Category: Health

Is my baby getting enough breast milk?

[mme_highlight] Breastfeed whenever your baby shows signs of being hungry, like awakening, searching for the breast, sucking on hands, tongue or lips. Parents want to be sure if their baby is getting enough milk. There are some simple ways to estimate it. [mme_highlight]

Human milk meets the nutritional needs of a full-term infant until 6 months with a lot of advantages for your baby’s health, particularly for the development of the immune system.

Mothers should start breastfeeding within the few hours after birth. If, by medical reasons, infant and mother are separated, it is recommended that mothers pump the milk and store it for later use, in order to stimulate the continuous production of milk.

Am I producing enough milk?

During the first days after giving birth, the milk mothers produce has a yellow appearance and it is called collostrum: it provides all the nutrients and calories  your baby needs for the first days of life. Many women worry because their milk production is low at beginning and fear their infants do not get adequate feeding. This is normal and with the continuation of breastfeeding the milk will be produced in larger amounts. Note that it is expected that babies lose weight during the first days, regaining it about two weeks after birth, in a gradual manner.

How often?

Breastfeed whenever your baby shows signs of being hungry, like awakening, searching for the breast, sucking on hands, tongue or lips. Note that usually babies only cry when they get very hungry, so you should not wait till your baby cries to breastfeed.

First 2 weeks of life: 8-12 times per day. Some can require it every 30 to 60 minutes while others may have to be awakened. If this is the case, wake the baby if 4 hours passed since the last breastfeeding; a good tip to wake up your baby gently is to change the diaper or move the feet.

The time required to finish breastfeeding is variable: it can be 5 minutes for some babies and 20 minutes or even more for others.  Leave your child determines it as long as the baby is sucking and swallowing regularly. Enjoy this sweet moment of active bonding.

How much? When should I be worried?

Parents want to be sure if their baby is getting enough milk. There are some simple ways to estimate it:
Write a kind of “diapers diary”, keeping a registry of how many of them are wet or dirty during the first two weeks; if less than 6 of the diapers are wet or if the color of urine gets darker or orange this can mean the intake may not be enough and you should seek for medical advice.
Monitor your baby’s weight: as said above, it is normal for a baby to lose weight in the first days; however, if the baby continues to lose weight after that or fails to regain it in two weeks, you should seek for medical advice.
Make sure your milk production continues: milk production is under hormonal control, so if milk is not removed regularly the milk production will decline.

Summary and Recommendations

• Collostrum is the yellowish milk produced during the first days after birth.
• With the continuation of breastfeeding, your milk production will increase.
• Breastfeed whenever you r child seems hungry, awakening, looking for breast or sucking on fingers.
• Some tips to assure your child is getting enough milk is keeping a diapers record, monitor weight and remove milk frequently in order to maintain milk production.
• Keep in mind that it is normal for babies to lose weight during the first days of life.
• The American Academy of Pediatrics recommendation is that all breastfeeding newborns are weighed and examined by a doctor three to five days after birth and at two to three weeks; it is part of the regular surveillance to look for signs of jaundice, dehydration, weight loss, or other complications.

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References

• Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012; 129:e827.
• World Health Organization. The World Health Organization’s infant feeding recommendation.http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/ (accessed on April 10, 2013)

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How to start my baby on solids?

[mme_highlight]Solid foods can be included in the menu of infants at the age of 4-6 months. The menu of infants becomes more varied in the second half of the first year. After a phase of adjustment to the diet with solids, which takes 1-2 months on average, the infant should have 3 milk meals and 2 meals with solids.[/mme_highlight]

Healthy eating since early childhood has great importance, because the form of nutrition that is established in early childhood tends to be maintained later in life and it can very difficult to change nutritional errors. The moment of introduction of solid foods is itself a milestone for children. Solid foods can be included in the menu of infants at the age of 4-6 months.

When is the right time to introduce solids?

Age of the baby is not the only criteria considered for inclusion of solids. It is important that the baby attains certain developmental milestones such as:

• The baby can hold up his/her head (without support);
• The baby can sit (with the support of parents);
• The baby knows to lean forward towards the food when she/he is hungry and lean back when she/ he doesn’t want food.

What can happen if solids are introduced too late?

The inclusion of solid foods should begin at the right time, because the late introduction of solid food can lead to iron deficiency, which causes anemia. According to studies babies whose parents feed them with vegetables rich in iron, have lower percentage of anemia (table below).

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Frequency of anemia in babies at 8 months (data from study)

• babies who received iron fortified cereal: 3.5%
• exclusive breastfeeding: 15%.

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In addition, slower progression of a child may occur due to insufficient caloric intake. However, parents have to pay attention not to include solid food too early, because it can cause food intolerance.

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Age of introduction of solids – Centers for Disease Control and Prevention (CDC):

• about 40 % of parents included solid foods in baby’s diet before they were 4 months old.
• 56% introduced solid food before age 6 months
• 6% didn’t included solids at age 8 months

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What can happen if solids are introduced too early?

Some research supported the fact that babies that are fed with formula are frequently fed with solids before 4 months (52.7 percent) and there was smaller percent of babies who started with solids before 4 months that are breast-fed exclusively (24.3 percent).

If solid foods are introduced too early, the food may not be completely digested, as the baby’s digestive system is not immunologically developed and the production of enzymes such as amylase is decreased. Also protein food can burden baby’s kidneys. In addition, it was found that early inclusion of solid foods increases the risk for obesity in adulthood.

