A Good Night’s Sleep…

After having a baby, most parents long for a good night’s sleep. Many turn to sleep training in order to make that happen. Sleep training is a controversial subject, especially lately with the Cry It Out method making national headlines. However, the importance of sleep for the health and happiness of the entire family is universally accepted. Very few infants sleep through the night before six weeks of age and if you ever meet a parent who says that their infant does – ask them specifically how and when they are sleeping. You will find that “sleeping through the night” has a very different definition for every family.

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While babies will start sleeping longer stretches (4-6 hours) at night around 8-12 weeks, most don’t truly sleep through the night consistently until 12-18 months. Even if a baby has been sleeping through the night, sleep patterns often changes with growth spurts, teething, and illness. If you make a decision to go through with sleep training, you will have to find a method that everyone is comfortable with and makes sense for your infant and parenting style. You may find that you must modify your chosen sleep training method at different stages in their child’s development and what works for one child may not work for another. Recent studies have found no long term impact on children’s development or emotional health with behavioral sleep interventions.

The most widely accepted sleep training methods range from the Cry It Out (AKA extinction or gradual extinction) to the No Tears Methods.
  • The Cry It Out methods involves putting your infant in the crib while sleepy, but awake. Then letting them cry either until falling asleep or leaving them for incremental longer periods of time before gently soothing with patting or shushing – but not picking up, rocking, or feeding. The goal is to teach your infant self-soothing tactics. These methods generally take from 3-5 days to work. Authors who have written on this subject include Richard Ferber, MD and Marc Weissbluth, MD.
  • The No Tears Methods typically involve repeating the same bedtime routine every night, starting when your baby is showing signs of sleepiness. This may be a bath, massage, lullaby, then rocking or nursing to sleep. Remember that your infant will likely require this same routine with each nighttime wakening, which may continue until early toddlerhood (but hopefully not). Authors who have written on this subject include Elizabeth Pantley and William Sears, MD.
  • If you are a parent who started off by sleeping with your baby or older child, then a method of gradual extinction from the room may be your best bet. Start with a nighttime routine, then gradually eliminate yourself from the bed, then room. Many parents start by turning away from their child, then sleeping on the floor, by the door, outside the door, then in your room with the doors open. This may take weeks to accomplish, depending on the degree of separation anxiety displayed by your child.
Typically, I recommend a combination of these methods, modified for each family and baby. I have had good luck with starting a daytime feeding and sleeping routine around 6-8 weeks, with little stimulation at night (dark room, quiet feeding). After the baby starts following a predictable eating and sleeping schedule, make an evening routine leading to bedtime. With both of my boys, I have ended up with a modified Cry It Out method, increasing in increments no longer than 10 minutes. After MY anxiety dissipated, everyone was sleeping better and now they have healthy sleep habits.
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The key to success with any sleep training method is developing a solid plan, being consistent and following through. Anticipate loosing some sleep and having some difficulty the first couple of nights with Cry It Out, seek support from your partner or family. You may feel that letting your baby cry is not the right approach for you or your baby and a No Tears Method may take longer, but will leave you feeling more at ease with your decision. Whatever your take, I hope for a good night’s sleep for everyone your family.
                                                                            —
Heather Joyce, MD
Sources and Sites:
Price, All M.H., BA, PhD; Wake, Melissa, MB BS, FRACP, MD; Ukoumunne, Obioha, PhD; Hiscoch, Harriet, MB BS, FRACP, MD. ” Five-Year Follow-up of Harm and Benefits of Behavioral Infant Sleep Interventions: Randomized Trial.” Pediatrics. Vol 130 No. 4 October 1, 2012 pp 643-651. http://pediatrics.aappublications.org/content/130/4/643

Breastfeeding Part 2 – The First Days Home

Congratulations…you gave birth, decided to breastfeed, and made it through your hospital stay!  With the support of doctors, nurses, and lactation consultants, by the time you are discharged, hopefully, you are feeling pretty comfortable with the breastfeeding process.

