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• Appetite Slump in Toddlers
• Breast - Feeding
• Cradle Cap
• Diaper Rash
• Formula - Feeding
• Jaundice of the Newborn
• Newborn Appearance and Behavior
• Newborn Rashes and Birthmarks
• Normal Newborn Skin Care
• Picky Eaters
• Spitting Up ( Reflux )
• Tear Duct, Blocked
• Teething
• Thrush

Once you allow your child to be in charge of how much she eats, the unpleasantness at mealtime and your concerns about her health should disappear in a matter of 2 to 4 weeks. Your child's appetite will improve when she becomes older and needs to eat more.

Put your child in charge of how much he eats at mealtime.
Trust your child's appetite center. All children eat as much as they need. Your child's brain will make sure he eats enough calories for normal energy and growth. Your only job is to serve well-balanced meals. If your child is hungry, he will eat. If he's not, he will be by the next meal. Even reminding him to eat or to eat more will work against you.

Allow one small snack between meals.
The most common reason for some children never appearing hungry is that they have so many snacks that they never become truly hungry. Be sure your child arrives at mealtime with an empty stomach. Offer your child no more than two small snacks of nutritious food each day, and provide them only if your child requests them. Keep the size of the snack to 1/3 of what you would expect him to eat at mealtime. If your child is thirsty between meals, offer water. Limit the amount of juice your child drinks to less than 6 ounces each day. Let your child miss snacks if she chooses and then watch the appetite return. Even skipping an occasional meal is harmless.

Never feed your child if he is capable of feeding himself.
Parents of a child with a poor appetite will tend to pick up the spoon, fill it with food, smile, and try to trick the child into taking it. Once your child is old enough to use a spoon by himself (usually 12 to 15 months), never again pick it up for him. If your child is hungry, he will feed himself. Forced feeding is the main cause of eating power struggles.

Offer more finger foods.
Finger foods can be started at 6 to 8 months of age. Such foods allow your child to feed herself at least some of the time, even if she is not yet able to use a spoon.

Limit milk to less than 16 ounces each day.
Milk contains as many calories as most solid foods. Drinking too much milk can fill kids up and dull their appetites. Excessive milk or juice is a common cause of a poor appetite for solid food.

Serve small portions of food-less than you think your child will eat.
A child's appetite is decreased if she is served more food than she could possibly eat. If you serve your child a small amount on a large plate, she is more likely to finish it and gain a sense of accomplishment. If your child seems to want more, wait for her to ask for it. Avoid serving your child any foods that she strongly dislikes (such as some vegetables).

Consider giving your child daily vitamins.
Although vitamins are probably unnecessary, they are not harmful in normal dosages and may help you relax about your child's eating patterns.

Make mealtimes pleasant.
Draw your children into mealtime conversation. Avoid making mealtimes a time for criticism or struggle over control.

Avoid conversation about eating.
Don't discuss how little your child eats in her presence. Trust your child's appetite center to look after her food needs. Also, don't praise your child for eating a lot. Children should eat to please themselves.

Don't extend mealtime.
Don't make your child sit at the dinner table after the rest of the family is through eating. This will only cause your child to develop unpleasant feelings about mealtime.

During office hours if:

• Your child is losing weight.
• Your child has not gained any weight in 6 months.
• Your child also has symptoms of illness (for example, diarrhea or fever).
• Your child gags on or vomits some foods.
• Someone is punishing your child for not eating.
• Following these guidelines has not improved mealtimes in your house within 1 month.
• You have other questions or concerns.

Babies who are breast-fed have fewer infections and allergies during the first year of life than babies who are fed formula. Breast milk is also inexpensive and served at the perfect temperature. Breast-feeding becomes especially convenient when a mother is traveling with her baby. Overall, breast milk is nature's best food for young babies.

The baby should nurse for the first time in the delivery room. The second feeding will usually be at 4 to 6 hours of age, after he awakens from a deep sleep. Until your milk supply is well established (usually 4 weeks), nurse your infant whenever he cries or seems hungry (demand feeding). Thereafter, babies can receive enough milk by nursing every 2 to 2-and-1/2 hours. If your baby cries and less than 2 hours have passed, he can be rocked or carried in a front pack. However, waiting more than 2-and-1/2 hours can lead to swollen breasts (engorgement), which decreases milk production. (Feeding less frequently is OK at night, but no more than 5 hours should pass between feedings.)

Your baby will not gain adequately unless he nurses 8 or more times per day initially. The risks of continuing to nurse at short intervals (more often than every 1 and 1/2 hours) are that "grazing" will become a habit, your baby won't be able to sleep through the night, and you won't have much free time.

During the first week, bring in your full milk supply by offering both breasts with each feeding. Try 10 minutes on the first breast and as long as your baby wants on the second breast (at least 10 minutes). Alternate which breast you start on. You may need to stimulate your baby to take the second breast.

After your milk supply has come in (by day 8 at the latest), encourage your baby to nurse as long as she wants to on the first breast (up to 20 minutes). This is so your baby can get the high-fat, calorie-rich hind milk. You can tell your baby has finished the first breast when the sucking slows down and your breast becomes soft. Then offer the second breast if your baby is interested. Alternate breasts at the start of each feeding.

HOW TO KNOW YOUR BABY IS GETTING ENOUGH BREAST MILK

In the first couple of weeks, if your baby has 3 to 4 good-sized bowel movements per day and six or more wet diapers per day, he is receiving a good supply of breast milk. (Infrequent bowel movements are not normally seen before a baby is 1 month old.) In addition, most babies will act satisfied after completing a feeding.

Your baby should be back to birth weight by 10 to 14 days of age if breast-feeding is going well. Therefore, the 2-week checkup by your baby's physician is very important.

The presence of a letdown reflex is another indicator of good milk production.

A letdown reflex develops after 2 to 3 weeks of nursing and is indicated by tingling or milk ejection in the breast just before feeding (or when you are thinking about feeding). It also occurs in the opposite breast while your baby is nursing.

Letdown is enhanced by adequate sleep, adequate fluids, a relaxed environment, and reduced stress (such as not expecting much housework to get done). If your letdown reflex is not present yet, take extra naps and ask your husband and friends for more help. Also consider calling the local chapter of La Leche League, a support group for nursing mothers.

