Posts for category: Newborn
Breastfeeding and Risk of Formula Supplementation.
The maxim, “breastfeeding is the way to go!” was drummed in early in my pediatric training and it remains a scientific fact to date. Recently the World Health Organization (WHO) conducted surveys and monitored growth for years on exclusively breast fed newborns in stable home environments from six racial backgrounds in six different geographic regions of the world to get an idea of how a normal human ought to develop in the first 2-years of life. The finding which shows that we all grow in a consistent manner regardless of racial background when exclusively breastfed corroborates the importance of breastfeeding. Baby friendly hospital initiatives gaining traction in some valley newborn nurseries draw their antecedents from these initiatives by the WHO.
There are various reasons why a newborn infant may not handle the transition to establishing normal breastfeeding after birth as well as anticipated. These situations often call for formula supplementation informed by medical reasons. This recommendation frequently meets resistance and understandably so from mothers who want to exclusively breastfeed their newborns. Their concerns are often premised on the fact, that formula supplementation would hamper subsequent establishment of successful breastfeeding.
In the May 2013 of Pediatrics, a publication of the American Academy of Pediatrics, Dr. Flaherman et al set out to address this question for the first time and find out what effects if any the early administration of small formula volumes would have on newborn breastfeeding rates between the first week and the third month of life. 40 exclusively breastfed newborns who had met the medical criteria for early formula supplementation were randomly assigned to a study arm and a control arm. The researchers used a randomized control trial (RCT) model to study the effects of formula supplementation on these newborns. RCT type studies are widely ranked high on the hierarchy of medical evidence and scientific scrutiny. Their findings show that longer term breastfeeding rates were better than anticipated at the first week of life and at 3 month in infants who were allowed early formula supplementation for medical reasons.
This is the first study of its kind to address this concern and indeed shows that our collective fears and concerns about potential adverse effects of early formula supplementation of maternal breastfeeding efforts may be exaggerated and not actually inimical to successful long term breastfeeding rates. There are caveats however, since the infants were supplemented with formula fed by syringe and not a bottle and nipple perhaps to avoid the hobgoblin of nipple confusion is one key outlier not adjusted for in this study. The small size of the study participants also limits the statistical power and applicability to the general population.
We laud the efforts of all mothers and acknowledge the challenge of exclusively breastfeeding a newborn. We champion this cause at our practice and support variations of it. Ultimately the overarching goal must remain optimal nutrition for the newborn to support healthy growth and development.
Dr.Vaughan my baby girl just started drooling and chews on her hands a lot I think she is a little young to be teething what age do most children start teething and what do I do if she is teething?
The salivary glands are active at birth and interestingly large amounts of saliva are produced and swallowed daily. Saliva has weak antibacterial properties and plays a key role in maintain oral hygiene. Salivation normally increases to full capacity around the 3rd to 4th month of life. This is usually about the same time parents notice drooling and health professionals this happens because of the infant's limited ability to co ordinate swallowing effectively by holding the neck upright consistently and the conspicuous absence of the lower row of front teeth to serve as a dam and staunch the downward flow of drool. Increased salivation as described above should not be associated with any signs of illness such as fever or respiratory symptoms; otherwise there will be a need for urgent medical evaluation.
Salivation may also increase temporarily with the eruption of new teeth, typically around age 6 months. Though gum irritation may begin earlier than appearance of the first cusp along with increased salivation. We think the gum irritation is why the babies reach for anything to help soothe the irritation. Their hands, usually when balled up into tiny fists are a favorite. This frequent introduction of otherwise “not-too-clean” hands into the mouth makes diarrheal illnesses and sometimes a fever especially common during this period since the newborn inevitably overwhelms the local immune system body defense mechanisms from the increased load of germs from the environment. This natural process fosters the age old perception that teething comes with fever and diarrhea etc – which as shown above is a consequence of increased oral germ burden and teething could ideally occur completely without any symptoms! In our practice, we recommend the use of teething rings as these have been shown to help. We do not encourage the use of topical anesthetic gels on the gum, since problems with excessive dosing which occurs when the infant ingests and swallows active medications intended for topical application only can lead to other complications. Besides, teething is natural and not a disease state!