This is exactly how I felt with my first son…so, when I got home and started having difficulty and pain, I felt frustrated and started doubting my ability to breastfeed. He was fussy and frantic at the breast, which lead to painful feeding sessions. I knew some pain was normal, so at the time I didn’t even know I needed help. Most parents would agree that the first couple of nights home with your first infant are the longest, most exhausting nights of your life. Add in difficulty with breastfeeding, and a time that should be filled with joy, becomes one that is filled with frustration. The good news is that this time passes quickly and with some patience and support, breastfeeding can get easier every day!

In my opinion, the biggest reason that new mothers are in this situation, is the fault of our current medical system. We send mothers and their infants home within 48 hours of delivery – well before most mother’s milk “comes in.”  So, many infants start to get very hungry within 24 hours of going home. This is a time when they start to gain back the weight that they lost after birth. If your milk is not “in” yet, then you are dealing with either a sleepy baby who does not have the energy to feed or a frantic, fussy baby.

The second problem that many mother’s run into is engorgement. Once the milk “comes in,” the breasts become hard, swollen and painful. A baby who was latching on perfectly before engorgement, can develop difficulty finding a comfortable latch – especially at the beginning of a breastfeeding session, when your nipple can lay flat against your areola.

Here are my tips to help you get through the fist days of breastfeeding, with as little difficulty as possible:

  1. Find support – a friend, relative, or lactation consultant
  2. Put your infant to the breast as often as they want (every 1-3 hours) – you can work on a feeding schedule later. In the first couple of weeks, the more your infant feeds, the faster your milk will “come in” and the more milk you will produce
  3. If your infant is too sleepy to feed or falls asleep at the breast, attempt to breastfeed for 10 minutes on each side, then pump to let your body know that you need more milk. If your infant is not gaining weight or having problems with jaundice, feed the baby this pumped milk (either with a supplementing tube/syringe or a bottle) after attempting to breastfeed. As a side note, this is exhausting – so utilize your partner or a relative to hold or feed the baby in between breastfeeding/pumping sessions. 
  4. If you are having pain or difficulty latching your infant due to engorgement, express breastmilk either with your hand or with a pump for about 1 minute prior to attempting to breastfeed. Be advised not to pump too much during this time (like after every feed) because you will overproduce milk and this can lead to lots of discomfort.

You will know that your infant is getting enough milk by the number of wet and dirty diapers they are having. They should increase every day until day 5 or 6. They will also start gaining weight around this time. So follow-up with your pediatrician is important.

It is normal to feel nipple discomfort for the fist 1-2 weeks of breastfeeding, though if the pain is making breastfeeding a dreaded task or you develop red sores, cracks or blisters – then find a lactation consultant to help work on your infant’s latch. You will also feel pain and fullness during engorgement – starting days 3-4 and resolving slowly over about a week. This pain should be tolerable with a supportive bra and cold packs.

Within 10-14 days, breastfeeding should become comfortable for both you and your infant. If it is not, or your infant is not gaining weight – seek help, because there are fixes for most breastfeeding problems. However, you need to know that some infants are not great breastfeeders and some moms don’t make enough milk – which makes me very thankful that formula was invented!

Heather Joyce, MD

Infant Reflux

This post was inspired by a friend who is having a tough time with a fussy newborn, but dedicated to all the parents out there who have ever cared for a baby with reflux, my husband included.

Reflux, colic, gas, milk intolerance, or general demeanor…there are many reasons for an overly fussy baby. Many babies who cry excessively swallow lots of air and always appear to have belly pain or gas, so figuring out the reason for a baby’s fussiness can be challenging. I will focus on infant gastro-esophageal reflux in this post, though many of these suggestions can help a baby with colic. Some babies with reflux are not fussy at all (they just make huge messes with spit-up), while others can have discomfort, poor weight gain and feeding problems. The symptoms of reflux are caused by milk that makes its way back up through a weak muscle at the top of the stomach, into the esophagus, and to the back of the throat or mouth. Infants do not all have the same symptoms, but can have spitting up, frequent hiccups, swallowing or grunting, arching of the back or neck, coughing, wheezing, difficulty feeding or excessive crying. Most infants with reflux act like they are always hungry, this is because they cry and root as a reaction to discomfort – often 1-2 hours after a previous feeding. If your child has been diagnosed with reflux or exhibits these behaviors, there are many techniques you can use to decrease symptoms.

