Category: Health

What does it mean Autism Spectrum Disorder (ASD)?

[mme_highlight] ASD is a neurodevelopmental condition that causes difficulties in social interaction and communication, with restrictive patterns of behavior and limited interests. Children with ASD have difficulty to read other people’s expressions, they tend to avoid eye contact and have trouble expressing their needs. It is hard for them to adapt to changes.[mme_highlight]

ASD is a neurodevelopmental condition that causes difficulties in social interaction and communication, with restrictive patterns of behavior and limited interests.  The criteria issued in May 2013 prefer using the term ASD, which includes classic autism, Asperger syndrome and others. An early intervention designed by health care providers along with parents and educators can minimize the impact of ASD on children’s lives and is a cornerstone to construct their future.

How common is ASD?

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Epidemiology (statistical data) of ASD

• Prevalence in general population : 2-20/1000 people
• Boys:girls ratio – 4:1 (4 times more frequent among boys).
• Rate in siblings: 2-8%; 18.7% (according to a recent longitudinal prospective study).
• Mental retardartion: present in 45 to 60% of cases of ASD.
• Seizures: present in 11 to 39% of cases of ASD.
• Only 10 to 25% of ASD cases are associated with a medical condition/syndrome (eg. Phenylketonuria, X fragile syndrome).

Prevalence – The total number of cases of a disease in a given population at a specific time.
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What are the causes for ASD?

ASD seems to be the result of an intricate interplay between genetics and environmental factors. In rare cases, toxic exposures, complications during delivery and infections before birth may also play a role.

What are the symptoms and signs of ASD?

Children with ASD have impairment in socialization and communication. They have difficulty to read other people’s expressions, they tend to avoid eye contact and have trouble expressing their needs. It is hard for them to adapt to changes. These children may also take longer to begin speaking. They have difficulty in playing with peers and they do not do the “pretend” games. They may show repetitive actions or repeat words or phrases. They usually focus their interest in one particular thing and have very limited interest in any other thing.

Is my child “just shy” or can it be a sign of ASD?

There are key features that differentiate a shy child from a child with ASD.   While in the first case, a child can be shy at new situations or places, in ASD there is a lack of spontaneous seeking to share playing with others.
A shy child may take longer to make friendships, but in ASD children prefer to play alone. When a shy child meets with strangers, she/he tends to look away, but a child with ASD has difficulty in establishing eye contact even with family members.

Does ASD increase the likelihood for psychiatric hospitalization?

Yes, among a sample of 760 children diagnosed with ASD, 11% were hospitalized. In addition, studies show this risk increases with age and overtime. The table below is taken from a study and shows factors that increase the odds of psychiatric hospitalization among children with ASD.
The main conclusions are that an early diagnosis and community based interventions may decrease the need for hospitalization in these children.

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Factors associated with Psychiatric hospitalization among children with ASD (only significantly

• Living in single-parent homes: almost 3 times more risk of hospitalization (OR 2.54; CI 95% 32–4.88)
• Later diagnosis: 1 time more risk of hospitalization (OR 1.10; CI 95% 00–1.21)
• Self-injurious behavior: 2 times more risk of hospitalization (OR 2.14; CI 95% 18–3.88)
• Aggressive behavior: almost 5 times more risk of hospitalization (OR 4.83; CI 95% 24–10.42)
• Diagnosis of depression: 2 times more risk of hospitalization (OR 2.48; CI 95% 33–4.63)

Diagnosis of obsessive compulsive disorder: 2 times more risk of hospitalization (OR 2.35; CI 95% 1.39–3.96)
OR – Odds Ratio; CI – Confidence Interval
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How is ASD detected?

Your doctor will do the routine developmental surveillance to your child. In addition to this, tell your doctor about any behavior you find not adequate in your child. The American Academy of Pediatrics has stated the need for validated screening tools for ASD in the latest practice guidelines.
Although there is not a consensus yet, there is only one broadband screener that has been studied to detect children with ASD – The Infant-Toddler Checklist (ITC). ITC can be downloaded for free at http://www.brookespublishing.com/resource-center/screening-and-assessment/csbs/csbs-dp/csbs-dp-itc/. It includes 24 questions with 3 to 5 choices about developmental milestones of social communication.
The ITC should be completed by a parent or caregiver when the child is between 6 and 24 months of age to determine the need for referral and further evaluation, according to the net score of the checklist. The results of the screening of a sample of children with ITC are shown below, suggesting that the ITC has high strength (sensitivity and specificity) for catching young children at risk for ASD and other developmental delays among general population.

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Screening with ITC
(initial sample: screening of 36 children with communication delay +  screening of 18 children with typical development; 18 of the 36 children with communication delay received a diagnosis of ASD at 3 years of age and the other 18 received a diagnosis of developmental delay in which ASD was ruled out)

Results

• ASD group: 94.4% had a positive screening with ITC (17 out 0f 18)
• Development Delay group: 83.3% had a positive screening with ITC (15 out 0f 18)
• Typical development group: 11.1% had a positive screening with ITC (2 out 0f 18)

Estimated Sensivity of ITC

• ASD group + Development Delay group : 88.9%
• ASD group only: 4%

Estimated Specificity of ITC
88.9%
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What is the treatment for ASD?

There is not a cure or specific treatment. An early intervention educational project should be developed in a multidisciplinary setting: family, educators, health care providers and community.

Summary and Recommendations

• Autism Spectrum Disorder (ASD) is a problem in brain, which seems to result from the interaction of genetics and environmental factors.
• Children with ASD have difficulties mainly in three domains: communication, socialization and interests.
• These children have more risk of psychiatric hospitalization.
• Along with healthcare providers, parents and caregivers should do a developmental surveillance of children. If an important milestone seems not to be attained, the child should be taken to a doctor.
• There is not a cure for ASD. An educational program should be developed early, coordinating parents, healthcare providers and educators.

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References

• Mandell DS. Psychiatrichospitalization among children with autism spectrum disorders.  Autism Dev Disord. 2008 Jul;38(6):1059-65.
• Wetherby AM, Brosnan-Maddox S, Peace V et al. Validationof the Infant-Toddler Checklist as a broadband screener for autism spectrum disorders from 9 to 24 months of age. Autism. 2008 Sep;12(5):487-511.
• Wetherby, A.; Woods, J. SORF: Systematic Observation of Red Flags for Autism Spectrum Disorders in Young Children, Unpublished manual. Florida State University; Tallahassee, FL: 2004.
• http://www.cdc.gov/NCBDDD/actearly/autism/case-modules/identifying.html (accessed 4.11.2013)
• Blumberg SJ, Bramlett MD, Kogan MD, et al. Changes in prevalence of parent-reported autism spectrum disorder in school-aged U.S. children: 2007 to 2011-2012. http://www.cdc.gov/nchs/data/nhsr/nhsr065.pdf (accessed 4.11.2013).
• Ozonoff S, Young GS, Carter A, et al. Recurrence risk for autism spectrum disorders: a Baby Siblings Research Consortium study. Pediatrics 2011; 128:e488.

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What are the common Breastfeeding Problems?

[mme_highlight] Breastfeeding is the recommended method of infant feeding. However, it is not always easy as it takes time and practice and some problems can appear along the way: inadequate milk production, mastitis, sore nipples, engorgement and others. [mme_highlight]

Breastfeeding is the recommended method of infant feeding. However, it is not always easy as it takes time and practice and some problems can appear along the way. In the United States it is estimated that 75 percent of women start breastfeeding but only 44 percent are still nursing at six months. Knowing how to manage the different problems related with breastfeeding can prevent an early stop in breastfeeding.

Is my milk production inadequate?

This situation or perception is the most common reason for an early stop of breastfeeding. Previous breast augmentation surgery can lead to insufficient production of milk and there are also some medicines that can interfere in the process too.
Note that infrequent feeding and inadequate latch-on are among the most common causes for the problem of milk production, because it is the suction the baby does that triggers the process which in the end leads to milk production.

