When Can My Baby Swim?

When Can My Baby Swim?

– When Can My Baby Swim?

This is a question I’m often asked in the clinic. Often parents ask whether they need to wait until after their baby has his first set of vaccinations.

Actually, the decision is based more on your baby’s size, or surface area: volume ration. This determines how rapidly your baby will lose heat when submerged in water. Babies can lose heat through their skin very rapidly, even in a tropical country like Singapore!

Usually, a baby with an average birth weight (around 3-4kg at birth) with good weight gain afterwards will be able to start swimming at around six weeks of age. This is a good time for Mom to return to swimming as well- starting swimming too early after giving birth may increase the risk of an infection.

When Is The Best Time To Swim?

I usually recommend that if you are swimming in an outdoor pool in a tropical country such as Singapore, you wait and take your baby swimming in the late afternoon, between 4-5pm, when the sun has had a chance to warm the water, but the midday heat has passed. Dress your baby in a SPF sun- protective swimming costume (many have SPF 50+ fabric), and cover his head with a hat.

If swimming indoors in a heated pool, then you don’t need to worry so much about heat or sun exposure. Just pick a time when your baby is not likely to be overtired, hungry or immediately following a meal.

Should I Use Sunscreen On My Baby?

Although many infant and toddler sunscreens often recommend their use only after three months of age, it is advisable to apply it to your one or two month old if they are going to be outdoors and exposed to sunlight for a significant period of time (which in a tropical country may be as little as five to ten minutes). Having seen second degree burns in a young infant patient, I would strongly recommend you use an infant or toddler sunscreen for your baby when he is swimming.

How Long Can My Baby Stay in The Pool?

You will probably find that a small baby who is less than 3 months will only be able to manage around ten minutes in the swimming pool before his lips turn blue or he starts to shiver. This is your cue to take him out of the pool and wrap him in a soft towel to warm him up.

Take your baby for a bath or shower immediately after swimming, as the chlorine in the swimming pool can be very irritant to baby’s skin.

Parents sometimes ask if it is advisable or appropriate to use a floatation device. I would recommend that, whether using one or not, you never take your hands off your baby, as babies can wriggle out of floatation devices.

What are your experiences with your baby and swimming? Did he love it or hate it? Share your experiences in the comments below. 

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Newborn Jaundice: What’s It All About?

Jaundice- the yellowish discolouration of the skin that occurs in around 50% of full term well babies (and up to 80% of babies born prematurely). Most of us will have seen it at some point, but what is it, and what does it mean for your baby?

Baby with jaundice

Newborn Jaundice

Jaundice is caused by a chemical called bilirubin. It is deposited in the skin and whites of the eyes, giving them a yellowish tinge. Bilirubin is released from red blood cells when they break down, or “haemolyse”. Red blood cells normally break down in the newborn period for a number of different reasons:

  • Thick blood: Babies have a haemoglobin level of around 16-20g/dL compared to adult levels of 11-14g/dL, so it’s much thicker and more viscous. As the thick blood travels through the small blood vessels they are more likely to break down releasing bilirubin.
  • Rapid rise in oxygen levels at birth: babies get used to low levels of oxygen in the womb; when they are born and start to breathe for themselves, the oxygen levels rise rapidly. This causes “oxidative stress”, leading to blood cell breakdown.

Sometimes, there can be other causes for increased red blood cell breakdown:

  • Incompatibility between the mother’s blood type and the baby’s blood type: for example, if a baby is B+ and the Mother is O-, as fetal blood “leaks” across the placenta during pregnancy, the mother’s immune system detects the “foreign” B antigens and Rhesus antigens (the +). Mommy doesn’t have either of those antigens and assumes they need to be removed so her body develops antibodies to remove the antigens. These antibodies cross back over the placenta into the baby’s blood stream causing red blood cell breakdown and release of bilirubin.
  • G6PD deficiency: G6PD is a chemical which makes red blood cells resistant to breakdown- without G6PD red blood cells are more prone to break- particularly within the first two weeks of life. G6PD deficiency is more common in people from Asian or Mediterranean races, and is seen more in boys than in girls.

Bilirubin may also also reach higher levels due to the newborn liver’s inability to convert the bilirubin into excretable forms, ready to be passed out of the body in the urine and stools. Breast milk itself possesses certain inhibitors which make jaundice last longer.

Finally, if breastfeeding is not going well, the baby may not pass sufficient urine and stool to remove the bilirubin from the body, causing it to build up.

NNJ causes

Causes of Neonatal Jaundice: Summary

Why Does It Matter?

Apart from making your baby’s skin and eyes yellow, why does it matter if your baby is a bit yellow?

Unfortunately , it’s not just about aesthetics. Bilirubin can cause permanent damage if not monitored and treated properly. Damage can range from impairment to the parts of the brain responsible for higher mathematic function, to permanent hearing loss, epilepsy, and even some forms of cerebral palsy.

Left unchecked, a baby with severe newborn jaundice may develop “kernicterus”: severe brain damage characterised by high-pitched screaming, poor feeding and back arching. This may lead to coma and, in the most serious cases, even death.

What Can You Do?

Fortunately, newborn jaundice is extremely treatable. Babies diagnosed and treated appropriately with blue light phototherapy have no long term damage at all. So, how do you make sure your baby is treated appropriately?

  • Attend all scheduled routine doctor or health visitor check ups in the first two weeks following your baby’s birth: your doctor or health visitor will then be able to assess the baby and decide if a bilirubin test is required.
  • Check if your baby is passing sufficient urine and stools: your baby should have at least one urine and stool output in the first day; this should increase to two to three on the second day and around four to five by day 3-4. By the end of the first week of life, your baby should be passing urine and stool around 6-8 times in a 24 hour period.
  • Make sure your baby is not losing too much weight: it is usual for a baby to lose up to 10% of his birth weight in the first 3-5 days of life. He ought to be back to his birthweight by around day 7 to 10 of life, and be gaining around 200g per week thereafter.

