Baby Booklet

EMERGENCY TELEPHONE NUMBERS Magical MomentsPoison Control…………………………..1-800-222-1222Emergency………………………………..911 Basic Parenting Information from Birth to Five YearsChildren’s Hospital of Pittsburgh……. 412-692-5325Pediatric Alliance Pediatric Alliance Allegheny location……………..412-930-0908 Allegheny Location Bloomfield……………………….412-578-4003 412-930-0908 Jefferson Hills…………………..412-460-8111 Wexford…………………………. 878-332-4920 Bloomfield Location 412-578-4003 74 Jefferson Hills Location 412-460-8111 Wexford Location 878-332-4920 1

Children Learn What They Live APPENDIX B FEVER MEDICATION DOSING CHART If a child lives with criticism, He learns to condemn. Ibuprofen (Motrin, Advil) Use every 6 hours as needed If a child lives with hostility, *do not use prior to 6 months old* He learns to fight. Go By Infant’s Ibu- Children’s Children’s Junior If a child lives with ridicule, Weight profen Con- Ibuprofen Chewable Strength He learns to be shy. When Suspension Tablets Chewable Known centrated If a child lives with shame, Drops Tablet He learns to feel guilty. 50mg/1.25ml 100mg/5ml 50 mg 100 mg If a child lives with tolerance, each He learns to be patient. If a child lives with praise, Syringe Teaspoon Tablet Tablet He learns to appreciate. Weight Age Use the sy- Use the If a child lives with encouragement, ringe provid- measuring He learns confidence. ed cup provid- If a child lives with fairness, 12-17 lbs 6-11 1.25 ml He learns justice. 18-23 lbs 12-23 1.5ml If a child lives with security, He learns to have faith. 24-35 lbs 2-3 yrs 2.5 ml 5 ml (1 tsp) 2 36-47 lbs 4-5 yrs 7.5 ml (1.5 3 If a child lives with approval, He learns to like himself. 48-59 lbs 6-8 yrs 10 ml (2 tsp) 4 2 5 2.5If a child lives with acceptance and friendship, 60-71 lbs 9-10 12.5 ml (2.5 6 3 He learns to find love in the world. yrs tsp) ~Dorothy Law Nolte Ph.D. 72-95 lbs 11 yrs 15 ml (3 tsp) 2 73

APPENDIX B Table of Contents FEVER MEDICATION DOSING CHART SECTION ONE………………………………………………………page 6 Acetaminophen (Tylenol) Office Policies Use every 4 hours as needed Appointments *do not use prior to 2 months old* Billing Policy Prescription RefillsGo By Infant Children’s Children’s Junior Prenatal VisitsWeight Suspen- Suspension Soft Chew StrengthWhen sion Liq- Chewable SECTION TWO……………………………………………………...page 7Known Liquid Tabs Tablets Your New Baby uid Birth RecordWeight Feeding Time 160mg/5 160mg/5ml 80mg each 160mg General Newborn Care ml Teaspoon Tablet each Spoiling Follow Up Syringe Tablet Child Proofing the House Sleep Time Age Use the Use the syringe measuring SECTION THREE…………………………………………………...page 20 provided cup provid- Routine Well Child Office Visits6-11 lbs. 2-3 mos 1.25 ml SECTION FOUR…………………………………………………….page 3612-17 lbs 4-11 mo 2.5 ml Illness18-23 lbs 12-23 3.75 ml Fever Taking a Temperature24-35 lbs 2-3 yrs 5 ml 5 ml (1 tsp) 2 Nasal Congestion/Colds 3 Ear Infections36-457lb 4-5 yrs 7.5 ml (1.5 Ear Aches Coughing48-59 lbs 6-8 yrs 10 ml (2 tsp) 4 2 Sore Throat60-71 lbs 9-10 yrs 12.5ml (2.5 5 2.5 Vomiting and Diarrhea Managing Acute Gastroenteritis72-95 lbs 11 yrs 15 ml (3 tsp) 6 3 Rehydration 96+ lbs 12 yrs 4 SECTION FIVE……………………………………………………..page 44 72 Accidents 3

Table of Contents APPENDIX A: RECOMMENDED BOOKSSECTION SIX– Parental Advice…………………………………page 48Immunization Schedule The BasicsOffice Screening Tests  What to Expect the First Year & What to Expect the Toddler YearsTeaching Your Child to EatFeet, Legs, and Shoes by Arlene EisenbergOral Hygiene  Your Baby’s First Year: Third Edition by American Academy ofSeparation AnxietyTemper Tantrums PediatricsLoving Discipline  Caring for Your Baby and Young Child, Fifth Edition: Birth to Age 5Toilet TrainingStarting School & 6-12 Years & 13-18 Years by American Academy of PediatricsSECTION SEVEN…………………………………………………..page 65  The Happiest Baby on the Block: The New Way to Calm Crying andSome Reflections on DevelopmentAppendix A………………………………………………………….page 71 Help Your Newborn Baby Sleep Longer by Harvey KarpSome Recommended Books  Your --- Year Old Series (One Year Through Fourteen Years) byAppendix B………………………………………………………….page 72Doses of Medications for Fever Louise Bates AmesEmergency Telephone Numbers………………………………..page 74  Little People: Guidelines for Common Sense Child Rearing by Ed- 4 ward R. Christophersen Personality  Infants and Mothers, Toddlers and Parents and Other Books by T. Berry Brazelton  Your Child’s Self Esteem by Dorothy Corkille Briggs  Secrets of the Baby Whisperer: How to Calm, Connect, and Communicate with Your Baby by Tracy Hogg Communication  How to Talk So Kids Will Listen & Listen so Kids Will Talk, Siblings Without Rivalry, and Liberated Parents, Liberated Children by Ade- le Faber  Mr. Rogers Talks to Parents and Other Titles by Fred Rogers Coping  When Your Child Drives You Crazy by Eda LeShan  Living With Children by Gerald Patterson  The Difficult Child by Stanlet Turecki  How to Eat Like a Child and Other Lessons in Not Being a Grown Up by Delia Ephron 71