What is Engorgement?

Engorgement is a medical term for breasts which are too full of milk, which can cause swelling and pain. Some women in this situation can feel their breasts warm and redden and even experience a low fever. In addition, engorgement flattens the nipples, making it more difficult for babies to reach them. The best way to deal with engorgement is to breastfeed frequently and fully. If this is not enough, you can use a pump or your hand to extract some milk, but do not do this more than about 3 minutes or letting too much milk out, as this can worsen the engorgement.
To help reduce the swelling, put your fingers from both hands on the sides of the nipple and press them against the chest; you can also use ice in a fabric pocket to relieve pain. Another tip is to massage your breast gently prior to a feeding, because this can help stimulate milk flow.

Why are my nipples sore?

Nipples become increasingly more sensitive during pregnancy with a peak about the fourth day and postpartum and generally a return to normal after that.  96% of breastfeeding mothers experience sore, painful nipples during breastfeeding and stop nursing before they intended. This situation is common during the first minute of breastfeeding, but usually relieves after that. If the pain persists it may have been caused by nipple cracks, blisters, or bruises.

The main recommendation is to optimize the position of breastfeeding and latch-on. Lanolin-based nipple ointments and other creams are also recommended by doctors. The study shown below investigated the efficacy of some of these measures for sore nipples;  94 women with sore nipples were divided into 3 groups: group 1 received lanolin ad shells + assessment, education and corrective measures; group 2 received glycerin gel + assessment, education and corrective measures; group 3 received assessment, education and corrective measures (no commercial products).
Based on the results, although no statistic difference was found between groups, one can speculate that assessment, education and corrective measures alone are effective to treat sore nipples.

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Comparison of 3 different treatment plans for sore nipples – pain scores at the final midwife visit (after intervention) are shown:

• Average pain rating at first visit: 3.42.
• Average pain rating at the last visit: 1.69
• Group 1: pain rating at the last visit = 1.48
• Group 2: pain rating at the last visit = 1.29
• Group 1: pain rating at the last visit = 1.68

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What is mastitis?

Mastitis means inflammation in the breast, which in most cases is caused by an infection. It usually occurs in the first 6 weeks after delivery. You may feel ill, with fever, chills and muscle pain and your breasts may be swollen and hard, with redness.  Risk factors implied are poor breastfeeding technique and a lowered immune status due to sleep deprivation or stress. 
Some studies have suggested the entry door for the infection may be a fissure in the nipple. The most frequent bacterial agents implied are Staphylococcus aureus or coagulase-negative staphylococci. To treat your mastitis you can take a pain-relieving medicine (ex. Ibuprofen), massage your breasts and, if prescribed by a doctor, take antibiotic medicines.

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Associations of breastfeeding practices and other health behaviors with lactation mastitis (logistic regression analysis)

(Study design: prospective cohort study of lactation mastitis, Michigan and Nebraska, 1994–1998; 946 breastfeeding women included in the study, covariates from the same week as mastitis shown)

• Mastitis history (previously): 4 times more risk for lactation mastitis (OR 4.0 – 95% CI 2.64-6.11)
• Nipple cracks or sores: 3.4 times more risk for lactation mastitis (OR 3.4 – 95% CI 2.04-5.51)
• 1 to 5 feeds per day: 60% less risk for lactation mastitis (OR 0.4 – 95% CI 0.19-0.82)

OR – Odds Ratio; CI – Confidence Interval
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What other problems can occur while breastfeeding?

You can notice a color change in your nipples, which may happen because of alterations in the blood vessels of the nipples. A tendered or reddened lump may suggest that a milk duct is blocked; in this case the best measure is to breastfeed often; try to massage gently your breasts.

Summary and Recommendations

• While breastfeeding you can experience problems like: inadequate milk production, mastitis, sore nipples, engorgement, and blocked milk duct.
• Always seek for medical advice in the following situations:
• If you notice a blocked milk duct that persists more than 3 days;
• If you have a swollen and red area of the breast associated with fever;
• If you notice a bloody discharge from your nipples;
• If the pain in the nipples lasts during the whole feed.

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References

• Snowden HM, Renfrew MJ, Woolridge MW. Treatments for breast engorgement during lactation. Cochrane Database Syst Rev 2001; :CD000046.
• Cadwell K, Turner-Maffei C, Blair A et al. Painreduction and treatment of sore nipples in nursing mothers. J Perinat Educ. 2004 Winter;13(1):29-35.
• Committee on Health Care for Underserved Women, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 361: Breastfeeding: maternal and infant aspects. Obstet Gynecol 2007; 109:479.
• Foxman B, D’Arcy H, Gillespie B et al. Lactationmastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol. 2002 Jan 15;155(2):103-14.

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What are the benefits of breastfeeding?

[mme_highlight] No water or other foods are needed for the baby until 6 months of age; this is called the “exclusive breast feeding” period. The benefits of breastfeeding are many, making it the healthiest option for your baby: adequate nutrition, protection from infections, lower risk for Sudden Death Syndrome and is a great moment for mother-child bonding. [mme_highlight]

Breast feeding is one of the greatest boons the newborn can get from the mother. The breast milk is the ideal nutrition as it exactly meets the requirements of the baby. The nutrients and benefits can’t be replaced by cow’s milk or any formula feeds. No water or other foods are needed for the baby until 6 months of age and this is called the “Exclusive breast feeding” period. Exclusively breast fed babies are superior in terms of their immune status, growth and overall health.

What is the composition of Breast milk?

To understand why breast milk should be preferred, it is important to know what its content is.

The exact composition of breast milk varies from day to day depending on the food taken by the mother, as well as hormonal and environmental influences.

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Composition of breast milk:

• Water – 85 to 90%
• Protein – 1%
• Fat – 4.5%
• Carbohydrates – 7%
• Minerals – 0.2%

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Breast milk also contains digestive enzymes, hormones, antibodies, vitamins and lymphocytes from the mother.

A research conducted in the Netherlands including more than 4000 infants was published in the Journal of Paediatrics. It has concluded that babies who were exclusively breastfed for more than 4 months had less probability for developing respiratory and gastrointestinal infections.

According to the WHO (World Health Organization), 1 million infant deaths could be avoided each year if the babies were exclusively breastfed for the period of 6 months.

What is colostrum?

Colostrum is the aqueous light yellow fluid, which initially comes out of the breast right after delivery. It is richer in proteins, sodium and vitamins than the normal breast milk. The importance of colostrum is related to the antibodies and immune cells it carries, which help protecting the baby from the first potential pathogens. Thus, it passes a kind of passive immunity to the baby like a vaccine protection the mother transfers to the baby. It is replaced by normal breast milk in 3 to 4 days.

What are the differences between human breast milk and cow’s milk?

The needs of the human baby are different from those of a calf; hence the mother’s milk has the most adequate composition for a baby. A human baby needs less protein and more fat and the cow’s milk contains more protein and almost equal quantity of fat, so it does not supplies adequately human’s need.
It should also be noted that the fat content of cow’s milk is richer in saturated fatty acids whereas that of the human milk is richer in unsaturated fatty acids, which are healthier. Cow’s milk is low in vitamins A, C, D and also poor in iron. Though calcium content is higher in cow’s milk, the calcium contained in human milk is better absorbed by the baby.

What are the differences between human breast milk and Formula feed

Though Formula feed is said to be a better alternative to cow’s milk, when compared to human breast milk it proves to be less adequate. Many working women choose formula feed due to its convenience and greater flexibility or in the cases when mother’s milk production is low in spite of adequate treatment to improve milk production.
Unless a health care provider tells you otherwise or you feel breast feeding cannot be continued for a strong reason, it is not advised to go for an alternative.

