take a rectal temperature. (See fever

section later in this chapter for details.)

2.Pulse: Feel your baby’s pulse in the inner part of the elbow or in the
groin. Count the number of pulsations for 15 seconds and multiply
by four. This gives you the beats per minute. Below is a list of
average heart rates for your baby’s age:
Average heart rates for babies, birth to three years of age:
Birth to one week: 95—160
One week to six months: 110—180
 Six to 12 months: 110—170
One to three years: 90—150
(Compare these to an adult’s heart rate of 60—100 beats
per minute.)

3.Respiratory Rate: Watch your baby’s chest as it moves in and out.

Count one breath for each time he breathes in for 30 seconds and
multiply by two. This gives you the number of breaths per minute.
Babies have very erratic breathing, so you won’t get an accurate
count if you only look for ten or 15 seconds. Below are the details.
Average respiratory rates by age:
Newborns: 25—50
One week to one year: 24—38
One to three years: 22—30
(Compare to an adult’s respiratory rates of 12—16 breaths per
minute.) (Gunn)

Helpful Hint
When a child runs a fever, all the other vital signs are elevated, too. Parents
worry about the heart racing when children run a fever. That is to be
expected and normal.

HOW CAN DOCS MAKE A DIAGNOSIS OVER THE

PHONE WITHOUT EXAMINING A CHILD?

Your doctor will rely on you to provide the signs and symptoms
(the clues).
 Doctors are very systematic in the way they make a diagnosis. A
professor once told me that 90% of the time, a diagnosis can be made
purely on the history of the problem. Only 10% of the time will the
physical examination of the patient be necessary to make the
diagnosis. It’s true. I usually know what I will find when I examine
the patient just by listening to the story. But this requires some
detective work. I always ask the same questions for each complaint to
get a history of signs and symptoms (that is, location/type of pain,
length of fever, appetite or lack of, sleep disruption, runny nose,
cough, vomiting, etc.) When you call, expect to be interrogated.
Nervous parents often focus on one particular aspect of a disease
process while doctors are trying to figure out the big picture. (See
fever section later in this chapter). Doctors need to know about
various symptoms to put the puzzle together. Let the doctor help
point you in the right direction!

The Most Frequent Phone Calls

First, here’s some doctor lingo: ever heard the guys on Grey’s Anatomy
say a patient was “in triage?” Triage just means to sort out by severity of
the condition. The point: phone calls are triaged by the doctor into the
following categories:
Priority 1: Needs immediate evaluation and treatment—NOW.
Priority 2: Needs appointment the next day.
Priority 3: Watch and wait. Needs appointment if there is no
improvement or worsening of symptoms.
Red flags: Denote symptoms that are medical emergencies.

We’ve adopted this system in this chapter to give you a general idea of
how problems are managed. But every problem is unique. If you have
concerns, call your doctor.
Abdominal Pain

Q. My baby has a stomachache. When do I need to

worry?
It’s hard to tell when an infant has a stomachache, unless he is vomiting
or has diarrhea. Some reliable signs include irritability during/after
feedings, pulling up of the legs, or a tense, full belly. There are also medical
problems that have nothing to do with the stomach that cause abdominal
pain (such as bladder infections).
Abdominal pain is divided into acute (a new event as of yesterday or
today) or chronic pain (the problem has been going on for over a week).
Acute issues only are discussed below.

Priority 1: Needs immediate evaluation and treatment—NOW:

The most serious problems are called surgical emergencies or an “acute
abdomen.” A piece of bowel may be kinked, blocked, or infected. Babies
with these problems look sick and are often inconsolable. Concerning
symptoms include: swollen and/or tender belly, lack of interest in eating,
persistent vomiting, unusual looking diarrhea, and difficulty settling down.
These problems need to be addressed quickly. See the Red Flags on the next
page. Diagnoses include: INTESTINAL OBSTRUCTION,
INTUSSUSCEPTION, INCARCERATED HERNIA, APPENDICITIS, PYLORIC
STENOSIS.

Priority 2: Needs appointment the next day.

Most problems fall into the non-urgent category. These symptoms are
less severe and babies are consolable. Symptoms include: gas, trouble
settling after a feeding, crying/straining while attempting to poop, and one
or two episodes of vomiting. Observation and medical evaluation is in order
if things are not improving. NOTE: In babies under a year of age, it’s better
to be cautious and contact your doctor if you are worried.
Diagnoses include: GAS, CONSTIPATION, EARLY VIRAL
GASTROENTERITIS
Helpful Hints
What the doctor will ask you about ABDOMINAL PAIN:
1. Does your baby have a fever?
2. Is your baby vomiting? What does the vomit look like?
3. Does your baby have diarrhea? Is it watery, bloody, mucousy, look like
grape jelly?
4. Does your baby’s tummy look like he is pregnant? Does it hurt to touch?
5. How long has the pain/vomiting/diarrhea been going on?
6. Does your baby have at least three wet diapers (urine) a day?
7. Is your son’s scrotum swollen?

RED FLAGS
Call your doctor immediately if you see the following symptoms with
abdominal pain:
Fever and pain without diarrhea.
Projectile vomiting or bright green/yellow vomit.
Diarrhea that is bloody/mucousy/grape-jelly like.
Tense, distended belly.
Pain more than two hours in duration.
Prolonged vomiting (see vomiting section later in this chapter).
Prolonged diarrhea (see diarrhea section later in this chapter).
Less than three wet diapers a day.
Swollen scrotum.
Crying with urination.
Feedback from the Real World
My four-year-old daughter slept for 12 hours once and awakened with the
tensest belly I had ever seen. She was very uncomfortable and was having
difficulty walking. She screamed when I tried to touch her belly. She had no
interest in eating. Being quite convinced that she had an acute abdomen, I
called one of my pediatric surgeon friends to evaluate her in the ER. As we
drove to the hospital, she proclaimed that she needed to pee NOW. I pulled
off the highway onto the shoulder. She urinated in my portable car trashcan.
She had had a full bladder. She felt much better and asked if we could go
out to lunch after visiting the doctor. We sheepishly walked into the ER
together. She skipped to the exam room. I apologized for calling my friend
to look at my perfectly normal child. His comment was, “Well, she does
have a cute abdomen!”
Lessons learned here:
1.Sometimes benign processes (like a full bladder, constipation, etc.)
can look like an acute abdomen. Doctors prefer to check out
suspicious patients rather than wait.
2.It’s hard to be objective when dealing with your own child.

Allergic Reaction

Q. I think my child is having an allergic reaction. Do I

need to go to the ER?
Clarify the reaction. Do you see a rash or is he having difficulty
breathing?

Priority 1: Needs immediate evaluation and treatment—NOW:

RED FLAGS
Anaphylactic Reaction
Call 911 for a child who is drooling, anxious, having obvious labored
breathing (stridor), lip swelling, sweating. Another serious allergic reaction
is called Stevens-Johnson Syndrome. This is an extensive rash accompanied
by mouth ulcers. This requires immediate medical attention.
If your child is having an anaphylactic reaction, do not attempt to drive
to the hospital. Call 911 and get immediate help. Most ambulances are
equipped with medicine to handle these reactions immediately.
Diagnoses: ANAPHYLACTIC REACTION, STEVENS-JOHNSON
SYNDROME

Priority 2: Needs appointment the next day.

Most rashes are less of an emergency. (See details of other rashes in the
rash section later in this chapter). Allergic reaction rashes can have various
configurations. They are all itchy. Rashes (except Stevens-Johnson
Syndrome, see above) can be evaluated by a doctor when the office is open.
These include:
Hives: raised mosquito bites with flat red circles around them or large
flat red areas with raised edges (for example, a drug allergy).
Erythema multiforme: extensive, small, flat, red patches with raised
edges (for example, a drug allergy).
Eczema: red plaques with a scaly rough appearance overlying it (for
example, a food allergy).
Contact dermatitis: red pimples or blisters in a patch or streak (for
example, poison ivy).

See our web site at Baby411.com for a visual library of common rashes.
Reality Check
Have your child in front of you when you speak to the doctor on the phone.
You will be asked to describe what you see over the phone.
What the doctor will ask you about ALLERGIC REACTIONS:
1. Is your baby having any trouble breathing?
2. What does the rash look like? Where is it on the body?
3. When did you first see the rash?
4. Is the rash itchy?
5. Is your baby currently taking any medication?
6. Has your baby been exposed to any new foods, laundry detergents,
clothing, or soaps?

Helpful Hints
Unless your child is having an anaphylactic reaction (see above), give
diphenhydramine (Benadryl) and schedule an appointment.
Stop any other medication until a doctor sees your child.
Don’t give diphenhydramine (Benadryl) in the morning before your
appointment—otherwise the rash will be gone.
Try to think of any new medication or food your child may have had
recently.

Reality Check
FYI: An allergic reaction is caused by a release of a chemical called
histamine. Diphenhydramine (Benadryl), an ANTI-histamine, effectively
clears the results of histamine (the rash) until the medicine wears off (about
six hours). Histamine levels stay elevated for several DAYS. So, don’t be
surprised to see the rash “come back” after the medicine wears off. You will
need to use the antihistamine medicine for a few days.
Causes of allergic reactions: Food allergy, medication allergy, bug bites,
poison ivy (rhus dermatitis).

Bleeding And Bruising

Q. My child bruises easily. Should I be worried?

No, not usually.
Bruising in high trauma areas is not worrisome (shins, knees, elbows,
forehead). We worry much more about bruising on the torso—most falls do
not cause bruising to this area.
Easy bruisability can be a sign of low platelet count (platelets help your
blood clot). Bruising is much more worrisome when it is seen with
PETECHIAE. (pe-teek-ee-eye). See box on the next page. Bruising
accompanied by excessive bleeding can indicate a blood clotting disorder.
See our web site at Baby411.com (click on Bonus Material) for a picture.
Common Diagnoses include: Trauma/injury, temporary bone marrow
suppression from a viral infection.
Uncommon Diagnoses include: Hemophilia, von Willebrand’s disease
Leukemia, Idiopathic Thrombocytopenic Purpura, Henoch-Schonlein
Purpura, Meningitis.

Priority 1: Needs immediate evaluation and treatment—NOW:

1. A fever with petechiae rash
2. Petechiae AND bruising, with or without a fever
3. Bruising and lethargy
4. Excessive bruising (beyond the knees/elbows)
5. Uncontrollable bleeding
Priority 2: Needs appointment the next day.
1. Bruising with no other symptoms
2. Recurrent nosebleeds

What the doctor will ask you about BRUISING OR BLEEDING:

1. Where are the bruises?
2. Are there any other rashes on his body?
3. Does he bleed excessively? Does anyone in the family have bleeding
problems?
4. Has he been unusually tired or been running a fever with no
explanation?

NEW PARENT 411: ALL YOU EVER WANTED

TO KNOW ABOUT PETECHIAE BUT WERE AFRAID TO
ASK

Petechiae are flat, purplish, pinpoint dots that almost look like
freckles. When you push down on them, they remain colored (that is,
they do not blanch). Petechiae are caused by broken blood vessels.
They arise for the following reasons:

1.Pressure: Straining while pooping, giving birth, coughing, or

vomiting forcefully.
2.Infection: Strep, meningitis, Rocky Mountain Spotted Fever.
3.Low platelet count: Leukemia, Idiopathic Thrombocytopenic
Purpura, temporary bone marrow suppression from a viral
infection.

If there is a good reason to have petechiae (such as repeated

coughing), and they are located above the level of the chest only, you
can relax a bit, but still call your doctor.
 If there is not a good reason, your baby needs to be seen quickly
to rule out the serious medical problems on this list.

Q. My child is having a nosebleed. What do I do about

it?
Lean your child’s head forward, not backwards. Apply pressure to the
base (soft part) of the nose for ten minutes. If this doesn’t work, you can
spray some medicated decongestant nose drops into the nostrils (Little
Remedies for Noses or Children’s Afrin are two brand names). This causes
the blood vessels to shrink and stop bleeding.
Most nosebleeds stop in about ten minutes. If it goes beyond that, call
your doctor.

Q. My child just vomited blood. Where is it coming

from and should I be worried?
If it looks like fresh red blood, it can’t be coming too far from the mouth.
Blood that comes from the stomach is partially digested and will look like
coffee grounds. Be prepared to describe the vomit. Lack of an obvious
explanation for the blood needs an evaluation.

What the doctor will ask you about VOMITING BLOOD:

1. How old is your baby?
2. Are you breastfeeding? Are your nipples cracked and raw?
3. Have you been suctioning your baby’s nose with a bulb syringe?
4. Has your baby been vomiting forcefully?
5. What does the vomit look like? Are there streaks of blood? Coffee
grounds? Mucous?

The most common cause of Upper GI Bleeding (official term for

vomiting blood) in a newborn is Mom’s cracked nipples. The blood in the
spit up is really Mom’s. There is a test to prove it, but one look at Mom’s
nipples is a dead give-away.
The next likely culprit is that dreaded bulb syringe we told you to throw
away in Chapter 4. It causes an irritation in the lining of the nose, making it
raw to the point of bleeding. Nasal secretions are swallowed and then spit
up.
As your baby gets older, he will explore his body. His finger will find his
nostrils and cause trauma. The number one cause of bloody vomit in an
older child is a nosepicker’s nosebleed.
Now, for more serious causes. Forceful vomiting can cause a small tear
in the lining of the esophagus. A child with persistent blood in vomit needs
to be examined.
Vomit that looks like coffee grounds also needs to be evaluated. In older
babies, doctors worry about a toxic ingestion/poison that irritates the
esophagus or stomach, ulcers, gastritis, or esophagitis. If the vomit looks
like Folger’s coffee, call your doctor.
Diagnoses of an upper GI bleed include: Mom’s cracked nipples,
esophagitis, toxic ingestion/poisoning, gastritis, ulcers

Priority 1: Needs immediate evaluation and treatment—NOW:

1. No obvious source for bleeding.
2. Vomit that looks like Folger’s coffee.
3. Persistent bleeding.

Q. My baby has blood in his poop. Should I worry?

No, but Lower GI bleeding always needs to be evaluated by a doctor. If
you see blood in the diaper, save the diaper. It’s helpful to bring a fresh
specimen to the office visit. If your baby doesn’t cooperate, doctors have
other ways to get what they need (via a rectal exam).
You will describe every detail of that poop to the On-Call Doctor. If the
blood looks red and fresh, the source is close to the anus. If the blood looks
darker or the poop looks like meconium, it comes from further up the pipes
(small or large intestine). The age of the child partially determines the cause
of the problem.
 Newborns: Bad diaper rash is often the explanation. Blood is usually
found on the diaper wipe more than in the poop with an obvious raw
bottom. Babies under four months of age with streaks of blood often have a
milk protein allergy. Even exclusively breastfed babies can encounter this
because the cow’s milk protein can enter the breast milk. It often takes six
weeks for the blood to clear once babies eliminate the cow’s milk from their
diets. Even if this is what the working diagnosis is, bacterial stool cultures
are in order to rule out infection.
Diagnoses include: diaper rash, milk protein allergy, food poisoning
(Bacterial gastroenteritis).

Older babies: Babies who have started solids often get constipated. If
your baby looks like he is giving birth when he pushes out a solid poop ball,
he might bleed with it. An anal tear or fissure can be seen if you look for it.
This is not serious. Put some petroleum jelly (Vaseline) on the area and
check out fiber facts in Chapter 8, The Other End.
Now for more serious causes. Babies can get food poisoning—even
those who aren’t eating off the Chinese buffet line yet. Where do babies get
it? Human carriers, pets, and food exposure. Babies in daycare are at higher
risk of parasite infections. Your doctor can test for all of these bugs with
cultures (see bacterial infections and parasites in Chapter 13, Infections).
Symptoms include diarrhea with streaks of blood and mucous.
Finally, poop that looks like grape jelly (currant jelly stool) is a medical
emergency. The diagnosis is intussusception, where the bowel telescopes on
itself and creates an obstruction. Symptoms include abdominal pain (pulling
up of the legs), irritability, and grape jelly stool.
Diagnoses: Anal fissure/tear (caused by constipation), food allergy, food
poisoning (bacterial gastroenteritis), parasite infection, antibiotic induced
colitis (C difficile infection), intussusception

What the doctor will ask you about BLOOD IN POOP:

1. How old is your baby? Was your baby premature?
2. What did you see in the diaper? Streaks of blood mixed in poop?
Solid poop with blood on the diaper wipe? Explosive bloody diarrhea?
Mucous also? Grape jelly?
3. Is there a diaper rash?
 4. What is your baby eating?
5. Has anyone in the house had diarrhea?
6. Does your baby look sick or well? Fever?
7. Is your baby’s belly full and distended?
8. Is your baby interested in eating? Is he vomiting?
9. Has your baby been on antibiotics recently?

Priority 1: Needs immediate evaluation and treatment—NOW:

Bloody diarrhea
Grape jelly poop
No obvious diaper rash or anal tear
Former premature baby

Priority 2: Needs appointment the next day.

Streak of blood with normal looking stool and well appearing child

Priority 3: Watch and wait. Needs appointment if there is no

improvement or worsening of symptoms:
Obvious constipation
Obvious diaper rash

Feedback from the Real World

Dr. Brown’s TRUE STORIES about food poisoning:
1. One mother was a short order cook who discovered she was a carrier of
Salmonella when her newborn had it. She truly was “Typhoid Mary”
(named for a woman who was a cook and a carrier of typhoid fever—a
cousin of Salmonella). Sometimes parents are carriers who have had a
previous infection and don’t know it.
2. Unusual pets can be carriers of Salmonella. One of my patient’s uncles
had a pet iguana that roamed freely on the family’s kitchen counter.
3. Raw eggs and chicken are also known to have Salmonella. I had a patient
who acquired Salmonella when Grandma was preparing chicken gizzards
next to Mom preparing a bottle for the baby.

HOW TO AVOID FOOD POISONING

Steer clear of the following foods and remember to clean cutting

boards, knives, and countertops when dealing with these products.
Keep a spray bottle of bleach handy in the kitchen to clean these
tools. Here is what to avoid:
unpasteurized dairy products
unpasteurized juices (fresh squeezed OJ, apple cider)
alfalfa sprouts
raw shellfish
oysters
undercooked and raw meat or seafood
unwashed fruit and vegetables
undercooked eggs* (sunny side up, raw cookie dough, fresh
Caesar salad dressing, homemade ice cream, homemade mayonnaise)
*We highly advise buying pasteurized eggs to limit the risk of
food-borne illness, especially if you are using undercooked eggs in a
recipe.

Natural food warning: While it doesn’t seem likely that you and
your baby would come across the above items, think for a moment
about unpasteurized juices. These are common in health food stores
and some vegetarian/vegan restaurants. It can be easy to pick up a
bottle of such juice without thinking about it. The same goes for
unpasteurized dairy products—gourmet cheeses at health food stores
sometimes fall into this category. While adults might be able to eat
these products without a problem, they are much more dangerous to
infants and children. Check the labels: raw milk cheese, for example,
should be clearly labeled as such.
Feedback from the Real World
There was an outbreak of the deadly E. coli 0157 bacteria (Hemolytic
Uremic Syndrome) on the East Coast several years back. It was traced to an
apple cider producer in New Hampshire. It had been a bad apple season, so
the producer used apples that had already fallen off the trees to press for
cider. Unfortunately, the cows that lived on the farm pooped on those apples
and contaminated them with the E.coli. There are new regulations for cider
production now. Moral of the story: Never drink unpasteurized apple cider.
A similar outbreak happened with Odwalla apple juice—a small batch of
unpasteurized juice contained E.coli bacteria, sickening more than a dozen
children. This juice was blended with other products as well. Be sure to
look for these products—make sure ALL the ingredients in a blended juice
product are pasteurized.

Burns: Water, Sun, Hot Drinks, Appliances, BBQ

Q. My child got a burn from _____. What do I do?

Does he need an appointment?
Don’t get out the butter . . . and yes, you may need a doctor visit.
First rule: If it blisters, it should be looked at.
Second rule: Apply cool water, not butter.
Third rule: Don’t pop a blister.

Any type of burn damages the top layer of skin. This causes redness
(first degree). Burns that go deeper than that create blisters (second degree)
or damage to the full thickness of the skin. Your skin is your body’s
protection from foreign invaders such as infection. Without the skin, the
body is defenseless. To help combat infection, it’s always a good idea to use
an antibiotic ointment (such as Neosporin) on a burn and cover it with a
non-stick dressing.
For second-degree burns, a prescription product called Silvadene may be
needed. Second degree burns (or worse) need to be seen by your doctor to
assess the damage, look for infection, and clean away any dead skin (this
debris inhibits healing and promotes infection). Any burns on the hands,
genitals, and on large areas should also be seen.

Priority 1: Needs immediate evaluation and treatment—NOW:

Extensive areas burned.
Area looks infected (red, weeping pus, fever)

Priority 2: Needs appointment the next day.

Second degree burns (blisters).
Burns on the hands or genitals.

Priority 3: Watch and wait. Needs appointment if there is no

improvement or worsening of symptoms:
First degree burns.

Breathing Problems (Respiratory Distress)

Q. My baby is having trouble breathing. What do I

do?
Knowing what true respiratory distress looks and sounds like is very
important. Read the section below first. Then understand how calls like this
are triaged. The short answer is—if your child is having labored breathing,
call your doctor immediately.

Understanding the Respiratory System

 Think of the respiratory system as one big tube. The opening of the tube
starts at the nose. The bottom end branches into tiny tubes in the lungs. Air
goes in and out of this tube with each breath.

What is an UPPER respiratory infection?

The common cold or flu viruses live in the top of the tube (nose and
sinuses). The body forms mucous or snot as a result of it. A person coughs
because the mucous drips down the tube towards the lungs. Coughing
protects our lungs. The cough brings the mucous up so it can be swallowed
(into the stomach) instead of collecting in the lungs. Upper respiratory
infections rarely cause labored breathing. They do cause noisy breathing,
though, as air travels through the snot in the nasal passages.

The Lungs

Diagnoses include: Common cold, the flu (influenza)

What is a LOWER respiratory infection?

Bronchiolitis (RSV), bronchitis, or pneumonia are infections (viral or
bacterial) that live in the lungs or tubes in the lungs. Because there is
swelling or mucous in the tiny tubes and lung tissue, it is hard to exchange
air effectively (remember that oxygen/carbon dioxide thing you learned
about in science class). A person with a LOWER respiratory infection may
become air hungry. We’ll discuss this more in detail later in this section.
Rattling in the chest or hearing wheezing are NOT usually signs of a
lower respiratory infection.
 Diagnoses include: RSV Bronchiolitis, bronchitis, pneumonia

Any others?
There are also infections that attack the middle of the tube (larynx and
trachea) where the voice box (vocal cords) is located. The tube swells in
this area. Because children’s tubes are smaller than adults, they are more
compromised by these infections. The younger the child, the more
problematic.
Diagnoses include: croup, whooping cough (pertussis)
Now that you understand the tube analogy, here’s the scoop.
Think about the tube. You know how your pipes are all attached in your
home? When you flush your toilet upstairs, you can hear it in the kitchen.
Here is the analogy: nose is to toilet as lung is to kitchen. The water is in
the nose, not the lung—but it can be heard and felt down there. This is
called transmitted upper airway noise. The wheezing noise is air passing
through snot—it whistles.

WHAT AN AIR HUNGRY CHILD LOOKS LIKE: A MUST

READ

The diagnosis of an air hungry child can be made without a

stethoscope. It’s not what is heard—it’s what is seen. A baby or child
who is air hungry breathes rapidly and shallowly (elevated
respiratory rate), sucks in his rib cage (retractions), and flares his
nostrils (flaring). A child may also make a grunting noise at the end
of each breath. These are the body’s way of using every muscle to
pull in more air with each breath. The number of breaths taken per
minute (respiratory rate) is much higher than normal. (See guide to
vital signs earlier in this chapter). If a child is air hungry, call your
doctor immediately.

A child who is really wheezing enough to be audible to the naked ear is

in such severe distress that you will see it in his chest (AIR HUNGRY).
 Helpful Hints
Sometimes your doctor can tell what the problem is just by listening
to the baby breathing on the phone. If the breathing noises are
dramatic, have the baby handy when you call.
When a person lies down, the snot from the nose drips down the back
of the throat. Our body’s job is to cough and keep it out of the
lungs. The cough is likely coming from nasal secretions when the
“cough is worse at night.”

Red Flags
Air hungry.
Croup under age two. (See below).
Repeated coughing spasms, followed by reddening of face, possibly a
“whoop,” or vomiting.
Episodes of not being able to catch one’s breath.

What the doctor will ask you about RESPIRATORY DISTRESS:

1. How long has he been having trouble breathing?
2. Could he have swallowed something?
3. Does he have a fever?
4. Is he barking like a seal? Any high-pitched squeals?
5. Look at his chest. Is he sucking in his ribcage with each breath
(retractions)? Is he panting or breathing fast? Are his nostrils flaring? Is
he grunting at the end of each breath?
6. Has he wheezed before? Ever stayed in the hospital overnight for it?
7. Are there coughing spasms? Any gasping for breath? Vomiting or
turning red with cough?
Priority 1: Needs immediate evaluation and treatment—NOW:
Signs of air hunger.
Any stridor noise (see croup box nearby).
Trouble catching breath.
Child who has asthma.
Child who is a former premature infant.
Choking (see choking emergencies on the next page).

Priority 2: Needs appointment the next day.

Barking like a seal, but no squeal.

Priority 3: Watch and wait. Needs appointment if there

is no improvement or worsening of symptoms:
Chest rattling.
Intermittent wheezing noises WITHOUT labored breathing.

EVERYTHING YOU EVER WANTED TO KNOW ABOUT

CROUP

A virus causes croup. It appears in epidemics every winter. A

croup cough has a characteristic bark that sounds like a seal.
Although impressive, this can be managed by quality time spent in
your bathroom with a steamy shower running for twenty minutes.
When the airway tube is markedly swollen, the bark changes to a
high-pitched squeal, called stridor. Stridor requires an emergency
breathing treatment and steroids to reduce the swelling or the airway.
FYI: Croup is always worse at night.
Red Flag
When your child stops breathing. Call 911 immediately if your baby has
any episode of true apnea (lack of breathing over 15 seconds).

Reality Check
There is a difference between apnea (not breathing) and PERIODIC
BREATHING. Newborns frequently pause for several seconds between
breaths. It is your child’s job in life to give you grey hairs. Adults breathe
12 times a minute at a nice regular rate. Newborns breathe 30-60 times per
minute at an irregular rate. Newborns can pause for up to ten seconds and
be feeling just fine. To monitor the respiratory rate of a newborn, count the
breaths for a whole minute.

What the doctor will ask about APNEA:

1. Is your child breathing okay now or is he having labored breathing?
2. Does he have a fever?
3. Has he had a problem with acid reflux?
4. Was he born prematurely?
5. Any recent trauma or injuries?
Babies with apnea get admitted to the hospital to be evaluated.

Diagnoses include:
1. Near Sudden Infant Death Syndrome (SIDS) event or acute life
threatening event (ALTE).
2. Gastroesophageal reflux.
3. Infection (whooping cough, RSV bronchiolitis).
4. Metabolism problem.
 5. Head trauma.

Choking Emergencies: 4 Tips

1 DO NOTHING IF YOUR CHILD IS ALERT AND MAKING NOISES

(CRYING, GAGGING, COUGHING). He is effectively attempting to clear his
airway.

2 IF YOUR CHILD IS IN DISTRESS AND NOT MAKING ANY NOISE, try to

dislodge the object by putting his belly on your forearm, face down (hold
him like a football). Push forcefully between the shoulder blades with the
lower part of your palm five times (called back blows). Do not perform the
Heimlich maneuver on infants under one year of age. If back blows are
unsuccessful, try performing five chest thrusts. Repeat the back blows and
chest thrusts until the object comes out or the baby becomes unconscious.
Call 911.

3 DO NOT BLINDLY SWEEP YOUR FINGER IN THE MOUTH AS IT MAY

PUSH THE OBJECT FURTHER INTO THE AIRWAY. Call 911 if the foreign
body does not come out.

4 IF YOUR CHILD BECOMES UNCONSCIOUS, CALL 911, AND BEGIN

CPR.
FYI: Need a quick visual on how to perform a back blow on a choking
baby? Search “Infant CPR” on YouTube and you will be a pro in no time.
We suggest viewing this video before a choking incident happens (not
during it!)

Feedback from the Real World

Another True Story from Dr. Brown
I was on-call and answering a page. While I was on the phone, my nine
month old son crawled over to our dog’s food bowl and did a taste test. In
my panic, the first thing I did was to blindly put my finger in his mouth to
pull the food out. I ended up pushing it down and he swallowed it whole.
After that scary (and painful) experience, he never touched the dog’s food
again! And I never made the mistake again of ignoring my own advice.

Cough And Congestion

Q. My baby’s nose is so congested that he can’t eat or

sleep. What do I do?
This is the second most popular phone call. (Fever is number one). Nasal
congestion happens for many reasons:
Newborns all have nasal congestion for the first four to six weeks of
life. They ALL sneeze and snort and snore. They do not have
allergies (and rarely have a cold).
Babies with acid reflux can have congestion from the milk that heads
upwards behind the nose.
Mucous pouring out the nose suggests an upper respiratory infection.

Diagnoses include: Common cold, the flu (Influenza), RSV bronchiolitis

Tricks of the trade: How To Make (And Use) Saline

Nose Drops
The most safe and effective way to clear the mucous is to flush the nostrils
with saline nose drops. Saline is just a salt-water solution. You can’t
overdose on it. You can make your own concoction (1/2 tsp salt to eight oz
water). Or you can buy it for about a dollar at the grocery store. Shoot
several drops in each nostril before feedings. You don’t need to suck it out
with a bulb syringe. The saline will either make your baby sneeze or loosen
the mucous enough to swallow it. Babies are usually not big fans of this
maneuver, but it is effective.
There are other methods of reducing the amount of mucous, but doctors
always suggest saline first. Over the counter cough and cold medicines are
not recommended under four years of age.

What the doctor will ask you about NASAL CONGESTION

1. Has he ever breathed through his nose?
2. Does he have a fever?
3. Is anyone else in the house sick? Is he in childcare?
4. Is he fussy or having disrupted sleep?
5. Does he have goopy eyes and/or green snot?

Helpful Hint
If a baby under age two has an upper respiratory infection, the flu, or
especially RSV, he is at risk of getting an ear infection. Nasal discharge
with fever, goopy eyes, and/or fussiness deserves a visit to the doctor to
check for an ear infection.

Priority 1: Needs immediate evaluation and treatment—NOW:

Has labored breathing or appears air hungry.
Under four weeks of age and has a fever of 100.4 or greater (see fever
section later in this chapter).
Irritable and inconsolable.

Priority 2: Needs appointment the next day.

Never breathes through the nose.
Under four weeks of age, WITHOUT fever.
Four weeks old to six months old, nasal congestion with or without
fever.
Fussy mood or disrupted sleep.
 Goopy eyes or red eyes.
New appearance of green nasal discharge after clear discharge for at
least one week.

Priority 3: Watch and wait. Needs appointment if there is no

improvement or worsening of symptoms:
Over six months of age with nasal congestion, runny nose, and cough
for less than one week’s duration (see fever section for other reasons to
call).

Q. My child is keeping up the whole house with his

cough! Make it go away.
Doctors are not miracle workers.
Nighttime coughs cause sleep deprivation for the child and the parent.
Take a moment to review the respiratory system lecture. Coughing is a
protective mechanism to keep the nasal discharge from collecting in the
lungs. So for an upper respiratory infection (cold), let the cough happen
during the day. The cough is worse at night because your baby is lying
down. Always try saline nose drops first. Stopping the drip may stop the
cough. Letting your baby sleep in an upright position (such as in a car seat)
is also helpful.
If the cough is keeping baby awake, the only “natural” product I can
recommend is Zarbee’s baby cough syrup. The active ingredient is agave
nectar (not honey!). It has more of a placebo effect on the parents than
actual effect on the baby, but it is safe to try. (Paul, I).
If the cough is keeping YOU awake, turn off the baby monitor!

What the doctor will ask you about COUGHING:

1. How long has he had the cough? (Over three weeks deserves an
appointment).
2. Is it worse at night or in the daytime?
3. Is he having any breathing difficulties? (See that section).
4. Is he barking like a seal? Squealing?
 5. Is he panting or breathing shallowly?
6. Any apnea (no breathing for 15 seconds or more)?
7. Any concern for having swallowed a foreign body?
8. Any new fever?

Priority 1: Needs immediate evaluation and treatment—NOW:

Breathing appears labored—grunting, flaring, retractions, stridor, or
elevated respiratory rate.
Trouble catching breath with coughing episodes.
Foreign object known to be swallowed.
Known asthma and not responding to medication.

Priority 2: Needs appointment the next day.

Persistent cough.
Cough sounds productive (wet or juicy).
Vomiting or turning red with coughing episodes, but no apnea.
Barking like a seal, but no squeal.
New fever with a cough and NO labored breathing.

Priority 3: Watch and wait. Needs appointment if there is no

improvement or worsening of symptoms:
Cough under three weeks duration.
Exposure to someone with a chronic cough.

Chronic Coughs

Not all coughs are caused by infection. Prolonged coughing (over three
weeks) should be evaluated. Occasionally, we discover something
interesting that has ended up in a branch of the lung airway. Mr. Dr. Brown
(the Ear/Nose/Throat specialist) removes toy jacks, beads, peanuts, teeth,
and popcorn kernels in the airways of small children on a regular basis.
 The major causes of chronic cough include: foreign object in airway
asthma, sinusitis, adenoiditis, whooping cough, tuberculosis (rare).

Red Flags
Cough with breathing difficulties.
Chronic cough over three weeks.
New fever with worsening cough.
Possible foreign body (swallowed object).

Diarrhea

Q. My baby has diarrhea. What do I do ? When do I

worry?
Most of the time, diarrhea is a sign of a stomach virus (VIRAL
GASTROENTERITIS). Some people call it the stomach flu. It’s not THE flu.
(The flu that we can get vaccinated for is influenza—a respiratory virus.) At
best, your baby vomits once and the diarrhea continues for three to five
days. At worst, your child vomits for 12-18 hours and has diarrhea 25 times
a day for ten days (see rotavirus infection in Chapter 13, Infections). Those
“24 hour bugs” don’t really exist.
Food poisoning (BACTERIAL GASTROENTERITIS) is a concern when
there is mucous or streaks of blood in the diarrhea. (See abdominal pain
section earlier for details). Bacteria will cause only 10% of intestinal
infections. Of those 10%, the most common culprit is SALMONELLA. Other
diagnoses include: Shigella infection (bacteria), Yersinia infection
(bacteria), Campylobacter infection (bacteria), C. difficile (bacteria, after an
antibiotic) Giardia (parasite), Cryptosporidium (parasite), food allergy.
FYI: Chronic diarrhea (over two weeks duration) is a different problem
More on this next.
Diarrhea for more than two weeks
If the diarrhea has been going on this long, your baby needs to see his
doctor. Most commonly, chronic diarrhea is the result of an acute stomach
virus.
Stomach viruses tear up the intestine’s normal “flora” of good bacteria
that help digest food. Stomach viruses can also break up a digestive enzyme
called lactase, which helps the body digest milk sugar (lactose).
Occasionally, infants and children can get a temporary lactose intolerance
for up to six weeks after a stomach virus. Diarrhea results from repeated
dairy intake and inability to digest it.
Another culprit is high juice intake. This is more of a problem with
toddlers who become juice-a-holics. The high sugar content pulls water into
the poop, causing increased frequency and watery stools.
Causes of chronic diarrhea include: Lactose intolerance (post-stomach
virus), high juice intake, food intolerance, celiac disease, parasite infection,
Inflammatory Bowel Disease.

What the doctor will ask you about DIARRHEA:

1. How old is your baby?
2. How long has the diarrhea been going on?
3. Has there been vomiting or fever?
4. What does the diarrhea look like? Watery, bloody, mucous or blood
streaked?
5. Is your baby still urinating?
6. Has your baby eaten any new foods?

Priority 1: Needs immediate evaluation and treatment—NOW:

Under three months of age.
Blood or mucous in diarrhea.
Grape jelly diarrhea.
Not urinating at least three times in 24 hours.
Unsure about frequency of urination.
Lethargy.
Priority 2: Needs appointment the next day.
Diarrhea more than one week.
Age over three months and fever more than three days.

Priority 3: Watch and wait. Needs appointment if there is no

improvement or worsening of symptoms:
Watery diarrhea for less than one week, with frequent wet diapers,
and over three months of age.

Q. I’m worried about my baby getting dehydrated.

Should I be?
Yes.
Babies under a year old are at higher risk of getting dehydrated.
Contrary to popular belief, dehydration is caused more by diarrhea than
vomiting. The vomiting part of an illness usually stops within about 12
hours. There is only a limited amount of fluid lost from vomiting (once the
stomach is empty, there’s not much left to throw up). As long as the
vomiting is short lived, dehydration is not a problem. Diarrhea is another
story. Frequent, explosive, watery diarrhea for a week causes a tremendous
amount of water loss. Your baby needs to keep up with these losses with
fluid intake.

BOTTOM LINE: Although vomiting is scary, persistent diarrhea is more

likely to cause dehydration.

HOW TO TELL IF YOUR BABY IS DEHYDRATED—A MUST READ

1 Urine output: When our body needs fluid, less water is released
as urine. If your baby pees (urinates) at least three times in 24 hours,
he is doing okay. It’s sometimes hard to tell if there is pee in the
diaper, though, when there is explosive poop in it. (See helpful hint
on the next page).
2 WEIGHT LOSS: If your baby has lost 10% of his body
weight, he is severely dehydrated. This is an
emergency.

3 SUNKEN FONTANELLE: Babies under a year still have a

soft spot in their skull. That is their oil gauge
equivalent. If the tank is low, the soft spot is sunken.
That’s the first place a doctor will touch when he
examines your baby.

4 SKIN TURGOR: You know what your skin looks like

when you have been in the bathtub too long? That
prune like appearance is a clue to dehydration. Nice
doughy skin has plenty of water in it.

5 DRY LIPS AND MOUTH: When you’re dry, you stop

making saliva.

6 CAPILLARY REFILL: Press down gently on your

fingernail. You will see the pink color turn white. When
you release the pressure, the pink color returns in less
than two seconds. In severe dehydration, that refill will
take more than two seconds because the blood supply is
sluggish.
 7 LETHARGY: This is a difficult one to assess. If your
baby looks like a wet noodle, it’s time to visit the
doctor.

Helpful Hint
How to tell if there is urine in the diaper:
Put a tissue in the front part of the diaper. The urine looks yellow on the
tissue because it is concentrated. You can also just opt for those disposable
diapers with built-in wetness sensors.

Q. What can I give my baby to eat and drink to

prevent dehydration?
Start with liquids, then slowly add solids.
Presuming that vomiting has come first in this scenario, make sure that
fluids stay down before going back to solid food (if baby is over four
months old). Liquids are much more important than solids. It’s the fluid that
replaces the losses. Babies make up for lost time and will eat when they are
feeling better.
Your doctor may recommend a rehydration electrolyte drink (Pedialyte)
to treat dehydration—see the vomiting section later for details. Once your
baby has kept the rehydration drink down, return to regular formula or
breast milk.
Here are some other suggestions:

1. Try Isomil DF formula for severe or prolonged diarrhea. (see

formula section in liquid nutrition, Chapter 6) The DF stands for
Diarrhea Formula. But it also stands for Dietary Fiber. The formula is
lactose free and has a high fiber content that helps bulk up the poop.
 2. Try a high fat, high fiber diet for babies over four months old.
Resume solids when a baby is interested in food again. Depending on
the age and what foods your baby has tried, look for high fiber foods
(prunes, oatmeal, beans) and high fat foods (whole milk yogurt,
avocados) to feed your baby.
3. Try yogurt or probiotics. Stomach viruses kill off the “good germs”
that live in the intestines and help digest food. Replenishing the gut with
good germs improves digestion. If your baby is over six months, offer
four oz. yogurt daily during the illness. Another option: probiotic
chewable tablets and powder packets are available over the counter. Use
half of a packet or crush up a tablet daily and mix into food.
4. Try a lactose (dairy) free diet for diarrhea lasting over one or two
weeks. If the diarrhea is prolonged, a secondary lactose intolerance may
be the culprit (see chronic diarrhea section earlier).

BOTTOM LINE: Liquids are the priority in re-hydration. Your baby will eat
solid food again when he is well.

Old Wives Tales

1. Avoid milk when your baby has diarrhea.
The truth: Your baby will have diarrhea no matter what he is eating or
drinking. Give him what he is willing to drink. If the diarrhea has been
going on for over a week, however, dairy restriction may be in order to
avoid a lactose intolerance (see earlier section on chronic diarrhea).

2. Use the BRAT diet for a baby with diarrhea (Bananas, Rice,
Applesauce, Toast).
The Truth: Fat and fiber are more effective in bulking up the poop than
these foods. The old school of thought was called the BRAT diet. It was
thought that a bland, carbohydrate diet was best for infants with diarrhea.
The latest research suggests that fat and fiber are actually more effective in
reducing water loss in diarrhea.
Q. Can I give my baby any anti-diarrhea medications?
No.
There are a couple of concerns here.
Concern #1: Infant deaths have been reported from products containing
loperamide (Imodium). The medication can bring intestinal movement to a
screeching halt. While it is nice to stop the diarrhea, stopping the intestines
from moving entirely can be life threatening.
Concern #2: Using products containing bismuth subsalicylate as an
active ingredient (Pepto-Bismol, Kaopectate) when a child has a viral
illness has a theoretical risk of causing liver failure (Reye’s Syndrome).
That is why both of those products are only approved for children ages 12
and up. Some doctors even feel uncomfortable using Pepto-Bismol and
similar medications on children under 18 years of age. Check with your
doctor for her opinion.
In short, the American Academy of Pediatrics advises against using anti-
diarrhea medications in infants. (AAP)

Reality Check
To make life even more confusing for consumers, Pepto-Bismol makes a
chewable tablet for children ages two and up. The active ingredient in the
product is calcium carbonate (similar to Tums). While it is safe to use that
product for a toddler who has some heartburn, it is no help for diarrhea!

Vomiting

There is spit up, and then there is vomit. All babies spit up (see acid
reflux in Chapter 8, The Other End). Vomiting is the forceful elimination of
food and fluid that is in the stomach.
There is only a fixed amount of stomach contents. So, if a child is
vomiting repeatedly, eventually he will have “dry heaves” (vomiting with
nothing coming out). If a child is vomiting bile (fluorescent green/yellow
fluid), that is coming from the small intestine and may be a concern for an
intestinal blockage.
In the strictest sense, repeated vomiting causes dehydration. If your child
is vomiting more than 18 hours straight, he is unable to maintain adequate
fluid intake. This rarely happens. With most garden-variety stomach
viruses, the vomiting stops within 12 hours and kids are drinking again. The
greater risk of dehydration is the water lost in the diarrhea that accompanies
the vomiting. Dehydration usually occurs later in the course of the illness.
All vomiting is not due to stomach upset. Babies and young children
have active gag reflexes. Forceful coughing can result in vomiting (see
POST-TUSSIVE EMESIS). So a baby with a common cold might vomit after
coughing. Headaches can also be accompanied by vomiting. This category
includes ear infections, head injury, brain tumors, or meningitis. That’s why
unexplained vomiting needs to be checked out.

BOTTOM LINE: Persistent vomiting with no obvious cause should be

evaluated.

