Having a new baby is one of life's great experiences. But happy as the experience is, it also involves a lot of work and responsibility. We have written this booklet in the belief that it will help make the care of your baby easier and give you greater enjoyment.

You will find many helpful friends and relatives to give you advice in caring for your baby. However, parents who listen to one source in which they have confidence generally are happier, more comfortable, and have less confusion in caring for their infant.

If problems or questions arise that cannot be solved with the help of this booklet, or with future printed material that you will receive, call the office between 9:00 AM and 4:00 PM. Please limit routine questions to these times. If you have "caller ID", please disable anonymous call rejection (by dialing *87) when you request that a call be returned (whether during or after office hours). We have dedicated outgoing lines which cannot be unblocked, and we would like to avoid tying up our incoming lines. If your phone cannot be accessed from an anonymous line, your call cannot be returned. Questions concerning well child care and minor illness are best handled during routine office hours when your child can be readily seen if necessary, and your child's records are available. Please use after hours only for emergencies or urgent matters that cannot wait until regular office hours.

Most calls to the office will involve your concerns with your child's health: his/her eating, sleeping, crying, or symptoms of illness such as fever, cough, irritability, or rashes. When calling about your child, please try to be prepared to answer the following questions:

* What is your primary concern?

* When did he/she start to get ill?

* What were the first symptoms?

* What symptoms have developed since the illness began?

* What has been done for him/her?

* What medicines is he/she taking?

* Telephone number of Pharmacy if needed

Please have a pencil and paper available with which to write out instructions. When you call, if you know that you want your child examined, please tell the receptionist immediately. This will allow us to make the necessary arrangements to see your child promptly.

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PRENATAL CARE

Childbirth is more than just a physical process of getting the infant into the world. It a very stressful and emotional time with very important implications for the infant's future growth and development. Childbirth can, and unfortunately often does, happen without much planning or preparation. However, with mental, physical, and emotional preparation, childbirth will become a very meaningful event in the life of a family.

Planning for a healthy environment for your new child began either before you became pregnant, or shortly after you learned you were going to have a baby. Careful attention to diet, prenatal care, and avoidance of alcohol and tobacco provided your child with a healthy "internal" environment throughout your pregnancy. Now you must consider the "external environment" including the potential for exposure to cigarette smoke. Environmental tobacco smoke is a major cause of morbidity and mortality in children. According to a study published in Archives of Pediatric Adolescent Medicine (July, 1997), "estimated annual excess cases of childhood illness and death attributable to parental smoking include:

* low birth weight (46,000 cases and 2,800 perinatal deaths)

* respiratory syncytial virus [RSV] bronchiolitis (22,000 hospitalizations and 1,100 deaths)

* acute otitis media [middle ear infection] (3,400,000 physician visits)

* otitis media with effusion [fluid in the middle ear that can result in temporary hearing loss] (110,000 tympanostomies [insertion of "PE tubes"])

* asthma (1,800,000 physician visits and 14 deaths)

* fire related injuries (10,000 physician visits, 590 hospitalizations, and 250 deaths)."

In short, the ill effects of tobacco are not limited to pregnancy, but continue throughout life.

Preparation consists of planning for the new baby. This means getting the crib, buying diapers, bedding, blankets, and clothing. It means discussing roles and responsibilities of mother and father, any sisters or brothers, grandparents and other helpers. For mother it means proper exercises and nutrition under the care of her obstetrician, and if possible, attendance at child birth classes for both parents.

In spite of careful preparation, the excitement of the birth, the sharing of the experience with husband and family, and even the presence of a very special baby, most mothers experience a natural period of "letdown" during the first month. Sometimes this occurs during the first few days after going home from the hospital. It is accentuated by "all of the things that need to be done" now that you have a new baby in the home. This "baby blues" or postpartum depression is both natural and frequent. Many mothers will have a tendency to cry, feel inadequate, and have doubts about their personal attractiveness. They feel inefficient, always behind schedule, and never able to catch up. This sounds terrible, but remember, these feelings last only a few days to a few weeks. The return of hormones to normal levels will help. However, organization of your daily routine, plenty of rest, and support from husband and family will lessen these feelings and shorten this trying period.

Frequently, it is beneficial to have someone to help for a week or two. This may be a relative or close friend, but no matter who comes to help, remember that this is your baby and you will be the one responsible for the care, rearing and training. Do not let the "helper" assume the care of the baby. Let him/her do the housework, take care of the other children, prepare the meals, and take care of you. You take care of your baby.

You will get advice from everyone you know concerning how best to care for your child. Listen to the advice, read and think about the topics discussed in this booklet and in other books, and watch how others care for their babies. Then you take care of your baby with love, concern, careful thought, and common sense. You can't help but be a success.

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YOUR "NEW" NEWBORN

There is a world of difference between a newly-born and a six hour old infant. Immediately following delivery, your baby will appear somewhat wrinkled and extremely wet. Newborns have been bathed in the amniotic fluid since the earliest stages of their development. This is the fluid that is lost when the membranes rupture during labor.

The baby's skin is protected in this watery environment by "vernix." This is a white, cheesy material that you may notice in the skinfolds and over the scalp. It is nature's handcream, and protects the skin from "soaking up" too much water. In addition to its protecting the skin from absorbing too much water, it helps to prevent bacterial infection of the skin. Persistence of the vernix continues to prevent bacterial growth, so do not be too quick to wipe it off and "clean the baby up."

Shortly after the baby is delivered and the umbilical cord is clamped and cut, the baby will be taken to a warmer so that he/she can be dried and examined. Keeping warm is important to your baby's health, especially during the first few days.

There will be watery mucous coming from his/her nose and mouth. This will be suctioned by the obstetrician, the pediatrician, or the nurse. Part of this material comes from amniotic fluid in the mouth, and part of it comes from fluid that filled the lungs prior to birth and the first breath. It is normal and no cause for concern.

Shortly after birth most babies are bluish to dark red in color. This does not mean that he/she is a "blue baby." With time, and occasionally a little extra oxygen and stimulation, he/she will become a healthy pink. However, even after his/her color improves, you will continue to notice a persistent blue color to hands and feet. This is called acrocyanosis, and is normal. Do not be alarmed.

One of the most prominent features of a newborn is the shape of his/her head. Generally, instead of the round, smooth, well formed head you are accustomed to seeing in a two day old infant, the head will be "molded" into a elongated or pointed shape. This results from the pressures within the birth canal. It is natural and will disappear within days.

Most mothers and fathers want to know what the APGAR score is for their new child. A number of years ago, physicians saw the necessity to describe the responsiveness of the infant at birth. Dr. Virginia Apgar devised a scoring system that judged five aspects of the newborn's response. These five aspects of responsiveness were then scored, both at one minute and five minutes of age, as zero, one, or two. The desired score is two for each criteria, for a total of ten.

Shortly after Dr. Apgar devised this scoring system, other physicians, in honor of Dr. Apgar, rearranged the criteria and used the letters of Dr. Apgar's name to designate each of the five criteria. "A" represents appearance; "P" stands for pulse, or heart rate; "G" is grimace, or the infant's response to uncomfortable stimulation; the second "A" stands for activity, or the amount of spontaneous movement the child makes; and "R" represents respiratory effort. A score of 8 to 10 is considered "best," and physicians feel there is no significant difference between scores of 8, 9, or 10. A one minute score of 6 or 7 indicates mild depression usually requiring intervention and resuscitation. Any score below 5 indicates significant depression which frequently requires intensive neonatal care.

