In my last blog, I mentioned that 6 muscles control the movement of each eye. This is a lot for a newborn’s brain to coordinate. As a result, it’s common for a newborn’s eyes to “wander” in the first few months of life. In most cases, the eyes move inward instead of outward. They are also more likely to wander when a baby is tired.
If the family history is positive for strabismus (lazy eye), the baby’s eyes are constantly out of balance or the baby’s eyes wander after 6 months of age, she should see a pediatric ophthalmologist. Keep in mind that eyes are supposed to converge (come together) if someone is looking at an object close up.
Like all referrals, it’s best not to schedule the appointment during the baby’s nap time because she’s more likely to cooperate with the exam is she isn’t tired.
Newborn babies will look at their parents right after birth, but their eyes can’t do more than “fix” on objects for a few weeks. Between 1 and 2 months of age, babies will begin to follow objects during quiet, alert periods. It’s important to realize that this is still a difficult task. There are six muscles that control each eye, and they must work in unison for a baby to follow an object through space.
The best way to get your baby to follow is to put your smiling face 12 to 18 inches in front of her face. Then, move your head slowly in one direction or the other. Most babies will be able to follow you for an arc of about 30 to 45 degrees. After that, their eyes may stop or wander a bit.
Have you ever watched a TV show where someone who’s having a heart attack grabs his left arm or shoulder? Have you ever had a stabbing pain in your forehead or the bridge of your nose after eating ice cream too quickly? With a heart attack, the source of the pain is in the person’s chest. With a brain freeze, the source of the pain is in the roof of your mouth.
Referred pain occurs because the body’s sensory nerves occasionally send signals in the wrong direction. The following examples commonly occur in children:
- When children complain of mouth, cheek or tooth pain, they sometimes have an ear infection.
- When children complain of ear pain, they sometimes have a throat or lymph node infection in their neck.
- When children complain of knee pain, they sometimes have a problem in their hip or testicle.
- When children complain of low back pain, they sometimes have constipation.
- When children complain of stomach pain in the middle of the night, they sometimes have a pinworm infection.
For over 20 years, pediatricians in the United States have recommended that infants sleep on their backs. One of the questions that parents frequently ask is what they should do if their baby starts rolling over before 6 months of age.
Although babies occasionally roll over in the first few months, determined rolling isn’t learned until 4 months or later. If a baby rolls over at night, most doctors (this one included) don’t recommend putting the baby on her back again. This reason for this is simple. If you turn the baby on her back, she will invariably roll to her stomach again. If you do this repeatedly throughout the night, no one will get a good night’s sleep, which could lead to other dangers, i.e., car accidents.
So while I would still recommend putting your baby to sleep on her back, I would leave her alone if she rolls to her stomach.
When parents think about developmental stages in their children, the ones that come to mind are major milestones like smiling, crawling and talking, etc. Despite the obvious importance of these landmarks, I am queried on a regular basis about a handful of “lesser” behaviors children exhibit.
- Hand regard. Babies usually discover their hands by two months of age. This can happen in three ways. First, the baby purposefully sticks his hands or fingers in his mouth to suck on them. Second, the baby starts swatting at things. Third, the baby stares at a fisted hand held in front of his face. The last behavior is called hand regard. Parents may mistake hand regard for a seizure. If your child’s hand jerks rhythmically with this behavior, call your doctor. Otherwise relax and enjoy your baby’s new discovery.
- Developmental drooling. Humans have two types of salivary glands. There are tiny ones in the cheeks and floor of the mouth that function from the time of birth. The parotid glands, which produce large amounts of saliva required for swallowing solid foods, don’t mature until a baby is about 3 to 4 months of age. This corresponds to the baby’s ability to chew and stick his hands in his mouth with ease. Parents often conclude that a drooling 4-month-old is teething. In reality, it’s due to the maturation of the parotid glands.