Do not offer your baby any routine bottles during the first 4 to 6 weeks after birth because this is when you establish your milk supply. Good lactation (breast milk production) depends on frequent emptying of the breasts. Supplemental bottles take away from sucking time on the breast. If your baby is not gaining well, see your physician or a lactation specialist for a weight check and evaluation.

After your baby is 6 weeks old and nursing is well established, you may want to offer your baby a bottle of expressed milk or 1 ounce of formula once a day so that he can get used to the bottle and the artificial nipple. Once your baby accepts bottle feedings, you can occasionally leave your baby with a sitter and go out for the evening or return to work outside the home. You can use pumped breast milk that has been refrigerated or frozen.

EXTRA WATER

Babies do not routinely need extra water. Even when they have a fever or the weather is hot and dry, breast milk provides enough water.

Severe engorgement (severe swelling) of the breasts decreases milk production. To prevent engorgement, nurse your baby more often. Also, compress the area around the nipple (the areola) with your fingers at the start of each feeding to soften the areola. For milk release, your baby must be able to grip and suck on the areola as well as the nipple. Every time you miss a feeding (for example, if you return to work outside the home), pump your breasts. Also, whenever your breasts hurt and you are unable to feed your baby, pump your breasts until they are soft. If you don't relieve engorgement, your milk supply can dry up in 2 to 3 days.

A breast pump is usually not necessary because pumping can be done by hand. Ask someone to teach you the Marmet technique.

Pumped breast milk can be stored for 5 to 7 days in a refrigerator and up to 6 months in a freezer. To thaw frozen breast milk, put the container of breast milk in the refrigerator (it will take a few hours to thaw) or place it in a container of warm water until it has warmed up to the temperature your baby prefers.

Clean a sore nipple with water after each feeding. Do not use soap or alcohol because they remove natural oils. At the end of each feeding, the nipple can be coated with some breast milk to keep it lubricated. For cracked nipples, apply 100% lanolin (no prescription necessary) after feedings. Try to keep the nipples dry with loose clothing, air exposure, and nursing pads.

Sore nipples usually are due to poor latching on and a feeding position that causes undue friction on the nipple. Position your baby so that he directly faces the nipple without turning his neck. At the start of the feeding, compress the nipple and areola between your thumb and index finger so that your baby can latch on easily. Throughout the feeding, hold your breast from below so the nipple and areola aren't pulled out of your baby's mouth by the weight of the breast. Slightly rotate your baby's body so that his mouth applies pressure to slightly different parts of the areola and nipple at each feeding.

Start your feedings on the side that is not sore. If one nipple is extremely sore, temporarily limit feedings to 10 minutes on that side. The pain will not improve, however, until your baby starts to correctly latch on and is correctly positioned during feeding.

VITAMINS / FLUORIDE FOR THE BABY

Breast milk contains all the necessary vitamins and minerals except vitamin D and fluoride. Full-term dark-skinned babies and all premature babies need 400 units of vitamin D each day. White babies who have little or no sun exposure (less than 15 minutes of sun exposure twice a week) also need vitamin D supplements. From 6 months to 16 years of age, children need fluoride to prevent tooth decay. For children up to 3 years old who are breast-feeding and not drinking any water, 0.25 mg of fluoride drops should be given each day. This is a prescription item that you can obtain from your child's physician.

VITAMINS FOR THE MOTHER

A nursing mother can take a multivitamin tablet daily if she is not following a well-balanced diet. She especially needs 400 units of vitamin D and 1200 mg of both calcium and phosphorus per day. A quart of milk (or its equivalent in cheese or yogurt) can also meet this requirement.

Almost any drug a breast-feeding mother consumes will be transferred in small amounts to her breast milk. Therefore, try to avoid any drug that is not essential, just as you did during pregnancy.

Some commonly used drugs that are safe for you to take while nursing are acetaminophen, ibuprofen, penicillin's, erythromycin, cephalosporins, stool softeners, antihistamines, decongestants, cough drops, nose drops, eye drops, and skin creams. Aspirin and sulfa drugs can be taken if your baby is more than 2 weeks old AND not jaundiced. Consult your physician about all other drugs. Take drugs that are not harmful immediately after you breast-feed your child so that the level of drugs in the breast milk at the time of the next feeding is low.

Some of the dangerous drugs that can harm your baby are tetracycline's, chloramphenicol, anti thyroid drugs, anticancer drugs, or any radioactive substance. Women who must take these drugs should not be breast-feeding or should request a safer form of treatment. Another group of drugs that should be avoided because they can suppress milk production are ergotamines (for migraine), birth control pills with a high estrogen content (most birth control pills are OK), vitamin B6 (pyridoxine) in large doses, and many antidepressants.

Burping is optional. Its only benefit is to decrease spitting up. Air in the stomach does not cause pain. If you burp your baby, burping 2 times during a feeding and for about a minute is plenty. Burp your baby when switching from the first breast to the second and at the end of the feeding.

Introduce your child to a cup at approximately 6 months of age. Total weaning to a cup will probably occur somewhere between 9 and 18 months of age, depending on your baby's individual preference. If you discontinue breast-feeding before 9 months of age, switch to bottle feeding first. If you stop breast-feeding after 9 months of age, you may be able to go directly to cup feeding.

During regular hours if :

• Your baby doesn't seem to be gaining adequately.
• Your baby has less than six wet diapers per day.
• During the first month, your baby has less than 3 bowel movements per day.
• You suspect your baby has a food allergy.
• You need to take a medication that is not mentioned in this discussion.
• Your breasts do not become full (engorged) before feedings by the time your baby is 5 days old.
• You have painful engorgement or sore nipples that do not respond to the recommended treatment.
• You have a fever (also call your obstetrician).
• You have other questions or concerns.

DEFINITION

• Yellow scales and crusts attached to the scalp
• Scales can be greasy or dry
• Not itchy or painful
• Begins in the first 2 to 6 weeks of life. Is usually gone by 6 months of age

CAUSE
The cause of cradle cap is unknown. It may be caused by maternal hormones that crossed the placenta before birth and stimulated the oil glands. It is not caused by poor hygiene. Cradle cap is not contagious and does not recur. If redness also occurs behind the ears, in body creases (armpit, groin and neck), and in the diaper area, cradle cap is part of a condition called seborrheic dermatitis.

EXPECTED COURSE
Without treatment it can last for months, but it will eventually clear up on its own. With treatment it is usually cleared up in a few weeks.

