Saturday, November 27, 2010

When to do What: Guidelines for Nutrition the First Year of Life


Parents often wonder when is the appropriate time to introduce solid foods to their infant's diet. It seems like a simple question. So simple that the American Academy of Pediatrics (AAP) cannot agree on the answer. The AAP Committee on Breastfeeding recommends starting complementary foods (rice cereal and baby foods) after six months of age and the Committee on Nutrition recommends the introduction of complementary foods between four to six months old. Pretty simple, right? Obviously, we do not know the exact answer, but there are some general themes which seem to make sense. Below are my recommendations based on the limited scientific evidence, developmental milestones, and common sense. These recommendations will fit most infants, but understand that each child is different and may be ready to transition from one stage to the next at a slightly different time.

There is some scientific evidence, although not overwhelming by any means, that introduction of solids prior to four months may have some adverse effects, such as increasing the risk for Celiac Disease or Type 1 Diabetes in your child. Likewise there seems to also be some increase risk later in life if solids are delayed beyond 6 months. Babies around four months old typically have enough head control that they can sit in a high chair and hold their head up. I generally recommend that parents hold off on rice cereal and baby foods until the infant is at least four months old. This is extremely hard for some parents despite my warnings of possible adverse health consequences. Many believe that giving the infant rice cereal will help them sleep. Wrong. Sleeping through the night is a training process, not a rice cereal deficiency.

Once infants reach four months old, I recommend feeding them rice cereal mixed to an apple-sauce-consistency with either breast milk, formula, or water. Do this once or twice a day for a week or so. This allows your infant to get the hang of eating from a spoon. Notice that I did not say put the cereal in the bottle, cut a bigger hole in the nipple and have him drink his solid food. Use a spoon, interact with your child. Sure, it is more labor intensive and it is messy, but that is what a bib is for.

After about a week, you can start introducing the Stage 1 baby foods. You can use vegetables or fruits. Some people will insist that you have to introduce one prior to the other, but there is no scientific evidence regarding this. Most theories are based on the adult palate ("introduce fruits last because they are sweeter"). If you have ever tasted formula you will realize that the infant's palate and taste preferences are not the same as an adult. So pick a fruit or vegetable and go with it. I do recommend a three to four day trial period for each new food. Whenever you introduce a new food, make it the only new one for three to four days, so if there is some sort of reaction or rash, you can narrow down which one likely caused the problem.

Around six months old, you can move onto the Stage 2 foods, which are slightly thicker and come in larger jars. I think two to three meals a day is adequate at this point. Some of the Stage 2 foods will have meats, which is fine. In the past, parents were often told to introduce meats very last. There is no scientific evidence that this is necessary. In fact, there has recently been increased attention to preventing iron deficiency in infants and toddlers. Meats are a good source of dietary iron and I suspect pediatricians will be recommending meats earlier rather than later.

Around nine months, I give parents the green light with Stage 3 foods. These are, once again, thicker (chunks) and come in larger jars. I recommend offering three meals a day. Parents can also start with finger foods (e.g., veggie puffs or cheerios) as the infant typically has a pincer grasp (finger to thumb) and can pick up finger foods easily.

Between nine to twelve months, parents can start introducing soft, mushy table foods. By their first birthday, most infants are eating table food and have transitioned off baby foods. At their birthday, it is alright to change the infant from formula to cow's milk. Whole milk used to be solely recommended, but there is no evidence that it is necessary, so I recommend either whole or 2 percent milk. Also, get your baby off the bottle and switched over to sippy cups by a year old (no wimps please).

I do not recommend "next step" formulas and baby foods after an infant is a year old. I believe these products are just a way to make their companies more money. A well rounded diet (like the one you should be eating) is adequate to meet your infant's nutritional needs, and "next step" products are not necessary.

I will address vitamin and mineral supplements (vitamin D, iron, fluoride) in a future post.

Saturday, October 30, 2010

Those Dangerous Foods




I am often asked when it is safe to introduce foods such as eggs, peanuts, and fish to an infant.  These foods can cause allergic reactions in some children, so parents are understandably anxious about introducing them to their infant or toddler.  My answer:  it is safe when she is old enough to eat it without choking on it. 

Choking?  What about the allergy risk?  Well, we just do not know when is the right time to introduce foods that may cause allergic reactions.  Despite the strong opinions you might encounter on the topic, there is very little scientific evidence that delaying the introduction of a certain food will decrease the chance of having an allergic reaction.  In fact, there is some evidence, although not conclusive, that early introduction of a food may actually decrease the risk of developing an allergy to that food. 

In 2000, the American Academy of Pediatrics recommended withholding foods such as peanuts and shellfish until a child was 2-3 years old.  The AAP also recommended that pregnant women and breast feeding mothers avoid these foods.  In 2008, the AAP revised this recommendation, stating that there is little evidence that the previous recommendations made any difference. 

Everyone has an opinion, and this is mine.  After 12 months old, I give parents free reign to introduce any foods that the parent eats.  I also warn parents to use common sense in terms of choking hazards.  Is it possible the child may have an allergic reaction to peanut butter?  Yes, but it is also possible the family could be in an auto accident driving home from the grocery store where they purchased the peanut butter.  There is risk to everything we do.  It is important to realize that delaying the food does not affect this risk.