- The fencing reflex. If you have a 2 to 3 month old, you may have noticed that he sometimes looks like he’s “fencing” when he’s lying on his back with his head turned to one side. The reflex consists of one arm extended and the other flexed as though the baby was getting ready to lunge at his opponent. The medical term for this posture is the asymmetric tonic neck reflex. It disappears by 6 months of age.
- The 6-month cough. Around six months of age, babies get more control over their vocalizations. In addition to babbling and guttural sounds, they often cough on purpose. You can recognize this cough because it is “throaty” rather than coming from deep within the chest. In addition, the child won’t have a runny nose or fever, and she will be acting completely normally except for the cough. The behavior lasts for a month or so, and then the baby moves on to other interests.
- Ear grabbing. I often joke with parents that when babies are first born, they consist of a stomach and a mouth. The stomach demands to be fed and the mouth is equipped with a sucking reflex to make this happen. This is an exaggeration, of course, because babies hear, see and respond to touch. They can even distinguish their mom from other women in the first few days of life. Despite these amazing skills, a newborn has little to no control over her arms and legs and doesn’t have a clue that she has a nose or other body parts. By 6 months, babies are very good at exploring their bodies. Hands and feet go to their mouths, and they often play with their bellybuttons. At 8 or 9 months, babies discover that they have ears. As a result, parents will often see their babies pulling and poking at their ears. This often makes parents wonder if the child has an ear infection. If your child doesn’t have a cold and isn’t fussy, there’s a very good chance that her ear tugging is body exploration rather than a sign of an ear infection.
When children come down with respiratory illnesses, they make lots of noises. The words parents use to describe these noises don’t always agree with how the doctors use the terms. Here’s the lowdown on the noises kids make when they have a cold or the flu.
- Congestion. This occurs with a stuffy nose and sinuses. When a child is congested, he will sound nasal because less air is passing through his nostrils when he talks. Which nostril is clogged varies throughout the day.
- Postnasal drip. If a child has a cold, mucus not only drips out of his nose, but some will also drip down the back of his throat. This can make his voice hoarse or raspy.
- Garbled voice. If a child has enlarged tonsils, he will often sound like he has “marbles” in the back of his throat.
- Chest rattle. Babies and young children don’t do a good job clearing mucus from their nose and throats when they have a cold. As a result, they often produce a rattle-like sound when they breathe. Parents not only hear this noise coming from the baby’s throat, but they may also feel it in the baby’s chest when he’s being held. A chest rattle is not usually a sign of pneumonia.
- Dry cough. This refers to a cough that has a rough, staccato quality.
- Wet cough. This refers to a cough that has a moist quality. It usually happens if a child has postnasal drip or bronchitis. Contrary to what many people believe, bronchitis in children is usually a viral disease and does not require antibiotics.
- Croupy cough. If a child has croup, his trachea becomes swollen below the vocal cords. This creates a hoarse voice and a barky, seal-like cough.
- Stridor. This sound is made during inspiration. It’s a brassy sound associated with a sense of difficulty getting air into the lungs. This is most commonly heard in children with croup: they “bark” when they cough and have stridor when they breathe in.
- Whoop. A classic whoop is heard with pertussis (whooping cough). The whoop is dramatic and occurs after a child has had a prolonged coughing fit. Nowadays, pertussis is more likely to be seen in older children or adolescents rather than babies or toddlers. An older child is more likely to “gasp” than whoop when he takes a breath after a prolonged coughing spell.
- Wheezing. This sound is made primarily during expiration. It’s a medium to high-pitched noise that sounds like the word. It is produced when a child’s bronchial tubes are tight (asthma) or narrowed with mucus (bronchitis, asthma). If a wheezing child is having respiratory distress (difficulty breathing), you may notice certain things when he breathes in: (1) his nostrils flare and (2) the spaces between his ribs pull in (“retract”).
When parents call me about rashes, I often hear that a child has “hives.” In most cases, parents use this term incorrectly. The question is, does that matter?