Just as there is no "normal" height or weight for adults, there is no "normal" height or weight for infants. However, seventy percent of term newborns will weigh between six pounds, ten ounces and eight pounds, six ounces with an average of seven pounds, eight ounces.

Almost all infants will lose four to ten ounces during the first days of life. It is acceptable to lose up to ten percent of birth weight. This is a normal loss and represents loss of stool, urine, and excess body water. His/her weight will be monitored while you and your baby are in the hospital, and, if you go home prior to 48 hours of age, will be checked in the office at three to five days of age.

The skin of the newborn infant displays a number of normal variations which often cause parental concern. We have already mentioned vernix which is a white creamy material that covers the skin and protects it from excessive water absorption while bathed in the amniotic fluid as well as providing some protection from bacteria. Some infants have a fine, downy hair covering the body, usually the shoulders, back and extremities. This is called lanugo. In dark skinned babies this can be quite prominent. Invariably, this fine hair is lost in the first few months and does not predict the amount of body hair the child will have in the future.

Very small, very fine white bumps are commonly found on the nose. These are called milia, and are the result of hormones passed to the baby prior to birth. They disappear during the first few months of life.

A common rash in the first few days of life is called erythema toxicum neonatorum. This is sometimes called a "newborn rash" or a "flea bite" rash. This rash consists of very small, 1/16th to 1/8th inch raised areas with a mild redness topped by a very small blister. It is a normal condition and no cause for concern. It will wax and wane, and eventually disappear without treatment within a few days.

Most children will have some slight peeling of hands and feet, and sometimes over the skinfold areas involving the knees, elbows, and groin. This is normal and does not require lotions or oils. Occasionally, the peeling will be severe and cracks will appear in the skin. There may even be some oozing and redness. If this should occur, bring it to our attention. Usually, an oil or lotion such as Keri Lotion applied to the skin two or three times per day is all that is required to resolve the problem.

A reddish, flame shaped mark is commonly seen over the forehead, especially between the eyes, over the eyelids, on the upper lip, and frequently over the nape of the neck. These marks are referred to as "flame nevi" and usually disappear without a trace in the first year. These marks have also been known as "stork bites".

Many infants will have a bluish discoloration of skin over the lower back, and occasionally mid back, called "mongolian spots". These are due to the presence of a specific pigment cell in the skin. They usually disappear by the fourth or fifth year of life.

These are most of the skin variations that you are likely to see in your baby. Of course, if you should have questions about any of these, or any other markings on the skin, be sure to tell us.

The shape of the baby's head has already been mentioned in terms of the molding that occurs during birth. As part of this molding, two other conditions occur that sometimes last longer than the first 24 hours. The first is referred to as "caput succedaneum." This results from a local collection of tissue fluid, called edema, caused by pressures exerted by the uterus during the birth process. These uterine contractions place a great deal of pressure on all parts of the baby except the top of the head (which is on its way out!). This results in the same processes that would occur if suction was applied to the top of the baby's head, and causes the local accumulation of tissue fluid where the pressure was lowest. This caput will disappear within the first few days. It is harmless and no cause for concern.

Another accumulation of fluid under the scalp is referred to as a cephalohematoma. This initially looks like a caput. However, instead of simple accumulation of fluid in the tissues of the scalp, a cephalohematoma results from bleeding over the surface of the skull bone. This results in no damage to the baby, to the baby's brain, or to the baby's skull. A cephalohematoma takes months to resolve. It too should cause no alarm, and it requires no treatment.

Grandmothers, and occasionally mothers, are concerned about tongue tie. This is a term that has been used to describe the very thin ridge of tissue that extends from the tip of the tongue to the floor of the mouth in some babies. There is considerable variation in the size and length of this ridge of tissue which is called a frenulum. Most physicians feel that there is no indication for "clipping" this tissue, though others feel differently. We believe, based on clinical studies, that this frenulum causes no problems and should be left alone.

Full term babies have a firm enlargement of the breasts. This is true for both girls and boys, and results from hormones that are passed from mother to infant prior to birth. No treatment is required. This enlargement will disappear during the first six months of life. Rarely, a milk-like material (formerly referred to as "witches milk") will be excreted from the breast. Nothing need be done for this either. It is extremely important that no attempt be made to express, or squeeze any of this milk from the breast. Leave the enlarged breasts strictly alone.

Most female infants have a vaginal discharge. Just as breast enlargement results from hormone stimulation, this vaginal discharge results from hormone stimulation prior to birth. In addition, some bleeding will be noted with the discharge in rare instances. This occurs because of the withdrawal of hormones following a child's birth, and is similar to the routine menstrual cycle of the mature woman. No treatment is required, and no special cleansing is necessary. Do not attempt to clean this area with soap and water.

As you can see, there are a number of normal, minor variations from child to child that should cause no concern or worry. Each variation makes your child a special individual. There is no one else like him/her. Do not be concerned if your child has one of these minor variations and you best friend's child does not. It does not make your child worse, or hers better.

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SLEEP PATTERNS

Mothers who have babies who sleep all the time during the first few days are concerned that their babies sleep too much. Other mothers whose babies are active, awake and crying during the same first days are worried they do not sleep enough. Most parents express concern that their baby's activity, sleep, and fussiness is different, not normal. This probably occurs for two reasons: most parents have little experience to draw upon in making a judgment about their child, and there is considerable variation in behavior, activity, and sleep during infancy. Just as the variations in physical appearance distinguish one individual infant from another, so too does the general behavior of one infant distinguish it from another.

During the first few days the baby will sleep much of the time, most up to 18 to 20 hours per day. When he/she is awake, he/she will demand as much of your attention as you can give. Until birth, he/she has been fed through the umbilical cord. After birth, he/she has to develop a feeding pattern, and that takes time. Do not be surprised or concerned that he/she does not have a regular schedule, or that he/she wants to eat immediately when he/she decides that it is time to eat. For him/her, hunger is a brand new sensation.

When awake, he/she will be looking around, moving arms, legs, mouth and head. It is during this period of alert activity that parents find the most enjoyment from their new baby. Pay attention to him/her, laugh and talk together, and hold him/her. He/she will respond to your voice, to your singing or to your humming. This early stimulation is extremely important.

When a new infant is not looking around or eating, he/she is sleeping. Contrary to the popular conception, an infant's sleep is not necessarily peaceful and undisturbed. Most will grunt, move about, draw up the legs, and move the head from side to side during sleep. This does not mean he/she is uncomfortable or having difficulty with sleep. It is normal baby behavior and should cause no concern.

Sudden loud noises and sudden movement will cause what is known as a "startle response", and it is usually followed by a prolonged cry that is easily stopped with a little soothing. Some infants startle more readily than others. Occasionally, the startle response is exaggerated and this can indicate an abnormality of blood sugar or calcium, or the effects of the withdrawal from drugs or medicines taken by mother before birth. If you feel that your baby's startle response is more exaggerated than other children with whom you have had experience, discuss it with us.