If there is a family history of severe allergic reactions to foods, I may tailor my recommendations a little.  There are rare cases where I will recommend allergy testing before giving a child a certain food because of previous reactions or family history.  For most families, I recommend what I have done with my own children.  After a year old, if I am eating it, he or she can eat it.

Saturday, October 9, 2010

Flu Shot Season is Here

It is that time of year again.  Time for flu shots and time to battle the myths that surround the flu shot.  Here are a few:
  • "The flu shot makes you sick."  This is by far the most common reason parents refuse the flu shot for their children.  The injectable flu vaccine is a dead virus and it cannot make you sick.  It is injected to create an immune response so that the recipient develops antibodies to protect against the flu, but the dead virus is incapable of replicating and creating a true flu illness.  So why do so many people think the flu shot makes people sick?  If 100 people receive a flu vaccine and on their way home from the doctor's office two of them get a speeding ticket, does anyone think the flu shot caused the speeding ticket?  (I hope not, but when it comes to immunizations, I have heard weirder claims.)  Now let's say two of the 100 people who received their flu shot caught a stomach virus the same day.  They are going to be convinced the flu shot made them sick.  I believe this is the phenomenon that leads to the myth that the flu shot makes one sick.  There are many illnesses circulating within our communities this time of year.  When someone catches an illness shortly after receiving a flu vaccine, he or she assumes that the shot caused the illness.  Not true.  (For the purpose of full disclosure, the live-attenuated nasal vaccine (FluMist®) can cause some cold symptoms after it administration.  This is a well known side effect.)
  • "The flu only makes older people sick."  Wrong.  The flu is an equal opportunity illness.  It does not care about age.  In fact, the very young are at high risk for complications from the flu.  Last season, when the H1N1 virus was the predominant circulating strain, death rates were highest in children less than two years old and pregnant women.  Children with underlying health problems, such as asthma or diabetes, are also at higher risk of complications.  Each year, an average of 36,000 people die from the flu or complications from the flu in the United States.  This is about 12 times the number of people who tragically died in the 9-11 terrorist attacks, and this happens each year without much media coverage or concern from the public. 
  • "Antibiotics cure the flu."  Nope, sorry.  The flu is a virus and an antibiotic will not improve flu symptoms.  There are antiviral medications that can help to shorten the illness if they are started early enough, but even these are far from miracle workers.  If you catch the flu, expect to be sick at least a week no matter what medications you take.  It is well known that the flu can lead to secondary bacterial infections, such as ear infections or pneumonia, that do require antibiotics.  These infections typically occur five to seven days after the flu illness starts. 
  • "The flu shot is part of a government conspiracy to make us sick."  Uhh, I have nothing for this one.
The flu vaccine is recommended for all children from six months to 18 years old.  Infants under six months old can be protected by everyone else in the household receiving a flu vaccine.  Call your doctor today and get your shot.

Monday, September 6, 2010

Wimpy Parent Syndrome

I woke up in the middle of the night last night and I could not fall back asleep.  I had a moment of brilliance laying there in bed.  I had discovered a new medical disorder, Wimpy Parent Syndrome (WPS).  For years I have been seeing it in clinical practice, but have been unable to put my finger on exactly what was taking place.  Then the idea of WPS came to me and everything seemed to make sense.  Unfortunately, this morning I Googled WPS and discovered that I am several years too late.  Someone has already coined the phase and provided some very good explanations of what WPS actually is.  Oh well, so much for fame and fortune. 

So what is WPS?  It is a parenting technique where parents fear making decisions that may upset their child.  They are loving parents that have the best intentions, but they have bought into the idea that "good" parenting and having their child get mad, cry, or angry are not compatible with one another.

WPS becomes very prominent when it is time to stop the bottle or pacifier.  It is well known that staying on the bottle or pacifier too long tends to cause dental problems.  At some point parents should stop giving their toddler these things.  I recommend stopping the bottle by 12 months and the pacifier by 18 months.  For parents with WPS, this is extremely stressful.  Children are creatures of habit and do not like change, and the parent recognizes that making these changes will create an emotional reaction in the child.  The parent will reply, "I can't take the paci away, he needs it."  Let's examine this.  I am fairly confident that, if the parent took the pacifier away, the child could not drive to Walmart and purchase a new one.  I am also pretty sure there is no physical reason why a child would "need" to have one.  So what the parent is truly saying is, "I am scared that taking it away will make my child upset."   Welcome to parenting!

Parenting is full of tough decisions, and many of them will make your child upset.  Do not fear this.  It is called parenting for a reason.  Not to embrace this fact and to allow your child to grow up believing that he can control his external environment by becoming angry, crying, or throwing a tantrum, is asking for trouble.  I am convinced that WPS creates some very poorly behaved children. 

Do not get me wrong.  I am not advocating that parents become unreasonable, abusive, or neglectful.  I am suggesting all parents step back and analyze their role as the parent.  It is possible to be loving and create a healthy emotional environment for your children, without letting the child controlling the family with his emotions.  You can take the beloved pacifier away.  You can let you child get mad and cry.  He will eventually realize that he is not getting it back. This is alright and it does not make you a bad parent.  In fact, it probably makes you a good one.