The factors that cause most rashes in children are environmental (insect bites, heat rash, allergic reactions) or infectious (viruses, bacterial, fungal). Hives are usually caused by viruses, but they can also occur with strep and allergic reactions to foods. (If you suspect that your child has hives because of an allergic reaction to a food, you should give him Benadryl and call the doctor right away. If your child also has coughing or trouble breathing, you should call 911 in case he’s having an anaphylactic reaction.)
The thing that distinguishes hives from other rashes is the margin between the normal skin and the rash. Most of the rashes children get consist of flat areas with or without a scale and small, raised bumps. (Doctors call flat rashes macules, bumps papules and hives wheals.) Papules come in different sizes, but they have one thing in common. The region between normal skin and the lesion rises slowly like a hill. With wheals (hives), the region between normal skin and the lesion rises more sharply, like a plateau. If you’ve ever seen a welt, the raised area at the edge is more characteristic of a wheal than a papule.
Most children contract hand, foot and mouth syndrome before kindergarten. The infection is usually caused by a member of the Coxsackie virus family. It typically presents with fever, sore throat and small blisters on the palms and soles. Some strains of the virus also cause a red bumpy rash on the body. The treatment is the same as it is for most viral infections: rest, fluids and fever control.
When I see kids with hand, foot and mouth syndrome, parents usually ask two questions. (1) How long is the child contagious? (2) When can she go back to daycare or school? The answer to the first question surprises parents. They’re contagious for 2 to 3 weeks after they get sick. The answer to the second question surprises them even more. Kids can return to school as soon as they feel better. What? How can doctors send kids back to school when they’re still contagious? The rationale for this is simple. Up to 20% of children with hand, foot and mouth syndrome are asymptomatic. This means they contracted the virus and are spreading it to others even though they’re not sick themselves. That fact, combined with the long contagious period, means keeping kids home will have no impact on the spread of the disease. That’s why we send them back when they feel better.
Parents often ask if babies need firm, high top shoes once they start to walk. This is especially true if they previously talked to a grandparent or a shoe salesman who recommended a “supportive shoe” so the baby learns to walk properly.
Shoes accomplish four things in babies.
- They keep feet warm on cold days.
- They provide protection from hard or sharp objects.
- They provide traction on slick surfaces.
- They go nice with certain outfits.
What shoes do not do is provide support or teach a baby to walk better. When babies first learn to walk, going barefoot is best. This allows them to feel the floor and makes it easier for them to stand on their toes, which babies love to do. So the best shoe for a baby is a soft, flexible shoe that has good traction on the bottom. The only advantage of a high top shoe is that it’s almost impossible for the baby to pull it off. This may come in handy at church or synagogue.
I often joke with parents that my gynecologic knowledge is limited because most female adolescent patients prefer seeing a woman doctor. However, my daughter suffered with severe cramps, and I learned the following tip from my partner, Promise Ahlstrom, MD.
If your daughter has bad cramps, she should take 400 to 600 mg of ibuprofen as soon as her period starts. Then, she should repeat the dose every 4 hours for the first 24 hours of her period. The goal here is to “stay ahead of the pain.” If a girl takes the first does at 8am, she may be tempted to skip the noon dose if the cramps have subsided. This is a no-no. By missing a dose, the physiology that causes menstrual cramps will worsen. By the second day of her period, she can usually drop the dose to every 6 hours, but she should still take the medicine on schedule. By the third day of her period, she can take the ibuprofen as needed.
Three things can interfere with staying on course with this regimen. First, if a girl is at school, she may need to go to the nurse to get her medication. If the school has a strict policy about leaving class, a note from the doctor can help. Second, some girls forget to take their medicine. This can be overcome by putting reminders in her cell phone or getting a friendly text from mom at the right time. Third, her period may start right before bedtime. In this situation, I would consider waking her up for a dose of ibuprofen unless doing so would disturb her sleep and cause other problems the following day.
If this regimen doesn’t help, your daughter should see her pediatrician or a gynecologist to discuss other options.