Can I Suntan My Baby Instead Of Using Blue Light Therapy?

Blue light therapy has been the mainstay of treatment for newborn jaundice since the 1960s. It safely and effectively converts the bilirubin into an excretable form so that it can be removed from the body.

Sunlight does contain blue light, but also ultraviolet and infrared light, which may be harmful to babies. Some studies have recently used filtered sunlight (plastic panels that remove ultraviolet and infrared, but allow blue light wavelengths to pass through the filter) in resource poor settings in developing countries. These show significant promise. However, in developed countries, high levels of jaundice should be treated with appropriate blue light therapy.

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Bedwetting: How To Help Your Child Stay Dry

The majority of children achieve daytime dryness somewhere between 2 and 3 years of life, and nighttime dryness at around 4 to 6 years of life. However, some children persist in having nighttime accidents after the age of 6 years. Often I will see these children with anxious parents just before a planned sleepover or a school camp, when potential anxiety and embarrassment force a visit to the doctor.

Bedwetting

Bedwwetting: How To Help Your Child Stay Dry

How Common A Problem Is Bedwetting?

Bedwetting, or nocturnal enuresis, is very common. Although around 16% of 5 year old children experience regular bedwetting, only 1-2% of children aged 15 years or over are still having bedwetting episodes. This suggests that the majority of children with bedwetting just have delayed maturation; this means the problem will go away by itself. Many of these children’s parents experienced similar issues as childre. Studies show 50% of children born to parents with a history of bedwetting will also have bedwetting issues (75% if both parents had issues with bedwetting). Boys are twice as likely to have problems with bedwetting as girls.

What Causes Bedwetting?

  • Genetics: family history is a strong predictor of bedwetting in children. This may be reassuring, as parents know that they eventually achieved dryness, and that helps them to be arrived their children will achieve dryness too.
  • Constipation: this extremely common problem of childhood can also cause reduced bladder capacity and lead to bedwetting. Take a look at http://www.doctor-natalie.com/tag/constipation/ for further information and advice on recognising and treating constipation in your child.
  • Nocturnal polydipsia: this is just a big long term meaning “drinks too much at nighttime”!
  • Deep sleep, or obstructive sleep apnoea. Children who are difficult to rouse, or are heavy snorers may not wake when they need to pass urine,
  • Rarely, medical problems such as diabetes, diabetes insipidus (water diabetes), urinary tract infection or pinworms may present as bedwetting.
  • Although people often assume bedwetting may be caused by psychological stress, this is rarely the case. Studies have failed to show any obvious link. In fact, many psychological problems in children with bedwetting show improvement after bedwetting improves. This suggests the bedwetting may predispose to psychological issues rather than be a result of such problems.

What Can You Do?

  • Temper Expectations: If your child is 5 years or younger, he may just not be ready yet. Give him time- especially if one or both of you also achieved nighttime dryness quite late.
  • Make sure he is not constipated: see http://www.doctor-natalie.com/tag/constipation/ for some practical pointers on how you can help your child with constipation.
  • Change your child’s drinking habits: many children with bedwetting drink most of their fluids later in the afternoon and evening. Keep a diary of how much your child drinks, and then help him to change his habits. He needs to drink most of his fluids in the morning and early afternoon. Allow him one drink at dinner time, and only small sips if necessary after dinner.
  • Make sure he goes to the toilet often enough. Most children will go to the toilet around 4- 7 times per day. Make sure your child is going to the toilet often enough. Aim to get him to “try” at least twice between the end of dinner and going to bed.
  • Take a look at bedtime: is he going to bed too late? If he is too tired going to bed, it can affect his ability to rouse himself to go to the toilet if he needs. It may also affect his ability to control his bladder whilst asleep.

Next Steps:

If the above measures fail to help, then it’s time to schedule a visit with your child’s doctor. The doctor will examine your child to see if there are any signs of constipation, and do a urine test. A urine test will exclude medical causes of bedwetting such as a urinary tract infection or diabetes. The doctor will also make sure your child is otherwise well and thriving. Bladder function tests may be needed if there is concern over small bladder size or unusually overactive bladder muscle activity.

If your child doesn’t have an underlying medical problem, then your doctor may suggest one of the following interventions:

  • A Bedwetting Alarm: a small sensor attached to an alarm is placed either on the child or on a pad underneath where he is sleeping. When the sensor becomes wet, the alarm wakes the child up. Over time, the child learns how to rouse himself to go to the toilet- hopefully before wetting the bed.
  • Bladder training: If your child seems to have a small bladder,  or seems unable to manage to hold his urine for a long time then bladder training may be beneficial. Children with small or overactive bladders may need to go to the toilet frequently during the day also.
  • Desmopressin (Vasopressin): this medication concentrates the urine, so that less urine is produced overnight. The idea is that the bladder will be less full and the child will be less likely to have an accident. This medication is ideal as a short term “rescue strategy” if nighttime dryness is urgently required- such as an overnight camp or a sleep-over. Unfortunately, the benefits don’t tend to last, and the relapse rate after stopping the medication is quite high.

Remember, your child is highly likely to grow out of this nighttime bedwetting in his own time. Manage any potential risk factors, and try not to worry. For most children, bedwetting is a benign reflection of delayed maturation of bladder control.

Join the conversation- what were your experiences with bedwetting? What worked for your child? Remember, if you enjoyed reading this article, don’t forget to sign up for regular medical and parenting advice delivered to your inbox.  Have a great week ahead!

 

How Much Calcium Does My Child Need?

Babies begin life drinking only milk. Whether breast or formula milk, all babies drink milk only until around 4 to 6 months of life. After a baby starts on solid food, milk is still regarded as his primary source of nutrition until 12 months of life. Most infants average between 600ml and 1000ml of milk per day (20-30oz). So why is it that so many children seem to stop taking milk entirely at around 3 years of age?