HOME CARE

1. Anti dandruff shampoo
Anti dandruff shampoos slow down the scaling and flaking of skin. They do not require a prescription. Be careful to keep it out of the eyes. Wash your baby's hair with it twice a week. While the hair is lathered, massage your baby's scalp with a soft brush or rough washcloth. Don't worry about hurting the soft spot; it's well protected. Once the cradle cap has cleared up, use a regular shampoo twice a week.

2. Softening thick crusts or scales
If your child's scalp is very crusty, put some baby oil or olive oil on the scalp 1 hour before washing to soften the crust. Wash all the oil off, however, or it may worsen the cradle cap.

3. Resistant cradle cap
If the rash is red and irritated, apply 1 % hydrocortisone cream (nonprescription) three times a day for 7 days.

CALL OUR OFFICE

During regular hours if

• The cradle cap lasts more than 2 weeks with treatment
• It starts to look infected
• The rash spreads beyond the scalp
• You have other concerns or questions

Any rash in the skin area covered by a diaper .

Almost every child gets diaper rashes. Most are due to prolonged contact with moisture,
bacteria, and ammonia. The skin irritants are made by the action of bacteria from bowel
movements on certain chemicals in the urine. Bouts of diarrhea cause rashes in most
children. Diaper rashes occur equally with cloth and disposable diapers.

With proper treatment these rashes are usually better in 3 days. If they do not respond, a
yeast infection (Candida) has probably occurred. Suspect this if the rash becomes bright red and raw, covers a large area, and is surrounded by red dots. You will need a special cream for a yeast infection.

Change Diapers Frequently
The key to successful treatment is keeping the area dry and clean so that it can heal itself. Check the diapers about every hour, and if they are wet or soiled, change them immediately. Exposure to stools causes most of the skin damage. Make sure that your baby's bottom is completely dry before closing up the fresh diaper.

Increase Air Exposure
Leave your baby's bottom exposed to the air as much as
possible each day. Practical times are during naps or after bowel movements. Put a towel or diaper under your baby. When the diaper is on, fasten it loosely so that air can circulate
between it and the skin. Avoid airtight plastic pants for a few days. If you use disposable
diapers, punch holes in them to let air in.

Rinse the Skin with Warm Water
Washing the skin with soap after every diaper change will damage the skin. Use a mild soap (such as Dove) only after bowel movements. The soap will remove the film of bacteria left on the skin. After using a soap, rinse well. If the diaper rash is quite raw, use warm water soaks for 15 minutes three times every day.

Nighttime Care
At night use the new disposable diapers that are made with materials that lock wetness inside the diaper and away from the skin. Avoid plastic pants at night. Until the rash is better, awaken once during the night to change your baby's diaper.

Creams and Ointments
Most babies don't need any diaper creams or powders. If your
baby's skin is dry and cracked, however, apply an ointment to protect the skin after washing off each bowel movement. A barrier ointment is also needed whenever your child has diarrhea.
Cornstarch reduces friction and can be used to prevent future diaper rashes after this one
is healed. Studies show that cornstarch does not encourage yeast infections. Avoid talcum
powder because of the risk of pneumonia if your baby inhales it.

Yeast Infections
If the rash is bright red or does not respond to 3 days of warm water cleansing and air exposure, suspect a yeast infection.
Apply Lotrimin cream (no prescription necessary) 4 times per day or after each bottom rinse for bowel movements.

Prevention of Diaper Rash
Changing the diaper immediately after your child has a bowel movement and rinsing the skin with warm water are the most effective things you can do to prevent diaper rash. If you use cloth diapers and wash them yourself, you will need to use bleach (such as Clorox, Borax, or Purex) to sterilize them. During the regular cycle, use any detergent. Then refill the washer with warm water, add 1 cup of bleach, and run a second cycle. Unlike bleach, vinegar is not effective in killing germs.

IMMEDIATELY if

• It looks infected (yellow pus, pimples, blisters, spreading redness, red streaks)
• Your child starts acting very sick

During regular hours if

• The rash isn't much better in 3 days
• You have other concerns or questions

• You decide not to breast-feed.
• You need to stop breast-feeding and your infant is less than 1 year old.
• Occasionally you need to supplement breast-feeding with formula after breast-feeding is well established.
  Note: If you want to breast-feed but you think your milk supply is insufficient, don't stop breast-feeding. Instead seek help from your physician or a lactation nurse.

Caution: Any bottle feeding, before breast-feeding has been well established, could reduce your supply of breast milk and make it difficult to continue breast-feeding.

The decision about the appropriate breast milk substitute for a child less than 1 year old should be made after talking with your physician or health care provider. When you and your physician select a method of infant feeding, you must consider your lifestyle and the costs of the different methods of feeding.

Infant formulas have been designed to meet the nutritional needs of your infant by providing all known essential nutrients in their proper amounts. Most formulas are derived from cow's milk. A few are derived from soybeans and are for infants who may be allergic to or have difficulty digesting the type of protein in cow's milk.

Most commercial infant formulas are available in three forms: powder, concentrated liquid, and ready-to-serve liquid. Powder and ready-to-serve liquid are the most suitable forms when formula is used to supplement breast milk. Powder and concentrated liquid formulas are less expensive per feeding than ready-to-serve formulas.

The majority of infant formulas contain lactose (milk sugar) as the only carbohydrate, just as breast milk does. Lactose aids digestion and promotes normal bowel function and healthy tissue formation. A mixture of easily digested fats is also contained in the formulas.
These help protect your baby's skin and aid the absorption and utilization of certain vitamins. All known vitamins necessary for the development and growth of your baby are provided by infant formulas, including vitamin A for building body cells and good vision;
the B vitamins for maintaining the nervous system, skin, and tissues; vitamin C for healthy gums and teeth; vitamin D for strong bones and teeth; and vitamin E for proper functioning of red blood cells.

Vital minerals such as calcium and phosphorus for developing bones and teeth, as well as iron for healthy blood and resistance to infection, are also among the nutrients supplied in formulas. The American Academy of Pediatrics recommends that all infants be given a commercial formula that is iron-fortified. These formulas do not contain enough iron to cause diarrhea, constipation, abdominal cramps, or any other symptoms. With iron-fortified formulas, no supplementary vitamins or minerals are needed.

PREPARING COMMERCIAL FORMULAS

Mix concentrated liquid formula with water in a ratio of one to one. Mix each level scoop of powdered formula with 2 ounces of water. Never make the formula for your baby more concentrated by adding extra concentrated liquid or extra powder. Never dilute the formula by adding more water than specified. Careful measuring and mixing ensure that your baby receives the proper concentration of formula.