Also, it was found that the frequency of obesity in children was significantly lower in the group where children were longer on exclusive breastfeeding: 3.8% for 2 months of exclusive breastfeeding versus 2.3% for 3-5 months of exclusive breastfeeding.

In addition, it was found that inclusion of solids before 15 weeks increases the possibility of infection, as shown in the table below.

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Age of introduction of solid foods and infection risk

• exclusively breast-fed have 40% fewer ear infections than breastfed babies with solids included
• 21% babies that are fed with formula had wheeze during childhood
• 7% of exclusively breastfed had wheeze during childhood

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Children with family predisposition to allergies should not take solid food until 6 months of age, because of the possibility of sensitization to food allergens. Those kids should be given iron supplements, because the amount of iron in the mother’s milk is not sufficient to satisfy the needs of a 4-month-old baby.

It is worth to be mentioned that a child from birth throughout the infancy period should be given drops that contain vitamin D (400 IU per day).

What are the basic principles of including solids?

• In order to identify and eliminate foods that cause allergy, new aliments should be given one by one at intervals of 4 to 7 days. If parents notice the presence of an allergic reaction (diarrhea, weakness, vomiting, skin rash, wheezing, facial swelling, coughing etc.) then this kind of food should be stopped and parents should consult a doctor.
• Meals are given in the mushy-liquid form and at the end of the first year as crushed or finely chopped.
• Feeding with bottle increases the risk of abandonment of breastfeeding, therefore food should be given to baby with the spoon.
• Parents should not add salt to the food, because breast milk contains enough salt. Excessive intake of salt burdens baby’s kidneys and increases a risk for high blood pressure in adulthood.
• Adding sugar to the diet of a baby is not recommended, especially in children who have familiar predisposition to obesity and atherosclerosis (obstruction of blood vessels with fatty deposits).
• Fats are optimally represented in the baby’s diet, so there is no need to add or reduce them.

The starting amount of solids should be small and parents should give the child one teaspoon of solid food at the end of breastfeeding. Then, gradually increase the amount from one to four spoons (up to 60ml) of solid food, twice a day.

Is there some order to follow when introducing solids?

Cereals are usually the first food that should be given to an infant. Cereals are an excellent source of iron, B vitamin and calories that the baby needs for growth and development. For example, one cup of oatmeal contains 10 mg of iron and babies between 7-12 months need 11 mg/ day. It should be started with rice and corn crops, as they are easily digested and rarely cause allergies, since they do not contain gluten.

Then, about three weeks after the inclusion of cereals, pureed vegetables should be included in the children’s diet. It is recommended to include mild vegetables, such as potatoes and carrots and then pumpkin, peas, cauliflower, spinach, broccoli etc.

After the inclusion of vegetables, parents should start giving the fruit, first in the form of 100% pasteurized juice (apple, peach), then in the form of mush (apple, peach, pear, banana). Finally, meat should be included by the end of the sixth month.

According to these principles, the menu of infants becomes more varied in the second half of the first year. After a phase of adjustment to the diet with solids, which takes 1-2 months on average, the infant should have 3 milk meals and 2 meals with solids- one meal should contain vegetables and meat and the other meal should contain fruits. Baby should get 25% of total energy intake calories from solids by the age of 12 months.

Which foods should be avoided?

The following foods should be avoided until the child reaches one year of age:

• Cow’s milk, because it could contain potential allergens. According to the American Academy of Allergy, Asthma, & Immunology, 2.5% of children under the age of 3 are allergic to cow’s milk.
• Honey, because of the possibility of infection with bacterium Clostridium botulinum.
• Foods that may cause choking in children (especially nuts, candies or grapes- these foods easily fall into a baby’s airways and in addition they have the ability to swell and completely obstruct the airway lumen). 81.5% of children younger than 1 year whose cause of death was unintentional injuries, died from suffocation.

Summary and Recommendations

• Solid foods should be ideally introduced around 6 months.
• Introducing solid food too late may cause anemia due to iron deficiency.
• When introduction of solids occurs too early, the digestion can be immature, the kidneys may be affected and there is a higher risk for obesity, infection and allergies.
• Do not add salt, sugar or fat to your baby’s food.
• Start solids with small amounts. Introduce cereals first, then vegetables, fruit and meat.
• If you notice any allergic reaction, stop giving the aliment and take your child to a doctor.

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References

• Developmental Readiness of Normal Full Term Infants to Progress from Exclusive Breastfeeding to the Introduction of Complementary Foods” Naylor and Morrow, 2001
• Walter T, Dallman PR, Pizarro F, et al: Effectiveness of iron fortified infant cereal in prevention of iron deficiency anemia. Pediatrics 1993; 91: 976-982
• Kries R,Koletzko B, Sauerwald T, et al. Breast feeding and obesity: cross sectional study  1999 Jul 17;319(7203):147-50.
• Wilson A, et al. Relation of infant diet to childhood health: seven year follow up of cohort of children in Dundee infant feeding study BMJ1998; 316:21

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How to prevent tooth decay in my baby?

[mme_highlight] Tooth decay has a high prevalence among young children but can be prevented with simple measures: keep your child’s mouth cleaned, take her/him to the dentist on a regular basis, do not give your child a bottle to walk around with or while in bed. [/mme_highlight]

Preventing tooth decay in your children should start even before the first tooth appears, with healthy oral hygiene habits. Other names you can hear referring to tooth decay in babies are “baby bottle tooth decay” and “early childhood caries”. Untreated dental disease can result in pain and infection, impair speech, and lead to learning and eating problems and often trigger a lifetime of dental treatment – that is why the focus should be on preventive strategies. It is estimated that about 6.3% of young children (1 to 3 year-olds) have caries in United States of America.

