Children are encouraged to get regular checkups. In addition to answering a parent’s questions, these visits are meant to reinforce a healthy lifestyle and to screen for certain conditions based on the child’s age. For babies and toddlers, screening questions focus on nutrition, growth and development, and safety. For school-aged children, this focus is broadened to include exercise, academic readiness, and the management of common childhood problems. Adolescents need more independence and should spend some time alone with the doctor.
Every checkup includes a physical examination where the doctor ensures the child is growing well and does not have any problems that could interfere with his health. Checkups are also accompanied by vaccinations to prevent the large number of serious diseases that children are at risk for.
Each question or test a doctor does has a purpose. For example, screen vision and hearing is screened yearly for two reasons:
- Children may not notice if they are not seeing or hearing well.
- Research has shown that vision and hearing can change over a span of six to twelve months.
The reason most pediatricians do not do blood tests every year is because the situation is different when it comes to blood work. Doctors routinely check for anemia (low blood count) at nine months and two years of age because the rapid growth of early childhood is a risk factor for developing iron-deficiency. However, if a child is healthy and has a healthy diet, the likelihood of developing anemia in elementary school is very low. This does not mean a doctor will not do blood work throughout this time period, however. But research does not support doing yearly blood counts on most children. Adolescent girls need blood counts more frequently because menstruation puts them at increased risk for iron-deficiency.
Other blood tests you may have heard of include:
- Cholesterol levels
- Liver and kidney tests
- Lead tests
- Vitamin D levels
While each of these tests is important, there is no reason to do them on a yearly basis. Each doctor will decide when to do them based on the child’s age and certain risk factors, which include family history, if the child has an underlying medical problem, and where the child lives.
The American Academy of Pediatrics (AAP) recommends breastfeeding for the first year. Most mothers are unable to breastfeed their babies for the entire year because of work or family situations. This is perfectly acceptable.
If breast milk is unavailable, babies should be fed an iron-fortified formula. Babies are transitioned to whole milk at one year of age. In most cases, babies do not need the special formulas that are marketed for the second year of life.
The AAP recommends that children drink whole milk until two years unless there is a reason to switch the baby to low-fat milk sooner. Doctors may make this recommendation for clinical reasons or because there is a family history of obesity, heart disease or a cholesterol problem.
The reason the AAP recommends whole milk until two years has to do with a baby’s growth and development. Infants triple their birth weight by one year of age and quadruple their birth weight by two years. During this period, a baby’s brain and nervous system are making amazing gains in size and complexity. Because the brain and nervous system are largely composed of fat tissue, it is reasoned that the baby should have a higher fat diet during this period of time.
Whole milk contains approximately 4% milk fat. Because children often have difficulty with transitions, it may help to gradually switch your child from whole milk to lower fat milk. Therefore, some doctors recommend that children get reduced fat (2%) milk for a few weeks before switching them to low-fat (1%) or no-fat (skim) milk.
Swaddling is a time-honored method to help babies calm down. It helps fussy babies relax during wakeful periods and makes it easier for most newborns to sleep.
Infants respond to swaddling for two reasons:
- Newborns have a number in innate reflexes, including the Moro (or startle) Reflex. If a newborn is jostled or surprised by a noise or physical movement, he will typically extend his arms outward and then rapidly flex them in front of his body. A Moro response can be triggered by an infant’s own movements or by actions coming from his surroundings. Either way, the reflex may cause the infant to wake up or start to cry. Swaddling inhibits the Moro Reflex.
- Before birth, infants are in the confined space of the uterus. While it is important to be able to move their arms and legs after birth, research has shown that newborns calm down if they are held with their arms against their bodies. This can be accomplished by a reassuring hug or by swaddling them in a blanket.
Like all aspects of parenting, it is important to strike a balance with your baby. It is important for your baby to experience different types of physical interactions. This includes hugs, kisses, skin-to-skin contact, gentle rocking, and massage, etc. So while swaddling can be a real “life saver” when a baby is fussy it is best used when the child is sleeping or for brief periods (around 20 to 30 minutes) while awake.
Two aspects of swaddling are important for you to consider:
- The best way to swaddle babies is by keeping their arms at their sides. The reason for this is because most babies will “break out” of the swaddle if their arms are positioned in front of their chest. There are a number of commercial blankets to make this easier to do.
- The goal of swaddling a baby is to restrain his arms. The swaddle should not restrict the baby’s legs because it is important for him to be able to flex his knees and hips at all times. The reason this is important is because infants can develop a hip problem (developmental dysplasia of the hip) if their hips are restrained in an extended (straight) position.
Most doctors recommend that parents stop swaddling babies by about four months. At this age, the newborn reflexes that can interfere with a baby’s sleep have disappeared and many babies are starting to roll (and trying to break out of a swaddle). This is also the time when a baby will more actively interact with his surroundings. He will grab objects and explore them with his mouth. He may use a pacifier or suck his thumb for self-soothing purposes.
For most children, immunizations are the most stressful part of an annual checkup. We have a policy in my office that helps reduce the anxiety associated with this necessary evil. Whenever a child needs two vaccinations, we administer the shots simultaneously. This works for a couple of reasons. First, having two nurses in the room helps to distract the child. Second, receiving both shots at once reduces the pain, possibly because the child perceives them as one injection instead of two.