crayons suddenly begins and this is the first step in the long path to Introductionwriting. He should be encouraged to try all of these new and wonderful We, the physicians and staff at Pediatric Alliance, would like to thankactivities. you for the confidence you have shown in choosing us as your pediatricians. Becoming a parent, whether it is for the first time or fifthThree to Five Years time, is perhaps the most joyous experience in our lives. However, it also carries with it a great responsibility. Understanding normal childThese pre-school years are important for the intellectual, social, and development and behavior, recognizing signs of serious illness, andemotional preparation for school. Begin to stress numbers, colors, and developing proper nutrition habits are only a few examples of areasletters. As your child matures, his attention span will lengthen, which is where, at times, you may feel unsure of yourself. We, as youra very important factor for the school days ahead. His motor activities pediatricians, feel that it is our duty to share with you some of thesewill become more refined. Coloring, for example, will become somewhat responsibilities. In turn, our reward is to also share in some of the joy ofmore accurate. And his energy will seem bottomless. Instead of walking watching your child grow and develop.from place to place, your child will learn to skip, hop and jump to get Within this booklet, we hope to provide you with detailed informationthere. concerning your baby and also information we want to discuss with you at each visit.Socially, your child is learning to spend time with others outside the In addition to being a reference manual, we can also record in thisimmediate family. This is immensely important. He should have friends booklet your child’s height and weight, immunization record, and theand playmates and should enjoy being with them. reason for your visit. Our sincere hope is that you find this booklet of value in both times ofEmotionally, he is also maturing. He is becoming more independent. illnesses and for routine general questions concerning your child’sNow it is possible for him to be separated from his parents for longer health. We feel that the information here can be beneficial in allowingperiods of time. This is an important time to teach him his telephone us to achieve our common goal of assuring the overall good health andnumber, his address and basic traffic and safety rules. well-being of our most precious commodity—our children.Finally, read to him often and let him see the words and pictures in the 5books you use. Help him to understand what you read and have himrepeat favorite stories and songs.ConclusionThis brief picture of child development is intended to inspire you to beespecially helpful in teaching your child in these early years. Eventhough the child is about to go to school, you should always be his firstteacher and your responsibility continues throughout those learningyears. It is a joyous and wonderful role that you play in your child’s life. 70

SECTION ONE another, and beside one another. Tupperware, pots and pans, and OFFICE POLICIES nesting blocks become favorite toys. Watch what he shows interest in and try to encourage him in these important exercises and experiences.For a true emergency, please call 911. For urgent medical needs, callthe office. During office hours the doctor or nurse will be available to Eighteen Months to Two Yearsinstruct you on what to do. After office hours, contact the office and youwill be connected with our triage line. Vocabulary development increases in this time period. Not only will the child use more words, but he will understand many more. Remember,Since the doctor is seeing patients during office hours, they are not the words he uses are primarily those he hears from you. While youavailable to answer routine questions immediately. Please leave your should not be concerned about proper pronunciation at this stage,message with our staff and the doctor or nurse will return your call as always be sure that you are exposing him to the proper pronunciation.soon as possible. The use of his hands with greater coordination makes rapid advancesAppointment Policy at this age. Games and toys which require dexterity are most helpful for him. Puzzles requiring placement of different objects in different placesRoutine appointments should be made up to 6 months in advance. or patterns are extremely useful. Likewise, he should be using the regu-Please call early in the day if your child is sick and needs to be seen lar, baby sized utensils for eating instead of his fingers. Notice how hethat day. Sometimes it is necessary to change your scheduled begins to copy your daily routine of washing, dusting, doing the dishes,appointment, so please notify us as soon as possible. Please know that and other activities of daily living. It is good to involve your child in yourif a child is sick, they will be seen for that scheduled problem. Their activities. It may slow you down a little, but remember that you are hisroutine exam cannot be done at that time. Any routine questions or teacher.problems should be discussed with the doctor during the child’s routineexamination. By the way, your child is rapidly approaching the stage of development where toilet training is possible. You may want to read over that sectionBilling Policy in the manual.All insurance and patient billing activities are done performed by our Two to Three Yearsbilling office. We participate with most major third-party insurancecarriers as well as a variety of managed-care organizations. Much time has been spent in learning to say words and to understand them. Now your child moves into a more sophisticated use of languageAs part of your office visit, you will be asked to sign a form authorizing communication. Putting words together, he discovers that sentencesus to receive a payment directly from your insurance company. Please can be formed. Instead of pointing to things, the child now asks forremember to bring your insurance card; we will need to retain copies for things. Asking questions becomes a way of life. For parents, this is aour records. We ask that you promptly notify us of any changes in your wondrous time of talking and teaching. Conversations with your child (ininsurance coverage to prevent billing delays. a limited sense) is possible and you should use every opportunity to speak with him.Prescription RefillsPlease call during office hours to request refills. Please allow 2-3 days Likewise, he is able to dress and undress himself since his hands canfor refills. Please have your pharmacy information available. be used in a more coordinated way. Scribbling with pencils and crayons 6 69

baby to a great variety of sounds during this period. Talk to your baby in SECTION TWOsuch a way that he can hear the sound clearly. This experience is oftremendous help in language development. YOUR NEW BABYNine to Twelve Months IntroductionYour child now begins to move around on his feet rather than just crawl. Congratulations on the arrival of your new baby! Whether you haveHe may not take steps of his own, but he will pull himself into a standing become a parent for the first time or an “old pro,” few things in life canposition. You may notice that the baby has progressed in picking things compare with the joy and wonderment of seeing your new baby for theup. Now he may be able to do it using his thumb and forefinger- the first time.“pincer grasp.” It is at this time that the baby should be helped to eatsmall pieces of finger foods. Along with this joy, however, sometimes comes uncertainty. You may not yet feel entirely confident in your ability as a new parent. You mayLikewise, the baby’s babbling begins to take on more form. There are sometimes feel awkward when handling the baby or unsure of yourself.more sounds used and the baby is putting them together in an effort to Do not get discouraged by these feelings should they occur. They aremake words. While only a few words are spoken at this stage, he will perfectly natural. Remember, although you have been aware of yourbegin to recognize and to understand certain words. Language is not baby for a few months, you are just now getting to know each other in aonly speaking words, but understanding them as well. At this point, you much more intimate way. Every day you will begin to feel more relaxedcan stimulate his language development by speaking more carefully and confident in your natural abilities as a parent. In the same way,and playing music with simple songs and very clear language. Continue your baby is getting to know you and also beginning to feel moreto stimulate the visual ability of your baby. Provide him with picture comfortable. It is with love that you brought your baby into the worldbooks and take to time to point out different objects to him. and that same love will allow you to grow together as a family.Twelve to Eighteen Months Enclosed in this section we hope you will find some answers to the many questions you will have. Please share with us any concerns thatAs your child becomes more mobile, provide him with a safe area to you have about your baby. We hope that you feel comfortable askingroam and fall. Take time to help him occasionally and try not to get us any questions which are not answered in this manual.upset when he has the inevitable falls. Feeding TimeWords are of intense interest to him now. He will be trying to figure outwhat word goes with what object. This is a particularly useful time to Feeding time should be a rewarding and satisfying experience for bothstimulate language growth. Read to him. Point to things and name you and your baby. It may take some time to get comfortable with thisthem. This entire year is more important for building up the child’s new task, but in no time you should be well on your way. Your decisionvocabulary. Use care in the selection of toys, for these can serve many to breast feed or bottle feed is not as important as making feeding timepurposes in stimulating growth in visual, auditory, tactile and language a very special time. Remember that this is one of the times that yourskills. baby is getting to know you. During feeding, your baby looks into your eyes, hears your voice, and feels the warmth of your body and even theYour child also becomes “creative” with objects in this period. He will beat of your heart. All this says something to your baby. It can be aspend a great deal of time placing objects within one another, on one joyful, pleasant time if you let it say how much you love your baby. You make the difference. 68 7

