Mayo Clinic Guide to Your Baby’s First Year: From Doctors Who Are Parents, Too!

Frequent checkups with a care provider are an important part of your baby’s first year. These checkups — often called well-baby visits — are a way for you and your baby’s care provider to keep tabs on your baby’s health and development, as well as spot any potential problems. Well-baby visits also give you a chance to discuss any questions or concerns you might have and get advice from a trusted source on how to provide the best possi-ble care for your baby. Well-baby visits sometimes aren’t easy on you or your baby. Your baby might not like getting undressed and measured, and then there are vaccinations. Rest assured, however, that visiting the care provider will soon become a part of your and your baby’s routine and, with time, the visits will become less stressful and more enjoy-able as your baby becomes familiar with exploring the office’s toy selection, and you look forward to finding out just how big your baby is getting. You’ll also find the care provider’s guidance invaluable in the months ahead.CHECKUP SCHEDULE Most newborns have their first checkups within 48 to 72 hours of being discharged from the hospital. This timeline is partic-ularly important for breast-fed babies, who need to have their feeding, weight gain and skin color — in case of jaundice — evaluated. During your baby’s first year of life, he or she should see a care provider at ages: Z2 monthsZ4 monthsZ6 monthsZ9 monthsZ1 yearYour baby’s care provider may also ask to see your baby more frequently. In addi-tion, you can make an appointment for your baby to see a care provider any time your child is sick or you’re concerned about his or her health and development. If possible, both parents should try to attend baby’s first few checkups. This will give both of you a chance to get to know the care provider and ask basic questions. CHAPTER 11Checkups CHAPTER 11: CHECKUPS151

If only one parent can attend, ask a family member or friend to help you nav-igate these early visits. Remembering your questions and listening to your care provider’s advice can be difficult when you’re also trying to undress or calm a fussy baby. An extra set of hands also may prove useful during your first few outings.WHAT TO EXPECT AT EACH VISITEach care provider does things a bit dif-ferently, but here’s what’s generally on the agenda during a well-baby exam.Measuring your baby Your baby’s checkup will usually begin with mea-surements. A nurse or your baby’s care provider will measure and record your baby’s length, head circumference and weight. To get accurate measurements you’ll need to take off your baby’s clothes and, for his or her weight, the diaper. To measure your baby’s length, the nurse will lay your baby on a flat table with his or her legs stretched. The nurse will use a special tape to measure your baby’s head size and an infant scale to weigh him or her. Keep a blanket, a fresh diaper and wipes handy.Your baby’s measurements will be plotted on a growth chart. This will help you and your baby’s care provider see how your baby’s size compares with that of other babies the same age. Try not to fixate on the percentages too much, though. All babies grow and develop at different rates. In addition, babies who are breast-fed gain weight at a different rate than do ba-bies who are formula-fed. Keep in mind that a baby who’s in the 95th percentile for height and weight isn’t necessarily health-ier than a baby who’s in the fifth percen-tile. What’s most important is steady growth from one visit to the next. If you have questions or concerns about your baby’s growth rate, discuss them with your baby’s care provider. Head-to-toe physical exam Your child’s care provider will give your baby a thorough physical exam and check his or her reflexes and muscle tone. Be sure to mention any concerns you have or spe-cific areas you want the doctor to check TIPS FOR SCHEDULING APPOINTMENTSWhen scheduling appointments, think about what are the care provider’s busiest times. You might have the best chance of getting in and out of the care provider’s office quickly if you ask for the first appointment of the day or choose a time right after lunch. On the other hand, if you think you’d like to have extra time to speak with your baby’s care provider, you might ask for an appointment at the end of the day. Also, try to avoid making appointments on Mondays and Fridays, as well as on holidays when the care provider’s office is open. These days tend to be busier than others. The end of summer vacation also tends to be a busy time for care providers, since many children are required to have a physical before the start of the new school year. 152 PART 2: BABY’S HEALTH AND SAFETY

out. The more information you can pro-vide about your baby’s health, the better. Here are the basics of what provider’s commonly check for during an exam: Head Your baby’s care provider will likely check the soft spots (fontanels) on your baby’s head. These gaps between the skull bones give your baby’s brain plenty of room to grow in the coming year. They’re safe to touch and typically disap-pear within two years, when the skull bones fuse together. The care provider may also check ba-by’s head for flat spots. A baby’s skull is soft and made up of several movable plates. If his or her head is left in the same position for long periods of time, the skull plates might move in a way that creates a flat spot. If flat spots are a concern, con-tinue to place your baby on his or her back to sleep. However, your baby’s care pro-vider may recommend alternating the di-rection your baby’s head faces in the crib, giving your baby more tummy time while he or she is awake, and limiting the amount of time your baby spends in a car seat — unless he or she is actually riding in a car. If these types of changes are made, the flattening typically improves in two to three months. Occasionally, babies need to wear a positioning helmet to im-prove head shape.Ears Using an instrument called an otoscope, the care provider can see in baby’s ears to check for fluid or infection in the ears. The care provider may ob-serve your baby’s response to various sounds, including your voice. Be sure to tell the care provider if you have any con-cerns about your son’s or daughter’s abil-ity to hear or if there’s a history of child-hood deafness in your family. Unless there’s cause for concern, a formal hear-ing evaluation isn’t usually needed at a well-baby exam. Eyes Your baby’s care provider may use a flashlight to catch your child’s attention and then track his or her eye movements. PREMATURE BABIESIf your baby was born prematurely, his or her growth and development will be measured using his or her corrected age — your baby’s age in weeks minus the number of weeks he or she was premature. For example, if your baby was born eight weeks early, at age 6 months, or 24 weeks, your baby’s corrected age is 4 months, or 16 weeks. This adjustment will be necessary until your baby reaches age 2½. Vaccinations, however, will be given to your baby according to his or her chronological age.

The provider may also check for blocked tear ducts and eye discharge and look in-side your baby’s eyes with a lighted instru-ment called an ophthalmoscope. Be sure to tell the care provider if you’ve noticed that your baby is having any unusual eye movements, especially if they continue beyond the first few months. Mouth A look inside your baby’s mouth may reveal signs of oral thrush, a com-mon, and easily treated, yeast infection. The care provider might also check your baby’s mouth for signs of tongue-tie (an-kyloglossia), a condition that affects the tongue’s range of motion and can inter-fere with a baby’s oral development as well as his or her ability to breast-feed. As your child gets older, the care pro-vider may ask whether your baby has started to drool more than usual, become fussy or irritable, or lost his or her appe-tite. These are often the first signs of teething. Your baby’s care provider will check for emerging teeth. After teeth erupt, he or she will likely discuss with you the importance of regularly cleaning your baby’s new teeth to prevent decay.Skin Various skin conditions may be identified during the exam, including birthmarks, rashes and jaundice, a yel-lowish discoloration of the skin and eyes. Mild jaundice that develops soon after birth often disappears on its own within a week or two. Cases that are more se-vere may need treatment. For more on jaundice, see page 378.Heart and lungs Using a stethoscope, your baby’s care provider can listen to your baby’s heart and lungs to check for abnormal heart sounds or rhythms or breathing difficulties. Abdomen, hips and legs By gently press-ing a child’s abdomen, a care provider can detect tenderness, enlarged organs or an umbilical hernia, which occurs when a bit of intestine or fatty tissue near the navel breaks through the muscular wall of the abdomen. Most umbilical her-nias heal without intervention by the toddler years. The care provider may also move your baby’s legs to check for dislo-cation or other problems with the hip joints, such as dysplasia of the hip joint. Genitalia Your baby’s care provider will likely inspect your son’s or daughter’s genitalia for tenderness, lumps or other signs of infection. The care provider may also check for an inguinal hernia, which results from a weakness in the abdominal wall. For girls, the doctor may ask about vaginal discharge. For boys, the care pro-vider will make sure a circumcised penis is healing well during early visits. The care provider may also check to see that both testes have descended into the scrotum and that there’s no fluid-filled sac around the testes, a condition called hydrocele.

Nutrition information Your baby’s care provider will likely ask you about your baby’s eating habits. If you’re breast-feeding, the care provider may want to know how often you’re feeding your baby during the day and night and whether you’re having any problems. If you’re formula-feeding, the care provider will want to know how many ounces of formula your baby takes at each feeding. In addition, the provider may also discuss with you your baby’s need for vi-tamin D and iron supplements. He or she will likely also ask how many wet diapers and bowel movements your baby pro-duces on a daily basis. Although breast milk or formula will be the main part of your baby’s diet throughout the first year, there will come a time when you will want to discuss in-troducing your baby to solid foods. A care provider can offer advice on the best foods to start with, the importance of making healthy choices and how to feed your baby. Once your baby starts eating solid foods, your child’s care provider may check to see if you’re having any problems feeding your baby or if your baby has had any allergic reactions. If you’re concerned about your baby devel-oping food allergies, discuss the issue with his or her care provider. As your son or daughter gets older, discussion topics may include drinking from a sippy cup and when it’s OK for your child to start to use utensils to feed himself or herself. You might also discuss weaning your baby from the bottle by age 1 and how to start giving your baby whole cow’s milk after he or she turns 1. Sleeping status Your child’s care pro-vider may ask you questions about your baby’s sleep habits, such as how you put your baby to sleep and how many hours he or she is sleeping during the day and night. Don’t hesitate to discuss any concerns you may have about your baby’s sleep habits. Development Your baby’s develop-ment is important, too. Over the course of your baby’s first year, the care provider will monitor your baby’s developmental milestones in five main areas, including: Gross motor skills These skills, such as sitting and walking, involve the movement of large muscles. Your baby’s care provider may ask you how well your baby can control his or her head. Is your baby FAILURE TO THRIVEFailure to thrive is a term — not a disease or diagnosis — that’s used to describe a baby or toddler who isn’t growing or developing at an appropriate rate. The term might be used when a child’s weight or height appears below the fifth percentile on a growth chart or if a child’s growth rate is lower than expected. Failure to thrive can be caused by multiple issues, such as an underlying health problem or environmen-tal problems. If your care provider is concerned about your baby’s growth and devel-opment, he or she may ask you questions about your pregnancy and delivery, your baby’s medical and dietary history, and your family history. With early intervention, many children respond well and catch up in their growth and development. CHAPTER 11: CHECKUPS155