Diarrhea is a common symptom in pediatrics. In most cases, children have a viral gastroenteritis (“stomach flu”) that does not require any lab work. In some cases, however, it’s important to find out what’s causing the symptoms.
Although it’s relatively easy for children to leave a urine specimen during an office visit, it is much harder to produce a bowel movement on command. Also, kids may be embarrassed at the thought of having to collect a stool specimen at the doctor’s office.
This situation can be avoided if you bring a stool specimen anytime your child is being seen with significant intestinal symptoms. If in doubt, ask the nurse who scheduled the appointment whether a stool specimen might be needed. If you end up not using the sample, it’s easy to dispose of when you return home.
A few rules (and tips) are in order when it comes to collecting stool samples.
- Do not scoop poop out of the toilet. It needs to go directly from the child’s bottom right into a container that comes with a tight-fitting lid.
- Older kids may be horrified at the thought of collecting stool, even in their own home. If this happens, ask your child to defecate into the container and leave the bathroom. You can then go in and prepare the sample for the office.
- Some kids may complain because there isn’t enough room to hold a container while they poop. In this instance, it may help if the child sits on the toilet backwards. One of my colleagues calls this going “cowboy style.”
- It may be hard for younger children to poop without urinating at the same time. In this situation, you can create a “hammock” out of plastic wrap that hangs below the toilet seat. If you poke a few holes in the plastic, urine can leak through the wrap, but the stool will be “caught.”
- Depending on the tests being ordered, the doctor may want poop that is kept cold, left at room temperature or both. If the sample needs to be cold, you should keep it in the refrigerator. However, regardless of where the sample is kept, putting it in a brown paper bag will keep the rest of the family from walking around holding their noses all day.
It’s very common for newborns to become jaundiced by the second or third day of life. Jaundice is a medical condition that presents with yellowing of the skin or sclera (whites of the eyes). It is due to a build up of bilirubin in the baby’s system.
Bilirubin is a breakdown product of red blood cells. Red blood cells live for three months after which the body breaks them down. Tens of thousands of red blood cells are destroyed and remade every day. Part of the breakdown process involves the release of bilirubin into the circulation. Before birth, a baby’s mother helps clear bilirubin from his blood. (Bilrubin is removed from the body by the liver.) Once the baby is born, he has to take over this process himself. Like many things, a newborn’s ability to process bilirubin is immature. As a result, bilirubin builds up in the circulation and can be seen in the baby’s skin.
Bilirubin is not dangerous to newborns unless it gets very high. The hospital staff follows standard protocols to make sure bilirubin levels stay in the safe range. In the past, this was done by visually checking the baby’s skin color. Nowadays, the bilirubin is checked every eight hours by placing a bilirubin meter on the baby’s forehead. If the reading is higher than expected for the baby’s age, the nurse will order a blood test to confirm the reading.
Most of the time, nothing needs to be done to treat a baby’s bilirubin. If the level continues to rise, the doctor may do additional blood tests, supplement the baby with formula or treat the bilirubin with something called phototherapy. This involves exposing the baby’s skin to ultraviolet light that increases bilirubin breakdown.
Because parents are commonly discharged when their newborn is 48 and 72 hours old, jaundice may not be noticed during your time in the hospital. When you have your first post-hospital visit, the doctor will carefully assess the baby’s skin to make sure he hasn’t gotten jaundiced since his discharge from the nursery. If necessary, additional blood tests and recommendations will be made at that time.
It is important for you to know that jaundice in the immediate newborn period is different from jaundice at any other time in a child’s life. If you notice that your one to 2-month-old baby is jaundiced, you should promptly call your doctor for an appointment.
Babies are traditionally weaned from formula after their first birthday. Although you can wean them from bottles when they are older, transitioning them to cups at the same time you discontinue formula is preferable for two reasons. First, it’s better for a toddler’s language development if he drinks from a cup versus a bottle. The reason for this is because babies protrude their tongues when drinking from a bottle. Drinking from a bottle in the second year of life may increase their risk for developing speech problems. Second, if toddlers are weaned from the bottle at 18 to 24 months, they are more likely to stop drinking milk. They have been drinking milk from a bottle for so long, many of them simply won’t drink it from a cup. (Imagine your reaction if you were served a spaghetti sandwich, and you will understand how the “presentation” of a food item can affect ones desire to consume it.)
No one has researched the best way to wean babies, but the following method is the one I’ve been using for the past twenty years:
- After your child’s first birthday, continue to give him formula from the bottle, but start offering whole milk in a straw cup at other times during the day. (Straw cups are preferred to sippy cups because they are better for speech development.)
- After your child has been drinking milk from a straw cup for a week or so, start to dilute the formula in his bottle with water. Replace one ounce of formula with water every few days.
- By gradually replacing the formula with water, you will be making the bottle a less desirable experience. In most cases, your child will figure out that whole milk in a cup is preferable to diluted formula in a bottle.
- After a few weeks, the bottle will only contain water. Some babies may drink it, but most will reject the bottle before this point.
- If your child refuses to drink milk from a cup after you have finished the dilution process, you should discuss this with your doctor.