Causes of vomiting include:

Gastroesophageal reflux Early viral gastroenteritis

Pyloric stenosis Intestinal obstruction (rare)
After coughing (post-tussive emesis) Ear infection
Head injury Brain tumor (rare)
Meningitis Metabolic disorders (rare)
Bladder/ kidney infections Food poisoning (bacterial
gastroenteritis)

What the doctor will ask you about VOMITING

1. How old is your baby?
2. How long has he been vomiting?
3. Is it projectile (Exorcist-like) or just coming up effortlessly?
4. What does the vomit look like? Any fluorescent green or yellow
color? Any blood or coffee grounds?
5. Does he have a fever?
6. Does he have diarrhea?
7. Is he around other children/anyone sick in the house?
8. Does he look like his stomach hurts?
9. Is he still urinating?
10. Any recent head injuries?

WHAT TO DO WHEN YOUR BABY VOMITS

1. While your baby is actively vomiting, DO NOT GIVE HIM

ANY FOOD OR DRINK. Parents are often so afraid that their baby
will get dehydrated, they offer fluids immediately. And it comes right
back at them. Don’t give fluids on an unsettled stomach.

2. If it has been at least one hour since your child

has vomited, offer a few sips of Pedialyte (see
below). The goal is one teaspoon every five minutes for
an hour. Do not offer a whole bottle to your child. He is
thirsty and will drink the whole thing—only to vomit
again because his stomach isn’t ready for that much. If
this plan fails (that is, your baby vomits again), call
your doctor.

3. If the Pedialyte stays down, you can add to the

volume one to two ounces every time your baby
wants to drink. If this plan fails, call your doctor.

4. If your child has four hours vomit free, return to

breastfeeding or formula.
 5. After eight hours of success, babies who are
already eating solid foods can return to eating again.

Priority 1: Needs immediate evaluation and treatment—NOW:

Vomiting with a head injury.
Vomiting bile (bright green or yellow).
Vomiting over 12 hours straight.
Projectile vomiting more than three times in a row.
Vomiting only in the mornings.
Vomiting blood or coffee grounds.
Appears dehydrated (see section earlier on this topic).

Priority 2: Needs appointment the next day.

Large volume spit ups frequently.
Recurrent vomiting.

Priority 3: Watch and wait. Needs appointment if there is no

improvement or worsening of symptoms:
Isolated episode of vomiting in well appearing child.

Q. What is Pedialyte?
Pedialyte, conceptually, is kind of like Gatorade for babies*. It’s a
rehydration electrolyte drink made especially for babies ages birth to one
year. Parents often ask if it’s okay to use for babies that young—this is
exactly who it is made for! It has a high salt and moderate sugar content and
tastes like salt water. Usually babies under a year don’t mind the flavor.
(Kids over a year are pretty smart and will refuse it.) If you want to make
your own Pedialyte, check out Appendix B for a recipe you can make at
home.
 Do NOT give plain water to babies when they have vomiting or diarrhea.
Their body salts are already depleted and giving plain water messes up the
delicate electrolyte balance even more.
For older kids, try Pedialyte popsicles, flat ginger ale, or clear chicken
broth.

*Note: The “oral rehydration” solutions (brand names Pedialyte or

Ricelyte) have the perfect concentration of salts to replenish body
electrolytes. Gatorade and other sports drinks actually have a higher salt
concentration and can lead to increased diarrhea—so don’t use them
interchangeably.

Reality Check
Regular Pedialyte is a clear fluid. But it also comes in “flavored” varieties
—which contain food coloring. Stick with the clear version. Why would
you give a child who is vomiting a purple drink?

Eye Problems

Q. My newborn has goop draining from his eyes. Does

he have pink eye?
No. It’s a blocked tear duct.
Babies are born with narrow canals that let the tears flow out of them.
Until the canals widen, the tears can get clogged. This can happen
intermittently through the first year of life. (See glossary for
NASOLACRIMAL DUCT OBSTRUCTION). Just wipe away the goop with
warm water.
Call your doctor if the white of the eye is red, or if the eyelids are
swollen.
 HOW TO AVOID HAVING THE WHOLE FAMILY GET PINK EYE

Pink eye is spread by the sick person touching the infected eye
and leaving the germs for someone else to touch (doorknobs, hand
towels, toys). The best approach if you have pink eye in your house
is to wash hands frequently and make a concerted effort not to touch
your face.

Q. My nine month old has goop draining from his eyes

and has a cold. Does he have pink eye?
Probably.
When the eye goop is accompanied by other symptoms (runny nose,
cough, fever), it’s more likely to be an infection called conjunctivitis or
pink eye.
Conjunctivitis can be caused by either a virus or bacteria. Bacterial
infections cause goopy eye discharge (eye boogers) and viral infections
cause watery eye discharge. Both are extremely contagious. Bacterial
infections can be treated with antibiotic eye drops or oral antibiotics.
Viruses cannot be treated and can last up to a week.
Children under age two years with bacterial conjunctivitis (goop) should
see a doctor. About 30% have an ear infection or sinus infection to go along
with it. The bug is usually Haemophilus influenza non-typable (a cousin of
the HIB we vaccinate against). This is a smart bug often resistant to first
line antibiotics.

BOTTOM LINE: A child under age two with goopy eyes needs to be seen by
a doctor. There is an association of pink eye with ear infections and sinus
infections.

Q. My baby’s eye is red. Does he have allergies?

 Unlikely.
As a general rule, babies under one year do not have seasonal allergies.
A red eye is either caused by trauma, irritation, or infection. If just one eye
is red, consider trauma (corneal abrasion—see below, foreign body) or
irritation (soap, sun block). If it is bothersome to your baby, try flushing the
eye with some lukewarm water.
If your baby looks uncomfortable, he needs to be evaluated.
Causes of red eyes: trauma, irritation, infection—viral or bacterial.

Q. My baby’s eye is swollen shut. Should I worry?

Yes—if she has a fever.
Usually the cause of impressive swelling is a local allergic reaction. If a
bug bite or poison ivy occurs on an eyelid, the reaction can be impressive.
Proof of a bite or rash is helpful.
The concern is a serious infection called ORBITAL CELLULITIS. This is a
sinus infection that extends into the area where the eye rests in the skull
(orbit). It happens in stages, and the prognosis is obviously better if caught
early. The first sign is redness and swelling of the eyelid. It then progresses
to a bulging eye, with limited motion of the eye itself.
If you see this, call your doctor NOW. This is a medical emergency. See
our web site at Baby411.com for a visual library picture (the picture titled
“eyelid swelling” is the example you’re looking for).

Q. My baby’s eye is tearing constantly today. What is

wrong?
Probably a corneal abrasion.
Babies can scratch their eyes accidentally. This is a superficial scratch
that takes a day or two to heal. Foreign bodies (dust, etc.) can also cause
similar symptoms. Doctors check for abrasions using a purple light and
fluorescent dye. If a scratch is found, antibiotic eye drops are prescribed. If
a foreign body is found, it can be flushed out.

What the doctor will ask you about RED EYES

 1. How old is your baby?
2. Is there eye discharge? Is it watery or goopy?
3. Is there fever, runny nose, or fussiness?
4. If the eyelid is swollen, is there any bug bite or rash visible? Any
fever?

Priority 1: Needs immediate evaluation and treatment—NOW:

Eyelid swollen shut with fever.
Question of foreign body in the eye.
Very uncomfortable child with a red eye.

Priority 2: Needs appointment the next day.

Goopy eyes with a cold, with or without fever

Priority 3: Watch and wait. Needs appointment if there is no

improvement or worsening of symptoms:
Newborn with eye that waters frequently, without redness.

Fever: Special Section

Fever is the number one reason pediatricians get called at night. At some
point in your baby’s life, he will have his first fever. And like every new
parent that has come before you, you will have some anxiety. So, let’s go
over our advice. Note: please read this section in its entirety! If you only
read a portion, you may miss key details. (Note: all temperatures are in
degrees Fahrenheit).

Q. What is the definition of a fever?

Fever is an elevation of the body’s regular temperature.
Contrary to what you learned in junior high science class, our body
temperature is not 98.6 for 24 hours a day. It varies on a daily rhythm based
on hormone levels. Our body is the coolest at 7 am (as low as 97.6) and the
hottest at 7 pm (as high as 100). The true definition of fever is a body
temperature of 100.4 or higher taken rectally.
When an infection (most common reason for fever) enters the body, the
body mounts a defense via the immune system. The immune system revs up
all other body systems into attack mode. This raises all vital signs
(temperature, heart rate/pulse, respiratory rate, blood pressure). A warmer
body temperature actually helps fight infection. FEVER IS NOT BAD.
Because the normal body temperature is lowest in the morning and
highest at night, our fever will be lower in the morning and higher at night.
With a typical viral infection, we may have a temperature of 99 in the
morning and be 102 at night. This is why pediatricians get phone calls
about fever at night. The fever doesn’t go away and come back. It’s always
there. It’s just lower in the morning. Fevers often last for three to four days
for a viral infection.
Fever, in and of itself, does not do any harm to the body. But it is an
indicator that something (usually infection) is going on in the body. Parents
tend to focus and worry about the fever. Pediatricians worry about what the
diagnosis/infection is. Body temperatures over 108 cause brain damage.
Infections do not cause body temperatures over the 106 range.
(Hyperthermia, the term for body temperatures over 107, are usually caused
accidentally—for example, someone locked in a car in the middle of
August).
Fever is often the first sign of illness. It can take several hours to see the
other symptoms blossom from the infection. So, unless a baby is under
three months of age (see protocol below), you may need to watch and see
how things evolve.

DR B’S OPINION: FEVER-PHOBIC

PARENTS

Here is a typical phone encounter on fevers:

 Parent: “Doctor, my baby has a fever.”
Doctor: “Yes, but what else is going on?”
Parent: “But, doctor, he has a fever.”
Doctor: “I understand, but can you tell me if he has any other
symptoms?”

You get the picture. I heard you. I know your baby has a fever. I
need to figure out WHY he has the fever. The fever is not the
problem—it’s a clue for the real problem. Be a good detective and
help me look for clues. It will make for a much more productive
conversation!

Fever Phobia
A study looked at parent misconceptions of fever: (Crocetti)
91% believed fever could cause harmful effects (death, brain
damage).
44% believed that a fever over 102 was a “high” fever.
7% believed that a fever could rise to 110 if left untreated.
25% gave fever reducing medicine for temperatures less than 100.
85% said they awaken their child to give fever-reducing medicine.
44% dosed the fever reducing medicine incorrectly.
52% said they checked their child’s temperature at least every hour
when they had a fever.

BOTTOM LINE
The body is coolest at 7 am (as low as 97.6) and hottest at 7 pm (as high as
100). So, the true definition of fever is a body temperature of 100.4 or
higher taken rectally.
 Fever is the body’s immune response to infection. The immune system
revs up all other body systems and raises all vital signs. A warmer body
temperature actually helps fight infection. Therefore, fever is not bad.
Remember, fever is not the problem, rather it is a clue to finding the
problem. And fever is often the first sign of illness.
Don’t be fooled that your child is fever-free in the morning if he had a
fever the night before. It’s just naturally lower in the morning. If you send
him to childcare, you will get called to take him home when his fever spikes
in the afternoon. Prepare to stay at home next day if your child has a fever
at night.

Reality Check
Most of the time, newborns have a virus they picked up from a family
member. But your doctor doesn’t want to take any chances. Now you know
why the standard advice is to limit visitors during the first four weeks after
birth.

Helpful Hint
Newborns can also have problems if they have LOW body temperatures. If
your newborn has a persistently low body temperature (under 97.6 taken
rectally), it’s best to check in with your doctor.

Q. At what temperature should I be worried?

Below is the protocol for fever in infants. The management plan is based
on a child’s age. The protocol is fairly universal for all babies under three
months.
Priority 1: Needs Immediate Evaluation And Treatment—NOW:

Age zero to four weeks: any fever in this age group is an emergency!
1.A rectal temperature of 100.4 or greater requires hospitalization
ASAP.
2.Newborns have a unique risk of serious bacterial infections due to
delivery and congenital urinary tract defects (Group B strep
meningitis, pneumonia, sepsis, urinary tract infections/kidney
infections). They are tested for all of these potential infections and
treated with antibiotics until bacterial cultures are clear of growth.
(see sepsis workup in Appendix C, Lab Tests).
3.Never give acetaminophen (Tylenol) to your feverish newborn. Call
your doctor.

Age four weeks to three months: any fever in this age group is an
emergency!
1.A rectal temperature 100.4 or greater requires examination and lab
evaluation.
2.These infants need to be seen either in the doctor’s office or in an
emergency room depending on the hour. They still run the risk of
having those bacterial infections that newborns get.
3.If there is an obvious source of infection (e.g. a cold), and the baby’s
lab work looks reassuring, hospitalization is unnecessary.
4.Never give acetaminophen (Tylenol) without calling the doctor.
Exception: If your two-month-old baby received his vaccinations,
and then starts running a fever within 24-72 hours, it’s not a
problem unless there are other symptoms going on. We expect your
baby to run a fever after getting his shots. Review Chapter 12,
Vaccinations, for more information.

Age three months to six months: a fever AND these problems in this
age group is an emergency.
1.A fever over 102.
2.A fever lasting more than three days.
3.A new fever, after a recent illness.
 4.No obvious symptoms of viral infection (cough, runny nose,
diarrhea).
5.Fussy mood/inconsolable.
6.Petechiae rash (See bleeding section earlier).

Age six months to one year:

1.A fever of 104 or above deserves a phone call. (We know—that’s way
beyond your comfort level.)
2.A fever lasting more than three days.
3.A new fever, after a recent illness.
4.No obvious symptoms of viral infection (cough, runny nose,
diarrhea).
5.Fussy mood/inconsolable.
6.Petechiae rash (see bleeding section earlier in this chapter.)

Priority 2: Needs appointment the next day.

Age three months to six months:
1.If everyone in the house has the flu and your baby has the same
symptoms, make an appointment if the fever persists longer than
three days (or something else is concerning—i.e. dehydration,
labored breathing).
2.You can give acetaminophen (Tylenol) for the fever. Just make sure
you have figured out why your baby has the fever first.

Priority 3: Watch and wait. Needs appointment if there is no

improvement or worsening of symptoms
Age six months to one year:
1.Obvious symptoms of a virus (cough, runny nose, vomiting,
diarrhea), you can probably manage the infection without a
doctor’s visit.
2.You can give acetaminophen (Tylenol) or ibuprofen (Motrin) when
your baby has a fever. Just make sure you know why your baby
has the fever.
Reality Check
After six months of age, it’s not the degree of the fever that is concerning,
it’s what the baby looks like. Everyone looks sick when they are running a
fever. If a baby still looks sick after taking a fever reducing medicine, it’s
time to call the doctor.

Insider Tip: Roseola

Children usually get the common childhood infection, ROSEOLA, between
nine to 12 months of age. It causes a high fever (103 to 104) for about three
days with no other symptoms. These kids look perfectly happy and go about
their daily routines. On day four, when they are fever free, the classic
roseola rash (flat red patches on the chest and arms) comes out. They are
not contagious with the rash. High fevers (104 or above) deserve to be
evaluated, but roseola is often the culprit.
See our web site at Baby411.com (Bonus) for a visual library of rashes.

Q. My baby is running a “low grade” fever. Should I

be worried?
Who started this urban legend? What is a low-grade fever? It’s not in the
doctor dictionary.
Parents worry about body temperatures of 99 to 100. This is not, by
definition, a fever. It has no association with an infection unless your baby
is 100 at 7am. In that case, it does not bode well for what the night will
bring.
Q. My baby has had a fever “on and off” for several
days. I thought he broke the fever. Why does it keep
coming back?
Let’s review. A typical viral infection will cause a fever for three or four
days.
Remember, it may look like your baby doesn’t have a fever in the
morning, but it always comes back at night. If there is a fever at any point
in a 24-hour day, your child still has fever on a daily basis. This is helpful
when you are reporting symptoms to the doctor. Doctors want a record of
how many days in a row your child has had a fever. It helps make
diagnostic decisions.
Fever reducing medicine, acetaminophen (Tylenol) and ibuprofen
(Motrin), will help bring the body temperature down for four to six hours.
But once the medicine wears off, the fever will return. The medicine does
not make the infection go away. (See later questions on fever-reducing
medications).

BOTTOM LINE: A truly NEW fever after being fever free for a period of at
least 24 hours is concerning for a bacterial infection that has capitalized on
a sick person (such as ear infection, sinus infection, pneumonia). Make an
appointment to see your doctor.

Helpful Hint
On Fever Curves
Another important trend doctors watch is the fever curve over a period of
days. At the beginning of an infection, the fever is the highest. As the body
effectively fights off the infection, the maximum fever spikes should be
lower. If a fever curve trends up instead of down (fevers are getting higher
on a day to day basis), this is more concerning and may prompt an
evaluation.
Q. How do you recommend taking a baby’s
temperature?
For the target age of this book (birth to age one), you need to take the
temperature with a rectal thermometer.
Most parents cringe just thinking about this task. Are you cringing?
Don’t. Babies really don’t mind. It does not hurt or make them feel like
you’ve invaded their space. In fact, it’s a good trick to make them poop. But
I digress.
Rectal temperatures are the most accurate way to check a human’s body
temperature. And for infants under three months of age, one tenth of a
degree will make the difference between whether you stay at home in your
nice warm bed or head out for an evening of fun at your local emergency
room.
If you call the doctor at 2 am and tell her that your six week old has a
fever, the first thing she will ask is, “How did you take the temperature?” If
you took it any way other than rectally, we make you get a rectal
thermometer and call us back. Invest in one now—digital rectal
thermometers cost about $5.
After one year of age, there is more flexibility about how to take your
child’s temperature. Trendy products on the market for toddler temperatures
include a pacifier thermometer, ear thermometer, temporal artery scanners,
and plastic skin stickers. Using an oral thermometer in the armpit is also
okay. None of these are as accurate as a rectal temperature. But after a year
of age, the actual degree of fever is much less important to making a
management plan for your child. That is, a child with 101 or 103 is
managed based on the other symptoms they have in addition to the fever.

DR B’S OPINION:
THERMOMETERS
 Ear thermometers are not my friend. Their reliability is based
upon the ability of the user to line the tip up with the eardrum. If
you compare your own two ears and get two different readings, you
will understand what I mean. Ear thermometers can also
overestimate the degree of fever and create parent panic. I’ve
received frantic calls regarding kids with fevers of 107 taken with
an ear thermometer that turned out to be 102 or 103 when taken
rectally.
Except for the ear thermometers (which OVER estimate fever),
alternative methods to check temperature UNDER estimate the
degree of fever. Parents often ask, “Do you add or subtract a degree
from the non-rectal measurement?” My response is, “If you ever get
an actual reading that is 100 or over, you know your child has a
fever. That is all the information I need.”

Mom Knows Best

There was a great study that tested Mom’s method of temperature taking
(placing the hand on the forehead). Guess what? Mom is usually right—at
least 80% of the time—with this method. Some thoughts on this:
1.After six months of age, if you say your child “feels hot,” that’s often
enough proof of fever.
2.Trust yourself! Parents think they need to take their baby’s
temperature periodically to make sure he is okay. You hold your
baby 24 hours a day. You will know when he feels hot. Then you
can get out the thermometer.

New Parent 411: How to take a baby’s rectal

temperature.
Don’t be embarrassed. You’ve never done this before. Get out your digital
rectal thermometer. Place some petroleum jelly (Vaseline) on the tip. With
one hand lift up your baby’s feet, holding them together. With your other
hand, insert the tip of the thermometer into his anus about one inch. Leave
the thermometer in there for one minute (or until it beeps at you). See, you
and baby did just fine.

FYI: The American Academy of Pediatrics recommends using digital

(rectal/oral) thermometers as opposed to glass mercury thermometers. The
latter are dangerous if broken.

TREATING A FEVER: DR. B’S 10 COMMANDMENTS

1 IF YOU HAVE YOUR DOCTOR’S BLESSING, IT’S OKAY TO GIVE A

FEVER REDUCING MEDICATION. (See age discussion earlier.)

2 BABIES FROM THREE TO SIX MONTHS CAN USE

ACETAMINOPHEN (Tylenol). It’s fine for two month olds to take
acetaminophen after getting vaccinations. However, many docs
suggest waiting until several hours later to give acetaminophen.
Giving a dose too soon may blunt the appropriate response to the
vaccination. Ask your doc for dosing instructions.

3 BABIES OVER SIX MONTHS OF AGE CAN USE IBUPROFEN

(Motrin/Advil) OR ACETAMINOPHEN (Tylenol).

4 I PREFER IBUPROFEN FOR OLDER BABIES BECAUSE THE

MEDICATION LASTS FOR SIX HOURS INSTEAD OF FOUR. Since the
fever will climb at night, this will buy everyone two extra hours of
sleep.

5 ACETAMINOPHEN IS PREFERRED IF A CHILD IS DEHYDRATED

or has a stomach virus (ibuprofen can upset an empty stomach).
 6 BE FOREWARNED: THESE MEDICATIONS ARE CALLED FEVER
REDUCERS NOT FEVER ELIMINATORS. At best, these medications
will bring the body temperature down by two degrees. If your baby is
cooking at 104, he will be feeling more comfortable at 102. That’s as
good as it gets.

7 I DON’T ROUTINELY INSTRUCT PARENTS TO ALTERNATE

ACETAMINOPHEN AND IBUPROFEN. If a baby is old enough for the
ibuprofen, stick with that. I only alternate medicines in babies prone
to febrile seizures (see glossary for details). There is no proven
benefit of alternating medicines.

8 DON’T BOTHER PUTTING BABY IN A TEPID BATH. If you had the

chills, would you want to sit in cold water? This cooling technique is
only necessary in an emergency situation (such as extreme
hyperthermia, a 107 temperature). Bringing your child’s temperature
down with this technique is not only unpleasant, but a waste of time
and effort.

9 NEVER GIVE YOUR CHILD ASPIRIN. It can cause liver failure

when given with particular viral infections.

10 ALWAYS USE THE MEDICINE DROPPER THAT COMES WITH

THE PACKAGE. The term “one dropperful” refers to the dropper that
comes with the medicine.

Q. What is the correct dose of medication? It says on

the box to consult a physician.
Ever wonder why it says this on the box? It’s to make sure that you call
the doctor when your newborn has a fever. Now that you know when you
need to call, we will tell you how to dose these medicines. Both
acetaminophen (Tylenol) and ibuprofen (Advil) are dosed at five milligrams
per pound per dose. See the dosing chart on the following page.

How to avoid overdosing your baby

1.Acetaminophen is the generic name for Tylenol, Feverall, and
Tempra.
2.Ibuprofen is the generic name for Motrin and Advil.
3.Both acetaminophen and ibuprofen are effective fever reducers and
pain medications.
4.Acetaminophen is dosed every four hours. Ibuprofen is dosed every
six hours.
5.As we’ve said earlier, always use the medicine dropper that comes in
the package. The dropper size varies between products. To reduce
dosing confusion, acetaminophen liquid now comes in only one
standard concentration. However, ibuprofen comes in two different
strengths—infant concentrated drops and a children’s syrup.
6.There is a difference in the concentration of medicine in the infant
drops and the children’s syrup. The infant drops are much more
concentrated so you won’t have to force a large volume of
medicine into your baby.
7.Acetaminophen suppositories (medicine bullets inserted in the anus)
are available for babies who resist taking medicine or are actively
vomiting.
8.When your doctor tells you to use “one dropperful,” it routinely
means the dropper that comes with the package, with the medicine
drawn up to the line marked on the dropper. A mother requested
that we share this with you because she mistakenly thought it
meant to fill the whole dropper up with medicine (look at a
medicine dropper and you’ll understand).
9.When you graduate to the syrup medicine, use a medicine cup to
dispense. Silverware teaspoons are not an exact teaspoon
measurement. They can be larger or smaller depending on your set.
Medicine syringes are also helpful—they make it easier to measure
and dispense medicine.
 DR B’S OPINION

“I have too many stories about Tylenol overdoses

to share in this book. It’s just not as easy to figure
these medicines out as it should be.”

Dosing Chart
Acetaminophen:

Ibuprofen:

* Note: Ibuprofen is NOT for babies under six months of age

Q. Is it safe to give a fever reducing medicine longer
than five days? It says on the box to consult a
physician.
The medicine itself is safe to give. This warning is a way to make sure
you have checked in with your doctor if your baby has a prolonged fever. A
child with a fever more than four days straight should be seen by her doctor.

Q. I have given my baby acetaminophen (Tylenol) and

he still has a fever.
This one is on the Top 10 List of most asked questions for any
pediatrician.
The most common reason this happens is that your child has outgrown
the dose of medicine you have given him. Fever reducing medicines (as well
as most other types) are dosed based on the weight of a child. A few pounds
can make a difference for the correct dosing.
Look at the chart above. When your doctor tells you the dose of
acetaminophen (Tylenol) at your child’s two-month well check, don’t think
that the dose will never change.

BOTTOM LINE: Acetaminophen and Ibuprofen are fever reducers (not

eliminators). If your child has a high fever, it won’t be completely
eliminated by the medicine. The fact that the fever does not go down with
medication has no implication on the severity of the illness.

Q. I’ve heard that fevers can cause seizures in babies.

Is this true?
Yes, babies can have febrile seizures or convulsions.
A few children—less than 5% (ages six months to five years) are prone
to having a seizure/convulsion as a fever is shooting up. “Febrile seizures”
do not cause brain damage or lead to a seizure disorder such as epilepsy.
 The seizure happens when the body temperature rises quickly. If your
child’s temperature is already at 104, he’s most likely missed the window of
having a seizure. So, you can relax now.
Yes, it is terrifying to watch a child have a full-blown seizure in your
living room. Fortunately, febrile seizures last less than five minutes. And
children are fine afterwards.
About 30% of children who are prone to febrile seizures have more than
one episode in their lives. But after the first time, parents are much more
comfortable about managing it. Parents will give fever medicine around the
clock so that the temperature elevation can never rise rapidly during the
course of an illness.
The first time a child has a febrile seizure, he needs to be evaluated
thoroughly. Once this diagnosis is determined, treatment focuses on the
cause of the fever.

Old Wives Tales

Don’t give your baby a bath while he has a fever.
Don’t let your baby drink milk while he has a fever. Fevers cause
brain damage.
Teething causes fever.
The Truth: None of these statements are remotely true. Keep feeding your
baby breast milk or formula, go ahead and give him a bath, and unless his
fever reaches the extreme temperatures mentioned earlier, relax a bit. Oh,
and teething has nothing to do with fever.

What the doctor will ask you about FEVER:

1. How old is your baby?
2. How did you take the temperature?
3. What other new symptoms are you seeing?
4. Is anyone else in the household sick?
5. Is your child exposed to other children?
6. How many days has the fever been going on?
 7. Any recent illnesses prior to the fever?
8. Any rashes?
9. Have you given any fever reducing medicines?
10. What dose of medicine did you give?
11. What does your baby look like after giving the medicine?

Red Flags
Fever under three months of age.
Fever over 102 in three to six-month-old.
Fever of 104 or above in six months and older.
Fever lasting over three days.
Fever without obvious source of infection.
Fever with petechiae rash.
Fever with irritability or lethargy.
Febrile seizure.
Fever with a limp or limb pain.

Poisonings/Ingestions

If your child accidentally swallows a household product, call poison

control immediately.
Have the phone number at each of your telephones. Do NOT try to make
your child vomit. Other treatments are more effective (and vomiting can, in
some cases, causes MORE harm than good).
Poison Control is an amazing resource of information on any product a
curious child might ingest. They will tell you whether the product can do
potential harm to the body or not. And they know the antidotes.
Occasionally, a parent is not even aware of the ingestion happening.
They only know that their child is acting unusual. Some clues to ingestion
include: mouth burns, drooling, rapid or shallow breathing, vomiting
without fever, seizures, extreme lethargy, or body/breath odor.

THE MOST DANGEROUS HOUSEHOLD PRODUCTS

Here is a list of childhood favorites to keep out of reach. (Place

items in high cabinets out of reach or in places with cabinet locks).

Chemicals
cleaning products
paint thinner
dishwashing detergent
gasoline

Medications
especially Mom’s prenatal vitamins (iron)
especially visiting grandparents (heart or blood pressure
medications)

Plants (some of these are common houseplants).

Christmas favorites: poinsettias, mistletoe, holly
wild mushrooms
hyacinth, narcissus, daffodil, elephant ear, rosary pea, larkspur,
Lily-of-the-Valley, iris, foxglove, bleeding heart, daphne, wisteria,
golden chain, laurels, azaleas, jasmine, lantana

Hygiene products
mouthwash
nail polish remover
rubbing alcohol
hair dye

Food and wine

liquor
pottery from foreign countries (lead)
Helpful hint
If Poison Control directs you to an emergency room, take the
poison/medication with you if you have it. It helps determine the
ingredients and the amount that was swallowed.

Feedback from the Real World

Dr. B True Story
I cared for a patient once who ate part of a necklace a mother had
brought back from traveling abroad. The beads were made of ricin, the
active ingredient of poison darts (think Bond, James Bond).
Bottom Line: Be careful. Babies are programmed to taste everything.

What the doctor will ask you about POISONING:

1. Is the product toxic vs. non-toxic?
2. Do you have the bottle/container?
3. Is your child having trouble breathing?

When to call:
All poisonings and ingestions are Priority 1: Needs immediate
evaluation and treatment—NOW!

Rashes

Trying to diagnose a rash over the phone is always a challenge. Someday

we’ll just take a picture of our rashy kid and text our pediatrician. (Most
docs do not currently offer telemedicine service.) But for now, you need to
be the eyes for your doctor. Without actually seeing the rash, the best we
can do is figure out whether the rash fits into the worrisome or the non-
worrisome categories. Worrisome rashes need prompt attention. Non-
worrisome ones can wait until the office opens the next day. Causes of
rashes include:
Infection: viruses, bacteria, fungi, mites
Allergy: eczema, contact allergy (poison ivy, sensitivity to a skin care
product), food/medication allergy
Newborn rashes: due to hormonal changes
Blood cell abnormalities

See our website at Baby411.com (Bonus Material) for a visual library of

rashes.

What the doctor will ask you about RASHES:

1. How long has the rash been there?
2. Where on the body did the rash start? Is it spreading? Where?
3. Is there a fever?
4. Is it itchy? Really really itchy?
5. Anyone else in the house with a rash?
6. Is the rash flat or raised? (Can you feel it with your eyes closed?)
7. Is it scaly on top?
8. What color is the rash?
9. How big are the spots?
10. When you press on the rash, does the color turn white? Or, does it
remain discolored?
11. Is your child taking any medications?
12. Has your child eaten any new foods?
13. Have you used any new skin products? (sun block, lotion, soap,
detergents)
14. How old is your child?

Q. Which rashes are worrisome?

 Petechiae with or without bruising. (See bleeding section earlier for
details on petechiae). Petechiae are small flat freckle or pinpoint dots,
purplish in color, that stay purple when you push on them.
This is really the only rash that needs immediate attention. Petechiae can
be caused by forceful coughing or vomiting. But this rash can also indicate
meningitis, Rocky Mountain Spotted Fever, idiopathic thrombocytopenia
purpura (ITP), or leukemia. Petechiae are Priority 1: Needs immediate
evaluation and treatment—NOW.

Q. What are hives and what causes them?

A rash that appears due to release of a chemical called histamine. 20% of
the population will get hives once in their lives. But 75% of the time, the
cause is never found. (Fleisher)
Hives look like mosquito bites with red circles around them. Or, they
look like a flat red area with a raised border. Hives vary in size and shape.
They are itchy and occur anywhere on the body. The individual lesions
come and go. See Chapter 14, Common Diseases for causes of hives.

What to do if your child breaks out in hives

Relax. If your child is not having any trouble breathing, this can be
managed at home.
Try to figure out what caused the hives (foods, medications, illness).
Stop any medications until you see the doctor.
Give an antihistamine. Liquid diphenhydramine (Benadryl) comes in
12.5mg per teaspoon syrup. A 20 lb. baby can have 3/4 tsp. If your
baby is smaller than 20 lbs., call your doctor before giving it.
Babies six months up to two years of age can have 1/2 tsp of liquid
cetirizine (Zyrtec) or loratidine (Claritin), which are also available
over the counter.

Q. What does a drug allergy rash look like?

 True drug allergies will cause hives or ERYTHEMA MULTIFORME. Any
other rash does not require avoidance of a particular medication.
Erythema multiforme basically means “redness in multiple forms.” What
you see is a full body rash of red flat patches and raised borders. Many of
the patches run into each other.
If you see a concerning rash while your child is on medication, hold the
dose of medicine and bring the child in to be seen. A particular medication
class should not be avoided unless there is a documented allergy.

Q. What does a food allergy rash look like?

 Food allergies can cause hives and lip swelling if the reaction is severe.
But it can also cause a flare up of a rash called eczema. Eczema is an
allergic skin disorder—the equivalent of hay fever. Eczema looks like a
scaly plaque lying on top of a red base. With a food allergy, the eczema can
cover huge body surface areas.
Food allergies do NOT cause mild diaper rash, a few patches on the face,
or heat rashes.

Q. My child has a scaly rash on his elbows and knees.

What is it?
Eczema. It is sensitive skin. In infants, it likes the elbows and knees
because these areas get chewed up from crawling. It also ends up in the skin
folds of the elbows and knees from rubbing. See Chapter 14, Common
Diseases for more details on this.

Q. Which rashes are likely to be contagious due to

infection?
Most of them. Kids have wonderful immune systems (much better than
ours). And rashes are created from an immune response to a particular
infection.
The diseases listed on the previous pages are The Classics. There are
also a variety of non-descript rashes that fit in the category of “viral and
non-worrisome.”

Q. I know that all newborns get rashes. Are there any

I need to be worried about?
Yes. Herpes.
Moms with genital herpes have a chance of spreading it to their newborn
during a vaginal delivery. (If Mom has an obvious outbreak a Caesarian
section is performed.) A herpes rash in a newborn shows up within two
weeks of life. The lesions look like little blisters either alone or in crops.
This is Priority 1: Needs immediate evaluation and treatment—NOW!

Q. My four week old has a pimply rash all over his

face and chest. What do I do?
It’s acne, but don’t break out the Oxy 10. This rash is caused by a
hormonal change in the baby. Leave it alone and it goes away by eight
weeks of age.

Feedback from the Real World

Dr. Brown True Story
My son woke up one morning with three distinct red circles on his chest.
I thought he had ringworm until I realized the circles matched the snaps on
his sleeper pajamas. He had an allergy to the metal snaps.
Necklaces, earrings, and snaps on jeans can cause a similar reaction in
people with sensitive skin.

Q. My one year old looks like he has the measles! Does

he?
No. Did he come in for his one year well check recently? That rash is the
response to the MMR vaccination. (Kids also get a chickenpox-like rash
with the chickenpox vaccine). Be happy. This means he has formed a good
response.
These rashes usually appear one to four weeks after being vaccinated.

Q. My baby has a diaper rash. What do I do about it?

See Chapter 4, Hygiene for details on how to treat diaper rash.
Priority 1: Needs immediate evaluation and treatment—NOW:
Hives that occur while taking medication or trying a new food.
Hives with difficulty breathing (Call 911).
Petechiae rash.
Newborn with a blistery rash.
Any rash with a fever.

Priority 2: Needs appointment the next day.

Rashes that are scaly, without fever.
Rashes that are not going away after being treated by a doctor.

Priority 3: Watch and wait. Needs appointment if there is no

improvement or worsening of symptoms:
Newborn (birth to eight weeks) with a non-blistery rash, acting well.
Diaper rashes.
One year old with rash after being in for his one year well check.

Seizures

Seizures are scary to watch. If your child has a seizure, dial 911. Once
the episode is over, you can review this information.

Q. What is a seizure?
Involuntary muscle (motor) activity is the definition of a seizure. This is
caused by an electrical brainwave that has fired incorrectly. In kids under
age one, the most common type of seizure is associated with a fever that is
rising quickly (See febrile seizure in the fever section of this chapter).
Causes of new onset seizures include: Febrile seizure (convulsion),
head trauma/injury, meningitis, poisoning/ingestion, metabolic disorder,
seizure disorder

What To Do If Your Baby Has A Seizure

Call 911.
 Put him in a safe place (a carpeted floor).
Make sure he can breathe.
Do not put anything in his mouth to hold his tongue (contrary to what
you see on TV).
Start CPR—do mouth-to-mouth resuscitation if baby looks blue.

What the doctor will ask you about SEIZURES:

1. Has your baby ever had a seizure before?
2. How old is your baby?
3. Does the baby have a fever?
4. Anyone in the family prone to febrile seizures as a child?
5. Any history of head trauma?
6. Any history of poisoning or ingestion?

Priority 1: Needs immediate evaluation and treatment—NOW:

Known history of febrile seizures, with another episode
Has a known seizure disorder.

Stitches (Sutures)

The key point to remember: Stitches (sutures) need to be placed within

12 hours of the injury. So they are always considered Priority 1. Any later
than that, the wound has a much higher chance of getting infected. If your
child has a wound that might need stitches, call your doctor now.

What the doctor will ask you about NEEDING STITCHES:

1. What happened? For example, animal bites usually are not stitched
because of infection risk.
2. How long ago did the injury happen? If over 12 hours, wound
can’t be sutured.
3. Where on the body is the cut (laceration)? Location of the wound
makes a difference because of cosmetic issues (face) and potential
nerve damage (hands).
 4. If on the face, is it crossing the lip/skin line or the eyebrow
line? It may need stitches for better cosmetic result.
5. How deep is it? If you can see fat, it needs stitches—anything
deeper than 1/4 inch.
6. Is the bleeding under control? If not, it needs stitches.
7. For older wounds: Is there any pus, redness around the wound,
streaks of red from the wound, or fever? Needs to be seen for
possible wound infection.
8. Are your child’s immunizations current? Needs tetanus shot if not
up to date.
9. Does your child have any bleeding disorders? There is a risk of
large volume of blood loss.

HOW TO CLEAN AND CARE FOR MINOR WOUNDS

It’s not what you use, it’s how you use it. Plain old soap and water
is fine. You don’t have to get high tech here. The key is to flush the
wound and repeat this several times. Wash the wound every day until
it heals. Here’s how to care for minor wounds:

1.Apply pressure to the wound with a gauze pad or towel for ten
minutes.
2.Thoroughly clean wound with soap and water. The most important
part of the cleaning process is flushing with water repeatedly—
especially with puncture wounds (bites, sharp objects). Your
doctor will use a mechanism much like a Waterpik to clean
“road rash” scrapes.
3.Apply antibiotic ointment for two or three days. This prevents
infection and improves cosmetic results.
4.Look for signs of infection. (Redness, pus, fever).
5.For cuts in the mouth or tongue, try popsicles or ice cream (if age
appropriate) to help control bleeding.
Q. Are there any body parts that always need stitches?
Yes. Eyebrows and lip lines. The lip line means the area where the lip
meets the skin. If a wound crosses this line, the lip will not line up correctly
without stitches. The same is true for the eyebrow line. Cosmetically, this is
a big deal.

Q. Are there any body parts that never need stitches?

It is RARE to need stitches on the lip itself, tongue, or gums. The blood
flow to these areas is tremendous (which is why they bleed so much). This
blood flow allows very rapid healing.

Feedback from the real world: Tongue injuries

One of our readers suggested we add some tips on tongue injuries (after her
$74 adventure to the doctor’s office). Her two-year-old daughter had bitten
her tongue and there was a visible gap. So, Michele C., this one’s for you!
As long as the tongue is not cut (lacerated) through, it usually does not
require stitches and will heal up beautifully in one or two days. You don’t
need to visit your doctor or the ER.
Our reader recommends offering scrambled eggs, mashed potatoes, and
ice cream to little ones with tongue injuries.

Q. How can I tell if the wound is infected?

Pus (white/yellow/green discharge) will start to ooze out of the wound.
There will be red and tender skin around the wound site, and maybe even a
streak of redness starting from the wound. There may also be a fever.

Q. Is my child’s tetanus shot up to date?

 If your child is receiving his immunizations regularly at well baby
checks, he is well protected. He gets a tetanus shot at two, four, six, fifteen
months and again at five years old. Your child is probably better protected
than you.

Q. Can I get water near the stitches?

YES!
This is a common misconception. Clean the wound, even if it has
stitches in it. The not-cleaned ones have crust around them, making it a
challenge for the doctor to remove the stitches.

Q. When should the stitches be removed?

It depends on the location. Skin heals at different rates on the body. The
doctor who puts the stitches in will tell you when they need to come out.
Try to do it when suggested— a delay in suture removal can not only impair
the cosmetic result, but can also be very painful if the stitches are imbedded
in the skin.
To give you an idea of the variability of suture removal, stitches on the
face come out in four days. Stitches on the palm of the hand come out in 14
days.

Q. What is that glue used to close wounds? Can we use

that instead of stitches?
The brand names are Dermabond or SurgiSeal, and they are fairly
popular alternatives to stitches. It’s like superglue. It dissolves on its own
and does not need any removal. Sounds great, right?
Well, it is only useful for a limited number of wounds. If the skin is
under any tension (gets pulled frequently), the glue won’t be able to hold
the wound together. The glue is also not intended for use near the eyes.
Dermabond and SurgiSeal are products sold only to medical providers.
There are some over-the-counter topical skin adhesives, but we cannot
attest to their effectiveness.

Q. I’ve also heard about using staples instead of

stitches. Is this better than stitches?
It’s easier than stitches for placement, but they are painful to remove. For
non-cosmetic areas such as the head, it is a reasonable option.

Helpful Hint
Cuts on the scalp and face bleed a lot. The blood flow to these body parts is
much greater than any other areas. Don’t be alarmed. It is only a problem if
you can’t get the bleeding under control.

Priority 1: Needs immediate evaluation and treatment—NOW:

Any skin wound that you think might need stitches.
Unable to control the bleeding after ten minutes of pressure to the
wound.
Wound in a cosmetically undesirable location.
Looks like it is getting infected (redness, pus, fever).
If immunizations are not current.

Priority 3: Watch and wait. Needs appointment if there is no

improvement or worsening of symptoms:
Make an appointment for suture removal.

Trauma (Accidental Injury)

No matter how good of a parent you are and how safety proofed your
house is, your child will find a way to hurt himself. Welcome to parenthood
—this is only one of the many reasons that your child will give you grey
hairs.
 This section is body part specific. The section on skin trauma/injury is
covered in the Stitches section.

What the doctor will ask you about TRAUMA / ACCIDENTAL

INJURIES

1. What happened?
2. Any loss of consciousness or did he cry immediately?
3. With head injury: Any vomiting or confusion?
4. With head injury: How far did the child fall and what surface did he
fall onto?
5. Any bleeding or fluid draining from the nose or ears?
6. Are there any obvious broken bones, sticking out of the skin?
7. Any pain with touching or movement of a body part?
8. Any bruising or swelling?
9. Can you check the eye pupils. Are they equal?

Helpful Hint
The mechanism of injury (that is, what happened) is the most reliable factor
in determining the severity of a body injury.

1. Head injury
Once babies are mobile, they run into things like the coffee table and
fireplace hearth. The result is a big bruise (a.k.a. “goose egg”) on the
forehead. It is an impressive bump because of that vast blood supply to the
head and face. Despite the appearance, goose eggs are not too worrisome.
The mechanism of injury is much more concerning. Here are the red
flags for head injuries:
 NEW PARENT 411: HANDLING MINOR HEAD
INJURIES

Put a bag of frozen vegetables on the goose egg, if your child lets
you. It will be less swollen in the morning, but will change into a
rainbow of colors for a week or two.
Watch for signs of concussion for the next two days (vomiting,
irritability from headache, confusion, lethargy)
Let your child go to bed. Invariably, it’s nap or bedtime when these
events happen (probably because your child is tired and clumsy
then). You can monitor him every few hours by watching his
breathing and gently touching him to see if he stirs. Vomiting or
seizure activity happens whether he is awake or asleep.