The first few days of your baby's life are extremely important. Such simple things as holding, touching, looking, talking, and loving during the first few days help determine his/her subsequent responses to you, and surprisingly, your responses and feelings toward him/her for years to come. Make room in your schedule of activities for quiet, undisturbed periods with him/her. These times of quiet play will pay large dividends in the future.

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HOSPITAL AND EARLY HOME CARE

During the few hours or days that you have in the hospital following the birth of your baby, many things will be occurring. You will be recovering from the work of labor and child birth, your infant will be adjusting to a brand new environment that requires him/her to do things he/she never did before such as breathing and eating. And at the same time you will be learning about your infant, he/she will be learning about you. Materials in the preceding section were designed to help you during this period of adjustment by providing a description of behavior and appearance found in most babies. This section will deal more with the immediate day to day care of your infant.

The umbilical cord is still attached when the baby goes home from the hospital. Some blood tinged oozing is common. This may persist while the cord is still attached and may continue for five or six days after the cord has fallen off. Usually, the cord will detach by the time the baby is three weeks old, but we have seen cords stay attached for four or five weeks with no abnormality or problem.

Some protrusion of the navel is frequently seen, but usually requires no treatment. If treatment is required, we will bring it to your attention. If you notice any drainage or redness involving the navel, call the office for an appointment.

Umbilical hernia (an opening below the navel that protrudes when the baby cries) is common, and in most instances will close and disappear within the first two years. "Belly bands" and taping the navel serve no purpose, are dangerous, and should be avoided.

Jaundice is the name given to a yellow discoloration of the skin and eye that occurs in infants, children and adults. This coloration is caused by an excess amount of bilirubin (pronounced billy-roo-bin) in the skin and blood. Bilirubin is a yellow pigment and is normally found in small amounts in everyone's body.

Bilirubin is created and released when red blood cells have broken down (red cells live about 120 days). Most babies have an excess of red blood cells at birth, and it is natural for the baby's body to break down these excess cells. As more cells are destroyed, more bilirubin is created and eventually, unless it is excreted from the body, the level builds up and the skin assumes a yellow color. In older children and adults, this bilirubin is easily passed through the liver where it is processed and excreted from the body. In newborn infants, however, organs such as the liver are not fully developed, and processes are still active that result in an increased amount of bilirubin being recirculated to the liver. Both the immature liver, and the recirculation of bilirubin result in increased levels of bilirubin in the blood of most infants.

Occasionally there are other factors which will cause the baby's red blood cells to break down more rapidly. The two most common conditions are called ABO incompatibility and Rh incompatibility. If the jaundice in your child is caused by either of these conditions, we will discuss it with you in more detail.

Jaundice is usually seen around the second or third day of life. With some babies going home at less than forty eight hours of life, it is possible the jaundice will not show up prior to discharge. Therefore, if your infant leaves the hospital prior to forty eight hours of age, we will suggest that he/she be seen again at three to five days of age. If your baby should get very yellow or orange prior to or after his/her first office visit, call us.

The most common treatment for jaundice is with phototherapy lights or a "bili blanket." The phototherapy light consists of a series of special fluorescent lights that are placed over the baby's crib or isolette. The light results in a chemical reaction in the skin which breaks down the bilirubin (photo-decomposition). The broken down bilirubin is excreted by both the liver and kidneys. This light is generally used for several days depending on the results of the laboratory tests. During this time that he/she is under the light, his/her eyes will be covered with a mask to prevent eye damage from the bright light (this is not necessary with the bili blanket). His/her position will be changed frequently to assure that all areas are exposed to the light as much as possible.

Contrary to the well intentioned suggestion of some, do not place your infant in sunlight in an attempt to bring down the bilirubin. Direct sunlight can quickly sunburn; sunlight filtered through glass still contains considerable amount of infrared and may seriously over heat your baby. There is no safe yet effective method of using sunlight to bring down the level of bilirubin. However, feeding breast milk or formula frequently is beneficial and highly recommended. Unfortunately, feeding water or glucose water is not helpful and there is very good evidence that water or glucose water feedings actually make the bilirubin level higher.

The phototherapy lights are well tolerated. Some children become fussy because they miss being wrapped up in their blankets, and others sleep contentedly. Occasionally, they will develop a skin rash which is temporary, and rarely will develop a greenish cast to the skin. Stools often become more frequent (this increases the excretion of the bilirubin) and become green in color.

Very rarely, treatments in addition to phototherapy are indicated. If your child has a level of bilirubin that warrants consideration of other treatments, we will discuss them with you in detail.

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CIRCUMCISION

Circumcision is the removal of the loose skin over the end of the penis. In the United States today, most of the male population is circumcised. However, in Europe and most parts of Asia, circumcised males are a minority. Circumcision is the result of religious tradition which has become a social tradition as well.

There are many reasons why parents may wish to have their son circumcised. The most frequently cited is so the boy will "look like his father." Some feel that a circumcised penis is easier to keep clean (it is), but in an industrialized Western society that encourages bathing and cleanliness, this is not a major cause for concern. There are studies that have shown a lower incidence of urinary tract infection in circumcised males.

Circumcision is a surgical procedure and complications can occur. They are extremely rare. Complications include excessive bleeding, loss of the skin of the penis, loss of the skin of the scrotum, damage to the head of the penis, damage to the urethra (the tube that carries the urine from the bladder to the outside) and painful scars. Very rarely, infection can arise in the circumcision site resulting in overwhelming illness and death.

If your child has been circumcised, there is little in the way of special care that is required. An antibiotic ointment or vaseline applied to the head of the penis for the first four or five days will prevent the penis from sticking to the front of the diaper and causing pain. A very small amount of blood staining is sometimes seen on the diaper and is no cause for concern.

For those who have not had their male children circumcised, do not attempt to retract the child's foreskin. It is not necessary and can be harmful at this age.

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 EARLY DISCHARGE

We recognize that your decision to go home early may be based on many considerations including your personal preference, your personal finances, your insurance company's decision to limit payment for uncomplicated deliveries, and your obstetrician's determination that you personally are doing well. Discharge at 24 hours has become normal, even expected. However, the transition from the protected environment that your infant knew while inside your body to the outside world is a process that will not be complete for several days.

The first three to five days of life are most critical. Many heart murmurs cannot be heard until the third or fourth day. Jaundice may occur early or late. Certain infections show no signs or symptoms until the infant is three to four days old. Therefore, in order to more closely observe newborn infants, we recommend that his/her hospital stay be at least two days. This also gives you an opportunity to rest, relax, and quietly "get to know" your new child.

The latest guidelines for Perinatal Care, written by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, states that there is "an element of medical risk" in the early discharge (less than 48 hours) of a newborn. We feel that it is important for you to be aware of this risk in making an informed decision to take your baby home early.

Should you choose to request discharge prior to 48 hours, nurses in the nursery will no longer be monitoring your infant and you will have to assess your infant for complications that can arise during the first few days. We, along with the nurses at the hospital, will try to provide you with the information you need to care for your newborn infant during this critical period. In addition, we want to see your baby in the office 48 to 72 hours after discharge. Please call 839-9097 to make the appointment.

