Parents

‘Ask Dr. Mark: Answers for Parents’

How often have you left the pediatrician’s office wishing there was more time to talk? Pediatrician and “Today” contributor Dr. Mark Widome helps extend your conversations with the pediatrician through his new book, giving in-depth answers to 150 of the most frequently asked questions, drawing from his popular magazine columns, “Today” segments, and general pediatric practice experience at the Penn State Children’s Hospital. Here's an excerpt:

FROM THE PREFACE

Pediatricians spend much of their time with parents discussing how to best raise children, with increasing attention to growth, development, management of common health problems, and prevention of illness and injury. Parents and pediatricians alike wish there were more time to discuss nutrition, behavior, disease prevention, and emotional growth. In an increasingly complex social environment, parents have more questions and the answers are less obvious. How often have you left your pediatrician’s office wishing there were more time?

Parents turn elsewhere for health information. In addition to advice from friends and relatives, parents rely heavily on print, television and, of course, the Internet. When, about a dozen years ago, the National Safety Council invited me to answer parents’ questions in the pages of their magazine, Family Safety & Health, I wondered whether I could usefully add to what was already available. Nevertheless, I accepted the invitation and tried my best to offer readers something equivalent to what I offered parents and families in the office.

In so doing, I discovered two things. First, I discovered that I was able, in relatively little space, to go into more detail on a topic in print than I could in person. This shouldn’t have surprised me. Pediatricians rarely have more than rarely have more than 15 or 20 minutes to spend with a parent and child during a health supervision visit, with only a fraction of that spent counseling and answering questions.

Second, I was reminded that parents routinely seek out and benefit from multiple opinions on a subject. In the magazine column, parents frequently asked me to comment on what they had read elsewhere, what relatives had advised, or what their child’s own physician had recommended. This should not have surprised me either. Parents in the office have often done their research, asking my opinion on what they have learned elsewhere.

On this second point, parents may be surprised to learn that physicians usually welcome the patient or parent who has done his research, the parent who had been doing some reading or exploring a subject on the internet, the parent who asks hard questions. I believe that most pediatricians share my view that parents who do their homework are usually prepared to make better decisions.

In putting this book together, the editors at NSC Press and I have gone back over all of our magazine columns, selecting those questions and topics we see as most useful and interesting. We have reread, expanded and updated every question and answer. I have added several dozen new questions as well as supplementary discussions. Some of the new material reflects parents’ questions from my academic outpatient practice at Penn State’s Children’s Hospital, while other material reflects the interests of viewers of my child health and safety segments on NBC’s TODAY Show.

FROM PART 1: DIET AND NUTRITION

Introducing Baby Food

My five-month-old grandson is still on formula only. I don’t understand this since my son was eating baby cereal at two months. (Both were born healthy.) Why is there such a discrepancy in recommended feedings?

Over the years there has been a great deal of variation in physician recommendations regarding the introduction of baby foods. Timing of the introduction of baby foods is based largely on custom, opinion, and individual preferences.

Until the 1920s, solid food was seldom introduced to infants in the United States until they were approaching their first birthday. Infants were exclusively breast-fed or fed an infant formula. Since that time, “baby foods’ have become widely available and heavily marketed.

By the 1960s, the pendulum had swung. It was not uncommon for physicians to recommend that baby cereal be introduced shortly after the “six-week check-up.” Fruits and vegetables were introduced in rapid succession. Babies introduced to solid foods this early certainly seemed to do well. Parents were gratified by the rapid weight gain in their infants. Perhaps even more significantly, many physicians—and even more parents—believed, incorrectly, that the introduction of “something solid” into the infant’s diet would help the baby to sleep through the night. What a welcome prospect to weary and sleep-deprived parents!

By 1980, physicians were becoming increasingly concerned about two problems with the early introduction of solid foods. The first was that there was a tendency to feed babies more calories than they needed for growth. As physicians became more aware of infants’ normal eating reflexes, they realized that until about 4 to 5 months of age, a baby has a natural tendency to reject the spoon with his tongue (the tongue-thrust reflex). To feed a younger baby, a parent needs to encourage (Force?) the infant to overcome this natural reflex to get food in his mouth. With this tongue-thrust reflex present, a parent has no way of knowing whether her baby has had enough to eat or if he is still hungry. Too often a healthy pattern of weight gain gives way to overfeeding and overweight babies!

