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Daily Dose

New Baby Questions!

1:30 to read

Lots of new baby questions this week in my office, so I that I thought I would cover a few of the most frequently asked by parents within days of bringing that precious newborn home from the hospital. So, here we go:

My baby has blue hands and feet…should I go to the ER?  The medical term for this is acrocyanosis.   It is not uncommon for a baby to have a bluish/purple discoloration to their hands and feet. This often occurs if the baby gets chilled or cold, whether that is after a bath or sometimes even after they are unswaddled to wake them up a bit to get them to eat.  If your baby has pink lips and tongue and seems otherwise fine this is the normal adjustment of a baby’s circulation and may last for a few weeks to months.  When parents are concerned about this and make a trip to the ER where they are discharged with the diagnosis of “worried well”.

What temperature do I need to have my thermostat set?  This question always makes me laugh a bit because some of it is truly dependent on the climate where you live. Many parents think they need to “crank up the heat” for a newborn, but actually a cooler room temperature has been shown to correlate with a reduction in sudden infant death (SIDS).  The “ideal” temperature that has been recommended is around 68 - 70 degrees, but for those of us who live in the south during the dead of summer, it is almost impossible to keep your house this cool and very expensive. At the same time, some parents are uncomfortable during the winter with the thermostat at 68 degrees…so I would recommend keeping your house comfortable and on the cooler side rather than too warm. You also do not need to bundle your baby when it is blazing hot outside, less is more if the house is hot.

What about a pacifier?  Mother’s come in and say, “I was told that I shouldn’t use a pacifier because it will cause “nipple confusion”.  While I am a huge proponent of breast feeding I think that a pacifier is also helpful for a breast feeding mother so that she does not use her own breast as a “human pacifier”. Many new moms come in to see me at the 2 week check up crying, exhausted and with bleeding nipples. They are putting their baby on the breast for hours at a time as “it seems the only way my baby is content”.  Although they were told that they could put their finger in their baby’s mouth as a way to help console their baby, that too does not provide much of a distance from the baby…even to go to the bathroom, take a shower or eat!! A baby has the reflex to suck which is termed, “non-nutritive sucking”.  This is one way that your baby will calm themselves.  So, once your baby is getting on the breast, I would buy a pacifier and “teach” your partner how to hold your baby in the position as if they were going to be fed,  but with a pacifier to suck on rather than the breast. Once situated you can try walking around, gentle bouncing or swaying while your baby is happily sucking on their pacifier. Mother gets a bit of a rest between feedings and infant is happy with a pacifier ( rather than a finger). We will discuss taking away a pacifier at another time! 

 

Daily Dose

FDA Warning for Simply Thick

Does Simply Thick work for reflux? Dr. Sue weighs in. I have been receiving many questions regarding Simply Thick, a thickening agent that is used in formula to aid in swallowing and gastro-esophageal reflux.  The FDA has issued a warning against the products use after a recent investigation.

The product is often used in premature infants as they seem to have more difficulty in coordinating suck and swallow and may aspirate breast milk or formula. It also seems to help with spitting up/reflux. Simply Thick has also been used in full term healthy infants who seem to have a problem with frequent spitting, including inability to gain weight due to their reflux, or even excessive irritability thought to be due to their spitting up and esophageal irritation. There have been recent reports from several medical centers around the United States relating necrotizing enterocolitis and the use of Simply Thick. Necrotizing enterocolitis (NEC) is seen more often in premature infants and causes severe inflammatory changes in the intestine, which may lead bowel perforations requiring surgery to remove the affected intestine, as well as overwhelming infection, and at times death. The FDA is now aware of 15 cases of NEC, including two deaths, involving premies who were being fed breast milk or formula with Simply Thick added. Each of these babies had received the mixture for varying amounts of time. While NEC typically occurs early in the course of a premature baby’s life, some of these cases have even occurred after the baby had been discharged from the hospital and were at home receiving thickened feedings. At this time the link between Simply Thick and babies becoming sick is not known. Bottom line? I would recommend to any patient, stop using Simply Thick immediately, even if your baby was not premature. Why take a risk?  We can go back to thickening feedings with rice cereal if necessary, as it was the standard before Simply Thick was introduced. A little bit messier and time consuming, but rice cereal has been used “forever” with no known problems. That’s your daily dose for today.  We’ll chat again tomorrow.

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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

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.

 

 

 

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”. 

 

Daily Dose

"White Noise" and Babies

1.00 to read

I received an email from Meredith (via our iPhone app) because she had heard that “white noise” might cause a child to have speech/language delays. She used a sound machine in her children’s rooms at night, and was concerned about the possibility of “interfering with their speech”.

So, I did a little research and found an article from the journal Science in 2003.  A study from the University of CA at San Francisco (UCSF) actually looked at baby rats who listened to “white noise” for prolonged periods of time. The researchers found that the part of the auditory cortex (in rats) that is responsible for hearing, did not develop properly after listening to the “white noise”.   

Interestingly, when the “white noise” was taken away, the brain resumed normal development. Again, this study was in baby rats, and to my knowledge has not been duplicated.  But, these baby rats were exposed to hours on end of  "white noise” which may not be the same thing as sleeping with a “sound machine” at night. 