In my experience, 90% of girls are not excited when puberty starts. And it’s not just their impending period that’s on their mind. Most girls are happy with the body they have and see no reason for it to change. This uncertainty happens because the physical changes of puberty precede the psychological ones. When I discuss this with girls at their 10- or 11-year-old checkups, my goal is twofold. First, I want them to know that they are not alone in their feelings about puberty. Second, I want parents to know that girls may be reluctant to talk about puberty even though moms want to provide them with the benefit of their experience. However, I encourage moms to always keep their “radar on.” If a girl brings up pubertal issues, moms should drop what they’re doing and be open for a discussion.
I also share a story about what happened in my own home when my daughter, now 21, turned eleven. My wife and I bought Molly a copy of the American Girl book, The Care and Keeping Of You, which is a terrific book for girls entering this stage of their lives. Molly looked at the book and literally threw it across the room. We told her that was okay, but added that her mom would be available to discuss anything in the book if Molly wanted to. Over the next six months, we found her occasionally reading the book at night before bed.
My final comment on this subject at checkups is to remind girls that puberty takes years to finish, and I guarantee that they will be happy with their grownup bodies once the process is over.
Parents often have questions about the things they see in their baby’s mouths. Here are the most common findings you may notice.
- Epstein’s Pearls. These are white spots on the roof of a baby’s mouth. They are usually the size of a sesame seeds. They disappear in a month or two.
- Bahn’s Nodules. These are white spots on the top or sides of a baby’s gums. They are bigger than Epstein’s Pearls, and parents sometimes mistake them for teeth. They disappear by 6 months.
- White or irregular gums. Some babies have smooth gums. Others have tiny ridges. The sides of a baby’s gums sometimes look white instead of pink. These are all normal findings.
- White coating on the tongue. Most parents are aware that newborns can get a yeast infection called thrush. However, if all you see is a thin, white coating on your baby’s tongue, it’s most likely from breast milk or formula. With thrush, you usually see cheesy-looking material on the inside of the cheeks and lips and on the roof of the baby’s mouth.
- Tongue-tie. This is hard for parents to see, but most have heard about it. The bottom of the tongue attaches to the floor of the mouth with a thin band of tissue called the lingual frenulum. In some cases, the frenulum is tight, thick or attaches near the tip of the tongue. If this happens, it may be harder for your baby to nurse properly. Doctors and nurses routinely check for this at newborn visits. In some cases, the baby will be referred to an oral surgeon or an ENT doctor to “clip” the frenulum.
In my last blog, I mentioned that it takes 6 months for testicles to descend from the abdomen into the scrotum. If this process doesn’t occur properly, a baby will be born with an undescended testicle. (If the testicle can be felt in the inguinal canal, it’s referred to as a partially undescended testicle.) In many cases, an undescended testicle will drop to its normal position by 2 to 3 months of life. If this fails to occur, the baby will be referred to a pediatric urologist.
Prior to puberty, a boy’s testicle is roughly the size and shape of a peanut. This fact, combined with an active scrotal reflex, often pulls the testicle into the lower part of the inguinal canal. We call this a retractile testicle. It’s not the same as a partially undescended testicle. In pre-adolescents, testicles commonly “hide” when boys giggle during the genital exam.
The way doctors differentiate between a partially undescended testicle and a retractile testicle is to see what happens when the boy squats. During a squat, a retractile testicle will drop down so it can be easily pulled into the scrotum; a partially undescended testicle will not. If there is any question about this, your child will be referred to a pediatric urologist.
If your child can’t get through the genital exam because he’s ticklish, there is a way parents can identify a retractile testicle without seeing a urologist. Have your child sit in a warm bath for about 5 minutes. Because the testicles are meant to be cooler than the body, retractile testicles will almost always drop down into the scrotum, which itself gets “baggy” in warm water. If you see or feel the testicles in the lower scrotum, you don’t need an appointment with a urologist.
When I see boys for routine physicals, I always check their testicles for lumps or swelling. The most common problem I find in the first year of life is something called a hydrocele. A hydrocele is a collection of fluid around the testicle.