A second concern with the early introduction of solid foods is the possible development of allergies. In very young infants, some food proteins are absorbed into the body with relatively little breakdown in the digestive tract. The absorption of these large, intact proteins may give rise to the later development of allergies in some children.

I tell parents that there is no one age that is the right time for all children to begin solid foods. However, for most infants, parents will do best to introduce solids shortly after the four-month-old visit to the doctor.

This time seems right to me for several reasons:

The infant is probably already sleeping through much of the night — something that begins naturally around eight to twelve weeks of age, regardless of diet.

Infants in this age group have well-developed head control, and they are losing their tongue-thrust reflex. That means that the child who is no longer hungry can turn his head away from the spoon or push the spoon out of his mouth with his tongue on purpose. Conversely, the infant who wants more to eat will lean forward and open his mouth. In other words, the four- or five-month-old infant can communicate with body language to tell his parent whether he is hungry or satisfied.

If that is the argument for not starting solid foods too early, then why not wait until later in the first year to introduce solid foods, as was the custom in the early 1900s? There are two reasons:

Many seven-, eight-, and nine-month-olds go through a normal stubborn streak. Those who have had no previous experience with the spoon may be extremely reluctant to give it a try.

By the time a baby is six months old, he has greatly increased his needs for protein and iron. In the second half of the first year, these needs cannot often be optimally satisfied by breast milk or infant formula alone. The introduction of infant cereals (and eventually, meats) provides excellent supplemental sources of protein and iron.

I recommend two rules when introducing table foods. First, start no more than one new food every four days. Second, start each new food with just a taste on the tip of the spoon. These two rules are helpful because there are usually one or more foods that “disagree” with any given baby. These “disagreements” are usually not food allergies, but rather “food intolerances.” They sometimes are manifested by spitting up, mild rashes, or mild diarrhea. If you start foods one-at-a-time and start with just a taste, then you will be able to identify any foods that disagree with your child’s body.

The order that you choose to introduce baby foods is mostly a matter of personal preference, not nutrition or science. It is customary to start with infant cereals and then move on to fruits or vegetables. Meats are usually saved for last (after the six-month visit to the pediatrician), because infants tend not to like meats at first and parents often mix them with a fruit or vegetable that the infant is accustomed tountil the infant can become accustomed to the new taste.

Early on, stick with baby foods that contain just one ingredient, such as the “Stage 1” foods. No single food is essential to an infant’s diet. If there is a food that your infant seems not to like, skip it. When you come back to that food a month later, your infant may have a completely different opinion!

FROM PART 2: HEALTH AND ILLNESS

Common Baby Questions

Pediatricians get more questions from parents in the first month of life than in any other month. Newborns change rapidly as they adapt from prenatal life to postnatal life. It is not only a first time experience for many parents, but it is in every way a first time experience for the baby! The following questions are those that parents ask pediatricians most frequently.

Weight Loss

Why do newborn babies lose weight before they gain?

Newborn babies are different from all other people in that they are born with lots of extra fluid in their bodies: they are waterlogged! This allows them to do well for the first 48 to 72 hours with relatively little nourishment until their mothers’ milk supply comes in. (It is the process of being born, plus putting the newborn frequently to the mother’s breast, that signals the mother’s body to begin milk production.) Babies typically loose between 5 and 10 percent of their body weight before they begin to gain. That could be a loss 5 to 10 ounces in a seven-pound baby. If you or I were to quickly loose 5 to 10% of our bodies’ weight, we would be dehydrated, sick, and perhaps needing an IV!

Babies start gaining when their mothers’ milk supply is in. Some babies will not regain their birth weight until they are 7 to 10 days old. Prematures can take considerably longer to get back to their birth weights. Full-term formula-fed newborns will often regain their birthweight in just a few days.

How do I know if my baby is losing too much weight, or gaining it back too slowly?