Monday, August 16, 2010

Autism and Vaccines: The Misinformation Superhighway

I have been hesitant to touch this topic.  The internet is teaming with people who believe vaccines cause autism, and for these people every claim that vaccines are safe strengthens their conviction that they are dangerous.  Those who promote the safety that science has proven are either misguided or even deceitful.  For some, a conspiracy of monumental proportions exists.  Any argument to the counter is simply part of the conspiracy.  It is difficult to argue against the conspiracy theory, when those who believe immunizations are safe can easily be filed into the section labeled "Part of the Conspiracy".   The internet has become a powerful tool to spread information.... and misinformation. 

With that being said, I think those who have the science to back their claims need to be vocal.  People go to the internet to get information and the information that is there can be misleading.  The scientific data is simply swept away by a brisk current of parental case reports and YouTube videos.  How is the open-minded, concerned parent supposed to find the truth in this sea of static?  People like me need to be more vocal. 

So what do we know?  After close to ten years of looking at the subject of vaccines and autism there is not one credible scientific study showing a link between the two.  Not one.  Large epidemiological studies from different countries by different researchers show the same results:  Immunizations are not associated with autism. 

What about thimerosal (the mercury based preservative formerly in vaccines)?  There is no scientific data that thimerosal in vaccines causes autism or neurological problems in children.  None.  Except for multi-dose flu vaccine vials, thimerosal has been removed from vaccines in the US.  Despite this the rate of autism has not decreased.

What about giving children all these vaccines when they are so young?  There is no scientific evidence that vaccinating at an early age leads to autism or neurological problems.  None.  In fact a recently published study looked at this very fact.  What they found was that, in terms of neurological testing, children who received vaccines as recommended by the CDC were no different from those who did not receive vaccines at an early age. 

But these illnesses are not around anymore, right?  Wrong.  Each year there are outbreaks of vaccine-preventable illness in the US, including measles, the whooping cough, chickenpox, etc.  These outbreaks typically happen in communities with low immunization rates.

I am a minimalist at heart.  I think modern medicine often tries to do too much.  However, I think immunizing children is the most important thing I do.  It prevents disease and changes outcomes.  Many illnesses that once cause pain, suffering, and death in children are now rare thanks to immunizations.

At some point, those on the immunization fence are going to have to decide whether they will trust the science that exists or put their faith in vocal celebrities, the lady down the street, or the internet persona that will invariably flame me for this post.   I know which one I have trusted when making decisions about my children.  That was easy.

A great link for more on this topic:  The Vaccine Song

Sunday, August 8, 2010

The Formula Carousel

You are a new parent. Your infant is gassy, fussy, spitty, and does not sleep much. In other words your infant is a normal baby. You are stressed, and like any good parent, you want to fix what "ails" your infant. As you stroll down the baby aisle at the grocery store, you see labels that tout words like gentle, comfort, and restful. Formula manufacturers are brilliant. They know their clientele and they know how to market to this stressed out audience.   There are formulas to stop your baby from spitting up, ones for gas, ones for fussiness, and even one to help your baby sleep.  If you have a problem, formula manufacturers are there to help.

This is the point when many parents punch their ticket and climb on the formula carousel. They try formula after formula in hopes that their infant will act less like an infant. Some parents do find formula bliss and their infant becomes "better," but there is no rhyme or reason to which formula "fixed" their baby. One family swears that switching from formula A to formula B has made all the difference in the world. The next family tells me that switching from formula B to A has been a lifesaver. I think the placebo effect is probably doing more than the nutritional engineering of the formula.

Most families do not find the cure for what ails their baby. Instead they just ride the carousel, switching from formula to formula, until everything seems to get better around 4 to 6 months old.

I have a few ideas about future formulas that would sell like gangbusters. These are niche formulas, but I am confident a market exists for them. In the same vein of existing formula marketing, my formulas will address specific concerns that parents have.
  • Sneaky Poop:  The perfect blend of nutrients and fiber to keep your infant very regular.  By promoting a healthy digestive system, your baby will strategically have a bowel movement when your spouse is holding him.  No more poopy diapers for you to change.  
  • The Contract:   Vitamins and minerals specially tailored to promote strong muscles and bones, helping your infant to develop athletic prowess and secure a long term, lucrative contract with a professional team.  It is time to get paid. 
  • Harvard Blend:  Specially designed proteins that facilitate brain development and intelligence.  Your child will not be attending a state college.  Start saving now, the Ivy League is in her future. 
  • Harvard Blend plus Early Scholarship:  Containing all the nutritional prowess of Harvard Blend but with Early Scholarship.  Early Scholarship contains specially designed carbohydrates that will aid in your child receiving many scholarships, reducing the need for saving for that Ivy League education. 
Of course there are real medical conditions that require a specific formula, but fortunately these conditions are relatively rare.  Talk with your pediatrician before you get on the carousel.  There is no sense going around in circles if it is not necessary. 

(Unfortunately my mother did not feed me The Contract as an infant, so if you are a representative of a formula manufacturer, please contact me for more ideas on future formulas... for a "small" fee of course.)