Many babies sleep a lot for the first 24 hours after birth and begin to awaken and become more alert by the third day. Their appetite increases about the same time and by the third day most infants are eating 6-8 times in a 24 hour period. Breast fed infants may nurse more often. If your child does not appear to be interested in eating at least 6 times a day or if you are changing less than 6 wet diapers a day, please call. (Note, it is difficult to count wet diapers when disposable diapers are used. Try putting a tissue in the diaper and count wet tissues instead of wet diapers.)

Prior to discharge your infant has urinated and had a bowel movement, so we know that the "plumbing" is working. You will see approximately 6 wet diapers in a 24 hour day. By the third day, you will see more than one and as many as 10-12 bowel movements a day. Initially these will be dark, greenish black, and thick, but they will become more yellow, soft and runny by the third day.

Jaundice (a yellow color of the skin, or the whites of the eyes) is common in newborns. It usually is at its worst on the 3rd or 4th day of life. It is caused by the breakdown of extra red blood cells that are no longer necessary. Part of these broken down cells become bilirubin, a yellow compound that causes the yellow color. Usually there is no problem. However, certain illnesses can occur that increase the breakdown of red blood cells or that interfere with the breakdown of bilirubin by the baby's liver. Even without such problems, the level of bilirubin can rise to harmful levels. This is one reason that we want to see your child in the office 48 to 72 hours after discharge. If his/her color looks yellow to you in the meantime, please call. We may need to see him/her earlier.

If your infant is a boy and has been circumcised, you will see the head of the penis somewhat red and swollen until healing is complete However, if there is a large amount of bleeding from the circumcision that occurs after you are home, or if the entire penis looks red and swollen, please call.

It is normal for the hands and feet of newborns to look blue at times and to feel cool to the touch. However, if you notice a persistent blue color around the lips, please call the office.

Many infants have rashes over the first few weeks of life. The most common rash looks like little red raised bumps similar to "flea bites". Sometimes it will be blotchy, with a little whitish or yellowish head. This is normal, and will go away within a few days or a week or so. However, rashes that look like a blister and appear to be filled with fluid may not be normal. If your infant develops a blistering rash, please call.

Most problems that occur during the transition period produce similar symptoms. These are:

* Fast breathing (over 60 times/minute when sleeping)

* Poor color (pale, or bluish color)

* "Grunting" sound with each breath

* Poor feeding

* Weak cry

* Fever (over 100.5°F rectally) or low temperature

* Poor muscle tone - "floppy"

* Irritable, & unable to get comfortable

If you notice any of the above with your infant, call or bring your infant back to the hospital for evaluation.

As infants make the transition from intrauterine life to extrauterine life, many changes occur. Most of the time this happens without difficulty but problems with your child's adjustment or transition can produce the symptoms listed above. The three major areas in which problems occur are infection, metabolic abnormalities and circulation/breathing.

At birth, the flow of blood through the heart and lungs changes dramatically. Occasionally, an infant is born with a structural defect of the heart that causes no problem during the pregnancy but major difficulties after birth. Sometimes these defects are not apparent until the baby is several days old. If problems develop, the signs are usually rapid breathing, poor color, poor feeding, and persistent fussiness. If any of these occur, call us, or bring your infant back to the hospital.

Newborns are very susceptible to severe infection. The birth process is stressful and presents many opportunities for infection to occur. These infections can be in the skin, the lungs, the gastrointestinal tract, the coverings of the brain or directly in the blood. Infection in a newborn rarely presents with a fever. Usually the temperature is low - 96 to 97 degrees rectally. Once established, an infection can spread very rapidly in an infant. The signs and symptoms described above, such as poor color and tone, decreased activity, fussiness, and change in breathing patterns can all be seen with an infection. If you think that your child may have a serious infection, take him/her immediately back to the hospital for evaluation.

During pregnancy, the placenta maintains normal levels of many chemicals in the body. After birth, the infant must do this alone. Rarely, infants have "inborn errors of metabolism" which usually means the absence of an enzyme which interferes with normal chemical processes and allows the build up of toxic chemicals. This may result in extremely poor responsiveness, like a coma, or the opposite, extreme irritability or convulsions. Any of the symptoms mentioned earlier may occur. These problems are rarely even suspected on the first day of life since toxins have not had time to accumulate. If you feel your infant might be having any of these problems, please bring him/her back to the hospital or to the office for evaluation.

It is very important to get as much rest as possible and to relax and enjoy your new baby. Do not have visitors, if possible, but if you do, do not let them hold and handle your infant. Tired, over-stimulated and stressed infants can behave like the sick infants described above.

Call as soon possible to make the follow up appointment (between 8:30 a.m. and 5:00 p.m. Monday through Friday and 9:00 a.m. until noon on Saturday). If your newborn shows the pattern of signs and symptoms described above, call immediately, or bring your infant back to the hospital for evaluation.

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METABOLIC SCREENING

There are a number of metabolic or inherited diseases that can cause mental retardation if undetected in the newborn. Fortunately these illnesses can be treated if identified early enough, and will not result in mental retardation.

We have requested that the hospital draw a blood sample for a multiple metabolic screening test on your infant prior to discharge. We also recommend a repeat blood test at seven days of life.

FIRST FEW WEEKS: During the first month your baby will sleep most of the time. During this period of adjustment and rapid growth, he/she will need plenty of uninterrupted, quiet rest. Excessive handling, jostling, and stimulation of the baby will result in his/her getting overly tired, cranky, fussy, and "colicky." Remember, he/she is not a doll that can be passed from person to person so that "everybody gets to hold the baby." Excessive stimulation by a variety of people will cause your child to develop exhaustion and a "nervous" fatigue that will result in him/her crying, screaming, drawing his/her legs up, and sleeping poorly (see the section on colic under "Common Causes of Concern in the First Month").

Your baby should have his/her bed (either a crib or a bassinet) in a quiet, well ventilated area where he/she can sleep undisturbed by others. This may be in his/her own room or in the parents' room. Room temperatures between 72 degrees and 78 degrees are generally the most comfortable. Dressing your baby should be appropriate for the room temperature. Your best guide to this is to feel his/her hands and feet, and his/her chest or stomach. The hands and feet should always feel cool, and the chest and stomach should always feel warm, but never moist or sticky.

You can take your infant outdoors whenever the weather is pleasant. You need not wait any particular length of time following birth. However, since infants have very sensitive skin, direct exposure to sunlight should be limited to a few minutes at first.

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BATHING

Until the umbilical cord falls off (usually two to three weeks of age) and the circumcision is well healed (seven to ten days), limit bathing to sponge baths. When both the navel and the circumcision are well healed, warm water baths may be given with particular attention paid to the diaper area.

Any soap can be irritating to your baby's skin and should be used very sparingly. Your baby can go many months with simple water and wash cloth baths without soap. If you do feel soap is necessary, use a mild soap currently available on the market such as Dove or Cetaphil skin cleanser. The bath water should be approximately body temperature (between 95 degrees and 98 degrees) for very young babies. The bath should be of short duration. Never leave the baby unattended, even for a second, while he is in or near the bath. When the bath is over, pat the skin dry, paying particular attention to the folds and creases of the skin. Powder or cornstarch is not necessary, but may be used sparingly if desired. It should be placed on your hands first, and then applied to the baby's skin. For girls, avoid heavy use of baby powder in the vaginal area as it clumps and increases irritation. Boric acid powders and solutions and powders with zinc stearate should never be used.