Formula feed is prepared with almost similar composition of breast milk with identical amounts of fat, carbohydrate, proteins, minerals and vitamins. However, formula feed lacks antibodies, antiparasites and antiallergens, as well as growth factors and enzymes that are present in Breast milk.

A study by Dukes University’s Medical study centre showed that breast milk is more effective in preventing infections than formula feed.

What are the benefits of breastfeeding for the baby?

• Breast milk has the right composition and nutrients which satisfy the thirst and hunger of the baby.
• Breast milk has anti infectious properties, as it carries antibodies and immune cells, thus preventing infections.
• Breast milk has enzymes which help digestion.
• Breastfed babies are less prone to middle ear and respiratory infections or diarrhoea, as bottle feeding is not necessary.
• Breastfed babies are healthier and they have less odds to suffer from heart disease, diabetes, cancer and obesity later in the life.
• Research suggested that breastfed infants have lower risk for Sudden infant death syndrome.
• The emotional bonding created between mother and infant helps baby’s growth and brain development.
• As breast feeding is available when baby wants, this avoids the hunger cries of the baby.

What are the benefits of breastfeeding for the mother?

• Breast feeding is protective against breast cancer and ovarian cancer.
• Breast feeding helps losing the weight gained during pregnancy.
• Breast feeding acts like a natural contraceptive.
• The emotional bondage of the mother and baby is strengthened and so the mother feels more confident and happier.
• Breast feeding saves money and time.
• Mothers who have breastfed have fewer chances to have osteoporosis later in life.

” While breastfeeding may not seem the right choice for every parent, it is the best choice for every baby.”
(Amy Spangler)

Summary and Recommendations

• During the first 6 months breastfeeding should be the exclusive nutritional source, as it has the complete range of nutrients your baby needs.
• The composition of human milk is different from that of cow’s milk; this is the reason why the latter is not adequate for babies during the first year of life.
• In comparison to cow’s milk, human’s milk contains less protein and more fat, predominantly unsaturated fatty acids, with high proportion of vitamins A, C, D and also iron.
• Although formula milk is similar to human’s milk in terms of composition, it lacks the antibodies and protective immune cells that pass from the mother to child through the milk, reinforcing the immune system of the baby.
• The benefits of breastfeeding are many, making it the healthiest option for your baby: adequate nutrition, protection from infections, lower risk for Sudden Death Syndrome and is a great moment for bonding.

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References:

• Belitz, H Food Chemistry, 4th Edition, p.501 table 10.5
• FSA, 2002. McCance and Widdowson’s The Composition of Foods, 6th summary edition. Cambridge, England, Royal Society of Chemistry.
• Hanson, L. A.; Söderström, T. (1981). “Human milk: Defense against infection”. Progress in clinical and biological research 61: 147–159. PMID 6798576.
• Dewey KG, Heinig MJ, Nommsen-Rivers LA (1995). “Differences in morbidity between breast-fed and formula-fed infants”. J. Pediatr. 126 (5 Pt 1): 696–702. doi:10.1016/S0022-3476(95)70395-0. PMID 7751991.
• Blaymore Bier JA, Oliver T, Ferguson A, Vohr BR (2002). “Human milk reduces outpatient upper respiratory symptoms in premature infants during their first year of life”. J Perinatol 22 (5): 354–9. doi:10.1038/sj.jp.7210742. PMID 12082468

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What are the benefits of breastfeeding for my baby?

[mme_highlight] A breastfed child does not need any other food or liquid during the first six months of life. Investigators have shown that breastfeeding lowers the probability to develop infections, obesity, diabetes, rheumatoid arthritis, allergic reactions, leukemia and other diseases.[mme_highlight]

Breast milk is the food that is naturally adapted to the needs of an infant. According to American Academy of Pediatrics, frequency of breastfeeding in the USA is as shown below.

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• 70% of women initially breastfeed their babies;
• 33% of women breastfeed their babies for 6 months after delivery;
• 18% of women breastfeed their babies for 12 months after delivery.

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What is the composition of breast milk?

A breastfed child does not need any other food or liquid during the first six months of life. The basic ingredient of breast milk is water (82.5 – 90%). The level of protein in breast milk is 9-11g/L, the level of fat is 35-45 g/L and level of carbohydrates is 70 – 80 g/L. Also, human breast milk contains optimal quantities of calcium, phosphorus, chloride, sodium, iron, vitamin A, vitamin D and vitamin C.
The electrolyte concentration is adjusted to the kidneys of baby. The antibodies and other immunological significant substances from mother’s milk provide antibacterial, antiviral and antiparasitic characteristics and thus protect the health of the child. This is why breast milk has an absolute priority in the nutrition of infants.

What are the benefits of breast milk for my baby?

Studies show that breast milk provides multiple benefits to child. As we said, mother’s milk contains a lot of immunologically active substances that help to baby’s undeveloped immune system to fight with infections. It has been proven that children who were breastfed have lower incidence of infectious diseases. This is supported by evidence from research, indicated below.

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Infections: breastfed vs. non-breastfed children
8.1% of children among breast-fed children had pneumonia and bronchitis in the first year of life

• 14.8% children who are not breastfed had pneumonia and bronchitis in the first year of life
• Ear infection is 3 to 4 times more frequent among non-breastfed babies.

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Human milk has the adequate ratio between fat, proteins and carbohydrates that completely and perfectly meets baby’s energetic and nutritional needs. According to scientific research, children who are breastfed have less chance for obesity than children who were fed with formula.
In addition, prospective research accompanying the study population from childhood through adulthood showed that breastfeeding reduces the incidence of diseases that are immune-mediated such as diabetes and rheumatoid arthritis. Many studies prove this thesis. e.g. in the group of people aged between 30 and 39 years with diabetes, it was shown that there is much higher percent of diseased among the people who were not breastfed.

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Obesity, diabetes and rheumatoid arthritis: breastfed vs. non-breastfed children

• 1% of obese children were fed with formula milk;
• 2% of obese children were breastfed;
• Chance for morbidity of rheumatoid arthritis was reduced by 40% in breastfed children.

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Breast milk contains less allergens. Therefore, breast milk is the safest food for baby.

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Allergic reactions and breastfeeding

• Only 2 to 3 % of babies react to allergens from mother’s milk.
• 75% of children younger than one year are allergic to the protein of cow’s milk.
• 8-14% of children who are allergic to cow’s milk, will also develop an allergic reaction to soy milk.

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It was demonstrated that baby girls who were breastfed had 25 percent lower risk to develop breast cancer compared to baby girls who were on adapted milk formula. Also, infants that were breastfed had 21 percent lower risk to develop leukemia.

Mother’s milk osmolality (concentration of dissolved substances in water) is 280-300 mOsm / kg of water; milk formula osmolality is greater. The concentration of protein in the mother’s milk is 11g / L, and the concentration of proteins in adapted cow’s milk formula is 15-19 g / L. Based on these data, we can conclude that underdeveloped baby’s kidneys are more protected with breast milk.
In addition, breast milk has a good influence on the blood pressure of the baby. It is much easier for a baby to digest breast milk than formula, consequently, the quantity of useful substances that are absorbed from digestive tract is much higher in breastfed babies.

Also, it was proven that breastfed children have reduced morbidity (meaning health consequences) from diseases like lymphoma, asthma, high cholesterol, chronic intestinal disorder, mental health problem, osteoporosis, atherosclerosis etc. Some research shows that breastfed children have slightly higher score on cognitive tests and improved “head-eye” coordination.

Breastfeeding relieve stress both for baby and mother. In addition, breastfeeding has an analgesic effect (relieves pain in babies), and it also has a positive effect on baby’s sleep and baby is satiated for a longer period.

Consult also the topic on benefits of breastfeeding for mother’s health: it should be noted that breastfeeding certainly contributes to the building of a unique emotional and psychological connection between mother and baby.