Many years ago, it used to be popular for parents to have baby scales at home to monitor their children’s weights. Parental anxiety, coupled with the scales’ inaccuracy, has caused the custom of weighing babies at home to fall out of favor. Nevertheless, parents should have little trouble telling whether their newborns are getting enough to eat and gaining adequate weight.

Once home from the hospital, your baby should be having at least 4 to 5 bowel movements a day, perhaps one after every feeding. The baby’s bowel movements should quickly be changing in color from the black color at birth (called meconium stools), to a green, seedy stool (called transitional stools), to a lighter yellow, indicating that milk is going through the digestive track. Diapers should be wet with urine, and the urine should be almost as clear as water. Breast-feeding mothers cannot measure the amount their infants are taking, but they should have a sense that their milk supply is in, and they should be able to see milk in their infants’ mouths and hear them swallowing. Once home from the hospital, feedings should leave the baby happy and satisfied.

The most important way to tell that the baby is getting enough—especially the breast-fed baby—is the follow-up visit with the pediatrician or the nurse practitioner several days after discharge from the hospital. This early “weight check” visit is important to assure that feeding has gotten off to a good start and that the baby is otherwise normally adapting to postnatal life. The American Academy of Pediatrics recommends that babies discharged from the hospital before 48 hours of age (now the rule, rather than the exception) have a brief follow-up visit with the doctor or nurse within the next 2 to 3 days.

Why does my baby always hiccup, sneeze, and spit up?

A three-part question—let’s take them, one at a time.

Hiccupping is a good sign. In fact, to the pediatrician, frequent hiccups are the sign of a well-fed baby. Hiccups are caused by a full stomach pushing up on—and irritating—the diaphragm (the wall of muscle that separates the belly from the chest). When the diaphragm is irritated, it goes into evenly-timed quick contractions for several minutes, each contraction causing an involuntary little gasp: a hiccup. Older kids and adults don’t get hiccups after a full meal, because as you get older, your stomach is relatively smaller compared to the overall size of your body, so even a full stomach of an older child is not large enough to press up against the diaphragm.

Babies frequently sneeze, not because they are catching a cold, but rather because it is the best way for them to clear mucous from their small noses. Babies sneeze instead of blowing their noses. They sneeze a lot because they are frequently congested. They are frequently congested because, with very small noses, it takes very little mucous to interfere with breathing. And, for the first several months of life, babies much prefer to breathe through their noses than their mouths. When older infants (and children and adults) get momentarily congested, they just open their mouths for a breath of air without even thinking about it. Newborn babies don’t. They get upset and cry — or they simply sneeze to clear their noses.

All babies spit up, at least occasionally. Some, affectionately referred to as “spitters,” seem to spit up a bit after every feeding. The spitting is another reflection of just how full a baby’s stomach gets after a good feeding. Spitting also results from the fact that the circle of muscle at the bottom of the esophagus has not yet had time to become tight enough to serve as an effective one-way valve for food a drink. Babies who normally spit, usually do so within fifteen to twenty minutes after a feeding. What comes up looks pretty much like what went down! The breast milk or formula will flow out of the baby’s mouth as if it is overflowing. It is usually a tablespoon or two at most, but it looks like much more. Spitting babies are not bothered by their spitting. (They are “happy spitters.”) Parents may be bothered by the frequent changes of clothes and extra loads of wash. Normal spitting does not interfere with growth; it rarely requires treatment beyond sitting the baby up after feeds and frequent burping; and spitting typically improves greatly over the first several months of life.

(Note that vomiting is quite different than spitting. Vomiting is forceful and unpleasant to the infant. Vomiting is not normal and sometimes may be serious. When an infant is vomiting, parents should not delay in contacting their pediatrician.)

Excerpted from “Ask Dr. Mark: Answers for Parents” by Mark D. Widome, MD. Copyright © 2003 by The National Safety Council, and available from www.nsc.org. Excerpted by permission of NSC Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission.

Mark Widome is Professor of Pediatrics at the Penn State Children’s Hospital. He writes frequently on topics of interest to parents and is a regular contributor to the Today show.

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