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River Valley Pediatrics |
531 Central Park Avenue, Suite 102
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Common Condition and Questions Crying Baby/Colic
An excessively crying baby can be one of the most frustrating experiences of parenthood, and indeed, of pediatric medicine as well. All babies cry. Some cry more than others. Most of the time this is completely normal, a process of the baby maturing and learning how to deal with external stimuli. The difficulty for all of us is in distinguishing when there is actually something wrong. Colic is generally defined as unexplained crying in an infant. It classically occurs between about 3 weeks and 3 months of age, is worse in the evening hours, and can last for minutes to hours. Babies will cry, scream, draw up their legs to their chests, turn bright red, and often pass gas. Many parents mistake these symptoms for constipation or formula intolerance. Most of the time, changing formula will not help. The number one thing to remember with colic is that it WILL GET BETTER. Sometimes it is just a question of doing what you can to try to make your baby comfortable and just waiting to get through this period. Many experienced parents consider dealing with a colicky baby a rite of passage. Check to make sure the baby is not hungry, overheated, has a wet or dirty diaper, or has a fever. Then try different methods of soothing such as the following: walking and rocking, swaddling, stroller rides, car rides, trying a pacifier, giving a bath, or playing soft music. There is no evidence that over the counter products like Mylicon drops, gripe water, etc. have any benefit. Colic can be very frustrating and fatiguing. If you know that there is nothing wrong with the baby, it is fine to allow the baby to cry in his or her crib for short periods. This can sometimes help the baby learn how to soothe himself or herself to sleep. It is perfectly natural to feel overwhelmed or angry when dealing with a crying baby and little to no sleep. Take a break. Take a shower. Your baby needs you to take care of yourself as well. Call our office immediately if the baby cries without stopping for more than 2 hours, has a fever (temperature of 100.4 or greater), is acting sick, turns blue, or if you are concerned that you might hurt the baby. If you have other concerns, we can always examine the baby to make sure that all is well.
Fever is defined as a temperature of 100.4 F (38 C) or greater. Fever is a symptom, not a disease. It is the body fighting off an infection, and can be beneficial. Fever does not hurt a child, but it can be uncomfortable. Contrary to popular belief, fever does not cause brain damage unless the temperature goes above 107 F. Our brain has a thermostat which keeps the body's temperature from getting that high in all but the most extreme cases. Most fevers are caused by common viruses and last 1-3 days. The fever can come and go. A child with a fever usually does not need antibiotics. Medications such as Tylenol or Ibuprofen can help the symptoms of a fever, but will not "cure" a fever, or the underlying infection. When the medication wears off, the fever will come back. If your child has a fever, it is important to get a reading with a thermometer. A rectal temperature is ideal, but oral or under the arm can be effective as well. Feeling a child with hand or lips can sometimes give us an idea if a child has a fever, but is notoriously inaccurate in judging the height of the fever. Tylenol can be used if the child is greater than 2 months, and Ibuprofen if the child is greater than 6 months. Please ask one of the doctors or see our dosing section for accurate dosing based on weight. Do not over-bundle your child, even if they have chills. Cool or cold baths cause shivering, which actually can increase the child's temperature. It is critical for the child to be drinking well to avoid dehydration. Call or come in immediately if your child has a fever and is less than 3 months of age. Newborn babies can have more serious infections and we would rather examine the baby to be safe. We would also like to see the child if the child is younger than 12 months and has a high fever, any child who has a fever for more than 3 days, or any child who is irritable or lethargic even when the fever is controlled. Any suspicious rash should be examined as well.
Pink eye, or conjunctivitis, can be caused by bacteria, viruses or allergies. It is characterized by red, itchy, uncomfortable and swollen eyes, and discharge. With bacterial conjunctivitis, the discharge is significant and continuous, thick, and yellow to green in color. With viral or allergic conjunctivitis the discharge can be more watery or white. When a child has an upper respiratory infection, there will often be slightly increased crust around the eyes, especially after sleep. This does not necessarily represent conjunctivitis. Antibiotic eye drops only treat bacterial conjunctivitis. Conjunctivitis is very contagious, and schools and childcare centers correctly attempt to limit children from attending school if they have true conjunctivitis. If the child has eye redness and little to no discharge, it is not bacterial conjunctivitis and they can attend school if they are comfortable. If your child has these symptoms, warm washcloth compresses can alleviate some of the discomfort. If you believe that the child has bacterial conjunctivitis or if you have other concerns, please call the office to make an appointment. Hand washing is critical to avoid spread. If redness and swelling around the eye begins to spread or if your child is ill-appearing, call the office immediately.