attempting to roll over? Is your baby trying to sit on his or her own? Is he or she trying to crawl and pull himself or herself up into a standing position?Fine motor skills These skills involve the use of small muscles in the hand. Does your baby reach for objects and bring them to his or her mouth. Is your baby using individual fingers to pick up small objects? Can your baby transfer objects from hand to hand?Personal and social skills These skills enable a child to interact and respond to his or her surroundings. Your baby’s care provider may ask if your baby is smiling. Does your baby relate to you with real joy? Does he or she play peekaboo? Is your baby showing stranger anxiety?Language skills These skills include hear-ing, understanding and use of language. The care provider may ask if your baby turns his or her head toward voices or other sounds. Does your baby laugh? Is he or she responding to his or her name? Does your baby appear to understand the word ? Is your baby babbling? noCognitive skills These skills allow a child to think, reason, solve problems and understand his or her surroundings. Your baby’s care provider might ask if your baby can bang together two cubes or search for a toy after seeing you hide it? Development milestones are dis-cussed further in Part 3 of this book.Behavior Your child’s care provider may ask you questions about your child’s be-havior. Explain what you’ve noticed so far and anything that seems out of the ordi-nary to you or is causing you concern. As your baby gets older and begins exploring everything in sight, you may find yourself saying no quite often. Your baby also might get frustrated as his or her growing sense of independence con-flicts with his or her limited vocabulary and physical abilities. Your baby’s care provider might discuss the importance of providing a predictable home environ-ment and routine and acting calmly when handling meltdowns. Vaccinations Your baby will need a number of vaccinations during his or her first year. The care provider or a nurse will DEVELOPMENTAL DELAYSIf your baby doesn’t reach a specific milestone by an expected age, he or she may have a developmental delay. Delays can occur in one or several areas of develop-ment. Your baby’s care provider might ask you about factors that can contribute to a delay, such as a history of developmental delays in the family or stressful home conditions. If your baby has a developmental delay, the care provider can recom-mend a type of developmental therapy that may help your baby make progress. Most babies are eligible to receive a wide range of therapies in their homes, often at no cost. Early identification of a developmental delay is important because it will en-able you to get your baby the help he or she needs as soon as possible. For more information on developmental delays, see Chapter 40.156 PART 2: BABY’S HEALTH AND SAFETY

explain to you how to hold your baby as he or she is given each shot or, in some cases, an oral solution. Be pre-pared for tears. Keep in mind, however, that the pain caused by a shot is typically short-lived and the benefits are long last-ing. Chapter 12 provides more detailed information on the immunizations your son or daughter will receive during the first year. Safety Your child’s care provider may talk to you about safety issues, such as the im-portance of placing your baby to sleep on his or her back and using a rear-facing in-fant car seat. As your baby becomes more mobile, the care provider may give you tips for baby-proofing your home. He or she may discuss how to prevent falls and the importance of water safety. QUESTIONS AND CONCERNSDuring your son’s or daughter’s check-ups, it’s likely that you’ll have questions, too. Ask away! Nothing is too trivial when it comes to caring for your baby. Write down questions as they arise be-tween appointments so that you’ll be less likely to forget them when you’re at your baby’s checkup. Feel free to ask your ba-by’s care provider for advice on topics that aren’t medically related, too. For example, if you’re looking for child care, ask the care provider if he or she has any advice. Also, don’t forget your own health. If you’re feeling depressed, stressed out, rundown or overwhelmed, describe what’s happening. Your baby’s provider is there to help you, too. Before you leave the care provider’s office, make sure you know when to schedule your baby’s next appointment. If possible, set the next appointment be-fore you leave the provider’s office. If you don’t already know, ask how to reach your child’s care provider in between ap-pointments. You might also ask if the care provider has a 24-hour nurse informa-tion service. Knowing that help is avail-able when you need it can offer peace of mind.KEEP A RECORDConsider starting a file, notebook or electronic medical record for your baby’s medi-cal information, such as his or her vaccination record, measurements, and any pre-scriptions or lab test results. Taking time to organize your child’s health information will give you a chance to review any information the care provider gives you. It’s also a good habit to start early because when your child enters school or preschool, you will likely be required to provide certain medical information. Plus, your notes about your baby’s growth make for a cherished keepsake. CHAPTER 11: CHECKUPS157



Before you met your baby, did you think about his or her health? Chances are, you did. Think back to your pregnancy — the things you did to keep yourself healthy and to prevent problems from occurring, so the baby inside you could grow and develop. Prevention is crucial to good health. It’s far better to prevent a disease than to treat it. And one of the best ways to pro-tect your family from many diseases is to get vaccinated. Immunization is the best line of defense against diseases such as tetanus, hepatitis, influenza and many other infections. Thanks to vaccines, many infectious diseases that were once common in the United States are now rare or nonexis-tent. As a parent, you no longer have to fear that your child will die of or become disabled by smallpox and tetanus. And you no longer have to keep your children away from water fountains and swim-ming pools to avoid getting polio.Truth be told, vaccinations aren’t ex-actly fun — for children and parents alike. It’s hard to see your little one cry after receiving a series of shots. But as much as you want to shield your child from discomfort and tears, keep in mind that the discomfort is temporary and very minor compared with the potential dis-comfort of a serious disease. Vaccinations have saved billions of lives worldwide. However, despite the availability of vaccines, many people re-main underimmunized. One reason is that some people have concerns about the safety and risks of vaccines. In addi-tion, some people feel it’s dangerous to give more than one vaccine at a time, and others feel certain vaccines are no longer needed. These concerns are often the re-sult of incorrect information.HOW VACCINES WORKEvery day, the human body is threatened by bacteria, viruses and other germs. When a disease-causing microorganism CHAPTER 12Vaccinations CHAPTER 12: VACCINATIONS 159

enters your (or your child’s) body, your immune system mounts a defense, pro-ducing proteins called antibodies to fight off the invader. The goal of your immune system is to neutralize or destroy the for-eign invader, rendering it harmless and preventing you from getting sick.One way the body’s immune system fights off foreign invaders is through what’s called post-exposure immunity. After you’ve been infected with a certain organism, your immune system puts into play a complex array of defenses to pre-vent you from getting sick again from that type of virus or bacterium.Another way the immune system prevents disease is through vaccine im-munity. With this method, a person avoids having to get infected with the or-ganism. A vaccine — which contains a killed or weakened form or derivative of the infectious germ — triggers your im-mune system’s infection-fighting ability without exposure to the actual disease. When given to you before you get infect-ed, the vaccine makes your body think that it’s being invaded by a specific or-ganism, and your immune system begins building defenses against the organism’s invasion to prevent the organism from infecting you again.If you’re exposed to a disease for which you’ve been vaccinated, the invad-ing germs are met by antibodies prepared to defeat them. And vaccines can be giv-en without the risk of the serious effects of disease.Sometimes it takes several doses of a vaccine for a full immune response — this is the case for many childhood vac-cines. Some people fail to build immunity to the first doses of a vaccine, but they often respond to later doses. In addition, the immunity provided by some vaccines, such as tetanus and pertussis, isn’t life-long. Because the immune response may decrease over time, you may need an-other dose of a vaccine (booster) to re-store or increase your immunity. And for some diseases, the organism evolves, and a new vaccine is needed against the new form. This is the case with the annual flu (influenza) shot.WHY GET VACCINATED?Because many vaccine-preventable dis-eases are now uncommon in the United States, some people feel less ur-gency about getting themselves or their children immunized. If you wonder if it’s necessary to vaccinate your family and to keep everyone up to date with vaccinations, the answer is yes. Many in-fectious diseases that have virtually dis-

appeared in the United States can reap-pear quickly. The germs that cause the diseases still exist and can be acquired and spread by people who aren’t protect-ed by immunization.As travelers unknowingly carry dis-ease from one country to another, a new outbreak may be only a plane trip away. From a single entry point, an infectious disease can spread quickly among un-protected individuals. Outbreaks of mumps and measles have repeatedly oc-curred in just this way in the United States the past few years.VACCINE SAFETY As a new parent, you might be under-standably leery about giving your child vaccines. You don’t want to do anything to harm your child. And while you know that vaccinations are important, you’ve also heard that they could be harmful, too — possibly causing side effects. You may worry after hearing or seeing reports about a severe “reaction” that occurs shortly after a child’s immunization visit that’s said to be a side effect or complica-tion of the vaccine. Unfounded stories such as these frequently circulate on the Internet.The fact is, vaccines are extremely safe. Before they can be used, they must meet strict safety standards set by the Food and Drug Administration (FDA). Meeting these standards requires a lengthy development process of up to 10 years, followed by three phases of clinical trials. These studies, unlike drug studies, involve tens of thousands of individuals.Once vaccines are licensed and made available to the general public, the FDA and the Centers for Disease Control and Prevention (CDC) continue to monitor their safety. Furthermore, vaccines are subject to ongoing research, review and refinement by doctors, scientists and public health officials. Those who provide vaccines, such as care providers and nurses, must report any side effects they observe to the FDA and CDC.The bottom line is, your child’s chanc-es of being harmed by a disease are far greater than his or her chances of being harmed by a vaccine used to prevent disease.Vaccine additives In addition to the killed or weakened microorganisms that make up vaccines, small amounts of other substances may be added to a vaccine to enhance the immune response, prevent contamination, and stabilize the vaccine against temperature variations and other conditions. Vaccines may also contain small amounts of materials used in the manufacturing process, such as gelatin.One additive that has received much attention is a preservative called thimer-osal, which is a derivative of mercury. Thimerosal has been used in medical products since the 1930s and in small amounts in some vaccines to prevent bacterial contamination. No evidence shows that children have been harmed by its use in vaccines. Nonetheless, child-hood vaccines are now made without thimerosal or with only trace amounts.Vaccines and autism Many parents have heard claims that vaccines cause autism. The most common and specific claims are that autism stems from the measles-mumps-rubella (MMR) vaccine or from vaccines that contain the preser-vative thimerosal. Many large studies have been conducted to investigate these specific concerns, but no link has ever been found between vaccines and CHAPTER 12: VACCINATIONS 161

WELL-CHILD VACCINATION SCHEDULE The following chart lists the recommended routine childhood vaccinations. Vac-cine guidelines for children change fairly often as new vaccines are developed, recommendations on timing and dosages are revised, and more combination vac-cines are created. Check with your child’s care provider to make sure that your child is up to date on his or her vaccinations. You can also view current vaccination schedules from the American Academy of Pediatrics (see page 552).Health insurance usually covers most of the cost of vaccinations. A federal program called Vaccines for Children provides free vaccines to children who lack health insurance coverage and to other specific groups of children. Ask your care provider about it.* Based on 2012 recommendations.† If monovalent HepB is used for doses after the birth dose, a dose at 4 months is not needed.‡The fourth dose of DTaP may be administered as early as age 12 months, provided six months have elapsed since the third dose.Indicates an age-range when vaccination is recommended. Recommended vaccination schedule for children ages 0-18 months*AgesVaccineBirth1 month2mos.4mos.6mos.12mos.15mos.18mos.Hepatitis BHepBHepB †HepB†RotavirusRVRVRVDiphtheria,tetanus,pertussisDTaPDTaPDTaPDTaP‡Haemophilusinfluenzae type bHibHibHibHibPneumococcalPCVPCVPCVPCVInactivatedpoliovirusIPVIPVIPVInfluenzaInfluenza (Yearly)Measles-mumps-rubella(MMR)MMRVaricellaVaricellaHepatitis AHepA (2 doses)Source: Centers for Disease Control and Prevention162 PART 2: BABY’S HEALTH AND SAFETY