Summary and Recommendations

• Breast milk perfectly meets the nutritional requirements of a child during the first 6 months.
• The benefits of breastfeeding are multiple and studies show increasing evidence on more advantages. Investigators have shown that breastfeeding lowers the probability to develop infections, obesity, diabetes, rheumatoid arthritis, allergic reactions, leukemia and other diseases.
• Breastfeeding relieves pain and stress in the baby and is a privileged moment to establish a bond between mother and daughter.

[mme_references]
References

• Watkins C. J., Leeder S. R., Corkhill R. T. The relationship between breast and bottle feeding and respiratory illness in the first year of life. Journal of Epidemiology and Community Health, 1979, 33, 180-182
• Zeiger RF, Sampson HA, Bock SA, et al. Soy allergy in infants and children with IgE-mediated cow milk allergy. J Pediatr. 1999;134:614–622
• Armstrong J, Reilly JJ, Child Health Information Team. Breastfeeding and lowering the risk of childhood obesity. 2002;359:2003–2004
• Pettit DJ, Forman MR, Hanson RL, Knowler WC, Bennett PH. Breastfeeding and the incidence of non-insulin-dependent diabetes mellitus in Pima Indians. 1997;350:166–168
• Freudenheim, J. et al. 1994 Exposure to breast milk in infancy and the risk of breast cancer. Epidemiology 5:324-331
• Shu X-O, et al. Breastfeeding and the risk of childhood acute leukemia. J Natl Cancer Inst 1999; 91: 1765-72
• Shu X-O, et al. Breastfeeding and the risk of childhood acute leukemia. J Natl Cancer Inst 1999; 91: 1765-72
• Duncan, B et al Exclusive breastfeeding for at least four months protects against Otitis Media, Pediatrics 91(1993): 897-872

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Which foods should mothers avoid while breastfeeding?

[mme_highlight] Caffeine, spices, alcohol, citrus fruit, mint and parsley, as well as the most common food causing allergy – peanut, dairy, wheat and eggs – should be avoided. If a mother has an allergic reaction, the suspected causative aliments must be suspended for 2 weeks and then introduced one at a time. [mme_highlight]

Breast milk is the food that is naturally adapted to the needs of an infant and has an absolute priority in the nutrition of infants. However, nursing mothers should pay particular attention to the fact that substances from food and liquids they intake can reach the baby’s body, through milk. Therefore some foods and substances should be avoided.

Which foods to avoid and why?

Caffeine can be found in coffee, cola drinks, tea and cocoa. Caffeine can reach the baby’s body through milk. Although a small percentage of caffeine (from 0.06 to 1% administered dose) has been found in breast milk, it is enough to cause a reaction in the baby. The baby eliminates caffeine slower than adults. Therefore, sleep disturbance, irritability and higher blood pressure may occur due to the presence of caffeine in the blood of a child.

Some groceries affect the taste and smell of milk (pepper, garlic, chili spices, sprouts, broccoli, cauliflower, etc.). These groceries should be avoided because your baby may refuse to suckle due to changes in smell and taste of milk. In addition, pepper, garlic, chili spices, broccoli and cauliflower could cause colic and irritability of baby.

Alcohol should be avoided, because it is excreted in breast milk. Less than 2 percent of the consumed amount gets into breast milk, but that amount is enough to damage the baby’s health. Impaired motor development, change in the sleep patterns and hypoglycemia may occur due to the presence of alcohol in the blood of a child. Besides this fat, alcohol also affects the lactation- 3 to 4 hours after alcohol intake, milk production is reduced for 20 percent. According to the American Academy of Pediatrics, a modest amount (one glass) of wine or beer is allowed.

Fishis high in protein and omega-3 fatty acids, but some species of fish are particularly rich in mercury. According to U.S. Environmental Protection Agency, 25 % percent of the fish that people eat had mercury levels above the safety levels. Mercury causes the damage of nervous system and it is especially dangerous for babies, as they slowly excreted mercury.
Therefore, lactating women should avoid fish high in mercury such as king mackerel, hark, tilefish and swordfish. Fish that contains small amounts of mercury (canned light tuna, pollock fish, salmon etc.) can be eaten, but its consumption should be limited to one portion per week.

Citrus fruit contains acid, which can irritate the baby’s immature digestive tract. Therefore, the intake of citrus fruits should be limited, however, mothers should enrich the diet with other aliments containing vitamin C.

If the mother has got allergy to some food allergens, this allergy can also occur in 0.2-0.3% of children through breastfeeding. A history of food sensitivity, asthma and/or eczema in family members increases the chances for a baby to have allergies. If both parents have allergies, the baby has 80% chances of having it too; if only one parent has allergies, then the odds decrease to 30%. Allergic reactions can occur in the form of eczema, colic, fussiness, wheezing, constipation or diarrhea, etc. There are rare milk allergies that can be severe or fatal.

The most common allergies are allergies to peanut, dairy, soy, shellfish, wheat and eggs. Peanut allergy is very common in infants. One to three hours after ingestion of peanuts, peanut allergens are present in 50% of mothers in milk. Between 5 to 10 % of babies are allergic to dairy. The babies who are only breastfed have about 0.5 % chance to develop soy allergy. In addition, babies who are only breastfed have about 0.5% chance to develop milk allergy.

Mother should thus exclude food that can trigger allergic reactions in babies. If an allergic reaction affects the baby, all suspected foods should be excluded from mother’s diet for two weeks. After that period, the mother should eat the suspected ingredients each day one by one to carefully observe the baby’s reaction after breastfeeding. This is the easiest way to discover the allergens.

Some products, such as mint and parsley, reduce milk production. Therefore, they should be avoided or mother should reduce their intake to a minimum.

It should be noted that smoking and the use of drugs are very harmful for baby’s health. It was found that children of mothers who smoke suffer from infant respiratory illness more frequently and gain less weight. If a sick mother considers the use of drugs, she should consult a pediatrician or a doctor who supports her breastfeeding.

With the exception of the restrictions stated above, mothers can eat a normal and balanced diet. After the termination of breastfeeding, the mentioned restrictions can return to the diet.

General advice is that food should be safe, clean and well heat treated if necessary. It is also recommended to avoid foods that contain a lot of additives, preservatives, artificial colors and sweeteners. The point is to establish healthy eating habits that will allow both mother and baby to feel good.

Summary and Recommendations

• Some substances, like caffeine, pepper and other spices and citrus fruit should be avoided, as they can pass through the mother’s milk and cause irritability or colic and, thus, should be avoided.
• A breastfeeding mother should avoid alcohol at all cost, because it decreases the production of milk and, since it passes to the milk, alcohol can impair child development.
• A family history of allergic reactions, particularly when these happened in parents, raises the probability for a baby to develop allergies.
• The most common causes of allergy to food are: peanut, dairy, wheat and eggs.
• If a mother has an allergic reaction, the suspected causative aliments must be suspended for 2 weeks and then introduced one at a time in an attempt to discover which one caused the allergy.

[mme_references]
References

• Poskit EME. Practical paediatric nutrition. London: Butterworhts, 1988:41-50.
• Food-a-pedia. U.S. Department of Agriculture.http://www.choosemyplate.gov/pregnancy-breastfeeding/eating-fish.html. Accessed May 13, 2013.
• Your guide to breastfeeding. U.S. Department of Health and Human Services Office on Women’s Health.http://www.womenshealth.gov/publications/ourpublications/breastfeeding-guide. Accessed May 13, 2013
• Things to Avoid When Breastfeeding. The American Academy of Pediatrics. http://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Things-to-Avoid-When-Breastfeeding.aspx. Accessed May 13, 2013
• Infant Allergies and Food Sensitivities. The American Academy of Pediatrics. http://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Infant-Allergies-and-Food-Sensitivities.aspx. Accessed May 13, 2013
• Berlin Jr CM, Denson HM, Daniel CH et al. 1984. Disposition of dietary caffeine in milk, saliva, and plasma of lactating women.Pediatrics 73(1):59-63
• Mennella JA, Beauchamp GK. The transfer of alcohol to human milk: Effects on flavor and the infant’s behavior.New England Journal of Medicine 325: 981 985, 1991.
• Vadas P. et al. (2001) Detection of peanut allergens in breast milk of lactating women. JAMA 285,1746-1748

[/mme_references]

Should I give my child a pacifier?