Diaper rashes are very common in infants. Most diaper rashes are due to irritation and skin breakdown from wetness and proximity of stool to the skin. Some are due to yeast or bacteria. If your infant has a diaper rash, try some of the following measures. First, change the infant's diapers frequently - at least every 3 hours, and more if you feel or smell a bowel movement. Barrier creams such as Desitin, Balmex, Boudreaux's Buttpaste, A&D ointment, or Triple Paste can help keep the urine and stool from touching the baby's skin. Apply a thick layer covering all exposed skin. Increasing air exposure by leaving the baby on a towel or pad with no diaper for several hours can help keep the diaper area dry and healthy. Rinsing the diaper area with warm water instead of using chemically treated wipes can also help. If the rash is getting worse, does not improve with several days of the above measures, or if the baby has other symptoms, please call for an appointment.
Eczema is a chronic recurring skin condition characterized by dry, itchy skin. It often starts in infancy with red, dry patches on the baby's cheeks. Other areas of the body can also be affected as the baby gets older. Our skin's main job is to provide a barrier between us and the external environment. Eczema is a disorder of this barrier function, where the skin allows precious moisture to leak out and irritants to get in. Eczema tends to run in families, but the frequency has been greatly increasing in recent years. It can also be associated with allergies and asthma. In about 1/3 of babies with moderate to severe eczema, a food allergy is worsening the condition. Common food allergies are milk, soy, eggs, wheat, nuts, and fish. The eczema can be improved (but usually not eliminated) by eliminating allergic foods. Eczema CANNOT be cured. It is a chronic condition that comes and goes. Some lucky children grow out of it. For most children, it will come and go, but the severity of the outbreaks can be controlled. The most important aspect of treatment for eczema is and will always be adequate hydration of the skin. No other medications will work if the skin does not have enough moisture. Moisturizing gels, creams, and lotions are not all created equal. Some parents have success with products like Aquaphor, Vaseline, Eucerin, and Aveeno. These should be applied AT LEAST once a day EVERY day, preferably after bath time (this helps to keep the moisture from the bath in the skin). The next step in treatment depends on the patient, but can include over the counter topical steroids, prescription steroids, or other prescription medications. A good place to start is to try a small amount of over the counter 1% Hydrocortisione to any red areas (except the face or genital area). Do not use more than once daily for 4-5 days before seeing a doctor. Sparing use of Benadryl in children older than 12 months can help if itch is interfering with sleep. Using hypoallergenic fragrance-free detergents and soaps also can help, and avoiding products with excessive perfumes or additives. Skin with eczema can also easily become infected with bacteria. Very red, yellow-crusted or weeping lesions should be seen and may require antibiotics.
Ear Infections (Otitis Media) Middle ear infections are very common in childhood. Children present with fevers, ear pain, pulling or batting at the ear, or even vomiting. Children who usually sleep well at night can be up crying inconsolably. Upper respiratory infections can predispose to ear infections. The Eustacian tube, which connects the nose to the ear, is very narrow and horizontal in children. This allows fluid to sit in the ear canal, which can lead to ear infections. Water from the bath in the ear does not cause middle ear infections. Ear infections can be very painful, so the most important thing is to control the child's pain with Tylenol or Ibuprofen. Only a doctor can diagnose an ear infection. While fevers, ear pulling and ear pain can indicate an ear infection, other conditions can mimic these symptoms. We cannot responsibly prescribe antibiotics unless we visually confirm the correct diagnosis. If you suspect that your child has an ear infection, please call for an appointment. It is NOT necessary to go to the emergency room unless you have other concerns. Tylenol or Ibuprofen for pain control can get your child through the night until you can bring the child into the office for an exam. Generally, once the diagnosis of an ear infection has been made, we will give you a prescription for antibiotics. The antibiotics can take 48-72 hours to start working well, so pain control with Tylenol or Ibuprofen is still critical. Some ear infections do go away on their own without antibiotics. We can discuss working with you to see if the infection resolves on its own within 24-48 hours; as long as we can continue to re-evaluate the child daily. If it does not improve, then antibiotics would be necessary. Some children have such frequent ear infections that we recommend a minor surgical procedure where small tubes are placed through the eardrum to equalize pressure. There are some ways to prevent or minimize ear infections. Number one is always good hand washing hygiene. Preventing upper respiratory infections through hand washing and covering coughs will help prevent ear infections. Secondhand smoke is another important factor that predisposes to ear infections. No one should smoke anywhere near children, and clothing saturated with smoke should be removed before entering the house or car. Breastfed babies have significantly less ear infections than formula-fed babies.