autism. In fact, large numbers of studies from around the world have shown, be-yond a doubt, there is no association. Unfortunately, the claims persist, and they’ve led some parents to refuse to vac-cinate their children. The causes of autism aren’t fully un-derstood, and it’s likely that many factors are involved. But scientific evidence over-whelmingly suggests that vaccines are not a possible cause. Some people also worry that receiv-ing too many vaccines early in life can overwhelm a baby’s immune system and that this might somehow lead to autism. Such reasoning doesn’t fit with what we know about the remarkable capacity of the immune system. From the moment a child is born, his or her immune system begins battling microorganisms in the form of bacteria, viruses and fungi on a daily basis. A system that copes with ex-posure to countless bacteria each day can easily withstand exposure to the antigens in vaccines. CHILDHOOD VACCINATIONS Fortunately, many of the most familiar diseases of childhood — measles, mumps, and chickenpox — can be prevented through immunization.Chickenpox Chickenpox (varicella) is a common childhood disease. It can also affect adults who aren’t immune. More children in the United States die of this disease than of any other vaccine-pre-ventable disease.The chickenpox virus is spread by breathing in infected droplets or by direct contact with fluid from the rash, which is the best-known sign of the disease. The rash begins as superficial spots on the face, chest, back and other areas of the body. The spots quickly fill with a clear fluid, rupture and turn crusty.Recommendation Children should re-ceive one dose of the chickenpox vaccine between 12 and 18 months of age.Diphtheria Diphtheria is a bacterial in-fection that spreads from person to per-son through airborne droplets. It causes a thick covering (membrane) to develop in the back of the throat and can lead to se-vere breathing problems, paralysis, heart failure and death. The disease is now rare in the United States.Recommendation The diphtheria vac-cine typically is given in combination with the tetanus and pertussis vaccines (a DTaP shot). Immunization should be-gin when a child reaches 2 months of age. A child should receive five shots in the first six years of life and continue to receive boosters of tetanus, diphtheria and pertussis (Tdap) every 10 years, be-ginning at age 11 or 12. The Tdap vaccine, approved in 2005, is recommended for children 11 years and older instead of the older Td booster vaccine.German measles German measles (rubella) is a contagious disease that spreads through the air from people sick with the infection. It’s typically a mild in-fection that causes a rash and slight fever. However, if a woman develops rubella during pregnancy, she may have a mis-carriage, or the baby could be born with birth defects.Recommendation Usually, two doses of the combination measles-mumps-rubella (MMR) vaccine are given, the first at ages 12 to 15 months and the second at ages 4 to 6 years. CHAPTER 12: VACCINATIONS 163

Hib diseaseHaemophilus influenzae type b (Hib) disease is primarily a child-hood illness, but it can also affect some adults. It’s caused by bacteria that spread from person to person through the air. This infection can cause serious and po-tentially fatal problems, including men-ingitis, sepsis, severe swelling in the throat, and infections of the blood, joints, bones and membranes around the heart (pericarditis).Recommendation The Hib conjugate vaccine is given to children at ages 2 months, 4 months, 6 months and 12 to 15 months. The vaccine typically is given at the same time as other vaccines.Hepatitis A Hepatitis A is a liver disease caused by the hepatitis A virus. It’s usu-ally spread by eating or drinking contam-inated food or water or by close personal contact.Recommendation The two-dose series of hepatitis A vaccine is recommended for all children in the U.S. The first dose is generally given at 12 months and the second dose at 24 months.Hepatitis B The hepatitis B virus can cause a short-term (acute) illness marked by loss of appetite, fatigue, diarrhea, vomiting, jaundice, and pain in muscles, joints and the abdomen. More rarely it can lead to long-term (chronic) liver damage (cirrhosis) or liver cancer.The virus is spread through contact with the blood or other body fluids of an infected person. This can happen by having unprotected sex, sharing needles when injecting illegal drugs, or during birth, when the virus passes from an infected mother to her baby. However, over one-third of people who have hepatitis B in the U.S. don’t know how they got it.Recommendation The hepatitis B vac-cine is given to children in three doses — at birth, at least one month later (1 to 4 months of age) and then at 6 to 18 months.Flu (influenza) Influenza is a viral in-fection that sickens millions of people each year and can cause serious compli-cations, especially in children and older adults. Flu vaccines are designed to pro-ALTERNATIVE VACCINE SCHEDULES Some health care professionals tout what they call alternative vaccine schedules that delay shots or space them further apart. For parents who may be skittish about giving their children so many shots, the idea of the alternative schedule is to encourage vaccination by slowing the pace. But public health officials say that these approaches leave too many kids unprotected for too long, and they aren’t backed up by science. Alternative schedules are unstudied, and they can be dangerous because of the increased risks they pose. Skipping or spacing out vaccines dramatically increases a child’s risk of illness. If you’re concerned, the best advice is to talk with your child’s care provider to make sure you are getting the correct information.164 PART 2: BABY’S HEALTH AND SAFETY

tect against strains of flu virus expected to be in circulation during the fall and winter. The vaccine is generally offered between September and March, which is typically the flu season.Recommendation The influenza vaccine is now recommended yearly for infants and children, beginning at age 6 months. Babies require two doses of the flu vac-cine the first time they’ve been vaccinat-ed for influenza. That’s because they don’t develop an adequate antibody level the first time they get the vaccine. Anti-bodies help fight the virus if it enters your child’s system. However, if a flu vaccine shortage were to occur and your child couldn’t get two doses of vaccine, one dose might still offer some protection.Measles Measles (rubeola) is primarily a childhood illness, although adults also are susceptible. It’s the most contagious human virus known. The measles virus is transmitted through the air in droplets, such as from a sneeze.Signs and symptoms include rash, fe-ver, cough, sneezing, runny nose, eye ir-ritation and a sore throat. Measles can lead to an ear infection, pneumonia, sei-zures, brain damage and death.Recommendation Typically, two doses of a combined measles-mumps-rubella (MMR) vaccination are given, beginning at ages 12 to 15 months and then again at 4 to 6 years. Mumps Mumps is a childhood disease that can also occur in adults. Mumps is caused by a virus that’s acquired by in-haling infected droplets. The disease causes fever, headache, fatigue, and swollen, painful salivary glands. It can lead to deafness, meningitis, and inflam-mation of the testicles or ovaries, with the possibility of sterility.Recommendation Two doses of a com-bined measles-mumps-rubella (MMR) vaccination are given, usually beginning at ages 12 to 15 months and then again at 4 to 6 years. Use of this vaccine has mark-edly decreased the incidence of mumps in the United States.Pneumococcal disease Pneumococ-cal disease is the leading cause of bacterial COMFORTING BABY DURING AND AFTER VACCINATION It can be difficult to see your baby cry or be uncomfortable as a result of a vaccina-tion. Try to keep in mind that protecting your baby against serious disease is worth the short-term discomfort.During each injection, hold your baby close. Softly sing a familiar song or whis-per reassuring words. Offer a pacifier, blanket or other comfort object. Your pres-ence and calm reassurance can help your baby feel secure.Your baby may experience mild side effects from the vaccines, such as red-ness, pain or swelling at the injection site. Ask the doctor what to expect. To mini-mize these effects, you can give your infant acetaminophen (Tylenol, others) before or after vaccination. Follow the label instructions for the correct dose, or ask your child’s care provider for specific dosing instructions. CHAPTER 12: VACCINATIONS 165

meningitis and ear infections among children younger than 5 years old. It can also cause blood infections and pneumo-nia. Children below the age of 2 are at greatest risk of the most serious compli-cations of this disease.Pneumococcal disease is caused by Streptococcus pneumoniae bacteria. The bacteria spread from person to person through physical contact or by inhaling droplets released into the air when a per-son with the infection coughs or sneezes. Because many strains of the bacterium have become resistant to antibiotics, the disease can be difficult to treat.Recommendation Pneumococcal conju-gate vaccine (PCV) can help prevent seri-ous pneumococcal disease. It can also prevent one cause of ear infections. The vaccine is given to all children in four doses between ages 2 and 15 months.Polio Polio is caused by a virus (poliovi-rus) that enters the body through the mouth. Polio affects the brain and spinal cord, often resulting in paralysis or death. Polio vaccination began in the U.S. in 1955. No polio cases have been reported in this country for many years, but the disease is still common in some parts of the world, and the virus could be brought to the United States. For that reason, get-ting children vaccinated against polio continues to be important.The vaccine, called inactivated polio vaccine (IPV), contains the chemically killed virus. IPV is given by multiple injections.Recommendation IPV is given in four doses, at ages 2 months, 4 months, 6 to 18 months and at about age 5 years. This last vaccination is a booster dose. Con-trary to the fears of some people, the shots can’t cause polio.WHY SO MANY SO SOON?Newborns need multiple vaccines because infectious diseases can cause more serious problems in infants than in older children. While a mother’s antibodies help protect newborns from many diseases, this immunity may begin to disappear as quickly as one month after birth. In addition, children don’t receive maternal immunity from certain diseases, such as whooping cough. If a child isn’t vaccinated quickly and is exposed to a disease, he or she may become sick and spread the illness. Research shows that it’s safe for infants and young children to receive multiple vaccines at the same time, as recommended by the Centers for Disease Control and Prevention. In addition, giving several vaccinations at once means fewer office visits, which saves time and money for parents and may be less traumatic for the child. Remember, newborns and young children can be exposed to diseases from family members, care providers and other close contacts, as well as during routine outings — such as trips to the grocery store. Vaccines can often be given even if your child has a mild illness, such as a cold, earache or mild fever. It’s important to keep your child’s vaccination status up to date. 166 PART 2: BABY’S HEALTH AND SAFETY

Rotavirus Rotavirus is the most com-mon cause of severe diarrhea among in-fants and children, resulting in the hospi-talization of approximately 55,000 children yearly in the U.S. Almost all children are infected with rotavirus before their fifth birthday. The infection is often accompa-nied by vomiting and fever.Recommendation Rotavirus vaccine is an oral (swallowed) vaccine, not a shot. The vaccine won’t prevent diarrhea or vomiting caused by other germs, but it’s very good at preventing diarrhea and vomiting caused by rotavirus.There are two brands of rotavirus vac-cine. A baby should get either two or three doses, depending on which brand is used. The first dose is given at 2 months, the second at 4 months and the third dose, if needed, at 6 months.Tetanus Tetanus causes painful tighten-ing of the muscles, usually all over the body. It can be difficult to open your mouth (lockjaw) or swallow. Tetanus isn’t a contagious disease. The tetanus bacte-ria enter the body through deep or dirty cuts or wounds.Recommendation The tetanus vaccine typically is given in combination with those for diphtheria and pertussis (DTaP vaccine). Vaccinations typically be-gin when a baby reaches 2 months of age and are given in a series of five shots in the first six years of life.Starting at age 11, people should con-tinue to be immunized every 10 years with the adult forms of the vaccine.Whooping cough Whopping cough (pertussis) is a disease that causes severe coughing spells, making it hard for in-fants and toddlers to eat, drink or even MISSING A VACCINATION If your baby falls behind on his or her vaccinations, catch-up vaccination schedules can address the problem. Make an appointment with your child’s care provider to determine the vaccinations your baby needs and when he or she should receive them.An interruption in the schedule doesn’t require a child to start a series over or redo any doses. Until your child receives the entire vaccine series, he or she won’t have maximum possible protection against diseases.