Priority 1: Needs immediate evaluation and treatment—NOW!

For injuries for a concussion or bleeding in the head.
Child falls a distance greater than his own height.
Child falls onto hardwood floors, tile, or concrete.
Child loses consciousness (blacks out) after the injury.
Child vomits more than once after the injury.
Baby’s soft spot is bulging.
Seizure after head injury.
Acting abnormal or confused.
Bruising behind the ear or bleeding from the ear.
Clear fluid draining from the nose.

Priority 2: Needs appointment the next day.

Child falls a distance less than his height, onto a padded surface, no
loss of consciousness.
Priority 3: Watch and wait. Needs appointment if there is no
improvement or worsening of symptoms:
Child has a minor accident resulting in a large bruise on the head
(goose egg), no loss of consciousness, no vomiting, and is acting
normally.

BOTTOM LINE
Every child who has rolled off a bed onto a carpeted floor does not need to
be rushed to an emergency room. (And yes, this will happen to you!)

Which head injuries require a CAT scan?

When there is a concern for a severe head injury (bleeding inside the skull),
a CT scan (Computer Tomography) is helpful to check it out. However,
because there is a significant amount of radiation involved, docs avoid
ordering them for every kid who rolls off the bed. Here are the criteria:

all kids under two years of age

loss of consciousness for over one minute
trauma (knife, bullet)
abnormal neurologic examination (dizziness, weakness, abnormal
reflexes..)
vomiting
seizures
bulging soft spot (fontanelle)
bruising behind the ear or bleeding from the ear
clear fluid draining from the nose
depressed skull fracture (i.e. a break in the skull detected on a plain x-
ray)
Reality Check
Walkers cause over 6000 head injuries in the U.S. annually. Yes, the newer
models have more “safety features” that keep them from rolling down
stairs. But we say save your money or buy some other really cool toy.

2. Neck and back injuries

CALL 911 and do not try to move your child. He will be immobilized on
a straight board until x-rays can prove that no spine damage has occurred.

3. Eye injuries
All eye injuries should be evaluated by a doctor immediately. Here are
the most common problems:
Corneal abrasion: surface of the eye is scratched. It heals in a day or
two. Frequent tearing is a clue to this diagnosis.
Hyphema: bleeding that occurs beneath the surface of the eye (a
doctor sees it with special equipment). If the blood is not removed,
vision can be lost. This is fairly uncommon, but it is the reason that
all eye injuries need a medical evaluation.
Subconjunctival hemorrhage: bleeding occurs on the surface of the
eye. It can be seen on the white part of the eye. Although it looks
dramatic, it’s not serious.

4. Ear injuries
Outer ear: (the part you can see) can be bruised and cause permanent
cartilage damage. If you see bruising, this is a Priority 1: Needs immediate
evaluation and treatment call—the blood might need to be drained.
Inner ear: (the inside) can be injured when curious kids put things in
their ears. Usually they don’t get anywhere near the eardrum. If you see
bleeding, it’s likely from scratching the lining of the canal. Doctors need to
see these kids, but it can wait until the office opens (a priority 2 call). The
only emergency is if your child had a head injury and you notice blood
draining out of the ear or a bruise behind the outer ear. This is a sign of a
skull fracture.

5. Nose injuries
Priority 1: Needs immediate evaluation and treatment—NOW:
A nosebleed after a nose injury increases the chances of it being
broken.
A clear drainage or bloody nose after a head injury increases the
chances of a skull fracture.
Inability to breathe through the nose after an injury may mean a severe
bruise in the nose (septal hematoma)
Nose is obviously crooked (displaced nose fracture).

Priority 2: Needs appointment the next day.

Nose injury without bleeding or obvious fracture.

6. Mouth injuries
See stitches section for details. The bottom line: Very few injuries to the
mouth require stitches. They bleed a lot but heal quickly and beautifully.
Injuries that go through the inside of the mouth to the outside of the skin, or
full thickness through the tongue need to be seen (Priority 1: Needs
immediate evaluation and treatment—NOW).

7. Tooth injuries
Injuries to baby teeth rarely need intervention. Worry only if the tooth
was “knocked out” and you can’t find it anywhere. That is a sign of a tooth
intrusion. The tooth can get pushed back into the gums (Priority 1: Needs
immediate evaluation and treatment—NOW; call the dentist).
FYI: You may know about the trick of placing a knocked out tooth in
milk and rushing to the dentist to re-implant it. They only do this for
permanent teeth, not baby teeth.
8. Bone injuries

Q. Is it BROKEN?
The best way to tell over the phone is to know the mechanism of injury
and what your child is doing with the limb. The list of red flags is below.
If there is a break (fracture), your child needs a cast. Some specialists
prefer to see kids with broken bones 48 hours after the injury so the
swelling will be down before casting. As long as the bone is immobilized, it
is fine. A temporary (splint) cast can be applied to keep the bone fixed and
comfortable.

RED FLAGS
Does it need an x-ray?
All of these are Priority 1: Needs immediate evaluation and treatment
—NOW:
1. Unable to move a limb without crying.
2. Limping or refusing to bear weight.
3. Impressive bruising or swelling.

BOTTOM LINE
Broken bones hurt. If you can distract your child and move or touch the
area without pain, it may just be bruised.
Helpful hint
Kids have areas in their bones called growth plates. This area is located at
the end of each bone that gives it growing room. These plates fuse when
children go through puberty (hormone levels cause them to close). A
normal x-ray of a child’s bone shows a gap where the growth plate is.
Occasionally, if there is a fracture along the line of the growth plate, it may
not be seen when the x-ray is read. So, even if an x-ray is read as “no
fracture,” call the doctor if there is no improvement in your child’s
symptoms in five to seven days.

HOW TO IMMOBILIZE AN INJURED LIMB

Use a scarf or large towel and wrap it around the shoulder to keep
an arm in place. Pinning a long arm sleeve to the shoulder also
works.
Use a piece of cardboard and an Ace wrap to form a makeshift
splint for an arm or leg..

Q. My child was walking and put his hand out to

break his fall. Is the wrist broken?
Probably. Your wrist joint is not intended to sustain your body weight.
Your baby needs an x-ray.

Q. I was walking with my child and holding his hand.

He pulled away from me and now he won’t use his
arm. Is it broken?
No—it’s probably dislocated.
This is called a nursemaid’s elbow. The elbow joint has gotten pulled out
of its socket. Some children are repeat offenders. It can be easily fixed by
your doctor in a matter of seconds. For frequent fliers, parents can learn
how to do it at home. It’s a good idea not to pull your kids up by their arms,
or jerk their arms when they resist motion. And obviously, kids with
frequent dislocations shouldn’t play on the monkey bars!

9. Fingers and toes

The classic injury here is the finger that gets slammed in a car door. If
there is bruising or swelling, it needs an x-ray (Priority 1: Needs immediate
evaluation and treatment—NOW). If there is a blood blister/collection of
blood under the fingernail (subungual hematoma), it may need to be lanced
by a doctor to relieve the pressure (Priority 1 or 2).
The fingers and toes are an exception for casting of broken bones. Some
of these breaks only require stabilization (buddy taping) to the finger or toe
next to it.
So, how do you immobilize a finger or toe? Tape fingers or toes together
(buddy tape) for an injured digit. The neighbor of the injured digit gets
taped to it for support.

RED FLAGS
A recap:
any true head injury in a child under two years of age
head injury with loss of consciousness
head injury with vomiting
head injury with confusion
significant height of fall or to a hard surface
any eye injury
head injury with nosebleed or ear drainage
ear injury with bruising
limb injury with swelling/bruising and discomfort
fall onto an outstretched arm
 jerked elbow
neck or spine injury–call 911
bone injury with exposed bone

BOTTOM LINE
If you are ever in doubt, call your doctor.

Notes
BABY
411
Section 6
The
Reference
Library
 MEDICATIONS
Appendix A

Here’s a look at the most common medications used by children. Obviously,

with the huge universe of possible medications, this chapter is by no means
comprehensive. Instead, we focus on the most popular and widely used meds
in children. We will cover both over the counter products and prescription
medications. (Murphy) FYI: We have also designated products that are safe
for moms who are breastfeeding. Let’s begin with some general questions
regarding administering medicine to your child.

Q. If my child throws up right after I give him

medicine, do I re-dose the medicine or wait until the
next dose is due?
If your child throws up less than 20 minutes after administering medicine,
give the dose again. It didn’t have time to get through the stomach and be
absorbed into the blood stream.

Q. Is a generic medication as good as a brand name?

For the most part, yes.
When a pharmaceutical company develops a medication, the company
obtains a patent for it, which lasts for 17 years. Because it takes several years
of research before a medication is approved for use, a medication may be on
the market for an average of eight years before the patent runs out. Once the
patent runs out, any pharmaceutical company can make their own product,
which is the exact duplicate of the original brand.
The potency is the same, but sometimes the taste is not. And the cost is
definitely not the same. Generic medications are often much cheaper than
the brand name.

Q. If my doctor prescribes an expensive medication,

can I ask for a generic brand at the pharmacy?
Good news. Most antibiotics used for children are available in generic
form. However, some medications that need to be specially compounded for
babies have no alternatives.

Helpful Hint
If you are paying out-of-pocket for prescription medications, speak up!
Don’t be shy about inquiring about the cost of the medication. Your doctor
may be able to prescribe a less-expensive generic drug if available.

Q. How do I get my baby to take her medicine?

Here are a few tricks to getting all the medicine down:
1.Give small amounts over several minutes, instead of the whole dose at
once.
2.It is okay to mix certain medications in with formula or juice—but
check with your pharmacist for the particulars. The only problem
with this plan is that your child has to drink the whole thing. Be
sure to mix the medicine in a small volume of fluid (less than an
ounce).
3.For a small fee, some pharmacies will add flavorings to your child’s
prescription to make it more palatable.
4.Taking a prescription medicine is not optional. It may take two parents
to administer medicine to one strong-willed child.
Reality Check
Just a spoonful of sugar makes the medicine go down. Here are some tips
from Edward Bell, Pharm.D., BCPS:
1.White grape juice or chocolate syrup masks a medicine’s after taste.
2.Graham crackers get rid of the leftover drug particles in the mouth.
3.Strawberry jam mixed with a crushed chewable tablet disguises the
flavor.

Q. Is it okay to use a medicine if it is past the

expiration date?
No.
For the most part, medications start to lose their potency after the listed
expiration date. So the medication may be less effective (for example,
Albuterol for an asthma attack).

Q. The prescription medicine was supposed to be given

for ten days. We ran out of it after eight days. What
happened?
Most of the time, this happens when a “teaspoon” dose is administered
with an actual teaspoon from your kitchen. Your silverware spoon may hold
anywhere from 4-8 ml of fluid. Buy a medicine syringe that lists both cc/mls
and teaspoons on it.

Q. I have some leftover antibiotic from a prescription.

Can I save it and use it for another time?
No.
 First of all, you should never have leftover antibiotics. Your doctor
wanted your child to have a specific length of therapy for that medication. If
your child stops taking an antibiotic “because he feels better,” you run the
risk of the bacteria growing back. This is particularly true of Group A Strep
(of Strep throat fame). Yes, people often forget to give all of the doses of
antibiotic—we’re human. But try to finish a prescription as it was intended
to be used.
Second of all, antibiotics that are in liquid form will only stay potent for
about two weeks. They come as a powder from the manufacturer and the
pharmacist mixes it with water when he fills the prescription order. If you
have any medicine leftover—toss it.

Q. Are all medications administered to children of all

ages?
No.
Many medications are not approved for infants under six months of age.
Doctors’ choices are more limited for these patients. There are also some
medications that are purely for adult usage (for example, Tetracycline).

Q. How do I know if there is a problem taking more

than one medicine at a time?
The official term is “drug interactions.”
Your doctor or pharmacist can answer this question. Don’t assume that
your doctor knows all the medications your child is taking. If your child
received a prescription from another doctor/specialist, it might not be
recorded in your child’s chart.

Reality Check
 Tell your doctor if your child is taking any herbal remedies. There can be
overlap in effects of herbal and over-the-counter products.
For instance, Sudafed (a traditional decongestant) and ephedra (an herbal
decongestant) can cause heart rhythm disturbances when taken together. It
pays to ask.

Q. Can you use acetaminophen (Tylenol) and an

antibiotic at the same time?
Yes. It is okay to use a fever reducing medication like Tylenol/Motrin and
an antibiotic simultaneously.

Q. What does the term “off-label” mean?

It means that a pharmaceutical company has not received FDA (Food and
Drug Administration) approval for a medication to be used for a particular
problem or age group.
Medications are approved for use based on research studies for particular
medical problems. Once a drug is available for use, doctors may find it
useful to treat other ailments. In this case, a doctor might prescribe a
medicine to a patient and explain that it is being used “off label.”
What frequently happens in pediatric medicine is that clinical research
studies are done on adults, so a medication is approved for use only in
adults. When it appears to be a safe product, the medication is used in
pediatric patients as well. Pediatricians feel relatively comfortable using
these medications for children, but your doctor should always explain to you
if he prescribes a medicine that does not have FDA approval for use in a
particular age group. Good news: There is now a law requiring
pharmaceutical companies to test medications in kids as part of their
research.

Q. How can I find out if a generic equivalent is

available for the medicine my doctor has prescribed?
 Ask your doctor or pharmacist. For the medication tables below, generic
availability is noted with an (*) asterisk. Note: while all medications have a
generic name, not all of them are available to be purchased in generic form.

Q. How do I read a doctor’s prescription? I’ve always

wondered what they really mean.
It’s written in medical abbreviations, so here’s how to read it. You’ll need
this for the medication tables later in this appendix.

How often to take a medicine

QD or QDay: once daily
BID: twice daily
TID: three times daily (preferably every eight hours)
QID: four times daily (preferably every six hours)
QHS: once daily, at bedtime
QOD: every other day
PRN: as needed

How medicine is given

po: taken by mouth
pr: insert in rectum
ou: put into each eye
au: put into each ear

How medicine is dosed

1 cc (cubic centimeter): 1ml (milliliter)
tsp: teaspoon (1 tsp is 5 cc or 5ml)
T: tablespoon (1 T. is 3 tsp or 15cc or 15 ml)
tab: tablet
gtt: drop
Q. How do I know which medications require a
prescription?
We’ve included some handy tables later in this chapter with information
on common medicines used for treating babies. In the tables, you’ll note the
following symbols.
Rx: Denotes that a product is available with a doctor’s prescription
only. If nothing is designated, assume the product in question is
prescription-only.
OTC: Denotes that a product is available Over The Counter (that is,
without a prescription).

Q. How do I know if a medication is safe for me to take

while I am pregnant or breastfeeding?
Some information is listed in the medication tables later in this appendix.
Your obstetrician, pediatrician, pharmacist, and lactation consultant all have
reference books in their offices with this information—if you have doubts,
call them.

Breastfeeding Categories
Category 1: Okay to use while nursing.
Category 2: Okay, but use with caution.
Category 3: Unknown whether there is a risk.
NO: Definitely harmful to baby.

Pregnancy Categories
Category A: Studies have been done with first-trimester pregnancies and
show no risk to fetus.
Category B: Animal studies prove medicine to be safe, but not enough
data in humans yet.
Category C: Animal studies prove medicine to be harmful, but no data in
humans.
Category D: Known risk to fetus, but benefit of medicine to mother may
outweigh the risk.
 NO: Known risk to fetus outweighs any benefit to the mother.

Drugs Of Abuse: Not To Be Used While Breastfeeding (And not

recommended otherwise)
Amphetamines, Cocaine, Heroin, Marijuana, Nicotine, Phenylcyclidine

Category 3 Medications (Unknown Risk)

Medications in the following classes of drugs have potentially concerning
effects on babies who are breastfed.
Antianxiety drugs
Antidepressant drugs
Antipsychotic drugs

Category 2 Medications (Okay, But Use With Caution)

Acyclovir (Zovirax)
Cetirizine (Zyrtec)
Diphenhydramine (Benadryl)
Fluconazole (Diflucan)
Ketorolac (Toradol, Acular)
Omeprazole (Prilosec)
Ondansetron (Zofran)

Category 1 Medications (Okay To Use While Breastfeeding)

Acetaminophen (Tempra, Tylenol)
Albuterol (Proventil, Xopenex)
Alcohol**
Allergy injections
Amoxicillin (Amoxil)
Amoxicillin + Clavulanate (Augmentin)
Cefadroxil (Duricef, Ultracef)
Cefazolin (Ancef, Kefzol)
Cefotaxime (Claforan)
Cefoxitin (Mefoxin)
Cefprozil (Cefzil)
Ceftazidime (Fortaz, Tazidime)
 Ceftriaxone (Rocephin)
Cimetidine (Tagamet)
Codeine (Tylenol #3, Empirin #3)**
Contraceptive pills
Dextromethorphan (“DM” products- Delsym, Robitussin DM)
Digoxin (Lanoxin)
Enalapril (Vasotec)
Erythromycin* (E-mycin, Ery-tab)
Hydralazine (Apresoline)
Ibuprofen (Advil, Ibuprofen, Motrin, Nuprin)
Loratadine (Claritin)
Magnesium sulfate
Prednisone (Deltasone, Meticorten, Orasone)
Propranolol (Inderal)
Valproic Acid (Depakote, Depakene)
Verapamil (Calan, Covera-HS)
Warfarin (Coumadin)

*Medication concentrates in breast milk, but is still acceptable to use while

nursing.
**Acceptable in moderation.

Note: Pseudoephedrine (brand names: Sudafed, Actifed), a popular

decongestant, may reduce milk supply by up to 25%. Use this product with
caution, especially if milk supply is already low. (Hale T, AAP Committee on
Nutrition) FYI: Because of some safety concerns, teeth whitening products
are not recommended while breastfeeding.

Herbal Remedies and breastfeeding

Fenugreek and Blessed Thistle are both considered generally safe to use
to improve milk production.
Herbal products that are unsafe while nursing include: Comfrey, Blue
Cohosh, Sage, and Valerian Root.

Medication Index
1. Allergies
2. Dental/Mouth
fluoride
teething products
3. Ear Problems
4. Eye Problems
5. Fever and pain
6. Gastrointestinal
antacids/gastroesophageal reflux
constipation
diarrhea
gas/colic
vomiting
rehydration solutions
7. Infections
antibiotics (for bacterial infections)
antifungals (for fungal infections)
antihelminthics (for pinworms)
amebicides (for Giardia infection)
antivirals (for viral infections)
8. Nutrition
iron supplements
vitamins
9. Respiratory
asthma
cough and cold preparations
10. Skin
antibiotic creams
antifungal creams
scabies/head lice medications
 steroids
anti-inflammatory
diaper rash creams

Medications

1. Allergy Medicines

These medications are used for allergic reactions, itching, and nasal
congestion. For skin allergy products, see skin section (10).
Antihistamines have been around for decades. They are classified by their
“generation.” The first generation products are very effective but also have
more side effects (drowsiness, dry mouth). Second and third generation
products do not cause nearly as much sedation and can be dosed once every
24 hours.
Under six months of age, doctors use all medications with caution.
Antihistamines, which are usually sedating, can result in excitability in
infants. Consult your doctor before using any of these products.

KEY: Rx? Rx medications are available by prescription only; OTC is over-

the-counter. * A generic is available for this brand-name medicine.

Side effects: Drowsiness, dry mouth, headache, paradoxical excitability

Serious Adverse effects: tremors, convulsions
Feedback from the Real World
You may be tempted to use diphenhydramine (Benadryl) as a sleep aid for
your child. A study, appropriately called the TIRED study—Trial of Infant
Response to Diphenyhydramine, showed there was no significant
improvement in a baby’s sleep when used in kids six to 15 months of age.
Go back to Chapter 9, Sleep, if you need tips that will actually work!

2. Dental/Mouth

Fluoride Supplements
Fluoride is a mineral well known to prevent cavities. But as we discussed
back in Chapter 5, Nutrition and Growth, the recommendations are
confusing and a bit of a moving target when it comes to babies and young
children.
Infants under six months of age should have little to no fluoride intake.
Thus, the American Dental Association currently recommends that you
prepare powdered or liquid concentrate formula with filtered tap water
(reverse osmosis) or bottled water.
Infants over six months of age until age 16 years need a source of fluoride
to significantly reduce cavities in both primary (baby) and secondary (adult)
teeth. Fluoride is added to tap water in many cities and counties in the
United States. Find out if your city has added fluoride to its water supply.
Ideally, your water supply should have 0.7 ppm of fluoride. Once your baby
is six months old, he should start drinking some water on a daily basis (about
four to six ounces).
Who needs a fluoride supplement? There are just four specific situations
where a fluoride supplement is recommended if baby is over six months of
age AND:

1. In a household that has well water, and has no other source of fluo-
ride-containing water.
2. Exclusively breast fed, and does not drink fluoride-containing water.
 3. Formula is prepared with bottled water or uses ready-to-feed formula,
and does not drink fluoride-containing water.
4. The local water supply does not contain added fluoride, and natural
fluoride levels are less than 0.6ppm.

If you fall into one of those categories above, the American Academy of
Pediatrics and American Dental Association recommends the following
dosages of fluoride (these are based on age and the amount of fluoride in
your drinking water):

How much extra fluoride does your baby need?

Fluoride supplements include: Luride*, Fluoritab, Pediaflor*, Poly-Vi-

Flor*, Tri-Vi-Flor*. These are all available by prescription only and dosed
once daily.
Possible side effects: Overuse of fluoride can cause white spots on the
teeth (fluorosis). This occurs in daily doses of greater than 2 mg of
fluoride/day.

Q. Is fluoride safe? I’ve heard it can cause bone cancer

in lab rats.
Yes it is safe. If you give toxic mega-doses of any product to rats, you
will create medical problems. So just how much fluoridated water would you
have to drink each day to equal the volume that the rats drank? Answer: 42
gallons a day!
Helpful Hint
Give fluoride drops on an empty stomach. Milk prevents the absorption of
the medication.

Teething
The only medication we recommend for teething is acetaminophen
(Tylenol), or ibuprofen (Advil) for babies who are at least six months of age
or older. They are both safe and effective pain relievers.
The FDA advises against using topical numbing products that are rubbed
on the gums to provide temporary relief. The active ingredient in all of these
products is benzocaine, which can potentially cause a life-threatening blood
disorder called methemoglobinemia. The brand names we are talking about
are: Baby Anbesol, Baby Numz-it, Baby Oragel, and Zilactin Baby.
The FDA recalled homeopathic “Hyland’s Teething Tablets” a few years
ago. These tablets contain a small amount of belladonna, which is a known
toxin to the nervous system. Because the tablets are homeopathic, they were
not required to have FDA approval for safety or therapeutic benefit. (This is
a convenient loophole in the lucrative alternative medicine industry. More on
that in Appendix B, Alternative Medications). The FDA stepped in because
they received reports of children having adverse reactions (adverse reactions
include seizures, difficulty breathing, lethargy, excessive sleepiness, muscle
weakness, skin flushing, constipation, difficulty urinating, or agitation).
Additionally, the FDA laboratory found the product to have inconsistent
amounts of belladonna in it. Safety regulators felt that the amount of
belladonna should be more tightly regulated—considering the health dangers
it can pose.
Although the product is back on the market, we still don’t recommend
them.
Reality Check
Teething gets blamed on fussy moods, disrupted sleep, runny noses, and
diarrhea. RARELY is teething the cause of any of these maladies! If you
want a natural teething remedy, try freezing a mini bagel or banana, and let
your little one gnaw on that!

3. Ear Medication

Antibiotic Ear Drops

For swimmer’s ear (otitis externa) or for children who have ear infections
with PE tubes, antibiotic eardrops are used. Because the medicine is not
absorbed into the bloodstream, there are more antibiotic family choices.
Below are the most popular antibiotic eardrops. Note: most products also
contain a steroid. The steroid reduces the inflammation and swelling of the
ear canal so the antibiotic can work more effectively.

KEY: Rx? Rx medications are available by prescription only; OTC is over-

the-counter.
* A generic is available for this brand-name medicine.

Side Effects: Irritation of the ear canal such as itching and stinging.

Swimmer’s Ear Prevention Drops

 These drops dry up any left over water in the ear canal after swimming.
Drops are placed in the ears immediately after swimming. These are used
primarily for older kids, not infants.
You can make your own concoction: 2 drops of rubbing alcohol and 2
drops of vinegar per ear.
Brand names: Auro-Dri, Swim Ear. Both products are OTC. Active
ingredient: Rubbing Alcohol.

Ear Pain Drops

These are topical numbing medications. They have a modest effect in
providing temporary relief of pain in the ear canal. (Remember that middle
ear infections occur behind the eardrum.)
Numbing drops are absolutely not intended for use if a child has PE tubes
(see Chapter 11, Infections, for more details) or has ruptured the eardrum
with infection.

Active ingredient: Antipyrine, Benzocaine Dosing: 2-3 drops to affected ear,

QID Rx only.

Reality Check
Although we don’t find them helpful, some doctors will prescribe
numbing drops for pain relief. But do NOT use the drops prior to your
doctor’s appointment. It makes it hard for the doctor to see the eardrum!

DR B’S OPINION

“Yes, some doctors will prescribe numbing drops

for ear pain. Know that these drops do not reach
 the real location of the pain (which is why many
ear, nose, and throat specialists don’t find these
drops very helpful). I think acetaminophen
(Tylenol) or ibuprofen (Motrin) and a heating pad
(low setting) placed on the ear are more effective
pain relief.”

Ear Wax Drops

These drops help loosen or dissolve earwax. Earwax rarely is a problem
unless it is hard and stuck in the canal (impacted). If the earwax is impacted,
earwax drops loosen up and break down the earwax.

Brand names are: Auro, Debrox, and Murine eardrops. OTC Active
ingredient: carbamide peroxide Dosing: 3 drops per ear, TID, for 3 days
Colace, a stool softener, also works nicely to soften up earwax. It’s
available OTC.

BOTTOM LINE
We don’t recommend routine cleaning with Q-tips. Q-tips can irritate the ear
canal and push the earwax backwards, creating wax that is hard and stuck
(impacted).

Helpful Hints
Rub the eardrop bottle in your hands for a minute or two before
administering the drops. Warm drops in the ear are less bothersome than cold
ones.
 If a child has a perforated eardrum or PE tubes, many types of eardrops
should NOT be used (exception: approved antibiotic drops). Check with
your doctor.

Reality Check
ENT specialists frequently use antibiotic eye drops for the ears. If you get a
prescription filled for your child’s ear infection and it turns out to be eye
drops, don’t think we have lost our minds. One caveat here: It’s okay to use
eye drops for the ears, but you cannot use eardrops for the eyes!

4. Eye Problems

Antibiotic Eye Drops/Ointment

These are used primarily for conjunctivitis (pink eye) and corneal
abrasions.
KEY: Rx? Rx medications are available by prescription only; OTC is over-
the-counter. * A generic is available for this brand-name medicine.
Note: Although the quinolone based products are not FDA approved for
under one year of age, your doctor may feel comfortable prescribing them.

Side effects: Burning, itching, local irritation

5. Fever And Pain Medications

Please keep in mind the following points about fever medication:

1. If your baby is less than four weeks old and has a fever, do NOT give
a fever reducing medicine—call your doctor immediately.
2. Never give aspirin to a child unless directed by a doctor. Aspirin use
is associated with Reye’s syndrome (liver failure) when taken
during an influenza or chickenpox infection.
3. Ibuprofen is not recommended for babies under six months of age.
4. Tylenol is the brand name. The generic name is acetaminophen (other
brand names include Tempra, Feverall)
5. Ibuprofen: brand names are Motrin, Advil
6. Do not use more than one fever reducing medicine at a time, unless
your doctor specifically recommends it.
7. REMEMBER TO USE THE DROPPER THAT COMES WITH THE
PACKAGE OF MEDICINE. See Chapter 15, First Aid, for details
on fever and when to administer medication (as well as a dosing
chart).

DR B’S OPINION: ALTERNATING

FEVER MEDS
 Unless your child is prone to febrile seizures, I do not recommend
alternating fever medications during the day to keep the body
temperature down. I also prefer to use acetaminophen (Tylenol) for
children who are dehydrated or not eating. Ibuprofen is more likely
to cause stomach upset when taken on an empty stomach.

6. Gastrointestinal Problems

Antacids/Gastroesophageal Reflux

KEY: Rx? Rx medications are available by prescription only; OTC is over-

the-counter.
* A generic is available for this brand-name medicine.

Note: Of all the reflux medications, only Zantac is FDA approved for
infants. Before 2004, pharmaceutical companies had no requirements to test
products on infants. Despite the lack of FDA approval, gastroenterologists
and pediatricians prescribe these medicines routinely.
Side effects:
Aluminum hydroxide (Gaviscon, and others) is generally not
recommended for use in babies due to possible side effects.
Most common side effects are headache, constipation, or diarrhea.
Metoclopramide (Reglan) can cause rare but significant neurological
problems, sedation, headaches, and diarrhea. Because of these adverse
effects, Reglan is only used in very sick babies.

Helpful Hints
It is more effective to give these medications 30 minutes before a meal if
you can.

Zantac is the cheapest choice, readily available at most pharmacies, with

the longest track record. However, it tastes like mouthwash. If your baby
spits out the Zantac because it tastes bad, it won’t work.

Prilosec liquid has to be specially compounded at a pharmacy. It will

become inactive within about two weeks. You will need to refill it
frequently.

Prevacid solutabs are a popular option because they can be cut into halves
or quarters for smaller kids and suspended in a few drops of water. Once a
day dosing is also convenient.

Zegerid is a popular choice among pediatric gastroenterologists because

the combination product seems to improve symptoms when nothing else has
worked. It can be extremely expensive, though.

Medications in the “proton pump inhibitor” family such as Prilosec,

Prevacid, and Zegerid carry an FDA warning. There is an uncommon, but
potential risk of developing a diarrheal illness caused by C. difficile
infection.
 As with other medications, dosing is based on a child’s weight. Your baby
may outgrow his therapeutic dose every few weeks/months. Ask your doctor
to recalculate his dose based on his current weight.
Often times, medication isn’t working because babies metabolize it at
different rates at different ages. If your baby is not responding to medication
and clearly has the diagnosis of acid reflux, ask your doctor to decide if your
baby’s medication should be adjusted.

Constipation

Side effects: diarrhea, bloating, gas, body salt (electrolyte) disturbances with
excessive or prolonged use.

Diarrhea

KEY: Rx? Rx medications are available by prescription only; OTC is over-

the-counter. *A generic is available for this brand-name medicine.
Helpful Hint
Fat and fiber intake both help bulk up the stools.

BOTTOM LINE
If diarrhea has been going on more than a week, check in with your
doctor. Doctors also want to know about blood or mucous in the stools. (See
Chapter 15, First Aid for more).

Gas/Colic

Cool product alert: Biogaia Protectis drops contain both Vitamin D and L
reuteri probiotic.

Reality Check
Remember, there is no miracle cure for either gas or colic. These products
are okay to try, but they may not work.
Vomiting

KEY: Rx? Rx medications are available by prescription, OTC is over-the-

counter. * A generic is available for this brand-name medicine.

Helpful Hints
Home remedy: The equivalent of Emetrol is to give 1-2 teaspoons of
heavy fruit syrup (fruit cocktail juice) every 20-30 minutes. This
occasionally works to relieve nausea.
Phenergan has a black box warning from the FDA discouraging its use in
kids under age two.
Zofran is very popular for babies and kids under age two.

Rehydration Solutions
These products are the Gatorade equivalent for babies. They are designed
to replace water, body salts, and sugar lost when a child has vomiting and
diarrhea. They are most helpful in the early phase of a stomach virus when a
child is just starting to take fluids after actively vomiting. Doctors prefer
rehydration solutions instead of plain water, juice, milk, Gatorade/sports
drinks, or soda for infants. Once a child is keeping down this clear fluid, we
usually suggest that your child resume breastfeeding or formula. All
products are available over the counter. See Chapter 15, First Aid, for more
information on using this product. See Appendix B, Alternative Medicine,
for a recipe you can make at home.
Brand Names: Enfalyte, Gerber Pediatric Electrolyte, Kao-electrolyte,
Pedialyte.

7. Infections

Antibiotics (Bacterial infections)

This list contains the most popular choices of antibiotics (taken by
mouth). There are basically four classes of medications approved for
pediatric use. There are more classes available to adults. Take special note of
the class or family each medicine belongs to. If a person develops an allergic
reaction to a medication, ANY antibiotic that belongs to that class is to be
avoided.
In this chart, we note what these medications are typically used for
(usage): Ear and sinus infections (1), Pneumonia (2), Skin infections (3),
Bladder infections-UTI (4), Strep throat (5).
Note: all products are available by prescription only.
KEY: Rx? Rx medications are available by prescription only; OTC is over-
the-counter.
* A generic is available for this brand-name medicine.
Side Effects:
The most common side effects include:
1.Diarrhea. The antibiotic kills the bacteria causing infection, but also
some normal bacterial “flora” that helps us digest food in our
intestines. Lack of bacterial flora can cause malabsorption (i.e.
upset stomach). ANY antibiotic can cause this problem.
 2.Yeast Infections. Again, the antibiotic kills both bad bacteria and
certain bacterial flora that live in our mouths and on our skin. Lack
of normal bacteria predisposes a person to yeast infections in the
mouth (thrush) and in the genital area (yeast diaper rash).
Allergic Reactions:
A true allergic reaction to these medications includes hives, lip swelling,
or difficulty breathing. About 25% of patients who are allergic to the
Penicillin family will also be allergic to the Cephalosporin family.
Rare Adverse Reactions:
1. Stevens-Johnson syndrome (severe allergic reaction)
2. C. difficile colitis (bacterial super-infection in intestines)

Antifungals:

Side effects: nausea, headache, rash, stomach upset

Griseofulvin can cause skin sensitivity to sunlight. Used with caution in
patients with Penicillin allergy.

Helpful Hint
Griseofulvin is absorbed better when taken with something rich in fat (milk,
ice cream . . .)

Antihelminthics (For Pinworm Infections):

Side effects: stomach upset, headache
KEY: Rx? Rx medications are available by prescription only; OTC is over-
the-counter.
* A generic is available for this brand-name medicine.

Insider Tip: Pin-X, available over the counter, is the first line treatment for
pinworms. Mebendazole (Vermox), a popular prescription medication, is no
longer on the market. However, some compounding pharmacies are able to
formulate it if your doctor writes a prescription for it.

Reality Check
Often the whole family gets treated when one child has pinworms.

Amebicides (For Giardia Infection):

Side effects: nausea, diarrhea, hives, metallic taste, dizziness

Antivirals:
Side effects: stomach upset, insomnia, headache, moodiness.
Adverse reactions: kidney failure with acyclovir—patient needs to be well
hydrated

KEY: Rx? Rx medications are available by prescription only; OTC is over-

the-counter.
* A generic is available for this brand-name medicine.

BOTTOM LINE
Because antiviral medications work by preventing replication of the virus,
the medication must be started within 48 hours of when the illness began.
Otherwise, it will have no effect on the course of the illness.

8. Nutrition

Vitamin supplements for children aged birth to one are used for specific
situations. These include Vitamin D for newborns who drink less than 32 oz
a day of formula and exclusively breastfed infants, and iron for children with
iron-deficiency anemia. A multivitamin for general well being of infants is
not routinely prescribed.

Vitamins
Vitamin D supplements:
Iron Supplements:
Iron is a necessary ingredient to carry oxygen on red blood cells. Babies
are born with a stockpile of iron from their mothers. However, by six months
of age, they need to consume iron in their diets to meet their daily needs
(11mg/day for ages six to 12 months). Some babies need an iron supplement
in addition to their food intake (see Chapter 5, Nutrition & Growth, for
details of iron containing foods).
Multivitamins often contain iron (see chart above). The dose of iron in
multivitamins made for infants is 9-10 mg of iron per daily dose. This meets
the daily nutritional needs of a six to 12 month old. If a child has iron
deficiency anemia, he needs daily nutritional iron requirements PLUS an
additional amount to fill back up his depleted iron stores. The only way to
get the higher dose of iron is to use the specific products listed below.

Iron Replacement Therapy

Brand Names: Fer-In-Sol*, Feosol*, Icar, Niferex
Dose: Comes in drops 15mg iron per 1 ml. Dose is based on weight. Your
doctor will calculate it for you. There are also syrups for older kids, which
can be confusing!
Rx: These drugs are OTC, but are behind your pharmacist’s counter so they
can help you select the appropriate product.
Side effects: constipation, black looking poop, nausea, stomachache,
temporary teeth staining
Helpful Hints
You can avoid staining the teeth by shooting the medicine in the back of
the throat. If the teeth do become stained, use baking soda on a toothbrush to
remove the stains.
Vitamin C improves the absorption of iron. Calcium interferes with the
absorption of iron. So if you are offering a drink with the iron medicine,
offer juice—not milk.
If you give the iron AFTER a meal, there is less stomach upset.

9. Respiratory Problems

Asthma
Asthma medications are divided into rescue medications and
preventative/long term control medications. The rescue medicines are used
as needed (with a certain interval between doses). A child is placed on
preventative medicine if he:

1. needs rescue medicine more than twice a week

2. has his activity affected by asthma flare-ups
3. has problems at night more than twice a month

The idea is to get the asthma under control, then cut back on the amount
of medications needed to minimize flare ups.
For information on asthma and home nebulizers, see Chapter 14,
Common Diseases.

Rescue medicines
 This class of medication is called a Beta agonist. Levalbuterol (Xopenex)
and albuterol are equally effective, but levalbuterol has fewer unpleasant
side effects. Unfortunately, levalbuterol is more expensive and some
insurance companies will require special authorization for use or completely
deny coverage for it.
Side effects: Increased heart rate, palpitations, nervousness, insomnia,
nausea, headache.

Preventative/Long term control medicines

KEY: Rx—Rx medications are available by prescription only; OTC is over-

the-counter.
* A generic is available for this brand-name medicine.

Side effects:
1.Mast cell stabilizer: bad taste, cough, nasal congestion, wheezing.
 2.Inhaled corticosteroid: sore throat, nosebleeds, cough, thrush (see
below for more information).
3.Leukotriene antagonist: stomach upset, headache, dizziness.

Helpful Hint
Pulmicort respules (a grainy substance dissolved in liquid) can be
administered in a nebulizer machine. Pulmicort is very effective for younger
children and has significantly fewer side effects than its oral counterpart.
Many doctors feel comfortable using this product in infants even though the
product is approved for ages one year and up.

Always rinse your child’s mouth after he has taken an inhaled steroid. It
reduces the incidence of thrush.

Steroid medications are always used cautiously. Steroids given by mouth

(liquid/pill) are more likely to cause systemic side effects if given for a long
time (more than one to two weeks). Inhaled steroids (nebulizer or inhaler)
have significantly fewer side effects because only a small amount is
absorbed into the bloodstream. As with any medication, the risks of taking
these medications are weighed against the potential benefit of therapy for the
disease.

Risks of long-term steroid use:

1. Mood change
2. Stomach upset
3. Intestinal bleeding
4. Impaired body’s stress responses (HPA axis suppression:
hypothalamic-pituitary-adrenal)
5. Bone demineralization (Osteopenia)
6. Weight gain, hair growth (Cushingoid features)
7. Cataracts
8. Growth suppression. Numerous studies show that children who have to
take inhaled steroids on a daily basis are about 1cm shorter than their
 peers. However, children with chronic problems with asthma also have
poor growth. Studies have not concluded whether or not these children
have “catch up growth” when steroids are discontinued. (Shared)

MAKE THE CALL: ASTHMA CONCERNS

If your child needs his rescue medicine more frequently than it has
been prescribed, CALL YOUR DOCTOR. Here are some important
points to consider:
1.Your child is air hungry and needs to be evaluated by a doctor See
Chapter 15, First Aid.
2.Administering asthma medicine more frequently than recommended
can be dangerous. A doctor’s office or hospital can administer
asthma medicine more often than prescribed because a medical
provider can be monitoring a patient for side effects of the
medicine.
3.If a child is having that much trouble breathing, it is likely that he
needs to receive oxygen in addition to medication, which is only
available in a medical facility.

Preventing RSV infection in premature babies

If you have a baby who has graduated from a Neonatal Intensive Care
Unit, you may already know that RSV (bronchiolitis) can be a serious lung
infection for a premature infant.
A product to prevent RSV infection is called Synagis (generic name is
palivizumab). This is a synthetic antibody given by a monthly injection
during the peak of RSV season (November to April). The antibody provides
immunity for a period of 30 days.

Children who are at risk for more severe cases of RSV are:
1. Babies born prematurely, prior to 29 weeks gestation and under 12
months or age at the start of RSV season.
2. Children with chronic lung disease under age one.
3. Children with congenital heart disease.
 4. Children with certain immune deficiencies.

Children who are more likely to get RSV infection include:

1. Babies under age six months when RSV season begins.
2. Babies in daycare.
3. Multiple births.
4. Babies with school age siblings.
5. Babies exposed to smoking.

The American Academy of Pediatrics recommends monthly Synagis

injections during RSV season for the following babies:
1. Children under age two years with chronic lung disease (requiring
treatment within six months of RSV season)
2. Babies under 12 months of age with chronic lung disease of
prematurity.
3. Babies born at less than 29 weeks gestation and less than one year of
age at the start of RSV season.
4. Babies at or under 12 months of age with severe types of congenital
heart disease.
FYI: Babies with weakened immune systems, airway abnormalities, or
neuromuscular disease may also qualify for Synagis during RSV season.

Cough And Cold Medicines

The Food and Drug Administration has banned the sale of all over-the-
counter cough and cold remedies for children under four years of age. Yes,
there are still “children’s” cough and cold products on the market, but they
all now warn “do not use in children under four years of age.”
Bottom line: please do NOT buy these products and then guess-timate
what dose to give to your baby. There is a reason these products are not
made for young children anymore. They were never very effective in doing
what they claimed to do, and the risk of adverse side effects is greater than
for older kids and adults. We will point out the products that are generally
safe for infants.

Decongestant
 These medications reduce or relieve congestion in the nose. They can be
taken by mouth (absorbed into bloodstream) or sprayed into the nose. Oral
decongestants: Pseudoephedrine, phenylephrine, ephedrine.

Side effects: Insomnia, restlessness, dizziness, high blood pressure, heart

rhythm disturbances.

Nasal spray: Oxymetazoline (Afrin), Phenylephrine (Little Remedies for

Noses) Side effects: stinging, burning, nosebleed, rebound nasal congestion
with prolonged use (more than 4 days)
Note: Little Remedies for Noses is approved for use in children ages two
years and up.

Nasal spray: Saline. This is a safe and effective product for all ages, starting
at birth.
Side effects: None! Saline is salt water. It is effective in loosening mucus and
can be used as often as needed.

Pseudoephedrine, another popular decongestant, has been replaced by

phenylephrine in many over the counter and prescription products. The
reason? Methamphetamine (Meth) labs use pseudoephedrine to produce
illegal drugs. Federal legislation in 2006 requires products containing
pseudoephedrine to be purchased from behind the pharmacy counter (not
“over-the-counter”), thus limiting supplies. Pharmaceutical companies
responded by just changing their formulations, to improve access to their
products and their bottom line.