Here’s a rule of thumb for the anticipated order of tooth eruption: 1st tooth 6-10 month.â€¨Number of newborn teeth = age (month) – 6 (until 30 month). Check the American Dental Association on http://www.mouthhealthy.org/en/babies-and-kids/
The teeth are counted with the expectation that the infant will have, on the average, one tooth for each month of age past 6 months up to 28 to 36 months of age, when the full complement of 20 primary teeth will have erupted. Follow up with your Dental health provider as recommended by your pediatrician, for surveillance to ensure proper teeth eruption and spacing in the early years is key to a life of excellent dental health.
We will follow through on addressing other therapeutic options for infantile colic in addition to the comfort measures discussed last week.
There is enough evidence in the medical literature suggesting that newborn infants go through a brief period of intestinal enzyme insufficiency simultaneously at the same time colic symptoms peak and wane. The specific enzyme tested for in these studies is called lactase. This enzyme plays a key role in the breakdown and digestion process of milk sugar otherwise known as lactose. A transient deficiency affecting lactase leads to poor milk digestion and lots of gas and other by products are produced. The gas produced contributes to abdominal discomfort and spasm we believe plays a key role in the progression of symptoms leading to infantile colic.
Medications aimed at attenuating this progression of symptoms have always being met with variable amounts of success. There isn’t any one therapeutic option that consistently gives symptomatic relief. A careful evaluation by your physician is always necessary since there are conditions that may mimic infantile colic and yet be very different and distinct disease processes.
Anti-gas over the counter drops often contain a drug known as simethicone. This medication has been described as an “anti-foaming” agent. The medication makes it less likely for the smaller gas bubbles from the maldigestion process described above to coalesce and form even bigger bubbles which end up making it more difficult for the infant to pass the gas as flatus. When simethicone was subjected to a high pedigree of scientific scrutiny known as randomized controlled trial, there was no scientific proof of its usefulness for infantile colic. Our experience has shown a variable response and because its not absorbed or pose toxicity concerns when used as recommended, it continues to be a favorite for colicky infants among parents.
There are other over the counter medications formulated to contain preparations of the lactase enzyme whose transient deficiency is believed to be central to the evolution of colicky symptoms. Lactase is an enzyme and can easily be denatured when exposed inappropriately to the elements. There are scientific studies with a small number of participants showing satisfactory response rates after 3 days of use in more than 20% of enrollees. We would advise readers to discuss with their physician before administering all medications.
Changing the infant formula to products that do not contain lactose sugar in the milk may sometimes be necessary as determined by your physician. These products contain a different form of sugar from corn-syrup. It is noteworthy that human milk contains lactose sugar and these products often contain other partially digested forms of milk protein as well.
The symptoms of infantile colic described in these series eventually resolve between the 3rd and 4th month of life when the partial lactase deficiency resolves and the infant gut usually resumes the production of adequate lactase. Preparing parents for the possibility of colicky symptoms that can affect as many as 20% of newborns during preventive health visits by far seems to be the best weapon against colic, after all to be forewarned is to be forearmed.
Parenting is a joyful and rewarding experience and the appearance of a concern in the newborn can be very distressing. We frequently encounter parental concerns themed on crying and suspicions of colic in newborns. This post on Infantile colic is the first of two addressing this concern commonly seen in about 1:5 newborns. The most widely used definition of colic is set in the rule of threes. These seriously fussy babies cried for more than 3 hours a day, more than 3 days a week, and for longer than 3 weeks. This cascade of events is Illustrated below.
Baby’s been home for more than 2 weeks already and everyone’s settling into the routine of caring and nurturing the newest member of the family, then here comes along these crying bouts, with a higher pitch than mom or dad ever recalled before. These crying episodes now occur more frequently and baby is only about 3 weeks old, and oh yes- they go on for hours, sometimes for as long as 3hours! It happens up to three times weekly! Even more perplexing to everyone is the fact that baby is dry, was fed recently, and doesn’t appear ill or unwell. The crying goes on and on, despite efforts to soothe and calm the baby and this is all happening in the evening – just when everybody is getting tired and getting ready for bed! Did the doctor also say this can go on for up to 3 or 4 months?