Most city water supplies are quite safe. If you make one bottle at a time, you don't need to use boiled water. When using tap water for preparing formula, use only water from the cold water tap. Let the water run for 2 minutes before you use it. (Old water pipes may contain lead-based solder and lead dissolves more in warm water or standing water.) Fresh, cold water is safe. After you prepare the formula with the cold water, you can heat the bottle to the preferred temperature. Ask you health care provider if you are not sure whether your water supply is safe for your baby.

If you have well water, you need to boil your water for 10 minutes (plus 1 minute for each 1000 feet of elevation above sea level) or use distilled water until your child is 6 months old.
If you prefer to prepare a batch of formula, you must use boiled or distilled water and closely follow the directions printed on the side of the formula can. This prepared formula should be stored in the refrigerator and must be used within 48 hours.

HOMEMADE FORMULAS FROM EVAPORATED MILK

If necessary, you can make your own formula temporarily from evaporated milk. (Evaporated milk formulas have some of the same risks as whole cow's milk, namely, iron deficiency anemia and allergies.) Mix 13 ounces of evaporated milk with 19 ounces of boiled water and 2 tablespoons of corn syrup. Place this mixture in sterilized bottles and keep the bottles refrigerated until use (up to 48 hours).

WHOLE COW'S MILK

Breast milk is the first choice for feeding during the first year of life. A commercially prepared infant formula is the second choice. Whole cow's milk should not be given to babies before 12 months of age because of increased risks of iron deficiency anemia and allergies. Skim or low-fat milk should not be given to babies before they are 2 years old because the fat in whole milk is needed for rapid brain growth.

TRAVELING

When you are traveling, powdered or ready-to-serve formulas are the most convenient. To prepare the formula, simply add the appropriate number of scoops of powder to bottled, previously boiled water, or pour ready-to-serve formula into a sterilized bottle.

FORMULA TEMPERATURE

In the summertime, many children prefer cold formula. In the wintertime, most prefer warm formula. By trying formula at various temperatures you can probably find out what your child prefers. If you do warm the formula, check the temperature of the formula before you give it to your baby. If it is too hot it will burn your baby's mouth. Be especially careful if you heat the formula in a microwave because the formula can get too hot very quickly.

Newborns usually start with 1 ounce per feeding, but by 7 days they can take 3 ounces. The amount of formula that most babies take per feeding (in ounces) can be calculated by dividing your baby's weight (in pounds) in half. For example, if your baby weighs 8 pounds, your baby will probably drink 4 ounces of formula per feeding. No baby should drink more than 32 ounces of formula a day. If your baby needs more than 32 ounces and is not overweight, consider starting solid foods. Overfeeding can cause vomiting, diarrhea, or excessive weight gain. In general, your baby will probably need six to eight feedings per day for the first 3 weeks, five to six feedings per day from 1 to 3 months, four to five feedings per day from 3 to 7 months, and three to four feedings per day from 7 to 9 months. If your baby is not hungry at some feedings, increase the time between feedings.

LENGTH OF FEEDING

Gently remove the bottle from time to time to let your baby rest. A feeding shouldn't take more than 20 minutes. If it does, you are overfeeding your baby or the nipple is clogged. A clean nipple should drip about 1 drop per second when the bottle of formula is inverted.

FORMULA STORAGE

Prepared formula should be stored in the refrigerator and must be used within 48 hours. Prepared formula left at room temperature for more than 1 hour should be thrown away. At the end of each feeding, throw away any formula left in the bottle.

EXTRA WATER

Babies do not routinely need extra water. However, when they have a fever or the weather is hot they should be offered a bottle of water twice a day. Run the water from the tap for 2 minutes before you use it for drinking. Keep some of this water in your refrigerator.

BURPING

Burping is optional. It doesn't decrease crying. Its only benefit is to decrease spitting up. Air in the stomach does not cause pain. If you burp your baby, be sure to wait until your baby reaches a natural pause in the feeding process. Burping two times during feeding and for about a minute is plenty.

VITAMINS / FLUORIDE

From 6 months to 16 years of age, children need fluoride to prevent dental caries. If the water supply where you live contains fluoride and your child drinks at least 1 pint each day, this should be adequate. Otherwise, fluoride drops or tablets should be given separately. This is a prescription item that can be obtained from your child's physician.

Sleeping with a bottle of milk, juice, or any sweetened liquid in the mouth can cause severe decay of your baby's first teeth. Prevent this tragedy of tooth decay by not using the bottle as a daytime or nighttime pacifier.

In jaundice the skin and the whites of the eyes (the sclera) are yellow because on increased amounts of a yellow pigment in the body called bilirubin. Bilirubin is produced by the normal breakdown of red blood cells. It accumulates if the liver doesn't excrete it into the intestines at a normal rate.

Physiological ( Normal ) Jaundice
Physiological jaundice occurs in more than 50% of babies. An immaturity of the liver leads to a slower processing of bilirubin. The jaundice first appears at 2 to 3 days of age. It usually disappears by 1 to 2 weeks of age, and the levels reached are harmless.

Breastfeeding Jaundice
Breastfeeding jaundice occurs in 5% to 10% of newborns. It's caused by insufficient intake of breast milk (calories and fluid). It follows the same pattern as physiological jaundice.

Breast-Milk Jaundice
Breast-milk jaundice occurs in 1% to 2% of breast-fed babies. It is caused by a special substance (inhibitor) that some mothers produce in their milk. This substance (an enzyme) increases the re sorption of bilirubin from the intestine. This type of jaundice starts at 4 to 7 days of age and may last 3 to 10 weeks.

If a baby and mother have different blood types, sometimes the mother produces antibodies that destroy the newborn's red blood cells. This causes a sudden buildup in bilirubin in the baby's blood. This type of jaundice usually begins during the first 24 hours of life. Rh problems are now preventable with an injection of RhoGAM to the mother within 72 hours after delivery. This prevents her from forming antibodies that might endanger subsequent babies.

High levels of bilirubin (usually above 20 mg/dl) can cause deafness, cerebral palsy, or brain damage in some babies. High levels usually occur with blood-type problems. These complications can be prevented by lowering the bilirubin by means of photo therapy (blue light that breaks down bilirubin in the skin). In many communities, photo therapy can be used in the home. In rare cases in which the bilirubin reaches dangerous levels, an exchange transfusion may be used.