Saturday, July 24, 2010

Deciphering the Common Cold

Viral upper respiratory illnesses, or common colds, are by far the most frequent illness I see in my office. It is called the common cold because it is, well, common. I typically can make the diagnosis with a high degree of certainty based on the pattern and the timing of the symptoms. Deciphering cold symptoms and knowing when to worry is what a pediatrician does more often than anything else, and I believe parents can learn how to do this as well. If a parent can get a handle on what a common cold looks like, they can certainly save some co-pays and visits to the doctor. You see, there is no real treatment for the common cold. I know, I know, this is the great failure of modern medicine.

Look at the chart below. Notice when the symptoms typically start and stop. A cold generally starts abruptly. Your child will be fine one day and then sick the next. Their nose becomes stuffy or runny and a cough usually develops. Older children may complain of a sore throat the first few days of the illness. The mucus in the nose will often thicken up and become yellow or green as the illness progresses. Contrary to popular belief, yellow or green mucus does not necessarily mean your child is getting worse. It may in fact mean he is getting better. Colds typically last 10 to 14 days. Nothing, including antibiotics, shortens the duration of the illness. Colds truly must run their course.

Fever is the big variable. As you can see, up to 20% of children will have fever within the first few days of the illness. So fever that starts at the beginning of the illness is not too concerning. Now if the fever starts later in the illness or does not go away by the 3rd day of the illness, something else may be brewing, such as an ear infection or pneumonia. This is very important and is illustrated in the picture below. Fever that starts during the first couple of days of the illness is probably related to the cold virus itself and not very concerning (green zone). Fever that starts after your child has had a runny nose and cough for several days, can represent a complication from the cold (red zone). The latter should be evaluated by a doctor.


During childhood, your child's immune system goes to school. Each cold teaches the immune system how to fight future viruses and prevent infection. As your child gets older, he will have fewer and fewer colds. The first couple of years will be full of these illnesses, especially if your child is in daycare. You will feel your child is always sick and something is wrong with him, but an average child in daycare will have about 10 colds a year. If each one last 14 days, well, you do the math.  Your child will have some sort of cold symptoms for close to half the year.

Thursday, July 15, 2010

Lumps and Bumps on the Head

I was recently scanning an online forum about pediatric health concerns. (What can I say?  I sometimes need inspiration.) There was one thread within the forum that was significantly longer than any other. Parent after parent posted about how they had noticed a knot on their infant or toddler. This concern parallels what I see in practice. An unexplained knot on the head is a common reason parents bring their child to be evaluated.

The first thing that comes to parents minds is that the lump represents something bad, like cancer. Fortunately, these lumps are almost always nothing to be concerned about. Worst case scenario is some lumps (cysts) may need to be surgically removed, but this is rare.

These are the things that parents notice:
  • Lymph Nodes.  By far these are the most common lumps that parent notice and worry about.  Most parents realize that lymph nodes can be found in the neck, but do not know that they are also found around the ears and at the back of the skull.  A pea-sized, rubbery knot beneath the skin is nothing to worry about. Often these are found in young infants (2 months old), leading to an office visit (if you have an infant, feel the back of his skull a few inches above the neck... you see what I mean?).  Healthy lymph nodes fluctuate in size, they grow and they shrink.  Bad lymph nodes keep growing and are not subtle.  If a lymph node is the same size that it was a month ago, it is healthy.  A lymph node needs to at least the size of a marble before I even bat an eyelash at it.  Even then, I will simply recheck it in a few weeks to make sure it is not continuing to grow. 
  • Congenital Cysts.  There are certain locations on the head that children can be born with a congenital cyst.  These can sometimes get infected and lead to problems.  However, some people could go their whole life with a cyst without having any problems.  Typical locations are in front of the ear (preauricular cyst), in the front middle of the neck (thyroglossal duct cyst), or the sides of the neck (brachial cleft cyst).  Cysts in these locations may also have dimples or tunnel from the skin down to the cyst.  Occasionally, these will need to be surgically removed.  Other times, they can be simply observed for problems.  (Your beloved, middle aged, blogging pediatrician has a thyroglossal duct cyst.  It has never caused me any problems and is not very noticeable, so I have just lived with it.) 
  • Dermoid Cysts.  I have probably seen 3 to 4 kids in my career with a cyst in their eyebrow.  These are typically located at the part of the eyebrow closest to the temple.  They are rubbery and the size of a pea or lima bean.  Because these can sometimes rupture due to trauma and cause a strong inflammatory reaction, they are often surgically removed. 
  • Bony Knot on an Infant's Skull.  Infants will often have swelling or bruising of their skull from delivery.  These areas of injury will sometimes calcify leading to a hard bony knot on the skull.  This is definitely something parents notice and worry about.  This calcified area is not dangerous and tends to remodel and go away as the skull grows, typically within several months.
These lumps certainly generate a disproportionate amount of anxiety relative to the true risk that exists from them.  If the lump is small and difficult for someone else to find, the chance it represents something that needs to be urgently evaluated is probably zero.  Things that make me concerned are typically blatantly obvious.  In other words, I can see it from across the room.  Otherwise, watchful waiting is probably going to be the safest, least invasive and most cost-effective approach to lumps and bumps on the head.