Antihistamine
These medications combat the effect of histamine in the body. Histamine
is released as an allergy response and causes nasal congestion.
Antihistamines are frequently found in cough and cold medicines because
they are sedating, improve the cough suppressant effect, and dry up a runny
nose.
Common ingredients: brompheniramine, chlorpheniramine,
diphenhydramine, (promethazine— Rx only), carbinoxamine
Side effects: sedation, dry mouth, blurred vision, stomach upset,
paradoxical excitement in infants.
Note: Diphenhydramine (Benadryl), cetirizine (Zyrtec), and loratidine
(Claritin) syrup are all generally safe for use in babies ages six months of
age and up. They effectively treat allergic reactions. They are not used to
treat symptoms of the common cold.

Expectorant
These medications make thick mucous looser. By doing this, the mucous
in the bronchial tubes (lungs) can be coughed up more easily. These
medications do not suppress the cough.
Common ingredients: guaifenesin
Side effects: sedation, stomach upset, headache

Cough Suppressant
These medications reduce the brain’s “cough center” activity. These
products are not recommended when someone has pneumonia.
Common ingredients: Dextromethorphan, codeine (Rx only),
carbetapentane
Side effects: drug interactions with psychiatric medications.

Helpful Hints
A study published in the journal, Pediatrics, looked at 100 children who
took over-the-counter cough medicines and whether they slept better or not.
The verdict: nobody slept better (child or parent). Since kids do about the
same with or without cough medicine, don’t feel like you are missing out
because infant cough and cold remedies are off the market.
The decision to take infant cough and cold remedies off the market came
after three deaths of infants under six months of age who had about 14 times
the recommended dose of pseudoephedrine decongestant in their
bloodstream. We’ll say it again: over-the-counter cough and cold meds
should NOT be given to kids under age four, unless instructed by your
doctor.
New Parent 411
If you feel like you must try something to help your baby, Zarbee’s
natural baby cough syrup is a safe bet. Does it work? Well, studies show it
does have a placebo effect for the parent. We are not so sure about its effect
on the child. The active ingredient is agave nectar (NOT honey).

Cold Medicines For Breastfeeding Moms

Cold medicines and breastfeeding: Decongestant nose sprays (like Afrin)
are usually okay for a day or two as are antihistamines. Some cough
medicines are NOT okay. Pseudoephedrine, a popular decongestant, may
reduce milk supply by 25%.

10. Skin (Dermatologic) Products

1.Antibiotic creams are used for wound care and minor bacterial
infections (impetigo, mild cellulitis).
2.Antifungal creams are used for fungus infections (ringworm, yeast
infection, jock itch, athlete’s foot) on the skin.
3.Scabicides and pediculocides are used for scabies and head lice.
4.Steroids are used for contact irritations (bug bites, poison ivy, local
allergic reactions), seborrhea, cradle cap, and eczema. Steroids are
divided into classes by their potency. Doctors always try to use the
lowest potency if possible. The higher the potency, the more the risk
of side effects (the high potency products can get absorbed into the
bloodstream).
5.Anti-inflammatories are FDA approved for kids over age 2 with
eczema.
6.Diaper rash creams form a barrier between the irritated skin and
recurrent insults caused by pee and poop.
Antibiotic Cream

Side effects: Burning, stinging, itching.

Antifungal Cream
Uses:
1. Yeast diaper rash (monilial dermatitis)
2. Ringworm of skin (tinea corporis)
3. Athlete’s foot (tinea pedis)
4. Jock itch (tinea cruris)
KEY: Rx—Rx medications are available by prescription only; OTC is over-
the-counter. * A generic is available for this brand-name medicine.

Reality Check
Ringworm of the scalp (called tinea capitis) requires an antifungal
medication by mouth for four to eight weeks. The fungus gets imbedded in
the hair follicles and will not respond to an antifungal cream.

Scabicides And Pediculocides

* A generic is available for this brand-name medicine.

**Medication has significant side effects/potential for seizures. Other
medications are better alternatives.
***Medication is derived from the chrysanthemum flower. Avoid use with a
ragweed allergy.
Side effects: burning, itching, redness, rash

Helpful Hints for Head Lice

1. Use OTC products as directed. I know you are grossed out, but don’t
overdose the medicine.
2. Don’t use more than one medicine at a time.
3. Use the nit combs every three days.
4. Wash clothing and bed linens in hot water and dry on the hot cycle.
5. Soak combs and hairbrushes in rubbing alcohol for one hour.
6. See Appendix B, Alternative Medications, for other possible
remedies.

Reality Check
When head lice enters your home, treat any family member who has an
itchy scalp.
When scabies enters your home, treat all family members, regardless of
whether they have symptoms or not.

Steroids
Low potency: can be used for longer periods (months) of time without
side effects, okay to use on the face
Mid potency: okay to use for short periods (weeks) of time without side
effects, use with doctor’s recommendation on the face
High potency: okay to use for limited period (days) of time without side
effects, do not use on the face
 Note: None of these steroid creams are FDA approved for use under age
two years. But they are used routinely by medical providers who feel that
they are safe and efficacious.

KEY: Rx? Rx medications are available by prescription only; OTC is over-

the-counter. * A generic is available for this brand-name medicine.

Side effects: skin irritation, decreased pigmentation, thinning of skin

Rare adverse reactions:
HPA axis (adrenal gland suppression)—only with high potency steroids

Emollients
Side effects: burning, redness, itching
Rare adverse reactions: worsens warts, herpes, and chicken pox infections
Note: FDA approved for use in kids over the age of two years.

Another class of eczema medications repairs the skin’s top layer and reduces
inflammation and itching. Brand names include Mimyx, Atopiclair,
Epiceram, Promiseb, Prumyx, and Pruclair. They are Rx only (and pretty
pricey).

Side effects: burning, redness, itching

Rare adverse reactions: Atopiclair, Promiseb, and Pruclair are derived from
the shea nut, so allergic reactions are possible.

Diaper rash creams

The idea behind all of the products listed below is to provide a barrier
between the skin and moisture (pee and poop). When applying these creams
and ointments, it is key to apply liberally and frequently.
Dr. B’s opinion: I prefer creams to powders. When powder is applied,
there is a risk that the baby will inhale the powder.

Diaper rash creams

A+D ointment OTC

Boudreaux’s Butt Paste OTC
Dr. Smith’s Diaper Ointment OTC
Silvadene Available by Rx only.

Used for rash that looks like a burn.

Triple Paste OTC
Vaseline OTC
Zinc Oxide (brands: Desitin, Balmex) OTC

BOTTOM LINE
Many pediatricians have a secret recipe of salves and barrier creams that
pharmacies will make especially for them. If none of these over the counter
products are working, it’s time to visit your pediatrician for some help.

Want to know more information about medications and get updated safety
alerts? Head to the FDA’s website at fda.gov/cder/drugsafety.htm. In an
effort for the FDA to provide more transparency, consumers can check on
post-marketing drug studies, adverse events reporting, and learn how to
report problems with medications.
 ALTERNATIVE MEDICINES
Appendix B

While it seems there is a drug for just about every malady, sometimes
there’s not. That may leave you frustrated as a parent. And some families
fear that medications will have harmful side effects. This leads some to
search out a “natural” or “alternative” remedy for their children.
Alternative and complementary therapies are big business (over $7
billion annually in the U.S.). Some of these treatment options have real
merit and the science to back them up. Those are the therapies we will
present to you. While there are many more choices in your local organic
grocer’s aisle, we are sticking to our comfort zone and our mantra: show us
the science.
As a consumer, you also need to know a few things about natural or
herbal remedies:
1. Are they effective? There are very few scientific studies that prove
with statistical significance that herbal remedies work. The
National Center for Complementary and Alternative Medicine, part
of the National Institutes of Health, is starting to investigate many
of these products.
2. Are they safe? There are no required clinical research trials that test
herbal products on humans to prove that they are safe before they
are sold to the public. Herbal remedies fall into the category of
“foods” by the FDA (Food and Drug Administration). This is a
convenient loophole for herbal product manufacturers. This means
that they do not need to do any of the scientific research that a
pharmaceutical company does to market their medications. This is
based on federal legislation from 1994. Attempts to revise this act
have failed in the past due to political pressure (and money) from
the dietary supplements lobbying group. (National Public Radio)
 3. Are production standards uniform? Production is not
standardized. The potency and purity of the product may vary
tremendously. This is especially true for products that contain
expensive herbs (e.g. ginseng). In fact, herbs produced in China are
often laced with unlabeled products such as steroids and antibiotics
to make them more potent. Also know that developing countries
may sell products that are contaminated with mercury, arsenic, and
lead. (Kemper) And, in the United States, researchers found that
only 7% of the studied Echinacea supplements complied with FDA
labeling standards and some of the supplements contained no
measurable amounts of Echinacea! (Gilroy)
4. Can I trust the label? The claims on the label for marketing
purposes do not require scientific evidence that the information is
accurate. Bottom line: consumers don’t have any protection against
misleading information.

Compare herbs to traditional medicine. Many traditional medications are

based on naturally occurring products. Penicillin is derived from a mold.
Digoxin, a popular heart drug, is based on the digitalis plant. It is true that
certain naturally occurring products have medical value. The difference
between herbs and medications is how they are tested and regulated. Some
herbs have absolutely no therapeutic value. And some herbs are so potent,
they can be harmful. Just because it’s natural, doesn’t mean it is safe.
Consider alcohol and tobacco. Both have known effects on the body.
Both are legal for use. But long term, chronic use of these products also can
cause problems. Alcohol and tobacco are as natural as the herbs you are
trying. No one knows what long-term problems some herbs can create.
We suggest you look at reliable resources to examine the evidence before
you try these alternative meds. Here are a couple of free online sources:
National Center for Complementary and Alternative Medicine
(nccam.nih.gov)
Cochrane Reviews (cochrane.org/reviews)
 DR B’S OPINION: A SIDE NOTE

Disclaimer: I admit that my medical training did not include

acupuncture, spinal manipulations, homeopathy, or herbal
supplements. So I have a certain degree of skepticism in
complementary therapies—particularly when used in children. But I
am always open to trying new remedies if they are proven beneficial
and safe.

Herbs: A review of uses and precautions

Aloe Vera
Uses: Used externally for minor burns, eczema. Used internally for
constipation.
Scientific Data: Good evidence that it reduces itching and promotes wound
healing. Not enough data to prove it works as a laxative, treats asthma,
cancer, ulcers, or diabetes.
Precautions: Risk of irreversible intestinal damage, kidney damage,
electrolyte imbalance when taken internally. Not safe for use as a laxative in
children under 12 yrs of age. (Rodriguez-Bigas, NIH, Fetrow)

Calendula
(calendula officinalis)
Uses: Used externally for skin irritation, wounds/burns, numbing drops for
earaches.
Scientific Data: Some evidence that it promotes wound healing and reduces
inflammation in rats. Virtually no studies in humans.
Precautions: Allergic reactions can occur, and can cause eye irritation. Not
recommended for use in the eye. (Kemper, NIH) Not recommended for
women who are breastfeeding as effects are unknown.

DR B’S OPINION: TELL YOUR

DOCTOR

A recent article in a parenting magazine stated that 12% of all

children have been given alternative therapies. Patients are using
these products—most of the time without their doctor’s knowledge.
Parents don’t tell the doctor they are trying herbals because:

a) they fear that their decision will not be respected or

b) think the doctor won’t know anything about the product.

The truth is, I respect parents’ decisions even though I may not
agree with them. As far as my knowledge about herbal remedies, I
am learning as I go along. But it is very important to tell your doctor
if you are giving your child an herbal remedy. Some herbal products
have significant drug interactions with other medications your
doctor might be prescribing.

Chamomile
(anthemis nobilis)
Uses: acne, allergies, colds, colic, diaper rash, ear infections, eczema, sleep
problems, sore throats, vomiting.
Scientific Data: One study shows 3-4 oz per day of a combination
(chamomile, fennel, vervain, licorice, balm mint) herbal tea improves
symptoms of colic. Chamomile is an antispasmodic and may help relax the
gut muscles, but it’s also possible that the fennel was the effective
ingredient. (Perry) Some evidence of improved wound healing.
Precautions: Infant botulism has been reported from contaminated
homegrown chamomile tea. Allergic reactions can be severe including
shortness of breath, throat swelling, and anaphylaxis. (Weizman, NIH) The
National Library of Medicine/National Institutes of Health discourages its
use during pregnancy, breastfeeding and for children.

Echinacea
Uses: allergies, prevention of colds, sore throats
Scientific data: Study results are conflicting whether or not Echinacea
prevents cold symptoms in adults. However, research shows no significant
benefit in reducing length and severity of cold symptoms in children under
11 years of age.
Precautions: It can cause allergic reactions. (Barrett, Kemper, NIH) When
taken at recommended doses, there are few side effects. These include:
stomachache, nausea, sore throat, rash, liver inflammation. Many tinctures
also contain high concentrations of alcohol.

Evening Primrose Oil

(Oenothera biennis)
Uses: allergies, eczema, attention deficit disorder
Scientific Data: Approved in several countries outside of U.S for eczema
and atopic dermatitis. Several studies show benefit.
Precautions: Stomachache, headaches reported. (Horrobin, Hederos, NIH)

Fennel
(foeniculum vulgare)
Uses: colic, gas, diarrhea, colds, conjunctivitis
Scientific Data: Studies show some benefit for colic. Fennel relaxes the gut
(antispasmodic) and increases intestine motility. (Perry)
Precautions: None (Weizman)

Ginger
(Zingiber officinale)
Uses: colds, diarrhea, headaches, nausea, vomiting, colic
Scientific Data: Some evidence shows it has anti-nausea, anti-vomiting
effects and reduces inflammation. Ginger may help relax the gut muscles.
One study shows some benefit for colic.
Precautions: heartburn. Not for use if prone to gallstones. (Schmid,
Mowrey)

Licorice
(glycyrrhiza glabra)
Uses: allergies, asthma, cough, eczema, sore throats, canker sores
Scientific Data: Minimal data on canker sores done on 20 patients, one
study on eczema.
Precautions: Long-term use has similar effects to steroids (high blood
pressure, altered body salts). Heart rhythm disturbances possible. Not for
use during pregnancy, or if patient has diabetes, liver, kidney disease. (Das,
Teelucksingh)

Reality Check
Most of the licorice candy sold in the U.S. is flavored with anise oil, not
real licorice!

Peppermint
(Mentha piperita)
Uses: Used externally as a decongestant (VapoRub). Used internally for
cough suppressant, irritable bowel syndrome, indigestion, headaches,
itching.
Scientific Data: Research shows positive effects on irritable bowel
syndrome and indigestion. Peppermint is an antispasmodic and may help
relax gut muscles. Peppermint actually INCREASES nasal congestion but
people subjectively report that they can breathe better.
Precautions: Heartburn. Peppermint oil should not be placed in nasal
passages of babies as it increases risk of apnea (they stop breathing) (Fox,
Eeles, Gardiner, NIH) National Institutes of Health does not recommend use
of peppermint leaf or oil in young children because of side effect risks.

Tea Tree oil

(Melaleuca alternifolia)
Uses: Used externally to treat dandruff, head lice, fungal infections.
Scientific Data: Some research shows benefit for mild to moderate
dandruff, lice, and fungal infections (athlete’s foot, toenail fungus).
Precautions: Toxic if taken by mouth. May mimic effects of estrogen and
cause pre-pubertal boys to have breast enlargement. (NIH)

Zinc
Uses: common cold, diarrhea, malnutrition, gastric ulcers, acne
Scientific Data: Positive effect seen in malnourished kids with diarrhea,
gastric ulcers. May reduce duration and severity of common cold if taken
within 24 hours of symptoms. May prevent the common cold if it is taken
daily for several months. No specific dosing information available on
children or adults. (Singh) Precautions: Unpleasant or “distorted” taste.
Occasional nausea, vomiting, diarrhea. (NIH)

BOTTOM LINE
Just because it’s natural doesn’t mean it’s safe. Get educated about these
products before using them.

Q. Is it safe to use VapoRub on my baby when she has

a cold?
No. Besides, it’s not clear that it even helps.
The most popular brand on the market, Vicks VapoRub, is a combination
of camphor, menthol, and eucalyptus oil. It is approved for use in children
ages two and up (because camphor has the potential for causing seizures in
young children when it is absorbed through the skin).
 Once your child is at least two, you are welcome to try it and see if it
works. People often report that they can breathe better when they use
VapoRub because of the cool sensation in their nostrils. However, the
medication does not stop snot production. Parents subjectively noted in one
recent study that their snot-nosed-VapoRub-treated children coughed less
and slept better than those who got treated with a placebo (a.k.a. Vaseline).
And the VapoRub treated group of parents slept better. But note: over 85%
of parents in the study correctly guessed if their child was using VapoRub
or Vaseline. So, take the study results with a grain of salt. (Paul)

Q. I love using essential oils. Are they safe to use with

my baby?
Essential oils (aromatherapy) are generally considered safe to use. The
therapeutic benefits seem to be most established for stress reduction—
which most babies don’t really need! While naturopaths tout numerous
other health benefits of essential oils, the data is much murkier on these
aromas as miracle cures. Using these products is probably okay, with one
caveat. I have had a few patients who have started wheezing from being
exposed to essential oils in their home. Kids with reactive airways
disease/asthma can be very sensitive to scents!

DR B’S OPINION: NEW STUDIES

MAY SHED LIGHT ON ALT MEDS

The NIH (National Institutes of Health) has numerous scientific

trials ongoing to study the effects and safety of herbal medicines.
Hopefully, this will provide the data that physicians need to feel
comfortable prescribing these products to their patients.

PRObiotics and PREbiotics

 Probiotics and prebiotics are popping up at natural and conventional
grocery stores alike, thanks to the potential health benefits. But what are
they?

What are PRObiotics?

These are “good germs” (bacteria or yeast) that help the body digest
food. They are found naturally in yogurt, kefir, kombucha, tea, and
sauerkraut. They also come in capsules or powder form. One capsule or
powder packet has about 1000 times more “germs” than what is in a serving
of yogurt. Note: the good germs are only present when you ingest them. So
once a person stops taking them, the benefits go away.

What are PREbiotics?

These are complex starches or polysaccharides in food that help the gut
grow the good bacteria mentioned above. This is what sustains the healthy
gut environment. Prebiotics are found naturally in whole grains, honey (a
no-no under age one), bananas, garlic, onions, leeks, and artichokes. Other
food and beverage products are fortified with them. Note: prebiotics
basically provide the nesting ground for good germs. So, even if someone
doesn’t take prebiotics everyday, the benefits have longer lasting effects.

Does your baby need these products?

There’s been quite a bit of hype about the health benefits of both pro-
and prebiotics. Formula companies have joined the bandwagon: one major
brand has added probiotics while another is touting prebiotics.
These “good germs” seem to reduce antibiotic-associated diarrhea and
diarrhea from stomach viruses in infants as young as one month of age.
Probiotics may also be useful for eczema, colic, and intestinal problems in
premature babies.
However, it’s debatable whether a daily dose is useful or not. More
research is definitely needed to know when, what type, how much, and how
often these products should be used for proven health benefits.

Which product should I buy?

Probiotic products are mostly bacteria from the Lactobacillus
acidophilus, Lactobacillus GG or Bifidobacterium families that are similar
to the germs that naturally live in our guts. A few probiotics are actually
yeast-based, like Saccaromyces sp. Specific products include: Lactinex
(Lactobacillus acidophilus and Lactobacillus bulgaricus), Culturelle
(Lactobacillus GG), Lactobacillus reuteri, and Florastor (Saccaromyces).

Do all probiotics have the same effectiveness?

Frankly, we don’t really know. Probiotics research is really in its infancy.
Lactobacillus reuteri is the probiotic that was specifically used in the study
done on reduction of colic in infants (see Chapter 11 for details).
Lactobacillus rhamnosus and Lactobacillus GG have proven results in
reducing diarrhea from rotavirus infection. Saccaromyces boulardii is also
effective for diarrhea.
So, will your local warehouse club version of probiotics prevent your
child’s diarrhea or colic? We don’t have the answers yet—the research is
still evolving. Watch our blog or sign up for our eNewsletter for the latest
updates at Baby411.com.

Do probiotics need to be refrigerated, or need any other special care?

Many need to be refrigerated for the germs to stay alive. Check the
packaging on the item you purchase.
Give probiotics and antibiotics at different times. Otherwise, the good
germs will be killed off.
If you are adding probiotics to infant formula, do not warm the bottle
over 100°F, or you will kill off the good germs.

Are these products safe for my baby to use?

Despite the general belief that these products are safe, there are some
serious safety concerns, particularly with young children and those with
immune deficiencies. There have been a few cases of bloodstream
infections among people with chronic illness. There is also some evidence
that newborns and young children who take L rhamnosus have a greater
risk of wheezing later in life. (Kopp) You also need to know that some
probiotics contain cow’s milk proteins, which could lead to an allergic
reaction for a baby with a milk protein allergy. (Moneret-Vautrin)
FYI: The only probiotic that is FDA approved for use in formula is B.
lactis. Other probiotics are not regulated for children.
How much and how often should I give probiotics to my baby?
Well, we’re kinda shooting from the hip here since there are no official
recommendations.
For colic: half teaspoon of L. reuteri powder per day to help with colic
symptoms.
For diarrhea: use 1/4 or 1/2 the powder contained in one capsule of L.
rhamnosus, B. lactis, or L. acidophilus per day for 5-7 days. (Land)

What about PREbiotics?

Prebiotics are certainly safe and they are the building blocks for good
germs. So, serve up another helping of bananas or whole grains to your
baby who has started solid foods. Is it worth it to buy prebiotic-
supplemented formula? It’s certainly not a bad idea, but we have to see
more data before we recommend it over other products on the market.

Homeopathic Remedies

These are products containing diluted ingredients that are listed in the
Homeopathic Pharmacopeia of the United States (HPUS). But according to
the National Center for Complementary and Alternative Medicine, “A
product’s compliance with requirements of the HPUS, . . . . . . does not
establish that it has been shown by appropriate means to be safe, effective,
and not mis-branded for its intended use.”
For more information on herbal and homeopathic remedies, check out
The Holistic Pediatrician, by Kathi J. Kemper, M.D. (see Appendix F). She
is a well-respected pediatrician who has done a great deal of research on
alternative therapies.
The National Center for Complementary and Alternative Medicine, a
branch of the National Institutes of Health, also has a useful website at
nccam.nih.gov/health/herbsataglance.htm.

Home Remedies
 Not every ailment requires a trip to the pharmacy. Here is a list of
household items and remedies that often provide symptomatic relief for
various problems.

Abdominal pain/gas/colic
Give your child a bath. The warm water is soothing. Playing in the
bathtub is also a nice distraction technique.

Bruises
Pull out a bag of frozen vegetables and place on the site.

Common Cold (URI)

Make your own saline (salt water) nose drops. Take 1/2 teaspoon of salt
and add to 8 oz. of water. Use as much as needed.
Chicken soup. Every culture has their own recipe, and for good reason.
The high salt and water content is good for hydrating a child with a fever.
Pull out the humidifier. This moistens the air your child breathes, and
loosens the mucous in his nose.

Cradle cap
Massage olive oil into the scalp. Then lift off the plaques.

Croup
Take your child into the bathroom. Close the door. Turn on the shower
for ten to 15 minutes. The warm mist will help relax the airway.
If this technique doesn’t work, walk outside with your child. The cold
night air will often shrink up the swollen airway. It also changes the scenery
for your child, which has a therapeutic effect too.
Croup usually occurs in the wintertime. If you live in a warm climate,
this might not work for you.

Diaper rash
Good old petroleum jelly (Vaseline) works well. It provides a barrier
between the skin and moisture.
Leave your baby open to air (diaper-less) in a safe place inside or outside
your house.
Use a blow dryer on the lowest setting to dry baby’s bottom.
 Some doctors recommend applying liquid antacids (milk of magnesia,
kaopectate) to the diaper rash. It might be worth a try.

Vomiting and Diarrhea

Make your own Pedialyte solution. Here is the recipe:
4 cups of water
1/2 tsp of salt
2 Tbsp. of sugar
1/2 tsp of instant Jell-O powder for flavor

Ear infections
Use a heating pad on low setting up to the ear.
Want to prevent your child’s ear infections? Stop smoking.
To prevent swimmer’s ear, you can make your own “Swim-ear” drops.
The alcohol will dry up the water left in the ear canal. The vinegar changes
the pH of the ear canal so bugs won’t want to grow there. Here’s the recipe:
2 drops rubbing alcohol
2 drops of vinegar

Eczema
Keeping the skin moist is the key. The best moisturizer (although not
very practical) is good old petroleum jelly (Vaseline). Lube your child up
head to toe.

Eye stye
Place a warm tea bag over the eyelid. It is soothing and reduces the
swelling.

Sore throat
Make a milkshake or smoothie (depending on the age of your child).
Cold drinks feel good and are a nice way to get the fluid intake in. This idea
makes me very popular with my patients.

Warts
Try duct tape. A study showed that smothering the warts suppresses the
growth of the virus that causes them. Apply a new piece of duct tape to the
wart nightly and leave on for the day. It takes about six weeks.

Reality Check: Clean your humidifier

Clean your humidifier properly every few days or else you will be
spewing dust particles and germs into the nursery. Be sure to check the
instructions that came with your humidifier for details.

DR B’S OPINION: ALTERNATIVE

MEDICINE

In today’s world, I tell the parent what their child’s diagnosis is,
explain the diagnosis, and explain the therapy that I would advise.
Then the parent often quotes recent information about alternative
therapies that they found on the Internet (sometimes accurate and
sometimes not) and asks what I think of it. I don’t mind these
interactions—I find them stimulating. They keep me on my toes. As
you can tell by now, I like educating parents. But not every
physician is enthusiastic about this style of practicing medicine.
As we discussed in the introduction to this book, our mantra on
complementary and alternative medicine for your baby is SHOW
US THE SCIENCE. If an alternative therapy is shown to be
effective in a reputable scientific study, then we are happy to
recommend it. But if it is just snake oil or an Internet myth, we
won’t hesitate to say so.
 LAB WORK & TESTS
Appendix C

When The Parent Wants Tests Done

Parents frequently ask their doctor to order lab work on their child.
Doctors are less interested in getting lab work done if they are comfortable
in making a diagnosis. But doctors also know that a parent may bring their
child in for the common cold and are actually concerned that the child has
leukemia or some other devastating diagnosis. In medical terms, this is
called “The Hidden Agenda.” It’s perfectly fine to have that agenda—you
are a parent. But don’t keep it a secret. Your doctor won’t laugh at you.
What we will do is make sure that your child does not have the problem that
is keeping you up at night worrying.
What you need to know is that there is no one “test” that will uncover
every disease that you have concerns about (like a total body CT scan or a
comprehensive blood test panel). In the past, doctors would perform annual
blood metabolic panels on adults to go on a fishing expedition for
abnormalities. This is out of vogue for adults and has never been standard
practice for children.
What we might do is order a particular test that would help to diagnose
or rule out the concern you have.

When The Doctor Wants Tests Done

Pediatricians can frequently make a correct diagnosis of illness in a child
without any tests. I wish I could say it’s because we are so much smarter
than our other doctor colleagues. The truth is, childhood illnesses are often
infections that follow classic patterns. And rashes, which occur more in kids
than adults, are helpful in determining the cause of illness.
When do doctors order a test?
1.When there is something about the child’s illness history or
examination that may indicate a bacterial infection.
2.When there is a concern infection is bacterial and cultures are needed
to know what bug it is (so it can be treated appropriately).
3.When a child has a fever with no obvious source.
4.When a baby under three months has a fever.
5.When your doctor thinks your child has a broken bone.
6.When your doctor feels a hip “click” in a newborn. Testing (hip
ultrasound) will verify he doesn’t have a congenitally dislocated
hip.
7.When a child is vomiting bile or has intractable vomiting.
8.When a child has blood in his poop.
9.When a child has pain when he urinates.
10.When a child’s head size is enlarging across percentiles (in other
words, the head is growing much faster than expected).
11.When a child’s head size is not enlarging.
12.When a child is failing to thrive (not gaining weight).
13.When a child wheezes for the first time and it doesn’t sound like
RSV bronchiolitis.
14.If an abnormality is found during a regular exam (such as distended
abdomen, swollen testes).
15.When a child is drinking or urinating excessively.
16.When a child has excessive bruising.
17.When a child has petechiae.
18.When a child has a persistent fever (five days or more).
19.When a newborn is jaundiced to the level below the belly button.
20.When a child is disoriented.
21.When a child has a seizure for the first time.
22.When a child appears dehydrated and the doctor needs to decide
how dehydrated he is (that is, does he need to be admitted to the
hospital and get IV fluids).
23.When a child bleeds excessively—with cuts or nosebleeds.
 24.When a mother has Blood Type O. Your doctor needs to know the
baby’s blood type so the doctor can be prepared for potential
newborn jaundice problems.
25.When your doctor thinks a child has pneumonia and want to confirm
it.
26.When a parent is worried.
27.When a child is limping.
28.When a child has recurrent bacterial infections (not just ear
infections) such as pneumonia, sinus infections, skin infections.
29.When a child has chronic or severe problems with wheezing.
30.Anytime a child is jaundiced out of the newborn period.
31.When a child has a heart murmur that does not sound like an
innocent heart murmur.
32.When a child has an irregular heartbeat.
33.When a child has a bladder or kidney infection.
34.When a child has swallowed a non-food object.

With that said, here are the most common tests we order and what they
mean.

Imaging Studies

Ultrasound
The beauty of ultrasonography is that no radiation is used. The
technology involves use of sonar waves and computer imaging. Doppler
flow studies in addition to ultrasound pictures are helpful in looking at
blood flow. Ultrasound pictures can be limited, however. Gas and fat
obstructs the view.
Abdominal. Looks at the anatomy of the liver, gallbladder, spleen. Not as
good at looking at intestines. Detects pyloric stenosis, intussusception,
gallstones, masses.
Head. Looks for bleeding inside the skull. Wand is placed on top of the
anterior fontanelle (soft spot) to see inside. Not used once fontanelle has
closed. Detects intraventricular hemorrhage (IVH), a problem that can
occur in babies born prematurely.
Hip. Looks at the hip joint. Detects hip dislocations (Developmental
Dysplasia of Hips or DDH) in infants under four months of age.
Heart (echocardiogram with Doppler). Looks at the anatomy of the heart
and the great blood vessels coming off of the heart. Detects heart defects.
Kidney (renal). Looks at the anatomy of the kidneys. Detects evidence of
enlargement, fluid collection (hydronephrosis), and infection.
Pelvic. Looks at anatomy of the ovaries, uterus, bladder. Detects ovarian
cysts, masses. Also detects location of a testes if it has not descended into
the scrotum.
Spine. Looks for spina bifida, an abnormal formation of the spine
Testicular, with Doppler flow. Looks at the anatomy of the testes. Detects a
twisted testes and can assess blood flow to the testes. Also detects some
hernias.

Plain x-rays
X-rays use diffraction of low doses of high-speed electrons (radiation) to
project an image. Solid or fluid filled objects appear white and air appears
clear. As a general rule, plain x-rays are better at detecting bone problems,
and less helpful at assessing problems with “soft tissues.”
Abdomen. Looks at the anatomy of the intestines, liver, spleen. Detects
intestinal obstructions, malrotations, constipation. Can detect some foreign
bodies (swallowed objects that are metal).
Chest. Looks at the anatomy of the heart, lungs, ribs. Detects fluid (blood,
pus) in lungs, masses in lungs, enlargement of the heart, rib fractures,
foreign inhaled objects.
Extremities. Looks at the bones of the arms and legs. Detects fractures
(broken bones), fluid or swelling occasionally. Less helpful in detecting
problems with muscles, tendons, and joints.
Neck. Looks at the anatomy of the throat (epiglottis, tonsils, adenoid,
trachea). Detects swelling of these areas, location of some swallowed
objects.
Skull. Looks at the anatomy of the skull bones. Detects craniosynostosis,
fractures.
Sinus. Looks at the anatomy of the sinus cavities of the face. Detects acute
sinus infections by identifying an air/fluid level. Not helpful in detecting
chronic sinus infections.
Spine. Looks at the anatomy of the vertebrae from the neck to the buttocks.
Detects fractures, slipped discs, scoliosis.

CT/MRI with or without contrast

Computerized Tomography (CT) uses x-ray technology (radiation) to
look at cross sectional slices of the body in a two-dimensional picture. Due
to the significant amount of radiation exposure with a CT scan, physicians
are very selective about ordering these studies. Magnetic Resonance
Imaging (MRI) uses a magnetic field to detect the body’s electromagnetic
transmissions. MRI’s produce narrow slices of the body without radiation.
As a general rule, CT and MRI scans are better at detecting
abnormalities with soft body tissues and less helpful with bone problems.
The decision to perform a CT versus an MRI is based on the particular
problem that is being assessed.
Abdomen. Looks at the anatomy of the liver, spleen, pancreas, gallbladder,
intestines, kidneys. Detects masses, tumors, abscesses—including
appendicitis, fluid collections, trauma.
Chest. Looks at the anatomy of the lungs and heart. Detects masses, tumors,
fluid collections, congenital abnormalities, trauma.
Extremity. Looks at the anatomy of the arm or leg. Detects fractures, torn
ligaments, masses, tumors, osteomyelitis (infection).
Head. Looks at the anatomy of the brain. Detects masses, tumors,
obstruction of spinal fluid flow (hydrocephalus), evidence of stroke
(cerebrovascular accident), evidence of trauma, bleeding.
Lymph node. Looks at the anatomy of a concerning (swollen) lymph node.
Detects pus (infection), masses, congenital cysts.
Pelvic. Looks at the anatomy of the ovary, uterus, bladder. Detects masses,
tumors, fluid collections.
Sinus. Looks at the anatomy of the sinus cavities. More helpful imaging
study than plain x-rays. Detects obstruction to flow in the sinuses, chronic
sinus infections, masses/polyps.

Special studies
Barium swallow/Upper GI. Looks at the anatomy of the upper
gastrointestinal tract (esophagus, stomach, upper small intestine). Detects
anatomic abnormalities, hiatal hernias, pyloric stenosis, ulcerations,
narrowings. Although gastroesophageal reflux may be seen (barium goes
backwards), it doesn’t tell you the severity of the reflux. It also does not
rule out reflux as a diagnosis.
Bone scan. Nuclear medicine study (uses a radio-isotope to be visualized on
x-ray). Looks at the all of the bones of the body in one study. Hot and cold
“spots” detect areas of inflammation. Detects: infection, tumors, avascular
necrosis, child abuse.

DMSA Scan. Special nuclear medicine study that uses a radio-isotope dye
visualized on x-ray. Looks for scarring of the kidneys. Detects: chronic
kidney scarring and damage due to kidney infections.
Voiding Cystourethrogram. Looks at the flow of urine from kidney to
ureters to bladder to urethra. Detects vesicoureteral reflux in children prone
to bladder infections. (Gunn)

Laboratory Tests

Blood tests
Amylase. This test looks at the level of an enzyme that the pancreas makes.
Detects: pancreatitis
Basic Metabolic Panel. This is a battery of tests that includes sodium,
potassium, chloride, bicarbonate, blood urea nitrogen, creatinine, glucose.
This combination of tests assesses body fluid and salt (electrolyte) balance
as well as kidney and adrenal function.
Detects: Dehydration, kidney dysfunction, diabetes, hypoglycemia, adrenal
dysfunction
Bilirubin. This test assesses the level of this substance circulating in the
bloodstream. Newborns uniquely have higher levels than any other time in
life because:

1. Newborn metabolism is not functioning at 100%.

2. Newborns are not eliminating bilirubin in their stool yet.
3. Newborns have bilirubin load due to prematurity, birth trauma, or
blood type incompatibility.

A total level is assessed as well as direct and indirect levels. These

indicate the cause of the total elevation. Beyond the newborn period, any
evidence of jaundice prompts a lab evaluation.
Detects: Hyperbilirubinemia, Hepatitis, Biliary Atresia, gallstones,
hemolytic anemia
Blood culture. see below
Blood sugar (glucose). This test assesses the body’s metabolism of sugar. A
random level above 110 is concerning for diabetes. In newborns, a level less
than 40 is concerning for hypoglycemia. Levels less than 60 in children is
concerning for hypoglycemia.
Detects: Hypoglycemia in large birth weights, babies whose mothers have
gestational diabetes or diabetes, body temperature irregularities, lethargy
Detects in children: Diabetes, hypoglycemia
Blood type. This test determines what proteins sit on the surface of a
patient’s red blood cells. There are A and B proteins. The AB blood type
means both A and B protein are present. The O blood type means there are
no proteins present. Rh typing refers to the presence (+) or absence (-) of
another type of protein that sits on the red blood cell surface. These tests are
necessary when a blood transfusion is needed. In an emergency situation,
however, everyone gets O (-) negative blood. Most hospitals no longer test
a newborn’s blood type on a routine basis.
C-Reactive Protein (CRP). This is a substance that circulates in the
bloodstream when there is an inflammatory process going on. It is one of
several “acute phase reactants” whose numbers change by at least 25%
when there is active inflammation. It is not specific for any one disease, but
it is accurate. It detects inflammation, infection, trauma, or tumors.
Cholesterol level. See lipid panel
Complete Blood Count (CBC). This refers to a test that looks at the number
of white blood cells, red blood cells, and platelets that are circulating in the
bloodstream..
1. White blood cell count (WBC). These cells fight infection, but also rise
with inflammation. An elevated count is concerning for a bacterial
infection. A depressed count is due to decreased bone marrow production
(where white blood cells are made)—usually caused by viral infections (e.g.
influenza, mononucleosis).

2. White blood cell count differential. Not only is the number of white blood
cells counted, but the types of white blood cells are identified in a CBC.
The types of cells also give your doctor clues as to the disease process
going on.
Neutrophils (PMN’s)- Cells that fight bacteria. If more than 50% of the
WBC’s are this type, the likelihood of a bacterial infection is greater.
Lymphocytes: Cells that fight viruses. If more than 50% of the WBC’s
are this type, the likelihood of viral infection is greater.
Eosinophils: Cells that fight parasites. Also revved up by allergies. If
more than 10-15% of these cells are present, it prompts an
investigation.

3. Hematocrit/Hemoglobin. These measurements assess the amount of red

blood cells in the circulation. Low levels detect anemia.
4. Platelet count. These cells help clot the blood. A low level detects a
cause for bleeding problems. A low level can also suggest bone marrow
suppression (where platelets are made) or an autoimmune disorder. Platelet
counts can be elevated with infection or inflammation.

FYI: When all thee cell lines (white, red, platelet) are depressed, there is a
concern for leukemia.
Uses: infection, inflammation, leukemia, anemia, bleeding disorder

Comprehensive Metabolic Panel. This is a large battery of tests that

assesses adrenal, kidney, liver, gallbladder, fluid and electrolyte balance,
and a measure of general nutrition. Many physicians pick a select number
of these tests and not the whole panel. These tests include:

Albumin Alkaline phosphatase

Alanine Aminotransferase (ALT) Aspartate Aminotransferase (AST)
Bicarbonate Bilirubin
Blood Urea Nitrogen (BUN) Calcium
Chloride Creatinine
Glucose Phosphorous
Potassium Sodium
Total Protein

Detects: Liver dysfunction, hepatitis, gallbladder dysfunction, kidney

dysfunction, dehydration, diabetes, adrenal dysfunction, malnutrition.

Chromosome analysis. This test assesses a patient’s chromosomes, the part

of each cell that contains genes. Blood, tissue, or an amniotic fluid sample
can be tested.
Detects: Chromosomal abnormalities related to developmental
delays/congenital defects; determines the sex of a baby born with
ambiguous genitalia.
Coagulation studies. These tests detect an abnormality in the clotting
“cascade” or chain of events that allow blood to clot. These tests include:
Bleeding Time, Factor levels, Prothrombin time (PT), Partial
thromboplastin time (PTT)
Detects: Bleeding disorders—such as Hemophilia, von Willebrand’s disease

Coombs test. This test looks for antibodies (reaction) to a person’s blood
type. In newborns whose mothers have O Blood type, many hospitals
perform a Coombs test on the baby routinely. There is some mixing of
mother’s and fetus’s blood in the placenta, which can cause a Type O
mother’s blood to create antibodies to a type A or B baby. These antibodies
can potentially kill some of the baby’s red blood cells creating an extra
bilirubin load in the newborn.
Detects: Blood type incompatibility in newborns

Electrolytes. See Basic Metabolic Panel

Erythrocyte Sedimentation Rate (ESR). This test looks at how fast it takes
for red blood cells to settle at the bottom of a test tube. It is a very
nonspecific test, but an elevated level suggests further testing. It is a non-
specific sign of inflammation.
Detects: inflammation, infection, pregnancy, malignancy, anemia

Liver function tests. This is a battery of tests that evaluates how the liver is
working. It looks at products the liver is in charge of metabolizing and
producing. Some tests look at the breakdown product of liver cells (but
these products are also seen in muscle breakdown) so they are not specific
in detecting liver disorders.

Alanine Aminotransferase (ALT) Albumin

Aspartate Aminotransferase (AST) Bilirubin
Total protein

Detects: Hepatitis, liver failure, drug toxicity, heart attack.

Monospot/EBV titers. For monospot, see rapid assays below.
Epstein-Barr Virus (EBV) titers detect a person’s immune response
(antibodies) to an EBV infection (mononucleosis). Because different types
of antibodies are formed through the course of infection, this test
differentiates a recent infection and a prior one.
Detects: Acute mononucleosis, prior mononucleosis.

Lipid panel/cholesterol. This battery of tests looks at how the body

metabolizes fat. Poor fat metabolism is associated with coronary artery
disease (heart disease) in later life. In children, often a random (non-fasting)
cholesterol level is an acceptable screening test. If that level is elevated, a
full panel is done with the child fasting prior to the test. Tests:

Cholesterol HDL
LDL Triglyceride level

Detects: Hypercholesterolemia, hepatitis, metabolic disorders, bile duct

obstruction, nephrotic syndrome, pancreatitis, hypothyroidism

Reticulocyte count. Reticulocytes are baby red blood cells. They circulate in
the bloodstream while they mature. This test looks at the number of these
present in the blood. A high level suggests good bone marrow production in
response to anemia.
Detects: Body’s response to anemia

Thyroid function tests. This is a battery of tests that assesses the function of
the thyroid gland. An indirect way of testing thyroid gland function is to
look at a Thyroid Stimulating Hormone (TSH) level, a hormone produced
by the pituitary gland. If the thyroid gland is not functioning well
(hypothyroidism), the TSH level is elevated to stimulate the gland to work
harder. This is a test included in all state metabolic screens to detect
congenital hypothyroidism.

T3 (triiodothyronine) level Thyroxine Binding Globulin

T4 (thyroxine) level Free T3, Free T4 levels
 TSH

Detects: Hypothyroidism, Hyperthyroidism

Viral titers. There are a few viruses for which a patient’s antibody response
can be detected. These tests are useful to make a diagnosis or confirm
immunity to a particular virus.