TREATMENT OF BREAST-FEEDING JAUNDICE

Try to increase breast milk production. Read about breast-feeding or talk with a lactation specialist. Increase the frequency of feedings. Nurse your baby every 1 ½ to 2 ½ hours during the day. Don't let your baby sleep more than 4 hours at night without a feeding. If you must supplement, supplement with formula, not glucose water.

TREATMENT OF BREAST-MILK JAUNDICE

The bilirubin level can rise above 20 mg/dl in less than 1% of infants with breast-milk jaundice. Almost always, elevations to this level can be prevented by more frequent feedings. Nurse your baby every 1 ½ to 2 ½ hours. Since bilirubin is carried out of the body in the stools, passing frequent bowel movements is helpful. If your baby sleeps more than 4 hours at night, awaken him for a feeding.
Occasionally the bilirubin will not come down with frequent feedings. In this situation the bilirubin level can be reduced by alternating each breast-feeding with formula feeding for 2 or 3 days. Supplementing with glucose water is not as helpful as formula for moving the bilirubin out of the body. Whenever you miss a nursing, be sure to use a breast pump to keep your milk production flowing. Breast-feeding should never be permanently discontinued because of breast-milk jaundice. Once the jaundice clears, you can return to full breastfeeding and you need not worry about the jaundice coming back.

IMMEDIATELY if :

• Your baby doesn't pass urine in more than 8 hours.
• Your baby develops a fever over 100.4°F (38°C) measured rectally.
• Your baby starts to look or act sick.

During regular hours if:

• Your baby looks deep yellow or orange.
• Your baby has less than 3 BM's per day.
• Jaundice is not gone by day 14.
• You have other concerns or questions.

Newborns often leave the hospital within 24 to 48 hours of birth. Parents therefore have the responsibility to closely observe the degree of jaundice in their newborn. The amount of yellowness is best judged by viewing your baby unclothed in natural light.

This discussion of these newborn characteristics is arranged by parts of the body. A few minor congenital defects that are harmless but permanent are also included. Call your physician if you have questions about your baby's appearance that this list does not address.

Molding
Molding refers to the long, narrow, cone-shaped head that results from passage through a tight birth canal. This compression of the head can temporarily hide the fontanel. The head returns to a normal shape in a few days.

Caput
This refers to swelling on top of the head or throughout the scalp due to fluid squeezed into the scalp during the birth process. Caput is present at birth and clears in a few days.

Cephalohematoma
This is a collection of blood on the outer surface of the skull. It is due to friction between the infant's skull and the mother's pelvic bones during the birth process. The lump is usually confined to one side of the head. It first appears on the second day of life and may grow larger for up to 5 days. It doesn't resolve completely until the baby is 2 or 3 months of age.

Anterior fontanel
The "soft spot" is found in the top front part of the skull. It is diamond-shaped and covered by a thick fibrous layer. Touching this area is quite safe. The purpose of the soft spot is to allow rapid growth of the brain. The spot will normally pulsate with each beat of the heart. It normally closes with bone when the baby is between 12 and 18 months of age.

Swollen eyelids
The eyes may be puffy because of pressure on the face during delivery. They may also be puffy and reddened if silver nitrate eye drops are used. This irritation should clear in 3 days.

Subconjunctival hemorrhage
A flame-shaped hemorrhage on the white of the eye (sclera) is not uncommon. It's harmless and due to birth trauma. The blood is reabsorbed in 2 to 3 weeks.

Iris color
The iris is usually blue, green, gray, or brown, or variations of these colors. The permanent color of the iris is often uncertain until your baby reaches 6 months of age. White babies are usually born with blue-gray eyes. Black babies are usually born with brown-gray eyes. Children who will have dark irises often change eye color by 2 months of age; children who will have light-colored irises usually change by 5 or 6 months of age.

Tear duct, blocked
If your baby's eye is continuously watery, he or she may have a blocked tear duct. This means that the channel that normally carries tears from the eye to the nose is blocked. It is a common condition, and more than 90% of blocked tear ducts open up by the time the child is 12 months old.

Folded over
The ears of newborns are commonly soft and floppy. Sometimes one of the edges is folded over. The outer ear will assume normal shape as the cartilage hardens over the first few weeks.

The nose can become misshapen during the birth process. It may be flattened or pushed to one side. It will look normal by 1 week of age.

Sucking callus (or blister)
A sucking callus occurs in the center of the upper lip from constant friction at this point during bottle- or breast-feeding. It will disappear when your child begins cup feedings. A sucking callus on the thumb or wrist may also develop.

Tongue-tie
The normal tongue in newborns has a short tight band that connects it to the floor of the mouth. This band normally stretches with time, movement, and growth. Babies with symptoms from tongue-tie are rare.

Epithelial pearls
Little cysts (containing clear fluid) or shallow white ulcers can occur along the gum line or on the hard palate. These are a result of blockage of normal mucous glands. They disappear after 1 to 2 months.

Teeth
The presence of a tooth at birth is rare. Approximately 10% are extra teeth without a root structure. The other 90% are prematurely erupted normal teeth. The distinction can be made with an x-ray. The extra teeth must be removed by a dentist. The normal teeth need to be removed only if they become loose (with a danger of choking) or if they cause sores on your baby's tongue.

Swollen breasts are present during the first week of life in many female and male babies. They are caused by the passage of female hormones across the mother's placenta. Breasts are generally swollen for 2 to 4 weeks, but they may stay swollen longer in breast-fed and female babies. One breast may lose its swelling before the other one by a month or more. Never squeeze the breast because this can cause infection. Be sure to call your physician if a swollen breast develops any redness, streaking, or tenderness.

Swollen labia
The labia minora can be quite swollen in newborn girls because of the passage of female hormones across the placenta. The swelling will resolve in 2 to 4 weeks.

Hymenal tags
The hymen can also be swollen due to maternal estrogen and have smooth 1/2-inch projections of pink tissue. These normal tags occur in 10% of newborn girls and slowly shrink over 2 to 4 weeks.

Vaginal discharge
As the maternal hormones decline in the baby's blood, a clear or white discharge can flow from the vagina during the latter part of the first week of life. Occasionally the discharge will become pink or blood-tinged (false menstruation). This normal discharge should not last more than 2 to 3 days.