We might need to be more concerned about background “white noise”. We do know that babies learn language by listening and absorbing human speech. They need to hear their parent’s talking to them from the time they are born.  They listen to not only their parent’s speech, but also to siblings, grandparents etc. and from an early age respond to that language by making cooing sounds themselves, often imitating the sounds they have heard. They are also exposed to a great deal of “white noise” or background noise with the televisions being on, computers, telephones, vacuum cleaners, lawn mowers etc. going on all day.  The “white noise” that may be reduced by turning off televisions, videos, computers etc and replacing that background noise with human speech through reading, singing and just talking to your baby and child could only be beneficial. One might surmise that “white noise” in the form of a sound machine at night would not affect a child’s speech development, as this is not a time for language acquisition.

Having a good bedtime routine, reading to your child before bed, or singing them a lullaby will encourage language development, and the sound machine may ensure a good night’s sleep.  Just turn it off in the morning!

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

Daily Dose

Feeding Baby Solid Foods

1.15 to read

I still get a lot of questions about starting solid foods in a baby.  The recommendation from the American Academy of Pediatrics is somewhat confusing as the latest recommendation is that mother’s should exclusively breast feed for the first 6 months of life...which means you do not start solid foods until 6 months.  But, the recommendation for formula fed infants is to begin introduction of solid foods between 4-6 months of age.

I recommend that parents routinely wait until their baby (whether breast or bottle fed) is about 5 1/2 months old to begin solid foods.. For a first baby, parents are really anxious to start cereal as they think it will, “make them sleep all night”, or want to try out all of those spoons people gave them as gifts. Those cute grand parents perpetuate the idea that cereal=sleep. Again, a myth, the majority of children are sleeping by 4 months of age whether breast or bottle fed, and no cereal.  Cereal is less calorie dense than milk! If we all drank breast milk or formula all day long we would definitely have weight problems, but for the first 4-6 months of life milk is all the baby needs.  

Whether you start your baby on solid foods at 4 or 6 months, it is important that you do give your child infant cereal. Whether you want to use rice cereal, oatmeal or mixed grains, baby cereal is iron and zinc fortified. The amount of iron and zinc in fruits, vegetables and even baby food meats is actually very low.  Baby cereals also provide vitamin B and other vitamins that are important for a baby’s nutrition. 

So, for parents who want to make their own baby food fruits, vegies and meats I am all for that. Did you know that there is more iron in pureed cooked meats than in infant prepared jar meats? But not all parents cook and some are uncomfortable in pureeing food at home. 

 At the same time, I encourage families to continue baby cereals for as long as they can.  For first children that may be until they are even 15-18 months of age. They don’t “know” that there are other cereals out there.   Mixing in some fruit will make that baby cereal just taste great as well as increase the absorption of iron.  Those toddlers will learn that we have Cheerios and Corn Flakes, and if it is your 2nd, 3 rd or even 4th child, they know about Cocoa Puffs and Fruit Loops by the age of one and are reaching for their siblings Captain Crunch. 

Birth order does play a role in foods introduction!

Daily Dose

Why Is Your Baby Not Sleeping?

1.15 to read

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

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

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

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

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

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

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

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

Daily Dose

Teething and Fevers

1:15 to read

Does teething cause a fever?  Ask many parents and they will say yes… but a recent study in the journal Pediatrics says no.  Researchers looked at signs and symptoms associated with primary tooth eruption in 3500 healthy children ages 35 months and under.  For most children the first tooth appears around 6 months, but don’t be overly concerned if your child does not cut their first tooth until later, there is still a lot of variability.

In this study 71% of children had some signs or symptoms related to teething including gum irritation, drooling and irritability.   Although about 25% of those studied reported “fever”, the rise in temperature was actually less than the level of 100.4 degrees, which is the definition of fever. About 20% of those studied also reported diarrhea.

The study also showed that the peak of signs and symptoms during teething were reported when the incisors (front teeth) erupted and that symptoms seemed to decrease with age. ( interesting as well, as I wonder if parents were just less focused on teething as their child gets older?).

While many parents will bring their child in to my office complaining that they are teething and have a temperature of 102 degrees, the two issues are not related. I had always been taught that teething does not cause a fever…so this study only serves as further confirmation.  Babies and toddlers are getting many viral infections during the same time that they are “teething” and their illness is the reason for the fever. This means that a child with a fever over 100.4 cannot go to daycare or school, despite the fact that parents want to send them with a note stating, “they are just teething”. 

I continue to tell many parents that their “irritable” toddler is probably just in a bad mood and “being a toddler” rather than attributing their temperament to cutting a tooth.  Once your child is older you begin to realize that teeth come ( and go) and many times you don’t even know it until your child drops to the floor throwing a tantrum and you see those molars have broken through the gums.  The same about sleep issues, as your child will cut teeth when they are 5, 7, 10 years of age and don’t complain that they can’t sleep or have hourly sleep awakenings.  A toddler that has sleep awakenings is more likely to be dreaming than teething, and is not “in pain”.

So when your child wakes up with a fever, don’t be attributing the fever to teething - something else is going on and that is usually yet another viral illness. 

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