There may be some problems with feeding. Newborns often seem bringing them together as well as reaching out for things.totally disinterested in feeding. This is a normal situation. A baby mustlearn to eat- mom was doing all the work for the baby while he was When you notice this period of discovery, be sure to provide the babyinside! Babies are born with excessive body fluids, which is nature’s with rattles and other objects which allow your baby to use his handsway of sustaining them until they learn to take food in a normal way. more frequently. As you provide more visual and auditory stimuli, yourTherefore, newborns lose weight immediately after birth, but in three to baby will begin to respond more clearly. For example, the baby willfour days this condition will correct itself. Do not be concerned about the follow your face and your voice, he will begin to smile or coo in reply tobaby’s occasional disinterest in feeding or about the loss of weight your face and smile at the sound of your voice.immediately after birth. In a short time the baby will be feeding well andthe weight loss will cease. Remember too, that your baby is being Four to Six Monthscarefully monitored by both us and the nursing staff.Remember these points: Your baby becomes more responsible during this stage. He will not only smile but also laugh and squeal during playtime with you. His tendency Do not be overly concerned about your baby’s schedule. As long as to reach out and hold things will continue. At times, the baby will hold a newborn is growing and tolerating the feedings; as long as you objects in his hand and begin to transfer them from one hand to are trying to make these feedings something special, and another. Of course, almost everything he holds will go into his mouth so attempting to help the baby enjoy feeding time, then despite the be careful that baby cannot get objects he could accidentally swallow. inevitable problems, things should go well. Make frequent checks of his environment and remove any small objects which he could place in his mouth. The first four months of a newborn’s life is a period of great growth. There will occur the so called “growth spurt days” when your baby Notice that the baby becomes more interested in objects that are seems to do nothing else but consume food. If you are aware that beyond his immediate reach. He will begin to move and wave his arms these days are normal, they will not take you by surprise. On these and feet. Kicking and waving are baby’s way of trying to move from one days, you should be prepared to spend most of your time feeding place to another. These are early signs that your baby is becoming the baby. mobile. At this stage, baby should be placed on the floor with a number of toys around him, slightly out of reach. When you do this, watch and Feeding time is a special “together” time for you and your baby. see if baby can move and grab hold of any of the toys. This will not Enjoy this togetherness. You should not worry about your baby’s happen immediately. If the baby begins to show frustration, merely weight, as we will be checking it at regular intervals. hand him the toys. You can try the experiment again after a few days. Breastfeeding is the recommended method of providing nutrition for Six to Nine Months your baby. The American Academy of Pediatrics recommends that infants should be exclusively breast fed for the first 6 months of life. Mobility is the keyword for this period. Your baby will gradually find better ways to move from place to place. Your job is to provide a safe 8 area for the child to do this limited roaming. Notice also that the baby is becoming more social. He enjoys playing little games with you, especially peek-a-boo and patty-cake. Most of all, he begins to imitate the sound he hears. The secret is to expose the 67

Some crawl at a certain age, some do not. Some speak at a certain BREAST FEEDING:age, some do not. We call this variable individual difference. This  Provides the best source of nutrition for the babymeans that every child is unique.  Provides the baby with natural protection against many diseasesSo what you are about to examine are only estimates or averages of and allergieswhat most children do at certain ages. Read it carefully, remembering  Most mothers and their babies find breast feeding an enjoyablethat every child is different. If you have concerns about your child’sdevelopment, always talk to your pediatrician. experience.Birth to Two Months Breast feeding is therefore to be encouraged. If problems occur with breastfeeding, please discuss with them us as soon as possible. ManyVision and hearing are the baby’s most important tools for leaning at of the offices have lactation appointments available in the office.this earliest stage in life. What the baby likes to see most are his Your baby will give you cues or signs that he or she is ready to breastparents’ faces, and what the baby wants to hear most is his parents’ feed. Some of these cues may include rooting, sucking, bringing hisvoices. You will notice how often your crying baby is calmed by simply hands to the mouth, and small fussing sounds. Do not wait until thehearing your voice or by looking into your face. Do not think that you baby is crying to begin feedings.are “spoiling” the baby by talking with him and allowing him to look atyou. These are real learning experiences for him. To begin breast feeding:  Gently tickle your baby’s lips with your nipple. Then wait until yourBabies like to look at objects that are brightly colored, especially objectswhich have contrasting colors such as black and white, stripes, or baby opens his mouth wide. You can tell the mouth is wide open ifcheck-board patterns. Likewise, fixtures which make pleasant noises, the lips are turned back and the tongue is over the lower lip. Oncesoft music, or little bells also capture the child’s attention and give the the baby’s mouth is wide open, bring your baby quickly onto thebaby a chance to develop visual and auditory skills. breast.  Make sure your baby’s lips cover both the nipple and as much ofThe American Academy of Pediatrics recommends all babies sleep on the areola (the dark part around the nipple) as possible. Do not lettheir back to decrease the likelihood of SIDS (Sudden Infant Death your baby suck only on the nipple- this will cause your nipples toSyndrome). Newborns should spend short periods of time awake on get sore. Baby’s lips should be curled out, not curled in.their belly, to help strengthen neck and back muscles. Do tummy time  You may feel a tingling or tightening sensation during the first fewdaily, and slowly increase the amount of time. minutes of nursing. This is what you may feel when your milk is “letting down.” Letting down is when your milk comes out fromTwo to Four Months where it was made and stored.At this time your baby begins to touch everything. In this way, the baby Once positioned correctly, let your baby nurse for up to 30 minutes onis learning about his own hands as well as about the things which his that side. Babies usually nurse for 10-20 minutes per side. Let the babyhands feel. Thus comes into his life the world of shapes and textures, lead the feeding and try to not watch the clock. If your baby begins tosoft and hard things, smooth and bumpy surfaces. The world he has nod off after a few minutes of nursing, unlatch and burp the baby. Ifbeen looking at and hearing is now open to his touch as well in addition your baby does not nurse on the second breast, offer that breast first atto his eyes and ears. Notice that he will begin to look at his own hands, the next feeding. Nurse your baby often. A newborn needs to nurse every 1-3 hours. Nursing often is important for mom too. It helps in 66 building the milk supply. The more a mom nurses, the more milk she will make. If feedings are delayed, or if attempts are made to fill the 9