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Proportion of Children  aged 2 to 4 years old who have ever had caries in  primary teeth  (United States National Health and Nutrition Examination Survey; 95% Confidence Interval)

– 1988-1994: 18%
– 1999-2004: 24%
– “Healthy People” (U.S. government program) goal for 2010: 11%

Proportion of Children  aged 2 to 4 years with untreated tooth decay in  primary teeth  (United States National Health and Nutrition Examination Survey; 95% Confidence Interval)

– 1988-1994: 16%
– 1999-2004: 19%
– “Healthy People” (U.S. government program) goal for 2010: 9%

Prevalence – The total number of cases of a disease in a given population at a specific time.
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Why do baby caries appear?

Both in adults and children, this is a complex process, but the resulting pattern is unique in young children, as it involves primary maxillary incisors, followed by the maxillary and mandibular primary first molars and the mandibular primary cuspids, in this order.

Tooth decay appears after a continuous exposition to aliments which collect around teeth and gums, being then transformed in acid by bacteria present in mouth. This acid can dissolve the enamel of teeth, causing tooth decay. This can happen particularly if parents put children in bed with a bottle of milk, juice or other sugared drinks, as well as when parents allow children to drink from a sippy cup, suck on a bottle or breastfeed for long periods.

What are the factors that influence tooth decay?

Studies have shown that factors such as low social status, drink from a bottle in bed or for long periods as well as snacking are risk factors for tooth decay; in the other hand, regular visits to the dentist are a protective factor.

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Risk and Protecting factors for tooth decay in young children  (statistical significantly results)
(Study design: 88 children suffering from baby bottle tooth decay and 88 children with no dental caries, multivariate analysis applied)

– Low social class: 6 times more risk for tooth decay (OR 6.39 [95% CI, 1.45–28.11])
– Prolonged bottle feeding or bedtime feeding: 153 times more risk for tooth decay (OR 153.2 [95% CI, 11.77–1994.96])
– Snacking: almost 6 times more risk for tooth decay (OR 5.94 [95% CI, 1.35–26.2])
– Regular dental visits: decreases the risk for tooth decay by 87% (OR 0.13 [95% CI, 0.02–0.77])

OR – Odds Ratio; CI – Confidence Interval
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What can I do to prevent tooth decay in my child?

• Teach your child to drink from a bottle as early as possible: this diminishes the exposition of teeth to liquids compared to bottles and sippy cups.
• Do not put your child to bed with a bottle: this has multiple risks – exposition of teeth and gums to sugar, risk for ear infections and for chocking.
• Give a bottle to your child only during meals and fill it with water: do not let your child walk around with a sippy cup or bottle for long periods.
• Take your child to be examined as soon as you notice signs of tooth decay: white spots at the gum line on the upper front teeth are the first signs and can be difficult to notice at first.
• Keep your baby’s mouth cleaned: use a gauze with water during the first 8 months of life. After that use a toothbrush twice a day.
• Do not forget the time for the first dentist visit: which is as soon as teeth start appearing.

What is the importance of tooth brushing?

The best moments for tooth brushing are after breakfast and before bed. Start with a fluoride-free toothpaste. When children are able to spit and not swallow the toothpaste – which happens between 2 and 3 years of age – you can start using a fluoride one. A Scottish study has shown that a twice a day brushing with a smear of medium-strength fluoride toothpaste can be about 25% more effective in preventing tooth decay that non-fluoride brushing.

Summary and Recommendations

• Tooth decay has a high prevalence among young children but it is a preventable disease.
• Tooth decay can be prevented with simple measures: keep your child’s mouth cleaned, take her/him to the dentist on a regular basis, do not give a bottle to your child to walk around with or while in bed.
• The American Academy of Pediatrics recommends that all infants should have an oral health assessment by 6 months.

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References

• Broderick E, Mabry J, Robertson D, Thompson J. Baby bottletooth decay in Native American children in Head Start centers. Public Health Rep. 1989 Jan-Feb;104(1):50-4.
• Khadra-Eid J, Baudet D, Fourny M. [Development of a screening scale forchildren at risk of baby bottle tooth decay]. Arch Pediatr. 2012 Mar;19(3):235-41.
• http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5802a3.htm (accessed 14.10.2013)
• http://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review_focus_area_21.pdf (accessed 14.10.2013)
• Scottish children brush away tooth decay. Br Dent J. 2005 Dec 10;199(11):698.

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How much do babies sleep?

[mme_highlight] During the first year of life, babies’ sleep and wake patterns change, mostly influenced by the interaction between the baby’s development and environmental factors. Duration of sleep decreases with age, while the consistency of sleep improves with age. It is important to provide a soothing sleep setting and consistent sleeping habits since birth. [/mme_highlight]

During the first year of life, babies’ sleep and wake patterns change, mostly influenced by the interaction between the baby’s development and environmental factors. The sleep is often a subject of concern among parents, who question about what is a normal sleep, if their infant’s sleep requirements are being met or if there is some problem.

Infants: a unique pattern of sleep

The sleep pattern of a healthy infant is quite different from that of adults. The most distinguishing feature is that it is longer: 16 to 18 hours per day. In addition, the REM (rapid eye movement) phase occurs at sleep onset and its duration is increased in babies.

“Sleeping through the night” is a complex phenomenon, although it does not imply, as often believed, sleeping without awakening during all night. To sleep through the night, the baby must acquire the following skills:

• Capability to sustain period of sleep.
• Capacity of self-soothing in order to independently reinitiate sleep during the night.
• Consistent development of these skills ideally during the same nocturnal period during which the other family members sleep.