Hydroceles have an interesting history. Although a baby’s gender is decided at the moment of conception, both sexes develop along the same path until the third month of pregnancy. At that point, a group of cells in the lower abdomen develop into ovaries in females or testicles in males. If the baby is a girl, the ovaries are in the correct anatomic position. If the baby is a boy, the testicles need to descend into the scrotum. This process takes about six months. As the testicles move downward, they pass through the inguinal canal before reaching their proper position in the scrotum.
After the testicle enters the scrotum, the inguinal canal is supposed to fuse thereby separating the abdominal cavity from the scrotum. In some cases, this doesn’t happen and a small amount of fluid travels into the scrotum. Most of the time, this occurs before birth and the hydrocele will be detected at the baby’s first examination. In some cases, fluid moves into the scrotum after birth, in which case the hydrocele won’t be found until the baby is older. Most turn up between 1 and 4 months of age.
Hydroceles are not dangerous and usually resolve before a child’s first birthday. If they persist beyond a year, there’s a possibility the child also has an inguinal hernia. In this case, he should see a pediatric urologist or a general pediatric surgeon.
At the time of birth, a baby’s umbilical cord has a shiny, off-white color. Over the next few days, the cord will dry out and turn a dark brown or black color. As this happens, the cord will shrink and often looks like a scab on the baby’s abdomen. In the past, the umbilical stump was coated with a blue dye after birth and parents were told to clean the area with rubbing alcohol at every diaper change. These recommendations were discontinued because they were found to increase the time it took for the cord to fall off. Nowadays, parents don’t need to do anything special other than keeping the stump from becoming irritated by the baby’s diaper and avoiding baths until the cord falls off.
A few things may happen that worry parents during the 7 to 10 days that it takes for the cord to fall off.
- The base of the cord may develop a gooey, greenish-yellow appearance. This is normal and not a cause for concern.
- The cord may smell bad. The reason the cord falls off is because it no longer has a blood supply, and the baby’s immune system is rejecting the dead tissue. If the stump became infected, the skin around the belly button would become red and swollen. If you think your baby’s umbilical stump is infected, you should see the doctor promptly.
- The cord may bleed a little before or after it falls off. If this happens, you can gently clean the excess blood with a cotton swab.
- A red, fleshy lump may appear after the cord falls off. This is called an umbilical granuloma. It’s not serious, but doctors treat the area with silver nitrate to make the lump fall off.
Most food allergies manifest themselves with non life-threatening reactions such as facial swelling or hives. That being said, it’s important to let the doctor know if your child has had an allergic reaction to a food. This will not only reduce the possibility of a serious reaction in the future, but you will be taught how to deal with such reactions.
Oral allergy syndrome is not a serious food allergy. Instead, it’s a mild reaction to foods that many people have not heard about. It occurs when someone experiences an itchy or tingling sensation in his mouth or throat after eating certain foods. The person does not get hives, facial swelling or other symptoms associated with a potentially serious food allergy.
Oral allergy syndrome is seen in people with spring and summer pollen allergies. It turns out that certain food have an allergen (something a person can be allergic to) that cross reacts in people who are allergic to certain types of pollen. Here are some examples.
If you’re allergic to birch pollen, you may react to apples, pears, cherries, plums, peaches, kiwi, celery, carrots, parsley, hazelnuts and almonds. If you’re allergic to grass, you may react to tomatoes, melons, celery, peaches and oranges.
The most interesting thing about oral allergy syndrome is that the person will not have symptoms if he eats the same food after it’s been cooked. In other words, apples cause symptoms, but applesauce does not. The reason you don’t react to the cooked food is because the allergen is destroyed when the food is processed.
Lots of parents think that giving a child acetaminophen or ibuprofen prior to seeing the doctor will compromise the visit. This is not true. Fever reducing medicine won’t make it harder for the doctor to figure out what’s wrong. In fact, reducing a child’s fever usually makes it easier for the doctor because the child is more likely to cooperate if her temperature is lower during the visit.
