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Daily Dose

Baby's First Foods

1:30 to read

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

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

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

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

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

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

 

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

Daily Dose

Babies & Bow-Legs

1.15 to read

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

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

Daily Dose

Flying With A Baby

1:15 to read

Overheard on the plane this week:  I am in row 15 and there is the cutest most precious 4-5 month old baby girl behind me in row 16.  Key point….she is sleeping as we are making our approach!

 

The mother of the baby is traveling with her mother so there are is a grandmother along to dote on this darling baby. The mother of the baby says to her mother…”we need to wake her up now!!!”  “Mom, please wake her up as we need to feed her NOW!”  At this point the mother takes out a whisk of some sort to put into the breast milk…do you have to mix with a whisk now?

 

So…of course they wake up the baby who starts to cry, but just a bit…and then the grandmother starts to feed the baby the bottle.  The mother is saying, “Mom, just make her eat”.  Now it is really bumpy as we are getting ready to land and I was wishing I had a bottle to calm me too!

 

The baby seems to be quietly eating, but then must have stopped eating as now the mother of the baby takes the baby from the grandmother and starts to try to give her daughter the bottle.  She starts talking to the baby saying, “ please keep eating so your ears will stay clear” followed by “Mommy is going to drink the bottle, so you can see me keeping my ears clear too”.  “If you keep sucking your ears will be pain free”. 

 

Everything seems to be going well…although we still have not landed, when the mother says “I am going to force feed you to keep your ears clear!”  Uh…oh I am thinking, I know where this may be going.  But it seems so far, so good. 

 

Just as we are about to touch down I hear this gurgling noise from behind me and then the mother saying, “Oh dear she is spitting up!!”   Really, are you shocked??

 

But…I must say, the baby was quiet and content…who knows, I would have never awakened that sweet baby girl, but then again, I still believe, “never wake a sleeping baby”, even on an airplane.

 

 

 

Daily Dose

Big Breasts in a Newborn?

Why do some newborn babies have large breasts? Should parents worry?I recently saw a new baby for their 2 week old check up.  During this visit there are many questions about what is “normal” and what is “abnormal”, as new parents are just finding out the nuances of their baby.

While all babies are different, there are many similarities among a newborn. One of the most commonly asked questions is “why does my baby look like they have breasts?”  This is even a more common question when the infant is a baby boy. Many parent’s will notice that their baby seems to have swelling under their nipples, sometimes it is both nipples at other times it may be asymmetrical.  There should not be any redness and the area should not be tender.  If you are feeling the area you may note a small moveable mass beneath the nipple.  All of this is very normal and the benign breast enlargement is due to maternal hormones that influences the baby’s breast tissue. At times parents may even report that they have noticed a milky substance coming from the baby’s nipple.  This is called galactorrhea, and the neonatal milk is also known as witch’s milk.  Galactorrhea is seen in about 5% of newborns and occurs in both sexes. The term “witch’s milk” is derived from ancient folklore where the milk was thought to be nourishment for witches spirits.  (I guess we’ve come a long way in our medical knowledge). Infant’s who seem to have galactorrhea seem to have more breast enlargement, and is also seen more often in babies who are breastfed. In most cases the breast enlargement resolves spontaneously within several months.  No treatment is necessary and I tell parents not to press on the baby’s breast tissue.  If you manipulate the breast tissue it may actually force bacteria into the milk glands. If the breast tissue gets infected an infant may develop mastitis, just like a nursing mother.  I actually saw a baby earlier this year who had developed a breast infection that actually had to be drained and required IV antibiotics and a short hospitalization. I am happy to say that baby is perfectly well, the breast enlargement has resolved and he will never know that he had “baby boobs” in the first month of his life!!!  Some things are better kept as secrets. That’s your daily dose for today. We’ll chat again tomorrow. Send your comment or question to Dr. Sue!

Daily Dose

Safe Sleep & Tummy Time

1.30 to read

I keep getting so many questions about “tummy time”   Ever since the American Academy of Pediatrics recommended that all infants sleep only on their backs (to reduce the chance of SIDS), parents forget or are afraid to put their baby’s on their tummies. Tummy time is important to help reduce the incidence of head flattening as well as to give your baby time to develop different muscle groups.   

Tummy time is encouraged from the first days after a baby’s birth, but so many parents ask, “just how much time?”  Tummy time does not mean “timed” in the sense that you do it for a certain amount of time or minutes a day.  Tummy time, is not rigid.....it is flexible.  Off and on throughout the day when your baby is awake, you let them experience tummy time.   

Just like so many activities with a newborn, sometimes tummy time is for only a minute or two before the baby starts to fuss or cry.  Other times an infant may enjoy their tummies for 10- 20 minutes before they are ready for a change.  

At other times you put the baby on their tummy, they settle down and then decide to fall asleep.  Keep in mind, you MUST turn them over, even if you are watching them. Remember, NO TUMMY sleeping until your child rolls over on their own. 