Cow's milk

How Much Calcium Does My Child Need?

For some, it is because parents just don’t think it is important anymore. After all, their child is taking a variety of other foods. For others, it is a conscious choice to avoid dairy. Dairy has been blamed for a variety of different problems, ranging from eczema and allergic reactions to behavioural issues. Some people believe dairy increases sinus congestion, or is generally inflammatory. However, little to no robust scientific data exists to support these claims.

Why Do We Need Calcium?

Dairy has existed in the diets of most cultures for around the last 8,000 years, so this would appear to be a useful part of our diet. Dairy is a nutritional powerhouse, containing high levels of protein, vitamins and minerals such as calcium, phosphorus, magnesium, etc. There are few, if any, foods that can match its ability to provide such a complete nutritional package.

Various studies have linked dairy (particularly full fat dairy) to a reduction in obesity and diabetes type II risk. There is also evidence that high protein dairy such as milk and yoghurt help to reduce risk of cardiovascular disease. Dietary intake of dairy also reduces risk of certain cancers such as colorectal cancer.

Dairy has long been known to reduce the risk of osteoporosis in later life. Risk of osteoporosis is linked to calcium intake within the first 30 years of life, as this is the period of maximum bone growth. People with high dairy intake within the first few decades have improved bone density, and reduced risk of bone fractures in later life.

How Much Calcium Does My Child Need?

As you can see from the table above, children continue to require high levels of calcium after infancy, and after the traditional age of weaning.

Let’s take a look at some of the most plentiful dietary sources of calcium:

As you can see from the table above, getting the recommended daily amount of calcium becomes quite tricky if we exclude dairy (which accounts for the majority of the “high- calcium” food sources on this list. Yes, kale and collard greens do contain dairy. However, your child would have to consume two whole boxes of collard greens- or four whole boxes of kale to get the equivalent of one 8oz glass of milk! Good luck getting the average toddler to go for that!

How about other sources of calcium?

A 3oz can of sardines will give your child around 325mg of calcium; a can of salmon will give him around half that. However, canned foods are often high in salt; most parents wouldn’t want to give their child an entire can (or three) of sardines every day.

What about fortified almond and soy milks? Yes, they do contain similar amounts of calcium to full fat cow’s milk. An 8oz glass of calcium fortified almond or soy milk contains 300mg of calcium. Interestingly, studies comparing the bones of children drinking soy and almond milk compared to full fat cow’s milk showed reduced bone density in the children drinking calcium fortified non-cow’s milks. This may be due to the combination of other nutrients found in cow’s milk, such as proteins, phosphorus and vitamin K2, which are also important for bone health.

If you are giving your child a non-dairy fortified milk, remember to shake the carton before pouring, as the calcium tends to solidify out at the bottom.

Bottom line, calcium continues to be important for your child long after the first year of life. Dairy continues to be loved by health care professionals for its ability to provide the daily recommended amounts of calcium for children in an easy and effective manner. There is also evidence that the combination of other nutrients in dairy gives it an additional advantage in the prevention of osteoporosis when compared to other sources of calcium. 

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Coughs and Sneezes: What works- and what doesn’t!

Coughs and sneezes, and runny noses are a part of life for every parent of a toddler. Studies suggest that the average child under the age of two has approximately 12 upper respiratory infections per year. That’s right, that works out to about one a month! That’s normal!

Coughs and sneezes

Coughs and sneezes: what works- and what doesn’t?

Although its reassuring to know having an almost permanently sick child is normal, its still hard work. Dealing with coughs and sneezes, runny noses, fevers and general crankiness (on top of the usual toddler crankiness) can get a bit wearing. Knowing that your child is developing a healthy immune system with all this exposure to viruses is only a little bit comforting when you’re sleep deprived and exhausted!

The Common Cold:

Coughs and sneezes are often referred to as “the common cold”. In fact, there are literally hundreds of viruses that can cause coughing and sneezing in young children… so it really is very common.

Viruses that affect the upper respiratory tract, such as influenza and rhinovirus, cause inflammation of the lining of the respiratory tract. The respiratory tract includes the nose and mouth, and the throat all the way down to the lungs (the lower respiratory tract). The ears are attached to the nose and soft palate, and are often involved in upper respiratory tract infections.

URT

Anatomy of the Upper Respiratory Tract

The inflammation triggers excess mucous production leading to runny nose and congestion. Coughing is caused both by irritation and inflammation of the lining of the respiratory tract, and the excess mucous production. Your child may complain of pain in the throat or itchy nose and eyes.

Coughs and Sneezes: When To Worry

The vast majority of coughs and colds are benign and self- limiting. Even if you do absolutely nothing at all, they generally last around 7 to 10 days and get better by themselves. Most toddlers will be a bit snotty and grumpy, and even more off their food than usual for a few days then gradually sort themselves out.

However, there are some signs you should not ignore. These are what I call “red flag” symptoms, that should prompt you to see a doctor:

  • Laboured breathing: you can observe this by looking at your child’s chest. Is he breathing more rapidly than usual? Can you see his rib cage drawing in with each breath? Can you see his windpipe (trachea) “sucking in” at the top of the breastbone? Does he seem to be breathless, or unable to speak as well as normal? These are signs your child needs immediate medical attention.
  • Lethargy: all of us feel a little tired when we have the “flu”. If your child wants to sit on the sofa watching endless repeats of their favourite Disney movie, this is fine. However, a listless and excessively sleepy child is cause for concern.
  • Poor feeding: although it is usual for children to refuse their solids when they are feeling congested and sick, it is important that you keep them well hydrated. Nothing terrible will happen if they don’t take much food for a couple of days. Conversely, a child can become very unwell if they are allowed to become dehydrated.
  • Prolonged high fever: a temperature of greater than 38 degrees centigrade (100.4 fahrenheit) is regarded as fever. If you have a newborn baby (less than 30 days old) with fever, you should seek medical attention urgently. A baby under three months with fever should be seen as soon as possible by a doctor. If you have an older child with fever and none of the other “red flag” symptoms, then you can monitor him at home for a couple of days. You should seek medical attention if it doesn’t seem to be improving after 2-3 days.