[mme_highlight] The pacifier should be offered to babies, but only after the breastfeeding is correctly established and its use must be limited to the first twenty four months of life. The pacifier, if correctly used, promotes well-being and gives babies a sense of comfort. [mme_highlight]

The question of giving a pacifier to a child is not a consensual one, not only among parents but also among health care providers. In many cases, using a pacifier soothes a baby, but parents are often afraid that a pacifier can impair breastfeeding, cause dental caries or deformations in children’s teeth.  Nevertheless, many pediatricians often refer the benefits of using a pacifier, including its role in the prevention of the Infant Sudden Death Syndrome.

Definitions and statistics

Since ancestral eras, pacifiers have been used, even if not in the same format as we see them today – there is evidence of their existence dating from 3000 years ago. It is estimated that nowadays, in the developed countries, the percentage of utilization of pacifiers is between 75 to 79%.

In babies, suction is a reflex, which means it is done in an involuntary way. It is present since the intrauterine life through the first to third years of life.

There are two types of suction: nutritive suction (present in breastfeeding) and non nutritive suction (like in finger suction or with pacifiers).

Can I give my child a pacifier even if I am breastfeeding?

The benefits of breastfeeding are widely known and it is recommended as the only nutritional source during the first six months of life. As the suction movement is different during breastfeeding from that with a pacifier, many parents fear that the baby can confuse both or that a baby using a pacifier does not want so many breastfeeds leading to a decrease in milk production. However, many scientific studies conclude there is no interference and pediatricians recommend offering a pacifier after breastfeeding is already established.

Can the use of a pacifier prevent the Infant Sudden Death Syndrome?

The American Association of Pediatrics recommends the use of a pacifier to prevent Infant Sudden Death Syndrome during the first year of life, after breastfeeding is fully established; however, parents should not force their babies to have a pacifier if they refuse it. In addition, the pacifier should not be put back in baby’s mouth after falling in the floor or if dropped during sleep. The pacifier should not be linked to clothes by other objects, as there is an asphyxiation risk.

[mme_databox]
Reduction of Incidence of Infant Sudden Death Syndrome with the use of a Pacifier

• About 30% reduction if used regularly (OR 0.71 with CI 0.59-0.85)
• About 60% reduction when used during last sleep (OR 0.39 with CI 0.31-0.50)
• About 17% reduction when regularly used during sleep (OR 0.39 with CI 0.31 a 0.50)

OR – Odds Ratio; CI – Confidence Interval
[/mme_databox]

Does a pacifier cause damage or caries in my child’s mouth?

The pacifier occupies the oral cavity and, overtime, it can produce changes in its development.

The majority of scientific studies conclude that the consequences are more important in children who continue using pacifiers after twenty four months of age. The later the pacifier is left, the higher the probability of these consequences in the teeth arcades.

Regarding caries, the Canadian Society of Pediatrics states that the appearance of caries can be associated only with a continued use of a pacifier past 5 years of age or with its utilization in association with sugar solutions.

What other benefits do pacifiers have?

It is nowadays acknowledged that a pacifier can relief pain in neonates and babies during painful procedures (like vaccines, punctions, test for rethynopathy of prematurity), thus a pacifier should be offered in these moments. This relief effect can be explained by the release of pain relieving substances (like serotonin) during the suction. In these situations, the relief of pain can be greater if a sugar solution is used with the pacifier.

[mme_databox]
Reduction of Crying Time with the use of a Pacifier

(study of the use of pacifiers for infants venipuncture in a pediatric emergency department)

• 0-1 month infants: reduction of 52 seconds
• 1-3 month infants: reduction of 123.9 seconds

[/mme_databox]

Is there any health problem related with the use of pacifiers?

Some studies have concluded that not using a pacifier can decrease about 29% the recurrence of an ear infection (acute otitis), which means that not using a pacifier decreases the odds for an ear infection to appear again. This conclusion lead to the recommendation that in children with history of ear infection, it may be prudent not to use a pacifier as it is a risk factor for recurrence of the infection.

Summary

• The pacifier should be offered to babies, but only after the breastfeeding is correctly established, which happens around the first month of life.
• Prefer to offer the pacifier during the main sleeping period of the child.
• Do not use objects to hold the pacifier to the child’s clothes, as there is a risk of asphyxiation.
• Do not offer your child a pacifier that has fallen in the ground.
• Careful consider not offering a pacifier to a child that is prone to ear infections.
• The use of a pacifier must be limited to the first twenty four months of life, since after this age its use raises the likelihood for dental caries and alterations in teeth structure.
• Pacifiers should be offered during painful procedures, as they promote the release of pain relieving substances.
• The pacifier, if correctly used, promotes well-being and gives babies a sense of comfort.

[mme_references]
References

• Sexton S, Natale R. Risks and benefits of pacifiers. American Family Physician. 2009
• Richard H. Schvartz, MD, Infant Pacifiers: An Overview. May 2008
• M Ponti. Recommendations for the use of pacifiers. Canadian Paediatric Society. Paediatr Child Health 2003;8(8):515-9 2003
• Niemelä M, Pihakari O, Pokka T, Uhari M. Pacifier as a risk factor for otitis media: randomized, controlled trial of parental counseling. Pediatrics. 2000;106:483-8.
• Hauck, F. R., Omojokun, O. O., & Siadaty, M. S. (2005). Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics, 116, e716–e723.
• Mitchell, E. A., Blair, P. S., & L’Hoir, M. P. (2006). Should pacifiers be recommended to prevent sudden infant death syndrome? Pediatrics. 2006 May;117(5):1755-8.
• SJ, Jou H, Ali S, Vandermeer B, Klassen T. A randomized controlled trial of sucrose and/or pacifier as analgesia for infants venipuncture in a pediatric emergency department. BMC Pediatr. 2007;7:27.

[/mme_references]

Screening tests in Newborns

[mme_highlight] The goal of screening newborns is to detect diseases early, either because the tested diseases are life-threatening or because they can bring serious complications. The conditions which can be detected include inborn errors of metabolism, endocrine disorders, hemoglobinopathies, immunodeficiency, cystic fibrosis, and critical congenital heart defects.
[mme_highlight]

The goal of screening newborns is to detect diseases early, before symptoms appear, either because the tested diseases are life-threatening or because they can bring serious complications for health if the diagnosis is done late. In addition to the early detection, the screening has the aim of providing referral and treatment of babies thought to be affected by such conditions.
Newborn screening began in the 1960s when the scientist Robert Guthrie developed the blood spot test, which initially only detected Phenylketonuria (PKU), a metabolic disorder.  Nowadays, the test can detect more than 60 disorders, depending of the panel of diseases defined by every country.  The conditions which can be detected include inborn errors of metabolism, endocrine disorders, hemoglobinopathies, immunodeficiency, cystic fibrosis, and critical congenital heart defects.

My baby looks healthy…why will she/he be screened?

Yes, newborn screening is part of Public Health programs developed by each country and all babies undergo screening even if they look perfectly healthy, because some diseases do not cause symptoms or show any manifestation soon after birth but can become serious later. Statistics show that newborn screening detects treatable conditions in 1 in each 300 babies per year.

How is the blood spot test done?

This test is generally performed by a nurse between the 3rd and 6th days after birth. A lancet is applied on the lateral borders of the baby’s heel. It is necessary to wait till a drop of blood is formed, which will then fill in each circle on the screening paper sheet. This sheet is then sent to the laboratory and parents have to wait for the test results. In most countries, parents know the results 4 weeks after the test, if they are normal. In case of alterations in the test, parents are usually notified sooner than this.