The same thing is true for asthma medicine or any other drug your child is taking. Unless the doctor or nurse specifically tells you not to give a medicine before a visit, you should do what you can to control your child’s symptoms.
Newborns have a sucking reflex that enables them to nurse or bottle feed. This reflex involves opening their mouths and moving their tongues in and out to “milk” the nipple. When babies start solid foods around 6 months of age, they usually push food out of their mouths because that’s what their tongues are used to doing. It takes a week or more for babies to learn how to use their tongues effectively with spoon-feeding, but they continue with the milking action when taking breast milk or formula.
Sippy cups have been around for as long as I can remember. Straw cups are relatively new on the scene. When babies drink from sippy cups, some of them continue to push out their tongues, which could lead to lisps and other speech problems later on. However, with straw cups, they are more likely to keep their tongues in their mouths, which is theoretically better for speech development.
So which type of cup is better for infants and young children? Here’s what Maia Magder, a speech pathologist at NIH, has to say about the matter: “There is no hard evidence that sippy cups cause speech delays, but it’s important to provide infants with opportunities to move their mouths in more advanced patterns to foster feeding and speech advancement.”
Regular “open” cups are the best for speech development, but babies are pretty messy, so many parents aren’t ready for this step until the toddler years. Here is Maia’s take on getting rid of spouts and straws: “Offering an open cup as early as 8 or 9 months helps with jaw stabilization, which is another important factor in speech development. As for the messiness, like other aspects of parenting, think of it as balancing the new with the old. It’s always important to read a baby’s signs and signals when using cups so that your baby doesn’t choke.”
If you spend time outdoors with children, you’ll need to keep them safe from mosquitos, biting flies and ticks. For young infants, the best approach is to protect them with clothing or nets that cover their strollers. For older children, you’ll need an insect repellent to get the job done. DEET can be used with infants as young as 2 months, but the American Academy of Pediatrics (AAP) recommends not using products with more than 30% DEET: http://www.healthychildren.org/English/safety-prevention/at-play/Pages/Insect-Repellents.aspx. Lower concentrations of DEET work well, but last for shorter periods of time. A 10% concentration lasts for about two hours. I prefer an ingredient called picaridin because it works almost as well as DEET, but feels nicer on the skin. If you want a natural product, the soy-based repellent in Bite Blocker lasts about 90 minutes.
If you use a product containing DEET or picaridin, a lotion or pump spray is safer than an aerosol. Don’t apply it to your child’s hands and be careful to avoid the eyes, nose and mouth. It’s also a good idea to wash it off when you come inside.
You should not use products containing insect repellent and sunscreen. Instead, apply the sunscreen first, wait until it’s absorbed, and then apply the insect repellent. Keep in mind that sunscreen should be used liberally and reapplied every two hours. Bug sprays are applied sparingly and many should not be reapplied. Always read the instructions that come with the product you’re using.
One of the frustrations that comes with itchy rashes is something doctors call the “itch scratch cycle.” The process goes like this: A rash itches so we scratch it. Although the scratching makes the itch go away, it can irritate the skin causing the itch to recur. This can lead to itch-scratch-itch-scratch, etc. Eventually, the skin can become so irritated that scratching the area actually hurts. The best way to deal with this is to put something cold on the itchy/painful area for 5 to 10 minutes. Of course, not getting into this bind is even better.
If your child starts to scratch a bug bite, you can use 1% hydrocortisone ointment (not cream) and a “dot” Band-Aid to stop the itch. First, put a small amount of the ointment on the bite. Second, open the Band-Aid and briefly stick it to your shirt or pants. (This takes some of the adhesive off the bandage so your child is less likely to complain when you remove it.) Third, place the Band-Aid on the bite and leave it in place for about 15 minutes. You can repeat this up to three times a day for four or five days if necessary. Facial skin is thinner than skin on the rest of the body, so don’t use Band-Aids for facial bug bites. The hydrocortisone can still help, but you shouldn’t use it for more than three days.
If the bite gets very red or develops discharge, call your doctor to make sure it hasn’t become infected.