1) Feed sitting upright – with bottle feeding, this is easy; but with breastfeeding you will have to find the most comfortable position for both you and your baby.

2) Burp frequently – with bottle feeding, this means every 1/2-1 oz; with breastfeeding it is still best to burp in between breasts or after 10-15 minutes.

3) If you are bottle feeding, find the right nipple and bottle. Babies who drink too quickly or swallow too much air spit up more. There are many choices and you may have to try several, but I say go with the one that works best for you and your baby.

4) Feed small amounts, frequently. For small infants, this means 1-2 oz every 1-2 hours; bigger infants need 2-4 oz every 2-3 hours and increase gradually. Do not over-feed your baby, this will lead to more discomfort!

5) Keep your baby sitting upright 20-30 minutes after each feed. Easy to say, not so easy to do (especially in the middle of the night or when you are chasing around another child). You do not have to hold your baby, you can use any contraption that works for you – bouncy/vibrator seat, upright swing, head elevating positioner, wedge with a sling, baby carrier/sling, just to name a few.

6) Position your baby to sleep elevated (30-45 degrees). The easiest way to do this is to put a couple of books under the legs at the head of the crib or bassinet. If you are using a co-sleeper or pack and play, a couple of rolled up towels or receiving blankets under the thin mattress works well. They also make special foam wedges for this purpose.

7) Do not lie your baby down flat on their back, especially after feeding. If possible, try to change your baby’s diaper prior to feeding.

After utilizing these techniques, your baby may still spit-up. If they are happy and gaining weight, your next step is to stockpile burp cloths, bibs, and wet wipes. If your baby has extreme fussiness, coughing, wheezing, difficulty feeding or poor weight gain, you need to take them to the pediatrician. They may recommend an elimination diet (for breastfeeding mothers), a formula switch, or medication for your infant. This can be a very stressful time as a parent, so keep in mind that whatever is causing fussiness in your baby will pass with time.

Heather Joyce, MD

Hives

Hives are very common in children. The rash is itchy, red, raised welts that often move from one location to the next within minutes. If you are like most parents, your first thought is an allergic reaction and you rack your brain trying to figure out what your child may have eaten or touched. However, hives have many different causes, the most common in children being illness, either viral or bacteria. Allergen exposure is second on the list. Allergens may be food, medications, lotions, insect bites, soaps, detergents, fabric softener, clothing …just to name a few. In many cases, it is difficult to figure out the exact cause.

Hives may last for hours to weeks, but most often 1-2 days. If they are due to an allergen exposure and the substance is taken away, the hives usually resolved within 24 hours with treatment. However, with illness, you may have to wait until the illness resolves for the hives to fully go away.

Most often, symptomatic treatment for hives is the best course of action. Antihistamines, like diphenhydramine  (Benadryl) are very effective at treating hives, however this medications may make your child drowsy or hyperactive. Your doctor may recommend a long acting antihistamine like loratadine (Claritin), fexofenadin (Allegra), certirizine (Zyrtec), or desloratadine (Clarinex) if the hives last longer than 2-3 days.

Home remedies to make your child more comfortable include placing your child in a cool bath (with or without oatmeal to sooth the skin) and dressing your child in light, airy clothing. Do your best to try and keep them from itching!

If your child develops swelling of the face, tongue, lips, or joints they need to be seen by a physician. If they develop difficulty swallowing or breathing, vomiting, abdominal pain, or pass out with hives – it is a medical emergency and can be a sign of a severe allergic reaction.