Saturday, July 10, 2010

Tired of Waiting at the Doctor's Office?

We all hate it when the cable company tells us that the technician will be at our house sometime between 11 a.m. and 5 p.m. Fantastic! Going to the pediatrician's office can be the same way. Your appointment may be at 9 a.m. but you may not get out of the office until noon. Unfortunately, this is the nature of running a medical practice. What should take ten minutes for one reason or another may take 30 minutes. Once the doctor is 20 minutes behind schedule, every patient will likely have to wait an additional 20 minutes for the rest of that day.

Here are some tips to make your appointment as fast and efficient as possible:
  • Ask for the first appointment in the morning or the first appointment after lunch.  If there are no patients before your appointment, the doctor is less likely to be running behind.  If you ask for the 4:30 p.m. appointment, understand that there are probably 10-15 patients the doctor has to see before she gets to you.  Each one of these patient encounters provides the opportunity for the physician to get further behind schedule. 
  • Ask about paperwork.  Inquire if there is any paperwork that may be required at the visit.  Most offices can fax or email these to you before your appointment.  Many offices have a website where forms can be downloaded.  You can then complete the paperwork before your appointment in the quiet of your own home and not in a waiting room full of screaming kids. 
  • Schedule yearly check-ups in the Summer.  Due to the seasonality of childhood illnesses, most pediatric practices are less busy in the Summer.  Less busy means less waiting time. 
  • Write down your questions before the appointment.  This allows you to efficiently inquire about your concerns.  This will not only get you through the office quicker, but will probably help the doctor stay on schedule.  Consider it an altruistic gesture for the parents who have appointments after yours.  Very noble, indeed. 
  • Pay your copay and schedule your follow-up appointment while in the waiting room.  You can save time at checkout by doing these things instead of watching Saving Nemo for the 23rd time.

Sunday, July 4, 2010

Laundry Problem or a Health Problem?

There is nothing that disturbs new parents more than their infant spitting up. If I were to make a top ten list of things about infants that provoke anxiety, spitting-up would be firmly ranked number one. Nothing else is close. Whether it is the breast milk, formula, or the infant, something is definitely wrong from the parent's perspective. When a baby spits up in a movie or on TV it is funny, but when it is your baby, it is no laughing matter!



At some point in time, spitting up went from a normal part of being a baby to being an abnormality that requires fixing. I am not sure how this happened, but I suspect it is related to the development of medications for reflux. There are medicines that decrease a baby's spitting-up. So when a parent expresses concern about spitting-up, pediatricians reach for medications to "fix" the problem. As more and more infants are being treated for reflux, we have shifted spitting up from a normal part of being a baby to an abnormality that requires drug therapy.

Why do babies spit-up?

There is a muscle (Lower Esophageal Sphincter or LES) at the top of the stomach that is responsible for closing and preventing stomach contents from coming back up. In babies, the LES is not very strong. Although parents always identify the formula or breast milk as the problem, the root of the issue is this muscle. It does not matter what liquid you put down into the baby's stomach, if the LES does not close down tightly, food is coming back up. Despite the fact that only one type of formula (one with added rice starch) has been shown to decrease spitting up, parents jump on the formula carousel. They switch from one formula to the next trying to fix the infant's spitting up. To their amazement the infant continues to spit up. That is because it is a stomach issue not a formula issue.  Combine a weak LES with a liquid diet and the fact that infants spend the majority of their life laying down, babies are born to reflux.

"Does my baby have acid-reflux?"

Reflux implies that the food went the wrong way and the stomach definitely has acid in it. So, yes, if your baby spits up, your baby does have acid reflux. The more important question is: "Does my baby have acid reflux disease?" Disease implies that the acid reflux is causing a problem. The vast majority of infants do not have any problems associated with their reflux (other than frequent clothes changes), so they do not have acid reflux disease.

When should parents worry about spitting up?
  • Poor weight gain. The pediatrician will determine this by looking at the infant's growth chart.
  • Projectile vomiting. This is a forceful vomiting that will shoot several feet. This may require evaluation to ensure there is not a blockage where the stomach empties into the small intestine.
  • Recurrent breathing problems. This most commonly presents as recurrent episodes of wheezing (a noise heard with a stethoscope within the lungs).
  • Excessively fussy infant. It is often hard to tell if an infant is fussy related to reflux or due to other causes, such as colic. But if an infant is miserable and spits up a lot, then reflux may be causing some pain.
These problems are rare. Most infants who spit up are completely healthy and happy, and, therefore, a laundry problem exists but not a health problem. Spitting up is a normal part of being a baby. Accept it. Embrace it. Laugh at it. But you don't have to fix it.

Saturday, June 26, 2010

Things That Make Parents Worry: The First Month

There are several normal things that make parents worry the first month.  Here are the typical concerns:

Stuffy Nose. Infants around a month old tend to have a congested nose.  This congestion leads to noisy breathing.  Often parents interpret this as "wheezing".  However, wheezing is actually a sound heard in the lungs and typically cannot be heard without a stethoscope.  This nasal congestion drives parents crazy, but rarely bothers the infant.  Using nasal saline drops (available at any drug store) and trying to aspirate any mucus from the nose is about all you can do for this congestion. Or you can ignore it since it is normal part of being one month old, and, remember, you do not have to fix normal.