CMV
Hepatitis A, B, C

HIV Parvovirus
Rubella Syphilis
Toxoplasmosis Varicella

Urine tests
Urinalysis. This is a test that looks at the components of urine and detects
any abnormal components. Urine is normally a sterile fluid, thus should not
contain any bacteria or white blood cells (which fight infection). Urine does
not break down sugar or protein, so it should not contain any of those
substances. Urine is produced in the kidneys, so some abnormalities will
point to a kidney dysfunction.
In children, obtaining a urine specimen can be a challenge. A urine
specimen needs to be clean to be able to make any decisions based on its
findings. The preferred method of obtaining this specimen is to insert a
small catheter in the urethra of a non-toilet trained child. If the reason for
testing urine is not to look for infection, a collection bag may be placed
over the urethra. Tests:

Specific gravity pH
Color, odor White Blood Cells
Red Blood Cells Glucose
Protein Nitrite
Microscopic analysis for bacteria

Detects: Bladder infection, dehydration, kidney disease, diabetes, adrenal

dysfunction, metabolic disorder, kidney stones

Skin tests
PPD. This is the preferred test for exposure to tuberculosis. PPD stands for
purified protein derivative, which refers to a synthetic protein “signature”
that belongs to the tuberculosis bacteria. If a person has had an exposure to
tuberculosis, their antibodies will also respond to this skin test. A positive
test requires further evaluation and testing.

Stool tests
Occult blood. This test detects blood in the stool. A small amount of stool
(poop) is placed on a special developing card. When a processing fluid is
added to the specimen, it turns blue in the presence of blood.
Detects: Gastrointestinal bleeding (e.g. food allergy, infection, ulcer,
inflammatory bowel disease, polyp)

Spinal fluid (CSF) tests

Cerebrospinal fluid (CSF) is a liquid that bathes the brain and spinal
cord. It transports important chemicals through the central nervous system.
A specimen of this fluid helps diagnose viral infection, bacterial infection,
tuberculosis meningitis (infection of the tissues protecting the brain), brain
infection, and obstruction of the spinal fluid collecting system.
CSF is obtained by performing a lumbar puncture or “spinal tap.” This
sounds scary, but it is a similar concept to having an epidural placed in
childbirth. A small needle is inserted between two vertebrae in the back. A
small amount of fluid is collected, and then the needle is removed.
We look at the pressure of the fluid, the appearance of the fluid (should
be clear/watery), the sugar/protein levels, and if there are any cells in the
fluid (white, red, bacteria).
 A culture of the fluid is also done (see below).

Sweat test
A specimen of sweat is obtained by warming the skin on the arm or thigh
and obtaining a small amount of sweat.
Detects: Cystic Fibrosis

Cultures
This group of tests takes a particular body fluid and incubates it (creates
ideal growing conditions for bugs). If there is a germ in a specimen, there is
a chance to identify it. Germs that grow are very accurate for infection
growing in the patient (except for contaminated/dirty specimens). But, lack
of growth in culture does not necessarily rule out an infection.
Most germs will grow out in a culture within three days. Fungus
infections, however, may take up to one month to grow.

Blood. Detects BACTERIAL infections

Urine. Detects bacterial infections
Spinal fluid. Detects primarily BACTERIAL infections, some VIRAL
infections
Stool. Detects BACTERIAL, PARASITE, AMOEBA infections
Throat. Detects BACTERIAL infection
Sputum. Detects BACTERIAL infection
Abscess. Detects BACTERIAL infection
Viral. Detects limited number of VIRAL infections (such as Herpes,
Varicella, Chlamydia)
Fungal. Detects FUNGUS infections

Rapid Antigen Assays

As a group, these tests identify responses that infections have to certain
chemicals. You might think of them in a similar way to a home pregnancy
test. A positive test accurately confirms infection. But a negative test does
not rule out infection. These “assay kits” also look like a home pregnancy
test. The earlier these tests are done in the course of an illness, the less
accurate they are.

Strep. Throat swab specimen

Monospot. Blood specimen
Influenza. Nasal secretion specimen
RSV. Nasal secretion specimen
Rotavirus. Stool specimen (Loeb)
 GLOSSARY
REALLY BIG LATIN WORDS

Appendix D

Abdominal tumors. There are some solid tumors that occur more
frequently in children than adults. These include Wilm’s tumor and
neuroblastoma. Patients with these tumors may (not always) have
enlarged, firm bellies with a mass that can be felt. Other symptoms
include weight loss, lack of appetite, or unexplained fevers.

ABO incompatibility. See Coombs test in Lab section.

Accessory Nipple. See supernumerary nipple.

Acholic stool. Official term for a clay colored poop. In isolation, it may
have no significance. But, it can indicate a problem with the biliary
system (liver, gallbladder, pancreas) if it is associated with other
symptoms—particularly jaundice (yellowing) of the skin. Diagnoses can
include hepatitis infection and biliary atresia. If you see this, check in
with your doctor.

Acne (neonatal). Skin inflammation due to hormonal changes in the

newborn period. Onset is usually by four weeks of age and lasts until
about eight weeks of age.
Acute abdomen. Term that refers to an emergency requiring surgical
intervention to alleviate an intestinal problem. Examples of these
problems include: appendicitis, intussusception, intestinal obstruction.

Acute life threatening event (ALTE). Term that describes an episode of

lack of breathing (apnea) that requires intervention to resume
spontaneous breathing. If an event like this happens, a thorough
evaluation is done to determine the cause of the event.

Acute otitis media. Infection in the middle ear space. This is primarily
caused by bacteria. When the infection comes up quickly, it is called
“acute.” Symptoms include fever, cranky mood, and vomiting.
Occasionally, children may also seem dizzy. Ear infections that smolder
for a long period of time are called “chronic” and do not have the same
symptoms.

Acrocyanosis. The blue discoloration frequently seen on the hands and feet
of newborns. This is due to the body circulation transitioning from fetal
to newborn. It doe not indicate any problem with the heart or circulatory
system. Blue discoloration only on the feet or legs (not hands) can be a
sign of a circulation problem (Coarctation of the Aorta) and needs to be
evaluated.

Air hungry. The inability of a person to get enough oxygen in with each
breath. The person then tries to get more air in with each breath by using
chest wall muscles and increasing the number of breaths taken per
minute. This is also known as respiratory distress.

Ambiguous Genitalia. It’s hard to tell whether the baby has boy parts or
girl parts. We’ll test chromosomes, hormone levels, and get an
ultrasound to look for internal genitalia (ovaries/uterus or undescended
testes).

Amblyopia. (Known as lazy eye). A reduction of vision in an eye that is

not correctable with glasses. This problem can be caused by a weakness
 of an eye muscle (strabismus). It is important to detect this eye problem
early (under age two or three years) so it can be treated.

Anal fissure. A crack in the anus opening usually due to passage of a hard
poop. The crack causes discomfort and occasionally blood in the diaper
or on a diaper wipe.

Anaphylactic reaction. An allergic response to exposure to a particular

item (that is, medication, food). The response is extremely serious and
life-threatening. These body responses include: difficulty breathing,
heart failure, loss of blood pressure.

Anemia. A reduced amount of hemoglobin that carries oxygen on red blood

cells. Because the body is less capable of getting oxygen, symptoms
include tiredness, pale appearance, and quick fatigue.

Ankyloglossia (tongue tie). The tongue is attached to the base of the mouth
too close to the tip. Not all babies with tongue tie need intervention. If it
is so tight that it interferes with feeding or talking, the tissue band can be
clipped. This is more likely to be a problem if the tip of the tongue is
forked.

Anomaly. Fancy word for abnormality, usually malformed prior to birth

(congenital anomaly).

Anterior Fontanelle. See Fontanelle.

Antibiotic induced colitis. Inflammation of the lower part of the intestine

which, rarely, can be caused by antibiotics. Symptoms of colitis include
blood and mucous in the poop, diarrhea, and cramping. If someone has
been on an antibiotic just prior to the onset of these symptoms, a
specimen of poop can be checked for this problem.

Apnea. Pause, or temporary absence in breathing. Frequently babies born

prematurely have these events when they just plain forget to breathe.
 This is called apnea of prematurity. Preemies eventually outgrow this
problem. Until they do, they are placed on an apnea monitor which
alarms when breathing stops. Some babies also need caffeine (in
medication form) to stimulate them to breathe.

Appendicitis. Inflammation of a small piece of the intestine called the

appendix. The appendix is usually located in the lower RIGHT side of
the belly, but this varies occasionally. When the appendix gets swollen,
symptoms include: vomiting, diarrhea, fever, and abdominal pain that
worsens over time. Appendicitis is extremely rare in the birth to age one
group.

Asperger’s Syndrome. A term that is no longer used to describe a

developmental disorder that is part of the Autism Spectrum Disorders.
Historically, children with Asperger’s have better communication and
language skills than those more severely affected.

Asthma. The swelling of the big and little airways in the lungs. The
swelling can occur due to allergic response. The episodes happen
intermittently. Symptoms include: coughing and labored breathing
(respiratory distress).

Atopy. A classic triad of allergic disorders: eczema, asthma, and seasonal

allergies (termed “allergic rhinitis”). Not everyone is unlucky enough to
have all three problems, but some people are.

Atresia. Means that something is completely absent or is significantly

narrowed
Anal atresia. Anus (opening of the intestines to the outside).
Biliary atresia. Bile ducts.
Choanal atresia. Nasal/throat.
Duodenal atresia. Small intestine.
Esophageal atresia. Esophagus.
Ileal atresia. Small intestine.
Tricuspid atresia. Heart valve.
Autism. A developmental disorder that is characterized by poor or no
language development, lack of normal social skills and repetitive self-
soothing behaviors. The disorder has a genetic basis in at least 10-15%
of the cases. The newer term, Autism Spectrum Disorders (ASD) more
appropriately describes the umbrella diagnosis that encompasses the
broad range from mild to severely affected individuals.

Autosomal dominant. A genetically inherited trait that requires only one

parent to have an abnormal gene to pass it on to a child. If one parent
carries an autosomal dominant gene, the chances are 50% that a child
inherits the gene.

Autosomal recessive. A genetically inherited trait that requires both parents

to have the gene to pass it on to a child. If both parents are carriers of
the autosomal recessive gene, the chances are 25% that they will have
an affected child. If both parents have the disease, chances are nearly
100% that they will have an affected child.

Bacterial gastroenteritis. (See gastroenteritis)

BAER. Brainstem Audio Evoked Response. An objective hearing test that

measures the electrical activity of the inner ear in response to sound.
This is a universal screening test done on newborns. It is recommended
by the American Academy of Pediatrics and currently mandated in most
states.

Balanitis. An inflammation of the tip of the penis, which becomes inflamed

an irritated. Balanitis can be caused by an infection.

Bladder infection (see UTI)

Blocked tear duct. See nasolacrimal duct obstruction.

Blood in stool. A symptom that may be caused by a variety of reasons.

Blood can be found in poop due to skin irritation (diaper rash), a crack
 or tear in the anus (see anal fissure), inflammation in the intestine (milk
protein allergy), intestinal infection (see gastroenteritis), or intestinal
obstruction (intussusception). As you can see, the problem may be a
minor or serious one. It always should be checked out by your doctor.

Brain tumor. Abnormal mass of cells that grow in the brain tissue.
Although not all tumors are malignant (fast growing, aggressive), even
benign tumors can be life threatening depending on the location that it
arises. Symptoms in infants and young children include morning
headaches accompanied by vomiting, increasing head size, behavior
changes, imbalance, seizures, and new onset eye abnormalities.

Branchial cleft cyst. An abnormality in fetal development of the throat that

results in a cyst that occurs on the neck

Breath-holding spell. An episode where a child holds his breath when

upset or angry. Usually occurs after one year of age. The episode
ultimately results in a child losing consciousness and regaining normal
breathing. Rarely, these episodes are due to anemia—but worth
checking out if the episodes occur frequently.

Breech position. Occasionally, a baby will decide to exit the womb with his
butt, foot, or feet first—instead of the usual head first (vertex) position.
Because this can increase the risk of complications at delivery, it is
preferable to deliver these babies by C-section. Babies who are breech
in the womb, particularly girls, have a slightly increased risk of having
hip dysplasia (also known as developmental dysplasia of the hips or
DDH). There is an association between abnormal formation of the hips
as a fetus leading to the unusual butt/foot first position for delivery. See
hip dysplasia.

Bronchiolitis. Swelling in the tiny airways in the lungs (bronchioles). In

children, this is caused primarily by a virus called RSV (Respiratory
Syncytial Virus). When the little airways are swollen, it can be difficult
to exchange oxygen poor air with oxygen rich air. In severe cases,
particularly infants under a year of age or those born prematurely, some
 children need medication to reduce the swelling (see bronchodilators in
medication appendix) and supplemental oxygen.

Bronchitis. Swelling in the larger airways of the lungs (bronchi). In

children, this swelling is usually caused by a virus or bacterial infection.

Broncopulmonary dysplasia (BPD). Term used to describe chronic lung

disease that occurs primarily in babies who are born prematurely who
require prolonged breathing assistance with a mechanical ventilator. The
longer the baby is dependent on mechanical ventilation, the poorer the
prognosis. Babies with BPD may have poor lung function, wheezing,
and higher risk of severe complications with Respiratory Syncytial Virus
(RSV) infection. Lung function, however, usually improves over the
first several years of life.

Cafe au lait spots. As the name implies, these are light brown (coffee with
milk) colored birthmarks. They occur in babies of all races. Most of the
time, there is no significance to these marks. When a child has more
than five of these birthmarks, there may be an association with a
disorder called neurofibromatosis.

Carotinemia. A benign yellow discoloration of the skin due to a large

dietary intake of carotene containing foods (carrots, sweet potatoes).
The whites of the eyes remain white, as opposed to what is seen with
jaundice—see jaundice.

Cataracts. A clouding of the eye’s lens. This can occur at birth (congenital
cataracts). If a newborn has cataracts, it can be detected by the lack of a
‘red reflex’ on an eye examination. A referral to a pediatric
ophthalmologist is made.

Celiac disease. A disorder of the intestines which causes poor digestion and
absorption of foods. The underlying problem is due to an abnormal
response to ‘gluten’ containing foods (e.g. wheat, oat, rye grains). The
classic symptoms of this disorder include foul smelling, chronic diarrhea
 and failure to thrive (lack of weight gain). Treatment is a lifelong
gluten-free diet.

Cephalhematoma. Literally, a head bruise. This often occurs in newborns

as a result of birth trauma. Some of these bruises are quite large and take
one to two months to completely go away. In the process of healing,
these areas can become very hard and firm. Since the bruise is a
collection of blood, it sometimes creates an additional bilirubin load and
can lead to jaundice in some newborns.

Cerebral palsy. An abnormality of the brain center that controls muscle

tone and movement. Cerebral palsy does not cause any abnormalities in
IQ. However, there are children who have both intellectual disability
AND cerebral palsy.

Choanal atresia. Lack of communication between the back of the nasal

passages and the throat. This can occur in one or both sides of the nose.
If both sides are blocked, a newborn will have severe breathing
problems. Newborns only know how to breathe through their noses for
the first four months of life.

Clavicle (collar bone) fracture. When Mom is small and baby is big, it can
be difficult to get the baby out of the birth canal. The baby’s shoulder
pulls out and can break the clavicle (collar bone) in the process. It heals
nicely without a cast. The area can feel crunchy under the skin, then it
feels like a hard lump. The lump is healing bone and goes away after
several weeks.

Cleft lip and palate. The roof of the mouth and/or the upper lip does not
completely form in a fetus. These defects can occur together or
separately in 1 in 1000 births. There is some hereditary predisposition.
Rarely, this defect is associated with other congenital defects.
Frequently, a team of providers manage babies with these defects (Ear,
Nose, and Throat doctors, Plastic Surgeons, Dentist, and Occupational
Therapists). See Appendix F for web sites on this issue.
Club foot. An abnormality in the formation of the foot of the fetus. The
result is a stiff foot that turns markedly inwards. Pediatric orthopedic
surgeons are consulted and a cast is made to correct the position of the
foot.

Coarctation of the Aorta. A narrowing or kink in the great artery (aorta)

that leaves the heart and supplies the body with oxygen rich blood. This
is a defect that occurs during fetal development (prior to birth). If the
abnormality is severe, it is diagnosed in newborns who have
weakened/no pulse in the legs. If the abnormality is small, it may go
undetected until later in life. It is repaired by surgery.

Colostrum. A first “milk” that a mother produces. This product is rich in

antibodies and cells. It has fewer calories than mature milk which
arrives on about the fourth day after birth.

Conductive hearing loss. Difficulty hearing due to a problem with the

transmission of sound waves to the part of the ear that controls hearing.
Sound waves can be blocked due to fluid sitting behind the eardrum (see
serous obits media) or a significant amount of earwax sitting in the ear
canal. The good news about conductive hearing loss is that the problem
can usually be fixed and normal hearing is restored.

Congenital. This refers to an abnormality in the formation of a certain

organ/body part that occurs in the development of an unborn fetus.
These abnormalities may be due to either hereditary problems or
environmental exposures during pregnancy. The lay term for these
disorders is birth defect.

Congenital Adrenal Hyperplasia. An abnormality in the gland that

produces steroids in the body (adrenal gland). This can cause severe
metabolism problems of body salts. This abnormality is routinely tested
in the newborn metabolic screen.
Congenital heart disease. A defect in the structural development of the
heart or the great vessels that attach to the heart. Because heart
development occurs in the first trimester of pregnancy, many congenital
defects can be identified on a prenatal ultrasound. Some abnormalities
will resolve on their own. Some require surgical repair. The disease
incidence is 1:1000. The most common defects are the least serious
ones. Remember, there is a difference between an innocent heart
murmur (no defect) and a pathologic murmur (caused by congenital
heart disease).

Congenital nevus. (Known as moles, birthmarks) A mark on the skin

which is present at birth, or appears within the first year of life. The
most concerning moles are ones larger than 10 to 20 cm (really big) that
are present at birth. These have more potential risk of skin cancer and
removal is usually advised.

Congestive heart failure. When the heart is unable to perform adequately,

the blood flow accumulates in the lungs and liver. So, symptoms of
heart failure include shortness of breath and enlarged liver size. In
children, symptoms include failure to thrive, sweating with feedings,
shortness of breath, and excessive fatigue.

Conjunctivitis. An inflammation of the lining of the eyelid. Otherwise

known as “pink eye.” The inflammation can be caused by a virus,
bacteria, allergies, or irritation. All types of conjunctivitis cause redness
and some discomfort. Here are the major types of conjunctivitis:
Allergic. An allergic response usually due to a sensitivity to something
in the air (e.g. pollens). Usually causes watery, somewhat itchy eyes.
Antihistamines treat the symptoms.
Bacterial. A bacterial infection in the eye (often accompanied by ear
and sinus infection). Causes thick yellowish eye discharge and may
even cause the eyes to be caked over or “matted.” Antibiotic eye drops
treat the infection.
Viral. A viral infection in the eye (that may be accompanied by a sore
throat). Causes watery and very itchy eyes.
 Irritation. Eyes become inflamed because of a chemical irritant (e.g.
shampoo).

Constipation. The texture of poop is significantly hard, and is passed either

in small pieces or in a very large mass of small pieces stuck together.
Contrary to popular belief, constipation is NOT defined by the
infrequency of poop (although this can contribute to the problem). There
is no defined length of interval for which a person needs to poop—it can
vary considerably. If the poop is soft when it comes out, your baby is
unlikely to be constipated.

Craniosynostosis. A baby’s skull bones have gaps that allow for the brain’s
growth in the first one to two years of life. This abnormality is a
premature closure of the gaps (sutures) that occurs in about 1 in 1800
children. The reason why this occurs is unknown, but is not due to any
birth trauma or complication. Early closure can cause deformities in the
skull and facial shape, inhibition of brain growth, and increased pressure
within the skull.

Cystic Fibrosis (CF). This is a genetic disease that causes body glands to
produce abnormal secretions. Lung, sinus, pancreas, intestine, and
reproductive organ problems occur because of it. One in 20 Caucasians
are carriers of this genetic abnormality. The disease incidence is 1:1600
for Caucasian babies (it is much less common in other races). Many
women now receive genetic testing during pregnancy for CF, although it
is not a routine screening test.

Developmental Dysplasia of the Hip (DDH). See hip dysplasia.

Diarrhea. Frequent passage of watery or very soft poop. In a breastfed

baby, diarrhea is defined more by the dramatic increase in frequency of
poop than by the texture.

Duodenal atresia. Congenital abnormality of the first part of the small

intestine to form. It’s often associated with other abnormalities. Babies
 are diagnosed with this disorder before birth by an abnormal ultrasound
(extra amniotic fluid found) or shortly after birth when they start
vomiting bile. This requires surgical repair.

Eczema. A skin disorder that causes redness and scaling. The underlying
problem seems to be allergic in nature, and children with eczema have
flare-ups with exposure to perfumed products and certain chemicals.
Eczema can be associated with other allergic disorders such as asthma,
seasonal allergies, and food allergies but it can also occur without any
other problems.

Egocentric. The inability to see things from someone else’s point of view.
This is a child’s view of the world from age two to about seven years.

Emesis. The technical term for vomit.

Enamel hypoplasia. A thinning of the enamel of the teeth found in babies

who are born prematurely. And, there appears to be less “catch up’
growth of that enamel in babies born prematurely compared to their full
term peers. This may result in increased risk of cavities.

Encephalitis. Brain inflammation usually caused by a virus or a bacterial

infection.

Engorgement. The Milkman Cometh. Period of excessive breast milk

production around three to five days after childbirth. Women’s breasts
feel full and often uncomfortable until milk demand and milk supply
equilibrate.

Epispadias. Congenital abnormality of the formation of a boy’s urethra

(tube connecting the bladder to the outside). The hole is located on the
top side of the penis, instead of in the center. This requires surgical
repair.
Epstein’s pearls. Tiny cysts (white bumps) found on the roof of the mouth
in newborns. These are common, non-problematic, and go away on their
own.

Erb’s palsy. An injury to the nerves that supply the arm. This occurs as a
result of a difficult delivery requiring the baby’s head to be pulled
forcefully. On examination, the arm will hang limp. The nerve injury
usually heals in a year, but may require surgery or physical therapy.

Eruption Hematoma. This is just a bruise under the gum line that can
occur as the tooth is breaking through the gums. It can look pretty darn
impressive—swollen and blue or purple. No worries. It means a tooth
will be arriving soon.

Erythema toxicum. A normal newborn rash that looks like flea bites
(white pimple with red around it). These tiny bumps come and go.

Esophagitis. The inflammation of the upper part of the gastrointestinal

system (esophagus).

Expressive language delays. A child whose ability to speak words is

behind his peers. A child with this delay may have completely normal
ability to understand and process language that he hears (see receptive
language).

Failure to thrive. When a baby or child falls below the 3rd percentile on
the weight curve. When the problem is a chronic one, height and head
size also drop on the growth curves. Failure to thrive prompts a
thorough medical evaluation.

Fat necrosis. An occasional complication from vaccination injection. As a

needle goes through the fat under the skin, it can injure it and create a
firm lump. This lump may be present for several weeks after the
injection is given. It is painless and not harmful.
Flaring (nostrils). When an infant or young child is having trouble
breathing (respiratory distress), he will use any additional methods his
body can to get in more air. Nostrils will flare with each breath to try to
capture more air. Thus, this is a red flag for respiratory distress.

Flat angiomata. Official term for an “angel kiss” birthmark on the forehead
or eyelids. These are flat, reddish colored marks that eventually fade.
The color becomes more dramatic with crying or anger.

Fomites. Objects handled by a person with an infection that subsequently

allows passage of the germs to someone else.

Fontanelle. A space between the bones of the skull that allows room for the
baby’s head to pass through the birth canal and room for the baby’s
brain to grow after birth. The main fontanelle is on top of the head
(anterior) and is sometimes called the baby’s “soft spot.” There is a
smaller fontanelle in the back of the head (posterior). The anterior
fontanelle closes between nine to 18 months of age.

Food poisoning (see gastroenteritis)

Foreign body/object. Term used to describe an object which has no place

being where it is in someone’s body. Kids have a way of putting objects
like small toys in their noses, ears, etc. as well as swallowing them.

Foremilk. A breastfeeding term used to describe the milk that is released in

the first several minutes of nursing. It is less fatty than what comes out
later (see hindmilk). If your breastfed baby is a snacker, he may not be
getting the richer milk. For these babies, its better to nurse on one breast
per feeding.

Frenulum. The tissue that connects the tongue to the base of the mouth.
(see ankyloglossia).
Frenulectomy. The process of clipping the tissue at the tongue base to
correct a ‘tongue tie’ or ankyloglossia. This procedure can be performed
in an office setting if the baby is less than a few weeks old.

Galactosemia. A rare metabolic disorder that makes a baby unable to

digest galactose, a milk sugar. Newborns are routinely tested for this
disorder in the state metabolic screen. If present, a baby needs a special
formula diet. Breastmilk contains galactose, so it is not possible to
breastfeed. Babies who have galactosemia and continue a normal diet
can have intellectual disabilities.

Gastroenteritis. An inflammation of the stomach and intestines caused by

either a virus or bacteria. The inflammation can cause both vomiting and
diarrhea. Viral gastroenteritis is commonly known as the “stomach flu”
and tends to cause watery diarrhea. Bacterial gastroenteritis is
commonly known as “food poisoning” and tends to cause diarrhea
mixed with blood or mucous.

Gastroesophageal reflux (GER, acid reflux). The backflow of food and

liquids from the stomach into the esophagus (and often all the way to the
mouth). This is a common problem for newborns up to age one year.
The muscle that separates the esophagus and the stomach (lower
esophageal sphincter) is relatively loose in infants, allowing food to
travel down to the stomach (good) and back up to the esophagus (not
good). Once food contents make it to the stomach, they are mixed with
stomach acid. So, when this partially digested food goes backwards, the
stomach acid can irritate the esophagus, cause discomfort, and
sometimes wheezing or coughing (GERD—Gastroesophageal Reflux
Disease). Most babies outgrow this problem by age one.

Gingivostomatitis. Inflammation and irritation of the gums and lining of

the mouth caused by the Oral Herpes virus. The amount of inflammation
is usually extensive and may lead to refusal to eat or drink anything.

Glaucoma. Increased pressure behind the eye. Babies with hemangiomas

near the eye need to be evaluated by an ophthalmologist because they
 are at risk for glaucoma.

Heart murmur. A noise heard in addition to the normal heart sounds

audible with a stethoscope. The murmur can be due to normal heart
function (termed innocent, benign, or transitional). Or, it can be due to a
structural defect of the heart or great blood vessels coming off of the
heart (termed pathologic). The type of noise, location of the noise, and
other abnormalities found on physical examination help determine the
cause of the murmur. All murmurs do not require an echocardiogram
and a cardiologist evaluation to determine the cause.

Hemangioma. See Strawberry Hemangioma.

Hemolytic Uremic Syndrome. (Also known as HUS). A group of medical

problems caused by some food poisoning (E coli, Shigella) infections.
The problems include severe anemia, low platelet count, and kidney
failure. HUS typically occurs in children ages four months to four years
of age.

Hemophilia. A genetically inherited blood clotting disorder. People with

this disorder lack a chemical clotting “factor” that impairs the body’s
chain reaction to clot blood when bleeding occurs. In general, this is a
disease of males and women are only carriers (i.e. not affected) because
the gene for the disorder is on the “X” chromosome.

Henoch-Schonlein Purpura. (Also known as HSP) Inflammation of the

blood vessels (vasculitis) after a viral illness. Symptoms include a
dramatic rash of raised bruised areas on the legs. Joint pain, abdominal
pain, and blood in the urine also occur. Although the disease sounds and
looks serious, 90% of children recover completely without any
treatment. Occurs mostly in children aged four to 10 years.

Hernia. The term used to describe a bulging out of tissue or organ where it
is not supposed to be. It occurs due to a weakness of a muscle wall. The
most common types include:
 Diaphragmatic hernia—abdominal organs protrude into chest
Femoral hernia—intestines protrude into thigh
Inguinal hernia—intestines protrude into groin
Umbilical hernia—intestines protrude into belly button
The risk of all hernias is that the organ that is bulging out will get stuck
in that position and cut off the blood supply to it. Umbilical hernias
rarely get stuck (incarcerate), thus rarely require any treatment.

Hemorrhagic disease of the newborn. A relatively common (one in 200)

problem of newborns who have a Vitamin K deficiency. Infants with
this disorder can have severe bleeding. Because of this risk, all
newborns receive a shot of Vitamin K shortly after they are born.

Hindmilk. Another breastfeeding term. This refers to the fattier milk that
comes out after several minutes of nursing. This milk can actually look
yellow (like fat). Don’t be alarmed—it’s good stuff.

Hip dysplasia. Also known as congenital hip dyplasia, or developmental

dysplasia of the hip. This is a congenital abnormality where the leg bone
is out of its socket at the hip. It is easily treated with a brace if detected
in the first few months of life. Babies who are breech have a slightly
higher risk of having this disorder.

Hirschprung’s disease. A congenital abnormality where the nerves of the

rectum (intestinal exit) don’t form. As a result, newborns cannot poop
(stool) without assistance. Infants with severe constipation may have a
partial defect and are also tested for this disorder. Treatment is surgical.

Histamine. A chemical compound the body produces in an allergic

response. Histamine causes the characteristic “allergy symptoms” that
people experience such as hives, itchy eyes, and congestion.

Human Papilloma Virus (HPV). A virus that is transmitted through sexual

contact. HPV can live in the undersurface of the foreskin of an
 uncircumcised man. HPV is also a known factor in the development of
cervical cancer in women.

Hydrocele. A fluid collection in a boy’s scrotum. Rarely, it is associated

with a hernia. Most of the time, the fluid is present at birth and goes
away on its own by six months of life. It makes the boy’s scrotum look
unusually large.

Hydrocephalus. An abnormally large collection of cerebrospinal fluid

(CSF), the fluid that bathes the brain and spinal cord. This can be caused
by excessive production, blockage of the collection pathway, or
decreased absorption in the body. Symptoms include: bulging fontanelle
(soft spot), headache, vomiting, enlarged head size, loss of
developmental milestones, and abnormal neurologic exam.

Hypospadias. A congenital abnormality where the urethra (tube that

connects the bladder to the outside) opening is on the underside of the
penis instead of in the middle. This requires surgical repair, usually after
six months of age. Because the foreskin is used to perform the repair,
these babies are not circumcised.

Hypothyroidism. A poorly functioning thyroid gland produces a

suboptimal level of thyroid hormone. Thyroid hormone is an essential
chemical needed for body metabolism. Babies with congenital
hypothyroidism can become mentally retarded (cretins) if they are not
treated. This is one of the screening tests performed in the state
metabolic screen. The incidence of congenital hypothyroidism is one in
4000 newborns.

Idiopathic Thrombocytopenic Purpura (ITP). The destruction of

platelets due to an autoimmune response in the body. Can occur after a
viral illness. Because platelets are needed to clot blood, a low count
causes bruising and petechiae. Some children need medication to help
the body increase platelet production in the body, others bounce back on
their own. The good news is that almost 90% of kids do beautifully and
have no further problems after the one episode.
Imperforate Anus. A congenital abnormality where the anus (opening of
the intestines to the outside) does not form completely. This abnormality
is often associated with a combination of abnormalities called VATER
syndrome. It is repaired surgically.

Inflammatory Bowel Disease (IBD). Chronic swelling of the intestinal

lining that results in bloody diarrhea. Crohn’s Disease and Ulcerative
Colitis are types of IBD. It is rare for a child under age two years to be
diagnosed with this disorder.

Inguinal hernia. (see hernia)

Inhaled steroid. Medication used to control chronic asthma symptoms. The

medication is administered via a machine that aerosolizes it (nebulizer)
or via a handheld “inhaler.” The inhaled method is preferable because
most of the medication goes to the location it is intended to help (i.e. the
lungs). Very little of the medicine gets absorbed into the bloodstream—
this means there is less of the unwanted side effects and more
therapeutic benefit.

Intestinal obstruction. This is a general term to describe the blockage of

the intestine. The gastrointestinal tract is like a big pipe, and in these
terms, obstruction is a clogged pipe. This can occur due to
intussusception, volvulus, malrotation (congenital defect), and hernias.
Because the area is blocked, blood flow to the intestines decreases and
may cause death of that tissue. This is a surgical emergency or an “acute
abdomen.” Symptoms include distended belly, vomiting bile.

Intraventricular hemorrhage (IVH). Bleeding within the brain area called

the ventricles due to a weak, fragile matrix of blood vessels and blood
pressure changes in premature babies. Premature babies born before 32
weeks gestation or less than three pounds are at risk for IVH, which
most often occurs in the first five days of life. Some bleeds may be
minor and have no significant long term consequences. Severe bleeds
can be potentially fatal or have significant neurologic effects.
Intussusception. When a piece of intestine telescopes upon itself creating
an intestinal obstruction. The most common time this occurs is between
six and 18 months of age. Symptoms include intermittent abdominal
pain with pulling up of the legs. Vomiting, and poop that looks like
“currant jelly” also occur. This is an emergency. Diagnosis (and
treatment) can be done with a special radiological study.

Jaundice. Yellowing of the skin and the whites of the eyes due to a
collection of body garbage called bilirubin. The newborn period is a
unique time in life that causes a “normal” jaundice. Outside of the
newborn period, jaundice is NOT normal. It requires a thorough medical
evaluation to look for the cause.

Kawasaki Disease. An illness that causes the body’s blood vessels to swell
(vasculitis). The cause is unknown. Occurs mostly in children under two
years of age. Symptoms include: fever for five or more days straight,
rash on the palms and soles, peeling skin on the fingertips, pink eye,
bright red lips/tongue, swollen lymph nodes in the neck, general body
rash, and irritable mood. The most severe complication is swelling of
the arteries that supply the heart (coronary artery aneurysm). This
disease is one of the reasons that doctors want to see a child who has
had a fever for five consecutive days or more.

Kernicterus. A serious consequence of jaundice. Bilirubin collects in the

brain, causing permanent damage.

Labial adhesion. A condition where the labia minora (smaller lips) of the
vaginal opening get stuck together. This happens in little girls because
they do not make estrogen hormone yet (pre-puberty). The amount of
tissue that is stuck can vary. The problem is that the urethra (opening for
the bladder) is located beneath the labia. If the lips are almost
completely fused shut, estrogen cream (RX) is applied so that the urine
can flow out more easily. Once the labia are unstuck, it is prudent to put
Vaseline on the area at diaper changes to prevent them from re-sticking.
All girls outgrow this condition once they hit puberty.
Laryngomalacia. A floppy airway. Some babies are born with relaxed
throat tissue. When they breathe in, they make a high pitched squeaky
noise (stridor). Babies outgrow this condition, often by age one. These
babies get evaluated by an ear, nose, and throat specialist just to confirm
the diagnosis. It does not affect their breathing and no treatment is
needed.

Leukemia. Abnormal production of body’s blood cells which then leads to

failure of the bone marrow to produce normal blood cells necessary for
body functioning. Symptoms include: fever, fatigue, paleness of the
skin, excessive bruising, petechiae, and joint pain.

Macrocephaly. Official term to describe a big head. Most of the time, a

child’s big head is due to his genes (i.e. someone else in the family has a
big head). But, if the head size percentile is enlarging or if there are
other concerning symptoms, a doctor may evaluate the head with an
imaging study to rule out hydrocephalus or a brain tumor.

Malabsorption. When the intestine is not performing its job of digesting

food. The result is a watery, foul smelling diarrhea. Some causes of
chronic malabsorption are celiac disease and cystic fibrosis. This
deserves to be checked out.

Malrotation. A congenital abnormality in the development of the

intestines. The abnormal position creates a problem with blood flow to
the intestines as well as potential for obstruction of food transit.
Newborns with this problem have vomiting, constipation, and
abdominal pain. Treatment is surgical.

Masturbation. A normal behavior of exploring one’s sexual organs. Both

boys and girls do it.

Meconium. The first poop a newborn passes. Black, tarry, sticky. Some
babies will pass this first poop before birth during a stressful labor. If the
meconium is seen prior to birth, a baby will have his nose, mouth, and
 throat suctioned at delivery to prevent passage of this stuff into the lungs
(called meconium aspiration syndrome).

Meconium ileus. A failure of the newborn’s poop (meconium) to pass

because of abnormally thick intestinal secretions. This condition is
associated with cystic fibrosis.

Meconium plug. A delay in passing of the newborn’s first poop

(meconium). This usually responds to rectal stimulation (e.g. taking a
rectal temperature).

Meningitis. Inflammation of the tissues that line the brain and the spinal
cord. This can be caused by a virus, bacteria, or by tuberculosis.
Symptoms include: headache, vomiting, TRUE IRRITABILITY (i.e.
inconsolable), bulging fontanelle (soft spot), fever, neck stiffness,
seizures, petechiae. This is a medical emergency.

Metabolic disorder. A broad term that describes disorders in breaking

down foods (see metabolic storage disease below). These disorders are
different than endocrine disorders, which involve abnormal levels of
body hormones (e.g. thyroid disease, diabetes, adrenal disease).

Metabolic Storage Disease (Inborn Errors of Metabolism). A group of

diseases that all cause an inability to break down certain food products.
As a result, byproducts of metabolism accumulate. In some of these
disorders this accumulation goes to body parts (liver, heart, brain,
kidney, eye) causing permanent damage or even death. The more
common storage diseases are tested for on the state metabolic screens
(PKU, galactosemia).

Microcephaly. The technical term for a small head. Head size is often
hereditary. Families with small heads have small headed babies.
However, if a child’s head size percentile is plateauing or decreasing, an
imaging study may be done to look for craniosynostosis.
Milk protein allergy. Milk contains protein, sugar, and fat. Some babies
(about 2%) have an allergy to the protein component that causes
inflammation and irritation of the intestine lining. This leads to diarrhea
that can be mixed with blood or mucous. A significant percentage of
babies who are allergic to milk protein are also allergic to soy protein.
The good news—most kids outgrow this problem.

Milia. A normal newborn rash on the nose that look like pinpoint white
dots. These go away on their own.

Miliaria. A normal newborn rash that looks like prickly heat. This goes
away on its own.

Mongolian Spots. A bruise like discoloration found on the buttocks of

darker pigmented newborns. These spots fade over several years. No
treatment is needed.

Murmur. (see heart murmur)

Nasolacrimal Duct Obstruction (blocked tear duct). Babies have narrow

tear ducts that lead out to the corner of the eyes. Occasionally, the tube
gets clogged. Tears, which are usually watery, get thick from being
backed up. The result—goopy fluid that comes out of the eyes. This can
happen intermittently for the first year of life. You can help open up the
duct by massaging gently just below the corner of the eye near the nose.
I usually refer patients to an eye doctor if this is happening beyond a
year of age. The difference between blocked tear ducts and pink eye
(infection) is that the eye is not red or irritated.

Natal Teeth. Every once in a blue moon, a baby is born with a tooth. These
usually fall out spontaneously and the real baby teeth come in at the
normal time, between 6-12 months.

Nevus Flammeus (Stork bite, angel kiss). These are newborn birthmarks
located at the nape of the neck, eyelids, and forehead. They are bright
 pink in color. The marks on the face fade over the first year of life. The
marks on the neck can last forever. These marks are not associated with
cancer.

Neural tube defects. A congenital abnormality of the brain/spinal cord

development. Many of these disorders can be detected prenatally via an
abnormal AFP test or an ultrasound. These disorders vary in severity.
The most severe form is lack of brain formation (anencephaly). The
least severe form is spina bifida occulta (see sacral dimple), where
there is completely normal nerve function.

Neurofibromatosis (NF). A genetic disorder (gene defect) that causes

tumors of the tissue covering nerves. Babies are often born without
symptoms, although some will have three or more cafe au lait spots at
birth. As a child grows, he develops numerous (more than five) cafe au
lait spots and freckles in the armpit and groin areas. The tumors on the
nerves grow later and can be seen as large bumps under the skin. Most
of these tumors are benign (not cancerous), but can occur in dangerous
places (e.g. eye, ear, brain, kidney). Children with this disorder are seen
regularly by a number of doctors. FYI: The diagnosis of NF is not made
on the presence of cafe au lait spots alone—this is only one of several
symptoms and signs. Most children with a few cafe au lait spots do not
have NF.

Newborn acne. (see acne)

Newborn nasal congestion. All newborns have snotty noses. They will
sneeze, snort, cough, and snore. This lasts for four to six weeks. If it
does not interfere with feedings or sleep, do nothing. If it is causing a
problem, use saline nose drops to flush the nose before feedings or
bedtime.
Nursing caries. These are cavities—the result of feeding a baby during the
night after his come in. If you don’t wipe teeth off after a midnight
snack of breast milk/formula/milk (which all contain sugar), the sugar
will sit on the teeth and make a nice place for plaque and subsequent
cavities.
Omphalitis. A belly button infection. The umbilical stump and skin
surrounding it looks red and swollen. There is a foul odor coming from
it. If this occurs in a newborn, it usually requires admission to a hospital
for intravenous (IV) antibiotics.

Orbital cellulitis. A serious infection that involves the tissue surrounding

the eye. It is caused by a sinus infection that spreads into the area.
Symptoms include: limited eye motion, bulging of the eyeball, eyelid
swelling, eye pain, and fever. This is the reason that doctors want to see
children who have eyelid swelling and a fever.

Orthotic. A custom made shoe insert designed by a podiatrist to provide

arch support for people who are flat-footed. The AAP does not currently
recommend orthotics for babies and young children.

Otitis media. Literally, middle ear inflammation. Acute otitis media refers
to an active infection that came up shortly before it is diagnosed in the
office. Serous otitis media (or otitis media with effusion) refers to
residual fluid that remains after the active infection is over.

Otitis externa. (Otherwise known as swimmer’s ear) Literally, external ear

inflammation. This is really an infection of the skin that lines the ear
canal. It is caused by water that pools in the ear canal and allows germs
to grow. Symptoms include pain with touching the ear itself, swelling
and redness of the canal, and sometimes a fever. This is uncommon in
the under one age group.

Paraphimosis. The foreskin gets stuck behind the head of the penis in an
uncircumcised boy. This causes lots of swelling and pain.

Pathologic Heart Murmur. (see Heart Murmur)

Penile adhesions. The head of the penis sticks to the shaft skin. In boys
who are circumcised, it is important to visualize the edge of the head at
diaper changes and clean the area of any debris (smegma). If the skin
 starts to get stuck together, try gently pulling down at the base of the
penis to separate the area.

Perforated eardrum. Occurs with severe middle ear infection. A small

hole in the eardrum lets the pus drain. It is the equivalent of a pimple
popping and draining. Pus and blood will be seen draining out of the ear
canal.

Periodic breathing. Newborns do not breathe in a regular pattern. They

breathe 30 to 60 times a minute, but very erratically. There may be a
stretch of several pants in a row, then a long p-a-u-s-e, then a big breath.
That is normal, as long as that pause is less than ten seconds.

Pervasive Developmental Delay (PDD). A disorder of development that

falls into the category of Autism Spectrum Disorders. Children with
PDD are higher functioning and capable of limited social interactions.
They may also have more language skills than those who are severely
affected.

Phenylketonuria (PKU). A metabolic disorder routinely tested on the state

metabolic screen. It is a genetic defect in an enzyme that breaks down
phenylalanine. The incidence is one in 10,000. People with this disorder
need to have a special diet. See metabolic storage disease.

Phimosis. Inability to pull the foreskin of an uncircumcised boy’s penis

back. In severe cases, circumcision is necessary to fix the problem.

Phototherapy. The term used for treatment of moderate-severe jaundice

(hyperbilirubinemia). A jaundiced baby is placed in a blue light source
(either via “bili” blanket or bank of lights). The lights help to breakdown
the bilirubin. For babies who are mildly jaundiced, we do NOT
recommend placing an undressed baby near a sunny window in the
house. It doesn’t help and makes the baby uncomfortable.
Pneumonia. Lung inflammation caused primarily by infection. Both
viruses and bacteria can cause pneumonia. The tiny air sacs (alveoli) fill
up with pus and prevent air exchange. Symptoms include fever, cough,
chest pain, and respiratory distress.