SCALP CARE (CRADLE CAP): Cradle cap is a skin condition affecting the scalp which is quite common in babies. It consists of a yellowish white scale (or flake) on the top of the baby's scalp. There may also be involvement of the eyebrows or eyelids. Often there will be a greasy looking crust.

To help cradle cap resolve, brush the scalp daily using a firm brush with closely placed bristles. Soap and water washings using the finger tips or wash cloth at the time of bathing will help. Never use oils or lotions on the baby's scalp as these will make the problem worse. If your baby does develop cradle cap, pay special attention to the shampooing of the scalp using a hand brush or fingernail brush and baby shampoo.

Babies who have cradle cap will frequently have a rash on their cheeks and forehead, or over the arms and chest. This rash may be very difficult to clear up until the cradle cap itself has been adequately controlled. Do not use medicated shampoos or soaps without specific instructions from us.

SKIN RASHES: Skin rashes are very common in infants, especially during the first few months of life. Many infants will have dry, peeling skin during this time. This is best treated with a simple lotion such as Keri Lotion, Aveeno, or Eucerin, and the avoidance of soap.

Heat rash is caused by plugging of the sweat pores and retention of sweat. This is extremely irritating and causes a very red, prickly type of rash especially in the neck region. It may spread over the entire back and chest. Treatment consists of dressing the child less warmly, bathing your child with tepid or cool water and a wash cloth (without soap), and occasionally, especially in the neck region, a very light application of baby powder after bathing.

Diaper rash is more easily prevented than treated. It is aggravated by the hot, humid environment produced by plastic covered diapers. Changing the diapers as frequently as practical is enough to prevent most rashes.

Changing the diaper soon after a bowel movement is particularly important to prevent irritation. For most children the diaper area should be cleansed with water and a wash cloth after each soiling. Baby wipes are usually fine to use, but may be irritating when there is a diaper rash. For girls it is extremely important to remember never to wipe from back to front when cleansing (try to keep the vaginal area as clear of stool as possible).

No matter how careful you are about cleaning the diaper area, some degree of diaper rash will occur in almost all children. Once it has started, determine if it is a moist, weeping type of skin rash or if it is a dry and scaly rash. The wet, weeping diaper rash is best treated by careful drying and a light application of baby powder. Once the rash is dry or scaling, heavy coatings of ointments such as Vaseline, A & D, or Desitin may be used to prevent contact of urine or stool with the skin.

It bears stressing that excessive heat and excessive moisture in the diaper area will always result in a diaper rash. Frequent diaper changes and careful cleaning of the diaper area are essential.

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THRUSH: Occasionally, a yeast will cause or worsen a diaper rash. It is referred to as a "fungal infection", a "yeast infection", monilia, candidiasis, or cutaneous thrush. The yeast, Candida albicans, grows rapidly on the lining of the mouth as well as in the diaper area. In the diaper area, the rash tends to occur in the groin area, skin folds, and above the penis or labia. The rash appears pink to red with an irregular but sharply defined border, and often the edges of the rash appear to be peeling. Occasionally, there are small blisters or pimples along the border area.

Treatment requires careful attention to hygiene in the diaper area (frequent changes, avoidance of disposable wipes, careful washing with water and occasionally with mild soap and water), and medication. LOTRIMIN, MICATIN, and MONISTAT creams may be purchased without a prescription and applied two to three times per day until the rash clears.

Oral thrush usually requires a prescription medication. However, it can usually be controlled by carefully wiping the white plaques from the gums, cheeks, and lips with a gauze pad. If you believe your newborn has thrush that requires prescription medication, please call the office to schedule an appointment.

STOOLS: Parents often become more concerned over the type and frequency of stools that their child has than about any other single bodily function. Occasionally a child will have sufficient difficulties with his/her bowel movements to cause concern, but this is actually quite uncommon. Normally a baby will have from one stool every three to four days up to six or seven stools in a single day. Bottle fed babies usually have fewer stools than breast fed babies.

The appearance of the stools will vary from loose, mushy, watery stools to firm, toothpaste consistency stools. They will occasionally have mucous mixed throughout. The color will vary from mustard yellow to dark brown with an occasional green stool (especially when the baby receives iron fortified formula). Breast fed stools tend to be looser and more frequent than bottle fed stools. One accurate description of a breast fed stool is "Karo syrup with a little cottage cheese mixed in."

As long as the stools are passed spontaneously with little sign of distress, they are normal. However, it is normal for a child to grunt and strain with bowel movements and occasionally turn red in the face, though prolonged crying may indicate difficulties. Never use cathartics, laxatives, enemas or suppositories without first consulting us. In most instances, when stool problems are present, dietary manipulation is all that is necessary to resolve the difficulties (see section on "Feeding").

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FEEDING

BREAST FEEDING: All current research indicates that breast feeding is superior to formula feeding. Breast milk offers a degree of protection from intestinal diseases and is much less likely to result in gastrointestinal upsets. However, with modern formulas, adequate hygiene, and a concerned, loving mother, these advantages are small. They are far outweighed by mother's own desires concerning breast feeding. Thus, for the mother who wants to breast feed, nothing is better. For the mother who does not wish to breast feed, formula feeding is adequate and nutritious.

There are two general considerations that you should appreciate about breast feeding: (1) The biggest single difficulty in nursing a baby successfully is lack of confidence in yourself. (2) The first two to three weeks of breast feeding always take more time and are harder than bottle feeding. However, this increased trouble is worthwhile because after three weeks or so, breast feeding is easier.

If you are planning to breast feed, approach it with a feeling of confidence in yourself and with an acceptance of the fact that breast milk does not come in fully for 3 to 5 days. It frequently can take 5 to 10 days for the supply to build up. Overall, the first 2 to 3 weeks may take a little more time and effort than bottle feeding. Once the supply is established, breast feeding is easier, less expensive, and offers many health benefits for your baby.

Your baby, when first given a chance to nurse, may settle down right away as if he/she had been doing it for weeks, or he/she may just act sleepy and only mildly interested. It doesn't really make a great deal of difference at this point, because the infant will primarily be getting colostrum until your milk "comes in". In addition he/she has excess fluid from which to draw until your milk does "come in". He/she will have several nursing periods during which he/she can learn the "knack" of nursing and become interested before he/she really needs the nourishment. The important thing during this time is to learn how to make yourself comfortable while nursing and how to hold the baby and to offer him/her the breast. It is most important to be gentle and patient. If your baby is slow to nurse at first, do not feel the least bit discouraged.

Initially you may nurse your baby for 10 to 15 minutes at a feeding. If your nipples are unusually sore, you may want to hold down the feeding time until they become less tender. If the baby is satisfied and content after the first breast, you do not need to offer the second breast. IF your other breast is very full and engorged or the baby is unsatisfied, you may offer that breast or use a breast pump to pump that breast and freeze the milk for future use. Frequently babies are sleepy and quite content with shorter feedings for the first 2 to 3 days and they become hungry and interested in nursing by the second to fifth day when the milk comes in.