baby with cereal or baby food, the mom’s milk supply will go down. A SECTION SEVENnewborn should nurse 8-12 times a day. A nursing mother should sip a CHILD DEVELOPMENTglass of water, juice or milk while nursing or immediately after. It is veryimportant for nursing moms to stay well hydrated. One of the greatest joys of parenthood is watching your child grow, develop, and learn. And at no time is this more wondrous andYou will know your baby is getting enough milk: spectacular than during the child’s first years. In such a brief period of time the newborn travels the road from total dependency to a level The baby maintains a steady weight gain. All infants lose some where the child can walk, communicate, eat, and take care of many of weight the first few days of life. By two weeks of age, a breast fed his needs and wants. During this time the baby goes through a great infant will return to birth weight. Please arrange for your infant to be variety of human experiences. No matter how many times one seen in our office as directed to monitor weight gain. Usually we observes this amazing change from total dependence to a state of recommend that the baby be seen 1-2 days after discharge from independence, it is a glorious and almost incomprehensible transition. the hospital. Parents receive great joy from this, and that joy can be enhanced by Monitor the infant’s output. The infant should have 5-8 wet diapers understanding how it occurs. Some of the change the parents can a day. Stools will vary in number but should change from green control, some they can only watch, and some they can enhance. transitional stools to yellow, seedy, soft stools within the first five days of life. In this section, a short version of the growth and development of the child from birth to five years is presented. It is only a quick overview. ItSome foods eaten by mothers are thought to cause a problem in breast is hoped this will help you better understand this amazing developmentfeeding babies. Generally, however, there are not foods that must be and therefore fulfill your indispensable role in the child’s growth moretotally avoided by mothers. Sometimes, a baby may be bothered by effectively.something eaten by the mother. Although it is rare, some foods thatmay be a problem are: dairy products, eggs, citrus fruits, garlic, onions, First, you must understand what is meant by readiness. This is a termcabbage, broccoli, and beans. If you think a food is causing a problem, which we use to indicate that your baby has certain inherent anddon’t eat it for 1-2 weeks. Then, eat the food again to see if the problem unique abilities to develop. But babies also must be taught so that thereturns. If the food does happen to cause a problem, then it should be behavior now possible can be done properly. You are the baby’savoided while you are nursing. Let your baby’s doctor know about the teacher. As it has been previously pointed out, certain things cannot befood and the problem it may cause your baby. taught until the baby is ready. For example, toilet training is impossible until the sphincter muscles can function properly. To attempt to teachBreast milk storage guidelines: before the child is “ready” will be unsuccessful. You are the baby’s teacher. You teach even when you don’t realize you are doing so. It is Room Refrigerator Home Deep up to you to know when things are to be taught so that you can do the Freezer best job possible. Temperature Freezer In the following pages we are going to put down certain things babiesFresh Breast 4-6 hours 5-8 Days 3-6 Months 6-12 Months do at certain ages. The time frame is an educated approximation. Every baby is different, and will reach milestones at different times.Thawed -- - - - - Must be Do not re- Do not re- 65Breast Milk used in 24 freeze freeze 10

STARTING SCHOOL BOTTLE FEEDINGIt is good to keep in mind that eventually your child must go to school. It If you prefer bottle feeding, please note the following:is perhaps one of the biggest events in the life of your child and your  We recommend using a commercially available iron fortified infantjob is to get him ready for it. Here are some hints: formula such as Similac or Enfamil. You may use Ready to Feed, 1. Always speak of school as something wonderful and special. Concentrate, or Powder formula. Never use school as a threat to the child: “Just wait until  Bottles and nipples can be washed in soapy hot tap water or in the they get you in school!” dishwasher. There is no need to sterilize these items. 2. Encourage your child to play with his peers. He must be able Ready to Feed formula is exactly that- you don’t have to do anything to to function outside your home. Playing, going to parties, prepare the formula before giving it to the baby (it’s “ready to feed.”) For and making friends are an important part of getting ready powdered formula, you put 2 ounces of water in a bottle, then add one emotionally to go to school. Each child must learn to do level scoop of formula. You can use tap or bottled water, whichever you things with others. prefer. Formula is only good for one hour after the baby starts drinking from the bottle, and for 24 hours in the refrigerator. 3. The child must be ready intellectually. Encourage his explorations and curiosity. Take time to teach him very Regardless if you are giving your baby formula or pumped breast milk, elementary things: colors, numbers, shapes, and even never warm the milk in the microwave. Instead, you may warm it by reading and writing if he shows interest. Read stories to running it under warm water or placing it in a bowl filled with warm your child frequently. Have toys and books which are water. stimulating. Listen to music- he will not only love the music but also the words. There is a great variation among newborns in their capacity to take food. Ordinarily, when a baby leaves the hospital, having 1-2 ounces is 4. Make school a desirable experience. Take your child ahead usual. However, this will vary among babies and at time, every baby will of time to meet the teachers. Take advantage of special take more or less than that amount. This variation usually isn’t school days held in the community. When the school puts concerning. on programs, plays, or other events, take the child to them. Visit the local library and let him see you reading and writ- Average intake by age: ing. Let him know how wonderful those skills can be and that he will soon learn them. 0-2 Months Ounces/Feed Average Ounces/Day 2-4 Months 2-5 ounces 26 ouncesRemember that a child must be emotionally, socially, and intellectually 4-6 Months 4-6 ounces 30 ouncesready for school. Despite all of your efforts, sometimes it happens that 5-7 ounces 31 ouncesthe child is not ready. If you have doubts about your child’s readiness,check with the school. There are simple tests which can give the an- 11swer to this question. Our doctors are also here to help. Do call if youneed this help. 64