Treatment of Coughs and Sneezes:

Home Remedies and Non- Pharmaceutical Treatments:

What Works:

  • Saline Spray: you can try squirting a nasal saline spray up your child’s nostrils to relieve nasal congestion and irritation. The physiological saline will help to decongest the nose and relieve itchiness.
  • Honey: (Caution- do not give to babies under 12 months of age due to risk of botulism infection). Several studies have pitted the soothing and cough- relieving effects of honey against common over the counter cough remedies- and guess which one came out on top? That’s right- honey consistently outperforms most cough syrups on the market! Simply dissolve a teaspoon of honey in some warm water, add a squeeze of lemon if you like, and allow your child to sip it as required.
  • Vitamin C: Vitamin C and zinc are major components of a healthy immune system. Vitamin C can be found in fruits such as grapes, kiwis and blueberries. If your child flat-out refuses to take any vitamin C containing fruits, you may consider a short course of vitamin C supplementation.
  • Vicks Baby Balsalm: good old Vicks Vaporub (use the kiddie version, not the adult version if you don’t want your child to complain of stinging!) apparently does work. A study done comparing Vicks to placebo showed reduced coughing duration and severity. You can only use it on children over three months of age, though.
  • Tilt the head of your child’s cot or bed slightly so that they are not lying totally flat. Roll a blanket and place it under the mattress of the cot, or pop a few books under the legs of the cot for a small child. Never place pillows in the cot of a small child where they may pose a risk of suffocation.

The Jury Is Out On:

  • Chopped onions at the foot of the bed
  • Vicks applied on the feet (!)

Over The Counter Remedies and Pharmaceutical Interventions:

  • Antihistamines: antihistamines act by reducing histamine release; as histamine is responsible for inflammation and subsequent mucous production, reducing histamine release seems like a good strategy. Unfortunately, antihistamines have consistently failed to demonstrate significant improvement in scientific studies. Some antihistamines such as promethazine are prescribed as cough suppressants- avoid giving these to young children, as they may suppress respiratory drive.
  • Decongestants: these include oxymetazoline-containing medications such as “Iliadin” and “Dimetapp”. These may be useful for short term relief of congestion. They should not be used for more than five consecutive days, unless on the specific advice of your doctor, due to concerns about dependency and rebound nasal congestion after stopping the drug.
  • Mucolytics: designed to break down phlegm and make it easier to remove. These drugs have shown themselves to be phenomenally valuable in the treatment of chronic conditions such as cystic fibrosis. Doctors in many countries use drugs such as “Fluimucil” to break down phlegm in the treatment of viral respiratory infections with good effect. Do not use this medication in very young infants unless your doctor has specifically instructed you to- the increase in secretions can sometimes be hazardous to small babies.
  • Antibiotics: the majority of coughs and sneezes are caused by viruses, and not bacteria. Antibiotics are designed to treat bacterial infections and not viral infections. Historically, antibiotics have been excessively over-prescribed in the treatment of viral respiratory infections- they will not help to treat your child if he has a viral infection. Antibiotics are occasionally indicated for treatment of a severe bacterial infection or prolonged respiratory infection lasting more than three weeks.

What have you found works for your child? Join the conversation by adding your comment below. 

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Gastro-Oesophageal Reflux: What Is It, and What Can You Do?

All babies vomit- any parent knows this is an irrefutable fact! But when is a vomit a vomit? Or a posset, or a regurgitation? What is the difference? And does it actually matter?

GERD

Gastro-oesophageal reflux: what is it, and what can you do?

The Terminology Of Vomiting!

You know you’re a real parent when you devote entire conversations to your child’s vomit: how, when, where and how he vomits! But do you know the difference between a vomit, a posset and a regurgitation?

  • Vomit: this tends to be relatively forceful. A vomit that travels across the room is called a “projectile” vomit, and may imply an obstructive cause, such as pyloric stenosis.
  • Posset: this is a benign little dribble of milk which comes up at the end of a feed, often accompanied by wind. There is no associated force; the volume is usually around a teaspoon to a tablespoon.
  • Regurgitation: a passive, non-forceful, bringing up of milk, which may occur immediately after a feed, or some time afterwards. Most babies will regurgitate a little milk from time to time; most often it is painless. Occasionally, regurgitation may be painful, or babies may regurgitate significant enough volumes of milk to compromise weight gain.

What is Gastro-Oesophageal Reflux?

Reflux is the term we use to describe milk flowing back from the stomach into the oesophagus. Sometimes the milk keeps on coming until both baby and mommy are wearing it. Sometimes the milk stays inside the oesophagus, but causes symptoms of pain and discomfort with no obvious vomit or spit up. This is known as “silent reflux”.

Depending on which version of English you subscribe to, Gastro-oesophageal reflux may be abbreviated to GOR or GER (for our friends who spell oesophagus “esophagus”- it’s ok, we still love you!).

As I often say to parents, all babies reflux:

Small stomach capacity, weak sphincter muscle (the muscle that closes the entrance to the stomach, preventing milk coming back into the oesophagus), and horizontal position all contribute to babies having some degree of reflux.

Provided your baby does not appear to be in pain or discomfort, and is continuing to grow well,you can grab a few more muslin cloths and wait for your baby to outgrow it.

However, some babies (around 10% of babies with symptoms of reflux) will have some degree of discomfort or compromised weight gain. These babies have GORD, or GERD (gastro-oesophageal reflux DISEASE), and require some form of intervention.

