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Daily Dose

Cord Blood Banking

1.15 to read

As a practicing pediatrician, I regularly participate in “grand rounds”.  This is doctor lingo for a weekly teaching conference, and grand rounds occur on a regular basis in teaching hospitals all around the country.   Recently, I attended the most interesting and informative “grand rounds” on cord blood banking. 

The topic this week was “umbilical cord blood banking: a safeguard for the future?”  I was really intrigued with the title as I have so many young couples who ask about cord blood banking and many of these couples choose to use private cord blood banks despite the American Academy of Pediatrics recommendations to use public cord blood banks.  But private cord blood banks are really just great advertisers. They play to the emotions of soon to be parents as there is not a parent out there who would not do almost anything (even if expensive) to ensure the long term health of their soon to be born child! 

There are more than 150 private cord blood banks, and 40 public banks. Only 27 states have cord blood banking laws which essentially means that private cord blood banks are not regulated well.  In general, it has been found that private cord blood banks specimens have lower cell counts, the cells may not be of good quality and also have a greater risk of infection. They are often inadequate for use. There are really not that many situations in which these cells would be used at all. In fact there is about a 99.9% chance your child will never need a stem cell transplant, and typically 50% of cord blood specimens which have been stored in private banks are not usable. 

With that being said ,why would you even need a stem cell transplant? The one disease process in which autologous  (meaning your own cord blood) stem cells would be used is if your child developed acquired aplastic anemia.  The incidence of this blood disease is 3/1,000,000 per year.   The chance of being struck by lightening is 1/576,000.  

Other childhood cancers including leukemia, lymphoma etc in which a stem cell transplant may be necessary would use stem cells from acquired from peripheral blood (which is the current standard of care).  These cells may be obtained from the public banks and may be obtained by anyone who is in need of a transplant after going through a matching system. You are not limiting their availability like a private banking situation. They may be used for the “greater good” where there is a much greater likelihood that they will be needed, and stored appropriately. 

So, the “gist” of the lecture was that private cord banks are for profit. While they do a great job of advertising, and play to new parents emotions as a “once is a lifetime opportunity” their claims may be falsely inflated.  The private banks have no published data to substantiate their claims. 

Better to give cord blood to a public bank and invest the money you save from not using a private bank in your child’s education (which you will definitely need in some shape form or fashion).  This seems to benefit the most.

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

Daily Dose

Baby's 1st Tooth

Dr. Sue answers an email whwn will my baby cur her first tooth?I received an iPhone App email from Lilli who was concerned that her son was almost one year of age, and had not cut a tooth yet.  I remember having the same feeling when our middle son had not cut a tooth at 15 months of age and my mother kept reminding me of “toothless” children.

Of course, our first son cut his first tooth at about 7 months of age, so despite trying NOT to compare them, of course I was.  Upon reviewing the literature I was thrilled to find out that there is a wide variation in dental eruption among babies and very few cases of children who never developed teeth! The first teeth to erupt are typically the lower central (middle) incisors, usually somewhere around 6 months of age, although just like many things in child development there may be those who have teeth earlier and those who will not cut a tooth until after their first birthday.  Girls typically cut their teeth before boys (just like pubertal development). Teeth usually erupt in pairs with the two lower central incisors being the first to erupt, then followed by the upper two central incisors and then the upper lateral incisors. Most children will have their full set of “baby teeth” by the age of three years. Personally, I would not worry about it, and not having teeth should not prevent your child from eating finger foods either.  It is wonderful to have a few extra months of that sweet baby breath (teeth make for bad breath) and you don’t have to worry about tooth brushing. It is still a good idea to give your child a toothbrush that they can begin experimenting with if only to brush the gums! That's your daily dose.  We'll chat again tomorrow

Daily Dose

Your Baby's Umbilical Cord

1.15 to read

I get a lot of phone calls several days after parents head home with their newborn regarding their baby’s umbilical cord.  The umbilical cord really is the lifeline for the baby for 9 months, but once the baby is delivered, and the cord is clamped, it becomes a nuisance and “grosses” many parents out.  So often parents don’t even want to touch the cord and one of my patients told me....”why can’t it just dry up and fall off immediately?”. My only answer to that is, “God did not make it that way?”.

So, in a nutshell the umbilical cord is made up of 3 blood vessels, actually 2 arteries and one vein.  When the cord is cut and clamped the vessels begin to clot and eventually the cord detaches, typically in 7-14 days and then falls off.  

In the interim the cord is developing a scab so it may “ooze” a bit and there may even be dried blood on the baby’s diaper or around the edge of the cord.  A tiny bit of blood is to be expected, and parents don’t need to be worried that the baby is bleeding!!!  I like to explain that it is the first time as a parent that you might need to clean off a little blood, the same way that you will again when this sweet newborn becomes a toddler and falls down and skins their knee.

On occasion the hospital forgets to take the cord clamp off before the baby is discharged and the family comes in with the baby for their first visit with the cord clamp still on.  Poor parents have no idea that this is typically removed before discharge...somewhat like leaving the store with the magnetic tag on the outfit....just no alarm to let you know it is still there. In that case they are amazed when we pop off that yellow or blue plastic attached to their baby!