Do not force feedings. Be guided by the baby’s appetite and not the TOILET TRAININGabove chart. When a baby has had enough to eat, you will know if youlearn to read the signals your baby gives. Remember that the bond of Toilet training can be a difficult and disappointing undertaking unlesslove you and your baby experience during feeding is much more you keep in mind some basic guidelines. Remember that no child canimportant than how many ounces are taken in. do everything perfectly. This is why it is called “toilet training.” There are certain developmental stages that must occur for a child to successfullySUPPLEMENTAL FEEDINGS/VITAMINS toilet train. First, the sphincter muscles must develop to the point that the child can control them. Only when the child gains control of theseLike all humans, babies need sufficient calories to grow and stay muscles which control urination and bowel movements is toilet traininghealthy. As a general rule, newborns (whether breast fed or formula possible. Additionally, the child must develop the awareness that beingfed) will receive these calories and do not require supplements. Never wet or having a bowel movement in his diapers is uncomfortable andgive the baby water. Substituting water for regular feedings of breast that it is better to be clean. Likewise, the child must realize that he canmilk or formula can be dangerous. do something about this. Signs that children give when they are ready to be potty trained include being really interested in the potty, or holdingIf you are breast feeding you may desire to occasionally supplement their urine or bowel movements. Most children are not ready to be pottywith a bottle. Supplemental feedings are rarely necessary to supply trained until closer to 2 years of age, but there is a wide range of whenadequate calories for a breast fed baby. They are for the occasions children begin potty training.when you are going to be away, when Dad or other family memberswant to feed the baby, and other “special situations.” If you supplement, If you understand that these developments take time, that there isyou may use either pumped breast milk or formula. nothing you can do to rush development, and that forcing it can make the situation worse, then you ready to toilet train.Formula fed babies do not need vitamin or iron supplementation,because the formula itself is fortified. The American Academy of Watch for the signs of fidgeting the child shows and then put him on thePediatrics recommends a Vitamin D supplement for breast fed babies. potty at the “best time”, ie at the time he usually has a movement, andThis will be discussed within in the first few appointments with the talk to him about what you are doing. Most of all make it a greatpediatrician. In certain circumstances we will also recommend starting a experience when everything works out. Clap your hands and showfluoride supplement when your baby is 6 months old. signs of joy. Praise him and talk about it to the family. Make the occasion a special one. Imagine what the child is thinking: “I don’t knowBabies grow beautifully on breast milk and/or formula. There is no need why all the fuss, but if I can produce that reaction, I’ll try again.”to add anything else into their diet. Even during growth spurt periods,you need only supply increased quantities of breast milk or formula. When it is not going well, do not punish the child. Be prepared forYou do not need to feed babies solids to make them grow better or failures and do not make a fuss about them. When you feel frustrated,sleep better. It is much better to add these foods at a time when the just relax and forget about it. Don’t let the failures get you down. Whenbaby is truly ready to learn how to eat solids. This will be discussed he succeeds, make him understand that you are happy and before youlater in this handbook. know it he will be fully trained. 12 Remember, the normal range for training is wide. Training only works when the child is ready and interested. 63

A MEMO FROM YOUR CHILD STOOLS 1. Don’t be afraid to be firm with me. I prefer it. It lets me know If you breastfeed the baby, stools may be quite frequent. There is no where I stand. standard for the “right” number of stools. Some babies will have a stool after every feeding, while others stool once every 2 weeks! Both of 2. Don’t use force with me. It teaches me that power is all that these scenarios are normal, as long as the baby is having soft stools. counts. I will respond more readily to being led. Formula fed babies usually have less frequent and firmer stools. Keep in mind that some babies show great strain when passing stools. Do 3. Don’t be inconsistent. That confuses me and makes me try hard- not be concerned about this if the stool that is passed is soft. er to get away with everything I can. Additionally, stools are usually either seedy yellow, green or brown, depending on what the baby is being fed. If the stool is ever black, 4. Don’t make me feel smaller than I am. I will make up for it by be- white, or red, then the baby needs to see the pediatrician. having like a “big shot.” If a baby continually passes hard stools, you can give 0.5-1 ounce of 5. Don’t do things for me that I can do myself. It makes me feel like apple, prune, or pear juice in a bottle one to two times daily if needed. a baby, and I may continue to put you in my service. Any problems or concerns you have should be discussed with the 6. Don’t try to discuss my behavior in the heat of a conflict. For pediatrician. Just remember that no two babies are alike, so do not some reason my hearing is not very good at this time and my worry if your baby’s stool patterns are different than those of other cooperation is even worse. It is all right to take the action re- babies you know. quired, but let’s not talk about it until later. GENERAL NEWBORN CARE 7. Don’t make me feel that my mistakes are sins. I have to learn to make mistakes without feeling that I am no good. Cord Care 8. Don’t forget that I love to experiment. I learn from it, so please The umbilical cord may require care for up to one month after birth. If it put up with it. is kept dry, especially at the base, the cord should fall off within this time frame. The baby’s diaper should be adjusted so that it does not 9. Don’t ever think that it is beneath your dignity to apologize to me. irritate the belly button. To clean around the cord, you only need to use An honest apology makes me feel surprisingly warm toward plain water. you. When the cord falls off, you may notice a small discharge of blood. This 10. Don’t ever suggest that you are perfect or infallible. It gives me is nothing to worry about. Should any unusual swelling, redness, or foul too much to live up to. odor occur near the cord, please call the pediatrician. 11. Don’t forget that I can’t thrive without lots of love, understanding and encouragement, but I know I don’t need to tell you that, do I?Treat me the way you treat your friends, then I will be your friend too. Remember, I learn more from a model than from a critic.Adapted from “The Whole Pediatrician Catalog”, Volume 2, Saunders Books, 1979, pp.456-457.62 13

Penis Care EFFECTIVE DISCIPLINEThe decision to circumcise or not circumcise is very personal. There Praisemay be compelling religious or cultural reasons for circumcision. TheAmerican Academy of Pediatrics does not have an official stance either Just as important as punishment is praise. A child needs to be praisedfor or against circumcision. Ordinarily, there are no complications with or rewarded when he behaves well. He needs to know that what he isthis procedure, but bleeding and/or infection can occur. If you have doing is good and acceptable, and you are the one to let him know. Aquestions regarding circumcision, please discuss them either with the little praise goes a long way. Correct his faults and reprimand what hepediatrician or your obstetrician prior to signing any surgical consent does wrong, but be sure to reward him by praising the good things heforms. does. It is wrong to ignore the good things and simply emphasize the mistakes he makes.If you decide to have your son circumcised, use Vaseline or A&Dointment on the circumcised area for 5-7 days to prevent the tender Self Imagearea from being irritated by the diaper. While redness and swelling arecommon during the first 4-5 days after the circumcision is performed, Every child is in the process of developing a “self-image”, or an idea ofany inflammation of the shaft of the penis or prolonged swelling or himself. If that image is a bad one, he will be troubled and troublesomeredness to the tip should be brought to our attention promptly. the rest of his life. He will believe that he is no good, and that he cannot do things correctly. If the idea of himself is a good one, his life can beIf you decide to not circumcise, the foreskin requires no special care. It happy and adjusted. His “self-image” determines what he thinks of him-serves as a natural protective layer of skin for the penis. During the first self and how he relates to others. It determines whether he is happy2 years of life, the foreskin will naturally become separated from the and adjusted, whether he is depressed or unhappy, and whether hehead of the penis. It can gently be partially retracted during bath time gets along well with other or not. So that “self-image” is very important.for cleansing with soap and water. After the area is clean and dry,return the foreskin to its normal position. Never forcefully retract the While the self-image comes from everything and everyone around him,foreskin. By age 9 years the foreskin will be completely retractable and it comes primarily from his parents. You tell him and show him what hedaily cleaning can be done during baths. If the foreskin is retracted and really is. So be sure you make it clear that he is something verycannot be returned to its original position, seek medical care wonderful and very special. Unless your child learns to think of himselfimmediately. as someone worthwhile, he will not do worthwhile things. It has been said that “the hand that rocks the cradle rules the world” which meansVaginal Care that parents are the most powerful influence in the formation of their children.Female babies usually have whitish vaginal discharge, which is normal.Remove the discharge with a soft cloth when changing diapers. There 61may be a small bloody vaginal discharge (false menstruation) during thefirst 2-3 weeks of life, and this is also normal. If the bleeding is a largeamount or if it persists, contact our office.Skin CareGive only sponge baths until the umbilical cord and/or the circumcision 14