Polydactyly. When there are more than five fingers or toes on a hand or a
foot. The extra digit can be removed.

Port wine stain. This is a large, red/purple, flat birthmark that occurs on
one side of the face or limb. These do not fade over time and are mostly
a cosmetic issue. If the birthmark covers the eyelid, a child is evaluated
for glaucoma. Any time it occurs on the forehead or eye, a child is also
evaluated for a brain abnormality (Sturge-Weber syndrome).

Posterior urethral valves. A congenital defect of the formation of the

urethra (tube that connects the bladder to the outside). There are valves
that normally push the urine (pee) outwards. In this condition, the valves
push the urine backwards into the urinary tract. This is rare, and only
occurs in boys.

Post-tussive emesis. The Latin words for “after-cough” vomiting. Babies

and young children have overactive gag reflexes. So a forceful cough
might bring up lunch. All vomiting in children is not due to an upset
stomach.

Preauricular pits and tags. Minor congenital defects of the formation of

the external ear. The pits are due to remnants of a cyst that occurred
prior to birth. Pits are rarely associated with hearing disorders. The tags
are extra pieces of skin. If severe, these can be removed for cosmetic
reasons.

Pseudostrabismus. The false appearance that a child looks cross-eyed or

has a lazy eye due to the child’s facial structure. Babies and young
children are often referred to a pediatric ophthalmologist for concerns of
a lazy eye (esotropia, amblyopia) and are ultimately diagnosed with
 this benign entity. But, it is better to be on the safe side and check out
any concerns.

Pustular melanosis. A normal newborn rash found in darker pigmented

babies. The original rash looks like little pimples. As the lesions fade,
they leave a temporary brown freckle. Some babies have hundreds of
these freckles. They go away on their own.

Pyelonephritis. An infection of the kidneys. In an acute infection, a child

has fever, back pain, and pain with urination. Infants under six months
of age with a bladder infection routinely get admitted to the hospital
because there is a greater risk of the infection extending into the
kidneys.

Pyloric stenosis. A narrowing of the outlet from the stomach to the small
intestine due to a congenital abnormality in the muscle (pylorus). Babies
(more commonly males) will have projectile (REALLY IMPRESSIVE)
vomiting at every feeding starting between two and four weeks of life.
The vomiting may start out in a small way, but progressively gets worse
and more projectile. Delay in seeking medical attention results in
dehydration. Treatment is surgical, by making a cut in the muscle.

Refractive errors. This fancy term means that one cannot focus an image
perfectly in the eye (retina). It includes near-sightedness, far-
sightedness, astigmatism, and amblyopia.

Respiratory Distress. This is the term used to describe a child who is air-
hungry. If a child cannot successfully get enough oxygen in with each
breath, he will breathe faster, heavier, and use chest wall muscles to get
as much air in as possible. This equates to a child who is panting,
grunting, flaring his nostrils, and retracting (sucking in of the ribcage).

Respiratory Syncytial Virus (RSV). This is a virus that causes different

symptoms depending on the age, and health status of the person.
Healthy adults may have an RSV infection and feel like they have a
 cold. A premature baby may have complete respiratory collapse and
need hospitalization. A healthy six month old may have a ton of nasal
secretions, wheeze, and breathe at twice his normal respiratory rate but
not have any distress. RSV shows up every year between November and
April in the northern hemisphere.

Retinoblastoma. A malignant tumor of the eye that occurs in babies.

Fortunately, this is quite rare. This is one of the important reasons we do
an eye exam in the nursery.

Retinopathy of Prematurity (ROP). Incomplete growth of blood vessels

in the eyes due to premature birth. Babies born at less than 32 weeks
gestation are at the greatest risk of ROP. The growth of the blood vessels
need to be monitored regularly by a pediatric ophthalmologist to head
off any abnormalities, such as retinal folding/detachment, or permanent
vision defects.

Retractions. The term used to describe the sucking in of the ribcage when a
child has respiratory distress. Retractions occur when the body starts
using the chest wall muscles to pull more air in with each breath. With
phone encounters, we will ask you to look at how your child is breathing
to tell us if he has retractions.

Rickets. Malformation of growing bones in children most commonly due to

Vitamin D deficiency. Vitamin D is necessary for calcium to be
deposited into the bone (which makes them hard). Bones will form with
a bent shape because they are softer than they should be.

Ringworm. (see fungal infections in Chapter 13, “Infections”)

Rooting reflex. This is a newborn ‘primitive’ reflex that causes a baby to

turn his head if you stroke his cheek. It is an instinctive mechanism that
encourages eating. Babies lose this primitive reflex by three to six
months of age.
Sacral dimple. This is a tiny divot, or dimple in the lower portion of the
back. These can be associated with a minor abnormality of neural tube
development called spina bifida occulta. The L5-S1 vertebrae bone is
slightly abnormal but the spinal cord (nerve) is formed normally. Most
babies with sacral dimples are unaffected and do not need evaluation or
treatment.

Seborrhea. (Also known as dandruff, cradle cap) A skin problem that

causes greasy, flaky, and sometimes red skin in areas where ‘sebaceous
glands’ reside—typically the scalp, ears, beside the nose, eyebrows.
Many babies are afflicted with this and outgrow it. Teenagers can also
get seborrhea and have it for a lifetime. Treatment includes anti-dandruff
shampoos, low potency steroid creams/lotions, and vegetable oil to
loosen up the flakes in the scalp.

Sensory Processing Disorder. A constellation of behaviors stemming from

an inability to process and adapt to stimuli of the five senses. Children
with this disorder have trouble with activities of daily living and social
encounters (aversion to textured foods, dislike of socks and tags on
clothing, avoidance of messy activities, avoidance of being touched . . .)
Diagnosis occurs most frequently in pre-school or school aged children.

Serous otitis media. Fluid in the middle ear space. This fluid can be
present several weeks to months after an acute infection (i.e. ACUTE
otitis media). This fluid is sterile (free of bugs), but has the potential to
get re-infected. Antibiotics are not usually necessary or helpful to clear
the fluid.

Shoulder dystocia. This refers to a difficult delivery where the shoulders

are forcefully pulled to get the baby out. This happens to a mom with a
small pelvis or a big baby. Occasionally, the collar bone (clavicle)
breaks during delivery. It heals nicely without any residual problems.

Sickle cell anemia. A hereditary abnormality of the red blood cell structure,
causing impaired oxygen carrying capacity and increased destruction of
the red blood cells.
Sinusitis. (see Chapter 13, “Infections”)

Skin tags. These are tiny pieces of raised skin that can occur anywhere on
the body. In the newborn, they are most frequently found in front of the
ear (preauricular tag) or on the vagina. They are not problematic and
require no intervention.

Spina Bifida. A congenital abnormality of the spinal cord development.

There is a spectrum of severity of the defect. Most severe defects cause
paralysis of the legs and body parts supplied by the affected nerves
(bowel, bladder function). The incidence of spina bifida is decreasing as
more women are taking pre-natal vitamins (folic acid) during pregnancy.
See neural tube defects.

Stevens-Johnson Syndrome. A serious allergic reaction that can be fatal.

Strabismus. An abnormal alignment of the eyes.

Strawberry Hemangioma. A birthmark made of a collection of blood

vessels. The vessels grow and enlarge for the first few years of life. So,
the birthmark gets bigger. The good news—the vessels shrink up and
disappear, usually by age five years. Surgery is usually not done to
remove these. However, laser therapy may be helpful for lesions on the
eyes, nose, or lips. Cool trend: using topical medication to shrink the
blood vessels.

Stridor. A squeaky, high pitched noise with breathing in that can be heard
without a stethoscope. In newborns, it is usually caused by
laryngomalacia. In any other situation, it is a sign of respiratory distress
at the level of the throat. Children with severe croup infection have a
very swollen airway if they have stridor. If your child has stridor, call
your doctor immediately.

Stork Bites. see Nevus Flammeus

Sturge Weber syndrome. A serious disorder that includes brain
abnormalities in combination with a port wine stain on the face. Brain
atrophy, seizures, and paralysis can occur.

Subconjunctival hemorrhage. Broken blood vessel on the surface of the

eye. Most often, this occurs in a newborn after delivery. It’s not serious
(even though it can look worrisome to a new parent). It can take a few
weeks to resolve on its own.
Supranumerary nipple (accessory nipple). These are extra, nonfunctional
nipples found along the same vertical line as the nipples themselves.
They are not problematic. They can be removed for cosmetic reasons.

Supraventricular Tachycardia (SVT). The heart beats at an

extraordinarily faster pace (over 200 beats per minute) because a faulty
electrical circuitry in the heart. The abnormality may be detected if a
baby appears pale, has trouble feeding, or is extremely irritable.

Syndactyly. Two or more fingers or toes are fused either partially or fully
together. The severity of the defect determines whether treatment is
required.

Thrush. (see Chapter 13, Infections)

Tongue-tied (see ankyloglossia)

TORCH infections. This is an acronym for the standard tests that are done
in Mom’s prenatal evaluation. They include: Toxoplasmosis, Syphilis,
Rubella, Cytomegalovirus (CMV), Hepatitis B, HIV, and Herpes. In
certain situations, Varicella (chickenpox) and Parvovirus are also tested.
If Mom has been infected, or is a carrier of the Hepatitis B virus, her
baby receives not only the Hepatitis B vaccine at birth, but also a shot of
medicine to prevent passage of infection.

Torticollis. Literally means, “twisted neck.” When it occurs in newborns,

(about 1 in 100 babies), it is called congenital torticollis. It occurs more
 commonly in babies who are born in breech presentation. It usually
becomes noticeable by two to four weeks of age, when the baby’s head
appears tilted to one side. Occasionally, a knot is felt in the neck where
the neck muscle is tensed and tightened. Rarely, these babies have other
associated issues like hip dysplasia or strabismus. If left untreated,
babies can develop asymmetry of the face and skull. Treatment includes
muscle stretching exercises and encouraging the baby turn his head in
the opposite direction.

Transient Tachypnea of the Newborn (TTN). A common cause of mild

respiratory distress in the newborn. Fetuses swallow amniotic fluid
while in the womb. When a baby is born vaginally, that fluid gets
squeezed out as the baby passes through the birth canal and cries for the
first time. Rarely, some of that fluid remains in babies delivered
vaginally. More commonly, babies delivered by C-section have this
problem. The good news is that the babies all do just fine. They breath
faster than normal and may need a little oxygen for the first hour of life.

Transitional heart murmur. The term for a benign, flow murmur heard in
the first 24 hours of life. As a baby is born, the fetal heart circulation
changes over to the newborn circulation. There are a series of valves
that close off the fetal blood pathways and open pathways to the lungs.
We often hear the turbulence of blood flow as this is happening. It’s
nothing to worry about. If a murmur is heard after 24 hours of life, or
has a different quality or location that it is heard, your doctor will
evaluate it further.

Transmitted upper airway noise. Noise that comes from the nose that is
heard and felt in the lungs. When there is a moderate amount of nasal
congestion (snot) in the nose, the air going through it makes a loud noise
as it passes through. Since babies and young children don’t know how to
blow their noses, this is often a unique occurrence in this age group.

Tuberculosis. (Known as TB. Previously known as “consumption”).

Infectious lung disease that causes nodules in the lungs, but can spread
to the lymph nodes and brain. The scary part of the disease is that people
 can be infected or be “carriers” of the infection without showing
symptoms. People 0with active infection classically have fever, cough,
weight loss, night sweats, and blood in the mucous they cough up.
Although TB is less common than it used to be, it occurs in urban
populations and immigrants from Asia, Africa, and Latin America.
Recommendations for TB screening (PPD) varies among communities,
but most public schools no longer require routine testing for their
students.

Umbilical hernia. See hernia. These are very common in newborns,

particularly African American babies. The size of the hernia can be
quite large, but the intestine almost never (I’ve had one patient) gets
stuck (incarcerated). These are caused by weak abdominal muscles
which will get stronger as the baby starts using them. Most of these
hernias resolve on their own. If the hernia is still present by age two, I’ll
refer a child to a pediatric surgeon for repair. Old Wives Tale: You do
not need to bandage the hernia or place a coin on it to make it go away.
Your baby will fix the problem himself when he starts doing Ab
crunches.

Undescended testes. Failure of the male sex organs to descend into the
scrotum in the newborn male. (In fetal development, they grow in the
pelvic area, then travel down to the scrotum.) Often, the testes will come
down on their own by six months of life. If they don’t, a surgical
procedure is performed to affix the testes in the scrotum. Testes in the
pelvis are at slightly higher risk for testicular cancer, and make it
awfully difficult to perform a monthly self-testicular exam in that
location.

Uric acid crystals. A waste product found in the urine. When the urine is
concentrated (low water volume), the uric acid will pull itself out of the
urine solution and can be found in crystal form in the diaper. It looks
like brick dust and tends to alarm parents who think it is blood. It is an
indication of mild dehydration—so aggressive feeding is the only
treatment.
Urinary tract infections (UTI). An infection in the urinary bladder. It is
difficult to diagnose a bladder infection in babies because they do not
complain that it burns when they urinate. Sometimes fever and
irritability are the only symptoms. It is a good idea to obtain a urine
specimen on babies who have a fever with no obvious source of
infection.

Vaginal discharge. Newborn girls often have vaginal discharge due to

fluctuating hormone levels. Older girls who have vaginal discharge prior
to puberty need to be evaluated for infection.

Ventricular Septal Defect (VSD). The most common type of congenital

heart defect (abnormal formation of the heart in the fetus). In this defect,
a hole is present in either the muscle wall or tissue between the two
large chambers (ventricles) of the heart. A murmur is detected due to the
blood flow that crosses between the chambers. Most of these holes close
on their own with no medical intervention. Children with VSD’s are
followed by pediatric cardiologists until the hole closes.

Vernix. A cheesy, greasy white coating found on the skin of newborns. It

will wash off at your baby’s first bath.

Vesicles. Pinpoint, fluid filled blisters seen classically with chickenpox,

shingles, and herpes infections. In chickenpox, these lesions appear in
crops over a period of a few days.

Vesicoureteral reflux (VUR). An abnormality in the urinary tract system

that causes urine to track backward towards the bladder and kidneys.
This urine is not sterile, thus these children are predisposed to bladder
and kidney infections. VUR is classified by the severity of how
extensively the urine tracks in the wrong direction. Grade 1 is mildest
and Grade 5 is the most severe. Many children outgrow this disorder,
but it can take several years (up to age seven). Children with severe
reflux (Grades 4-5) may need surgical repair to prevent scarring and
permanent kidney damage. About 70% of children with Grade 3 reflux
outgrow it on their own. Virtually all children with milder forms
 (Grades 1-2) outgrow VUR without any intervention. There is a
hereditary predisposition to this disorder.

von Willebrand Disease. A genetically inherited bleeding disorder that

affects both the platelets and the blood clotting chain reaction. People
with this disorder have frequent, excessive nosebleeds, easy bruising,
and heavy periods.

Whooping Cough. (See pertussis in Chapter 12, “Vaccines.”)

Yeast infection. (See thrush, yeast diaper rash in Chapter 13,

“Infections.”)

References for this section are footnoted in Appendix F, “Footnotes.”

 REFERENCES
RECOMMENDED READING, WEB SITES &
MORE
Appendix E

Q. How do I know if a website has reliable medical

information?
Here are a few thoughts:
1. Find out who has created the website. Is there contact information?
2. What is the purpose of the website?
3. Who are the experts giving the advice?
4. What references are cited? Citations should be listed from scientific
journals.
5. Be suspicious of information that is opinionated or seems biased.
6. Be suspicious of products that are touted as cure-alls or miracles.
Source: ImmunizationInfo.org

Reality Check
80% of people who Google for information online do not bother to check
the source of the information they are reading. Know your source. Fact
check before believing everything you read!
Good books to have in the house

Alternative and Complementary Therapies

Kemper, K. The Holistic Pediatrician. New York: HarperCollins, 2002.

Breastfeeding
Hale, T. Medications and Mother’s Milk. 16th Edition. Amarillo: Pharmasoft
Publishing, 2014.
Huggins, K. The Nursing Mother’s Companion. 7th edition: 25th
anniversary edition. Boston: Harvard Common Press, 2015.

Child Development/Behavior
Brazelton, T. Touchpoints. Revised edition. Cambridge MA: DeCapo Press
2006.
Davis, L. Becoming The Parent You Want to Be. A Sourcebook for the First
Five Years. New York: Broadway Books, 2012.

Medical Information
American Academy of Pediatrics. Caring for Your Baby and Young Child.
Birth to Age 5. Elk Grove Village, IL: AAP, 2014.

Nutrition
Jana, L and Shu, J. Food Fights. Elk Grove Village, IL: AAP, 2012.
Swinney, B. Baby Bites. New York: Meadowbrook Press, 2011.

Sleep
Mindell, J. Sleeping Through the Night: How Infants, Toddlers, and Their
Parents Can Get a Good Night’s Sleep. Revised Edition. New York:
Harper Collins, 2010.
Weissbluth, M. Healthy Sleep Habits, Happy Child. New York: Fawcett
Books, 2009.

Vaccinations
Offit P and Moser C. Vaccines and Your Child. Separating Fact from
Fiction. New York: Columbia University Press, 2011.

Reliable web sites

For starters, go to our website at baby411.com for a wealth of useful

information, a visual library of rashes and diseases (see Bonus Material),
parent chat room, and links to reliable websites (several of which are listed
below).

Adoption

University of Minnesota, Adoption Clinic peds.umn.edu/iac

Adoption Alliance i-a-a.org
Association for Research in International adoption-research.org
Adoption
Centers for Disease Control cdc.gov/ncidod/dq/
U.S. Dept. of State travel.state.gov/adopt.html

Allergies

American Academy of Allergy, Asthma, and Immunology aaaai.org

Food Allergy Network foodallergy.org
Allergy and Asthma Network aanma.org
Asthma and Allergy Foundation of America aafa.org

Alternative Therapies/Herbal remedies

National Center for Complementary nccam.nih.gov

and Alt. Medicine
 library.ucsf.edu/collres/reflinks/cam
UCSF Complementary- Alt. Med

Breastfeeding

iBreastfeeding Bookstore ibreastfeeding.com

Breastfeeding.com breastfeeding.com

Cancer

National Cancer Institute cancer.gov/cancer_information/

Johns Hopkins hopkinscancercenter.org

Carseats

Children’s Hospital of Philadelphia chop.edu/carseat

National Highway Traffic Safety Administration Safercar.gov
American Academy of Pediatrics HealthyChildren.org
National Safe Kids Campaign safekids.org

Childcare

National Association for the Education of Young NAEYC.org

Children
Child Care Aware childcareaware.org

Child Development
Centers for Disease Control cdc.gov/actearly
Reach Out and Read reachoutandread.org
Zero to Three zerotothree.org
National Institutes of Health (cerebral palsy) ninds.nih.gov
Learning Disabilities Association of America Idanatl.org
Easter Seals easterseals.org

Cord blood banking

General info parentsguidecordblood.com

National Marrow Donor marrow.org

Diabetes

American Diabetes Association diabetes.org

Juvenile Diabetes Research Foundation International jdrf.org

Emergency Care

Emergency Medical Services for Children emscmn.org

Gastrointestinal problems (stomach/intestine)

North American Society for Pediatric Gastroenterology and naspgn.org

Nutrition

General medical information

American Academy of Pediatrics aap.org
Food and Drug Administration fda.gov
Keep Kids Healthy keepkidshealthy.com
Kids Health kidshealth.org
Mayo Clinic mayoclinic.com
National Institutes of Health ncbi.nlm.nih.gov
Medscape medscape.com
Parents Magazine parents.com
Centers for Disease Control cdc.gov

Heart defects

American Heart americanheart.org

Association
Cincinnati Children’s cincinnatichildrens.org/heartcenter/encyclopedia/
Hospital

HIV in children

U.S. Dept. of Health and Human Services aidsinfo.nih.gov

Lung Problems

American Lung Association lungusa.org

Cystic Fibrosis Foundation cff.org
Stanford University CF Center cfcenter.stanford.edu
American Academy of Allergy, Asthma, and aaaai.org
Immunology
Nervous System/Seizure disorders

American Academy of Neurology aan.com

Epilepsy Foundation epilepsyfoundation.org

Nutrition

Centers for Disease Control cdc.gov

American Dietetic Association eatright.org

Sickle Cell Disease

Sickle Cell Disease Association of America, Inc. sicklecelldisease.org

Skin Disorders

Johns Hopkins Hospital med.jhu.edu/peds/dermatlas

National Eczema Association nationaleczema.org

Supplemental Newborn Screening

Baylor
Baylorhealth.com/medicalspecialties/metablicdisease/newbornscreening.htm
March of Dimes Marchofdimes.com
Mayo mayoclinic.com
National Newborn Screen genes-r-us.uthscsa.edu
Pediatrix pediatrix.com
Save The Babies savebabies.org
National Coalition for PKU pku-allieddisorders.org

Travel Health

Centers for Disease Control cdc.gov/travel/index.htm

Vaccinations

American Academy of Pediatrics HealthyChildren.org

World Health Organization who.int/gpv
Immunization Action Coalition immunize.org
National Network for immunization info immunizationinfo.org
Vaccine Adverse Event Reporting System fda.gov/cber/vaers/vaers.htm
Centers for Disease Control cdc.gov/nip
Children’s Hospital of Philadelphia vaccine.chop.edu

National Organizations

*There is a support group for virtually every medical disease and syndrome.
The organizations below should be able to link you to a specific
organization to meet your particular needs.
American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove
Village, IL 60007. Phone: (847) 434-4000; Web: aap.org
Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta,
GA 30333. Phone: (800) 311-3435; Web: cdc.gov
Easter Seals, 230 West Monroe St., Suite 1800, Chicago, IL 60606 Phone:
(800) 221-6827 x7153; Web: easter-seals.org
March of Dimes Birth Defects Foundation, 1275 Mamroneck Ave., White
Plains, NY 10605 Phone: (888) 663-4637; Web: modimes.org
National Center on Birth Defects and Developmental Disabilities, 4770
Buford Highway, N.E., Atlanta, GA 30341, Phone: (770) 488-7150; Web:
cdc.gov/ncbddd
ZERO to THREE: National Center for Infants, Toddlers, and Families.
2000 M Street NW, Suite 200, Washington, DC 20036, Phone: (202) 638-
0851; Web: zerotothree.org

Growth Chart: Boys (Birth to 24 months)

Growth Chart: Girls (Birth to 24 months)
Head Circumference: boys
Head Circumference: girls
Preemie growth chart
 FOOTNOTES
Appendix F

Chapter 1: Birthday
Abrams SA. Calcium and phosphorus requirements in newborn infants. In
Rose BD (Ed), UptoDate, Waltham, MA, 2007.
American Academy of Pediatrics Policy Statement: Initial medical
evaluation of an adopted child. Pediatrics 1991; 88(3): 642-44.
American Academy of Pediatrics Section on hematology/oncology and
section on allergy/immunology. Cord blood banking for potential future
transplantation. Pediatrics 2007;119:165-170.
American Academy of Pediatrics Clinical Report: Late Preterm Infants: a
population at risk. Pediatrics 2007;1389-1400.
AAP Task Force on Circumcision: Circumcision Policy Statement.
Pediatrics Vol 130 (3) Sept 2012: 585-586.
American Academy of Pediatrics Policy Statement. Newborn and Infant
Hearing Loss: Detection and Intervention. Pediatrics 1999; 103(2): 527-
530.
American Association of Blood Banks. AABB.org. Accessed May 11,
2015.
American Urological Association. Circumcision. auanet.org/about/policy-
statements/circumcision.cfm. Accessed May 11, 2015.
Centers for Disease Control. CDC.gov. Accessed May 11, 2015.
Collins S, etal. Effects of circumcision on male sexual function: debunking
a myth? J Urol 2002 May; 167 (5): 2111-12.
Foundation for the Accreditation of Cellular Therapy. FACTWebsite.org.
Accessed May 11, 2015.
Kim D, etal. The effect of male circumcision on sexuality. BJU Int 2006
Nov 28, PMID 17155977
Martinez F. The “coming of age” of the hygiene hypothesis. Respiratory
Sciences Center, University of Arizona, Respiratory Research, April
2001.
Masood S, etal. Penile sensitivity and sexual satisfaction after circumcision:
are we informing men correctly? Urol Int. 2005:75 (1): 62-6.
Pasquini, et al: The Likelihood of Hematopoietic Stem Cell Transplantation
(HCT) in the United States: Implications for Umbilical Cord Blood
Storage. American Academy of Pediatrics. Pediatrics 1999 July; 104
(1): 116.
Quinn TC. Circumcision and HIV Transmission. Current Op In ID
20(1):33-38 2007
Shaheed K. Monitoring growth of preterm NICU graduates. In Basow D
(Ed), UptoDate, Waltham, MA, 2011.
Sturgeon PE. Care of the neonatal intensive care graduate. In Basow D
(Ed), UptoDate, Waltham, MA, 2011.
Tobian AA, etal. Male circumcision for the prevention of HSV-2 and HPV
infections and syphilis. NEJM. 2009;360(13):1298-309.
Hoffman B, etal. Unsafe from the start: critical misuse of car safety seats
for newborns at initial hospital discharge. Abstract presentation,
American Academy of Pediatrics, October 13, 2014. San Diego, CA.

Chapter 2: You and Your Baby’s Doc

American Academy of Pediatrics. AAP.org. Accessed May 11, 2015.

Chapter 3: Parenthood
Celedon, et al: Day care attendance, respiratory tract illnesses, wheezing,
asthma, and total serum IgE level in early childhood. Archives of
Pediatric and Adolescent Medicine 2002; 156: 241-245.
Huston AC, Aronson, SR: Mothers’ Time With Infant and Time in
Employment as Predictors of Mother-Child Relationships and
Children’s Early Development. Child Development 2005;76 (2):467-
482.
Kamper-Jorgensen M, etal. Population-based study of the impact of
childcare attendance and hospitalizations for acute respiratory
 infections. Pediatrics 2006;118:1439-1446.

Chapter 4: Hygiene
American Academy of Pediatrics. Guidelines for Perinatal Care. 5th Ed. Elk
Grove Village, IL: 2002
American Academy of Pediatrics Policy Statement: Oral Hygiene.
Pediatrics 2003; 111(5): 1113-1116.
Chang WU etal. Six children with allergic contact dermatitis to
methylisothiazoli-none in wet wipes (baby wipes). Pediatrics 2014; 133
(2) e434-438.
Fradin, MS: Comparative efficacy of insect repellant against mosquito
bites. New England Journal of Medicine 2002; 347: 13-18.
Huang JT, etal. Treatment of Staphylococcus aureus colonization in atopic
dermatitis decreases disease severity. Pediatrics. May 2009;123:e808-
e814.
Palazzi DL, etal. Care of the umbilicus and management of umbilical
disorders. In Rose BD (Ed), UptoDate, Waltham, MA, 2007.
Integrated Management of Pregnancy and Childbirth. Pregnancy,
Childbirth, Postpartum and Newborn Care: A guide for essential
practice. World Health Organization. 2nd Ed. 2006.
Wall Street Journal May 20, 2003. PD8.
Zupan J, etal. Topical umbilical cord care at birth. Cochrane Database Syst
Rev 2004;(3):CD001057.

Chapter 5: Nutrition & Growth

American Dental Association. ADA.org, Fluoride and Infant Formula
Frequently Asked Questions, indexed 3/22/07.
American Academy of Pediatrics Clinical Report. Persing J, etal.
prevention and management of positional skull deformities in infants.
Pediatrics 2003;112(1):199-202.
American Academy of Pediatrics Committee on Nutrition: Pediatric
Nutrition Handbook, 7th Ed. Elk Grove Village, IL, 2013.
American Academy of Pediatrics Section on Breastfeeding. Breastfeeding
and the use of human milk. Pediatrics. 2012;129:e827-e841
Baker RD, Greer FR, and AAP Committee on Nutrition. Diagnosis and
prevention of iron deficiency and iron-deficiency anemia in infants and
young children (0-3 years of age) Pediatrics 2010;126:1040-1050.
Behrman, RE. Editor: Nelson Essentials of Pediatrics. Philadelphia: WB
Saunders, 1990.
Bernbaum JC. Primary Care of the Preterm Infant. St. Louis: Mosby, 1993.
Gabbert D, etal. Adenovirus 35 and obesity in children and adolescents.
Pediatrics 2010;126:721-726.
Gartner LM, et al: American Academy of Pediatrics. Prevention of rickets
and Vitamin D deficiency. New guidelines for Vitamin D intake.
Pediatrics 2003;111(4):908-910.
Huh SY, etal. Timing of solid food introduction and risk of obesity in
preschool aged children. Pediatrics 2011;127:e544-e551.
Institute of Medicine, 2010 iom.edu/Reports/2010/Dietary-Reference-
Intakes-for-Calcium-and-Vitamin-D.aspx
Kim J, etal. Growing up to a new standard. WHO growth charts make
breastfeeding the norm. Pediatric Basics, Journal of Pediatric Nutrition
and Devel 2007;116:16-20.
Nield LS, etal. Odd skull shapes: head’s up on diagnosis and therapy.
Consultation for Pediatricians. November 2006:701-709.
Taylor SN, etal. Vitamin D: benefits for bone, and beyond. Contemporary
Pediatrics 2006;23(11):70-82.
Van Wijk RM, etal. Helmet therapy in infants with positional skull
deformation: randomized controlled trial. BMJ 2014;348:g2741.
West D. Lowmilksupply.org. Accessed February 15, 2015.

Chapter 6: Liquids
American Academy of Pediatrics Committee on Nutrition: Soy protein-
based formulas: recommendations for use in infant feeding. Pediatrics
1998;101:148-153.
American Heart Association, etal. Dietary guidelines for children and
adolescents: a guide for practitioners. Pediatrics 2006;117(2):544-59.
Barnes GR, Lethin AN, Jackson EB, et al. Management of breastfeeding.
JAMA.1953;151:192.
Centers for Disease Control. E. sakazakii infections associated with the use
of powdered infant formula- Tennessee 2001. MMWR 2002;51:297-300.
Centers for Disease Control, Breastfeeding Report Card 2014. CDC.gov
accessed May 11. 2015.
Chandran L. Is there a role for long-chain polyunsaturated fatty acids in
infant nutrition? Contemporary Pediatrics 2003;20(2):107-124.
Danner SC. Breastfeeding the neurologically impaired infant. Waco, TX:
NAACOGS Clin Issu Peri Womens Health Nurs. 1992;3(4):640-6.
Georgieff M. Taking a rational approach to the choice of formula.
Contemporary Pediatrics 2001;18(8):112-130.
Huggins K: The Nursing Mother’s Companion. Third Revised Ed. Boston:
The Harvard Common Press, 1995.
Human Milk Banking Association of North America, February 2011
Lawrence, RA: Breastfeeding: A Guide for the Medical Profession, 5th ed.
St. Louis: Mosby, 1999.
Montgomery-Downs HE, etal. Infant feeding methods and maternal sleep
and daytime functioning. Pediatrics 2010 DOI: 10.1542/peds 2010-
1269.
O’Connor NR, etal. Pacifiers and breastfeeding: a systematic review. Arch
Pediatr Adolesc Med 2009;163(4):378-382.
Oddy W, etal. Breastfeeding duration and academic achievement at ten
years. Pediatrics 2011; 127(1):e137-e145
Riordan J, Auerbach KG. Breastfeeding and Human Lactation. Sudbury:
Jones and Bartlett Publishers, 1999.
Sampson, HA. Food Allergy, Part 1. Immunopathogenesis and clinical
disorders. J Allergy Clin Immunol 1999; 103:717-28.
Sicherer S, etal. Maternal consumption of peanut during pregnancy is
associated with peanut sensitization in atopic infants. JACI
2010;126(6):1191-1197.
Suitor CW. Nutrition care during pregnancy and lactation: new guidelines
from the IOM. J Am Diet Assoc 1993;93:478.
Vennemann MM, etal. Does breastfeeding reduce the risk of Sudden Infant
Death Syndrome? Pediatrics 2009;123(3):e406-e410.
Weizman Z, etal. Effect of a probiotic infant formula on infections in child
care centers: comparison of two probiotic agents. Pediatrics
2005;115(1):5-9.
West D. Physician’s Breastfeeding Triage Tool Kit. International Lactation
Consultant Association. Copyright 2006. Adapted with permission.

Chapter 7: Solids
American Academy of Pediatrics Committee on Nutrition: Pediatric
Nutrition Handbook, 6th Ed. Elk Grove Village, IL, 2009.
Du Toit G, etal. Early consumption of peanuts in infancy is associated with
a low prevalence of peanut allergy. JACI 2008;122(5):984-91.
Eigenmann PA, et al: Prevalence of IgE mediated food allergy among
children with atopic dermatitis. Pediatrics 1998;101(3):e8.
Fleisher DM, etal. Primary prevention of allergic disease through nutritional
interventions. JACI 2013; V1(1):29-36.
Greer FR, etal. Effects on early nutritional interventions on the development
of atopic disease in infants and children: the role of maternal dietary
restriction, breastfeeding, timing of introduction of complementary
foods, and hydrolyzed formulas. Pediatrics Jan 2008;121:183-191.
Hill ID. Celiac disease in children. In: UpToDate, Basow DS (Ed).
UpToDate.com. Waltham, MA 2013.
Huh SY, etal. Timing of solid food introduction and risk of obesity in
preschool-aged children. Pediatrics 2011;127:e544-e551.
NIAID. Guidelines for the diagnosis and management of food allergy in the
U.S., December 2010.
Ruffner MA, etal. Food protein induced enterocolitis syndrome: insights
from a large referral population. JACI 2013;1(4):343-49.
Sampson HA. Food allergy. J Allergy Clin Immunol 2003;111(12):540-547.
Sampson HA. Food-induced anaphylaxis. In UpToDate, Basow, DS (Ed),
UpToDate, Waltham, MA, 2011
Snell-Bergeon JK, etal. Early childhood infections and the risk of islet
autoimmunity: the diabetes autoimmunity study in the young (DAISY).
Diabetes Care. 2012 Dec;35(12):2553-8.
Wood, RA. The natural history of food allergy. Pediatrics
2003;111(6):1631-1637.
Chapter 8: The Other End
American Urological Association. Pediatric VUR Clinical Practice
Guidelines Panel. Report on the Management of VUR in Children.1996.
American Urological Association. Management and screening of primary
vesicoureteral reflux in children. 2010.
Edmunds A. Gastroesophageal reflux disease in the pediatric patient.
Therapeutic Spotlight 2005;4-13.
Finnell SME, etal. Diagnosis and management of an initial UTI in febrile
infants and young children. Pediatrics 2011;128(3):e749-770.
Friedman AL. Acute UTI. What you want to know. Contemporary
Pediatrics 2008;25(10):68-75.
McClung HJ, et al: Constipation and dietary fiber intake in children.
Pediatrics 1995;96:999-1001.
Nelson SP, etal. One-year followup of gastroesophageal reflux during
infancy. Pediatrics 1998;102(6):e67.
Orenstein SR. Symptoms and reflux in infants: infant gastroesophageal
reflux questionnaire revised (I-GERQ-R)—utility of symptom tracking
and diagnosis. Curr Gastro Rep 2010 Dec;12(6):431-6.
van der Pol RJ, etal. Efficacy of proton-pump inhibitors in children with
gastroesophageal reflux disease: a systematic review. Pediatrics
2011;127:925–935.

Chapter 9: Sleep
American Academy of Pediatrics, SIDS Task Force, press conference,
October 10, 2005.
Coleman-Phox K etal. Arch Ped Adol Med 2008;162:963.
Duncan JR, etal. Brainstem serotonergic deficiency in SIDS. JAMA
2010;303(5):430-437.
Ferber R. Solve Your Child’s Sleep Problems. New York: Simon & Schuster,
1985.
Kleitman N. Sleep and Wakefulness, 2nd Ed. Chicago: University of
Chicago Press, 1963.
Mindell JA, etal. Behavioral treatment of bedtime problems and night
wakings in infants and young children. Sleep 2006;29(10):1263-1276.
Okami P, et al. Outcome correlates of parent-child bed sharing: an eighteen-
year longitudinal study. Dev and Behav Pediatrics 2002;(23)4:244-253.
Paterson DS, etal. Multiple serotonergic brainstem abnormalities in sudden
infant death syndrome. JAMA 2006;296(17):2124-2132.
Price AMH, etal. Five-year follow-up of harm and benefits of behavioral
infant sleep intervention: randomized trial. Pediatrics. 130(4) 2012:
p643-651.
Rao MR, etal. Long-term cognitive development in children with prolonged
crying. Arch Dis Child 2004;89:989-992.
Rechtman LR, etal. Sofas and infant mortality. Pediatrics 2014
pediatrics.org/cgi/doi/10.1542/peds.2014-1543
Stifter CA, etal. The effect of excessive crying on the development of
emotion regulation. Infancy 2002; 3(2): 133-152.
Thach BT, etal. Deaths and injuries attributed to infant crib bumper pads.
Jnl Peds 2007;(4)28:271-74.
Touchette E. Lecture at annual meeting of the Associated Professional
Sleep Societies, 2003.
Willinger M, etal: Trends in infant bed sharing in the United States, 1993-
2000: The National Infant Sleep Position study. Arch Ped Adol Med
2003;157(1):43-49.

Chapter 10: Development

American Academy of Pediatrics website
aap.org/immunization/families/safety.html American Academy of
Pediatrics, Committee on Public Education. Children, Adolescents, and
television. Pediatrics 2001;107:423-426.
American Academy of Pediatrics. Health supervision for children with
Down syndrome. Pediatrics 2001;107:442.
American Academy of Pediatrics. Council on Communications and Media.
Policy Statement: Media use and children younger than two years.
Pediatrics. 2011;128(5): 1040-1045.
Anderson DR, Pempek TA. Television and very young children. American
Behavioral Scientist 2005;48(5):505-522.
Atladottir HO, etal. Autism after infection, febrile episodes, and antibiotics
during pregnancy: an exploratory study. Pediatrics. 2012; 130(6) e1447-
1454.
Brainerd, C. Piaget’s Theory of Intelligence. Englewood, NJ: Prentice-Hall,
1978.
Brenner RA, etal. Association between swimming lessons and drowning in
children: a case-controlled study. Arch Ped Adol Med 2009
Mar;163(3):203-10.
Chahrour M, etal. MECP2, a key contributor to neurological disease,
activates and represses transcription. Science 2008 May
30;320(5880):1224-9.
Cheslack-Postava etal. Closely spaced pregnancies are associated with
increased odds of autism in California sibling births. Pediatrics
2011;127(2)
Chyi LJ, etal. J Peds 2008;153;25-31
Croen LA, etal. Maternal and paternal age and risk of autism spectrum
disorders. Arch Ped Adol Med 2007 Apr 161(4):334-40.
Dehaene-Lambertz G, etal. Functional organization of perisylvian
activation during presentation of sentences in preverbal infants.
Proceedings of the National Academy of Sciences, France, 2006.
Pnas.org/cgi/doi/10.1073/pnas. 0606302103
Fatemi SH, etal. Maternal infection leads to abnormal gene regulation and
brain atrophy in mouse offspring; implications for genesis of
neurodevelopmental disorders. Schizo Res 2008;99(1-3):56-70.
Goodwyn SW, etal. Impact of symbolic gesturing on early language
development. 2000;24;81-103.
Harder AF. Learningplaceonline.com.
Jamain S, etal. Mutations of the X-linked genes encoding neuroligins
NLGN3 and NLGN4 are associated with autism. Nature Genetics
2003;34:27-29.
Kaiser Family Foundation, 2003.
Krakowiak P, etal. Maternal metabolic conditions and risk for autism and
other neurodevelopmental disorders. Pediatrics. 2012. 129 (5) e1221-
1128.
Limperopoulos C, etal. Positive screening for autism in ex-preterm infants:
prevalence and risk factors. Pediatrics Apr 2008; 121:758-65.
Maestro S. Psychopathology 1999; 32(6):292-300.
Mills JL, etal Elevated levels of growth-related hormones in autism and
autism spectrum disorder. Clinical Endocrinology 2007;67(2):230-7.
Suren P, etal. Association between maternal use of folic acid supplements
and risk of autism spectrum disorders in children. JAMA. 2013 Feb
13;309(6):570-7.
Vandewater EA, Bickham DS, etal. Time well spent? Relating television
use to children’s free-time activities. Pediatrics 2006:117:181-191.
Volk HE, etal. Traffic-related air pollution, particulate matter, and autism.
JAMA Psychiatry. 2013; 70(1):71-77.

Chapter 11: Discipline &Temperament

Harriett Lane Handbook, 2002.
High P: Data compiled at Infant Development Center, Brown Univ, 2003.
Jaafar SH, Jahanfar S, Angolkar M, Ho JJ. Pacifier use versus no pacifier
use in breastfeeding term infants for increasing duration of
breastfeeding. Cochrane Database of Systematic Reviews 2011, Issue 3.
Art. No.: CD007202. DOI: 10.1002/14651858.CD007202.pub2.
Kurcinka MS. Raising your Spirited Child: A Guide for Parents Whose
Child is More Intense, Sensitive, Perceptive, Persistent, Energetic.
Harper, 1998.
Perry R, et al. Nutritional supplements and other complementary medicines
for infantile colic: a systematic review. Pediatrics, April 2011. 127:720-
733. Robertson J, etal. The Harriett Lane Handbook. A Manual for
Pediatric House Officers. 17th Ed. Philadelphia: Mosby, 2005.
Savino F, etal. Lactobacillus reuteri vs. simethicone in the treatment of
infantile colic: a prospective randomized study. Pediatrics
2007;119:e124-130.
Thomas A, Chess S. Temperament and Development. New York:
Brunner/Mazel 1977.
Viggiano D. Arch Dis Child 2004;89:1121-1123.