Heather Joyce, MD

Don’t Forget the Sunscreen!

This blog post is brought to you by guest blogger Dr. Elizabeth Miller.  Dr. Miller received her medical degree from the University of Missouri-Columbia, and completed her residency in dermatology at the Medical College of Wisconsin in Milwaukee.  She now works in a multi-specialty group in Austin, Texas, and sees patients of all ages.

Summer is quickly approaching and now is a good time to think about how you can protect your child’s skin from sun damage. We know that the sun damage accumulated as a child and young adult is an important risk factor for several types of skin cancer like basal cell carcinoma, squamous cell carcinoma, and melanoma in their adult life.  It’s never too early to start teaching your child about sun safety!

Here are a few tips for sun safety:

*Seek shade, especially between the hours of 10am-4pm when the sun’s rays are the strongest

 *Look for a sunscreen with an SPF 30-50

 *Look for “broad spectrum” on sunscreen labels (equal UVB and UVA protection)

 *Reapply every 2 hours-even the best sunscreen wears off and loses its effectiveness over time

 *Use sunscreen even on cloudy days. Up to 80% of the sun’s UV rays are transmitted through clouds!

 *There is no such thing as a “waterproof” sunscreen-reapply after swimming or toweling off

*Wear “rash guards” or other long sleeved swim tops. Broad brimmed hats are also a great way to block the sun, especially on kids with light colored or fine hair. These are becoming easier and easier to find at local stores like Target, but you can also buy them online from companies such as Coolibar. Don’t forget the sunglasses and lip balm with SPF!

 *There are many good brands and types of sunscreen are available, find one that you and your children like best. Spray sunscreens are especially good for kids, but make sure you apply enough—the skin should look wet when you spray it on and then you need to rub it in to make sure you have even coverage. If using a spray sunscreen on your child’s face, spray it on to your hand first and then rub on to your child’s face, never spray directly on their face. Avoid inhaling the sunscreen.

A bit of technical information on the two different types of sunscreens available:

Chemical sunscreens

 * These absorb the sun’s rays in the top layer of skin, preventing damage to the underlying skin

 *Advantages: rubs in easily, most common type of sunscreen available, good sun protection

 *Disadvantages: some people with very sensitive skin develop skin irritation with this type of sunscreen

 *Read the label, the “active ingredients” will have one or more of these sunscreen chemical

-Avobenzone

-Oxybenzone–>rarely people can become allergic to this sunscreen ingredient    and develop an itchy or painful rash (although this is not a dangerous rash)

-Octisalate

-Octocrylene

-Oxtinoxate

-Homosalate

Physical sunscreens

These sit on top of the skin and reflect the sun’s rays

 *Advantages: good for people with very sensitive skin, good sun protection

 *Disadvantages: a little more opaque, harder to rub in

 *Physical blocker active ingredients

-Titanium dioxide

-Zinc oxide

The dangers of tanning bed use:

Talk to your child about the dangers of tanning bed use. It is NEVER ok to use a tanning bed, even for special events or vacations

 *The World Health Organization (WHO) has classified tanning beds to be as carcinogenic (cancer causing) as cigarette smoking

 *There is a 75% increased risk of developing melanoma with tanning bed use

Even just 4 tanning bed sessions a year increases the risk of skin cancer by 11-15.  Melanoma is the second most common cancer in women between the ages of 20 and 35, and the leading cause of cancer death in women ages 25 to 30

Elizabeth Miller, MD

Tricks of the Trade: Giving Medications

I have two boys, one who asks for medication whenever he thinks he might need it, the other who spits it back at us like we are giving him poison. As a health care provider for children, giving medication and helping parents give medication to their children is a big part of my job. Some children need medication only intermittently for fever or pain, others daily for chronic illnesses or infections. It is important that parents find the best way to give medication to each of their children for the times when it is important. Thankfully, medications come in a variety of forms, including pills, capsules, chewables, powder, granules, and liquids. Unfortunately, not all children’s liquids taste good (even after flavoring).