breathe. The word pertussis is from the Latin word for “cough.” These coughing spells can last for weeks and can lead to pneumonia, seizures, brain damage and death. Severe whooping cough primarily occurs in children younger than 2 years and is contracted by inhaling infected droplets, often coughed into the air from an adult with a mild case of the disease.Recommendation The DTaP vaccination combines vaccines for diphtheria, teta-nus and pertussis. It’s given as a series ve shots beginning when the infantfiof is 2 months old and continuing to be-tween ages 4 and 6. The DTaP vaccine is a better tolerated version of an older vac-cine called DTP. The “a” stands for acel-c partsfilular, meaning that only speci of the pertussis bacteria are used in the vaccine.At age 11, a form of the vaccine for adolescents and adults, called Tdap, is recommended.VACCINATIONS FOR PRETERM BABIESIf your baby was born early or with a low birth weight, you might be con-cerned about having your baby immu-nized at the standard schedule. How-ever, it’s recommended that even premature babies should be given the routinely recommended vaccinations at the normal times.Keep in mind that premature babies have a greater chance of having dis-ease-related problems, putting them at particular risk if they acquire a prevent-able infection. All of the vaccines that are currently available are safe for pre-mature and low birth weight babies, and pose the same risk of side effects.There is only one exception to this: the hepatitis B vaccine that is given soon after birth. For an infant that weighs less than 2.2 pounds at birth, your pediatrician may advise to delay the timetable for this particular vaccine until the baby is older. But stable pre-mature babies weighing more than 2.2 rst hepatitisfipounds may be given the B vaccine as scheduled.168 PART 2: BABY’S HEALTH AND SAFETY

SIDE EFFECTS OF VACCINESAlthough vaccines are considered very safe, like all medications they aren’t com-pletely free of side effects. Most side ef-fects are minor and temporary. Your child might experience a sore arm, a mild fever or swelling at the injection site. Serious reactions, such as a seizure or high fever, are very rare. According to the Centers for Disease Control and Prevention (CDC), serious side effects occur on the order of 1 per thousand to 1 per million of doses. The risk of death from a vaccine is so slight that it can’t be accurately determined. When any serious reactions are reported, they receive careful scrutiny from the Food and Drug Administration and the CDC.Some vaccines are blamed for chronic illnesses, such as autism or diabetes. (See page 161 for more on the issue of autism and vaccines.) However, decades of vac-cine use in the United States provides no credible evidence that vaccines cause these illnesses. Researchers have, on oc-casion, reported a link between vaccine use and chronic illness. But when other researchers have tried to duplicate those results — a test of good scientific re-search — they haven’t been able to pro-duce the same findings.When to avoid vaccination In a few circumstances, immunization should be postponed or avoided. Talk to your child’s care provider if you question whether your baby should be vaccinated.Immunization may be inappropriate if a child has:ZHad a serious or life-threatening reaction to a previous dose of that vaccineZA known, significant allergy to a vac-cine component, such as chicken eggs or gelatinZA medical condition, such as AIDS or cancer, that’s compromised the child’s immune system and could al-low a live virus vaccine to cause illnessImmunization may need to be de-layed if a child has:ZA moderate to severe illnessZTaken steroid medications in the last three monthsZReceived a transfusion of blood or plasma or been given blood products within the past yearImmunization shouldn’t be delayed because your baby has a minor illness, such as a common cold, an ear infection or mild diarrhea. The vaccine will still be effective, and it won’t make your child sicker.SIGNS OF A SEVERE REACTIONAfter vaccination, watch for any unusual conditions, such as a serious allergic re-action, high fever or behavior changes. Signs and symptoms of a serious allergic reaction include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heartbeat, dizziness, and swelling of the throat. Severe reactions are rare, but if you think that your baby may be experiencing one, call your child’s care provider or go to an emergency department immediately. CHAPTER 12: VACCINATIONS 169

170 PART 2: BABY’S HEALTH AND SAFETY

WEIGHING THE RISKS AND BENEFITSThe consequences of acquiring a disease that can be prevented by immunization are far greater than the extremely rare risk of a serious side effect that may result from vaccine use. For example, if your child gets mumps, the risk of him or her developing encephalitis, a brain inflam-mation that can cause permanent, seri-ous brain damage, is 1 in 300. For mea-sles, the risk is 1 in 2,000. In contrast, the risk of contracting encephalitis from the mumps and measles vaccines is less than 1 in 1 million.If a child gets serious Hib disease, the chances of death are 1 in 20. The vaccine for Hib disease, meanwhile, hasn’t been associated with any serious adverse reac-tions and is highly effective.Most childhood vaccines are effective in 85 to 99 percent or more of children who receive them. For example, a full se-ries of measles vaccine protects 99 out of 100 children from measles, and a polio vaccine series protects 99 out of 100 chil-dren from polio. CHAPTER 12: VACCINATIONS 171



When you first bring your baby home from the hospital, it might be hard to imagine trusting anyone else to take care of him or her. You might have a difficult time feeling comfortable taking your baby with as you run errands, let alone picturing yourself dropping him or her off at a child care center. But for many families, child care — whether in the form of a nanny, family member or a child care center — is a necessity. So how do you find child care that will promote your baby’s health, safety and develop-ment but won’t completely empty your bank account? To begin with, determine how much you can afford to spend on child care, and identify your expectations — what’s important to your family when it comes to child care. Then begin researching the available options in your area as soon as possible. Before your visits, make sure you know how to identify quality child care providers. GETTING STARTEDWhether you plan to work after your baby is born or just need some help a few days a week, it’s never too early to start thinking about child care arrangements. Even if you’re not sure about your plans, start exploring and researching your op-tions early. You might want to visit mul-tiple child care centers to find the right one for your baby — and many child care centers have long waiting lists. If you’re looking for in-home care, you might need time to find a child care agency, in-terview caregivers, and set up health in-surance or workers’ compensation for your child’s caregiver. Before you return to work, you might want to have your child spend time at a child care center or with a child care pro-vider to see how your baby handles the situation and whether the arrangement works for your family. When you begin to look for child care, start by asking your friends, neighbors and co-workers for recommendations. CHAPTER 13Child care CHAPTER 13: CHILD CARE173

You might ask your baby’s care provider for advice. Child care agencies or referral services are great resources, too. Your local child care resource and referral agency can tell you about licensing requirements in your area, how to get information about complaints or licensing violations, and whether your family qualifies for financial assistance. If you’re still having trouble finding information, consider contacting placement services at local colleges for the names of child development or early edu-cation students who baby-sit. You might also find the names of potential sitters in community newspapers or on church or community bulletin boards. CHILD CARE OPTIONSChild care options vary. Generally, though, child care options include the following settings.In-home care Under this arrangement, a caregiver comes to your home to pro-vide child care. The person might live with you or come to your home each day, depending on the agreement you have worked out. Some examples of in-home caregivers include relatives, nannies and au pairs. Au pairs are people who typi-cally come to the United States on a stu-dent visa and provide child care in ex-change for room and board and a small salary.Pros One of the big advantages of this type of arrangement is that your baby can stay at home. You don’t have to be bun-dling up your baby early in the morning to drop him or her off on your way to work. In addition, you set your own stan-dards, and you might have more flexibil-ity with your work hours. Other advan-tages of an in-home arrangement are that your child will receive individual at-tention, and he or she won’t be exposed to other children’s illnesses or bad be-havior. Plus, you won’t need backup care if your baby becomes ill. You won’t need to worry about transportation for your baby unless you want your child care provider to take your baby somewhere. An in-home caregiver also might be able to help with light housework or prepar-ing meals during your baby’s naps. If you use an agency to find a child care provider, you’ll have the comfort of knowing that someone has already checked the backgrounds and references of potential candidates. If you have more than one child, the cost of in-home care might not be significantly more expen-sive than other care options. Cons This type of care isn’t well regulated and is typically more expensive than oth-er options. If you use an agency to find a child care provider, you’ll likely have to pay a hefty fee. Your caregiver might have minimal training in child development, first aid or CPR. As an employer of a child care provider, you also might have cer-tain legal and financial obligations, such as meeting minimum wage and tax-re-porting requirements or providing health insurance. Some people also feel uncom-fortable having another person spending time in or living in their home. There might not be as much opportunity for your baby to socialize with other chil-dren. When your child care provider be-comes sick or goes on vacation, you’ll need to find back-up care. Unless you set up a home surveillance system, you won’t be able to observe what happens to your baby in your absence. Family child care Many people pro-vide child care in their homes for small 174 PART 2: BABY’S HEALTH AND SAFETY

groups of children, sometimes in addi-tion to caring for their own children. Typ-ically, family child care centers provide care for children of mixed ages. Small programs provide care for up to six chil-dren at one time, while large programs are for seven to 12 children. Pros One of the main attractions of family child care is that it allows your baby to be in a homelike setting with other children. In addition, family child care is often less expensive than care provided by an in-home caregiver or a child care center. Homes that offer child care usually have to meet state or local safety and cleanli-ness standards. Some facilities might be able to cater to your baby’s and family’s specific needs, providing care for children with special needs or extended hours. Cons The quality can vary widely. While many family child care providers under-go background checks and participate in ongoing training, not all may be required to do so. Unless the facility has an online surveillance system, you won’t be able to see what your baby is doing in your ab-sence. You may have to drop off and pick up your baby at the family child care at specified times. Child care centers Child care centers, also called day care centers, child devel-opment centers, or sometimes preschool or pre-kindergarten programs, are orga-nized facilities with staff members who are trained to care for groups of children. In these settings, care typically is provid-ed in a building — rather than a home — with separate classrooms for children of different ages. Programs can be large or small, based on their maximum capac-ity. A child care center can be part of a chain, independent for profit, nonprofit, state-funded or part of a federal program, such as Head Start. Some child care pro-grams also have religious affiliations or income eligibility requirements. Pros Child care centers offer many ad-vantages. They’re generally required to meet state or local standards. Many have structured programs designed to meet the needs of children at different age lev-els. Child care centers often have high education requirements for staff. And because most centers have several care-givers, you likely won’t need backup care if a child care provider becomes sick. In addition, child care centers provide op-portunities for socialization with other children. Some centers might allow you to enroll your baby for less than a full week if you work part time or provide ex-tended hours. Some child care centers also allow you to check in on your baby CHAPTER 13: CHILD CARE175

during the day via secure online surveil-lance systems. Cons Some of the drawbacks of larger facilities are that they might have long waiting lists for admission, and spending time with other children can increase your baby’s risk of getting sick. Because of this, some child care centers might not let you bring your child to the center if he or she is mildly ill. Child care centers also can be expensive, depending on the ser-vices offered. Regulations also vary. If the program is large or the ratio of care pro-viders to children is low, your child might not receive a lot of individual attention. You may have to drop off and pick up your baby at the child care center at spec-ified times. Some centers charge fees if you don’t pick up your baby on time. Relative or friend Many people rely on relatives or friends to provide part-time or full-time care for their children. While having someone you know and trust take care of your child is comforting, there are advantages and disadvantages to this type of arrangement, too.Pros Chances are your baby will receive plenty of individual attention. You might even be able to have your relative or friend care for your baby in your own home so you don’t need to worry about transporta-tion. Your baby won’t be exposed to other children’s illnesses or bad behavior, and you won’t need backup care if your baby becomes ill. This type of arrangement also might give you some flexibility with your work hours. It’s also possible, depending on the agreement you work out, that you might not need to pay your friend or rela-tive for child care services, or you can pay at a discounted rate. Cons Your friend or relative might not have any training in CPR or other emer-gency care. The main drawback of having a family member or friend provide care is that it can cause tension. You might not feel comfortable talking to a family mem-ber or friend if you have differing opin-ions about how he or she cares for your child. Your relative or friend might also offer unwanted parenting advice. FACTORS TO CONSIDERBefore you begin looking at facilities or interviewing child care providers, take some time to think about what kind of child care might work best for your fam-