The best way to prevent violent behavior is to give your child a stable, are completely healed. While some parents like making baths part ofsecure home life with firm, loving discipline and full time supervision the daily routine, bathing every 3-4 days is sufficient. Babies can beduring the toddler and preschool years. Everyone who cares for your washed with just water and no soap; you can use mild, non irritatingchild should agree on the rules the child is expected to observe as well soaps (Aveeno, Dove, etc that have no dyes or perfumes) and anyas the type of punishment used. Whenever the child breaks a rule, he brand of baby shampoo to wash the hair. Newborn skin does notshould be reprimanded immediately so that he understands exactly usually require the use of lotions or creams. In the event that the skinwhat he’s done wrong. When your child does something wrong, you becomes dry or cracked, a moisturizer (ex Aquaphor, Aveeno Baby)have a duty to let him know it is wrong and that you will not tolerate can be used twice daily. Cornstarch or talcum powder is notsuch behavior. Just because we are advocating a loving discipline does recommended because inhalation of these may cause respiratorynot mean that you are to tolerate everything and anything the child problems for the infant.wants to do. Diaper rash is usually caused by urine or stool irritating the skin.There are many times when your child will do wrong and unacceptable Change diapers frequently. You may leave a baby without a diaper onthings, and there will be times when you will become very angry with to let the skin air out. If a mild irritation does occur, then a layer ofyour child. This too is normal. Sometimes your anger will be enough diaper cream (like A&D, Desitin, Vaseline, etc.) may help that isbecause children do not like to see their parents angry. At times you reapplied with each diaper change. If a rash persists despite thesemay have to punish your child. Here, you must use good sense. treatments, contact our office.Removal of a favorite toy, making him come in the house, or timeoutare examples of punishments the child can understand. Do this Eye Careimmediately after the incident because the memory is very short at thisage. Keep in mind two things about punishment: To protect the eyes of newborn against any infection which could have Make it clear that you love him but are angry about what he is been acquired during the birthing process, ointment will be placed into the baby’s eyes shortly after birth at the hospital. It is possible that this doing. Make it clear to him that he is good and that you love him may cause some puffiness around the eyes and produce a yellowish even when he does wrong. discharge- do not be alarmed by this. Within 2-3 days after birth, these Remember the big limitation of punishment is that it only tells the symptoms should be resolved. The ointment is quite harmless and the child what is wrong. It does not tell him what he should do. Always minor inconvenience caused is a slight price to pay for the important try to be as positive as you can be when is necessary to punish protection which your baby receives. your child. During the baby’s first month, there may be occasional discharge orAlways watch your behavior around your child. One of the best ways to matter found in the eye. Discharge is usually caused by blockage ofteach him nonviolence is to control your own temper. If you must punish the tiny tear duct the newborn has. If you notice discharge buildup,him, do not feel guilty about it and certainly don’t apologize. If he clean the eye from the inside corner outward with a wet cotton ball orsenses your mixed feelings, he may convince himself that he was right place a wet, slightly warm washcloth over the eye. Occasionaland you are the “bad” one. While punishing your child is never pleasant, massage of the tear duct area in the inner corner of the eye may alsoit is a necessary part of parenthood and there is no reason to feel guilty help open a clogged duct. Redness in the white part of the eye, theabout it. Your child needs to understand when he is in the wrong so that eyelid, or swelling around the eye is concerning. Should any of thesehe will take responsibility for his actions and be willing to accept the occur, contact our office promptly.consequences. 15 60

Nail Care In time, children learn other ways of dealing with their frustrations. Temper tantrums, if handled correctly, will disappear over time. TheySometimes a newborn will have toenails or fingernails that are trouble- can become a problem if the child discovers that he can manipulate hissome; that is, they are so long that they scratch the baby. This is why parents by this sort of behavior. Difficult though it may be, the best curesome people cover baby’s hands with small mittens. If a nail needs to for temper tantrums is to ignore them. Once the child realizes that off ofbe cut, cut them straight across; do not attempt to shape them. If sharp the tears, yelling and jumping do not produce instant results, otheredges remain, remove them with an emery board or nail file. The best ways of handling frustrations will be found. It is also important totime to trim a baby’s nails is when the baby is asleep. attempt to divert the child’s attention to something else when tantrums occur. Be creative.State Newborn Screen Test Remember that there will be many times when you may say “no.” ThereWhile your baby is in the hospital, usually at 36 hours of age, a blood is nothing wrong with this. Indeed, when it must be said, you say “no”test is done to screen for several rare diseases. If detected early, these for the good of and love for your child. Try to balance your “no’s” withdiseases can be treated. If the results are abnormal, our office is plenty of “yes’s”. Remember that your child is simply trying to learn, thatnotified immediately. We would then inform you and a repeat test would he will test you, that you are teacher, and that you must be patient andbe required. If the results are normal, we will update you of this at the calm.baby’s two week visit. LOVING DISCIPLINETravel and Dress When a youngster is said to be disciplined, what image comes to mind?Your baby is ready to go outdoors as soon as you get home from the Most of us think of a child who has lived under tough parents, difficulthospital. In fact, fresh air is good for you and the baby. Let your period rules, and loads of punishment for stepping out of line or making aof exercise be the baby’s period of “exercise” and take the baby with mistake. Discipline and love seem to be incompatible, because all tooyou in whatever way is convenient. A stroller is fine, as is a front baby often we associate discipline with punishment.carrier is fine (read their instructions on proper positioning). Note thesesuggestions: Discipline means instruction or teaching. Next to the word love, the Avoid large crowds of people term discipline best tells us what a parent is. Whether or not Mom and The baby will need one more layer of clothing on compared to what Dad realize it, they are teachers. As parents you are always teaching your child. You teach him how to walk and talk, how to behave, how to type of clothes you are wearing learn the difference between good and bad, right and wrong, and what Keep your home temperature at a level that is comfortable for you is acceptable and not acceptable. You teach your child many things, but among the most important are the values, ideals, and attitudes heCar Seats holds about life. You teach him not only by telling him how to live, but by showing him how to live. It is love that makes you show him how toThe single greatest risk to your baby’s well being is a car accident. live. It is love that inspires you to teach your child the values he will takeSpecial care should be taken with your infant when you use your car. through life with him.Drive safely and remember that the precious cargo you have is bestprotected by a car seat. Remember that you own well being is im- 59portant to your baby as well as to yourself. Therefore, use your seatbeltin addition to your baby’s car seat. 16