Hydrocele
The newborn scrotum can be filled with clear fluid. The fluid is squeezed into the scrotum during the birth process. This painless collection of clear fluid is called a "hydrocele." It is common in newborn males. A hydrocele may take 6 to 12 months to clear completely. It is harmless but can be rechecked during regular visits. If the swelling frequently changes size, a hernia may also be present and you should call your physician during office hours for an appointment.

Undescended testicle
The testicle is not in the scrotum in about 4% of full-term newborn boys. Many of these testicles gradually descend into the normal position during the following months. In 1-year-old boys only 0.7% of all testicles are undescended; these need to be brought down surgically.

Tight foreskin
Most uncircumcised infant boys have a tight foreskin that doesn't allow you to see the head of the penis. This is normal and the foreskin should not be retracted.

Erections
Erections occur commonly in a newborn boy, as they do at all ages. They are usually triggered by a full bladder. Erections demonstrate that the nerves to the penis are normal.

Tight hips
Your child's physician will test how far your child's legs can be spread apart to be certain the hips are not too tight. Upper legs bent outward until they are horizontal is called "90 degrees of spread." (Less than 50% of normal newborn hips permit this much spreading.) As long as the upper legs can be bent outward to 60 degrees and are the same on each side, they are fine. The most common cause of a tight hip is a dislocation.

Tibial torsion
The lower legs (tibia) normally curve in because of the cross-legged posture your baby was confined to while in the womb. If you stand your baby up, you will also notice that the legs are bowed. Both of these curves are normal and will straighten out after your child has been walking for 6 to 12 months.

Feet turned up, in, or out
Feet may be turned in any direction inside the cramped quarters of the womb. As long as your child's feet are flexible and can be easily moved to a normal position, they are normal. The direction of the feet will become more normal between 6 and 12 months of age.

"Ingrown" toenails
Many newborns have soft nails that easily bend and curve. However, they are not truly ingrown because they don't curve into the flesh.

Scalp hair
Most hair at birth is dark. This hair is temporary and begins to shed by 1 month of age. Some babies lose it gradually while the permanent hair is coming in; others lose it rapidly and temporarily become bald. The permanent hair will appear by 6 months. It may be an entirely different color from the newborn hair.

Body hair (lanugo)
Lanugo is the fine downy hair that is sometimes present on the back and shoulders. It is more common in premature infants. It is rubbed off with normal friction by 2 to 4 weeks of age.

• chin trembling
• lower lip quivering
• hiccups
• irregular breathing (This is normal if your baby is content, the rate is less than 60 breaths per minute, any pauses are less than 10 seconds long, and your baby doesn't turn blue. Occasionally infants take rapid, progressively deeper, stepwise breaths to completely expand their lungs.)
• passing gas (not a temporary behavior)
• sleep noise from breathing and moving
• sneezing
• spitting up or belching
• brief stiffening of the body after a noise or sudden movement (also called the startle reflex, the Moro reflex, or the embrace reflex)
• straining with bowel movements
• throat clearing (or gurgling sounds of secretions in the throat)
• trembling or jitteriness of arms and legs are common during crying (Jittery babies are common. Convulsions are rare. During convulsions babies also jerk, blink their eyes, rhythmically suck with their mouths, and don't cry.) If your baby is trembling and not crying, give her something to suck on. If the trembling doesn't stop when your baby is sucking, call your physician's office immediately.
• yawning.

More than 30% of newborns develop acne of the face: mainly small, red bumps. This neonatal acne begins at 3 to 4 weeks of age and lasts until 4 to 6 months of age. The cause appears to be the transfer of maternal androgens (hormones) just prior to birth. Since it is temporary, no treatment is necessary. Baby oil or ointments will just make it worse.

Drooling rash

Most babies have a rash on the chin or cheeks that comes and goes. Often, this rash is caused by contact with food and acid that have been spit up from the stomach. Rinse your baby's face with water after all feedings or spitting up.
Other temporary rashes on the face are heat rashes in areas held against the mother's skin during nursing (especially in the summertime). Change your baby's position more frequently and put a cool washcloth on the area that has a rash.
No baby has perfect skin. The babies in advertisements wear makeup.

Erythema toxicum

More than 50% of babies get a rash called erythema toxicum on the second or third day of life. The rash is composed of 1/2- to 1-inch-size red blotches with a small white lump in the center. They look like insect bites. They can be numerous, keep occurring, and be anywhere on the body surface (except palms and soles). The cause of this rash is unknown and it is harmless. The rash usually disappears by the time an infant is 2 weeks old, but sometimes not until a child is 4 weeks old.

Forceps or birth canal injury

If your baby's delivery was difficult, a forceps may have been used to help him through the birth canal. The pressure of the forceps on the skin can leave bruises or scrapes or can even damage fat tissue anywhere on the head or face.
Pressure from the birth canal can damage the skin overlying bony prominences (such as the sides of the skull) even without a forceps delivery. Fetal monitors can also cause scrapes and scabs on the scalp. You will notice the bruises and scrapes 1 or 2 days after birth. They will disappear in 1 to 2 weeks. Injury to fat tissue won't be apparent until the fifth or sixth day after birth. A thickened lump of skin with an overlying scab is what you usually see. This may take 3 or 4 weeks to heal. For any breaks in the skin, apply an antibiotic ointment (OTC) until healed. If it becomes tender to the touch or soft in the center or shows other signs of infection, call your physician.

Milia

Milia are tiny white bumps that occur on the faces of 40% of newborn babies. The nose and cheeks are most often involved, but milia are also seen on the forehead and chin. Although they look like pimples, they are smaller and not infected. They are blocked-off skin pores and will open up and disappear by 1 to 2 months of age. Do not apply ointments or creams to them.
Any true blisters (little bumps containing clear fluid) or pimples (little bumps containing pus) that occur during the first month of life (especially on the scalp) must be examined and diagnosed quickly. If they are caused by the herpesvirus, they must be treated right away.
If you suspect blisters or pimples, call your child's physician immediately.

Mongolian spots

A Mongolian spot is a bluish-gray, flat birthmark that is found in more than 90% of American Indian, Asian, Hispanic, and black babies. They occur most commonly over the back and buttocks, although they can be present on any part of the body. They vary greatly in size and shape. Most fade away by 2 or 3 years of age, although a trace may persist into adult life.