Recent studies have shown that the greatest change in the ability to sustain the sleep period is within the first three months of age, particularly between the first and second months. Hence, it is important to provide a soothing sleep setting and consistent sleeping habits since birth.

In fact, with the maturation of the central nervous system of infants some changes occur: decrease in the total sleep time and in the duration of REM sleep. Thus, in children, the phase at the onset of sleep is the NREM (non rapid eye movement) and not the REM, like in infants.

How does the sleep duration change throughout childhood?

As the table below shows, there is a consistent decline in the sleep duration as the child growths. Data from studies estimate that the decline in the sleep duration is about 10.5 minutes per month between the first and sixth months of age and 5.4 minutes per month between the seven and twelve months of age.  Later the rate of declining slows: the duration of sleep approximately diminishes 7.8 minutes per year between one and four years and then from five to twelve years about 5.9 minutes per year.

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Mean period of sleep in children by age.

Age	Mean period of sleep (24 hours)
0-2 months	14,6 h
3 months	13,6 hours
6 months	12,9 hours
9 months	12,6 hours
12 months	12,9 hours
1-2 years	12,6
2-3 years	12,6
4-5 years	11,5 hours

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Night waking impairs sleep consolidation and shortens sleep. This table, based on data from various studies, evidences the decline in the number of waking per night with age. Thus, not only the sleep consolidation improves with growth, but mostly during the first months, as stated above.

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Night waking in infants

Age	Mean number of wakings per night
0-2 months	1.7
3-6 months	0.8
7-11 months	1.1
1-2 years	0.7

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What are the problems of inadequate or short sleeping?

• Negative impact on behavior and cognitive development.
• Poorer neuropsychological functioning in adolescence.
• Obesity: recent studies have come to the conclusion that children who do not get enough sleep are at increased risk of becoming overweight.
• Higher Blood Pressure: investigators found that blood pressure is elevated in children who sleep less.

Summary and Recommendations

• Implementing sleeping habits and providing a soothing sleeping setting should be priorities since birth.
• Duration of sleep decreases with age, while the consistency of sleep improves with age (less night waking per night in older children).
• Inadequate sleeping has a negative impact for babies and children, principally regarding behavior and cognitive development.
• Poor quality of sleep increases the odds for a child to be overweight or to have high blood pressure.

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References

• Galland BC; Taylor BJ; Elder DE; Herbison P. Nora sleep patterns in infants and children: a systematic review of observational studies. Sleep Medicine Reviews: vol 16, issue 3; p. 213-222.
• Henderson, JMT; France KJ; Blampied NM. The consolidation of infants’ nocturnal sleep across the first year of life.
• Anders TF, Sadeh A, Appareddy V. Normal sleep in neonates and children. In: Principles and Practice of Sleep Medicine in the Child, Ferber R, Kryger M (Eds), W.B. Saunders, Philadelphia 1995. p.7.

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How much do babies eat?

[mme_highlight] Children demonstrate an innate capacity to self-regulate the dietary intake. There are some factors that can affect this self-regulation diminishing the drive that leads one to eat, like coercive feeding, intake restriction or environmental factors. The dietary reference values are different for every nutrient and vary during the first year.[mme_highlight]

At a microscopic level, your baby’s body is, like yours, composed of tissues and cells, where processes that are essential to life and to growth take place at every instant. So, the major determiners of your baby’s dietary needs are:

• keeping the body’s tissues (depends on the body mass)
• new tissues construction (depends on the growth velocity)
• individual variety.

The right time for every food…

Breastfeeding is the preferable primary source of nutrition for healthy full term infants during the first year of life; if human milk is not available, infant formulas enriched with iron can be an acceptable substitute. Solid foods can be added between the four and six months of age and as the infant acceptance and motor skills develop, more complex foods and textures can be gradually introduced.
After the completion of 12 months of age, an infant can usually share the familiar’s diet, if it is healthy and well balanced.

Breastfed infants: how much do they eat?

Basically, let your baby determine the frequency of breastfeeding. Breastfeed whenever your baby shows signs of being hungry, like awakening, searching for the breast or sucking on hands. Note that usually babies only cry when they get very hungry, so you should not wait till your baby cries to breastfeed.
Typically, an exclusively breastfeeding infant nurses every two to three hours if awake – about 8 to 12 times per day. All babies on exclusive breastfeeding should be given vitamin D supplementation. Your baby will gain 15 to 30 g per day during the first 6 months.

Energy requirements of your baby

The nutritional needs vary with age, being approximately:

• 0 to 2 months: 100-110 Kcal/Kg/day
• 3 to 5 months: 85-95 Kcal/Kg/day
• 6 to 8 months: 80-85 Kcal/Kg/day
• 9 to 11 months: 80 Kcal/Kg/day

The variables that influence the dietary energetic intake per day are the number of times the child eats, the energetic content of the foods and the portion size.

Children demonstrate an innate capacity to self-regulate the dietary intake. There are some factors that can affect this self-regulation diminishing the drive that leads one to eat, like coercive feeding, intake restriction or environmental factors.

Dietary reference intakes

The dietary reference values are different for every nutrient and vary during the first year. The approximate percentages are shown below and the approximate absolute values in the table.

• Carbohydrates: 35% at birth increasing to 60% of the total energetic value at first year.
• Fat: 55% at birth decreasing to 35% of the total energetic value at first year.
• Proteins: 7% at birth increasing to 15% of the total energetic value at first year.