Crying is a welcome response to stimulation especially right after the newborn is removed from the birth canal during the birthing process and pretty much a normal feature of infancy. When it occurs in the context described above, Infantile Colic becomes a strong possibility in the affected infant. Physician notification and evaluation is necessary in these situations to exclude other potentially serious conditions that may be amenable to medical and occasionally surgical intervention that can also present with prolonged crying bouts.
The mnemonic PURPLE, developed by the National Center on Shaken Baby Syndrome, is designed to reinforce parental education which as we discuss in this post is the cornerstone of treatment and to help reduce the incidence of shaken baby syndrome, which sadly still happens. Never shake a baby. This mnemonic PURPLE helps to remind parents of the characteristics of infant crying: P for the peak pattern occurring around the third week of life to about 3 months, U for the unexpected timing of episodes, R for resistance to soothing, P for pain-like look or drawing up of knees, L for long bouts lasting for 3hours are not uncommon, and E for the evening pattern of occurrence of these symptoms.
What Can I do to help my baby with colic? “Anticipation is more potent than surprise”, once quipped a very successful military commander. Anticipating colic and having a plan in place during these fussy periods can be a particularly potent intervention. In our practice, parents are encouraged to first ensure that the baby is dry and fed. Soothe the baby by swaddling, or gentle rocking motions. Certain distracting sounds, not subjected to scientific scrutiny at any level yet, but commonly generated in the home e.g., from a kitchen blender or vacuum cleaner or the static noise from a poorly tuned TV or radio have oddly worked sometimes too. A short car ride with the gentle din of the engines etc. have anecdotally worked too. These interventions take the infant’s attention away from the discomfort central to colic. When crying continues despite these interventions, parents should allow the infant to cry for a short period and observe. This approach allows parents to reassess the situation and is a cautious reminder that crying is a feature of infancy. This can assuage parental concerns however momentarily. The rule remains, never shake a baby. Calling your pediatric office to review the situation offers much needed support and a follow up plan on the infant's symptoms usually follows. Parents should not neglect themselves, their overall health and well being directly affects their ability to care adequately for the infant. Good amounts of rest, and enlisting the help of family members or friends to take over from time to time to reduce stress on themselves.
Image: www.michealmillerprojects.com via Google 9/29/12
We will briefly explore a common concern associated with noisy breathing in infants, medically termed, Laryngomalcia.
Laryngomalcia, from its name suggests a softening of sorts involving portions the upper airway structures anatomically known as the larynx. This part of the respiratory system houses the vocal cords and adjacent structures, all of which play a key role in inspiration, expiration and phonation (the generation of sound). Laryngomalacia as a diagnosis is often made by clinical assessment in the newborn period and requires a careful examination of the presenting and associated symptoms along with examination by your physician before the diagnosis is made. It is one of the probable causes of noisy breathing in the newborn period. Associated structural or functional problems may make the presentation worse and these require additional diagnostic evaluation involving a specialist..
Most newborns however have this as an isolated condition. The noisy breathing is usually worse during the inspiratory portion of the breathing cycle and during feeding. The nosiy sound generates anxiety with parents and comes to clinical attention as a result. Laryngomalacia is most common in the first few weeks of life and may worsen through the fourth month of life before improving spontaneously towards the end of the first year of life. The cartilage (flexible plastic like consistency tissue- similar to consistency of the ear) supporting the structures of the upper airway inevitably thicken with age and attenuate the likelihood of collapse with the negative pressures generated during inspiration as shown in the image above which is what allows air to flow into the babies lungs down that pressure gradient. This partial collapse is one of the reasons why the noisy sound is “guttural” and frightening to the observer. Other structural or functional problems affecting the upper airway may also predispose to this like problems affecting the nervous system and moderate to severe reflux of stomach contents periodically, otherwise known as gastroesophageal reflux.
Affected infants with mild presentation show no other signs of illness or disease and thrive and grow well. Time and close physician follow up is the best treatment for mild cases of Laryngomalacia. More severe cases would require evaluation by an otolaryngologist especially if other signs of illness accompany the presentation. An endoscopy view of the upper airway is usually the first step.