ily and what you can afford. Understand-ing your priorities will help you figure out what questions to ask as you start evalu-ating your options.Expectations Think about your fami-ly’s needs and what’s most important to you in a child care provider. How many days and hours a week do you expect your child to need care? What kind of disciplinary techniques do you want your child care provider to use? If you’re considering hiring a nanny, do you want him or her to be able to drive and do light housework? If you’re considering out-of-home care, how far away from your home or place of work would you like your child to be? How will you han-dle transportation to and from the child care center or access to transportation your caregiver and child might need dur-ing the day? What kind of backup ar-rangements can you make if your child or an at-home care provider becomes sick? Do you want your child to be exposed to a specific language? Budget Think about how much money you can afford to spend on child care and how different types of child care will af-fect your budget. Are you eligible for any state subsidies or assistance from your employer, such as employer discounts or dependent care spending accounts? If you’re considering in-home care, are you prepared to pay any necessary state taxes and the cost of backup care during your child care provider’s vacation and sick days? If you’re concerned about the ex-pense of child care, could you or your partner adjust work hours or schedules to reduce your need for child care? CARE FOR BABIES WITH SPECIAL NEEDSIf your baby has a developmental disability or chronic illness, finding quality child care is more important than ever. The best programs encourage normal activities and also meet each child’s special needs. To find a child care program for your baby, consult your baby’s care provider or your state’s department of health or education. Your baby’s care provider can also help you determine what kind of care will best address your baby’s needs. Look for a program that meets the basic requirements you’d want in a child care program. In addition, look for: Specialized staffing and equipment Has the program’s staff been trained to meet your baby’s specific needs and recognize when your baby might need med-ical attention? Does the program have a medical consultant who is involved in the program’s development? What kind of specialized equipment does the program provide, and is it in working condition? Has the staff been trained to use it? Does the program tailor emergency plans to the needs of its children?Confidence-building activities What kinds of activities will your baby be able to participate in? Does the program include children who don’t have special needs? Programs that contain children who have different levels of ability can help encourage social confidence and sensitivity. CHAPTER 13: CHILD CARE177

EVALUATING YOUR OPTIONSOnce you’ve thought about what kind of child care will work best for your family, compile a list of potential caregiv-ers or facilities in your area. Next, call or visit the caregivers or facilities. During your visit, pay special attention to the way staff members treat the children. Af-ter the tour, be prepared with a list of questions. If you’re evaluating several different settings or child care providers, consider taking notes and recording your first impressions. In-home care When looking for some-one to come into your home to care for your baby, checking references is crucial. Talk to several of the child care provider’s previous employers and ask questions about his or her strengths and weakness-es, as well as any problems or concerns the employer might have had. Do a back-ground check. Search for information about the person online via a search en-gine or social networking site. Ask about the child care provider’s approach to child rearing. What will the care provider do if your baby won’t stop crying? What kind of disciplinary techniques does he or she typically use? What kind of hours can he or she work? What kind of salary does the child care provider expect? Does he or she need health insurance? Does he or she have CPR and first-aid training? Family child care Look for a facility that’s certified, licensed and provides a safe environment for children. Ask about how many child care providers are on staff and if they have undergone back-ground checks. Request references. Ask about the provider’s training, how many children are enrolled and about the facil-ity’s hours. Discuss the facility’s approach to child rearing. How many child care providers are currently certified in CPR and have first-aid training? Who lives in and visits the home? What are their backgrounds, and how might they inter-act with your child? How does the facility plan to deal with emergencies? What safety measures are in place? Are there daily activities for the children? Find out what happens if the care provider be-comes ill and if he or she closes for vaca-tions. How much does the program cost? Child care center When evaluating child care centers find out about each SICK CAREWhen your baby becomes ill and you need backup care, you might have options beyond staying home to care for him or her. Some child care centers or family child care programs offer care for sick children in a segregated area. Your community might also have child care centers or family child care programs that specialize in providing care only for sick children. Some employers also provide sick care for their employees’ children. Investigate your options before your baby becomes ill. When looking for this type of care, ask about how much individual care your baby will receive, how the facility and equipment are cleaned, and whether the facility has a care provider on call.178 PART 2: BABY’S HEALTH AND SAFETY

program’s practices. Many child care cen-ters provide pamphlets or have websites that will answer your questions. You can also speak to the program’s director. Consider asking about:Credentials and staff qualificationsMake sure the program is licensed and has a recent health certificate. Programs that are accredited have met voluntary standards for child care that are higher than most state licensing requirements. The National Association for the Educa-tion of Young Children and the National Association for Family Child Care are the two largest organizations that accredit child care programs. Staff should have training in early child development, CPR and first aid. References should be avail-able upon request. Ask if there are fre-quent staff changes, since high staff turn-over might be a sign of a problem, and changing care providers can be hard on a child. Talk to at least one parent whose child was in the program in the past year. Be sure to search for information online about the program and its child care pro-viders, too. Adult-to-child ratios Ask about the ratio of adults to children. The fewer the children for each adult, the better the child care experience may be for your son or daughter. For infants, look for an adult-to-child ratio of 1-to-3 or 1-to-4. Also, look for a group size that’s no larger than six to eight infants or six to 12 young toddlers. Keep in mind that infants and young tod-dlers do better in smaller groups. Health and sanitation practices Ask whether the program requires children and staff to have standard vaccinations and regular checkups. Is the staff prohib-ited from smoking inside and outside of the building? What happens if your baby becomes ill during the day? Are parents notified when a child or staff member HANDLING THE SEPARATIONBabies up to age 7 months often adjust well to being taken care of by a new child care provider. Older babies, however, might have a harder time with the transition. Between age 7 months and one year, babies begin to develop stranger anxiety. They might need extra time and help getting used to a new child care provider and setting. If possible, arrange for an in-home care provider to spend time with your baby while you’re at home. Or take your baby to visit the family child care or child care center before he or she begins attending it. Stay nearby while your child plays, and steadily increase the length of your visits. When you begin dropping your child off at the program, create a goodbye ritual, and let him or her bring a reminder of home, such as a stuffed animal or picture of you, to the program. Always say goodbye to your baby before leaving. If your baby shows persistent fear about being left alone with a caregiver, talk to your baby’s care provider. Separation is sometimes harder for the parents than the baby. Checking in regularly with your child care provider to see how your baby is doing might help reassure you. Talk to friends and family who’ve been through it before. Carrying a picture of your baby with you might help, too. CHAPTER 13: CHILD CARE179

contracts a communicable disease, such as chickenpox? When should you keep your sick baby home? How are medica-rst aid administered? Howfitions and often are a baby’s diapers changed? Are diapering areas and toys regularly cleaned and sanitized? Do staff members regularly wash their hands? How are ba-bies put to sleep? How regularly is bed-ding cleaned? Safety and security What kind of secu-rity system does the facility have to en-sure that strangers don’t enter the build-ing? What happens if a child becomes injured or lost? Are outdoor play areas secured? Do outdoor play areas have sturdy structures and safe surfaces? What kind of security measures are taken dur-eld trips? How are children trans-fiing ported? What is the program’s emergen-cy evacuation plan? How are other emergencies handled? Daily activities Ask what your child’s daily routine would be like. Is there a mix of group play and individual attention? Is there a balance between physical activity and quiet time? Is there time for free play? Are there activities appropriate for different age levels? Do care providers read to the children? Are meals and snacks provided? If so, what kinds? What are the program’s overall goals? Is paren-tal involvement expected or encouraged? Additional details What is the pro-gram’s admissions policy? What kind of information will you need to provide? If the program has a waiting list, how long is it, and how does it work? What are the program’s hours of operation and cost? Can you pay in installments? Will you need to pay if your baby is absent for a vacation? What is the policy for with-drawing a child from the program? How ed of weather cancella-fiare parents notitions? Do parents need to provide any supplies? Can you drop in and visit your baby during the day? How can parents contact staff? CONTACT INFORMATIONWhenever you leave your baby with a child care provider or a sitter, make sure you’ve provided a list of important con-tact information, including your phone number and how to reach you at all times. Also, provide the phone numbers of any other close family members or friends who can be contacted in the event of a problem. Explain what you want your baby’s care provider to do in the case of an emergency. If you’re leaving your baby with a child care provider in your home, show the child care provider the locations of re extin-fiall exits, the smoke detector, guisher and the poison control telephone number. Make sure that anyone who provides care for your baby understands the importance of putting your baby to sleep on his or her back. If the child care provider will be driving your child any-where, make sue he or she knows how to properly use car seats. It’s also a good idea to write down your address and your child’s full name and birth date in the event of accident. The stress of an emergency may make it cult for a child care provider or sitterfidif to remember those details.WORKING TOGETHERIn the coming weeks, carefully monitor the performance of the child care pro-180 PART 2: BABY’S HEALTH AND SAFETY

vider you hire or the child care providers at the center your baby attends. Pay close attention to your baby, his or her adjust-ment, and the way he or she interacts with the child care provider or providers. Establishing a good relationship with your baby’s care provider benefits every-one involved. You may worry that your child will come to love his or her provider as much as you. Remember, no one can replace you in your child’s heart. Showing your baby’s child care pro-vider warmth and courtesy will make him or her, as well as your baby, comfort-able. This will also make it easier for you and your baby’s care provider to commu-nicate. Be sure to set aside a few extra minutes when you leave your baby with the care provider and when you return to discuss any relevant issues. If your baby didn’t sleep much the previous night, is teething or there’s another matter that might affect his or her behavior that day, let your baby’s care provider know. If your baby is taking any medications, ex-plain what the medication is for and pro-vide written instructions detailing how it needs to be stored and administered and what side effects might occur. If there are certain activities you’d like your baby’s care provider to do with your baby, or if you don’t want your baby to watch any TV, discuss it with the child care provider. When you return, you’ll want to find out what happened with your baby that day. How much did he or she drink and eat and at what times? How many dia-pers did he or she wet and soil? What activities did he or she do? How many naps did he or she have, and how long were they? Did your child achieve any new milestones or display any behavior that’s of concern? Are you running low on any necessary baby supplies? Going over these topics regularly will help en-sure consistency in your baby’s care and might help eliminate some confusion. For instance, if you’re unaware that your baby skipped his or her afternoon snack, you might be bewildered when he or she has a total meltdown due to hun-ger just before dinner. Some child care centers provide daily logs with this infor-mation. You can also ask your baby’s care provider to create a daily log for you. Beyond going over your baby’s daily activities, make time occasionally to have longer talks about your baby’s changing needs and how to meet them. This will also give you and your baby’s care pro-vider a chance to discuss any other issues or concerns. Be sure to listen to your child care provider’s thoughts on each topic and, if possible, work together to come up with solutions. If you’re happy with your baby’s care, don’t forget to mention it, too. Showing appreciation for your baby’s caregiver can help strength-en your relationship. Finding good child care can be a stressful process. By considering your family’s needs at the outset and thor-oughly researching your options, you’ll save time and energy. Carefully review-ing each candidate’s background and evaluating different child care settings will help you feel more comfortable with your decision and ease your concerns about spending time apart from your baby. CHAPTER 13: CHILD CARE181