Your Baby May Have Reflux If He Has:

  • Fussiness during a feed
  • Back arching (also known as opisthotonus) or trying to pull away from a feed
  • Crying during or after a feed
  • Crying whilst regurgitating milk
  • Feed refusal, leading to poor weight gain, or “failure to thrive”

Many signs of colic may also be similar to signs of GORD, leading to some confusion over the diagnosis. If in doubt, discuss your baby’s signs and symptoms with his doctor.

What Can You Do?

Nursing Strategies:

These are often the most effective, and least invasive, interventions:

  • Feed your baby in an upright position: whether you are breast feeding or bottle feeding your baby, try to feed him at an angle rather than lying flat.
  • Stop regularly to “burp” or “wind” your baby: many people find that their baby brings up more milk at the end of a feed with a large burp. Frequent burping can help to reduce this.
  • Keep your baby in an upright position for at least half an hour after a feed.
  • Tilt the head of the cot 30 degrees up. This can be done either by placing a rolled blanket under the mattress or a few books under the legs of the cot. Never place anything on the mattress itself as this could pose a risk of suffocation.
  • Lie your baby slightly left-side down: this encourages the milk to drop into the main body of the stomach, away from the oesophageal sphincter, reducing the risk of reflux.

Supplements:

Recent studies have shown that probiotics can be very useful in treatment of colic. This is especially true for babies born to mothers via Caesarean section, or in babies whose mothers received antibiotics during or following delivery.

Some studies suggest that probiotics may be beneficial in the treatment of GORD also. However, this may be due to the fact that symptoms of both these diseases can be very similar, and babies may be misdiagnosed as one or the other.

Dietary Interventions:

Although many things have been written about dietary exclusions, few have any scientific evidence. However, dairy, or cow’s milk protein, has been implicated in either contributing to or directly causing up to 40% of cases of pathological reflux disease.

Given this very high percentage, it is worth a trial of dairy-free diet in the mother if breastfeeding. If formula fed, a trial of soy formula is worth trying as only 15% of cow’s milk allergic babies will be allergic to soy protein as well. (And yes, soy is a safe alternative to cow’s milk: there are no longer any concerns about any risks associated with phyto-oestrogen exposure from soy protein).

If you are excluding dairy in your diet, you will need to exclude all forms of dairy. This includes cheese, yoghurt and butter. You will also need to exclude all foods containing dairy products, such as most breads, biscuits and cakes, and many processed foods. Read labels: anything that contains whey, casein or “lacto-anything” should be avoided whilst excluding dairy.

Try this intervention for two weeks at most. By then, you should see a difference if dairy is an issue for your child. If you are unsure, fall off the wagon! Have a latte, or a couple of scoops of ice-cream. If your baby is truly dairy intolerant, he will let you know!

Medication:

For me, medication is generally a last resort. Something we come to when all other interventions have failed. This is partly because I don’t like to give unnecessary medications. It’s hard work for parents- especially as babies don’t tend to outgrow their reflux until around 6-7 months of age (or around 9-12 months if dairy intolerant). That’s a long time for your baby to be on medication!

What medications do we use?

  • Thickeners: These aim to keep the milk down with the help of gravity! Thickeners may be carob- based powders that can be added to your baby’s normal milk (a bit tricky to combine with breast milk, but can be done with perseverance!). There are also some thickened formulas on the market specifically designed for babies with reflux. They are usually labelled “AR”, or anti- reflux.
  • Antacids: These don’t prevent the milk coming back up, but do reduce the acidity of what comes up, reducing the burning sensation. This is often the first true “medication” doctors try; it can be very effective in reducing pain symptoms. Examples of antacids include Omeprazole (Losec) and Ranitidine (Zantac).
  • Motility Agents: Drugs such as Domperidone (Motilium) increase gastric emptying into the small intestine. The milk stays in the stomach for a much shorter period, resulting in less reflux.

What was your experience? Have you had a baby with reflux or cow’s milk intolerance? What helped for you? Join the conversation by adding your comments below. 

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Warts and all: How to Treat Molluscum Contagiosum

One of the most delightful things about having children is their propensity to develop wonderful skin conditions. Of these, molluscum contagiosum, or “water warts”, is one of the more challenging and frustrating conditions parents have to deal with.

What Is Molluscum Contagiosum?

What Is Molluscum Contagiosum

Molluscum Contagiosum: Image Courtesy Of JAMA Dermatology

Molluscum contagiosum, or “water warts”, as it is sometimes called, is caused by a virus from the pox family. The most common feature of this viral infection is the small round nodule that appears on the skin- usually 1-2 mm in diameter. There is usually a central dimple, called an umbilication. Inside the wart is a seed made of a waxy shiny material.

Natural History Of Molluscum Contagiosum:

Molluscum contagiosum is extremely contagious (the clue is in the name!). Your child can pick it up via direct contact with a friend’s warts. He can also become infected via “fomites”- the viral particles that cling to solid surfaces for several hours after an infected person has come into contact with them.

KIds often become infected by sharing towels and body boards in the swimming pool, leading to the nickname “water warts”, although the virus is not actually spread via water at all.

Left to itself, molluscum is self- limiting in the majority of cases; it will resolve without treatment within approximately 9-18 months. For this reason, many doctors recommend no treatment, and adopt a “watch and wait” policy.

When to Treat Molluscum:

Although molluscum is regarded as generally benign, some children may experience complications such as:

Children with complications may require active intervention to prevent further spreading, and reduce discomfort.

How to Treat Molluscum:

We’ve already discussed the “do nothing” approach. If your child has no discomfort, and there are relatively few spots, this may be your best approach.

However, if your child is experiencing complications, your doctor may discuss certain interventions:

Topical Creams and Paints:

  • Wart paints such as Salicylic Acid have been found to be very helpful on plantar warts, or verrucas. However, molluscum are less thickened, so this treatment may be painful and may blister normal skin nearby.
  • Imiquimod, or “Aldara”, is an immune modifier which supposedly encourages the immune system to “wake up” and fight the molluscum, clearing it up faster. However, several studies have shown no improvement following this treatment, so it is no longer recommended for treatment of molluscum.
  • Cantharidine: a paint derived from a beetle, and dating back to ancient Chinese medical traditions. This paint causes a blister to form on top of the molluscum, which should peel off after 3-4 days, taking the molluscum with it. In the majority of cases it is relatively painless and causes little to no scarring. Occasionally, it may be painful, and there is a small chance of bacterial contamination of the blisters.