So, many parents come in during the first days to weeks after their baby’s birth with not only feeding charts, but “pee and poop” charts and graphs of tummy time down to the minutes.  It is really not necessary to graph the amount of tummy time your baby gets, just make sure you remember to do it.  

As your baby gets older, they typically enjoy their tummies for longer periods of time and are soon lifting their heads, supporting themselves with their shoulders and around 4 months will likely begin to roll from tummy to back. After that milestone it is not long before they start sitting alone and tummy time is old hat by then.  Your baby should also have a beautiful rounded head from getting tummy time from the start. 

Daily Dose

Learning to Crawl

1.15 to read

Back to more funny office stories - they really keep my job interesting and always a little bit of fun. 

Many of my “new” young parents worry (haven’t we all?) and one of the new comments I have started to hear is “why is my baby not crawling?” Well, for one reason, they are only 6 months old!  I know we are expecting children to achieve some milestones at younger and younger ages, an example of this is reading.  But while not all children are ready to read at 4-5 years, MOST children do not crawl until they are around 9 months of age. 

I am suddenly having moms and a few dads ask me how to “teach their baby to crawl”?   What???  This is new to me.  I wish I could remember   each of my own children as they learned to crawl. It is just a foggy memory now, but I do remember that suddenly they were mobile, and that changes everything! 

Babies instinctively want to move and explore their environment. For most babies, if you have been doing “tummy time”, which is followed by your baby learning to sit, they suddenly figure out how to go from the sitting position back to their tummy.   Why?  That maneuver is the precursor to learning to crawl.  They just do it!  You need to put them on the floor and let them figure it out. You DO NOT need to crawl around the house.  

While you will have to help “teach” your child to walk, in a manner of speaking, they WILL just crawl if given the opportunity.  That means putting them down and letting them figure out how to move. I had one mother who asked me if “her baby could sit in the grass?”  She was afraid to even let the child touch the ground. Other parents are worried that it is “too dirty” for their child to sit on the floor and crawl.  The world is full of dirt, grass and who knows what else, but children have to spend some time on the floor to learn to crawl.   

Take home message....no instructions for a baby to crawl, they just figure it out, and we parents figure out that some of the things our wonderful children accomplish are despite us!

Daily Dose

Kidney Reflux in Children

1.30 to read

Have you ever heard of vesico-ureteral reflux (VUR)? This is a problem that I have be seeing lately which occurs in the urinary tract.

In the normal scenario urine is produced in the kidneys and then travels through the ureters (which are like a straw) from the kidneys to the bladder. The urine is supposed to only proceed in one direction, and only down and into the bladder and then out the urethra when you urinate. But in some children, the kidneys are fine and doing their work of making urine but the ureters (the straws) allow the urine to go in a retrograde fashion (both up and down, or back and forth or whatever terminology you want) from bladder to kidney,  and this is termed vesico ureteral reflux (not to be confused with gastro-esophageal reflux).

Vesico-ureteral reflux is often diagnosed in infants and young children who present with prolonged fever which may be an indicator of a urinary tract infection.

When a child under the age of 2 has persistent fever (usually over 72 hours), without any other focus of infection, a urinalysis and culture is often performed to rule out a urinary tract infection. It is also more prevalent to see this occur in little girls rather than in boys.

If a urinary tract infection is confirmed it was previously the “standard of care” to perform a VCUG (voiding cystourethrogram) which is a radiographic study where dye is injected via a catheter into the bladder to look for retrograde flow of urine (the back and forth, up and down) to rule out VUR. In the past several months there have been changes in the management of VUR especially as it relates to first urinary tract infections.

The new recommendations state that, “children of any age, regardless of gender, with a first febrile UTI should undergo a renal/bladder ultrasound, rather than a VCUG.”  In other words, no more radiation and dye (not to mention the associated trauma) that went along with the voiding study.

Years ago a VCUG was performed without any sedation, but over time it became standard to sedate the children before this procedure, and with that there were other issues about safety etc.  It was also recommended that a VCUG be done yearly to watch the regression or progression of reflux. That yearly VCUG just sent some kids and parents over the edge (including me!).

The concern with VUR is that over the years this retrograde flow of urine could cause damage and scarring to the kidneys. This scarring could cause numerous problems (high blood pressure, kidney disease etc) for a child later in their life. The problem was figuring out who might go on to scar and need surgery etc.   The new guidelines recommend using a different type of scan in management of reflux.

If your child has a urinary tract infection in association with a fever you might want to discuss whether they should see a pediatric urologist, and/or have an ultrasound. But if someone mentions a VCUG consider the newest guidelines. And, if you have a child with VUR, talk to your doctor about the changes in management and don’t stress about a VCUG this year!

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

Daily Dose

Teething Pain & Recalled OTC Products

Do OTC teething products really work? Which ones have been recalled? WHat parents need to know.I am getting a lot of questions from patients related to teething, pain, and the recall of over the counter teething products that contain benzocaine.