The most important step in giving medication to children is making sure you are giving the correct medication and dosage. Most children will be prescribed liquid, so your job is to measure the medication correctly and make sure your child swallows it. Infants and toddlers will usually take medication measured in a syringe (1 ml, 5 ml or 10 ml). However, they do make special nipples that hold medication, which some infants prefer. Older toddlers and children will drink medication from a measuring spoon or cup, they can also take chewable medication. Once your child is big enough to take a pill (5-7 years old for most children), you can start teaching them to swallow pills/capsules.

Tips for getting your child to take medication:

1) Give it slowly in their cheek

2) Offer a tasty bribe for after they take the medication or in between squirts – juice, popsicle, sucker

3) Get the pill form, crush it and put in apple sauce/pudding – this only works if it is not a long acting medication

4) Get the capsule form and open into apple sauce/pudding

5) Give a very small amount of medication in between screams/crying, most children will swallow it with their saliva

6) Get the rectal suppository form (acetaminophen) and place it gently into your child’s bottom

Giving medication to your child is not always easy, so if you are having trouble, ask for advice from your doctor or nurse. They may be able to prescribe a different form of the medication or offer other ideas for getting your child to take the medication.

Heather Joyce, MD

Hand, Foot, and Mouth Disease

Just so we are clear, I am not talking about foot and mouth or hoof and mouth disease in farm animals, but a mild virus in children that causes fever, mouth sores, and rash. Hand, foot, and mouth disease is caused by a virus that likes warm weather, so it is most common spring through fall in my neck of the woods (Middle America), but can occur any time of year in tropical locations. The illness is very common in young children because it is spread by direct contact with saliva and stool – think lots of drooling, diaper changing and hands in the mouth. It starts with fever and is followed by sore throat, drooling, and rash. The rash is characterized by red, raised bumps or blisters on the hands and feet. In my opinion, it should be called hand, foot, mouth and bottom disease, because I see diaper rash as a symptoms just as commonly as the rash on the hands and feet.

With this illness, your child may get fatigue, fussiness, runny nose, vomiting and diarrhea. Often, little children refuse to eat and drink. The illness typically lasts 7-10 days, with fever for 2-3 days. The most important part of hand, foot, and mouth disease for a parent, is keeping your child from getting dehydrated. Below are my tips for keeping your child comfortable and hydrated during this common illness:

  • Ibuprofen or acetaminophen – give an appropriate dose for your child’s weight as needed for fever and pain (including feeding refusal). If your child will not swallow medicine by mouth, there is a rectal form of acetaminophen that works well.
  • Offer fluids at all times – this includes breastmilk, formula, milk, Pedialyte, Gatorade, water, popsicles, ice cubes, ice cream (basically anything they will drink!)
  • Avoid spicy and acidic foods/drinks
  • Offer soft, easy to swallow foods

Home remedies:

  • Salt water rinses for older children – 1/2 teaspoon of salt mixed with 1 cup of warm water, swish and spit as needed for pain
  • Magic mouth wash – Maalox (Aluminum Hydroxide and Magnesium Hydroxide) and Benadryl (diphenhydramine) mixed together 1:1 and dropped in or placed in the mouth with a Q-tip. The best way to make this is to mix 5 ml of Maalox with 5 ml of Benadryl. Use 1 ml on the sores every 6 hours.
  • Gly-Oxide is another over the counter product that works well to clean and coat the ulcers

I do not recommend mouth numbing gels (like Orajel) during this illness, because of the large amount required to numb all of the sores and the short lived relief. There are rare, but serious side effects from using too much of this medication. Unfortunately, there is no antibiotic or medication to shorten the length of the illness. Seek medical care if your child is refusing to drink, has decreased urination or wet diapers, dry mouth or you are concerned about dehydration.

Heather Joyce, MD