Invasive Treatments:

  • Curettage: removing the roof of the wart to remove the contagious “seed” from the centre. This is usually done after applying local anaesthetic cream, but may still cause some discomfort. If there are multiple warts to treat, a young child may become very distressed. There is a small risk of scarring.
  • Cryotherapy: using liquid nitrogen to freeze the warts off. Again, this is best done after applying local anaesthetic creams to the area. It may also cause scarring.

Home Remedies:

So we have “do nothing” and we have various quite invasive, or painful, options. Is there a middle of the road approach? Although rarely recommended by medical professionals, there is growing evidence that several other, more innocuous, therapies may be beneficial:

  • Tea Tree Oil: dabbing a drop of tea tree oil on each of the molluscum once or twice a day may help prevent them spreading, and may actually reduce the number of molluscum. It appears to work by causing the immune system to “wake up” and get started on removing the molluscum. It is a good idea to try this before going for a more invasive option. At the very least, your doctor may have to treat less warts!
  • Wheat Grass Spray : this is a similar idea to Tea Tree Oil, but it is a little harder to come by. Unless you already have some at home, in which case, have a go!
  • Tape Stripping: this rather bizarre treatment may work for you. Apply duct tape or Elastoplast onto the molluscum, with the adhesive part in contact with the warts. Keep it on for a couple of days and then take it off. I must admit though- I haven’t had any personal experience with this one!

My favourite of the above home remedies is the tea tree oil. It is readily available and easy to apply. And it really works! Among all the parents I have recommended it to, the majority find that the warts either disappear or reduce greatly. This is fantastic for your child and your doctor, as any further wart removal will be quicker and less traumatic for all concerned!

What molluscum therapies have you tried? Which worked for you? Have you any advice or stories you would like to share? Leave your comments below.

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Childhood Eczema: How To Stop HIm Scratching That Itch!

So your child is driving you crazy with his constant scratching of his skin, and the dreadful red marks he leaves all over his body. When you ask him to stop, he says he can’t- it’s too itchy! What can you do to help him?

Atopic dermatitis

Childhood eczema: image courtesy of National Eczema Society

What Is Childhood Eczema? 

Childhood eczema, or atopic dermatitis, is a dry and irritated skin condition caused by sensitivity to various factors. Infants with eczema often have red scaly skin over their cheeks. Older children have redness and flaking of the skin in the skin creases, or joint flexures, such as elbows and backs of knees.

Over time, excessive inflammation of the skin may cause skin thickening (called lichenification) and plaque formation over the affected parts of the body.

Eczema is a relapsing and remitting condition. Unlike other diseases, we cannot treat it and make it go away. There will be times in your child’s life when the condition is better, and when it is worse. It is important to learn what triggers exacerbate your child’s eczema, and how best to manage it.

How common is Childhood Eczema?

Childhood and infantile eczema is common. Around 10% of children under the age of 12 months will have some degree of itchy dry skin; fortunately many grow out of the tendency by later childhood. Some children go on to have chronically dry irritated skin for many years.

Risk factors include:

  • Parents or first degree relatives with eczema or environmental allergies.
  • HIstory of other “allergic” conditions, such as asthma, allergic rhinitis or seasonal allergies.

What Makes Childhood Eczema Worse?

Childhood eczema

Sand can irritate dry and sensitive skin

  • Environmental conditions; some children find that their eczema becomes worse in dry winter conditions; others have flare ups in hot humid weather, when they are more sweaty.
  • Exposure to harsh chemicals: the chlorine in swimming pools can often exacerbate sensitive, dry skin conditions.
  • Emotional stress: fear and anxiety can lead to release of hormones that may worsen eczema.
  • Adolescent hormonal surges: some children find that their eczema worsens during adolescence.

I’m often asked whether food allergies and sensitivities are linked to childhood eczema. The answer is “no” in the vast majority of cases. Large studies of children with eczema have failed to show any causative food allergy, despite what many parents believe.

It can also be dangerous to cut out various different foods in the belief that they are causing your child’s eczema: your child may be deprived of important nutrients, and may even develop severe vitamin and mineral deficiencies as a result.

What Makes Childhood Eczema Better?

  • Reduce exposure to known triggers: of course, you can’t ask your child to stop swimming,  but you can make sure that he washes himself immediately rather than running around covered in chlorine for several hours afterwards.
  • Stop using soap- based cleansers: soap dries the skin. Instead, choose non-soap cleansers such as QV, Cetaphil, Sebamed, etc.
  • Reduce baths in favour of showers: baths are more drying to the skin that showers (bubble-baths are the worst, I’m afraid- you will have to find some other treat for a little girl with eczema). If you absolutely must use a bath (and this is often preferable with small babies) add half a capful of an emulsifying oil such as Oliatum or QV Oil into the bath water.
  • Although biological washing detergents are undoubtedly better for the environment, many children with sensitive skin react to the enzymes. Consider changing to a non-biological washing detergent; some children with very sensitive skin may benefit from you washing their clothes in an extra rinse cycle.
  • Dress your child in light cotton clothes: these allow the skin to breathe and reduce sweating. Cotton also reduces skin irritation compared to polyester and other man made fabrics. Wool clothing is also more likely to cause excessive itching.

Medical Therapies:

Moisturisers:

Also known as emollients: these are the mainstay of eczema treatment. In dry conditions, emollients used are often thick and oil based, such as paraffin. In hot and humid climates, emollients are water based lotions to reduce the risk of additional sweating and itchiness.