Stork bites (pink birthmarks)

Flat pink birthmarks (also called capillary hemangiomas) occur over the bridge of the nose, the eyelids, or the back of the neck in more than 50% of newborns. Most of these spots fade and disappear, but some can persist into adult life. Those on the forehead that run from the bridge of the nose up to the hairline usually persist into adult life. Laser treatment during infancy should be considered.

CHANGING DIAPERS

After you remove a wet diaper, just rinse your baby's bottom off with a wet washcloth. After soiled diapers, rinse the bottom under running warm water or in a basin of warm water. After you clean the rear, cleanse the genital area by wiping front to back with a wet cloth. If you have a boy, carefully clean the scrotum. If you have a girl, carefully clean the creases of the vaginal lips (labia).

SHAMPOO

Wash your baby's hair once or twice a week with a special baby shampoo that doesn't sting the eyes. Don't be concerned about hurting the anterior fontanelle (soft spot on the head). It is well protected.

LOTIONS, CREAMS, AND OINTMENTS

Newborn skin normally does not require any ointments or creams. Especially avoid putting any oil, ointment, or greasy substance on your baby's skin because this will almost always block the small sweat glands and lead to pimples or a heat rash. If the skin starts to become dry and cracked, use a baby lotion, hand lotion, or moisturizing cream twice a day.
Cornstarch powder can be helpful for preventing rashes in areas of friction. Avoid talcum powder because it can cause a serious chemical pneumonia if inhaled into the lungs.

UMBILICAL CORD

Try to keep the cord dry. Put rubbing alcohol on the base of the cord (where it attaches to the skin) twice a day (including after the bath) until 1 week after it falls off. Air exposure helps the cord stay dry and eventually fall off, so keep diapers folded down below the cord area. If you are using disposable diapers, you can cut out a wedge of diaper with a scissors so the cord is not covered.

FINGERNAILS AND TOENAILS

Cut the toenails straight across to prevent ingrown toenails. When you cut fingernails, round off the corners of the nails so your baby doesn't scratch himself or others. Trim the nails once a week after a bath, when the nails are softened by the bath. Use clippers or special baby scissors. This job usually takes two people unless you do it while your child is asleep.

• The child complains about or refuses specific foods, especially vegetables and meats.
• The child pushes foods around the plate.
• The child hides foods or gives them to a pet under the table.
• The child eats enough total foods and calories per day.

Children of all ages (and adults) commonly have a few food dislikes. Sometimes children dislike foods because of their color, but more often it's because they are difficult to chew. Children accept tender meats better than tough ones, and well-cooked vegetables better than raw. Some children are repulsed by foods with a bitter taste. Occasionally a child who gags on large pieces of all foods has large tonsils that make it difficult to swallow.

Most children who are picky eaters will try new foods in the school years because of peer pressure. The voracious appetite during the adolescent years also increases the willingness to experiment. If you try to force your child to eat a food he doesn't like, he may gag or even vomit. Force feedings always interfere with the normal pleasure of eating and eventually decrease the appetite.

• Try to prepare a main dish that everyone likes
  Try to avoid any unusual main dish that your child strongly dislikes. Some children don't like foods that are mixed together, such as casseroles. Try reintroducing such dishes when your child is older.
• Allow occasional substitutes for the main dish
  If your child refuses to eat the main dish and this is an unusual request, you may allow a substitute dish. An acceptable substitute would be breakfast cereal or a simple sandwich the child prepares for himself. Never become a short-order cook and prepare any extra foods for mealtime. The child should know that you expect him to learn to eat the main dish that has been prepared for the family.
• Respect any strong food dislikes
  If your child has a few strong food dislikes (especially any food that makes her gag), do not serve that food to her when it's prepared as part of the family meal. Never pressure your child to eat all foods. It will only lead to a power struggle, gagging, or even vomiting.
• Don't worry about vegetables, just encourage more fruits
  Because vegetables tend to be hard to chew and some of them are bitter, they are commonly rejected by children and even by many adults. Keep in mind that fruits and vegetables are from the same food group. There are no essential vegetables. Vegetables can be entirely replaced by fruits without any nutritional harm to your child. This is not a health issue. Don't make your child feel guilty about avoiding some vegetables.
• Don't allow complaining about food at mealtimes
  Have a rule that it's okay to decline a serving of a particular food or to push it to the side of the plate. But complaining about it is unacceptable.
• Ask your child to taste new foods
  Many tastes are acquired. Your child may eventually learn that she likes a food she initially refuses. For some picky eaters, it may take seeing other people eat a certain food 10 times before they're even willing to taste it, and another 10 times of tasting it before they develop a liking for it. Don't try to rush this normal process of adapting to new foods. Trying to force a child to eat one bite of a food per year of age is not helpful with most picky eaters. Instead, it's better to trust them when they say that they have tasted the food in question.
• Don't argue about dessert
  An unnecessary area of friction for picky eaters is a rule that if you don't clean your plate, you can't have any dessert. Since desserts are not necessarily harmful, a better approach is to allow your child one serving of desert regardless of what she eats. However, there are no seconds on dessert for children who don't eat an adequate amount of the main course. Desserts don't have to be sweets, they can be nutritious desserts such as fruit.
• Don't extend mealtime
  Don't keep your child sitting at the dinner table after the rest of the family is done. This will only cause your child to develop unpleasant associations with mealtime.
• Keep mealtimes pleasant
  Make it an important family event. Draw your children into friendly conversation. Tell them what's happened to you today and ask about their day. Talk about fun subjects unrelated to food. Avoid making it a time for criticism or struggle over control.
• Avoid conversation about eating at any time
  Don't discuss what your child eats in your child's presence. Trust your child's appetite to look after your child's caloric needs. Also don't give praise for appropriate eating. Don't give bribes or rewards for meeting your eating expectations. Children should eat to satisfy their appetite, not to please the parent. Occasionally you might praise your child for trying a new food that he does not like the taste or texture of.
• Consider giving your child a daily vitamin-mineral supplement
  Although vitamins are probably unnecessary for most of us, they are not harmful in normal amounts and may allow you to relax more about your child's eating patterns.

During office hours if:

• Your child is losing weight.
• Your child gags on or vomits certain foods.
• You have other questions or concerns.

Reflux or regurgitation is the spitting up of one or two mouthfuls of stomach contents. Formula or breast milk just rolls out of the mouth, often with one burp. It usually happens during or shortly after feedings. It begins in the first weeks of life. More than half of all infants have it to some degree.