When you have to be away or when you come home from work, always Pennsylvania state law requires the use of a car seat, and it is importantlet your baby know that you are home and always make a big fuss over that you take the time to learn the proper way to use this equipment.him. Cuddle the baby and talk to him. What the baby fears, of course, is Here are some tips:that you will leave and never return. You must teach him that you do  consider buying a car seat that is useable until your child is 4 yearsreturn, and that he is secure even when you leave. old or 40 lbs.During this period in your baby’s life, sleeping patters are often upset.  car seats should be in the backseat of the car always and never inThe baby will frequently wake at night and may even cry aloud. He isonly trying to determine if you are near. This can be handled by merely the front passenger seatreassuring your baby.  your child should remain backward facing until he/she is at least 2You have observed how often a crying child is quieted if only the parent years old or at the maximum weight/height limit for the car seattakes a minute to comfort or cuddle him. This reminds the child that you  once your child is over 40 lbs. and 4 years old, a booster seat islove him, that all is well, and that he is secure. During this same time ina baby’s life, attachments are often made with other objects. For exam- recommendedple, the baby will become attached to a teddy bear or blanket. Do not beconcerned about this. It is a normal stage in the baby’s life. Two websites with helpful information about car seats and places where car seat instillation can be checked are: TEMPER TANTRUMS  NHTSA website: http://www.safercar.gov/cpsApp/cps/index.htm  www.pakidstravelsafe.orgAs the child grows and develops, greater mobility and curiosity isevident. Constantly on the move and looking at things, reaching, and Spoilingtouching, the child is trying to learn all about the world. Since children’smovements, the ability to walk and to touch are still at a very unstable “Spoiling” in the first few months of life is not possible. The rule withstage, they often fall or knock things to the ground. Responsible parents babies, especially in the first few months of life, is that they need all thewill set up certain limits on the activities of their children without sup- love and affection that you can give them.pressing these important flurries of inquiry and curiosity. Such limita-tions are important. The child can’t recognize at this early age the Your newborn cannot talk, but there is communication which you mustdanger, the damage, or the hurt which some motions or touches can strive to understand. Sometimes the cries mean that your baby wants tocause. The stove, the good dishes, Dad’s best hat, the concrete steps be fed, or can mean that the diaper needs to be changed or the baby isoutside the door- a thousand example come to mind which cause good tired. Your baby will cry too if love and attention are the objectives.parents to limit the child’s high speed travels through those second and Babies need to be picked up and cuddled; they want to look at and hearthird years of life. things and to know that you are around.Imposing these limits, putting things out of reach, and not allowing the Remember that you are the baby’s first teacher and you are helpingchild to climb in dangerous places can cause frustrations. At age one or your infant to learn. Through your voice, touch, face, and hands thetwo a child cannot sit down and discuss calmly the reasons for these baby is beginning to discover things about the world. You are the one tolimits, nor can he make deals or compromises with you. The child’s way guide this pilgrimage. Holding, loving, and cuddling your baby is notof dealing with and expressing his frustration the temper tantrum. “spoiling”, no matter what anyone else says. Such attention is healthy and it is all part of the baby’s growth process. Notice how the baby in 58 time begins to look at you and smile and giggle. Those experiences are all part of the wonders of being a parents and assure you that your baby enjoys the love and attention you give. 17

Remember that your child sucks instinctively, even when not hungry. It sugar and lead to decay. This is especially true if the bottle sits in theis fine to use a pacifier, but let your baby associate it with you by child’s mouth for long periods of time (ex overnight). Reflect on theholding and caressing the infant when the pacifier is in use. following recommendations:  Between 9-12 months of age introduce a cup so that your child willOf course, there will be times when nothing seems to satisfy the baby.These “fussy” periods are inevitable, and you should expect them. become familiar with this type of drinkingFeeding, changing, cuddling- nothing seems to work at these times.  If the baby desires the bottle for security reasons, after the first yearSome identify these periods as times when the baby has “colic” or“gas.” Usually, some sort of soft motion will help. Bouncing the baby on put water in the bottle instead of milk or juice. At this age the babyyour knee, allowing the infant to swing carefully from side to side, or should be eating quite well and needs very little milk.placing a child in an infant carrier/stroller may help. Other suggestions  If the baby becomes attached to the bottle, substitute anotherinclude a warm bath, massage, or swaddling. security object, like a teddy bear or blanket.If you find yourself getting upset, it is best to lay the baby down in the SEPARATION ANXIETYcrib for 5-10 minutes and to get away. Your feelings of frustration arenormal. Infants are bound to have these “fussy” periods. Call a friend or At age 6-9 months, you will note that your baby cries, often intensely,family member to help you, or call the office if you have concerns about when you are out of sight. Even though a baby sitter or relative may bethe baby’s fussiness. Whatever you do, do not shake the baby, as it watching the baby, the cries can be dreadful at times. This is a verycan cause serious harm to the baby. normal developmental stage in your baby’s life. It indicates that the baby knows you and then when separated from you, the baby feels NEWBORN HOSPITAL FOLLOW UP this loss. During these early months, your baby has to know you, to distinguish you from others, and to rely on you. You are the one whoYou should have a first office visit 1-2 days after discharge from the feeds him, loves him, talks to him, and holds him. Your baby feelshospital. The baby’s weight will be checked, and we will discuss how secure with you. That is good.things are going at home. Things not covered in this manual nor in ourdiscussion are bound to happen. Please call the office during office As the baby develops and grows, he becomes aware of his uniquenesshours to discuss any questions you may have. During the first two and separateness. He realizes that he and his mother are separate andmonths of life, if your child has a rectal temperature greater than distinct persons. That you can leave, or even might leave, is a new and100.4F, is extremely lethargic, or is inconsolable, this may be an frightening idea. Often the baby feels certain, relaxed, and happy asemergency. Call our office immediately. long as you are near. You provide security and the baby must have that to feel safe.Child Proofing the House Understanding this stage of development is most important for parents. Turn water heater down to 120 degrees Each child needs security; you are giving the baby that security. The Put safety locks in high risk areas (under sinks) child’s cries tell you how well you have done your job. You want the Outlet covers on all electric outlets child to feel safe, comfortable and secure even though you are not the Watch for dangling cords from window blinds one caring for the child. That takes time and good teaching. Remember Gates for stairs (top and bottom) that you can be present to your child in many ways. Your voice is one Anchors for topple hazards (TVs, dressers, bookcases) way of being present. So talk to the baby even when you are out of the room. Talk to him when he shows any anxiety. 18 57