The FDA recently issued a warning to parents who use OTC products like Oragel and Anbesol on their infant’s gums for relief of teething pain. These products come as both liquids and gels, and benzocaine is the active pain reducing ingredient. It has now been found that excessive amounts of benzocaine may lead to a very rare, condition called methemoglobinemia. (Hemoglobin is the molecule in the red blood cell that carries oxygen). With methemoglobinemia there is a reduced amount of oxygen that is carried in the bloodstream which may lead to a bluish gray discoloration to the skin, shortness of breath, a rapid heart rate and fatigue and lethargy. Although the FDA did not withdraw these products from the market, they did recommend that they not be used in children under two, and then should be used “sparingly”. Unfortunately, the benzocaine containing products do not yet contain warning labels. I have never recommended using these products in the first place. I always wondered if they really helped a baby who was teething, as I am not sure you can tell when a baby is teething in the first place. If you watch any infant over the age of 4 months, their hands are always in their mouths, and they are constantly drooling!  Does that mean they are getting teeth? Unlikely, as most babies don’t even cut their first tooth until about 6 months, so they have been drooling and putting anything they can in their mouths for months prior. The drooling and “gnawing” on their hands (and sometimes feet too) is rather a developmental milestone and not always a sign of teething. My theory is let the baby chew on a teething ring, a frozen piece of a bagel (cut into quarters, good for gnawing and can throw out when used), or rub their gums with a cold washcloth if you think your child has discomfort. Babies will get teeth for many years to come and once the first several have broken the skin we don’t seem to pay as much attention anyway, right?  I mean, who is going to worry about a child cutting their 2 year old molars, there are way too many other issues to deal with (tantrums, climbing, throwing food) than if their molars are erupting. So, save your money and don’t buy teething products. Now the FDA even agrees! What do you think? I look forward to your feedback.

Parenting

Breast Feeding

1:30 to read

I recently read an editorial in The New York Times entitled “Overselling Breast Feeding”. It was written by Courtney Jung who is a professor of political science at the University of Toronto.  It was quite interesting to me as she stated “the moral fervor surrounding breast feeding continues unabated, with a steady stream of advocacy and education campaigns”.  The WHO (World Health Organization) developed “ten steps to successful breast feeding” in hopes of increasing breast feeding initiation and duration around the world. Hospitals have been designated “Baby-Friendly”  (aren’t they all supposed to be?)  if they adhere to these steps as well. But the United States has done well with breast feeding rates as 79% of mothers initiate breast feeding.

Most, if not all of the new mothers I make rounds on are proponents of breast feeding. They have read the books, gone to classes and are determined to be successful at breast feeding. But, in my experience over the last several years, I have actually seen more and more new mothers becoming over-wrought and wary of breast feeding fueled by the “rules” that they are being required to follow. With that being said, having someone “tell you that you must breast feed your baby in the first hour after birth”, and that “your baby must remain in your room 24 hours a day“, and that they “may not have a pacifier”, “and should “breast feed on demand” is actually anxiety promoting and leaves many a new mother exhausted and tearful within a day or two of having a baby. 

While breast feeding is “natural” it also requires some practice and the only practice is really “on the job” training.  Some babies just latch on quickly and are pros immediately, but not all babies will become proficient at breast feeding in the first day or two. The mothers are told to “let the baby nurse on demand” and some mothers have had their babies at the breast for hours on end and are exhausted, with sore and bleeding nipples. I have walked in to too many hospital rooms with a mother in tears and a fretful baby, and a “helpless” new father.  Some feel as if “they are failures” as mothers before they even are discharged, and at the same time are having serious doubts about continuing to breast feed.  They are sure that their baby will catch serious illnesses and have a lower IQ if they don’t breast feed, but how can they maintain this constant breast feeding and no sleep and never put a pacifier in their baby’s mouth??? Is there only one way to be successful at breast feeding?

I loved breast feeding but it was a long time ago and we were instructed by caring nurses “to just go home and put the baby to the breast every 2-3 hours”. While that may not have been the best education has the pendulum swung too far?  Will giving the baby one bottle when a mother is having postpartum anxiety and sleeplessness really harm the baby?  Should a mother have to sign an order allowing her baby to have a pacifier??   While guidelines for breast feeding are helpful should they be so rigid that a mother “gives up” on breast-feeding because she can’t follow 10 steps in the first 24-48 hours?   

The New York Times article was quite interesting and I had to agree with many of the author’s  points. Supporting a woman’s choice to breast feed is admirable and “policy changes promoting maternity leave, and flexibility” are definitely needed to encourage women to continue to breast feed. But as she states “is all of this breast feeding advocacy crossing the line?”   A mother should choose to breast feed because she wants to, and that does not mean if her baby does not breast feed in the first hour that she will never bond with her baby or be successful at breast feeding.  Some woman are unable to breast feed for a multitude of reasons and that decision should not label her as a “bad mother”.  Again, breast feeding, like a woman’s breast, is not “one size fits all”. 

 

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