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Nutrient	0 to 6 months	7 to 12 months
Carbohydrate	60 g/day	95 g/day
Fat	31 g/day	20 g/day
Protein	1,5g /Kg/day	1,0 g/Kg/day
Calcium	200 mg/day	260 mg/day
Iron	0,27 mg/day	11 mg/day
Zinc	2 mg/day	3 mg/day

Data adapted from: Committee on Nutrition American Academy of Pediatrics. Appendix J. Dietary Reference Intakes: Recommended Intakes for Individuals, Food and Nutrition Board, Institute of Medicine. In: Pediatric Nutrition Handbook, 6th ed, Kleinman RE (Ed), American Academy of Pediatrics, Elk Grove Village, IL 2009. p.1293.
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How should I use the data above?

The purpose of the above data is purely informative. The key point is to understand that overfeeding can induce an excessive weight gain, which can lead to later complications. Allow your infant to stop eating if they seem to be full – you can notice, for instance, a lack of attention or turning away. Oppositely to what common sense believes, there is no evidence that giving cereals before bedtime allows a better sleep.
There is no need to monitor or keep a record of the diary intakes of every nutrient if your child is healthy and shows a good weight progression. The main points are to take your infant to the doctor if you notice a fail to increase weight (except during the first days of life, in which it is a normal occurrence) and to provide your child with a healthy feeding environment:

• Recognize your child’s progresses in terms of feeding skills;
• Respond adequately to hunger and fullness signs;
• Provide a relaxed setting, preferably at home.

Summary and Recommendations

• The frequency of breastfeeding is usually 8 to 12 times per day.
• Nutritional needs vary with age.
• Children have a ccity to self regulate the adequate intake of food, which can be disrupted by coercive feeding, restrictive feeding or other environmental factors.
• Overfeeding translates into overweight children, which leads t health problems.
• If you notice your child is not gaining weight, take her/him to see a doctor.

[mme_references]
References

• Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012; 129:e827.
• World Health Organization. The World Health Organization’s infant feeding recommendation.http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/ (accessed on April 10, 2013).
• Guthie HA. Introduction of solid foods – Part 2. Consequences of early and late timing. In-Touch 1998; 15:1.
• Kleinman RE. Learning about dietary variety: The first steps. Pediatric Basics 1994; 68:2.

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How does Primary dentition appear?

[mme_highlight]The first tooth to appear is the central incisor, between 6 and 12 months. The most common clinical manifestations of teething in children are fever, drooling and diarrhea. Clean and healthy teeth are not only important to chew the food properly but also to pronounce the words clearly.[mme_highlight]

Humans are diphyodont, which means we have 2 sets of teeth in our lifetime- a temporary set, with 20 teeth (also known as primary, baby, milk or lacteal dentition) and a permanent dentition composed by 32 teeth. Diphyodont literally means “two generations of teeth”. The chart below can help to understand the eruption and shedding pattern of the teeth in children.

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Eruption and Shedding pattern of primary teeth

	Erupts at	Sheds at
Central incisor	6-12 mo	6-7 y
Lateral incisor	9-16 mo	7-8y
Cuspid or Canine	16-23 mo	9-12 y
First bicuspid	13-19 mo	9-11 y
Second Bicuspid	23-31 mo	10-12 y

mo- months and y-years
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Primary Teeth: Those beautiful pearls

When the child is born, there is an immediate reflex to suck.  Breast milk provides all the essential nutrients and water for the first 6 months. Babies start basic food after 6 months, when the first tooth forms (chart1). Dentition begins in fetus at 4 months and at the time of birth the crown of the first 20 deciduous teeth is formed. Between 2 1/2 and 3 years, the baby has 20 white teeth to flaunt. The process of dentition is dynamic – there is continuous growth of the child’s jaw that makes way for the permanent teeth.

How to take care of primary teeth?

Primary teeth though deciduous, need proper care. Clean and healthy teeth are not only important to chew the food properly but also to pronounce the words clearly. Infectious gums lead to oral pain and compromise the healthy growth of permanent teeth. In children, tooth decay is called early childhood caries, baby bottle tooth decay or nursing mouth syndrome.

How does teething affect children?

Teething is often remembered by most parents as a phase of distress and discomfort. The child is disturbed with the simultaneous changes in the oral cavity. Ballooning of the gums, with swelling and redness, as well as oral ulcers and increased drooling are some of the problems encountered by children. Redness of mucosa is a very common phenomenon and occurs in 30-90% of the babies.
Noor-Mohammed and Basha in a recent study (2012) showed that the most common clinical manifestations of teething in children are fever, drooling and diarrhea (Chart2). These manifestations were prominent during the eruption of primary incisors. Boys tend to suffer from diarrhea more than girls, though other clinical manifestations did not vary much with gender.

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Clinical Manifestations observed during teething

Med Oral Patol Oral Cir Bucal. 2012 May 1;17 (3):e491-4.
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How can parents help to relief teething associated symptoms?

• Something to chew on: Give the child something to chew, like a cold washcloth.
• If the child is old enough to eat, give her/him something cold to eat such as yogurt, ice-cream or an apple purée. Cold numbs the gums and it is often regarded as a natural anesthetic.
• Unsweetened teething crackers are available in the market and are believed to provide relief to the child.
• Rubbing the sore gums with clean fingers or topical relief gels can also help, though you should refer to your doctor first.
• Drooling often causes a rash on the baby’s face. In such a situation, just wipe the face with a soft cloth. Applying petroleum jelly on the chin also brings relief.