What does it mean if the test results are normal?

If the results are negative it means that none of the conditions included in the screening was detected. The test is highly specific (99 to 100%), which boosts the security of a negative result as truly negative.

What does it mean if the test results are abnormal?

A positive or out-of-range result does not mean your baby has got a disease. It means that he/she will need further testing. The apparent sensitivity for most of diseases screened are 100% and specificity levels are all above 99%. However, there is a lack of evidence regarding the false negatives and false positives for individual diagnosable disorders included in this screening and the positive predictive values range from 0.5% to 6.0%. Consequently, on average, there are more than 50 false-positive results for every true-positive result identified through newborn screening in the United States.

What diseases can be diagnosed with this screening?

[mme_databox]
Screening Outcomes (United States statistical data)

• Detection rate: 1:4000 live births
• 5 most frequently diagnosed diseases:
• hearing loss
• primary congenital hypothyroidism
• cystic fibrosis
• sickle cell disease
• medium-chain acyl-CoA dehydrogenase deficiency

[/mme_databox]

Primary congenital hypothyroidism

The diagnosis of this condition of the thyroid gland is based on the levels of TSH (a hormone). If diagnosed lately, primary congenital hypothyroidism can lead to serious mental retardation and non-reversible neurological problems. The prognosis depends on the time passed before replacement therapeutic is initiated.

[mme_databox]
Incidence Rates of Congenital Hypothyroidism (United States statistical data)

• 1991: 2.89 cases per 10000 births
• 1996: 3.67 cases per 10000 births
• 2000: 3.86 cases per 10000 births

Incidence – number of new cases within a specified time period in a population.
[/mme_databox]

Hemoglobinopathies including sickle cell disease

Sickle cell disease is a common hereditary blood disorder in which red blood cells present an odd shape caused by a mutation in the hemoglobin gene. The life expectancy is shortened. Finding sickle cell disease early through newborn screening helps to prevent deaths and other complications that can appear.

[mme_databox]
Sickle Cell disease-related mortality  0 to 3 years age group (United States statistical data 1983-2002)

• 1983: Death rate 2.42 per 100.000 black children
• 2002: Death rate 0.78 per 100.000 black children

[/mme_databox]

Cystic fibrosis

This is an inherited disorder of the mucus glands. Mucus is a substance that covers lungs, digestive system, reproductive system as well as other organs, protecting them. In cystic fibrosis, the body produces too much mucus, which is abnormally thick and sticky, which. Without an early diagnosis and treatment, this condition can cause serious complications and even early death.

Hearing loss

1 to 3 in each 1000 apparently healthy newborns have hearing loss, 20 to 40 per 1000 if risk newborns. This should be identified before 3 months and intervention should start not after 6 months, since a normal hearing function is required to language development.

Phenylketonuria

This is an inherited disease characterized by a deficiency in the enzyme phenylalanine hydroxilase, whose function is to metabolize phenylalanine (an amino acid). The accumulation of this amino acid becomes toxic in the body. Treatment consists in a hypoproteic diet, with restriction of phenylalanine.

Summary and Recommendations

• Newborn screening, known as the blood spot test, tests a long list of diseases which may be life threatening or cause severe complications if not diagnosed and treated early.
• All newborns should be screened with this test, even if they look healthy, because many diseases do not show signs after birth and can only become apparent when it is too late.
• The blood spot screening test results are very reliable.
• Examples of diseases that can be diagnosed with this screening are: hearing loss, primary congenital hypothyroidism, cystic fibrosis, sickle cell disease, phenylketonuria.

[mme_references]
References

• Centers for Disease Control and Prevention (CDC). CDC Grand Rounds:Newborn Screening and improved outcomes. MMWR Morb Mortal Wkly Rep 2012; 61:390.
• Kwon C, Farrell PM. The magnitude and challenge of false-positive newborn screening test results. Arch Pediatr Adolesc Med. 2000 Jul;154(7):714-8.
3. http://www.cdc.gov/ncbddd/pediatricgenetics/newborn_screening.html (accessed 29.10.2013).
4. http://www.cdc.gov/ncbddd/pediatricgenetics/data.html (accessed 29.10.2013).

[/mme_references]

“My baby is yellowish… “- Neonatal jaundice

[mme_highlight] Neonatal jaundice is a yellow coloration of skin caused by a yellow pigment called bilirubin. If the levels of this substance get too high there is a risk of brain damage. It generally appears between 72 to 96 hours after birth, disappearing by one to two weeks of life. [mme_highlight]

What is Jaundice?

Jaundice is the medical term for a yellowish coloration of the skin or when the white part of the eye turns yellow.  It generally appears between 72 to 96 hours after birth, disappearing by one to two weeks of life.

Jaundice is a sign that reflects a high blood concentration of a substance called “bilirubin”. This substance is released to blood by the disruption of red blood cells, but usually the liver does its clearance and bilirubin is excreted in urine and stool. However, if the pace of red blood cells disruption gets too fast, bilirubin is not adequately eliminated and accumulates, causing jaundice. As bilirubin is a yellow pigment, it causes a yellow coloration of tissues.

Why does my baby have jaundice?

Neonatal jaundice can be caused by different reasons:

• High turnover of red blood cells: this is a normal situation, because baby’s blood is richer in red blood cells than the adults’ blood and, in addition, these red blood cells have a shorter life than the ones from adults’ blood (approximately 85 days vs. 120 days); as the turnover of red blood cells increases, more bilirubin is produced.
• Deficiency of UGT1A1, an enzyme envolved in the clearance of bilirubin. This enzyme does not work properly until around 14 weeks of age, so the bilirubin is not well cleared and accumulates.
• Mild injuries occurred during birth can leave to red blood cells destruction, hence causing a raise in bilirubin concentration.
• Incompatibility of blood types between mother and child, which causes destruction of red blood cells.
• Inherited diseases causing destruction of red blood cells (such as deficiency of glucose-6-phosphate dehydrogenase, an enzyme).
• Asian race baby or having asian ancestors also rises the odds of having jaundice.

Can jaundice be related to breastfeeding ?

Yes, in two distinct situations. When the intake provided by breastfeeding is not adequate, because this way the blood concentration of bilirubin increases. The other situation is the called “breast milk jaundice”, which happens due to the babies immature organs and occurs mainly during the first two weeks of life. It is not a reason to stop breastfeeding if the baby is gaining weight, but this situation should be monitored by a doctor.

Does jaundice happen to many babies?

Yes, it is very common in babies. In fact, the so called benign jaundice is physiologic and affects almost all newborns. However, as it consists of a mild elevation in bilirubin levels, there is generally no danger for babies. A concentration of blood bilirubin greater that 1mg/dL is above the upper normal limit for an adult. The highest levels are those above 25 mg/dL, which is called hyperbilirubinemia, which associates with a greater risk for brain damage, as the study below shows.

[mme_databox]
Odds of Having Acute Brain Damage (ABD) at Admission and/or at Discharge (logistic regression analysis)
(Study population: 249 newborns with severe hyperbilirubinemia)

• High total serum bilirubin: 1 time more risk for ABD (OR 1.09 – 95% CI 1.03-11.6)
• Higher admission weight: 17% less risk for lactation mastitis (OR 0.83 – 95% CI 0.74-0.93)
• Incompatibility Rh: 48 times more risk for ABD (OR 48.6 – 95% CI 14-168)
• Sepsis (general infection): 20 times more risk for ABD (OR 20.6 – 95% CI 4.9-87.5)

OR – Odds Ratio; CI – Confidence Interval
[/mme_databox]

How can I check if my baby has jaundice?

To check if your baby has jaundice, press one finger on her/his forehead or nose. If it is the case, the skin will appear yellow when you release your finger from the baby’s skin.

What are the symptoms of jaundice?