In both dry and humid climates, keeping the skin well moisturised is crucial to reducing itch in childhood eczema. Although the media is full of stories of miracle creams for eczema, the truth is less satisfactory. There is no one miracle cream that will work for everyone. The reality is that you will probably have to try a few different creams until you find one that works well for your child.

Aim to moisturise your child’s skin at least twice a day. The best time to moisturise in within 2-3 minutes after a shower, as the skin will more readily absorb the cream then.

Steroids and Immune Modulators:

Steroids occur naturally in our bodies- they help to reduce inflammation and prevent secondary damage. Doctors prescribe steroids to reduce itch and prevent scratching. They act by reducing inflammation and therefore stop the irritation.

Overuse of steroids is associated with thinning of the skin. It is important to only use a small amount, and only on the irritated skin- do not use steroids on normal skin. Do not apply steroids onto broken skin, or on skin you suspect may be infected. Do not use steroids as a moisturiser. You should apply your child’s moisturiser on top of the steroid cream.

Your doctor will prescribe the lowest strength of steroid he or she feels will be able to control the symptoms. It may be necessary to increase the potency of the steroid if you are not getting control of your child’s symptoms. Your doctor will usually try to reduce the potency or the frequency of application of the steroids once the symptoms are under control.

Other medications are sometimes used (such as tacrolimus and pimecrolimus), which also modulate the immune system’s response to inflammation. These medications can have rare but serious side effects; your doctor will discuss these with you before commencing this medication if required.

Complications Of Childhood Eczema:

Let your doctor know if your child’s eczema changes. If you can see little pockets of pus, or it is weepy, or has golden coloured crusts on the surface, he may have a secondary infection.

Common infections occuring in children with eczema include:

  • Staphylococcus (Staph): this can usually be treated with topical antibiotic creams. More severe forms or widespread infections may require oral antibiotics.
  • Herpes virus (cold sore virus): this may require topical and oral antiviral treatment such as aciclovir.

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Childhood Constipation: What To Look For In Your Child

Childhood constipation is common. The prevalence of childhood constipation has been estimated at somewhere between 4 and 36% (that’s one in three kids with constipation!). Constipation accounts for 3% of childhood hospital admissions and 25% of referrals to paediatric gastroenterologists.

What Is Constipation?

Although many people seem to think that constipation is defined by how frequently a person passes stool, this is not the most important factor. More important is what it looks like (and feels like) when it comes out. A child may pass tiny hard pellets several times per day- this is obviously not good.

An ideal stool looks like a sausage- long and smooth, with no lumps or cracks on the surface. This is a “type 4” stool on the Bristol stool chart, which we often use to describe the appearance of stool.

Poo chart

Bristol Stool Chart

A type 1 stool is associated with quite severe constipation, and even a type 2 or 3 stool may be associated with pain and straining, and possibly some abdominal discomfort. Strangely, type 6 and 7 stools can sometimes be associated with severe consitpation: it is possible for the bowel to become so loaded with hard stool that only watery stool is able to bypass the obstruction, giving the appearance of diarrhoea.

What Causes Constipation?

Children can become constipated for a number of reasons. Often, the trigger can be toilet training. Some children find “pooping in the potty” a frightening experience and hold on to their poop (a practice doctors call “stool holding”). Unfortunately, the situation is then exacerbated by the child finally passing a very large and hard stool, which can be very painful; this then reinforces the fear of passing stool, and the cycle continues.

Starting school can also be a trigger; children are encouraged not to go to the bathroom during class time. Some children learn to stool-hold and ignore the urge to go to the toilet. Children may dislike passing stool in school, preferring to hold onto it until they get home.

Diet can play a part in the evolution of constipation: children who eat less fruit and vegetables are at increased risk of constipation. Too much fibre in a child’s diet without adequate fluid intake can also lead to consitpation.

Children who drink too little water are more likely to be constipated, which is often a problem in tropical countries such as Singapore, where children sweat more, and need to drink even more to stay well hydrated. Most children (and most adults) do not drink enough fluids. An average 12kg two year old child who takes around 500ml of milk per day needs approximately 500-600ml of water every day for adequate hydration.

What are the signs of constipation?

  • Straining and difficulty in passing stool
  • Small and hard stools (although some children may pass exceptionally large and hard stools)
  • Stool holding: your child may actively suppress the urge to pass stool due to fear of the pain associated with it
  • Abdominal pain
  • Bloating and frequent passing of gas
  • Reduced food intake, and a sensation of fullness
  • Vomiting: if your child vomits due to constipation, you should seek medical attention urgently

What Can You Do?

  • You should make sure your child is drinking enough fluids. An infant under 12 months requires between 600-1000ml; a toddler needs around 1-1.5 litres. A child above the age of five years needs more than 1.5 litres, depending on their size and physical activity)
  • Ensure your child is eating sufficient fruits and vegetables: your child should have around two half cup portions of fruits and two half cup portions of vegetables. For more help with feeding a picky toddler, see http://www.doctor-natalie.com/tag/feeding-a-picky-toddler/ 
  • Encourage your child to sit on the toilet for ten minutes after a meal. You can also ask him to sit on the toilet when you see him showing signs of stool holding. You can offer to read him a story to encourage him to stay for longer, or rub his tummy if he is hurting.
  • Try reducing foods that predispose to constipation, such as eggs, banana and avocado. Instead, try giving prunes, apricots, papaya and red dragon fruit, all known for their ability to move mountains!