During the first week, do not let anyone tell you that you don't have enough milk to nurse the baby. Your milk supply will build up gradually over the first week or two as the baby nurses and stimulates the milk production. Once you do have milk, it is important to nurse your baby at each of his/her hungry periods, both day and night. It is not wise to give supplementary formula during the first three weeks to a breast fed baby unless he is unusually hungry and seems to require the breast too frequently for your comfort. Formula at this period satisfies him/her too quickly and gives him/her less incentive to nurse. This also results in a poor supply of breast milk.

During the first few weeks, your milk supply is very much influenced by your fatigue, anxiety, and the possible use of a supplemental bottle. Having a hungry baby nurse often is the best way to increase your milk supply. Relax and try to get all the rest that you can. Use your energy and time to get adjusted to the baby and to take care of your growing family. Let everything else go for the time being. Doing this for the first two weeks will pay dividends in having a satisfied baby and an easier feeding time.

Your diet should include an abundance of liquids, meats, fruits and vegetables; that is, well balanced meals. Avoid excessive chocolate, caffeine, spices, nuts, shellfish, and other highly seasoned foods, or any other foods which appear to cause discomfort in your infant. Do not use laxatives or other drugs without the knowledge of your pediatrician or obstetrician while you are breast feeding (Stool softeners such as bran, mineral oil, or Colace may be used without worry).

BOTTLE FEEDING: Most babies will be able to take one of the "common" baby formulas, such as Similac. Similac with Iron is the formula we recommend for most infants, as it is closest to breast milk in composition. Occasionally, a child will not be able to tolerate the formulas made from cow's milk, and for those children there are milk substitutes such as soy formulas (Isomil would be recommended), and hypoallergenic formulas (Alimentum would be recommended).

Sterilization is no longer a necessity with today's improved sanitation standards, refrigeration, and purification of city water supplies. However, it is essential that you wash and rinse both bottles and nipples well. Washing in a dishwasher is preferred. Always keep prepared formula refrigerated.

Many families use powdered formulas because they are generally the least expensive. Powdered formula can also be more convenient than even ready to feed formula. This convenience results from your ability to store the dry powdered milk in a dry bottle, adding water only when ready to feed your infant as follows: clean the bottle carefully and allow it to dry thoroughly. Add the desired amount of powdered milk to each bottle, then cap the bottle and place it on a shelf. When it is time to feed your infant, simply add the proper amount of bottled water, shake, and you are "ready to go".

The temperature of the formula is of no real consequence. It may be given at refrigerator temperature, room temperature, or body temperature. In the hospital formula fed babies are given the formula at room temperature. Since breast milk is given at body temperature, most mothers are most comfortable warming the formula to approximately 95 degrees to 98 degrees.

The quantity of formula placed in each bottle should be approximately the amount that the baby takes in any one feeding plus one ounce. Thus, if your baby is taking approximately two ounces per feeding, you should prepare approximately three ounces of formula in each bottle. Then, when your baby is ready to take more formula, it will be there. As his/her formula intake increases, increase the amount of formula in each bottle. Whatever is not taken in the bottle should be discarded. Never reuse a bottle of partially taken formula.

At first most infants want to be fed at approximately two to four hour intervals, day and night. This is, however, quite variable from baby to baby, and will also vary from one feeding to the next. Do not try to set up a rigid feeding schedule for your child. All that your baby knows is that he is hungry and that it is time to eat. He does not know how to tell time.

A healthy baby will always let you know when he is hungry. Therefore, unless it is for your own convenience, it is best not to awaken a child for feeding. Most babies will take all the milk that they want within 15 to 30 minutes, whether this is one and a half ounces when he first comes home, or six ounces when he is three months old. If he is taking longer than 30 minutes to feed, it may be because the nipple holes are not large enough, because the bottle top is screwed down too tightly, or because he needs a different type of nursing system (such as rigid bottled vs. plastic collapsible bags). The top should be loosened enough so that bubbles will rise through the milk when the child is nursing (except disposable bottle). Frequently you will find that cross cut nipples work more effectively than nipples with holes in them.

The average age at which a baby will sleep through the night is approximately three months. It is not related to the amount of feeding or whether or not he is on solid foods.

Whether breast feeding or bottle feeding hold your baby comfortably close to you. He derives a great deal of pleasure and security when fed and cuddled properly. Allowing an infant to take formula by propping or by allowing him/her to "feed himself" will result in an increased risk for middle ear infections and will significantly retard his/her emotional and social development. We strongly recommend that you never "prop a bottle" for feedings.

SPITTING UP (often known as reflux) in babies is very common and a frequent cause is over feeding. It may occur during the burping, during the feeding, and frequently will occur following the feeding. Sometimes it appears to be an entire feeding that has been spit up, but it very seldom is. These babies usually take much more than their stomachs can handle and will spit up the excess. They are characteristic in that they tend to gain weight more rapidly than the average infant despite the spitting up. As a "rule of thumb" any infant who is able to go two and a half to three and a half hours between feedings and who is gaining weight well is likely spitting up because of excessive feeding. However, if vomiting becomes forceful, if the child is not gaining weight properly, or if he does not seem to be satisfied between feedings, this should be evaluated. If spitting up seems to become quite painful for the infant, an evaluation is necessary as well.

When you were an infant, babies were fed formula for a short period of time, frequently only four to five months. Today, because of increasing evidence that babies do better on formula for a longer period of time (preferably twelve months), we recommend you continue formula through the first birthday. As this first birthday approaches, we will decide together whether to continue formula, switch to another formula preparation, or to homogenized milk (whole milk).

Your friends or relatives may suggest that you change your baby to cow's milk during the first year. This is not appropriate. Cow's milk is low in iron, vitamin C, vitamin E, and essential fatty acids. It also has more salt than he/she needs which results in the need for additional water for the kidneys to excrete the salt and other wastes. Finally, cow's milk contains more protein than he/she needs and this places additional unnecessary burdens on the kidneys. It can even cause intestinal bleeding and anemia. Please, do not use regular cow's milk during the first 12 months.

WATER: Supplemental water is generally not needed since there is sufficient water in both breast milk and modern infant formulas. For the infant who is gaining weight well, supplemental bottles of water may be given as desired. They should not be sweetened with sugar or any other sweetener. If you offer plain water and it is refused, he/she is not thirsty. If he/she is thirsty, the water will be taken quite well. If he/she consistently refuses water, then it is not necessary to offer it at all.

JUICE: Juice is simply flavored sugar water. Although fruit juice does contain Vitamin C, the extra sugar is completely unnecessary and will only serve to create a "sweet tooth". We do not recommend the routine use of juices for any infant.

SOLID FOODS: There was the tendency through the 1970's to start infants on solid foods at a very early age. Frequently, this was done because "everybody was doing it" rather than for any demonstrated benefit to the baby.

Milk is the only natural food for an infant during the first five to six months of life. It is a complete food containing all the nutrients that an infant needs during the all important first four to six months of life. The infant digestive system is not designed to handle complex foods other than milk. Although most infants will not be obviously harmed by early introduction of solid foods, there is an increasing body of evidence that indicates subtle but definite disturbances of the intestinal tract can occur when solid foods are started too early.