The yellow coloration that appears in jaundice is generally first noticeable in face, but can also been seen in the chest, belly, and arms; legs are usually the last part of the body affected.

Sometimes, when the level of bilirubin are very high (hyperbilirubinemia), jaundice can be severe. There are some symptoms a baby in this situation can show, although they do not appear only in the case of severe jaundice: if a baby is difficult to wake up, has a high-pitched cry, gets difficult to console and bends her/his body or neck backwards.

How is neonatal jaundice treated?

The most common treatment for neonatal jaundice is called phototherapy, where babies are put under a light therapy, either using a special light or a light blanket over skin. The light breaks the bilirubin molecule, making it easier to eliminate through urine and stool. Generally, this treatment is enough to treat the baby.

Adequate breastfeeding is also very important to prevent and treat this condition, as it promotes the elimination of bilirubin through urine and stool. The study below investigated 22547 infants and shows the estimated number needed to treat (NNT) with phototherapy to prevent one infant from reaching a high bilirubin level with need for exchange transfusion (this is the treatment used for high bilirubin levels when phototherapy is not enough).

[mme_databox]
Estimated NNT with Phototherapy to prevent one infant from reaching the exchange transfusion level (first 24 hours of life)
(Study population: 22547 newborns)

• Boys, 35 weeks of gestation: NNT= 14 (we have to treat 14 with phototherapy to prevent one baby from needing transfusion)
• Boys, 39 weeks of gestation: NNT= 74
• Girls, 35 weeks of gestation: NNT= 21
• Girls, 39 weeks of gestation: NNT= 113

[/mme_databox]

Summary and Recommendations

• Neonatal jaundice is a common and usually benign condition in neonates. It generally appears between 72 to 96 hours after birth, disappearing by one to two weeks of life.
• It can be caused by situations that raise the levels of bilirubin (yellow pigment) or that difficult its elimination, which can be normal in the first weeks of life, because the baby’s organs may be not mature and the turnover of red blood cells is higher. There are also diseases that can cause jaundice.
• The most common therapy for neonatal jaundice is that with a special light, which generally is successful.
• You should always seek medical advice if: your baby’s jaundice worsens, if your baby bends is body backwards and also if she/he is irritable, difficult to wake up or shows a different pattern of crying (high-pitched).

[mme_references]
References

• Dennery PA, Seidman DS, Stevenson DK. Neonatal hyperbilirubinemia. N Engl J Med 2001; 344:581.
• American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004; 114:297.
• Preer GL, Philipp BL. Understanding and managing breast milk jaundice. Arch Dis Child Fetal Neonatal Ed 2011; 96:F461.
• Maisels MJ, McDonagh AF. Phototherapy for neonatal jaundice. N Engl J Med 2008; 358:920.
• Gamaleldin R, Iskander I, Seoud I et al. Risk factors for neurotoxicity in newborns with severeneonatal hyperbilirubinemia. Pediatrics. 2011 Oct;128(4):e925-31.
• Newman TB, Kuzniewicz MW, Liljestrand P et al. Numbers needed to treat withphototherapy according to American Academy of Pediatrics guidelines. Pediatrics. 2009 May;123(5):1352-9.

[/mme_references]

My baby is vomiting…

[mme_highlight] Vomiting is one of the most common reasons for parents to take their child to the Emergency Department. The most frequent conditions that cause vomiting in infants are gastroesophageal reflux, pyloric stenosis and intestinal obstruction. Preventing dehydration and spread and being aware of alarm signs are fundamental measures.  [mme_highlight]

Vomiting is one of the most common reasons for parents to take their child to the Emergency Department. Vomiting is not a disease, but a non-specific symptom which is often related with benign self-limited conditions, but it can also be associated with serious illness. The reason for vomiting varies with age, but the most frequent is a viral infection.

What can be considered vomiting?

Vomiting can be defined as an oral expelling of the gastric content, either in a voluntary or involuntary way, associated with a contraction of abdominal and thoracic muscles. It should be distinguished from spitting up (regurgitation), in which the gastric content comes to mouth without contraction of abdominal muscles. However, in infants, this distinction may not be easy to make, as some infants reflux in large amounts or forcefully.

Why does vomiting appear?

Vomiting occurs when a message to do so reaches the “vomiting center” in the brain. This message can be transmitted from various triggers, such as an infection, food poisoning, certain medicines or motion.

Vomiting is a response of the body to eliminate potentially harmful substances and, in this sense, it is beneficial. However the use of medicines or manual induction of vomiting is not recommended even if a child has ingested a harmful substance; in this case, call the emergency number immediately.

What are the most common causes of vomiting in infants?

Gastroesophageal Reflux

Gastroesophageal reflux (GER) is the most common cause of vomiting in the first year of life; generally, it is self-limited (this means it goes away without any treatment). It results from the immaturity of the lower esophageal sphincter (a muscle between stomach and esophagus). The presentation signs and symptoms are generally regurgitation, refusal to eat, poor weight gain, irritability and episodes in which the baby turns blue (cyanotic).

[mme_databox]
Prevalence of Gastroesophageal Reflux during the first year of life

• 4 to 5 months of age: 67% of all babies have GER
• 6 to 7 months of age: 21% of all babies have GER
• 12 months of age: 5% of all babies have GER

Prevalence – The total number of cases of a disease in a given population at a specific time.
[7mme_databox]

Intestinal Obstruction

Depending on the location of the constriction, vomits can appear bile-stained (“greenish”); if this is the case, take your child immediately to the emergency department. If the constriction is more proximal (more close to esophagus), generally the vomitus is not bile-stained and can be caused by different conditions (pyloric stenosis, upper duodenal stenosis, gastric volvulus, or annular pancreas).

Pyloric Stenosis

If the pyloric muscle is too thick, this can lead to an obstruction, and children may present with non-biliary vomitus during the first weeks of life. This condition is nowadays early diagnosed, using an ultrasound examination of the abdomen.

[mme_databox]
Epidemiology data for Pyloric Stenosis

• Prevalence in population – 3:1000 (3 babies per 1000 live births)
• More common among boys – 4:1 (4 boys for each girl with pyloric stenosis)
• 30% of cases occur in firstborn children

Prevalence – The total number of cases of a disease in a given population at a specific time.
[/mme_databox]

Gastroenteritis
This condition is characterized by a sudden onset but also a fast resolution, most times without any specific treatment. It is more frequent during winter season and caused by a viral infection – most frequently Rotavirus. Vomiting can be the only symptom during the first two days of a Rotavirus infection. Bacterial gastroenteritis may be associated with more prolonged and severe illness.

What can I do to help my infant?

Monitor your child’s hydration: Vomiting leads to a great loss of water from body, so your child can become dehydrated. If your child is thirsty and presents a slightly dry mouth, give her/him fluids. Do not give time for signs of severe dehydration to appear; these are: dry mouth,   decreased quantity of urine (6 or more hours without going to the bathroom or wetting a diaper), lack of tears when crying, sunken eyes.

Oral rehydration therapy: Vomiting leads body to lose water and fluids, which are very important for health balance, so in cases of dehydration these have to be replaced with a liquid solution that contains glucose (a sugar) and electrolytes (sodium, potassium, chloride).

Medicines: Always seek for medical advice before giving your child’s a medicine. Your doctor can recommend the use of antiemetics to prevent vomiting from occur, this way preventing dehydration if your child is vomiting repeatedly.

Preventing spread: Wash your hands and your child’s! It is a simple measure but very effective to prevent spreading a gastroenteritis. Your child should not go to school until she/he stays without a vomiting episode for 24 hours.

Summary and Recommendations

• The most frequent conditions that cause vomiting in infants are gastroesophageal reflux, pyloric stenosis and intestinal obstruction.
• Preventing dehydration and preventing spread if a contagious cause is present are fundamental measures.
• Be aware of alarm signs:
• any episode of vomiting in a newborn;
• vomiting that lasts more than 24 hours in an infant;
• green or blood-stained vomitus;
• signs of dehydration;
• refusal to eat;
• if your child seems more sleepy than usual;
• high fever.