Can my baby have Dental Caries?

Dental caries occur at an early age in children; in fact, caries can appear as soon as there is an eruption of the first tooth, and is presented as white lines or spots. It is a chronic disease in which teeth have bacteria (a mutant of streptococci). These bacteria are fed by sugars (monosaccharide and disaccharides) producing acids which erode teeth causing infection.

[mme_databox]

• Only 6% of the chewing career of an average human being (70 years) uses deciduous dentition
• Timing of eruption of teeth is governed by genetics
• Shedding of deciduous teeth begins early in girls

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Summary and Recommendations

• The first tooth to appear is the central incisor, between 6 and 12 months.
• Teething can be a source of distress both for children and parents. According to a study, the most common clinical manifestations of teething in children are fever, drooling and diarrhea.
• Hygiene and general good care of teeth are essential to help chewing, speaking and a normal growth of permanent teeth.

Oral care tips for infants – Do’s:

• Wipe your child’s gums after each feed
• Brush your child’s teeth and supervise them if fluoride toothpaste is used. They must be taught the concept of rinsing the teeth after brushing

Oral care tips for infants – Don’ts:

• Never let your baby sleep with sweetened juice of milk-bottle in the mouth
• Never dip pacifier in honey or sugar syrup

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References

• Tooth eruption. The primary teeth. JADA, Vol. 136, 2005.
• Hulland SA, Wake MA. Eruption of the primary dentition in human infants: a prospective descriptive study. Pediatric Dentistry – 22:5, 2000.
• Noor-Mohammed R, Basha S. Teething disturbances; prevalence of ob- . Teething disturbances; prevalence of ob- Teething disturbances; prevalence of objective manifestations in children under age 4 months to 36 months. Med Oral Patol Oral Cir Bucal.;17 (3):e491-4, 2012 May 1.
• Douglass JM, Douglass AB, Silk HJ.A practical Guide to Infant Oral Health. Am Fam Physician. 2004 Dec 1;70(11):2113-2120.

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Frequently asked questions about measuring temperature in children

[mme_highlight] The cut-off value to be considered a fever depends on how and where the temperature is measured (rectal, oral, armpit, ear or forehead temperature). Rectal temperature is the most accurate. In 4 year old and older children mouth temperatures are also reliable. [/mme_highlight]

Fever is a raise in body’s temperature above a certain temperature that translates a normal response of the body to numerous situations – an infection is the most frequent. The cut-off value to be considered a fever depends on how and where the temperature is measured (rectal, oral, armpit, ear or forehead temperature). Fever is still a matter of concern for most parents as there are many misconceptions, including on the correct way to measure fever in children and on how should measurements be interpreted.

Do parents know how to measure fever?

Regarding fever, as with other health matters, sociodemographic data counts. A study conducted in Harvard with a multiethnic and socially diverse sample of parents, concluded that parents who had not graduated from high school had 5 times the odds of not using a thermometer to check for fever and 3 times the odds of not asking a health care provider for advice.

A study was conducted to compare the accuracy parents’ and nurses’ measurement of fever in children, either using the same home thermometer, either when parents used a home thermometer and nurses used one from the hospital. Results are presents below.

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Accuracy of parents in measuring body temperature with a tympanic thermometer(Study Design: Parents and then nurses measured the temperature of 60 children with a tympanic thermometer) Mean difference when both parents and nurses used a tympanic thermometer designed for home use: –        0.44 ± 0.61 °C –        33% of the readings differed by ≥ 0.5 °C   Mean difference when parents use a home thermometer and nurses use a hospital one: –        0.51 ± 0.63 °C –        72 % of the readings differed by ≥ 0.5 °C. Using the home thermometer

OR – Odds Ratio; CI – Confidence Interval
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A glass or a digital thermometer…which one to choose?

Nowadays, digital thermometers are an inexpensive widely available device and, in addition, they are recognized as the most accurate way to evaluate the body’s temperature. Glass thermometers continue to be used among many families, but parents should be aware that they’re not recommended because they contain mercury and, if broken, there can be a dangerous exposition to this toxic metal. If a digital thermometer is not at your disposal and you have to use a mercury one, shake it down carefully before using it.

What is the most accurate way to take my child’s fever?

Rectal temperature is the most accurate. In 4 year old and older children mouth temperatures are also reliable. Remember that armpit, ear temperatures are not as accurate as rectal or mouth temperatures. In addition, the forehead temperature is not accurate to evaluate a child’s temperature, because it depends on the temperature of the person who is touching the child’s skin. A survey was conducted to understand how parents recognize their children fever and where they measure it.

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Parent’s methods to evaluate their child’ fever(Study Design: survey among 402 parents whose children were enrolled and presented for health care at a primary health care clinics) Fever recognition: –        Touching child: 65.4% –        Measure Temperature: 31.6% –        Touching child and measuring temperature: 3%   Site used to take temperature: –        Mouth: 50.2% –        Anus: 25.9% –        Armpit: 21.1% –        Other: 2.7%

OR – Odds Ratio; CI – Confidence Interval
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Correct way of taking a rectal temperature

Prepare the thermometer putting a little bit of petroleum jelly (Vaseline) in its silver end. Then put your child lying down across your lap and introduce carefully the silver end of the thermometer inside your child’s anus. Wait holding it in place – note that a glass thermometer will take about two minutes and digital one less than a minute.

Correct way of taking an ear temperature

To measure ear temperature, often referred to as tympanic temperature, you have to use a thermometer specially designed for the ear pavilion – non-contact tympanic thermometer. Gently pull back your child’s ear and then insert the thermometer, holding the probe for about two seconds.