Poor closure of the valve (ring of muscle) at the upper end of the stomach is responsible. This condition is also called gastroesophageal reflux (GE reflux) or chalasia. Spitting up is harmless as long as your infant doesn't spit up large amounts that interfere with normal weight gain.

Spitting up improves with age. By 7 months of age, most reflux has decreased or is gone. The reasons for this are probably because the baby is old enough to sit up or is eating solid foods. By the time your baby has been walking for 3 months, even severe reflux should be totally cleared up.

Feed smaller amounts

Overfeeding always makes spitting up worse. If the stomach is filled to capacity, spitting up is more likely. Give your baby smaller amounts (at least 1 ounce less than you have been giving). Your baby doesn't have to finish a bottle. Wait at least 2 and 1/2 hours between feedings because it takes that long for the stomach to empty itself.

Avoid pressure on your child's abdomen

Avoid tight diapers. They put added pressure on the stomach. Don't put pressure on the stomach or play vigorously with him right after meals.

Burp your child to reduce spitting up.

Burp your baby two or three times during each feeding. Do it when he pauses and looks around. Don't interrupt his feeding rhythm in order to burp him. Keep in mind that burping is less important than giving smaller feedings and avoiding tight diapers.

Keep your child in a vertical position after meals.

After meals, try to keep your baby in an upright position using a front pack, backpack, or swing for 30 minutes. When your infant is in an infant seat, keep him from getting scrunched up by putting a pad under his buttocks so he's more stretched out. After your child is over 6 months old, a jumpy seat or infant play station can be helpful for maintaining an upright posture after meals.

IMMEDIATELY if:

• You see blood in the spit-up material.
• The spitting up causes your child to choke or cough.

During office hours if:

• Your baby doesn't seem to improve with this approach. ( We can discuss how to thicken feedings with cereal. )
• Your baby does not gain weight normally.
• You have other concerns or questions.

• Continuously watery eye
• Tears running down the face even without crying
• During crying, nostril on blocked side remains dry
• Onset at birth to 1 month of age
• Eye not red and eyelid not swollen
(unless the soggy tissues become infected)

Your child probably has a blocked tear duct on that side. This means that the channel
that normally carries tears from the eye to the nose is blocked. Although the obstruction
is present at birth, the delay in onset of symptoms can be explained by the occasional
delay in tear production until the age of 3 or 4 weeks in some babies. Both sides are blocked 30% of the time.

This is a common condition, affecting 6% of newborns. Over 90% of blocked tear ducts open up spontaneously by the time the child is 12 months of age. If the obstruction persists beyond 12 months of age, an ophthalmologist (eye specialist) can open it with a probe.

Because of poor drainage, eyes with blocked tear ducts become easily infected. The infeted eye produces a yellow discharge. To keep the eye free of infection, massage the lacrimal sac (where tears collect) twice daily. Always wash your hands carefully before doing this. The lacrimal sac is located in the inner lower corner of the eye. This sac should be massaged to empty it of old fluids and to check for infection. Start at the inner corner of the eye and press upward using a cotton swab. (CAUTION: Massaging downward is not helpful and may lead to infection.) If the eye becomes infected, it is very important to begin antibiotic eye drops.

IMMEDIATELY if :

• The eyelids are red or swollen.
• A red lump appears at the inner lower corner of the eyelid.

During office hours if :

• The eyelids are stuck together with pus after naps -Much yellow discharge is present.
• Your child reaches 12 months of age and the eye is still watering.
• You have other concerns or questions.

Your baby's teeth will usually erupt in the following order:
1. Two lower incisors
2. Four upper incisors
3. Two lower incisors and all four first molars
4. Four canines
5. Four second molars

Gum Massage
Find the irritated or swollen gum. Vigorously massage it with your finger for 2 minutes. Do this as often as necessary. If you wish, you may use a piece of ice to massage the gum.

Teething Rings
Your baby's way of massaging her gums is to chew on a smooth, hard object. Solid teething rings and ones with liquid in the center (as long as it's purified water) are fine. Most children like them cold. Offer a teething ring or wet washcloth that has been chilled in the refrigerator but not frozen in the freezer. A piece of chilled banana may help. Avoid ice or Popsicles that could cause frostbite of the gums. Avoid hard foods that your baby might choke on (such as raw carrots), but teething biscuits are fine.

Diet
Avoid salty or acid foods. Your baby probably will enjoy sucking on a nipple, but
if he complains, use a cup for fluids temporarily. A few babies may need acetaminophen for
pain relief for a few days.

Acetaminophen
If the pain increases, give acetaminophen orally for 1 day. Special
teething gels are unnecessary. Many teething gels contain benzocaine, which can cause an
allergic reaction. If you want to use a gel, do not apply it more than four times a day.

• Teething does not cause fever, sleep problems, diarrhea, diaper rash, or lowered
resistance to any infection. It probably doesn't cause crying. If your baby develops fever
while teething, the fever is due to something else.
• Don't tie the teething ring around the neck. It could catch on something and strangle your
child. Attach it to clothing with a "catch-it" clip.

During regular hours if
• Your child develops a fever over 101°F (38.3°C)
• Your child develops crying that does not have a cause
• You have other questions or concerns

• White, irregularly shaped patches that coat the inside of the mouth and sometimes the tongue, adheres to the mouth, and cannot be washed away or wiped off easily like milk. (If the only symptom is a uniformly white tongue, it’s due to a milk diet, not thrush.) Thrush causes mild discomfort.
  
• Bottle-fed or breast-fed child.

Decrease Sucking Time to 20 Minutes per Feeding. Prolonged sucking (as when a baby sleeps with a bottle or pacifier) can abrade the lining of the mouth and make it more prone to yeast infection. If sucking on a nipple is painful for your child, temporarily use a cup. If the thrush recurs and your child is bottle-fed, switch to a nipple with a different shape and made from silicone.

Restrict Pacifier Use to Bedtime. Eliminate the pacifier temporarily except when it’s really needed for going to sleep. If your infant is using an orthodontic type pacifier, switch to a smaller, regular one. Soak all nipples in water at 130°F ( 55°C ) the temperature of most hot tap water, for 15.

Diaper Rash Associated with Thrush. If your child has an associated diaper rash, assume it is due to yeast. Request nystatin cream and apply it four times daily.

During regular hours if :

• Your child refuses to drink.
• The thrush gets worse on treatment.
• The thrush lasts beyond 10 days.