Lastly, the newborn baby can have some time on their tummy, if they are awake, even with the remnant of the cord still on. It will not hurt the baby at all and early tummy time is important...just NOT when a baby is sleeping!

I have to admit that I opened the baby book 30 years later and that dried umbilical stump was in there..Yes, I too was a first time mother.....don’t save it!

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.

Daily Dose

Belly Button Care

1:15 to read

Belly buttons seem to make new parents a bit crazy.  Once the “lifeline” from mother to child is clamped in the delivery room, the umbilical cord really serves no further purpose...other than to cause a lot of anxiety and annoyance for new parents.

I get many questions concerning “how to fold the diaper” and “not rub the cord” or “what if I got a little water on the cord when I gave the baby a sponge bath?”.  I had a text today saying, “the cord is dripping a bit of blood, did we do something to it?” 

It typically takes anywhere from 5-14 days for the cord to fall off. During that time it typically just “sits” there...and dries up. Some hospitals still apply gentian violet to the umbilical cord and others now just leave it alone and let it dry.  Either way....your job is to try to ignore the cord and just let it fall off.

As the cord dries up and it detaches it may bleed a bit...remember the umbilical stump is like a scab.  It is not uncommon to see if few drops of blood or dried blood on the edge of the diaper.  As the cord detaches even more there may be a part that oozes a bit as well....but don’t be concerned, just like a skinned knee your child will have one day...the scab will heal with a bit of time and TLC.

Once the cord falls off you can now give your baby a bath...no more sponge bathing. And don’t worry if the belly button is a bit of an “outy, as it will often change over time unless there is an umbilical hernia...which is yet another discussion.

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

What is Thrush?

1.15 to read

I get a lot of phone calls and questions from worried mothers who have noticed that their baby’s tongue has a bit of white coating and is this thrush?  Thrush is fungal infection of the mouth that is seen in babies (about 2-5% of babies), but thrush typically affects the sides of the inside of the baby’s mouth or under the lips and along the gum line. A white tongue alone is most likely residual milk. 

There are many cases of thrush that are mild enough that they may resolve on their own. On the other hand, a severe case of thrush may be painful and may make it difficult for a baby to feed, which then leads to a fussy, irritable baby. 

Thrush is caused by the fungus candida and despite everyone’s best efforts at cleanliness, candida like bread mold, can just happen.  Candida may be acquired at the time of delivery as the baby passes through the birth canal that is colonized with candida, or during nursing from the skin of the breast, or from a pacifier or the nipple of a bottle.  

Thrush is typically treated by wiping the inside of the mouth with a soft washcloth followed by an antifungal medication given as drops in the baby’s mouth after the baby has eaten. In a breast fed infant I treat the mother’s breast with a topical antifungal cream as well. 

Best way to look for thrush may be when you baby yawns and you get a good look at the inside of their mouths (bucal mucosa).  You don’t need to be a detective to find thrush, it is usually fairly evident and the biggest clue that it is not milk as it will not wipe off with a soft washcloth.

Daily Dose

Research Supports "Back to Sleep"

1.00 to read

This month’s issue of The Archives of Pediatrics and Adolescent Medicine has an interesting article on sleep position in infants. A recent issue of The Archives of Pediatrics and Adolescent Medicine has an interesting article on sleep position in infants. As I have discussed previously, the safest position for an infant’s sleep is on their backs.

Placing a baby “back to sleep” became a routine recommendation beginning in 1994 after evidence showed that babies who slept on their backs had a much lower risk for sudden infant death syndrome. SIDS is the leading cause of death for children under the age of one year. In this study out of Yale University, researchers found that the number of babies who were put on their backs to sleep increased from 25 percent to 70 percent since the recommendations changed in 1994. But in this study, the number of caregivers heading this advice has not changed since 2001. The researchers looked at how different caregivers positioned their babies for sleep to see if there were any factors affecting a caregiver’s choice of an infant’s sleeping position. Interestingly, one of the factors was whether or not the caregiver was ever told to place the baby on their back to sleep. One-third of those surveyed said that their doctor did recommend that their child sleep on their backs, but many did not receive any recommendation. How is a parent to know how to position their baby for sleep if their doctor does not discuss sleep positioning? Another factor, which influenced a caregiver’s choice of infant sleep position, was comfort. Again, more than one-third of those surveyed felt like the baby was more comfortable on their tummy. Another 10 percent were worried that an infant might choke if they were lying on their back. It is imperative that physicians discuss infant sleep position with parents and the need to reiterate this is evident in my own practice. Just today I saw a two-month-old baby with her mother and babysitter. The mother and I had discussed “back to sleep” (this is her third child), but the babysitter happened to mention that she “puts the baby on her tummy to sleep if she is in the room watching her”. It doesn’t matter if you are in the room, sleeping next to the baby, or watching on one of those new video monitors. Placing babies on their backs to sleep remains the most effective means to reduce the risk of SIDS, and there are few exceptions. The risk of a baby sleeping on their tummy “because they seem more comfortable” is just too great. The evidence is compelling. So…. until your child is old enough to role all over their crib, put them “back to sleep” and know that you are doing the very best thing to protect your baby. Tummy time is only for awake time. Don’t cheat! That’s your daily dose, we’ll chat again tomorrow. Send your question to Dr. Sue!

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