Correct way of taking a mouth temperature

If your child has drunk or eaten something hot or cold, you should wait 30 minutes or more before taking a mouth temperature, otherwise, results would not be reliable. In addition, do not forget to wash the thermometer with cool water and soap.

To take your child’s mouth temperature, put the thermometer under the child’s tongue and ask her/him to hold it with her/his lips, and not use the teeth. Wait about 3 minutes with a glass thermometer and less than a minute in the case of a digital one.

Correct way of taking an armpit temperature

To take an armpit temperature, place the extremity of the thermometer in the children’s armpit after checking first if it’s dry. Tell your child or hold yourself her/his arm against the chest for about 5 minutes.

What are the values considered fever?

• Rectal temperature: > 38ºC (100.4ºF)
• Mouth temperature: > 37.8ºC (100ºF)
• Armpit temperature: > 2ºC (99ºF)
• Ear temperature: >38ºC (100.4ºF)

Summary and Recommendations

• The cut-off for a temperature measurement to be considered fever depends on how it is done and where in the body it is taken.
• Knowing how to take your child’s temperature adequately is important to obtain an accurate measurement.
• Digital thermometers should be preferred over the glass ones, which have a risk for toxic exposure to mercury if they are broken.
• Rectal temperature is the most accurate measurement, although mouth temperature is also accurate in children older than 4 years of age. Touching the forehead is not reliable to assess fever.

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References

• Taveras EM,Durousseau S, Flores G. Parents’ beliefs and practices regarding childhood fever: a study of a multiethnic and socioeconomically diverse sample. Pediatr Emerg Care. 2004 Sep;20(9):579-87.
• Zyoud SH,Al-Jabi SW, Sweileh WM. Beliefs and practices regarding childhood fever among parents: a cross-sectional study from Palestine. BMC Pediatr. 2013 Apr 28; 13:66.
• Robinson JL,Jou H, Spady DW.Accuracy of parents in measuring body temperature with a tympanic thermometer. BMC Fam Pract. 2005 Jan 11;6(1):3.
• Schmitt BD. Feverphobia: misconceptions of parents about fevers. Am J Dis Child. 1980 Feb;134(2):176-81.

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Breastfeeding: myths and facts

[mme_highlight] There are a number of myths associated with breastfeeding which should be clarified, as these can significantly alter the quality of feeding  by decreaseasing the efficacy and compliance of mothers. A major mistake by which many mothers quit breastfeeding their child is lack of knowledge on this topic. [mme_highlight]

Healthcare providers recommend exclusive breastfeeding to all babies during the first 6 months of postnatal life and continuation of breastfeeding as part of the nutritional plan until the baby turns 2 years. Y. Vandenplas (1) suggest that exclusive breastfeeding with delayed introduction of weaning foods reduces morbidity and mortality by decreasing the risk of infections and allergies in babies.

However, there are a number of myths associated with breastfeeding which should be clarified, as these can significantly alter the quality of feeding  by decreaseasing the efficacy and compliance of mothers.

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Decision to breastfeed
(study conducted by Eugene Declercq (2))
– 70% of primiparous mothers (mothers who have their first child) decide to breastfeed their babies;
–  only 50% of others remain compliant with their decision after first post- delivery week.
– 49% of the mothers who introduce early formula supplementation do not breastfeed their babies ;

almost 45% of mothers who introduce pacifiers gave up breastfeeding before baby turn 6 months.
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What are the myths commonly associated with breastfeeding?

Myth # 1: If you work full time, you can’t breastfeed your baby:

Research conducted by AS Ryan (3) suggested that the decision to breastfeed is higher among mothers soon after delivery; however, the scenary is different among working mothers.

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Decision to breastfeed among working mothers
(study conducted by AS Ryan (3))

• Full-time working mothers: proportion of breastfeeding mothers decreases from 66% (stay at home mothers) to 26.1% (in full-time working mothers)
• Part-time working mothers: proportion decreases to 36.6%.

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Nevertheless, in the past few years, due to the increasing awareness and maternal education,  the breastfeeding rate has increased to over 204.5% in full- time working mothers, but overall results are still unsatisfactory.

If you are working a full-time job, you can still feed your baby. Here are a few tips:

• Get a good quality breast pump or extractor and pump milk frequently at work. In order to obtain greater results, carry with you bottles or clean sterilized bags to store milk in a refrigerator at work place to feed your baby with once you get home.
• You can also extract milk in the morning before going to work (the nanny or caregiver can feed the baby with your milk in your absence).
• Make sure to breastfeed the baby as much as you can when you are home.

Myth # 2: During breast feeding you do not need contraception

Lactation acts as a natural contraception period during which most women do not need any protection as high prolactin levels inhibit ovulation. However, contraception is not permanent and if you strictly want to avoid another pregnancy, it is better to consult a healthcare professional for a reliable contraceptive option that does not interfere with your lactation.

R.H. Gray (4) reported the results of his study on breast feeding moms of Baltimore and Manila and identified that ovarian cycles are not started until 27 to 38 weeks post partum. He further identified that:

• Luteal defects are seen in almost 41% of all early ovulatory cycles;
• Anovulatory cycles are reported in 46.1% women for 6 months after childbirth.