Chapter 12: Vaccinations

American Academy of Pediatrics Technical Report: Mercury in the
environment: implications for pediatricians. Pediatrics 2001; 108 (1):
197-205.
Centers for Disease Control website at
cdc.gov/vaccines/pubs/pinkbook/pink-appendx.htm#appg Accessed on
March 8, 2009.
Centers for Disease Control website at
cdc.gov/mmwr/preview/mmwrhtml/mm57e625a1.htm. Accessed May
25, 2009.
Communicable Disease Surveillance Center, London, 2007.
Dept of Health and Human Services, Agency for Toxic Substances and
Disease Registry, Tox FAQ’s for Aluminum, Sept 2008.
Dept of Health and Human Services, Agency for Toxic Substances and
Disease Registry, Tox FAQ’s for Formaldehyde, June 1999.
DeStefano F, etal. Increasing exposure to antibody-stimulating proteins and
polysaccharides in vaccines is no associated with risk of autism. Journal
of Pediatrics 2013. DOI 10.1016/j.jpeds.2013.02.001
Eick AA. Maternal influenza vaccination and effect on influenza virus in
young infants. Arch Ped Adol Med 2011 Feb;165(2):104-11.
Mills JL, etal Elevated levels of growth-related hormones in autism and
autism spectrum disorder. Clinical Endocrinology 2007;67(2):230-7.
EPA. Mercury study report to Congress: Vol 4: An assessment of exposure
to mercury in the US; 1997. www.epa.gov/mercury.
Fenn EA: Biological warfare in eighteenth century North America: beyond
Jeffrey Amherst. Journal of American History 2000; (86) 4: 1552-1580.
Johns Hopkins Hospital, Bloomberg School of Public Health, Institute for
Vaccine Safety. Vaccinesafety.edu/cc-exem.htm.
Mitkus RJ, etal. Updated aluminum pharmacokinetics following infant
exposures through diet and vaccination. Vaccine 2011;29:9538-9543.
Nelson K. Pediatrics 2003;111(3):674-678.
Newsweek at newsweek.com/id/185853
O’Brien MA, etal. Parental refusal of pertussis vaccination is associated
with an increased risk of pertussis infection in children. Pediatrics
2009;123(6).
Offit P. Addressing parents’ concerns: Do multiple vaccines overwhelm or
weaken the infants’ immune system? Pediatrics 2002;109:124.
Offit P. Pediatrics 2003;112(6):1394-1401.
Omer SB, etal. Geographic clustering of non-medical exemptions to school
immunization requirements and associations with geographic clustering
of pertussis. Am J Epidemiology 2008;168(12)1389-96.
Omer SB, etal. Vaccine refusal, mandatory immunization, and the risks of
vaccine preventable disease. NEJM 2009;360(19):1981-8.
Pickering LK, editor. Red Book: 2006 Report of the Committee of Infectious
Diseases. 27th ed. Elk Grove Village, IL: American Academy of
Pediatrics, 2006.
Reis EC, et al: Taking the sting out of shots: control of vaccination-
associated pain and adverse reactions. Pediatric Annals 1998;27(6):375-
386.
Schechter R, etal. Continuing increases in autism reported to California’s
developmental services system: mercury in retrograde. Arch Gen
Psychiatry 2008;65(1):19-24.
Schuval S. Avoiding allergic reactions to childhood vaccines (and what to
do when they occur). Contemporary Pediatrics 2003; 20(4): 29-53.
Smith M, etal. On time vaccine receipt in the first year does not adversely
affect neuropsychological outcomes. Pediatrics 2010;125:1134-1141.
Thompson WW, etal. Early thimerosal exposure and neuropsychological
outcomes at 7 to 10 years. NEJM 2007;357:1281-1292.
UCLA website at library.ucla.edu/libraries/biomed/smallpox/
Vaccine Education Center, Children’s Hospital of Philadelphia. Parent
PACK Newsletter, June 2008.
Wakefield A.J, et al: Ileal-lymphoid-nodular hyperplasia, non-specific
colitis, and pervasive developmental disorder in children. Lancet
1998;351:637-641.
Zeiger RS. Current issues with influenza vaccine in egg allergy. Journal
Allergy Clin Immunol 2002;110:834.

Chapter 13: Infections

Baker RB. Is ear pulling associated with ear infection? Pediatrics
1992;90:1006-7.
Centers for Disease Control website at cdc.gov, accessed March 1, 2007.
Chai G, etal. Trends in outpatient prescription drug utilization in U.S.
children 2002-2010. Pediatrics 2012;130:23-31.
Donowitz L. Infection control in the office: keeping germs at bay.
Contemporary Pediatrics 2000;17(9):47.
Dowell SF. Seasonal variations in host susceptibility and cycles of certain
infectious diseases. Emerg Infect Dis 2001;7(3):369-74.
Hoberman A, etal. Treatment of acute otitis media in children under two
years of age. NEJM 2011. 364(2):105-115.
Leader S, etal. RSV coded hospitalizations, 1997-1999. Ped Inf Dz J.
2002:21:629.
Mangione-Smith RM, et al. The relationship between perceived parental
expectations and pediatrician antimicrobial prescribing behavior.
Pediatrics 1999;103:711-718.
MMWR March 4, 2011 Vol 60(3)
Peter G. Bacterial resistance in office practice: the need for judicious
antimicrobial therapy. Lecture at 25th Annual Pediatric Postgraduate
Symposium, Houston, 2003.
Pickering LK, editor. Red Book: 2006 Report of the Committee of Infectious
Diseases, 27th ed. Elk Grove Village IL: American Academy of
Pediatrics, 2006.
Post JC, et al: Is pacifier use a risk factor for otitis media? Lancet
2001;357:823-4.
Rosenfeld RM, etal: Clinical efficacy of antimicrobial drugs for acute otitis
media: meta-analysis of 5400 children from thirty-three randomized
trials. Journal of Pediatrics 1994;124:355-67.

Chapter 14: Diseases

Allmers H, etal. Acetaminophen use: a risk for asthma? Curr All Asthma
Rep 2009;9(2):164-7.
Bakkeheim E, etal. Paracetamol in early infancy: the risk of childhood
allergy and asthma. Acta Paediatrica 2011;100(1):90-96
Barrow Neurological Institute, St Joseph’s Hospital and Medical Center,
Phoenix AZ and Cranial Technologies, Phoenix AZ. 2008.
Beasley R, etal. Association between paracetamol use in infancy and
childhood, and risk of asthma, rhinoconjunctivitis, and eczema in
 children aged 6-7 years: analysis from Phase Three of the ISAAC
programme. Lancet 2008;372(9643):1039-48.
Behrman, RE. Editor: Nelson Essentials of Pediatrics. Philadelphia: WB
Saunders, 1990.
Expert Panel Report II: Guidelines of the Diagnosis and Management of
Asthma. 1997.
Fleisher G, Ludwig S, editors: Pediatric Emergency Medicine, 3rd Ed.
Baltimore: Williams and Wilkins, 1993.
National Institutes of Health website at nhlbi.nih.gov/guidelines/asthma/
Ownby, D. et al: Exposure to dogs and cats in the first year of life and risk
of allergic sensitization at six or seven years of age. JAMA
2002;288(8):963-972.
Persky V, etal. Prenatal exposure to acetaminophen and respiratory
symptoms in the first year of life. Ann Allergy Asthma Immun
2008;101(3):271-8.
Snell-Bergeon JK, etal. Early childhood infections and the risk of islet
autoimmunity: the diabetes autoimmunity study in the young (DAISY).
Diabetes Care. 2012 Dec;35(12):2553-8.
Stein RT. Early-life viral bronchiolitis in the causal pathway of childhood
asthma: is the evidence there yet? Am J Respir Crit Care Med
2008;178(11):1097-8.
Stellwagen L, etal. Look for the “stuck baby” to identify congenital
torticollis. Contemporary Pediatrics May 2004;21:55.

Chapter 15: Environmental Health

American Academy of Pediatrics Committee on Environmental Health:
Pediatric Environmental Health, 2nd ed. Elk Grove Village, IL:
American Academy of Pediatrics, 2003.
American Academy of Pediatrics Committee on Nutrition: Pediatric
Nutrition Handbook, 6th Ed. Elk Grove Village, IL, 2009.
American Cancer Society
cancer.org/cancer/cancercauses/othercarcinogens/athome/cellular-
phones accessed April 5, 2015.
Canfield RL, etal. Intellectual impairment in children with blood lead
concentrations less than 10 mcg/dl. NEJM 2003 Apr 17;348(16):1517-
 26.
Centers for Disease Control at
cdc.gov/nceh/clusters/fallon/organophosfaq.htm.
Centers for Disease Control accessed April 8, 2013.
atsdr.cdc.gov/toxfaqs/TF.asp?id=19&tid=3
Center for Science in the Public Interest at
cspinet.org/reports/chemcuisine.htm.
Council on Environmental Health. American Academy of Pediatrics. Policy
Statement Chemical-Management Policy: Prioritizing Children’s Health.
Pediatrics 2011;127:983-990.
Food and Drug Administration at FDA.gov accessed May 25, 2009.
Forman J, Silverstein J, AAP Committee on Nutrition, AAP Council on
Environmental Health. Organic foods: environmental advantages and
disadvantages. Pediatrics 2012;130:e1406.
Goldman LR. Chemicals and children’s environment: what we don’t know
about risks. Environ Health Perspect 1998;106(suppl 3):875-880.
National Institutes of Health. Niehs.nih.gov/emfrapid/booklet/home.htm.
Sherburn RE, Jenkins RO. Used cot mattresses as potential reservoirs of
bacterial infection: J Appl Microbiol 2008 Feb;104(2):526-33.
Tran TT, et al: Effect of high dietary manganese intake of neonatal rats on
tissue mineral accumulation, striatal dopamine levels, and
neurodevelopmental status. Neurotoxicology 2002;23:635-643.
Wall St. Journal, June 24, 2003 p. D4.

Chapter 16: First Aid

American Academy of Pediatrics: The management of acute gastroenteritis
in young children. Pediatrics 1996; 97(3):424-35.
Crocetti M. Fever phobia revisited: have parental misconceptions about
fever changed in 20 years? Pediatrics 2001;107(6):1241-6.
Fleisher, G., Ludwig, S, editors. Pediatric Emergency Medicine, 3rd Ed.
Baltimore: Williams and Wilkins, 1993.
Gunn VL, Nechyba C, editors. The Harriet Lane Handbook: A Manual for
Pediatric House Officers, 16th ed. Philadelphia: Mosby, 2002.
Paul I, Beiler J, Vallanti J, Duda L, King T. Placebo Effect in the Treatment
of Acute Cough in Infants and Toddlers: A Randomized Clinical Trial.
JAMA Pediatrics. 2014;168(12):1107-1113

Appendix A: Medications
American Academy of Pediatrics Committee on Nutrition. Pediatric
Nutrition Handbook, 4th ed. Elk Grove, IL: American Academy of
Pediatrics, 1998.
Hale T. Medications and Mother’s Milk. A Manual of Lactational
Pharmacology, 12th ed. Amarillo: Pharmasoft Publishing, 2006.
Murphy JL. editor: Prescribing Reference for Pediatricians: Spring-
Summer 2007. New York: Prescribing Reference, Inc., 2007.
Shared PJ, etal. The effect of inhaled steroids on the linear growth of
children with asthma: A meta-analysis. Pediatrics 2000;106(1):E8.

Appendix B: Alternative Medicines

Barrett BP, et al: Treatment of the common cold with unrefined Echinacea.
A randomized, double blind, placebo-controlled trial. Annals of Int
Medicine 2002;137(12):939-46.
Das SK, et al. Deglycyrrhizinated liquorice in aphthous ulcers. J Assoc
Physicians India 1989;37(10):647.
Eeles R: The effect of menthol on nasal resistance to airflow. J Laryng Otol
1983;97:705-9.
Fetrow CW, etal. Professional’s Handbook of Complementary and
Alternative Medicines, 3rd Ed. Philadelphia: Lippincott, Williams and
Wilkins, 2004.
Fox N. Effect of camphor, eucalyptol, and menthol on the vascular state of
the mucous membrane. Arch Oto HNS 1027(6):112-122.
Gardiner P. Longwood Herbal Task Force website:www.mcp.edu/herbal/
Gilroy CM, etal. Echinacea and truth in labeling. Archives of Internal
Medicine 2003;163:699-704.
Hederos C, Berg, A. Epogram evening primrose oil treatment in atopic
dermatitis and asthma. Arch Dz in Childhood 1996;75:494-7.
Horrobin DF. Essential fatty acid metabolism and its modification in atopic
eczema. Am Jnl Clin Nutrition 2000;71(supp):367s-372.
Kemper, KJ: The Holistic Pediatrician. A pediatrician’s comprehensive
guide to safe and effective therapies for the 25 most common ailments of
infants, children, and adolescents, 2nd ed. New York: HarperCollins,
2002.
Kopp MV, etal. Randomized, double-blind, placebo-controlled trial of
probiotics for primary prevention: no clinical effects of Lactobacillus
GG supplementation. Pediatrics 2008;121:e850-6.
Land M. Probiotics, hype or helpful? Contemporary Pediatrics 2008;
(25)12:34-42.
Moneret-Vautrin DA, etal. Probiotics may be unsafe in infants allergic to
cow’s milk. Allergy 2006;61:507-8.
Mowrey DB. Motion sickness, ginger, and psychophysics. Lancet
1982;91:655-7.
National Institutes of Health. National Library of Medicine, Medline Plus.
nlm.nih.gov/medlineplus accessed April 26, 2013.
National Public Radio. Politics and lobbying in the US nutritional and
dietary supplements industry. National Public Radio, All Things
Considered, June 23, 2003.
Paul IM, etal. Vapor rub, petrolatum, and no treatment for children with
nocturnal cough and cold symptoms. Pediatrics. 2010;126:1092-99.
Perry R, etal. Nutritional supplements and other complementary medicines
for colic: a systematic review. Pediatrics 2011;127:720-733.
Rodriguez-Bigas M. A comparative evaluation of aloe vera in the
management of burn wounds in guinea pigs. Plastic Reconst Surg
1988;81:386-9.
Schmid R, et al. Comparison of seven commonly used agents for
prophylaxis of seasickness. Jnl Travel Med 1994;1;203-6.
Singh M, etal. Zinc for the common cold. Cochrane Database Review.
2011. Issue 2.
Teelucksingh S. Potentiation of hydrocortisone activity in skin by
glycyrrhetinic acid. Lancet 1990;335 (8697):1060-3.
Weizman Z, et al. Efficacy of herbal tea preparation in infantile colic.
Journal of Pediatrics 1993;122:650-2.
Appendix C: Lab Tests
Gunn VL, Nechyba C, editors: The Harriet Lane Handbook: A Manual for
Pediatric House Officers, 16th ed. Philadelphia:Mosby, 2002.
Loeb S, editor: Clinical Laboratory Tests: Values and Implications.
Springhouse, Pennsylvania: Spring House, 1991.

Appendix D: Glossary
Behrman RE, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia:
W.B.Saunders, 1990.
Cloherty JP, Stark AR. Manual of Neonatal Care, 3e. Boston: Little Brown,
1992.
Shelov, SP. Your Baby’s First Year. New York: Bantam, 1998.
Urdang Associates. The Bantam Medical Dictionary. New York: Bantam,
1981.
INDEX
The index that appeared in the print version of this title was intentionally removed from the
eBook. Please use the search function on your eReading device for terms of interest. For
your reference, the terms that appear in the print index are listed below

AAFP. See American Academy of Family Physicians

AAP. See American Academy of Pediatrics
Abacavir
Abdomen
acute
CT/MRI for
distended
ultrasound for
x-rays for
Abdominal pain
home remedies for
questions about
red flags with
Abnormalities
biochemical
congenital
development
hormone
lung
ABO incompatibility. See Coombs test
Abscesses
brain
Acetaminophen
asthma and
dehydration and
dosing
fever and
taking
Acholic stool
defined
Acid reflux
breastfeeding and
diagnosis with
feedings and
heartburn and
red flags with
symptoms of
treating
Acidophilus
ACIP. See Advisory Committee on Immunization Practices
Acne
defined
Acrocyanosis
defined
Acupuncture
Acute life threatening event (ALTE)
defined
Acute otitis media
defined
ADA. See American Dental Association
Adair, Steven
ADD. See Attention Deficit Disorder
Additives
described
Adenovirus
ADHD. See Attention Deficit Hyperactivity Disorder
Adjusted age
Adjuvants, described
Adoption
web sites on
Adrenal dysfunction
Adrenal gland insufficiency
Advil
Advisory Committee on Immunization Practices (ACIP)
Aerola
Affordable Care Act
Afrin
Agency for Toxic Substances and Disease Registry
Agenesis of the corpus callosum
AIDS
Air: indoors/outdoors
pollutants in
quality
toxins in
Air hungry
defined
Alanine Aminotransferase (ALT)
Albumin
Albuterol
Alcohol
Aliphatic hydrocarbons
ALL Free and Clear
Allergic reactions
questions about
Allergies
asthma and
cat
developing
drug
eczema and
egg
food
hereditary patterns of
IgE-mediated
medication
metal
milk
over the years
peanut
prebiotics and
preventing
problems with
protein
ragweed
rashes and
seasonal
skin
vaccine
 web sites on
Allergy Asthma Technology, Ltd.
Aloe vera
ALTE. See Acute life threatening event
Alternative therapies
thoughts on
web sites on
Aluminum: autism and
exposure to
Alvarado, L.
Alzheimer’s Disease, aluminum and
Amazon
Ambecides
Ambiguous genitalia
defined
Amblyopia
defined
American Academy of Family Physicians (AAFP)
American Academy of Pediatric Dentistry, first dental visit and
American Academy of Pediatrics (AAP)
autism and
Babywise and
“Back to Sleep” Campaign and
bed sharing and
breastfeeding and
car seats and
chickenpox vaccine and
circumcision and
contact information for
cord blood and
dental visit and
DHA and
diarrhea medications and
diet and
Down syndrome and
ear infections and
feeding schedules and
flat feet and
fluoride and
 food allergies and
food introduction and
hearing screen and
interactive media and
jaundice and
juice and
late preterm infants and
Nutrition Committee and
pacifiers and
policy statement for
room sharing and
RSV and
screen time and
SIDS and
sleep positioners and
soy formula and
swim classes and
thermometers and
toxins and
UTI and
vaccinations and
vision screening and
Vitamin D and
walkers and
water and
American Association of Poison Control Centers
American Cancer Society
American Dental Association (ADA)
fluoride and
formula and
American Heart Association
American Red Cross
American Sensors
American Urological Association
Amniotic fluid
Amoxicillin
ear infections and
strep throat and
Amylase
Anal fissure, defined
Analgesics
Anaphylactic reaction
defined
red flags with
Anderson, Kelly
Anemia
breastfeeding and
breath-holding and
defined
hemolytic
iron-deficiency
testing
treating
Anesthesia
Aneurysms
Angel kiss
Anise oil
Ankyloglossia. See Tongue-tie
Anomaly, defined
Antacids
Antibiotic drops
Antibiotics
abusing
avoiding
classes of
common colds and
ear infections and
expensive
infections and
leftover
meat and
oral
prescribing
probiotics and
resistance to
too many
using
viruses and
Antibodies
breast milk and
Anti-CIO (Cry It Out) activists
Anti-circumcision groups
Antifungals
Antihelminthics
Antihistamines
using
Anti-inflammatories
Anti-vaccine movement
web sites
Antivirals
Anxiety
at 9 to 12 months
separation
stranger
AOP. See Apnea of prematurity
Apgar test
Apnea
defined
monitors
questions about
Apnea of prematurity (AOP)
defined
preemies and
Appendicitis
defined
Appliances
Appointments
arriving early for
flu season and
making
problem-focused
running late for
scheduling
sick visit
unnecessary
wait times for
Arachidonic Acid (ARA)
Arachis oil
Arms: dislocated
limp
Aromatherapy
Aromatic hydrocarbons
Arsenic
rice cereal and
Artificial sweeteners
Asbestos
ASD. See Autism Spectrum Disorders
AskLenore.info
Asner, Ed: quote of
Aspartate Aminotransferase (AST)
Asperger’s Syndrome
defined
Aspirin
Association for Children with Down syndrome
Association of Women’s Health Obstetric and Neonatal Nurses
Asthma
acetaminophen and
allergies and
chronic problems with
defined
developing
diagnosis with
eczema and
factors causing
long-term consequences of
outgrowing
preventing
Reactive Airway Disease and
risk of
RSV and
severity of
smoking and
Athlete’s foot
Atopy
defined
Atresia: anal
 biliary
choanal
duodenal
esophageal
ileal
tricuspid
Attachment parenting
advantages of
family bed and
Attachment Parenting International
Attention Deficit Disorder (ADD)
autism and
food coloring and
soy formula and
Attention Deficit Hyperactivity Disorder (ADHD)
AuPairAmerica.com
Au pairs
Auditory processing disorder
Auro-Dri
Authoritarian parenting, described
Autism Science Foundation
Autism Spectrum Disorders (ASD)
aluminum poisoning and
anti-vaccine movement and
behavior and
defined
diagnosis with
environmental exposures and
genetics and
HFCS and
interventions and
language delay and
late onset
Mad Hatter’s Disease and
mercury and
misdiagnosis for
MMR vaccine and
parent training for
red flags for
 screen for
therapy for
thimerosal and
vaccines and
Autism Toolkit (AAP)
Autoimmune disorders
Autoimmune responses
Autonomy, doubt vs.
Autosomal dominant
defined
Autosomal recessive
defined
Avascular necrosis
Aveeno
Avent, nipples from
Axid
Azithromycin
AZT

B. lactis
Baby Anbesol
Baby Bargains (Fields and Fields)
bottles/nipples and
breast pumps and
car seats and
high chairs and
humidifiers and
Baby Bjorn
Baby blues
Baby Book, The (Sears)
Baby Connect
Baby food
nitrates and
organic
preparing
squeezable-package. See also Food
Baby Numz-it
Baby Oragel
Baby-wearing, attachment parenting and
Baby411.com
Babysitting
Babywise method, described
Back sleeping
“Back to Sleep” Campaign
Bacteria
antibacterial soap and
antibiotics and
described
drug-resistant
ear infections and
eye
good
growth of
gut
infections and
intestinal
killing
mattresses and
middle ear infections and
mouth
nostril
pasteurization and
penicillin and
poop and
skin
TB
vaccines and
vagina
water and
Bacterial conjunctivitis
overview of
returning to childcare/playgroups after
Bacterial enteritis
Bacterial infections
antibiotics and
contagiousness of
diagnosis with
nipple
overview of
 secondary
viruses and
Bactroban
Bad habits
undoing
BAER. See Brainstem Audio Evoked Response
Balanitis
defined
Balmex
Barenaked Ladies, quote from
Barium swallow
Barley, exposure to
Barnes, Sarah
Barnes & Noble
Barracuda, The: described
Bassinets
Baths
eczema and
fever and
sponge
steps for
warm
Baylor Medical Center
BBQ
Bed sharing
SIDS and
Bedding
Beds
Bedtime: changing
consistent
scheduling
Bedwetting
Behavior
aggressive
ASD and
bad
books on
changing
feeding
 good
guiding
learned
parent
praise for
repeat
sleep and
Bell, Edward
Belladonna
Belly button: care
red flags with
Belushi, John
Benadryl
Benzene
BeTheMatch.org
Bifidobacterium
Bile
duct obstruction
Bili bed/blanket
Bilirubin
blood test
checking
getting rid of
metabolizing
Biofilm
Biogaia protectis
Biopsies
Birth canal
Birth control
Birth parents, medical history of
Birth plans
Birth process
Birth trauma
Birth weight
breastfeeding and
regaining
Birthing centers
Birthmarks
Bisphenol-A (BPA)
Biting
Bladder infections
diagnosis with
medications for
overview of
proneness to
untreated. See also Urinary tract infection
Bladders: abnormal
checking
full
Blebs
Bleeding
bruising and
controlling
disorders
gastrointestinal
head
lower GI
nipples
postpartum
upper GI
Blindness
Blisters
Bloating
Blood
drawing
hormones and
medical concerns about
in pee
in poop
storing
vomiting. See also Cord blood
Blood banks
Blood cells: abnormal
red
white
Blood count
Down syndrome and
Blood flow
Blood in stool
defined
Blood pressure
Blood sugar
testing
Blood tests
Blood type
incompatibility
testing
Blood Urea Nitrogen (BUN)
Blue Baby Syndrome
Body Mass Index (BMI)
autism and
calculating
described
obesity and
Body odors
Bone injuries
red flags with
Bone marrow
Bone scans
Bones
broken
medical concerns about
Books: behavior
board
breastfeeding
childcare
child development
complementary/alternative therapies
favorites for kids
language skills and
medical information
nutrition
parenting
sleep
vaccination
Boric acid
BOTOX injections
Bottles
feeder
glass
plastic
polycarbonate
propping/ear infections and
sterilized
vented
Botulism
Boudreaux’s Butt Paste
Bouncer seats, vibrating
Bovine growth hormone
Bow leggedness
Bowel obstructions
Bowels
Boy parts
checking
BPA. See Bisphenol-A
BPD. See Broncopulmonary dysplasia
Braces
Brain
preemies and
Brain damage
Brain development
abnormal
stages of
Brain disorder, degenerative
Brain dysfunction
Brainstem Audio Evoked Response (BAER)
defined
Bras
BRAT diet
Brazelton, T. Berry
Breads: fiber in
servings of
Breast implants
Breast milk
antibodies/vitamins in
buying
 caffeine and
calcium and
calories in
cancer and
contaminants in
cow’s milk and
enzymes and
expressing
fat in
feeding
fluoride and
food mixed with
and formula compared
fresh
lactic acid and
lactose and
mature
nutrition and
poop and
preemies and
production of
pros/cons of
protein and
pumping
stimulating
storing
supplementing
supply of
taste of
weaning off of
Breast pumps
buying
cleaning
electric
high-efficiency
hospital-grade
manual
nipples and
rental
 using
Breast reduction, thoughts on
Breast shells, described
Breast shields
Breastfeeding
birth to 2 weeks
at 2 weeks
2 weeks to 2 months
at 1 month
2 to 4 months
4 to 6 months
6 to 9 months
9 to 12 months
at 1 year
acid reflux and
adoption and
advantages of
advice on
alcohol and
anemia and
attachment parenting and
breast cancer and
breast implants/reduction and
calories and
categories of
challenges of
class
co-sleeping and
cold medicines and
comfort
concentrating on
continuing
dairy and
described
diet and
exercising and
falling asleep while
fever and
fiber and
first days of
fish and
fluoride and
formula and
frequency of
GERD and
germs and
herbals and
jaundice and
language of
as learned process
length of
LPI and
maternity leave and
medications and
milk allergies and
moms and
multiples and
nighttime
obesity and
pacifiers and
poop and
positions for
preemies and
problems with
red flags with
SIDS and
sleep and
smoking and
stopping
successful
supplementation and
supplies for
support for
vomiting and
web sites on
weight loss and
work and
yeast infection from
Breastfeeding, Inc.
Breastfeeding Committee (AAP)
Breastfeeding pillow
Breasts: alternating
changes in
large
leaking
preferred
Breath-holding
defined
Breath odors
described
Breathing
environmental hazards and
labored
periodic
problems with
rapid
red flags with
shallow
treatments
Breathing motion detectors
Breech position
defined
Bronchiolitis (RSV)
asthma and
defined
overview of
Bronchitis
defined
Bronchodilator
Bronchopulmonary dysplasia (BPD)
defined
Brown, Ari
Brown, Mr. Dr. (ENT)
Bruising
bleeding and
delivery
home remedies for
 petechiae and
worrisome
Budesonide
Bug bites
Burnett, Carol: quote of
Burns
mouth
second-degree
Burping
Burrito wrap
Butler, Ginny

C. difficile
C-Reactive Protein (CRP)
C-sections
Cabinet locks, installing
Cadmium
Caesarian section, herpes and
Café au lait spots
defined
Caffeine
breast milk and
preemies and
Calcium
consuming
iron and
Calendula, uses of/precautions with
Calories
big babies and
breastfeeding and
changing needs for
consuming
extra
fewer
infant
preemies and
Campaign for Safe Cosmetics
Camphor
Campylobacter infection
Cancer
 anal
artificial sweeteners and
BBQ and
bone
breast
breast milk and
cervical
endometrial
fluoride and
HPV-related
liver
lung
ovarian
penile
risk of
skin
testicular
throat
web sites on
CAP-RAST test, described
Capillary refill, dehydration and
Car seats
convertible
forward-facing
head control and
infant
installing
preemies and
rear-facing
sleeping in
testing
web sites on
Carbamates
Carbon monoxide
Carcinogens
Care.com
Carnation Instant Breakfast
Carotene, yellow skin and
Carotinemia
 defined
Carpeting
Carriers, using
Cartilage damage
Carvalho Fisheries
Casein, whey and
Castor oil packs
CAT scan, head injuries and
Cataracts
defined
Cats, exposure to
Cavities
CBC. See Complete blood count
CDC. See Centers for Disease Control and Prevention
Cefdinir
Cefixime
Celiac disease
defined
screening/Down syndrome and
Cell phones, limiting use of
Cellulitis, overview of
Center care
Center for Evaluation of Risks to Human Reproduction
Centers for Disease Control and Prevention (CDC)
ASD and
autism and
circumcision and
contact information for
government conspiracy theory and
immunization schedule from
infant growth charts by
pesticides and
rubella and
triclosan and
vaccines and
Cephalhematoma
defined
Cephalosporins
Cerave
Cereal
fiber in
iron-fortified
toxic. See also Rice cereal
Cerebral palsy
defined
Cerebrospinal fluid (CSF)
Cerebrovascular accident
Cetaphil
Cetirizine
CF. See Cystic Fibrosis
Chamomile
uses of/precautions with
Chemicals
exposure to
safety with
Chemotherapy
Chest: CT/MRI for
examining
x-rays for
Chest rattling
Chickenpox
described
overview of
preventing
returning to childcare/playgroups after
vaccine-associated
Chickenpox vaccine
described
Child abuse
Child Development, quality time and
Child magazine, Sears and
Childbirth
class
Childcare
cost of
ear infections and
food allergies and
in-home
 inspecting
options for
out-of-the-home
red flags with
returning to
thinking about
transition to
web sites on. See also Daycare
Children’s Health Insurance Program (CHIP)
Chlamydia
Chloride
Choking
emergencies with
Cholesterol
screen
Choosemyplate.com
Chorioamnionitis
Chromosomes
abnormal
analysis
Chronic issues
vaccines and
Chronological age
Circadian rhythm
Circulation, examining
Circumcision
arguments against
arguments for
caring for
debate on
deciding on
described
experts on
healing of
HPV and
hygiene and
normal
problems with
sexual pleasure and
Claritin
Clavicle fracture
defined
Clavulanate
Cleaning products
Cleft lip/palate
defined
Clinical Immunization Safety Assessment Network
Clitoris
Clothing, layers of
Clotrimazola
Clots
Club foot
defined
Cluster feedings
CMV
Co-sleeping
breastfeeding and
independence and
problems with
Coagulation studies
Coarctation of the Aorta
defined
Cocamidopropyl betaine (CAPB)
Coconut oil, in products
Cochrane Reviews
Cognitive skills
4 to 6 months
6 to 9 months
Cold medicines: breastfeeding and
infants and
Cold season
Cold sores
Cold viruses
Colds. See Common colds
Colic
described
gas and
home remedies for
 medications for
probiotics and
research on
treatments for
Colitis, antibiotic-induced
Colostrum
defined
Comfort objects
Committee on Nutrition (AAP)
Common colds
described
diagnosis with
ear infections and
exposure to
home remedies for
returning to childcare/playgroups after
and sinus infections compared
symptoms
treating
vaccinations and
Communication
Communication skills
at 2 weeks
at 2 months
at 4 months
at 6 months
at 9 months
at 1 year
non-verbal
Complementary/alternative therapies
Complete blood count (CBC)
Compression
described
stripes
Computerized Tomography (CT)
Concrete operational development, 7 to 11 years
Concussion, treating
Conductive hearing loss
defined
Cone head
Congenital, defined
Congenital Adrenal Hyperplasia, defined
Congenital heart disease
defined
Congenital nevus
defined
Congenital rubella syndrome
Congestion: coughing and. See also Nasal congestion
Congestive heart failure
defined
Conjunctivitis
allergic
bacterial
defined
returning to childcare/playgroups after
viral
Consciousness, loss of
Consistency
importance of
Constipation
defined
fiber and
indications of
relieving
rice cereal and
Consultations: phone call
prenatal
scheduling
Consumer Product Safety Commission (CPSC)
Consumer Product Safety Commission Hotline
Consumer Product Safety Improvement Act (2007)
Consumer Reports
Contact dermatitis
Containers: glass/porcelain/stainless steel
plastic
Contaminants
breast milk
Convulsions
Cookbooks, baby food
Cookies
Cooking
Coombs test
Copper chromium arsenate (CCA)
Cord blood: collecting
donating
embryonic stem cells and
storing
Cord blood banking
described
private
web sites on
Cords, electrical/telephone
Corneal abrasions
Cornell University, study from
Costco, formula from
Cough suppressant
Cough syrup, infant
Coughing
chronic
congestion and
nighttime
questions about
red flags with
Cowpox virus
Cow’s milk
breast milk and
and goat’s milk compared
hypersensitivity to
protein and
Coxsackievirus
described
overview of
CPR
course
CPSC. See Consumer Product Safety Commission
Cradle cap
home remedies for
Cradle hold
described
Cramps
Craniosynostosis
defined
Creams: antibiotic
barrier
diaper rash
moisturizing
1% hydrocortisone
steroid
Creamy Vaseline
Creatinine
Cribs
safety hazards with
Cromolyn
Cross cradle hold, described
Cross-infection
Croup
home remedies for
nighttime
overview of
returning to childcare/playgroups after
Cruise, Suri
Cry management approach
Crying
car rides and
inconsolable
medical causes for
persistent
soothing
Crying it out
problems with
thoughts on
Cryobanks International
Cryogenic techniques
Cryptosporidium
CT. See Computerized Tomography
Cultures
 blood
sputum
stool
throat
urine
Cystic Fibrosis (CF)
defined
wheezing and
Cysts: branchial cleft
congenital
ovarian

D-Vi-Sol
Dactylitis
Dairy
alternative
breast-feeding and
combination
eliminating
introducing
organic
requirements
servings of
single-ingredient
Day-Night Reversal
Daycare: biting at
commuting to
cost of
diseases from
ear infections and
finding
in-home
infection control at
naps and
observing at
private. See also Childcare
DDH. See Hip dysplasia
Deafness
congenital
Decision making
Decongestants
herbal
DEET
Deformity
Dehydration
acetaminophen and
diarrhea and
preemies and
preventing
signs of
vomiting and
Delivery
full-term
Dental care
medications for
pacifiers and
preemies and
Denver Developmental Checklist
Depression
Dermatologic products
Desitin
Detergents
Development
birth to 2 months
autism and
challenges
daycare and
described
differences in
fostering
interventions and
preemies and
sleep and
web sites on
Developmental checklists
preemies and
Developmental delays
genetic/metabolic defects and
help for
 isolated
LPI and
risk of
Developmental dysplasia of the hip. See Hip dysplasia
Developmental specialists
Developmental stimulation
providing
DHA. See Docohexaenoic acid
Diabetes
adult onset
gestational
HFCS and
insulin dependent
juvenile
risk of
solid food and
Type 1:
Type 2:
web sites on
Diabetes.org
Diaper bags
Diaper changes
Diaper rash
home remedies for
severe
treating
yeast
Diaper wipes, using
DiaperFreeBaby.org
Diapers
blood in
chlorine-free
contents of
disposable
feedings and
wet
Diarrhea
allergies and
bloody
 chronic
defined
dehydration and
diet and
dramatic
home remedies for
milk allergies and
persistent
poop and
questions about
teething and
vomiting and
watery
Diet
balanced
BRAT
breastfeeding and
changes in
diarrhea and
elimination
fussiness and
healthy
high fat/high fiber
lactose free
liquid
restrictions on
toddler
vegan/vegetarian
weight loss and
Difficult child
described
Digoxin
Dioxin
Diphenhydramine
Diphtheria: described
vaccine for
Discipline
age-appropriate/temperament-appropriate
goal of
 managing
non-physical forms of
physical
starting
temperament and
Diseases
body odors and
common
health risks of
immunity and
vaccine-preventable
vaccine specifics and
Dislocations
arm
hip
DMSA scan
DNA
autism and
Docohexaenoic acid (DHA)
described
sources of
supplementing
Dr. Smith’s Diaper Ointment
Dosing
chart
Doubt, autonomy vs.
Doulas, hiring
Down syndrome
therapy for
Down time
Dream feeds
Drooling
Droppers
Drug abuse
DrugStore.com
Dry lips/mouth, dehydration and
Dry skin
antibacterial soap and
Dryer sheets, avoiding
DSM-5
DTaP
aluminum in
described
DTP
Dyes
Dyslexia

E. coli
overview of
Ear drops
Ear infections
acute
amoxicillin and
antibiotics and
bacteria and
bath water and
childcare and
cold season and
feeding and
flu season and
focus on
home remedies for
medications for
middle
number of
pacifiers and
pink eye and
preventing
pulling on ears and
risk factors for
summertime
and swimmer’s ear compared
travel and
viruses and
wind/ceiling fans and
Eardrums
function of
infected
PE tubes and
 perforation of
Early Childhood Intervention (ECI)
Early Head Start, autism and
Ears: examining
infant
injuries
inner/middle/outer
medications for
EarthEasy.com
Earth’s Best
Easter Seals
contact information for
Easy child, described
Eating
challenges of
as developmental milestone
ebbs/flows in
screen time and
EBV. See Epstein-Barr Virus
Echinacea, uses of/precautions with
Echocardiogram
ECI. See Early Childhood Intervention
Eco hazards, reducing
Eczema
allergies and
antibacterial soap and
asthma and
dealing with
defined
developing
diagnosis with
food allergies and
home remedies for
managing
outgrowing
probiotics and
severe
soap and
treating
Educational apps, using
Ego, development of
Egocentric
defined
Elastogel
Elecare
Electro magnetic fields (EMFs)
Electrocardiogram (EKG)
Electrolytes
Elimination
red flags with
table
Elimination Communication (EC)
Elimination diet
Emergencies
evening/weekend
handling
pediatricians and
protocols for
respiratory
Emergency care, web sites on
Emergency rooms
Emesis, defined
Emetrol
EMFs. See Electro magnetic fields
EMLA
Emollients
Emotional growth
Emotional health
Enamel hypoplasia
defined
Encephalitis
defined
Endocrine, medical concerns about
Endocrine disruptors
Endoscopy
Enfamil: AR
Gentlease
Infant
 Newborn
Nutramigen
Premium
Prosobee
Puramino
Supplementation
Engerix-B
Engorgement
defined
surviving
ENT specialists
calling
PE tubes and
Enterobacter sakazakii
Enterovirus
Entrapment
Environment
health and
heredity vs.
Environmental exposures
autism and
lifetime burden and
Environmental health
Environmental Health and Toxicology
Environmental Protection Agency (EPA): lead exposure and
mercury exposure and
perchlorate and
radon and
Environmental Working Group
Enzymes, breast milk and
Eosinophils
EPA. See Environmental Protection Agency
Ephedra
Ephedrine
Epidemics
Epispadias
defined
Epsom salts
Epstein-Barr Virus (EBV)
Epstein’s pearls
defined
Erb’s palsy
defined
Erikson, Erik: social/emotional development and
Erythema infectiosum, overview of
Erythema multiforme
Erythema toxicum
defined
Erythorbic acid
Erythrocyte Sedimentation Rate (ESR)
Esophagitis
defined
Esophagus
Esotropia
Essential fatty acid
Essential oils, using
Estradiol
Estrogens
Ethylmercury
Eucerin cream
Eustachian tubes
common colds and
dysfunction of
infections/ allergies and
Evening primrose oil, uses of/precautions with
Excited Ineffective, The: described
Exfoliation
Exhaustion
supplementation and
Expectorants
Expressive language delays
defined
Extremities: checking
CT/MRI for
x-rays for
Eye contact
Eye drops, antibiotic
Eye infections
Eye problems
medications for
red flags with
Eyes: crossed
examining
medical concerns about
red
swollen shut

Failure to thrive
defined
Fakes, Dennis: quote of
Family bed
attachment parenting and
SIDS and
solitary sleep versus
Family caretaker, described
Family Medical Leave Act (FMLA)
Family practitioners
Fat
servings of
Fat necrosis
defined
Fatty acids
FDA. See Food and Drug Administration
Feeding
acid reflux and
behaviors
cluster
on demand
distraction during
ear infections and
eliminating
first morning
frequency of
missed
naps and
night
nutrition and
paced
 parental control of
patterns
per breast
poop and
preemies and
schedules
self
sleep and
travel and
vomiting and
Feeding table
Feingold Hypothesis
Fennel
uses of/precautions with
Fenugreek
Feostat
Ferber, Dr.
sleep disorders and
theory of
Ferber Method, described
Ferberizing
Fever
bathing and
brain damage and
breastfeeding and
curves
defined
evaluating
fear of
high
immune system and
low grade
milk and
questions about
red flags with
seizures and
teething and
thoughts on
viral infections and
 vomiting and
Feverall
Fiber
breastfeeding and
constipation and
food and
sources of
Fields, Alan
Fields, Ben
Fields, Denise
Fifth disease
described
returning to childcare/playgroups after
Fine motor skills
2 to 4 months
4 to 6 months
6 to 9 months
9 to 12 months
described
toys for
Fingers, injured
First aid kits, contents of
First, Lewis: formula and
Fish
breastfeeding and
eating
Fisher Price Rock ‘N’ Play
Flame retardants
Flaring (nostrils)
defined
Flat angiomata
defined
Flat feet
Flat heads
tummy time and
Flavorings
Flu. See Influenza
Flu nasal spray
Flu season
 appointments during
ear infections and
Fluid accumulations
chronic
Fluoride
breast milk/formula and
cancer and
extra
safety with
Fluoride supplements
Fluoritab
Fluorosis
Flushield
Fluvirin
Fluzone
Folate
Folic acid, autism and
Fomites
defined
Fontanelle
anterior
defined
dehydration and
posterior
sunken
Food
after 6 months
at age 1:
after age 1:
brain
canned
chemicals in
combination
complementary
dangerous
environmental hazards and
ethnic
fiber and
finger
 first
flavoring
gassy
introducing
iron-containing
malabsorption of
multiples and
natural warming of
organic
pollutants in
poop and
pre-chewing
preemies and
presentation of
processed
reaction to
single-ingredient
sleeping through night and
solid
stage
starting
take-out
television and
toxins in. See also Baby food
Food Allergy Network
Food and Drug Administration (FDA)
anti-inflammatories and
approval by
BPA and
cough and cold remedies and
fish and
flu vaccine and
food coloring and
GMOs and
government conspiracy theory and
herbal remedies and
labeling standards of
mercury exposure and
probiotics and
 rotavirus vaccine and
teething tablets and
thimerosal and
topical numbing products and
toxins and
vaccinations and
Food challenges
Food coloring
Food poisoning
overview of
returning to childcare/playgroups after. See also Gastroenteritis
Food processors, using
Food pyramid
FoodAllergy.org
Football hold
described
Foreign body/object
defined
Foremilk
defined
Foreskin
Formal operational development, 12 to adulthood
Formaldehyde
Formula
birth to 2 weeks
2 weeks to 2 months
2 to 4 months
4 to 6 months
6 to 9 months
9 to 12 months
aluminum in
artificial ingredients in
brand-name
and breast milk compared
breastfeeding and
calcium and
calories from
casein protein
commercial
concentrate
cost of
cow’s milk
feeding
fluoride and
food mixed with
generic
gentle
gourmet
high-calorie
history of
hypoallergenic
incorrect preparation of
infant
iron-containing
lactose free
making
maternal reasons for
nutrition and
older baby/toddler
organic
per day
poop and
powder
prebiotics and
preemies and
premature
probiotics and
ready-to-feed
recommended
rice cereal and
soy
supplementing with
switching
testing
thickened
transition to
vitamin D and
volume of
Formvirisen
Four Cs, avoiding
Fractures
Fragile X Syndrome
Frenulectomy
defined
Frenulum
defined
Fruits
citrus
fiber in
organic
peeling and
pesticides in
scrubbing
servings of
Fungus
Fungus infections
overview of
Fussiness
diet and
GERD and
teething and