Whether you’re bringing your baby home from the hospital, taking him or her for a stroll around the block, or going on your first family flight together — you and your baby are likely to do some trav-eling in the months ahead. As you might have guessed, traveling anywhere with a baby takes some plan-ning. Your baby may never have a leaky diaper, spit up all over, or stray from his or her eating schedule when you’re at home, but it always seems to happen when you’re out and about. It’s a good idea to be prepared for anything when you’re traveling with your child. In addition to knowing what to bring with you to meet your baby’s needs while you’re away from home, you’ll have to figure out which modes of transporta-tion work best and how to use them safe-ly. You probably have more options than you might realize.Before you hit the road, find out what you need to know about traveling with a child, and then have fun!HEADING OUTYou and your baby are both likely to ben-efit from getting out of your home. As early as your baby’s first month, you might consider taking him or her out for walks. While you may feel nervous about leaving the comfort of your home as you learn to care for your baby, fresh air and a change of scenery may lift your spirits. Taking small trips with your baby now will also help you gain confidence and help you prepare for bigger adventures later on.Remember, if you’ve been up all night with your baby, your baby is having a fussy day or you can’t face figuring out how to work the stroller yet, that outing you planned can always wait until to-morrow. There’s no gold medal for the new mom who gets out of the house first. Take your time and head out with your baby when you feel ready. To help ensure a successful outing, consider the follow-ing tips. CHAPTER 14Traveling with baby CHAPTER 14: TRAVELING WITH BABY 183

Limit contact When you first take your newborn out, consider avoiding places where he or she will come into close con-tact with a lot of people and, as a result, germs. Or head to a destination when it’s least likely to be crowded. Check the weather report If possi-ble, avoid going out with your baby in cold and rainy weather — especially early on. If you do head out, bundle your baby and cover his or her head and ears in a warm hat. Dress for the weather Young babies have trouble regulating their body tem-peratures when exposed to extreme heat or cold. As a rule, dress your baby in one more layer than you’re wearing. Infants should wear hats when it’s cold because they can lose a large amount of heat from their exposed heads. If you’re unsure about your baby’s temperature, check her hands, feet and the skin on her chest while you’re out. Your baby’s chest should feel warm, while her hands and feet should feel slightly cooler than her body. If your baby feels cold, unwrap him or her and hold him or her close to your body. Feeding your baby something warm also might help. Dressing your baby in layers and bringing extra layers will help you adapt if the weather changes. Provide sun protection Babies have sensitive skin. If your baby is younger than 6 months, keep him or her out of direct sunlight for long periods of time. Protect your baby from sun exposure by dressing him or her in lightweight, light-colored protective clothing and a hat with a brim. If adequate clothing and shade aren’t available, apply sunscreen on exposed areas of your baby’s skin. For more information on babies and sun-screen, see page 103) Keep baby equipment cool Avoid letting your baby’s car seat or stroller sit uncovered in the sun for long periods of time before using them. Plastic and metal parts may become hot enough to burn your child. Be prepared Don’t leave your home without diaper supplies, a change of clothes for your baby and, if you’re bot-tle-feeding, food for your baby — just in case. If you’re nervous, ask a family mem-ber or friend to go with you on your first few outings. BABY CARRIERSOne of the most convenient and intimate ways to carry your baby around is in a baby carrier. If you’re considering pur-chasing a baby carrier, you’ve got op-tions, including:ZBackpack or front pack. This device allows you to carry your baby in an upright position on your back or against your chest. ZBaby sling. This is a one-shouldered baby carrier made of soft fabric.Choosing a baby carrier Not all baby carriers are created equal. Some carriers aren’t appropriate for certain babies. Others are quickly outgrown. When looking for a carrier: ZFind the appropriate size for your baby. The carrier’s leg holes should be small enough so that your baby can’t fall through them. Keep in mind that some models aren’t appropriate for newborns. ZCheck the weight minimum and limit.Different models have different weight limits. Consider how long you’d like to use it.184 PART 2: BABY’S HEALTH AND SAFETY

ZLook at the construction. Will the car-rier provide adequate support for your baby’s head and neck? Is the material sturdy? If you’re looking for a backpack with an aluminum frame, is it padded to protect your baby if he or she bumps against it?ZTry it out. Is the carrier comfortable for you and your baby? If you plan to use the carrier for a while, consider how the straps will feel when your baby grows, gains weight and be-comes more restless.Baby carrier risks When used incor-rectly, a baby sling can pose a suffocation hazard to an infant younger than age 4 months. Babies have weak neck muscles and can’t control their heads during the first few months after birth. If the baby sling’s fabric presses against a baby’s nose and mouth, he or she may not be able to breathe. This can quickly lead to suffoca-tion. In addition, a baby sling can keep a baby in a curled position — bending the chin to the chest. This position can restrict the baby’s airways and limit his or her ox-ygen supply. In turn, this can prevent a baby from being able to cry for help. A baby is at higher risk of suffocating in a baby sling if he or she:ZWas born premature or with a low birth weight (less than 5 pounds, 8 ounces)ZIs a twinZHas breathing problems, such as a coldIf your baby meets one of these con-ditions, don’t use a baby sling until you talk to your baby’s care provider. In addition, if your baby was born prema-turely or has respiratory problems, don’t use an upright positioning device until you talk to your baby’s care provider. Safety tips When using any baby car-rier, take the following precautions:ZBe careful when bending. Bend at the knees, rather than at the waist, when picking something up. This will help keep your baby settled securely in the carrier.ZKeep up with maintenance. Keep an eye out for wear and tear. Repair any rips or tears in the carrier’s seams and fasteners. Also, check the Consumer Product Safety Commission’s website to make sure the carrier hasn’t been recalled (see page 553). ZKeep your baby’s airway unobstruct-ed. If you use a baby sling, make sure your baby’s face isn’t covered by the sling and is visible to you at all times. Check your baby frequently to make sure he or she is in a safe position.ZBe careful after breast-feeding. If you breast-feed your baby in a baby sling,

make sure you change your baby’s position afterward so his or her head is facing up and is clear of the baby sling and your body.STROLLERSIf you’re like most parents, you’ll want to get at least one stroller for your baby. But what’s the best stroller for your baby, fam-ily and lifestyle? When looking for a stroll-er for your baby, consider the following: Where and how will you use it?If you live in or near a city, you’ll need to be able to maneuver your stroller along crowded sidewalks and down nar-row store aisles. You also might need to be able to collapse your stroller in a pinch to get on a bus or down stairs to the sub-way. Suburban parents, on the other hand, might want to look for a stroller that fits into their trunk. If you have twins or an older child, you might consider get-ting a double stroller or a stroller with an attachment that allows your older child to stand or sit in the rear. Frequent travelers might also want a collapsible umbrella stroller — either in addition to or as their primary stroller. Plan to take your baby along on your runs? You might look for a jogging stroller, too. Is it appropriate for a newborn?If you plan to use a stroller while your baby is a newborn, you’ll need to make sure that the stroller offers enough of a recline — since newborns can’t sit up or hold up their heads. Some strollers fully recline or come with bassinet attach-ments. Strollers that can be used in com-bination with an infant-only car seat are also a good choice. However, most um-brella strollers typically don’t provide ad-equate head and back support for young babies. In addition, most jogging strollers SHOPPING CART SAFETYShopping carts are more dangerous than they might appear. They can easily tip over when a child is in the shopping cart seat or basket. A child could also fall out of the shopping cart seat if he or she isn’t properly buckled in. If possible, look for an alternative to placing your child in the shopping cart. If you must place your child in the cart, make sure he or she is buckled into the seat — and never leave him or her unattended. Don’t allow your child to ride in the basket or ride on the outside of the cart.

aren’t appropriate for a baby until age 5 or 6 months. Do you need a travel system?If so, you might look for a stroller that can hold your baby’s car seat. Some car seats and strollers come in matching sets, while others require you to buy sep-arate attachments that allow the strollers to be used with certain car seats. Once you strap your baby into his or her car seat, these kinds of strollers will allow you to easily move your baby between the stroller and car. This type of stroller can also be helpful in an airport, if you plan to take your baby’s car seat on the plane. What kinds of accessories are available? You might consider whether you’ll want features or accessories for your stroller, such as a basket, rain cover, a stroller blanket, a sun shade or parasol, or a cup holder. Some accessories aren’t available for certain strollers. Other features Strollers with wide bases are less likely to tip over. Many strollers have brakes that lock two wheels — a special safety feature. If you’re look-ing for a double stroller, choose one with one footrest that extends across both sit-ting areas — since small feet can get trapped in between separate footrests. Always read the stroller manufacturer’s weight guidelines, especially when look-ing for a stroller with an area for an older child to sit or stand. Safety tips Once you find the right stroller, follow these safety tips, and re-member to never leave your child unat-tended in his or her stroller: ZTake caution when folding. Always make sure the stroller is locked open before you put your child in it.ZBuckle up. Always buckle your child’s harness and seat belt when taking him or her for a stroller ride.ZBe careful with toys. If you hang toys from a stroller bumper bar to keep your baby entertained, make sure that the toys are securely fastened.ZProperly store belongings. Don’t hang a bag from the stroller’s handle bar, which can make a stroller tip over. Place items in the stroller basket.CAR SEATSWhenever you travel by car with your baby, a car seat is a must. Not only are car seats required by law in every state, but they’re essential for your child’s safety. Traveling with your baby in your lap could put him or her at risk of serious in-jury in case of an accident. Find out how to choose the right car seat for your child and use it safely. The best time to get a car seat for your baby is during your pregnancy, so you’ll be able to install the car seat in your car — which might be a more complicated process than you realize — and have it ready for your baby’s trip home from the hospital. When choosing a car seat, you’ll have lots of options. Don’t assume that the pricier models are best. Instead, look for a car seat that will keep your baby safe and best serve your family’s needs. First, decide if you want an infant-only car seat or a convertible car seat. You might also check with the store to see if they will let you try out the car seat before you pur-chase it.If you have two cars, you might con-sider buying two car seats or, for an in-fant-only car seat, two bases. Otherwise, be sure to always move the car seat to the car in which your child will be traveling. CHAPTER 14: TRAVELING WITH BABY 187