Upper Respiratory Infection (Common Cold) Upper respiratory infections (URIs) are among the most common diagnoses that we make as pediatricians. Upper respiratory infections are characterized by cough, runny nose, and sometimes fevers. They are caused by viruses, and typically last between 7 and 10 days. Children are very susceptible to URIs, due to the contagious nature of these viruses, being together at school or daycare, and their frequent ability to forget to wash their hands. Normal children can have 6 to 10 URIs in a year. Since they are usually concentrated in the winter months, this can make it seem as though these children are "sick all winter". Since URIs are caused by viruses, and antibiotics only kill bacteria, antibiotics DO NOT HELP. We are all desperately awaiting the genius who can invent the anti-viral agent that will make the common cold a thing of the past. Until that happy day, we can take measures to make our children more comfortable while their amazing immune systems do the job. Cough and cold medicines have been shown to be ineffective in children, and can be harmful. The mainstays of treatment are as follows. Drink plenty of fluids, since the virus and fevers cause the body to use up fluids at a faster rate. A dry hacking cough can keep a child up all night. Humidified air from shower steam or a humidifier help loosen up phlegm so that a child can either blow their nose, or, more commonly, swallow it. Nasal saline drops or sprays with or without a suction bulb can help clear the nasal passages. Propping older children up on 2 pillows can help drainage. Tylenol or Ibuprofen can help fevers or a sore throat from coughing. Honey has been shown to help a cough, and can be given as often as necessary. Honey should not be given to infants under one year of age. Children with URIs can still attend school unless they have fevers (greater than 100.4F) or they are so under the weather that they would not be able to participate. If your child has a URI, he or she does not necessarily need to be seen by a doctor. Infants under the age of 4 months should be seen, especially if they have fevers. URIs can predispose some children to ear infections or wheezing. If you suspect these conditions, your child should be seen. A URI that lasts for more than 10 to 14 days without any improvement may have become a sinus infection, and should prompt a visit.
Acute Gastroenteritis (The Stomach Bug) Gastroenteritis, or the stomach bug, is usually caused by one of many common viruses. It is characterized by vomiting, a stomachache, diarrhea, and sometimes fever. Diarrhea is defined by at least 5 loose, watery bowel movements in 24 hours. These stomach viruses are very contagious, so hand washing is imperative. There are no medications that can cure gastroenteritis. The most important thing to do to protect your child is to make sure that they do not become dehydrated while the body is fighting off the virus. Keep a close watch on how often your child is urinating. Sometimes this can be difficult when diapers are mixed urine and diarrhea. A child should have at least 4 good wet diapers in a 24 hour period. If your child cries, make sure that they are making tears. Check to see if the insides of their mouths are moist. Encouraging, and sometimes actively pushing fluids are critical. If you are nursing, breastmilk is the best, since it has immune cells that help the baby fight the infection. The next best replacement fluid is something like Pedialyte or Liquidlytes, since these have some of the salts and electrolytes that children lose in vomit and diarrhea. They come as liquids, powders, and ice-pops. Water is another good replacement fluid. Milk and juices cannot be absorbed well during these types of infections, but are better than nothing. Fluids should be given in small amounts VERY frequently (sometimes every 5-10 minutes). Start with a teaspoon at a time, then wait 5-10 minutes to make sure it stays down. If the child responds well, continue this every 5-10 minutes for 30-40 minutes. If they are still doing well, increase the amount to 2 teaspoons. If they continue to do well, keep gradually increasing the amount of fluid as tolerated to several ounces. If the child vomits in between, backtrack to the last amount that was tolerated and keep giving that amount every 5-10 minutes. While tedious and time-consuming, this method maintains hydration and putting something into the stomach helps the stomach and intestines heal faster. If the child can tolerate food and wants to eat (after the fluids have stayed down for several hours), encourage solids as well, as this also helps the stomach heal faster. While recent evidence shows that you do not need to adhere to a strict "BRAT" diet of bland foods, use common sense. Though many children will claim that all they can tolerate is a cookie or a cupcake, this is generally not productive. Kids with gastroenteritis do have more problems absorbing things like milk and juices, so holding off for a few days can also be helpful. We all have good bacteria in our intestines that help us digest food. Sometimes with one of these viruses, the good bacteria can be lost, causing an imbalance and causing the diarrhea to last longer. Probiotics are products that replace the good bacteria in our intenstines, helping to heal and absorb food better. There are commercial preparations that you can get at the pharmacy that can help. These products are very safe (comparable to eating a lot of yogurt) and generally can either shorten the symptoms by a day or two or help make the stools more firm. Two brands that we are familiar with are Florastor and Culterelle. These are small packets designed for children that can be mixed into liquid or food like applesauce or yogurt. You do not need a prescription, so ask your pharmacist if they carry these products. Usually these illnesses begin with vomiting, and end with diarrhea. The diarrhea can last for up to 7-10 days. As long as the child is well hydrated, this is not worrisome. If there is blood in the stool, worsening abdominal pain, the child also has fevers and a rash, or the diarrhea lasts for more than 7 to 10 days, we would like to see your child in the office. Sometimes, no matter what we do, we cannot keep up with the loss of fluids. If your child is not tolerating fluid despite the above methods, if they are lethargic, or have had significantly less urination, they may benefit from intravenous fluids. Speak to one of our doctors, and we will recommend the best course of action. Children should not be in school if they are vomiting, have fevers (greater than 100.4F), have loose bowel movements that cannot be contained in a diaper, or cannot keep up with regular activities. Hand washing is the most important method to prevent the spread of these viruses.