Gas.  And you thought your newborn was gassy?  At one month old, it is surprising your baby does not float off into the sky because of excessive gas.  See fixing normal for more on gas.

Fussiness.  Babies at 1 month old are often more fussy than they were initially.  From around one to two months old many babies can be colicky.  We do not know what causes colic or how to fix it.  It too can be considered to be a normal phase of infancy.  These baby cry a lot and are hard to sooth.  They tend to be gassy and parents believe the baby's stomach hurts.  The severity of colic can be mild, very bad, or anywhere in between.  Often there is a pattern to the fussiness, with early evening being the most common time infants get fussy.  Strange things often sooth the baby, such as turning on the vacuum cleaner, turning the radio to static, or driving the infant around in a car.  The good new about colic is that nothing is wrong from a health perspective with the baby.  Colic goes away and the infant is fine.  The most important thing about colic is for parents to find a way to maintain their sanity during this tough time. 

Rash.  There are two rashes that show up at this age.  One is infant acne.  This is related to exposure to mom's hormones when the infant was inside the womb.  It presents as pimples on the infant's cheeks.  Another rash is called seborrhea or cradle cap.  It presents as dry, scaly skin on the scalp or flakiness in the eyebrows.  With seborrhea there typically is also a red, prickly rash that goes down the cheeks, around the ears and down to the upper chest.   Both of these rashes go away without treatment.  However, if seborrhea gets bad, washing the infant's scalp with Selsun Blue shampoo every other night for a few weeks can help it to resolve. 

Congratulations!  One month down and only 215 more to go until she is 18 and leaves for college.

Wednesday, June 16, 2010

Watchful Waiting: A Powerful Diagnostic Tool

Childhood is full of self-limited illnesses. Kids get sick and kids get better. The majority of childhood illnesses will get better on their own. Because of this, observation and "watchful waiting" is often the most useful diagnostic test at the pediatrician's disposal.

Parents are often confused about the need for testing. Their experiences with adult medicine is typically full of lab tests and imaging studies. Unfortunately some parents equate the quantity of testing with the quality of care. Choosing observation is often viewed as not caring or not taking the complaint seriously. So there is an intrinsic struggle between what the pediatrician feels is needed, the parent's expectations, and the risk if something is "missed." The skilled pediatrician can navigate this rocky road and have happy parents and good outcomes. This is the art of medicine.

Why not order more tests?

There are several reasons why ordering blood test or x-rays is not always the best choice. Testing often leads to false positive results, which often leads to more testing. This runs up healthcare costs and puts kids through unnecessary procedures. Test results often do not change the management of the child's illness. If the same course of action is going to be recommended whether a test is positive or negative, the test has no value to the child's management. Finally, testing can have negative side-effects. A needle brings on anxiety in children and it hurts. X-rays and CT scans expose children to radiation.

It is estimated that 1 child out of every 1000 to 5000 children receiving a head CT scan will die from cancer attributable to the radiation from that scan. This cancer would likely show up decades later, but the process was started with that radiation exposure. Pediatricians see children who fall and hit their head or who complain of headaches almost daily, giving ample opportunity for ordering CT scans and possibly causing a cancer later in life. Even the most anxious parent would likely accept watchful waiting given these numbers.

Is there a time when testing should be done?

Absolutely! Technology has given medicine the power to diagnose, treat, and cure illness, and there is a time when it should be utilized. If a toddler is in a car wreck, hitting his head and losing consciousness, and now he is vomiting excessively, he absolutely should receive a CT scan of his head. Cancer risk be damned. Physicians are taught to balance the risk of doing something versus observation, and sometimes the scales lean dramatically in one direction or the other.

Trust and communication.

Trust is a crucial part of this equation. The parents need to trust the doctor's skill and the doctor needs to trust the parent's capacity to observe and detect signs of a worsening condition. The doctor must be able to communicate warning signs and parents need to feel free to contact the physician with questions or concerns.

With modern medicine there has been great leaps in technology that have enabled us to do things once unimaginable, yet watchful waiting remains the most powerful diagnostic instrument that the pediatrician has in his or her bag.

Saturday, June 12, 2010

Fixing Normal

Imagine taking your car to the mechanic and asking him to fix the light in the glove compartment. You explain that every time you open the glove compartment the light turns on and then when you close the glove compartment the light turns off. Something is wrong and it needs to be fixed. The mechanic patiently explains that the glove compartment light is not broken. It is operating normally. But you remain skeptical. Maybe you go to another mechanic to get a second opinion. Maybe you search the internet and find a remedy recommended by a lady named Cheryl in Idaho.