There is strong indication that early introduction of solid foods will lead to an increased incidence of allergies later in life. Obesity frequently begins in infancy and has been related to the early introduction of solid foods.

For these reasons we recommend that infants start solid foods no earlier than four months of age (six months for some infants). This is also the recommendation of the Committee on Nutrition of the American Academy of Pediatrics.

Decisions as to what solid foods are introduced first is quite arbitrary. Any foods that the baby accepts readily are appropriate though we would recommend delaying introduction of sweet, dessert type foods until after the first year. Generally, the more bland foods should be begun earliest and the more tasty, sweetened foods last. Juice is not recommended for this reason as well, and also because it has no nutritional value other than sugar, thus being only "empty calories".

There are no advantages to baby foods over prepared table foods other than their convenience. Any table foods that can be pureed are satisfactory for your baby. Whichever form of infant feeding you wish to use (prepared baby foods or prepared table foods), introduce no more than one new food every three to five days. This will allow you to identify any food that might be causing your baby a problem.

VITAMINS AND SUPPLEMENTS: Most infants and children who are properly fed with a well-balanced and age appropriate diet require no additional vitamin or mineral supplements. We do not routinely recommend supplemental vitamins or minerals. Overuse of these supplements can be harmful to your child's health. If you feel that your child may need a vitamin, mineral, or fluoride supplement, please discuss it with us.

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 COMMON CAUSES OF CONCERN IN THE FIRST FEW MONTHS

COLIC: One of the most distressing problems to confront a new mother and father is an infant who cries uncontrollably and who seems inconsolable. The parents become frightened because the child appears to be in distress, they become frustrated because they cannot seem to solve the problem and calm him/her down, and they become tired because the crying keeps everyone from getting a restful sleep. The resulting tension, fatigue, and anxiety in the parents unfortunately compounds the problem and makes the child cry more.

Colic is many things to many people. It has been attributed to immature intestines, to gas pain, to poor bowel habits, to problems with the formula or the breast milk. Colic, however, is almost never related to these "problems". It is caused by excessive infant fatigue compounded by continued stimulation and inability to rest, compounded by parental anxiety and fears. Colic is easily prevented once you are aware of it's cause. Some babies with milk intolerance or severe spitting up can be extremely fussy as well, and if you suspect this may be an issue with your newborn, please make an appointment for evaluation in the office.

A newborn requires a great deal of rest. He/she will sleep two-thirds to three quarters of the day, or even longer. Without sufficient rest, he/she will be unable to eat properly, and will have actual physical distress. This sleep deprived and over stimulated state is called "frazzled" by many people.

An infant thrives on the warmth, tenderness, confidence and assurance of his/her mother and father. If the parents are nervous, fatigued, upset or just plain worried, these feelings will be communicated to the infant and will make it difficult or impossible to comfort him/her. The best way to avoid these negative feelings is to avoid fatigue. Get plenty of rest!

A newborn infant has no way of knowing which of those objects, noises, colors or voices in his/her environment are important and which ones are not. He/she will do his/her best to concentrate on all of them at once. Obviously, this is exhausting work. Thus, the more stimulation in an infant's environment, the more tired he will become. Infants are like newborn puppies and kittens; too much handling by too many children (or adults!) will make them sick, weak and unable to nurse effectively.

From the foregoing it can be seen that the easiest way to prevent colic is to prevent fatigue, both for mother and child:

1) Minimize your baby's exposure to other people. He/she is not a new doll that should be passed from person to person for all to hold. Keep his/her interests first.

2) Do not take him/her out with crowds. For an infant, more than two or three people is a crowd.

3) Allow him/her to sleep in a quiet, undisturbed area of the house. Do not wake him/her so that others may see him/her, and do not wake him/her to go to the store or friend's house.

4) Get plenty of rest. You will be much better able to handle the demands of your child if you are rested than if your are fatigued and bordering on exhaustion.

5) Remain confident in your ability to care for your child. No one is better qualified to take care of your infant than you are. Have confidence in yourself.

Your baby will thrive on the attention that you give him/her. Those quiet times during the day and night when he/she is awake and quietly looking about are extremely important. When he/she is "being quiet and good," make every effort to hold, talk and play with him/her. These are the times that he/she will learn the most from you (and when you will have the most fun with him/her).

HICCUPS: During the early weeks of life, a baby will often have hiccups after meals. This should not cause any concern or anxiety. Hiccups result from a normal reflex that begins during the last third of pregnancy and is designed to strengthen the diaphragm, the main muscle of breathing. This reflex continues during the first month or two of postnatal life. The hiccups will stop whether you "do anything" or not. It is not necessary to feed water or peppermint, to burp or to hold. Hiccups cause distress in parents, not in babies.

SNEEZING: Your baby is very likely to sneeze from time to time. This usually does not mean that he/she is getting a cold. He/she may sneeze only to clear his/her nose of tiny particles of fuzz which often lodge there. These particles frequently come from the new blankets or flannel clothes.

One way to tell whether your baby is sneezing because he has a cold or because of fuzz or dust is to notice the amount of nasal discharge produced. If he has a cold, there is usually a large amount nasal discharge produced, while in the healthy child the nose will be dry and the only mucus that you will see will be expelled with the sneeze. In addition, an infant with a cold usually will have difficulty in eating and will have other signs of illness.

BURPING: Most babies, whether breast fed or bottle fed, swallow air. The air that is swallowed does not cause discomfort, although it could possibly be enough to fill the stomach and prevent the baby from drinking as much as he needs for complete satisfaction. It is worthwhile to try burping him once or twice during a feeding. If he burps readily, he may then wish to eat more. If he does not burp readily, he has not swallowed a significant amount of air and continued efforts to make him burp are not necessary.

HERNIA OF THE UMBILICUS (NAVEL): Many babies have a small protrusion of the navel. Sometimes it is a small hernia into which abdominal contents may pass because the muscles of the abdominal wall are not yet very strong. More often there is no hernia, but only a small collar of skin which extends out for one-quarter to one-half of an inch. Even when an actual hernia is present, it is likely to close during the first three years of life.

Unless the hernia (protrusion) is very large, we do not feel that treatment is necessary Some people recommend "taping" of the hernia or "bellybands." We do not recommend them and feel that they are potentially quite hazardous.

Care of the navel prior to loss of the umbilical cord was discussed in a previous section.

THUMB SUCKING and PACIFIERS:  In our society thumb sucking is often considered to be quite a problem.  Except for the very rare child who causes real deformity of his/her teeth by sucking very hard and for many years, it is difficult to see why thumb sucking should be taken so seriously by so many people. 

In the first year of life, all children do a great deal of sucking and mouthing objects other than foods.  Watch a 9 month old child at play and you will see that each new toy quickly finds its way into the mouth for sampling of taste and texture before he goes on to play with it.  A baby uses his/her mouth the same way he/she uses his/her hands and his/her eyes, to find out about things.