Starting Solid Foods Starting solid foods is a very exciting time for parents and infants. We generally recommend that solids start between 4 and 6 months of age. Before that time, most babies do not have control over their tongues and mouths, and still have a newborn tongue-thrusting reflex that can make feeding difficult. When starting solids, the infant should be sitting up in a high chair, and should be fed with a spoon. We do not routinely recommend mixing cereal or other foods in the baby's bottles. The first foods to introduce to infants are usually cereals. Rice cereal and oatmeal are usually first, followed by barley, and later the mixed cereals. Most parents use dry baby cereal to which water, formula, or breastmilk may be added. Usually we start with about one tablespoon of cereal mixed with about 3 tablespoons of one of the above liquids. The thickness of the cereal can be adjusted to whatever is easiest for the baby. Do not be surprised if much of the first feeds end up on the baby's face or on the floor. Eating solids is a learning process. There is no set schedule or amount of food that infants must take. After beginning solids, most babies have solids meals two to three times a day. They may take slightly less formula or breastmilk. Babies are excellent at determining when they are hungry and when they are full. Every baby is different. If your baby is gaining weight, having wet diapers and soft stools, and gradually increasing the variety and amount that they consume, they are doing great. After the baby is taking one or two varieties of cereals well, we advance to other solids, such as fruits and vegetables. Most parents use commercially made jarred foods. Stage 1 foods are the easiest for the infants to eat and digest. Usually we start with one of the Stage 1 foods such as sweet potato or carrot, and advance a new food every 4-5 days. If your baby has any side effects such as a new rash, diarrhea, or vomiting that you feel is associated with a new food, stop the food and ask one of our pediatricians. Some parents wish to make their own foods. All foods must be soft and should have no added flavoring or salt. Some foods to avoid making at home are carrots, beets, turnips, spinach, and collard greens. There may be high levels of nitrates in these foods that can cause anemia in babies. Prepared jar foods are tested for nitrates, so tend to be safer for these particular foods. As your baby matures, he or she will be able to start eating finger foods (usually around 9 months). Easily dissolving "puffs" are good to teach your infant how to mash solid food in their mouths. As they learn to eat these, they can be advanced to other finger foods. Commercial low sugar cereals such as Cheerios, small pieces of soft fruit like bananas, small pieces of soft cheese, and small soft pieces of chicken are good starter foods. Allergic foods such as nuts, cow's milk, soy, eggs, fish and shellfish should be avoided until the baby is at least 12 months old. Nuts, seeds, popcorn, raw vegetables, hard candy, and gum are choking hazards and should be avoided until age 4. Round foods such as grapes and hotdogs must be cut into appropriate small pieces to avoid choking. Juice is not necessary and can often make babies full, unable to eat foods with good nutritional content. If you do introduce juice, do so only after 6 months, only in a sippy cup, and only in small amounts (4 ounces or less). Juice should also be watered down to decrease the amount of sugar. Babies can be given extra water in a sippy cup if they seem thirsty. Infancy is an excellent time to get a baby used to drinking plain water, which is much healthier than juice, avoiding future "sweet tooth" problems. It is important to use plain tap water, since it is fortified with the fluoride necessary to prevent cavities. Your baby's stools will change dramatically after starting solid foods. They will change colors, become more solid, and smell much more than previously. This is generally not constipation. As long as the baby is passing soft bowel movements without pain there is not a problem. While we do not introduce cow's milk until after the baby's first birthday, yogurt and small soft pieces of pasteurized cheese are fine after about 8 months. Healthy eating habits start early. Eat together as a family as often as possible. Model healthy eating habits for your baby by eating many different fruits and vegetables and avoiding fatty and sugary foods and drinks. Do not eat in front of the TV, and avoid fast and fried foods.
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