Infant-only car seat Infant-only car seats are for babies who weigh up to 22 to 32 pounds, depending on the model. ve-point or three-pointfiThey come with harnesses and can only be used in the rear-facing position. This type of car seat typically has a handle and can be snapped in and out of a base in your car. This allows you to strap your baby into the car seat inside your home and then simply lock the car seat into the base. You can also use this type of seat without a base, which might make traveling a little easier. Some models can also be snap-ped in and out of a stroller base. When your baby reaches the maximum weight or height allowed for an infant-only car seat, you’ll need to purchase a convert-ible car seat.Convertible car seat You can also start with a convertible seat, which can be used rear-facing or forward-facing and typically has a higher rear-facing weight and height limit than an infant-only seat. ve-fiThis type of car seat typically has a point harness or an overhead shield — a padded guard that can be pulled down around the child. When your child reach-es 2 years of age or the rear-facing weight or height limit of the convertible seat, you can begin to face the seat forward. Other considerations Once you know what type of car seat you want, t into your car.filook for a model that will Also, look for a model with a cover that’s easy to clean — in case your child spits up, vomits or spills food in the car seat at some point. No matter what kind of car seat you choose, make sure the label says that it meets all federal safety standards. llingfiRegister your car seat online or by out the manufacturer’s product registra-ed in thefition card so you can be noti event of a recall.Infant-only seat© MFMER188 PART 2: BABY’S HEALTH AND SAFETY

Used car seats If you’re considering borrowing or buying a used car seat, make sure the car seat is safe. Look for these things: ZComes with instructions and a label showing the manufacture date and model numberZHasn’t been recalledZIsn’t more than six years oldZHas no visible damage or missing partsZHas never been in a moderate or severe crashIf you don’t know the car seat’s his-tory, don’t use it. If the car seat has been recalled, be sure to find and follow in-structions for how to fix it or get the nec-essary new parts.INSTALLING A CAR SEATProperly installing a car seat and correct-ly buckling your child into it before the Convertible seatIS YOUR CAR SEAT TOO OLD?Yes, car seats do expire — typically after six years. The expiration date is usually stamped in the plastic on the bottom of the seat. With time, pieces of the car seat may become worn, jeopardizing the seat’s ability to keep your baby safe in a crash. As technology improves, safety recommendations may also change, but for now, the six-year time frame does matter. © MFMER CHAPTER 14: TRAVELING WITH BABY 189

start of every car ride, is crucial. Before you install the car seat, read the manu-facturer’s instructions and the section on car seats in your vehicle’s owner manual. To install an infant-only car seat, you’ll use a back seat seat belt or a car seat latch. To install a convertible car seat, you can use a back seat seat belt or, in vehicles made after 2002, a Lower An-chors and Tethers for Children (LATCH) restraint system. In the LATCH system, lower anchors secure the car seat to the vehicle. However, the tether — a strap that hooks to the top of the seat and at-taches to an anchor in the vehicle to pro-vide stability — is only used on forward-facing seats. Make sure the seat is facing the correct direction and it’s tightly se-cured — allowing no more than one inch of movement from side to side or front to back when it’s grasped at the bottom near the attachment points. If necessary, use a locking clip to secure the position of the seat belt holding the car seat in place. All new car seats come with lock-ing clips. If you’re using an infant-only seat or a convertible seat in the rear-facing posi-tion, use the harness slots described in the instruction manual, usually those at or be-low the child’s shoulders. Also, place the harness or chest clip even with your child’s armpits — not the abdomen or neck. Make sure the straps and harness lie flat against your child’s chest and over his or her hips with no slack. If your car seat has a carrying handle, position it according to the manufacturer’s instructions. After you install the car seat, consider having a certified child passenger safety technician check your handiwork at a lo-cal car seat clinic or inspection event. You can also check with the National High-way Traffic Safety Administration for help finding a car seat inspection station. Be-fore each trip you take, check that the car seat is installed tightly. In the rear-facing position, recline the car seat according to the manufacturer’s instructions so that your child’s head doesn’t flop forward. Many seats include angle indicators or adjusters. You can also place a tightly rolled towel under the seat’s front edge to achieve the cor-rect angle. To prevent slouching, place tightly rolled baby blankets alongside SLEEPING IN A CAR SEATA car seat is designed to protect your child during travel. It’s not for use as a re-placement crib in your home. Limited research suggests that sitting upright in a car seat might compress a newborn’s chest and lead to lower oxygen levels. Even mild airway obstruction can impair a child’s development. Sitting or sleeping in a car seat for lengthy periods can also contribute to the development of a flat spot on the back of your baby’s head and worsen reflux, a condition that causes a baby to spit up. In addition, a child can easily be injured by falling out of an improperly used car seat or while sitting in a car seat that falls from an elevated surface, such as a table or counter. While it’s essential your child be in a car seat during car travel, don’t let your child sleep or relax in the car seat for long periods of time out of the car. 190 PART 2: BABY’S HEALTH AND SAFETY

your newborn. If necessary, place a rolled washcloth between the crotch strap and your baby to prevent slouching. Don’t use any additional products unless they came with the car seat or from the manufacturer. Resist the urge to place your child’s car seat in the forward-facing position just so you can see his or her smile in your rearview mirror. Riding rear facing is recommended until a child reaches age 2 or the highest weight — typically at least 35 pounds — or height allowed by the car seat manufacturer. If you want to know what’s happening with your baby, have someone sit in the back seat next to your baby or pull over to check on your baby. Back seat mirrors, while helpful, can be distracting to drivers. Remember, never leave your baby alone in a car. Babies can quickly become overheated, cold or frightened, and a baby alone in a car could easily be ab-ducted. Even though it might be hard to imagine forgetting your child and leaving him or her in the back of the car, it can happen. To remind yourself of your pre-cious cargo, place your purse or wallet on the floor of the back seat whenever your baby rides in the car with you so you’ll have an extra reason to check the back seat before leaving the car. As your baby gets older, he or she may not enjoy riding in a car seat. Some chil-dren may even try to climb out of a car seat. If your child begins to put up a fight about sitting in a car seat, be stern. Tell your child that he or she must stay in the car seat during travel and that you won’t get going unless everyone is securely buckled up. Try to remain calm and remember that this is likely a passing phase. To keep your child entertained during travel, talk, play music or sing songs together. RENTALS, TAXIS, TRAINS AND MOREFollow the same car safety rules, whether you’re traveling in your own car, a rental car, a taxi, train or any other vehicle. Plan to bring your baby’s car seat with you on any trip in which you might be riding in a vehicle or renting a car from a rental car company. If you’re using an infant-only car seat that has a base, determine if you’re going to bring the base with you. If not, make sure you know how to install the car seat in a vehicle without the base.

Car seat and air bag safety The safest place for your child’s car seat is the back seat, away from active air bags. If the car seat is placed in the front seat and an air bag inflates, it could hit the back of a rear-facing car seat — right where your child’s head is — and cause a serious or fatal injury. A child who rides in a for-ward-facing car seat could also be harmed by an air bag. If it’s necessary for a child to travel in a vehicle with only one row of seats, de-activate the front air bags or install a power switch to prevent air bag deploy-ment during a crash. Otherwise, air bag power switches should only be used if your child has certain health problems, his or her care provider recommends constant supervision of your child during travel, and no other adult is available to ride in the back seat with your child. If you’re placing only one car seat in the back seat, install it in the center of the seat — if possible — rather than next to a door to minimize the risk of injury in case of a crash. PREEMIES AND SMALL BABIESIf your baby is born prematurely or at a low birth weight, he or she might need to be monitored while sitting in a car seat before he or she is discharged from the hospital. If this is the case, you’ll need to bring your baby’s car seat to the hospital. Your baby will be placed in it and have his or her vital signs recorded for a cer-tain period of time. This is because sitting semireclined in a car seat can increase the risk of breathing problems or a slow heartbeat. If your baby has a health prob-lem that requires him or her to lie flat, a vehicle bed may be recommended. Look for a vehicle bed that’s been crash tested. Position the bed lengthwise in the back seat so that your baby’s head will be in the center of the car. Always use the buckle and harness to secure your baby in the bed.When you have the OK to use a car seat, you may need an infant-only car seat to accommodate your small baby. Use it only during travel, and don’t let your child sleep in it outside of the car. If you use a convertible car seat for a small infant, make sure you use a model with a five-point harness, rather than an over-head shield. During an accident a baby’s head could hit the shield. If your baby needs to travel with de-vices such as an oxygen tank, secure them in the vehicle so they don’t become flying objects in case of a sudden stop or acci-dent. You might try placing the equipment on the floor and surrounding it with pil-lows or buckling it in with a seat belt.MOTION SICKNESSAny type of transportation can cause motion sickness, a feeling of uneasiness that might cause your child to develop a cold sweat, feel dizzy or vomit. While children ages 2 to 12 are particularly susceptible to motion sickness, the problem doesn’t seem to affect most infants and toddlers. If your baby experiences motion sickness, talk to your child’s care provider for advice. Keep in mind that medications typically used to treat motion sickness aren’t recommended for children under age 2. 192 PART 2: BABY’S HEALTH AND SAFETY

AIR TRAVELYour first flight with your baby will likely be a lot different than your previous flights. Instead of worrying about wheth-er you have enough reading material, you may now be worried that your baby will scream the entire flight. While there’s no telling how your baby will react to his or her first time on an airplane, careful planning can go a long way toward calm-ing you and your baby’s nerves. Identification Depending on your des-tination, your baby might need a pass-port. If you know you’ll be traveling out-side of the country with your baby in the future, consider applying as soon as pos-sible. The application process can typi-cally be expedited for a fee. Seat safety Although airlines typically allow infants to ride on a caregiver’s lap during flight, the Federal Aviation Ad-ministration recommends that infants ride in properly secured safety seats. Most infant car seats are certified for air travel. In order for your baby to travel in a car seat on the plane, your child will need his or her own seat. The best way to en-sure your child has a seat is to buy one. When booking your flights, check if there are any discounts for infant children. Keep in mind that car seats must be se-cured in a window seat so other passen-gers will be able to exit the row. If you don’t want to buy a seat for your baby, try to take a flight in which empty seats are likely to be available. Or, if you’re traveling with another person, try booking the aisle and window seats — which might give you a better shot at an empty middle seat. You can also ask about open seats when you board the plane — in case one can be assigned to your infant. If you don’t bring a car seat for your child on the plane, ask the flight atten-dant for instructions on how to hold your baby during takeoff and landing. If you sit in an aisle seat with your baby, be sure to protect your baby’s head, hands and feet from getting bumped by service carts or other passengers. Many traveling families seek out the bulkhead of the plane, which offers extra space. Others prefer the back of the plane, which is typically noisy enough to IS IT SAFE FOR YOUR BABY TO FLY?Generally, age doesn’t affect an infant’s ability to handle air travel. While it’s always a good idea to avoid enclosed, crowded spaces when you have a newborn, most healthy term babies are OK to fly at age 1 to 2 weeks. If your baby was born prema-turely or has a history of lung disease, however, consider talking to your baby’s care provider before flying with your baby. Because your baby’s lungs might be sensitive to the effects of the changes in altitude, the care provider might recommend post-poning air travel until age 1 or later. If your baby has an underlying respiratory condi-tion, his or her care provider might recommend supplemental oxygen. Ear infections and ear tubes aren’t thought to pose problems during air travel. However, if your baby is ill you might want to consider postponing the flight. CHAPTER 14: TRAVELING WITH BABY 193

drown out crying and may even lull a baby to sleep. Do what makes the most sense to you. Getting through the airport If you plan to bring a car seat on the plane, a stroller that allows you to attach the car seat to it is a smart investment. You’ll be able to wheel your child in his or her car seat until you board the plane, at which point you can collapse the stroller base and check it at the gate. You will, however, have to take your baby out of a car seat to go through the metal detector. While the Transportation Security Administration limits the amount of flu-ids you can bring on a plane, exceptions are made for baby-related items, such as medications, formula, baby food, juice and breast milk. Be sure to notify security officials about what you’re carrying and expect it to be inspected. Also, let security officials know if your baby is using or has any special medical devices. Boarding Many airlines allow families to board the plane first. This might be a good option if you have a lot of baggage. However, some families prefer sending one parent ahead with the bags, while the other boards last with the baby to minimize the amount of time spent stuck on the plane. Keeping baby happy Dress your baby in comfortable, easy-to-remove layers. This will help you keep him or her warm or cool enough and make diaper and clothing changes easy. Sucking on a pac-ifier or bottle might ease discomfort dur-ing takeoff and landing, since babies can’t intentionally “pop” their ears by swallowing or yawning to relieve ear pain caused by air pressure changes. Breast-feeding your baby — when it’s safe to do so — also can help. Take occasional breaks to walk up and down the aisle — as long as the crew ap-proves moving throughout the cabin.