[mme_references]
References

• Nelson, S, Chen, EH, Syniar, GM, Christoffel, KK. Prevalence of symptoms of gastroesophageal reflux during infancy: a pediatric practice-based survey. Pediatric Practice Research Group. Pediatr. Adolesc. Med. 1997; 151:569-572.
• Ikeda H, Matsuyama S, Suzuki N, et al. Small bowel obstruction in children: review of 10 years experience. Acta Paediatr Jpn 1993; 35:504.
• Sondheimer JM. Vomiting. In: Pediatric Gastrointestinal Disease: Pathopsychology, Diagnosis, Management, 4th ed, Walker WA, Goulet O, Kleinman RE, et al (Eds), BC Decker, Ontario 2004. p.203

[/mme_references]

My baby has a common cold…what should I know?

[mme_highlight] Young children have about 6 to 8 colds per year.  The most common virus causing colds are rhinovirus in all age groups. The symptoms of a common cold are seen about 10-12 hours after the viral infection. Generally cold is well tolerated by babies but in certain situations take your baby to the doctor for medical help. [mme_highlight]

According to research studies, young children have about 6 to 8 colds per year. During the initial years of life, boys seem to have more respiratory infections as compared with girls. Daycare attendance has been cited as one of the most important risk factors for respiratory illnesses in children and it is known that the frequency of cold increases with the number of children in a daycare group with respiratory infections.

What causes common cold?

Studies have reported that there are more than 200 different cold viruses. The relative proportion of the virus causing cold is dependent on factors such as age, season and viral detection method. The most common virus causing colds are rhinovirus in all age groups. It has been found that by the age of 5 years, virtually all children have been exposed to one or the other cold virus. 5% of all the patients suffering from cold are dually infected by two viruses.

Research studies have shown a high incidence of rhinovirus infection in children during their first years of life. By the age of 6 months, over 20% of the children have shown a rhinovirus infection confirmed by the laboratories. By the age of 2 years rhinovirus infection has been proved in almost 79% of the children while 91% had developed antibodies against the rhinovirus infection.

The table below enlists the most common viral causes of common cold (Heikkinen & Jarvinen, 2003).
[mme_databox]

Virus	Estimated annual proportion of cases
Rhinovirus	30-50%
Coronavirus	10-15%
Influenza virus	5-15%
Respiratory syncytial virus	5%
Para influenza virus	5%
Adenovirus	<5%
Enterovirus	<5%
Metapneumovirus	Unknown
Unknown	20-30%

[/mme_databox]

What are the symptoms of common cold?

The symptoms of a common cold are seen about 10-12 hours after the viral infection,  while influenza virus may take 1 to 7 days to present symptoms. The mean duration of a common cold is 7 to 10 days in children but in younger children it may linger longer.

The most common symptoms of common cold in babies and children are:

• Runny nose (watery discharge at first, which later becomes thicker and yellowish);
• Sneezing;
• Nasal congestion.

More aggravated symptoms (which are rare) are;

• Dry cough worsening when the baby lies down;
• Fever;
• Itchy throat;
• Fatigue;
• Loss of appetite.

What can be the complications of a common cold in my child?

The symptoms of a common cold may persist in some children even after 3 weeks. The most common complication arising as a result of coldis acute otitis media occurring in almost 20% of children with viral upper respiratory infections; the viral infection may the middle ear fluid and cause inflammation in the mucosa of the middle ear. Bronchitis, pneumonia and sinusitis are other complications associated with cold.

How is common cold diagnosed?

The biggest problem associated with a cold in infants and younger children is that they may not show the typical symptoms. Diagnosis in infants is especially difficult when fever is the major symptom during the early phase of the infection and the doctor is faced with the difficulty of distinguishing viral infections from severe bacterial infections.

A survey conducted for Disease Control and Prevention in 1991 showed that almost two thirds of three year olds had taken a medicine for cough or cold in the preceding 30 days. It is very important that physicians correctly diagnose the cold before deciding on the use or refuting the use of medications in young babies.

How is common cold treated?

There is not a cure for common cold, but symptoms can be treated to provide relief for the baby or the young child. The treatment options that have been recommended for common cold in babies and young children are the following:

• Suctioning of mucus with a suction bulb. Over the counter saline nasal drops may be used to soften the hard mucus before the suctioning of mucus. This will help the baby to feed properly and sleep well.
• Keep the air in the room humidified to moisten the air, reduce congestion and facilitate breathing in babies.
• Make the baby sleep on his /her belly with head elevated to ease breathing.
• Petroleum jelly or similar ointment should be applied lightly to the outside of and under nose to prevent chapping and reddening of the skin.
• Decongestants prescribed by the physician should be given to ease congestion so that the baby can eat and sleep properly.
• Nose drops may be used when prescribed by the doctor to ease the congestion. Overuse may lead to a rebound reaction, thus worsening the condition of the baby.
• Cough medicine may be prescribed by the doctor to ease a dry cough in extreme cases. However, generally, cough suppressants are not prescribed for the babies. The American Academy of Pediatrics cautions against the use of any cough medicines in infants and children. Antibiotics should be used only in case of secondary bacterial infection.
• The baby should be isolated from others in the family for the initial three days to prevent spreading of the cold to others.
• Dietary changes: baby should be continued on normal diet. The intake of milk and other dairy products may be reduced as these can thicken the secretions. Fluid intake should be increased to replenish the lost fluids. Vitamin C rich foods, like strawberry and orange, should be given to the baby.

What are the alarm signs parents should be aware of?

Generally cold is well tolerated by babies but in certain situations take your baby to the doctor for medical help. These situations are:

• If this is the first cold of your baby;
• If your baby is under 3 months or 4 months of age and has a fever over 101˚F (38 ºC);
• If the temperature suddenly goes up or stays high for more than 2 days;
• A dry cough lasting more than 2 weeks or interfering with the baby’s sleep, or which causes choking or vomiting, becomes thick and productive or wheezy;
• A cough lasting for more than three weeks in an infant or six weeks in an older baby;
• If breathing difficulties develop;
• If a thick greenish yellow nasal discharge develops lasting for more than a day;
• If the nasal discharge is streaked with blood;
• Unusual amount of crying or loss of appetite.

Summary and Recommendations

• It is normal for young children to have common colds: the average frequency is estimated in 6 to 8 per year. It seems to be more prevalent in boys.
• Being at a daycare facility is a risk factor to catch a common cold.
• The most frequent agent causing common cold is rhinovirus.
• It has been documented that almost all fiver-year-old have already contacted with common cold viruses.
• Possible complications are: acute media otitis, bronchitis, pneumonia, and sinusitis.
• Some options to relieve symptoms are: nasal mucus drainage, keeping air humidified, use decongestants when you have a medical prescription, reinforce oral hydration and give your child aliments rich in vitamin C.
• Your baby’s first cold, a cold in young infants, dry cough that lasts more than 2 weeks and difficulty to breathe are indications to seek for a doctor.

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References

• Eisenberg, A., Murkoff, H. E., & Hathaway, S. E. (1996). When Baby is Sick. In A. Eisenberg, H. E. Murkoff, & S. E. Hathaway, What to Expect The First Year (pp. 418-420). NewYork: Workman Publishing.
• Heikkinen, T., & Jarvinen, A. (2003). The Common Cold. THE LANCET, 361, 51-59.
• NHS, C. (2011, June 10). Common Cold in Children. Retrieved from NHS choices: http://www.nhs.uk/Conditions/Cold-common/Pages/Commoncoldinchildren.aspx
• Simasek, M., & Blandino, D. A. (2007). Treatment of The Common Cold. American Family Physician, 515-520.

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