Gagging
Gagnon, Tricia
Galactosemia
defined
Galbreath, Laurie
Gallbladder, dysfunction of
Gallstones
Gas
colic and
concerns about
home remedies for
medications for
Gas drops, OTC
Gastritis
Gastroenteritis
defined
 viral
Gastroesophageal reflux (GERD)
breastfeeding and
defined
fussiness and
hiccupping and
hunger and
patience with
preemies and
questionnaire about
sleep and
symptoms of
treatment
Gastrointestinal problems: medications for
preemies and
web sites on
Gastrointestinal tract
colic and
Gastrointestinal viruses
overview of
Gatorade
Gauze pads
Gel pads
Genetic defects
developmental delays and
finding
Genetically-modified foods (GMOs)
Genital herpes
Genitals: checking
medical concerns about
playing with
sticking together
Gerber
Good Start
Good Start Protect
Good Start Soothe
Good Start Soy
Pediatric Electrolyte
GERD. See Gastroesophageal reflux
German measles, described
Germs
breastfeeding and
good
spreading
Giardia
returning to childcare/playgroups after
Ginger, uses of/precautions with
Gingivostomatitis
defined
Girl parts: checking
cleaning
Glands, swollen
Glans
Glaucoma, defined
Glucose
Gluten
Glycerine bullet, using
GMOs. See Genetically-modified foods
Goop, eye
Gourmet, The: described
Grains
fiber in
servings of
Great Binky Debate
GREENGUARD
Gripe water
Gross motor skills
2 to 4 months
4 to 6 months
6 to 9 months
9 to 12 months
delays in
described
Group A Strep
Group B Strep
overview of
Growth
catch-up
 concerns about
Down syndrome and
infant
preemies and
spurts
Growth charts
boys (birth to 24 months)
dropping off
girls (birth to 24 months)
preemie
Growth percentiles, drop in
Growth plates
Grunting
Grunting Baby Syndrome
Guilt, initiative vs
Guns, safety with
Gunter, Jennifer
Gut absorption, environmental hazards and
Guthrie, Robert
Gymboree

Haemophilus influenza
Haemophilus influenza B (HIB)
aluminum in
described
vaccine for
Haemophilus influenza B (HIB) vaccine, described
Haemophilus influenza non-typable
Hair, on ears/back
Hale, Thomas
HALO Innovations
Hand cleansers, triclosan-containing
Hand, foot, and mouth disease
described
overview of
returning to childcare/playgroups after
Hand sanitizers
Happiest Baby on the Block (Karp)
HDL
Head: banging
 CT/MRI for
examining
growth of
shape of
support
ultrasounds for
Head circumference: boys
girls
Head control
car seats and
Head injuries
CAT scan and
red flags with
Head size
autism/mercury poisoning and
large
measuring
Head Start, autism and
Headaches
Health concerns
environment
exposure to
Health insurance
changing
coverage by
lactation services/breast pumps and
vaccinations and
Health privacy laws
Health records, electronic
Healthcare
deciding on
outpatient/inpatient
pediatric
Healthy Sleep Habits, Happy Child (Weissbluth)
Hearing, milestones with
Hearing loss
conductive
congenital
Hearing screen
 described
Heart: examining
medical concerns about
normal
ultrasounds for
Heart attack
Heart defects
Down syndrome and
web sites on
Heart disease
congenital
Heart murmurs
benign
defined
transitional
Heart rate
Heart rhythm disturbances
Heartburn
acid reflux and
Heat rash
Height
predicting
weight and
Heimlich maneuver
Hemangioma. See Strawberry Hemangioma
Hematocrit
Hematoma: eruption
septal
subungual
Hemoglobin
Hemolytic Uremic Syndrome (HUS)
defined
Hemophilia
defined
Hemorrhages: brain
defined
intraventricular
subconjunctival
Hemorrhagic disease of the newborn
 defined
Hemphill, Jim
Hemphill, Meredith
Henoch-Schonlein Purpura (HSP)
defined
Hepatitis
Hepatitis A
described
screening
Hepatitis A vaccine
aluminum in
described
Hepatitis B
described
infection with
screening for
Hepatitis B vaccine
aluminum in
described
Hepatitis C
screening for
Herbals
breastfeeding and
colic and
drug interactions and
effectiveness of
knowledge about
potency of
precautions with
purity of
safety of
web sites on
Herd immunity
Heredity, environment vs.
Hernia
defined
diaphragmatic
femoral
hiatal
 incarcerated
inguinal
umbilical
Herpes
Herpes Stomatitis
returning to childcare/playgroups after
Herpes Type-1
Herpes virus-6:
overview of
Herpetic whitlow, described
Heterocyclic amines (HCA)
HIB. See Haemophilus influenza B
Hiccups
GERD and
questions about
High chairs
High fructose corn syrup (HFCS)
Hill, Linda
bottles and
breastfeeding and
latching and
plugged ducts and
Hindmilk
defined
foremilk and
Hip dysplasia
defined
risk of
HIPAA
Hips: problems with
testing
ultrasound for
Hirschsprung’s disease
defined
Histamine 2 Receptor Antagonists
Histamines
defined
HIV
screening for
 web sites on
Hives
Holding
Holistic Pediatrician, The (Kemper)
Home: delivering at
pollutants in
toxins in
Homeopathic Pharmacopeia of the United States (HPUS)
Homeopathy
Honest Co.
Honey, avoiding
Hormones
autism and
avoiding
blood and
growth
levels
rashes and
Household Products Database
Housekeepers, hiring
HPV. See Human Papilloma Virus
HSP. See Henoch-Schonlein Purpura
Huggies Naturally Refreshing Cucumber & Green Baby Tea Wash, formaldehyde and
Huggins, Kathleen
Human Milk Banking Association of North America
Human milk fortifiers
Human Papilloma Virus (HPV)
circumcision and
defined
intercourse and
Human Papilloma Virus (HPV) vaccine
Hume, Mary C.
Humidifiers
Hunger: cues
drive
GERD and
strikes
HUS. See Hemolytic Uremic Syndrome
Hydration
Hydrocele
defined
Hydrocephalus
defined
Hydronephrosis
Hydroureter
Hygiene
circumcision and
good
products
Hygiene Hypothesis
Hyland’s Teething Tablets, recall of
Hyperbilirubinemia
Hypercholesterolemia
Hyperthyroidism
Hyphemia
Hypoallergenic
Hypoglycemia
Hypospadias
defined
Hypothyroidism
defined

I-GERD score
IBD. See Inflammatory bowel disease
iBreastfeeding.com
Ibuprofen
dosing
fever and
taking
Identity, role confusion vs.
Idiopathic Thrombocytopenic Purpura (ITP)
defined
IgA levels
IgE levels
IgG levels
Ileus
ILikeMyTeeth.org
Illnesses
chronic
 first signs of
food-borne
frequency of
missing work for
parent at home and
sharing
sleep and
vaccines and
viral
Imaging studies
Immune compromise
vaccinations and
Immune disorders
Immune response
vaccines and
Immune systems
fever and
vaccines and
viruses and
Immunity
herd
zinc and
Immunization schedule
ImmunizationInfo.org
Imodium
Imperforate anus, defined
Impetigo: described
overview of
returning to childcare/playgroups after
Inborn Errors of Metabolism
defined
Independence
Industry, inferiority vs.
Infant Formula Act
Infant scales
Infant Swimming Resource (ISR)
Infections
amoeba
antibiotics and
 bacterial
bladder
blood
breast
ear
exposure to
eye
fungal
home
itchy
kidney
localized
lung
middle ear
mite
nipple bacterial
preemies and
preventing
rashes and
respiratory
responding to
secondary
sexually transmitted
sharing
sinus
skin
strep
throat
TORCH
umbilical cord
urinary tract
viral
womb
yeast
Inferiority, industry vs.
Inflammation
Inflammatory bowel disease (IBD)
defined
Influenza
 complications from
described
exposure to
overview of
returning to childcare/playgroups after
symptoms/length of
types of
vaccine for
wintertime and
Influenza vaccine
described
preemies and
pregnancy and
preservatives and
thimerosal-free
Ingestions
Initiative, guilt vs.
Injuries
body
questions about
Insect repellent
Insecticides, indoor
Institute of Medicine (IOM)
Insulin, impaired response to
Intellectual development
at 9 months
at 1 year
Intercourse, HPV and
International Committee on Taxonomy of Viruses
International Lactation Consultant Association (ILCA)
International Pediatric Sleep Education Task Force
Interventions
autism and
development and
Down syndrome and
partial wakenings and
sleep
temperament and
Intestinal obstruction
 defined
Intestines
formation/abnormal
probiotics and
Intoeing
Intolerance
lactose
food
milk
Intraventricular hemorrhage (IVH)
defined
Intussusception
defined
Iodine deficiency
IOM. See Institute of Medicine
iPhone Oto HOME app/scope
IPV
aluminum in
Iron
calcium and
deficiency
dietary source of
need for
recommended daily allowance for
sources of
vitamin C and
Iron-replacement therapy
Iron supplements
preemies and
taking
ISR. See Infant Swimming Resource
Itching
ITP. See Idiopathic Thrombocytopenia Purpura
IVH. See Intraventricular hemorrhage
iVillage, Sears and

Jaundice
abnormal
assessing for
breastfeeding and
 defined
described
physiologic
poop and
preemies and
risk for
significant
treating
Jenner, Edward: vaccination and
Jerked elbow
Jock itch
Johnson, Tiffany Journal of Allergy and Clinical Immunology
Juice

Kaiser Family foundation

Kaopectate
Karo cocktail
Karp, Harvey: colic and
Karyotyping
Kawasaki Disease (KD)
defined
Kemper, Kathi J.
Kernicterus
defined
Kiddie
Kidney disease
Kidney infections
Kidney stones
Kidneys: checking
dysfunction of
enlargement of
malformation of
ultrasounds for
King of the Sea
Krum, MK
Kunik, Randy: pacifiers and

La Leche League
Labia
normal
Labial adhesions
defined
Lactase
deficiency/hereditary/transient
Lactation consultants (LCs)
breastfeeding and
finding
help from
Lactic acid, breast milk and
Lactinex
Lactobacillus
Lactobacillus acidophilus
Lactobacillus bulgaricus
Lactobacillus GG
Lactobacillus reuteri
colic and
Lactobacillus rhamnosus
Lactose
Lancet
Language
development/early
multiple
sign
understanding
Language delay
autism and
expressive
receptive
Language skills
birth to 2 months
at 2 weeks
at 2 months
2 to 4 months
at 4 months
4 to 6 months
at 6 months
6 to 9 months
at 9 months
9 to 12 months
 at 1 year
autism and
boys/girls compared
described
expressive
poor
receptive
tantrums and
Lankey, Lori
Lanolin
described
Lansinoh
Lansoprazole
Large muscle: at 2 weeks
at 2 months
at 4 months
at 6 months
at 9 months
at 1 year
Laryngomalacia
defined
Latching
comfortable
poor
Late preterm infants (LPI)
breastfeeding and
clothing for
concerns about
developmental delays and
Lawrence, Ruth
Lazy eye
LCs. See Lactation consultants
LDL
Lead
exposure to
removing
screen
in toys
Lead poisoning
 concerns about
“Learn the Signs. Act Early” (CDC)
Learning impairments
Legs, checking
Legumes
“Let Cry” Plan
Let down
Lethargy
dehydration and
extreme
Leukemia
defined
Levalbuterol
Lice
overview of
returning to childcare/playgroups after
Licorice, uses of/precautions with
Lifestyle
Ligaments, torn
Limits
setting
testing
Linden, Dana
Lipids
Liquids
Little Gym
Liver
failure
function tests
Loberamide
Location, environmental hazards and
Logical thinking
Loratidine
Lotions
dry skin and
Lotrimin AF
Low platelet count
Lower esophageal sphincter
LPI. See Late preterm infants
Lubrication
Lung disease, chronic
Lung infections
overview of
Lung problems, web sites on
Lungs
destruction of
medical concerns about
Luride
Lyme disease
described
Lymph nodes
Lymphocytes
Lymphoma

Macrocephaly
defined
Macrolides
Mad Hatter’s Disease
Madaras, Area
Magnetic fields, exposure to
Magnetic Resonance Imaging (MRI)
Malabsorption
defined
Malnutrition
Malrotation
defined
Manganese
March of Dimes Birth Defects Foundation, contact information for
Mason, Jackie: quote of
Massages
colic and
Masses
Mastectomy
Mastitis
Masturbation
defined
Maternity leave
Mattresses: bacteria and
organic
 SIDS and
Mature milk
arrival of
“Maybe Cry” Plan
Mayo Clinic
McCarthy, Jenny
MCI. See Methylchloroisothiazolinone
MCV 4:
Measles
contagiousness of
described
immunization rates for
outbreak of
treatment for
vaccine for
Meat
organ
organic
Meconium
defined
Meconium aspiration syndrome
Meconium ileus, defined
Meconium plug
defined
MECP2 gene, autism and
Medela pumps, rental
Media: interactive
passive
Medicaid
Medical information
abbreviations/reading
web sites on
Medical passports, immunizations and
Medical problems
answering
MedicAlert
Medication index
Medication tables
Medications
allergy
alternating
alternative
anti-diarrhea and
anti-viral
asthma
bacterial infection
blood pressure
brand-name
breastfeeding and
category 1:
category 2:
category 3:
control
cough and cold
dangerous
dental care
diarrhea
dosing
ear
fever-reducing
generic
infection
off-label
oral
OTC
pain
paying for
pediatric
potency of
prescription
preventive
questions about
rescue
safety with
side effects of
taking
teething
travel and
 vomiting and
Medications and Mother’s Milk (Hale)
Melanin
Memory loss
Meningitis
defined
HIB
meningococcal
overview of
pneumococcal
Meningitis Angels
Menstrual cycles
Mental health
Mental retardation
Mercury
autism and
controversy over
exposure to
Metabolic diseases
testing for
Metabolic disorders
defined
developmental delays and
Metabolic panel, basic

Metabolic screens
described
Metabolic Storage Disease
defined
Metabolism
Methamphetamine
Methanol, ethanol and
Methemoglobinemia
Methylchloroisothiazolinone (MCI)
Methylmercury
exposure to
neurological development and
Metoclopramide
Metric system, conversions from
Microcephaly
 defined
Middle ear, pressure change and
Middle ear infections
bacteria and
described
Milestones
achieving
checklist for
developmental
failing to reach
normal
Milia
defined
Miliaria
defined
Milk
alternative
avoiding
coating from
conventional
evaporated
fever and
goat’s
intolerance for
mature
organic
puberty and
rice
servings of
skim
soy
2%
unpasteurized
whole. See also Breast milk
Milk banks, certified
Milk ducts
Milley, Frankie
Milley, Ryan
Mindell, Dr.
Mindell method, described
Miracle Blanket
Mistrust, trust vs.
Mite infections, overview of
Mites
Mitochondrial disorders
MMR vaccine
autism and
described
preservatives and
Moeller, E.
Moisturizing
eczema and
Molluscum contagiosum, described
“Mommy and Me” community programs
Mommy Wars
“Mom’s Day Out” program, finding
Mongolian Spots
defined
Monitors
Mononucleosis
Monospot
Montagu, Lady Mary Worthy
Montelukast
Moods
More Milk Plus
Moro, Debby
Mortality rates
Mother Earth News
Mother’s Milk Banks
Motor skills
birth to 2 months
2 to 4 months
autism/mercury poisoning and
delays in
tantrums and
Motrin
Mouth: burns
care
 examining
injuries
medications for
Mouth and tonsil viruses, overview of
Mouthwash, antifungal
Movement, sleep and
MRI. See Magnetic Resonance Imaging
MRSA
Mucous
Multiple sclerosis
Multiples
breastfeeding and
sharing and
sleep habits and
sleep through night and
soothing and
Multivitamins
Mumps
described
Mupiricin
Murine
Murmurs. See Heart murmurs
Muscles, medical concerns about
Mutagens, health risks with
My Brest Friend
Mylicon drops

Nails, clipping
Naked Crib
Nannies
described
Naps: birth to 2 months
2 to 4 months
4 to 6 months
6 to 12 months
afternoon
daycare and
feeding and
length of
missed
 preserving
scheduling
Nasal congestion
defined
questions about
Nasal spray
Nash, Ogden: quote of
Nasolacrimal Duct Obstruction
defined
Natal teeth
defined
National Adoption Information Clearinghouse
National Allergy Supply, Inc.
National Association for the Education of Young Children (NAEYC)
National Asthma Education and Prevention Program
National Center for Complementary and Alternative Medicine
National Center on Birth Defects and Developmental Disabilities, contact information for
National Donor Program
National Highway Transportation Safety Administration, car seats and
National Immunization Program (NIP)
National Institute of Allergy and Infectious Diseases
National Institutes of Health (NIH)
alternative therapies and
HCA and
Vitamin D and
National Lead Information Center (NLIC)
National Library of Medicine
National Marrow Donor web site
National Newborn Screening & Genetics Resource Center
National Poison Control Center
National Sleep Foundation
National Toxicology Program
National Transportation Safety Board
National Vaccine Program Office
Native Americans, ear infections and
Natural Society
Nature’s Way
Naturopaths
Nebulizers
Neck: examining
injuries
muscles/tightening of
rotation
stretching
x-rays for
Neck/spine stability screen, Down syndrome and
Neisseria meningitides
NEJM. See New England Journal of Medicine
Neocate Infant
Neomycin
Neonatal intensive care unit (NICU)
Neosporin
Nephrotic syndrome
Nervous system: checking
development of
sleep and
web sites on
Nestle, formula by
Neural tube defects
defined
Neurexin 1 protein
Neurodevelopmental disabilities
Neurofibromatosis (NF)
Neurological concerns
preemies and
Neurological development
methyl mercury and
Neurotoxins
Neutrophils (PMNs)
Nevus Flammeus
defined
New England Journal of Medicine (NEJM)
New Toy Rule
Newborn hold, described
Newborn screening tests
expanded
supplemental
web sites on
Newborns: high-maintenance
low-maintenance
needs of
surviving
NF. See Neurofibromatosis
Nichols, Jill
Nicotine
NICU. See Neonatal intensive care unit
Night terrors
NIH. See National Institutes of Health
NIP. See National Immunization Program
Nipple pain
Nipple shields
Nipples
accessory/supernumerary
air drying
cracked/bleeding
cross cut
enlargement of
flat
healing
inverted
large
older baby
sterilizing
taking baby off
Nitrates
Nitrites
Nitrosamines, conversion to
Nizatidine
Nizoral AD
NLIC. See National Lead Information Center
“No Cry” Plan
No Cry Sleep Solution, The (Pantley)
theory of
Norovirus
overview of
Nose, examining
Nose drops, saline
Nose fractures, displaced
Nose sprays
Nosebleeds
nosepicker’s
syringes and
treating
Numbing drops
Nursemaid’s elbow
Nurses
breastfeeding advice from
Nursing caries
defined
Nursing Mother’s Companion, The (Huggins)
Nutrition
at 4-6 months
at 6-9 months
at 9-12 months
at 1 year
autism and
breast milk and
deficiency in
feedings and
improving
infant
liquid
milestones with
missing
poor
preemies and
solid
sources of
web sites on
Nutrition Committee (AAP)

Obesity
autism and
BMI and
breastfeeding and
childhood
concerns about
 HCFS and
risk of
solid food and
viral infections and
Object permanence
Oblique heads
Obstetricians (OBs)
circumcision and
Obstructed airways, chronic
Occult blood
Odors, checking out
Odwalla apple juice
Offit, Paul
Oil of Lemon Eucalyptus
Ointments
antibiotic
eye
Olive oil
Omega-3
Omega-6
Omeprazole
“Omnibus Autism Proceedings”
Omphalitis
defined
On Becoming Babywise (Ezzo and Bucknam)
theory of
Oppenheimer Toy Portfolio
Oral exploration
Oral herpes stomatitis, overview of
Oral immunotherapy
Oral motor skills
4 to 6 months
6 to 9 months
9 to 12 months
Oral rehydration solution, offering
Orbital cellulitis
defined
Oregon Health and Science University, car seats and
Organic
Organochlorine
Organophosphates
Orothodontic problems
Orthotics
defined
Osteomalacia
Osteomyelitis
Osteoporosis
Otitis externa
defined
Otitis media
defined
Otoscopes
Overdosing, avoiding
Overeating
Overstimulation, preemies and
Overtired
Overweight
Owlet Smart Sock
Oxygen level

PABA
Pacifiers
breastfeeding and
as crutch
dental issues and
ear infections and
Nuk style
orthodontic
SIDS and
sleep and
Soothie brand
speech impediments and
sterilizing
sucking on
thermometer
thumb sucking and
using
PAH. See Polycyclic aromatic hydrocarbons
Pain
 abdominal
breastfeeding
nipple
relieving
Pain medications
narcotic
Palmar grasp
Palmer, Julie DeCamp
Pancreas
Pancreatitis
Pantley, Ms.
Parainfluenza
Paraphimosis
defined
Parasites
intestinal
overview of
“Parent and me” classes
Parent at home
described
Parent directed feedings (PDF)
Parenthood
entering
Parenthood, quote from
Parenting
distracted
guidelines for
rules for
Parenting choices
Parenting styles
Parent’s Choice
ParentsGuideCordBlood.com
Parton, Dolly
Parvovirus
described
overview of
Pasteurization
Patient portals
PCBs. See Polychlorinated biphenyls
PCV 13:
described
PDD. See Pervasive developmental disorder
PDD-NOS. See Pervasive developmental disorder, not otherwise specified
PE tubes. See Pressure Equalization tubes
Peanut butter
“Peanut challenge” test
Peanuts
avoiding
Pediaflor
Pedialyte
Pediarix
Pediasure
Pediatric intensive care units
Pediatricians
adoption and
breastfeeding and
calling
emergencies and
hospital-based
medical problems and
meeting
office-based
on-call
questions for
relationships with
schedules of
selecting
visits to
Pediatrix
Pediculocides
Pee
blood in
odors/described
red
tracking newborn
Pelvis, CT/MRI for
Penicillin
resistance to
Penile adhesions
defined
Penis
circumcision and
healing of
hidden
normal
uncircumcised
Pentacel
Peppermint
uses of/precautions with
Pepto-Bismol
poop and
Perchlorate
Perfumes
Periodic breathing
defined
Periodontal disease screening, Down syndrome and
Permissive parenting, described
Personality
temperament and
Personality development
2 to 4 months
4 to 6 months
6 to 9 months
9 to 12 months
Pertussis
described
vaccine for. See also Whooping cough
Pervasive developmental disorder (PDD)
defined
Pervasive developmental disorder, not otherwise specified (PDD-NOS)
Pesticides
avoiding
exposure to
fruits/vegetables and
Petechiae
bruising and
questions about
Petroleum jelly
Pharmaceutical companies
Phenergan
Phenylephrine
Phenylketonuria (PKU)
defined
Phimosis
defined
Phosphorous
Phototherapy
defined
Phthalates
Physical therapists
torticollis and
Physicals, school/camp/sports
Physician assistants
Phytoestrogens
Piaget, Jean
Picardin
Picky eaters, dealing with
Pierced ears
Pigeon toeing
Pigment
Pincer grasp
Pink eye
ear infections and
overview of
returning to childcare/playgroups after
Pinworms
overview of
returning to childcare/playgroups after
Pityriasis rosea, described
PKU. See Phenylketonuria
Placentas
Plagiocephaly, positional
Plants, dangerous
Plaque
Plastic
Playgroups
Pleasure zones, exploring
Plugged ducts
described
Pneumonia
concerns about
defined
medications for
overview of
weather and
Pneumonia vaccine
Point and grunt skill
Poison Control
Poison ivy
Poisonings
Poling, Hannah
Polio
described
Polio vaccine
Pollutants
Pollution, air
Poly-Vi-Flor
Poly-Vi-Sol
Poly-Vi-Sol with Iron
Polychlorinated biphenyls (PCBs)
Polycyclic aromatic hydrocarbons (PAH)
Polydactyly
defined
Polyethylene glycol
Polymyxin B
Polyps
Polysaccharides
Polysporin
Polyurethane foam
Polyvinyl chloride
Poop
allergies and
appearance of
bacteria in
bilirubin and
 black
black tar
blood in
blue
breast milk and
breastfeeding and
brick dust
brown
bulky
changes in
color of
diarrhea and
feedings and
food and
foremilk and
formula and
frequency of
grape jelly
green
jaundice and
mucous in
newborn
odors/described
preemies and
red
solid
texture of
washing out
white/clay-colored
worrisome
yellow
Port wine stains
defined
Positional plagiocephaly
Positions
Positive parenting, described
Posterior urethral valves
defined
Postpartum
Postpartum depression, red flags with
Post-tussive emesis
defined
Potassium
PPIs. See Proton Pump Inhibitors
Preauricular pits and tags
defined
Prebiotics
Preemies
autism and
breastfeeding and
caffeine and
calorie needs for
challenges for
concerns about
developmental checklists for
formula and
iron supplements and
medical issues for
sleep through night and
solid food and
soy formula and
special situations with
Preemies Primer, The (Gunter)
Preemies: The Essential Guide for Parents of Premature Babies (Linden)
Pregnancy
categories of
closely spaced/autism and
flu vaccine and
Premastication
Prenatal care
Prenatal consultations
questions for
Pre-operational development, 2 to 7 years
Preschools
Prescriptions
Preservatives
described
Pressure Equalization tubes (PE tubes)
 understanding
Prevacid
“Preventing or Delaying the Onset of Food Allergies in Infants”
Prevnar
aluminum in
described
vaccine for
Prilosec
Primary care providers, meeting
Priorities: checking
setting
Probiotics
antibiotics and
colic and
described
diarrhea and
effectiveness of
formula with
using
Procrastinator, The: described
Progressive waiting
and rapid extinction compared
Prolactin
Protein
abnormal
breast milk and
comfort
cow’s milk
egg
servings of
soy
Protein hydrolysate, calories from
Proton Pump Inhibitors (PPIs)
Protopic
Prozac
Pseudoephedrine
Pseudostrabismus
defined
Psychiatric, autism/mercury poisoning and
Puberty
bladder infections and
bovine growth hormone and
milk and
Public hair
Public health
Pulmicort
Pulse
Purified protein derivative (PPD)
Pustular melanosis
defined
Pyelonephritis
defined
Pyloric stenosis
defined
Pyrethroids

Quality time, importance of

RabAvert
Rabies
Radiation
Radio frequencies
Radionuclide DMSA scan
Radon
Raising Arizona, quote from
Raking
Rantidine
Rapid antigen assays
Rapid extinction
and progressive waiting compared
Rash-o-rama
Rashes
allergic reaction
contagious
food allergy
non-blistery
non-descript
pimply
questions about
 scaly
viruses causing
worrisome
RAST testing
RBGH
Reach Out and Read
Reactive Airway Disease, asthma and
Reading programs
Red Cross, swimming and
Reflexes, birth to 2 months
Reflexology, colic and
Reflo drinking cups
Reflux
Refractive errors
defined
Reglan
Regurgitation
Rehydration
Relaxation, sleep and
Remedies: alternative
cough and cold
herbal
home
natural
Repellents, applying
Reproductive system
male/problem with
Residuals, described
Respiratory problems
defined
preemies and
questions about
red flags with
signs of
Respiratory rate
Respiratory Syncytial Virus (RSV)
defined
preemies and
preventing
Respiratory system
understanding
Respiratory viruses, overview of
Rester, The: described
Resuscitation
Reticulocyte count
Retinoblastoma
defined
Retinopathy of Prematurity (ROP)
defined
Retractions
defined
Reverse osmosis
Reye’s syndrome
Rheumatoid arthritis
Rhinovirus
Rhus dermatitis
Rice cereal
arsenic in
calories in
constipation and
formula and
introducing
sleep and
Ricelyte
Ricin
Rickets
defined
Ringworm
described
returning to childcare/playgroups after
Robeez
Rocking
sleep and
Rocky Mountain Spotted Fever
described
Role confusion, identity vs.
Role models
Rolling over
Room sharing
Room temperature, SIDS and
Rooting
defined
ROP. See Retinopathy of prematurity
Roseola
described
overview of
Ross, T.
Rotateq
Rotavirus
described
overview of
Rotavirus vaccine
described
Routine: changing
importance of
RSV. See Bronchiolitis; Respiratory syncytial virus
Rubella
described
vaccine for
Rule of Threes, colic and
Runny noses
S. mutans

Saccaromyces
Saccharin
Sacral dimple
defined
Safety: home
preemies and
vaccine
Safety devices
Safety gates
Safeway
Saline drops
Saliva
Salmonella
overview of
Salt
Sam’s Club
Sandboxes, safety with
Sarcomas, soft tissue
Scabicides
Scabies
described
overview of
returning to childcare/playgroups after
Scarlet fever, described
Scarring
Science: showing
technology and
Scoliosis
Screen time
daily limit on
distracted parenting and
eating and
starting
Scrotum
Seals, breaking
Sears, Bob
Seborrhea
defined
Sebulex
Seinfeld, Jerry: quote of
Seizures
described
febrile
fever and
full-blown
temperature and
questions about
web sites on
Self
Self-esteem
Self-feeding
Self-regulation
Self-soothing
learning
 masturbation and
Sensorimotor development: birth to 1 month
birth to 2 months
birth to 2 years
1 to 4 months
4 to 8 months
8 to 12 months
12 to 18 months
18 to 24 months
Sensory: autism/mercury poisoning and
stimulation
toys for
Sensory processing disorder
defined
Separation anxiety
Sepsis
Serous otitis media
defined
Serving sizes
after age 1:
larger
Severe Combined Immune Deficiency (SCID)
Sexual pleasure, circumcision and
Sexually transmitted infections
Shaking
Shampoos
Shannon, Michael
Sheet savers
Shigella
overview of
Shingles
described
Shoes: buying
corrective
Shopper’s Guide to Pesticides
Shoulder dystocia
defined
Shoulders, examining
Showers
Sick-child policy
Sick visits: appointments for
problem-oriented
well-child visits and
Sickle cell disease
as autosomal recessive disease
defined
web sites on
Side-sleeping
described
SIDS. See Sudden Infant Death Syndrome
Sierra Club
Silber, Seth
Silvadene
Silverstone, Alicia
Simethicone
Similac
Advance
Advance Organic
Alimentum
Expert Care for Diarrhea
Isomil DF
Soy Isomil
for Spit-Up
Total Comfort
Singer, Alison
Singulair
Sinus infections
acute
chronic
and common colds compared
medications for
overview of
Sinuses
CT/MRI for
x-rays for
Sinusitis
Sitting up
Skin
 irritation
medical concerns about
redness in
sensitive
trauma
yellow
Skin adhesives, OTC
Skin disorders, web sites on
Skin infections
medications for
overview of
Skin products
Skin tags
defined
Skin tests
described
Skin turgor, dehydration and
Skulls: fractures
malleable
x-rays for
Slapped cheek
overview of
Sleep
birth to 2 months
birth to 2 years
2 to 4 months
4 to 5 months
4 to 6 months
6 to 12 months
after 12 months
activity/noises
behavior problems and
breastfeeding and
car rides and
changes in
development and
disrupted
Down syndrome and
feedings and
 GERD and
illnesses and
lengthy
movement and
nervous system and
newborn
non-REM
pacifiers and
parental
parental behavior and
preemies and
questions about
relaxation and
REM
rice cereal and
science of
side
skin-to-skin
statistics on
teething and
travel and
Sleep associations
Sleep clusters
Sleep crutches
Sleep cycles
length of
Sleep deprivation
Sleep diary, using
Sleep disorders
interventions and
outgrowing
persistent
Sleep disturbances
overtired and
Sleep gurus, compared
Sleep habits
multiples and
poor
struggling with
Sleep patterns
changing
developing
disrupted
erratic
Sleep position
head shape and
inclined
SIDS and
Sleep positioners, thoughts on
Sleep problems
long-term
newborn
Sleep routines
commandments of
consistent
deciding on
establishing
healthy
mistakes with
Sleep safety
Sleep schedule
inconsistent
Sleep through night
food and
multiples and
preemies and
rice cereal and
Sleep Tight
Sleep training
attempts at
impact of
one-size-fits-all
Sleep walking
Sleeping Through the Night (Mindell)
theory of
SleepSack
Slings
Slow to warm up child, described
Small gestational age
Small muscle: at 4 months
at 6 months
at 9 months
at 1 year
Smallpox
Smallpox vaccine
Smegma
Smoking
asthma and
breastfeeding and
ear infections and
quitting
second-hand
SIDS and
Snacks
Sneezing
Snot, green
Snotty nose
Soap
alternatives to
antibacterial
Dove
moisturizing
Social development
birth to 2 months
described
Social skills
birth to 2 months
2 to 4 months
4 to 6 months
6 to 9 months
at 9 months
9 to 12 months
at 1 year
Soft spots
Solitary sleep, family bed versus
Solka, Shelley
Solve Your Child’s Sleep Problems (Ferber)
 theory of
Solvents
Soothing
sucking and
temperament and
tricks for
Sorbitol
Sore throats
home remedies for
Soy
Soy formula, ADD and
Space heaters, ventilating
Speech: autism/mercury poisoning and
pacifiers and
Speech therapy
Sphincter muscle
Spina bifida
defined
Spinal cord, development of
Spinal fluids
Spinal manipulations
colic and
Spinal taps
Spine: checking
damage
ultrasounds for
x-rays for
Spit up
reflux and
worries about
Spleen
Staph
Steenhagen, Deb
Stem cells
cord blood and
Sternocleidomastoid muscle
Steroids
eczema and
inhaled
 potency of
risk of
Stevens-Johnson Syndrome
defined
Stewart, Jon
Stitches
Stomach sleeping, SIDS and
Stomach virus
diarrhea and
returning to childcare/playgroups after
Stomachaches
concerns about
Stool
described
odors
Stork bite. See Nevus Flammeus
Stough, Wendy
Strabismus
defined
Stranger anxiety
Strawberry Hemangioma
defined
Strep bacteria
Strep pneumoniae
described
overview of. See also Group A Strep; Group B Strep
Strep pneumoniae vaccine, described
Strep throat
amoxicillin and
medications for
Streptomycin
Stress
Stridor
defined
Strokes
Strollers, rides in
Sturge-Weber syndrome
defined
Styes, home remedies for
Subconjunctival hemorrhage
defined
Subsalicylate
Succinic acid
Sucking
finger
lip
soothing and
thumb
tongue-tie and
Sudafed
Sudden Infant Death Syndrome (SIDS)
bed sharing and
breastfeeding and
campaign against
family bed and
mattresses and
pacifiers and
potential for
preventing
risk for
room temperature and
sleep position and
smoking and
stomach sleeping and
suffocation and
ventilation and
Sudden Unexplained Infant Death (SUID)
Suffocation
Sugar
breakdown of
colic and
lactose
SUID. See Sudden Unexplained Infant Death
Sulfa
Sulfonamides
Sun block
Sun damage
Supplementation
 breastfeeding and
exhaustion and
nutritional
thoughts on
Support groups, finding
Suppositories
Supraventricular Tachycardia (SVT)
defined
Suprax
Surgery
reconstructive
SurgiSeal
Survival guide, two-week
Sutures
SVT. See Supraventricular Tachycardia
Swaddling
instructions for
Swallowing
Sweat tests
Swelling
Swim classes, infant
Swim Ear
Swimmer’s ear: described
and ear infections compared
prevention drops
Swine flu, vaccination for
Swings
Symmetrel
Synagis
Syndactyly
defined
Syphilis
Syringes

Tachypnea of the Newborn (TTN)

Talk time
screen time and
Talking
Tamiflu
Tantrums
Target, formula from
TB. See Tuberculosis
Tea tree oil, uses of/precautions with
Tear ducts
Tearing, constant
Technology
Teeth
arrival of
cleaning
decay/sippy cups and
injuries to
Teething
biting and
diarrhea and
drool and
fever and
fussiness and
natural
relieving pain of
sleep and
Teething gels
Teething necklaces
Teething tablets
Television
bedrooms and
educational
food and
Temperament
as cake mold
discipline and
figuring out
interventions and
personality and
soothing and
thoughts on
Temperature
increase in
instability
preemies and
 rectal
regular
seizures and
taking
time of day and
Temporal artery scanners
Tempra
Teratogens, health risks with
Terrible Twos
Testes: swollen
ultrasounds for
undescended
Tests
abnormal
additional
adoption and
doctor requests for
early
optional
parental requests for
recommended
screening
Tetanus
described
Tetanus vaccine
Tetracycline
Texture
Thermometers
digital
ear
glass mercury
oral
pacifier
rectal
using
Thimerosal
autism and
controversy over
influenza vaccine and
Thirst drive
Thompson, Judithe A.: quote of
Throat
examining
Thrush
Thumb sucking
pacifiers and
Thyroid
function tests
Thyroid screen, Down syndrome and
Thyroid Stimulating Hormone (TSH)
Thyroxine
Thyroxine Binding Globulin
Tide Free
Tincture
Tinea capitis
Tobacco
Toes, injured
Toilet training
Tongue thrusting
Tongue-tie (ankyloglossia)
Tongues
injuries
Toothpaste
TORCH infections, defined
Torticollis
defined
Total Baby
Touchpoints (Brazelton)
Towels
Toxic Substance Control Act (1976)
Toxic Toy Fiasco
Toxins
autism and
exposure to
Toxoids, vaccine for
Toxoplasmosis
Toys
birth to 6 months
 6 to 12 months
cause and effect
finding
lead in
safe
Toys R Us
Transient Tachypnea of the Newborn (TTN), defined
Transitional objects
Transmitted upper airway noise
defined
Trauma
questions about
Travel: ear infections and
feeding and
lowering expectations with
sleep and
Travel health, web sites on
Tri-Vi-Flor
Tri-Vi-Sol
Trial of Infant Response to Diphenhydramine (TIRED)
Triclosan
Triglyceride level
Trihibit
Triiodothyronine
Tripedia
Triple Paste
Truman, Harry S.: quote of
Trust: developing
mistrust vs.
TTN. See Tachypnea of the Newborn Fever
Tuberculosis (TB)
defined
screening for
vaccine for
Tucker Sling
Tummy time
flat heads and
SIDS and
torticollis and
Tumors
abdominal
brain
Twain, Mark: quote of
Twelve Hours’ Sleep by Twelve Weeks Old
“Two stop” rule
Tylenol

Ulcers
Ultimate Crib Sheet
Ultrasounds
fetal
hip
prenatal
Umbilical cord
checking
cleaning
cutting
infection with
Unilateral laterothoracic exanthem, described
Upper GI
bleeding
Upper respiratory infections
ear infections and
home remedies for
Urethra
Uric acid crystals
defined
Urinalysis
Urinary tract defects, congenital
Urinary tract infection (UTI)
defined
medications for
overview of. See also Bladder infections
Urination
Urine
cloudy
dehydration and
described
flow
 foul smelling
sterility of
testing
U.S. Department of Agriculture (USDA)
U.S. Department of Health and Human Services
U.S. News and World Report, on obesity
USA Today
UTI. See Urinary tract infection
UVA/UVB sunrays

Vaccination Revealed (Butler)

Vaccination schedules
alternative
Vaccinations
adoption and
civic duty and
colds and
declining
delays with
disease/mortality rates and
fever/rash and
first set of
health insurance and
lessening pain with
optional
preemies and
primary
protection from
rates of
records of
red flags with
required
routine
side effects of
success with
types of
viral infections and
web sites on
Vaccine Adverse Event Reporting System (VAERS)
Vaccine Education Center
Vaccine Injury Compensation Program (VICP)
Vaccines
acellular
additives in
all-inactivated
aluminum in
autism and
combination
controversies over
described
effectiveness of
exemptions for
immune response and
impact of
inactivated
invention of
live attenuated
mercury and
misinformation on
preservatives in
questions about
reactions to
research on
respect for
risks of
safety with
school entry and
shortage of
successful
too many/too soon
truths about
web sites on
whole cell
Vaccines and Your Child. Separating Fact from Fiction (Offit and Moser)
Vaccines For Children (VFC)
VAERS. See Vaccine Adverse Event Reporting System
Vagina
Vaginal delivery, herpes and
Vaginal discharge
 defined
Vapo-rubs
Vapocoolants, using
Vaporizers
Varicella
described
overview of
Varicella vaccine
described
Vaseline
VCUG. See Voiding Cystourethrogram
Vegetables
fiber in
organic
peeling
pesticides in
scrubbing
servings of
Ventricular Septal Defect (VSD)
defined
Vernix
defined
Very low birth weight (VLBW)
Vesicles
defined
Vesicoureteral reflux (VUR)
defined
Vi-Daylin
Videos
Viral exanthems
overview of
Viral gastroenteritis
overview of
Viral infections
average number/year
detecting
diagnosis with
fever and
length of
 obesity and
passing
preventing
Viral rashes, returning to childcare/play-groups after
Viral respiratory infections, listed
Viral titers
Viruses
antibiotics and
bacterial infections and
described
ear infections and
exposure to
fall
gastrointestinal
infection by
mouth and tonsil
rashes and
spring
summer
vaccines and
winter
Vision: birth to 2 months
2 to 4 months
6 to 9 months
autism/mercury poisoning and
development of
milestones with
Vision screen
described
Down syndrome and
Vital signs
Vitamin A
yellow skin and
Vitamin B12
Vitamin C
iron and
juice and
Vitamin D
deficiency in
 drops
formula and
supplementing
Vitamin K
Vitamins
anemia and
breast milk and
injections
multi-
preemies and
prenatal
supplements
Voiding Cystourethrogram (VCUG)
Volatile Organic Compounds (VOCs)
Vomiting
active
allergies and
blood
breastfeeding and
coffee grounds
dehydration and
diarrhea and
drinking and
feeding and
fever and
fussiness and
headaches and
home remedies for
medications and
morning
persistent
projectile
questions about
red flags with
Von Lengerke, S.
Von Willebrand Disease
defined
VSD. See Ventricular Septal Defect
VUR. See Vesicoureteral reflux
Wakenings: abnormal
night
partial
Walgreens
Walkers
Walking
Wall Street Journal
Wal-Mart
formula from
Warehouse clubs, formula from
Warts, home remedies for
Water
bacteria in
boiling
bottled
distilled
drinking
filtered
fluoride and
pollutants in
well
Waterpik
WBC. See White blood cell count
Weaning
Web sites
reliable
Weight
concerns about
height and
low birth
percentile
Weight gain
checking
newborn
Weight loss
breastfeeding and
dehydration and
diet and
excessive
 newborn
Weissbluth, Dr.
sleep physiology and
theory of
Weissbluth Method, described
Well-child visits
arriving early for
immunizations and
length of
questions about
scheduling
sick visits and
vaccinations and
West, Mae: quote of
West Nile Virus (WNV)
Wet nurses
Wheat
Wheezing
chronic
Whey, casein and
Which Toys for Which Child: A Consumer’s Guide for Selecting Suitable Toys, Ages Birth
Through Five (CPSC)
White blood cell count (WBC)
White, E.
WHO. See World Health Organization
Whole Foods
Whole milk
calories from
drinking
Whooping cough
catching
described
epidemics of
outbreak of
vaccine for. See also Pertussis
Williams, Bern: quote of
Wills, making
Witch’s Milk
WNV. See West Nile Virus
Womanly Art of Breastfeeding, The (La Leche League)
Work
breastfeeding and
family life and
hidden costs of
World Health Organization (WHO)
circumcision and
growth charts from
influenza virus and
smallpox and
Worms
Wounds: cleaning/caring for
infected
Wright, Karen L.
Wrists, broken

X chromosome, autism and

X-rays
Xylene

Yeast: overgrowth of
treating
Yeast diaper rash
described
Yeast infections
Yellow fever vaccine
Yersina infection
YF-VAX

Zantac
Zarbee’s natural baby cough syrup
Zegerid
ZERO to THREE: National Center for Infants, Toddlers, and Families, contact information
for
Zilactin Baby
Zinc
uses of/precautions with
Zinc oxide
Zofran
Zovirax
Zwiener, R. Jeff
Zyrtec
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