However, despite exclusive breastfeeding, 1 to 5% women become pregnant. If you are not breastfeeding regularly, there are 10% chances of becoming pregnant with unprotected intercourse. The risk of conception doubles after 6 months post-delivery.  Some helpful contraceptive options during breastfeeding are:

• Condoms
• Spermicidal jellies
• Diaphragm
• Intrauterine device (IUD)
• Permanent contraception options (if you are sure you have already completed your family; possibilities are vasectomy and tubal ligation).

Myth # 3: You cannot improve your milk supply

A lot of mothers complain that their babies do not suckle well or feed properly. Sometimes, mothers feel their baby is not getting enough milk or they are not producing enough milk. You should look for a doctor if you wish to improve your milk supply and in order to optimize breastfeeding.  There are a number of natural, herbal and holistic methods that can help in improving the production of milk but the most important is that you let your baby suckle frequently. Other helpful tips are:

• Gently massage your breasts 4 to 8 times a day (it enhances circulation, decreases the risk of developing obstructed ducts and also improves milk production).
• Use of certain herbs like Fenugreek, Red Raspberry, Blessed Thistle and Brewer’s Yeast has known efficacy in increasing milk production and flow (make sure to speak to your healthcare provider before starting any herbal or medical remedy).
• Medical drugs like Sulpiride and Metoclopramide are prescription drugs that increase milk supply.

Myth # 4: If you are not producing enough milk, your baby needs formula milk

Research conducted by Samir Arora (5) suggested that the second most common reason why mothers prefer to bottle-feed their baby is “insufficient milk production”.  This study identified that approximately 46.3% women bottle-feed their babies from day 1, but out of 44.3% who initiated breastfeeding after childbirth, more than 50% switched to bottle-feeding within the first month post-delivery due to low milk production.

It is normal for the milk supply to be low during the first few weeks after delivery, but depending on the suckling frequency of babies, the milk production and flow increase. Your body adapts itself to the nutritional demands of the child. Make sure:

• To allow your baby to suckle often;
• To allow your baby to suckle both breasts;
• The position of feeding is comfortable both for you and your child.

Myth # 5: You don’t need any additional help and resources other than your doctor’s recommendations:

This is another big mistake mothers can follow. It is highly recommended that a pregnant mother with her partner attends classes on breastfeeding during pregnancy. These classes provide first hand information on advantages of breastfeeding, how to take a start and explain some common problems face by a mother during nursing.
These sessions also play a good role in building relationships with other expectant parents and lactation professionals who can help in any problem. Nowadays some hospitals have breastfeeding classes. Make sure the classes you attend are conducted by authentic healthcare provider or a certified lactation educator.

In fact, a major mistake by which many mothers quit breastfeeding their child is lack of knowledge on this topic. During the end of pregnancy, a mother should build a circle of people, consisting of friend and family members, who have the knowledge on nursing and who have successfully breastfeed their babies.
Make sure to maintain a good relationship with any certified lactation educator or lactation consultant who can help you in any problem occur during your nursing period.

Research by Samir Arora suggested that 71% women who breastfeed their babies are influenced by the choices and preferences of their partners and maternal grandmother of the baby. The study further showed the main sources of information about breastfeeding used by lactating moms (table below).

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Main sources of information about breastfeeding used by lactating moms

• Family (33.9%)
• Books, magazines, social media (17.4%)
• Other (13.2%)
• Physicians (8.3%)
• Friends (9.9%)

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Myth # 6: Every baby feeds in one position

This is totally untrue. Feeding position determines a good latch. You have to try and test different positions in order to determine what position your baby is more comfortable in. Nature designed a mother’s body in a way that she can easily feed her baby.
Like parenting, breastfeeding is a natural thing every woman experiences after child’s birth. A mother needs a lot of practice to recognize her child’s hunger signs, and to help her baby sucking the milk correctly.
She should learn all the nursing position through which she can properly comfort her baby. A child also needs a lot of practice to suck the milk from mother’s breast correctly. Therefore both mother and child need proper practice and patience to optimally adjust to breastfeeding.

Summary and Recommendations

• There are some myths related with breastfeeding that, if not correctly clariied, can lead to an early breastfeeding stop or a suboptimal breastfeeding process.
• Working mothers tend to have a lower proportion of sustained breastfeeding; mother can pump milk and leave it to be given to the baby during her absence and she can try to make schedule adjustements to breastfeed as many times as possible.
• Mothers should talk with a health care provider if she thinks her milk production is impaired.
• Contraception issues should be discussed with a doctor.
• Parents should look for information on breastfeeding and attend sessions on this topic.

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References

• Vandenplas, Y. (1997). Myths and facts about breastfeeding: does it prevent later atopic disease?. Acta Paediatrica, 86(12), 1283-1287.
• Ryan, A. S., Pratt, W. F., Wysong, J. L., Lewandowski, G., McNally, J. W., & Krieger, F. W. (1991). A comparison of breast-feeding data from the National Surveys of Family Growth and the Ross Laboratories Mothers Surveys. American Journal of Public Health, 81(8), 1049-1052.
• Ryan, A. S., Zhou, W., & Arensberg, M. B. (2006). The effect of employment status on breastfeeding in the United States. Women’s health issues: official publication of the Jacobs Institute of Women’s Health, 16(5), 243.
• Gray, R. H., Campbell, O. M., Apelo, R., Eslami, S. S., Zacur, H., Ramos, R. M., … & Labbok, M. H. (1990). Risk of ovulation during lactation. The Lancet, 335(8680), 25-29.
• Arora, S., McJunkin, C., Wehrer, J., & Kuhn, P. (2000). Major factors influencing breastfeeding rates: Mother’s perception of father’s attitude and milk supply. Pediatrics, 106(5), e67-e67.

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