Actually, using his/her mouth came first.  A newborn baby is adept at finding the breast and is sucking long before he/she uses his/her hands and his/her eyes.  Throughout his first year he has a strong urge to suck.  Most of this urge will be satisfied at feeding time, but frequently there is a strong desire to suck "left over" after feeding is completed.  For these infants pacifiers or thumbs are perfectly appropriate.  Pacifier use is recommended by the American Academy of Pediatrics (and this office) during infancy, as it has been shown to be a factor in reducing Sudden Infant Death Syndrome (S.I.D.S.).

A few babies stop sucking their thumbs in a few months, but most continue until the beginning of the second year.  Some of them gradually stop completely.  A few cut down and suck their thumbs only at special times such as bedtime or when they are tired.  Some don't stop at all, but continue until they are five or six years of age.

It is not wise, and very seldom effective, to tie or cover the baby's hands, to put splints around the elbows, or to paint the fingers with bitter tasting medicines to stop thumb sucking.  These punishing measures hardly ever work and you make the child more eager than ever to suck his/her fingers.  He or she might stop temporarily, but will go back to sucking with more determination than ever before.

Pacifiers, on the other hand, should be discontinued by one year of age.  A pacifier can be discontinued without the child switching to thumb sucking.  Pacifiers are recommended for infants, but become a major source of contagious illness in toddlers, especially those in daycare.  Prolonged pacifier use has also been shown to increase the incidence of ear infections.

Don't worry that thumb sucking will cause permanent deformity to the teeth. If a great deal of sucking occurs after the age of two, the upper teeth may be pushed out and the bottom teeth in, depending upon the position of the thumb in the mouth.  The structure of the jaw is not altered, however, and the permanent teeth which begin to come in after the age of six years will come in straight.  Thumb sucking or finger sucking after the permanent teeth have erupted will cause permanent deformity requiring orthodontic care.

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IMMUNIZATIONS

Immunizations mean protection for your child against many contagious diseases for which we have no effective treatment. We can prevent these diseases, but can only support the non-immunized child once he/she contracts the illness. You should see to it that your child has received all the protection he/she can for many of these diseases are extremely serious and can cause permanent crippling and even death.

There have been numerous concerns about the safety of vaccines over the years. Our "EVCC Links" page on the EVCC website has links to several organizations that explain in detail the risks of vaccines as well as the common myths that have been associated with vaccines. All of the vaccines your child will receive are thimerosol (mercury) free with the exception of the influenza vaccine, for which a preservative free version is available.

HEPATITIS B: The first immunization your child will receive is the Hepatitis B vaccine, as it is typically given in the hospital. There are no serious reported side effects. Hepatitis B is a viral illness that causes severe liver damage and death in a high proportion of infected individuals. It is preventable with a series of three immunizations beginning at birth, one month, and nine months. It is one of the required immunizations in Arizona schools.

DaPT: The DPT stands for Diphtheria, Pertussis (whooping cough), and Tetanus (the "a" stands for acellular, a type of pertussis vaccine that causes less fever and soreness than the traditional DPT). Diphtheria is an infection of the throat which is often fatal. It also affects the heart. Whooping cough is an infection which causes a spasmodic type of cough and can be fatal in the young infant. Tetanus is usually a fatal disease at any age and is characterized by continuous contractions of muscles throughout the body.

The DaPT vaccine is given in three successive shots in the first six months. Boosters of this vaccine are given at fifteen months of age, four to five years of age, and then the adolescent or adult version of the vaccine is given between ages 11 and 14 years, and every 10 years thereafter.

The DaPT shot occasionally will cause a local reaction with fever, fussiness, and possibly some redness and swelling at the injection site. Very rarely this fever will be high, and even more rarely, convulsions will occur. Some continue to believe that there is an extremely rare chance of shock developing as a result of the Pertussis vaccine that can cause permanent damage and even death. However, information developed since 1990 indicates that there are no permanent injuries that result from Pertussis vaccine. However, without the vaccine, the risk of damage from the illness (Pertussis) is far greater than any risk from the vaccine. The acellular Pertussis vaccine (DaPT) is now used exclusively by our office. It has been shown to cause less crying and less fever. DaPT immunization is recommended by the American Academy of Pediatrics, the Center for Disease Control, and this office.

POLIO: Polio is an infection of the spinal cord and brain, which can result in permanent muscular paralysis and death. Killed Polio virus vaccine (IPV) is given at 2 and 4 months. Boosters of this vaccine are given at fifteen months of age and four to five years of age. Polio vaccine used to be given by mouth (live, or Sabin Vaccine-OPV) but is now only given by injection (killed, or Salk Vaccine-IPV) and has no immediate side effects. It does not make the child irritable or fussy.

HiB: Hemophilus influenzae type B (called by the initials HiB) is responsible for many infections in children, and, prior to the vaccine, caused over half the cases of meningitis in children below age five. Between 5% and 10% of all children who develop HiB meningitis will die, and those who survive may have lasting damage to the nervous system. HiB also causes epiglottitis, an infection that can cause death if not treated immediately. Serious HiB diseases are contagious, so one sick child can expose other children to HiB. The vaccine is not a guarantee that HiB disease cannot occur, but it dramatically reduces the probability of illness. Side effects are rare and minor, consisting of a low grade fever or local reaction at the injection site.

The HiB immunization is given in three successive shots in the first six months. A booster dose of the vaccine is given at fifteen months of age.

PREVNAR or PNEUMOCOCCUS (PCV7): Streptococcus pneumoniae, or Pneumococcus, is a bacteria that is responsible for many illnesses in young children, including meningitis, pneumonia, and ear infections. It is the most common cause of "blood poisoning" or bacteremia, and is well known for it's antibiotic resistance. Many illnesses caused by this bacteria can cause death or serious permanent damage. There are numerous different strains of this bacteria. The Pneumococcal Vaccine (Prevnar™) is a vaccine against 7 of the more common types of Pneumococcus. It became available in 2000 and as of June of 2000 is recommended for use in all children under age 2 by the American Academy of Pediatrics. Studies show this vaccine to be 97% effective against meningitis caused by this bacteria, as well as decreasing pneumonia by 11% and ear infections by 8%. It has unfortunately been hailed as "the ear infection vaccine", but it is much more important than simply reducing ear infections.

An older Pneumococcal vaccine against 23 strains of this bacteria has previously been used over age 2 only for children at high risk of certain illnesses. This older vaccine is still available and still recommended for children with certain illnesses. Please ask your doctor about it if you have questions.

Prevnar Pneumococcal vaccine has been reported to cause the same typical side effects of most vaccines, which include soreness or redness at the injection site, fever, irritability, restless sleep, and decreased appetite. These uncommon side effects are usually gone within 48 hours after the vaccine is given. As with other vaccines, it may be administered during mild illness.

The routine immunization schedule for this vaccine is listed in the chart below, but there will be a reduced number of doses of this vaccine recommended for older infants based on their age. Please ask us about how many doses your child may require while you are in the office.

TUBERCULOSIS: A tuberculosis skin test (called a Mantoux, or PPD skin test) is performed at one year of age. There are no side effects. In Arizona, the risk of TB is greater than in other parts of the country due to our proximity to Mexico and the testing is therefore recommended at one year, four or five years, and 11 to 14 years of age.