Such is the life of a pediatrician. We are constantly being asked to fix normal, and if we can't (or discourage trying) parents often look for answers themselves. A common example is infant gas. I am convinced that being gassy is a normal part of being an infant. Why else would I have 5 parents a day ask me why their infant is so gassy? I typically explain that gassiness is normal and that, if I had an answer for gas, I would have retired long ago. Yet, many parents are convinced that something is wrong and it needs to be fixed. They buy gas drops. They buy boutique formulas "for gassy infants." They buy special bottles and nipples. They try herbal remedies. They watch YouTube videos on massage techniques for infant gas:



There is a whole industry designed to fix the normal gassiness of infants, a whole industry designed to placate parent's anxiety. Anxious parents love it, because they are doing something to make their infant "better" from a perceived problem. The placebo effect courses through the parent's veins. In the above video, who is benefitting from the massage? The parent is probably benefitting more than the infant. Sure the infant enjoys the stimulation and interaction, but is the parent truly fixing something?

In the example of infant gas, parents are most likely doing no harm, but there are examples where parents are so convinced they have to fix something that is normal, that they put the infant at risk.

Understand what is normal. Accept it. Embrace it. Laugh at it. But you don't have to fix it.

Thursday, June 10, 2010

Things That Make Parents Worry: Week 1

There are several things that parents will notice the first week of life. Most of these concerns are related to physical appearance. Fortunately, these are all normal and anxiety is not warranted.
  • Flea-bite Rash. Infants will often have a rash that looks like several flea bites at various places on the body. This is called Erythema Toxicum. The name sounds awful, but the rash is of no significance. It goes away in a few weeks
  • Breast Buds. Because infants have been exposed to mom's hormones for 9 months, their breast tissue may be enlarged. This will feel like a knot under the nipples. Yes, boys can develop this too. The breast buds usually shrink away by 1-2 months old.
  • Vaginal Discharge or Bleeding. Little girls, once again because of maternal hormones, will often have a clear to white colored vaginal discharge for several weeks. They can even have some vaginal bleeding, like a women's period, during the first week or two of life.
  • Bowed Legs. Legs and feet will often look odd shortly after birth. Because of the infant's position within the uterus, the lower extremities can be bowed and the feet can often assume an unnatural position. This tends to go away as the infant grows.
  • Cone Head. Babies will often have molding of their skull from the birth process. The infants skull was designed to contort in order to fit through the birth canal, and it will often retain an unusual shape for the first week or two of life. Likewise, a vacuum extraction will almost always lead to impressive swelling and sometimes bruising of the head.
  • Purple Hands and Feet. Babies have poor circulation to their extremities. This leads to acrocyanosis, purple or blue hands and feet. This is not a sign of trouble breathing or trouble with the heart.
  • Dry Skin. Babies will shed layers of skin shortly after birth. This is related to living in water for 9 months. This will resolve in a few weeks and generally does not require any lotions or creams. Sometimes the skin can actually crack and bleed a little, especially around the ankles. In this case, you can put some Vaseline petroleum jelly on the area twice a day.
Your baby certainly does look odd, but fortunately she is normal!

Saturday, June 5, 2010

Anxiety That Works: Breast Feeding 101

Some parents are not interested in breast feeding, and that is fine. Many, however, want to but "can't." This is for them.

There are many reasons why a mother may be unsuccessful at breast feeding. I want to discuss the most common ones. First, it is important to understand that formula is an invention of the 20th century. Before this breast milk was essential for survival. No other species uses infant formula. So, believe it or not, women were designed to be able to breast feed. Without this capacity the human race would have ended long ago. So why are so many well intentioned women unsuccessful?

The most common reason that I see is improper expectations. No one told the mom how hard breastfeeding is. The first week of breastfeeding is hell. Expect that and you will be ready to go. It gets much easier, but during the first week, you will have major doubts about how well you are doing, your nipples will be sore, your baby will not be satisfied, and dads will be stressed as well.

There is a natural cycle that takes place. The baby is hungry and cries. The mother reads this as a sign of hunger and puts the baby to the breast. Not much milk is produced, so the baby is not satisfied. The unsatisfied baby either remains on the nipple or falls asleep for a short period and then wants to eat again. Mom puts baby on the breast again. In order for the mother to start producing milk she must receive this sucking, and a hungry baby is going to want to suck more than a full baby. This sucking causes mom to produce a hormone, called oxytocin, which is responsible for making milk. So, yes, you are "starving" your baby, but that is what nature intended. A hungry baby yields more sucking and more sucking produces more milk. A mom who is concerned that she is not giving her baby enough nutrition is going to be inclined to keep putting the baby on the breast, which leads to more sucking. You see how that works? Nature is pretty smart.

Problems arise when that anxiety hits, and, instead of putting the infant on the breast, many families jump to formula. The baby is satisfied and everyone is happy, but breastfeeding is essentially over. It is important to embrace the anxiety (this is one of the very few times I will suggest this) of breastfeeding. This is what nature intended. Anxiety is part of the cycle.

Giving formula in addition to breastfeeding almost never leads to long term breastfeeding. The infant gets full and mom therefore misses out on important sucking. When well intentioned families are already doing "both" during the first week of life, the chance of long term breastfeeding drops dramatically.

Likewise, the long term success for mothers who are trying to pump and then bottle feed the breast milk is pretty poor. Moms often resort to this because they are anxious that the baby is not getting enough milk. Pumping allows them to see how much the baby is taking. This may help the family's anxiety level, but it typically does not lead to long term breast feeding.

