In the past, babies rarely got funny shaped heads because they slept on their tummies. When we started putting babies to sleep on their backs 20 years ago, unusual head shapes started to be noticed. The pictures above show three types of head shapes: symmetrical, plagiocephaly (flat on one side) and brachycephaly (flat along the back).
A baby’s head will take on an unusual shape if he spends more time sleeping with his head in one direction. This occurs because more pressure is applied to one area and the head “molds” the corresponding location. In most cases, this represents a temporary finding that will resolve over time.
When pediatricians examine babies with unusual head shapes, we look for two problems. This first is a common condition called congenital muscular torticollis. If a baby has torticollis, the neck muscles that bend and rotate the head are tighter on one side causing the baby to spend more time turned in one direction when asleep. It many cases, it will also be noticed when the baby is awake. Over time, this will deform the shape of the skull. Torticollis is treated with physical therapy or watchful waiting depending on its severity.
The second is a rare condition called craniosynostosis. In this situation, one of the skull bones is not growing properly because it is “stuck” to the opposing bone, causing a misshapen head. If there is a question whether your baby has this condition, he will be x-rayed or referred to a pediatric specialist (neurosurgeon or plastic surgeon) for a thorough evaluation.
For the past 10 years or so, companies have sprung up to “fix” plagiocephaly and other asymmetric head shapes. A handful of studies have been published showing that this is not necessary. If your baby’s head is flat on the side or back because of positional forces, the problem will usually resolve by 2 to 3 years of age. The head may not look perfect, but a corrective helmet won’t make it look any better.
Now that babies sleep on their backs, it’s important for them to get tummy time throughout the day to help strengthen the muscles in their arms, neck, shoulders and back. I usually recommend that parents start tummy time when babies are 4 weeks of age. You could do this sooner, but I figure parents have enough things to worry about in the first month without putting tummy time on their list.
There is no “right way” to do tummy time, but it makes sense to do it when babies are alert. First, put the baby tummy down on a firm surface like a couch, bed or the floor. If possible, lie down next to the baby, which will encourage her to look up and see your face. If the baby is fussy, you can help support her upper body by pulling her elbows in to her sides. If you smile and talk to your baby, she will be more likely to work her muscles to make tummy time a success. If your baby is still fussy, try putting her on a slant to make it easier to look up. The best way to accomplish this is to put her on her father’s chest while he is lying at a 30-degree angle.
Do tummy time for 5 to 15 minutes a handful of times during the day and evening. Obviously, how long tummy time lasts will depend on your baby’s interest. Never leave the baby alone in this position, even for a second, or she may roll over and hurt herself. Likewise, make sure you are alert because we don’t want babies to fall asleep during tummy time because that is a SIDS risk just like sleeping on their tummies at night.
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.
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.
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.
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.
A common finding in male infants is a circumcised penis that has some extra foreskin—it is most noticeable on the underside of the penis. When babies are circumcised, the person doing the procedure has to be careful not to remove too much foreskin. As a result, sometimes a little extra skin will remain behind the head of the penis (glans). It is very important to retract (pull back) this skin in the immediate post-circumcision period so it does not heal to the head of the penis, which could cause problems later. This is one of the things the doctor should check at your first post-hospital visit.
If the circumcision heals properly, the extra skin may develop a thin attachment to the back portion of the glans in early childhood. (Your doctor will be able to tell the difference between a post-circumcision scar and this thin attachment.) It is not necessary to do anything if your child’s penis has a thin attachment because it will resolve over time.
It is common knowledge that you don’t have to pull back on a baby’s foreskin to get it to detach from the head of the penis (glans). This is a natural process that will occur as the baby grows. Like many aspects of growth and development, a child’s foreskin detaches from the glans gradually. Once the foreskin is fully retractable, it’s important to clean the glans daily with mild soap and water. The purpose of this cleansing is to keep the penis clean and wash away any smegma that accumulated under the foreskin. Smegma is a whitish, greasy substance that is found normally in uncircumcised males.
There is a finding that may occur in uncircumcised children, which can worry parents. Smegma sometimes accumulates under the foreskin before it fully retracts. These accumulations are called “smegma pearls” because they have a round or oval appearance. Most of the time, they are whitish, but on occasion they have a yellowish hue. If this happens, parents may conclude that their child has an infection. There is an easy way to determine if the child has foreskin infection vs. a smegma pearl. The tissue surrounding an infection is red, swollen and tender. If your baby has a white or yellow accumulation under the foreskin that doesn’t look angry and isn’t tender to touch, it’s not likely to be infected. Of course, if you have any questions about this, call your doctor.
It’s very common for the penis of an older infant or toddler to look smaller than it is. Parents (especially dads) worry that the child will have a small penis when he is older. Unless a child had an abnormally small penis at birth, this finding is usually due to something doctors call a “buried” or “hidden” penis.One of the cute things about young children is that they are pudgy. In particular, children often have a prominent fat pad in front of the pubic bone. When this occurs, the penis tends to disappear within the fat pad making it appear small. In some cases, all you may see is the tip of the penis poking out of the fat pad like a tiny turtlehead.The way to assess the true length of the penis is to gently push down on the fat pad. When you do this, you will notice that the penis elongates revealing its true size as the fat is pushed towards the baby. I use this maneuver to reassure parents on a daily basis.