Medications:

Laxatives

How Laxatives work

  • Osmotic Laxatives, such as Lactulose: a non-absorbable sugar. This medication stays within the bowel and is not absorbed by the body. It acts by a process called “osmosis”, actively pulling water through the wall of the bowel to soften the stool, making it easier to pass out.
  • Polyethylene Glycols: This group of medications includes Movicol, Mirolax and Forlax. They also act primarily by osmosis, causing the stool to become more soft. Care needs to be taken when using osmotic laxatives to ensure that the child takes enough fluids.
  • Glycerin Suppository: this can be useful in small children if the stool is impacted and cannot come out.
  • Enemas: you should consult a doctor before using an enema in a young child. Your doctor may use these to disimpact hard stool that cannot come out with osmotic laxatives alone.
  • Stimulant Laxatives, such as Senna: these are rarely used in young children as they tend to increase pain and discomfort. Young children are at risk of stool holding in respond to pain and discomfort; medications that increase fear surrounding passing stool should be used only as a last resort, and only under the supervision of a paediatric gastroenterologist.

Remember that children will often need to stay on medication for a long period of time to allow the bowel to return to its normal size, and learn how to function properly again. A good rule of thumb is to think how long your child has been suffering with constipation: if it is only a couple of weeks, then you may only need to treat for a week or two. However, if the problem has been going to for several months, treatment may last several months too.

Has your child suffered with constipation? What did you find helpful? Leave your comments in the box below. And remember to subscribe to receive weekly medical and parenting information direct to your inbox. Have a great week ahead.

 

Postnatal Depression- Are You At Risk?

Everyone tells you that the birth of a new baby is a joyful, exciting thing. It’s a day many of us look forward to from the moment we discover we are pregnant. The big day arrives, a little bundle is placed in our arms… and our lives are irrevocably changed. But what happens if the thoughts and emotions are not what we anticipated? What if, instead of joy and excitement, we feel fear and anxiety. Who do we turn to? What do we do?

Postnatal depression

Postnatal Depression: Are You At Risk?

The Statistics:

Many women experience “baby blues”, a feeling of sadness and emotional let-down that classically begins on day 2 to 3 after the birth of the baby, and may last up to two weeks.

This phenomenon is partly due to the sharp drop in your “happy hormones”, oestrogen and progesterone, which were keeping you going throughout pregnancy (think of it as a super-magnified premenstrual tension!). Some women also experience a sharp drop in their thyroid hormone levels, which can lead to feelings of excessive tiredness and lethargy.

Studies show that around 1 in every 8, or 10-15%, of women will experience something a bit more intense than the baby-blues- true postnatal depression.

Who Is At Risk?

Women who have a history of pre-existing depression or other psychiatric illness, such as bipolar disorder or anxiety, may be 60% more likely to suffer postnatal depression than mothers with no history of psychiatric illness in the past.

Other risk factors:

  • unplanned or accidental pregnancy
  • unsupportive partner
  • teen or single parent
  • socio-economic needs
  • stress
  • baby with disability or special needs
  • premature baby, or baby requiring hospitalisation
  • previous history of losing a baby

 Signs of postnatal depression include:

  • Sadness and feelings of emptiness worsening, rather than improving at around the two weeks mark, and lasting considerably longer
  • Feelings of isolation and loneliness
  • Feelings of desperation
  • A sense of failing or being a failure (at breastfeeding, being a mother… ), or not being able to bond with your baby
  • Tiredness or lethargy
  • Poor sleep, difficulty in falling asleep or sleeping too much
  • Eating too much, or too little
  • Unable to feel happy about anything
  • Unable to motivate yourself to do things, or get out of the house
  • Frightening thoughts about harming yourself or your baby

A small number of women with postnatal depression may go on to experience postnatal psychosis. Signs of postnatal psychosis include:

  • Auditory or visual hallucinations
  • Extreme feelings of worthlessness
  • Feelings that your baby/ your family/ your partner would be better off without you
  • Escalating thoughts of harming yourself or your baby, or planning to commit suicide

What Can You Do?

Self help interventions:

  1. Ask for help: recognise how you feel and tell someone! Anyone! It can be a friend, family member, ora a complete stranger- but you should tell someone! Once you have acknowledged the feelings, they are less powerful to harm you or your family, and other people can share the burden with you.
  2. Be good to yourself: forget all the projects you were convinced you would get done during your maternity leave (finally bringing order to the study, anyone…?). Just concentrate on getting through the day!
  3. Get yourself out of the house: arrange a coffee morning with friends or your sister. Talk and let them know how you’re feeling.
  4. Force yourself to do something physical! Put your baby in the stroller and go for a walk.
  5. Reach out to your pastor/ priest, or faith leader in your faith community for help and support.
Walk

Go for a walk on the beach

Help And Support:

Talk to your doctor (your family doctor, obstetrician or your child’s paediatrician) about accessing more help. Psychotherapy such as cognitive behavioural therapy helps you to see your situation clearly, and gives you the tools to manage and move forward.

Your doctor can also recommend medications (or send you to someone who can prescribe medications) to treat anxiety and depression. Don’t worry: Your doctor can prescribe medications that are safe to use during breastfeeding.

There are suicide helplines and support groups in most countries that you can reach out to if you feel you cannot talk to a family member or friend about how you’re feeling:

  • Singapore: Samaritans of Singapore at 1800 221 4444
  • United States: National Suicide Prevention Lifeline at 800-273-TALK (800-273-8255)
  • UK And ROI: Samaritans UK & ROI
    Hotline: +44 (0) 8457 90 90 90 (UK – local rate)
    Hotline: +44 (0) 8457 90 91 92 (UK minicom)
    Hotline: 1850 60 90 90 (ROI – local rate)
    Hotline: 1850 60 90 91 (ROI minicom)

For a full list of suicide lines see: https://en.m.wikipedia.org/wiki/List_of_suicide_crisis_lines

And finally… a few reminders:

YOU ARE A GOOD PARENT 

THIS IS NOT YOUR FAULT

YOU ARE WORTHY OF BEING LOVED

YOUR BABY IS NOT BETTER OFF WITHOUT YOU- EVER!

YOU CAN ASK FOR HELP! 

As always, feel free to leave a comment below. And don’t forget to subscribe to receive weekly medical and parenting advice direct to your inbox. Have a great week ahead!