Tips for success:

  1. Relax! Trust the system that nature has designed. Understand that your anxiety and frustration is a crucial component to the system. Your baby being unsatisfied is also part of the system.
  2. Be a breastfeeding gladiator. The first week is a battle. Let nothing get in your way from being successful. Sleep, pain, and anxiety are for the weak, not the breastfeeding gladiator. Understanding the challenges that lie ahead is half the battle. Prepare yourself mentally!
  3. When in doubt, put the baby on the breast. The more sucking you get, the sooner and more milk you will produce. If the baby is on the breast for 24 hours straight, that is great! You may not like it, but you have just dramatically increased you chance of successful breast feeding.
  4. Fight through the soreness. There is no way around this, your nipples will get sore. Sometimes they will crack and bleed. Continue putting the baby on the breast. The soreness will improve.
  5. Ask for a Lactation Consult prior to leaving the hospital. Most hospitals will have a Lactation Consultant on staff to help breastfeeding mothers. If one is not available have a nurse watch how the baby latches on and feeds. They can be very helpful. (However, there are nurses that will see the breastfeeding frustration and recommend that you give the baby a bottle. Politely refuse, she does not know the harm she is doing.)
  6. Trust the baby's weight. This will show how well you are doing. All babies lose weight in the first 3-4 days of life, but they should be getting back to their birth weight around 7-10 days old. Ask you doctor to recheck the infant's weight if you are concerned about how you are doing.
  7. Let your pediatrician tell you when things are not going well. As I mentioned, you are going to be convinced that the breastfeeding is not working. Ignore that voice in your head, listen to an outside source that knows the process. There may be times that supplementing or pumping is recommended, but parents, who are overwhelmed with breastfeeding anxiety, are often not good at making that decision.

Finally, around day 3-5 of life, moms will start producing milk. This is typically an overwhelming sensation. When a mom says that her milk "might" be in, she is not yet producing milk. If the answer is, "oh, yeah," then her milk is in. Once a mom has made it to this point, the chance of long term breastfeeding is excellent.

Thursday, May 27, 2010

Getting Started

Welcome to parenthood! So that new baby is out in the real world. Now what? Here are the very basics. If you can do these 3 things you will be well on your way.

  • Feed the baby. You must choose between breast feeding or formula feeding. Any pediatrician is going to tell you that breast feeding is better for the infant, however, breast feeding is not going to work for every family. Especially, those with a high initial anxiety level. I have found anxiety level to be inversely related to breast feeding success. I will be posting about breast feeding in much more detail in the coming days. As far as formula goes pick a "regular formula." Formula companies have created a huge market for "specialty formulas" (formulas for gas, fussy babies, babies that spit up, etc) based on the issues parents worry about. (Yes, companies will use your anxiety to market products to you.) I will go into greater depth about formulas in the near future. A typical newborn will eat 1-3 ounces every 2-4 hours. However, during the first 24 hours of life it can be hit or miss, some infants just sleep a lot and are a little sluggish with eating.
  • Change dirty diapers. Pretty self-explanatory, right? Infants will pass a dark, tarry stool within the first 24 hours or life. This is normal. Over the next couple of days the stool will become softer, and often take on a seedy quality. Yellow, green, and brown are all normal colors of baby stool. A normal baby stool will appear like diarrhea to most adults. Breast fed babies will often have a decrease in wet and dirty diapers on day 2 and 3 of life, but this will ramp up significantly once mom's milk comes in.
  • Love on the baby. Hold them, rock them, and kiss on them. Let them sleep. A normal newborn can sleep up to 20 hours a day. Don't let sleeping worry you.

That is it. Pretty simple. All you have to do is these 3 things for starters. Don't make things more complicated than they need to be. Keep it simple.

Thursday, May 20, 2010

Winning the Lottery

Even before that baby pops out, parents are worrying. Will the child be healthy? Will he be smart? Will he have his father's ugly nose? Which crib is the best? What about the 17 strollers at BabiesRUs? And on and on. This is just the tip of the iceberg.

Once born, then the anxiety really sets in. Most parents have no real hands on experience with caring for an infant, especially one this important (this is the survival of your genes we are talking about). Everything is new and every little grunt or poop makes the new parent wonder if everything is alright.

In fact, everything is completely fine for the vast majority of infants. Most infants are perfectly healthy. Sure some will have issues, but statistically you are much more likely to have a healthy child than not. Yet, most parents dwell on that very small chance that something is wrong or going to go wrong. It is akin to the guy who is convinced he is going to get rich by playing the lottery. Most of us realize that the chances of winning the lottery are minuscule so we go to work each day. Yet, most parents are convinced that they are going to win the unhealthy child lottery. So they buy tickets daily, even multiple times a day. They are so convinced that they have won they rush to the emergency room because the baby has not had a bowel movement in a day. Fortunately, most of you are not going to win the unhealthy child lottery. That is just how it works.

Don't get me wrong, bad things can happen, but the vast majority of these bad things are not preventable, and, certainly, worrying that they might happen does not decrease the likelihood of them happening. Statistically, bad things are much less likely than most parents believe, and realizing that statistics are in your favor is a very good starting point for quelling parental anxiety.