Giving your baby a sedating over-the-counter medication to make him or her sleep during the flight isn’t recommend-ed. The medication could end up produc-ing the opposite effect. If your baby does cry during the flight, do your best to figure out what’s wrong — just as you would at home — and try to stay calm. Chances are that many pas-sengers on the plane have been in your situation before and likely sympathize. TRIP BASICSTaking your baby on a trip — particularly those involving flights, overnight stays and different time zones — requires some planning. When you schedule your trip, think about your baby’s normal rou-tine and what you can do during your travels and trip to accommodate his or her daily needs. Minding your baby’s internal clockIf your baby is an early riser, consider booking an early morning flight and scheduling morning activities during your trip. Think about what times your baby typically naps and eats and how you’ll be able to keep his or her schedule intact while away. Keep in mind that if you cross time zones during your trip, it might take your baby a few days to adjust to new sleeping and eating schedules.Gathering essentials Start by packing your baby’s diaper bag, which you’ll need to keep with you at all times. Fill it with diapers, wipes, diaper ointment and a changing pad. If you feed your baby for-mula, make sure you have formula, bot-tles and nipples. Bring enough formula to cover your travel time and well beyond, just in case you encounter delays. If you’re breast-feeding, a blanket or nurs-ing cover might come in handy. If your baby uses a pacifier, bring at least one. It’s always smart to pack an extra change of clothes — or two — for your baby and an extra shirt for yourself in the diaper bag, just in case. You might also bring disposable bags for dirty diapers, in case you don’t have immediate access to a garbage can during travel, and travel-size hand sanitizer. When packing your baby’s clothes for the trip, think about the weather you’re likely to encounter, how many outfit changes your baby typically needs in a day, and whether you’ll have access to a washer and dryer. You might bring along a few familiar items, such as small toys or a white noise machine, to help your child feel comfortable in the new environment. If you’ll be staying at a hotel, call ahead and see if you can reserve a crib for your room. Otherwise, you’ll need to bring a collapsible crib with you. In addition to the bottle supplies you bring with you on the plane, consider what kind of steriliz-ing or cleaning equipment you might need to bring for the rest of your trip. Traveling with a baby takes some planning and — often — a lot of luggage. Think about what your baby might need, and do your best to prepare for the worst. And don’t forget to enjoy your trip! CHAPTER 14: TRAVELING WITH BABY 195



As your baby becomes more mobile, ex-ploration will become the name of the game. Rocking, rolling and sitting will give way to crawling, climbing and cruis-ing along the furniture. Your baby’s bud-ding curiosity and inexperience, howev-er, can prove to be a dangerous mix. Power cords, dresser drawers, kitchen cabinets, dish soap and the toilet are just a few household items that your baby might touch, grab or try to climb onto in the coming months. Small toys, hot drinks, slippery surfaces and furniture with sharp edges can also pose hazards for your little explorer. While trying to prevent injuries, you can take lots of steps to safeguard your home and keep your baby safe outdoors. To get started childproofing your home, consider your family’s lifestyle and the layout of your home. Think about which rooms your baby will spend time in and what dangers each room poses. Sit on the floor in each room to get an idea of what might catch your baby’s at-tention or be within your baby’s reach. If you don’t childproof every room in your home, you’ll need to take extra vigilance to keep your child away from those areas. Remember, however, that as your child gets older, it will become harder to ex-clude him or her from certain areas of the house. NURSERY SAFETYYour son or daughter will spend a lot of time in the nursery. To help keep him or her safe while in the room, here are some helpful tips:Use safety straps Always use the safety strap on your baby’s changing ta-ble and never leave a baby alone on the changing table. Even at young ages ba-bies can move suddenly and flip over the edge of a high surface. Look for a chang-ing table with a guardrail and keep dia-pering supplies within your reach but beyond your child’s reach. CHAPTER 15Home and outdoor safety CHAPTER 15: HOME AND OUTDOOR SAFETY197

SAFE TOYSBabies love to play with toys, but you want to make sure the toys around them don’t pose any dangers.Choose toys carefully Don’t let your baby play with balloons, marbles, coins, toys that contain small parts or other small items. Balloons, in particu-lar, pose a major choking hazard when uninflated and broken. Avoid projectile toys, extremely loud toys and toys with cords, long strings and small magnets. Remove plastic wrapping and stickers from new toys, and make sure any decorations or small parts — such as eyes, wheels or buttons — are tightly fastened to the toy. Regularly check your baby’s toys for small parts that could come loose, sharp edges and mechanical parts that could trap a child’s finger, hair or clothes. Safely store toys with small piecesIf you have an older child, you likely have toys in your home with small pieces that your baby could easily choke on or swallow. Gather up games and toys that have small parts, and do your best to keep them out of your baby’s reach. When your older child wants to play with these kinds of toys, make sure he or she plays with them in an enclosed area and picks up all of the pieces afterward. Take care with electronics Don’t al-low small children to play with toys that need to be plugged into electrical out-lets. Make sure battery covers are se-curely fastened. If the toy contains a button battery, make sure your child cannot access the battery.Avoid baby walkers A young child may fall out of the walker or fall down the stairs while using a walker. The American Academy of Pediatrics has called for a ban on the manufacture and sale of baby walkers with wheels.198 PART 2: BABY’S HEALTH AND SAFETY

Safely store disposable diapers If you use disposable diapers, keep them out of your baby’s reach and cover them with clothing when he or she is wearing them. A child can suffocate if he or she tears off pieces of the plastic liner and eats them. Avoid powders Baby powders contain-ing talcum can harm your baby’s lungs if they’re inhaled. Take crib precautions Keep your ba-by’s crib free of small objects. Always put your baby to sleep on his or her back and not on a soft comforter or pillow. Don’t allow your baby to sleep with loose blan-kets. For more information on crib safety, see page 120.Watch toy box lids If you use a toy box, look for one with no top, a light-weight lid, or sliding doors or panels. If you have a toy box with a hinged lid, make sure it has lid support for any angle to which it’s opened. In addition, look for a toy box with ventilation holes, in case your child gets trapped inside it. Don’t block ventilation holes by storing the toy box against the wall. Rounded edges are also a plus.KITCHEN SAFETYThe kitchen can be an especially danger-ous place for a baby. When you need to spend time in the kitchen, consider plac-ing your baby in a high chair with a few toys to play with. Or fill a kitchen cabinet with safe items for your baby to play with — such as plastic bowls and cups. You might place your child in a playpen in an adjoining room where you can see him or her. Also take steps to prevent accidents.Reduce water temperature Set the thermostat on your hot water heater to below 120 F. If you bathe your baby in the kitchen sink, never run the dishwasher at the same time — in case hot water from the dishwasher backs up into the sink. Don’t run the faucet while your baby is in the sink. Safely store hazardous objects and substances Keep sharp instru-ments in a drawer with a latch or a locked cabinet. Make sure appliances are un-plugged and out of your child’s reach. Don’t allow electrical cords to dangle where your child could tug on them. Keep hazardous substances out of sight, out of reach and — whenever possible — in a high cabinet that locks automatically every time you close it. Hazardous sub-stances in the kitchen might include dishwasher soap, cleaning products, vita-mins and alcohol. Avoid hot spills Don’t cook, drink or carry hot beverages or soup while hold-ing a child. Know where your child is when you’re walking with a hot liquid so you don’t trip over him or her. Keep hot foods and liquids away from table and counter edges. Don’t use tablecloths, placemats or runners, which young chil-dren can pull down. When you’re using the stove, use the back burners and turn the handles of your pots and pans in-ward. Don’t leave food cooking on the stove unattended. Safeguard your oven Try to block ac-cess to the oven. Place tape on the floor around the oven and call it a “no-kid” zone. Never leave the oven door open. If you have a gas stove, turn your dials to the off positions and — if possible — re-move them when you’re not cooking. Otherwise, use knob covers. CHAPTER 15: HOME AND OUTDOOR SAFETY199

Look around Watch out for other situa-tions that could be hazardous. ZPut away small refrigerator magnets. A baby could choke on or swallow them. ZAddress slippery or uneven surfaces and clean spills quickly. ZKeep a fire extinguisher handy. FEEDING SAFETYFeeding your baby is often a messy expe-rience, but you don’t want it to be a dan-gerous one. If you use a high chair during feedings, always use the chair’s safety straps to buckle your child in. And before you feed your child, always check the temperature of the food. Never warm your baby’s formula or milk in the micro-wave. Food or liquids warmed in a micro-wave may heat unevenly. For more infor-mation about feeding your baby, see Chapter 3.Choking prevention Choking is a common cause of injury and death among young children, primarily be-cause their small airways are easily ob-structed. It takes time for babies to mas-ter the ability to chew and swallow food, and babies may not be able to cough forcefully enough to dislodge an airway obstruction. Sometimes health conditions in-crease the risk of choking as well. Chil-dren who have swallowing disorders, neuromuscular disorders, developmental delays and traumatic brain injury, for example, have a higher risk of choking than do other children. To prevent infant choking:ZDon’t introduce solids too soon. Giv-ing your baby solid foods before he or she has the motor skills to swallow them may lead to infant choking. Wait until your baby is at least 4 months old, preferably 6 months old, to intro-duce pureed solid foods. ZStay away from high-risk foods. Don’t give babies or young children small, slippery foods, such as whole grapes and hot dogs; dry foods that are hard to chew, such as popcorn and raw carrots; or sticky or tough foods, such as peanut butter, marshmallows and large pieces of meat. ZSupervise mealtime. Don’t allow your child to play, walk, run or lie down while eating. Keep in mind that as babies explore their environments, they also commonly put objects into their mouths — which can easily lead to infant choking. For in-