child is 6-7 years old, the experience is important. Giving praise when Sleep Timeyour child brushes and assisting with the cleaning will go a long way.When you assist, simply have the child lean his head against your body Though many new parents are often distraught over a lack of sleep,as you stand behind him and give the teeth a quick brushing. Once most babies actually sleep two-thirds of the day away. Like adults,your child reaches the age of 4-5 years old, teach how to floss teeth in children vary in their need for sleep; some need a lot, while others veryaddition to brushing. little. Here is a handy guide to typical sleep requirements in the first two years of life:Tooth Decay Newborn Day NightTooth decay (cavities) occurs when sugar remains on teeth after eating 4 months 8 hours 8.5 hoursbecause bacteria tend to grow on sugar. It is the bacteria that cause the 6 months 6.75 hours 8.75 hourstooth enamel to decay. Foods with lots of sugar, especially those that 1 year 3.5-4 hours 11 hoursstick to the teeth (candies and juice), promote decay. Part of good oral 18 months 2.5 hours 11.5 hourshygiene is to discourage children from eating such foods, and 2 years 2 hours 11.5 hoursencourage them to eat fresh fruits and vegetables which help clean the 1-1.5 hours 11.5 hoursteeth. Never let a baby go to bed with a bottle, as this encourages thesugar to stick to teeth. In order to possibly avoid sleep problems during the first year of life, it is helpful to put infants down to sleep in a drowsy state rather than rockingFluoride or holding them to fully asleep. This way, an infant can learn to console him/herself to sleep rather than relying solely on the parent. The parentFluoride applied topically and ingested will strengthen tooth enamel. may also want to change weekly which end of the crib the baby’s headMost areas provide water that is fluoridated. It is good to check in your is placed in order to keep the head rounded.area and determine if the water is fluoridated. If not, contact our officeand we will provide supplemental fluoride drops. If you are breast The American Academy of Pediatrics recommends that all infants befeeding, your baby may need a fluoride supplement. Additionally, ask placed on their backs to sleep. The baby may be swaddled, but noyour pediatrician if they will apply fluoride varnish to your child’s teeth to other blankets, pillows, bumpers, or stuffed animals should be in theprotect against cavities. This is typically done every 6 months. crib. Lying on the stomach has been found to be a risk factor for sudden infant death syndrome (SIDS). Since the “Back to Sleep” campaign wasThe Dentist launched in 1994, the percentage of infants sleeping on their belly has been significantly reduced, and deaths from SIDS also fell considerably.Most dentists suggest that children make their first visit age 2 or 3years. You are urged to do this. Children should get to know the dentist 19as a friend. Moreover, the dentists now emphasize a preventativeprogram and will have many suggestions on the proper care of teeth.The Teeth and the BottleImproper use of the bottle can cause teeth decay. Drinking any fluidcontaining sugar (milk, formula, juice, etc) can bathe the teeth in 56

SECTION THREE FEET, LEGS, AND SHOESROUTINE OFFICE VISITS It is often said that if the child is to learn to walk properly, special shoes 20 will be needed. There is no truth to this claim. The baby will not need high-top shoes or support shoes. Babies have all the support needed in their muscles, ligaments, and tendons. In learning to stand and walk, the baby is gradually putting these to work and at the same time strengthening them. However, there is some information to know about shoes. Be sure that the shoes fit. Prior to any purchase of shoes, the child’s feet should be measured properly. It is advisable to leave about ½ inch toe room to accommodate the child’s growth. Therefore, a soft, comfortable, inexpensive shoe that fits well is what your child needs. ORAL HYGEINE Introduction Teeth can appear any time, usually around 6 months, but possibly as late as 13 months old. Often the chewing, drooling, and rubbing of the gums which occur between 4-6 months of age is related more with the baby’s desire to eat than with the onset of teeth. Most teeth appear without any symptoms whatsoever. Of course, that is not always the case. In some instances, the baby will become fussy and redness and swelling appear on the gums. Fever is not usually a sign of teething. Your child’s first set of teeth will last until he/she is 5-6 years old. It is important to keep these teeth healthy and to use this time to develop proper habits and attitudes concerning good oral hygiene. Cleaning the Teeth When your child has only one or two teeth, it is sufficient to keep them clean by rubbing them off with a washcloth. Once there are more than eight teeth, toothpaste may be used with a very soft bristle brush. This is the time to get your child into the habit of brushing properly at least twice per day. While the child’s efficiency will be very poor until the 55

Suggested Infant Feeding Schedule 1 WEEK VISITAge Breast Formula Cereal Fruit, Veg- Tips Date:_______________ Age:__________________ milk gies, & Present Diet______________________________________________0-2 Every 2-4 Every 2-4 None None Questions you would like to ask:Months hours hours 1.______________________________________________________ 8-10 feed- 2-3 oz per ings/day feed 2.______________________________________________________ 6-8 times/ 3.______________________________________________________2-4 6-8 feed- Every 2-5 None None Advice for this visit:Months ings/day hours 1. Your baby learns with you as his/her teacher. Please review the “Development” section of this book for what is age appropri- 4-6 oz per ate. feed 2. Obtain a rectal thermometer and read the section of this hand- book entitled “Fever.” 5-6 times/ 3. Read the section of this handbook entitled “Car Accidents” and make sure you are using a car seat properly. Safety issues for4-6 Usually 6 4-7 oz per Once per Once per Cereal and this age include:Months feedings day fruit baby foods Crib Safety per day feed day oat- veggie can be start- Water heater being set at 120 degrees Fahrenheit Stage 1 ed between 4 Never leave a baby alone with pets or young siblings 4-6 times/ meal ce- -6 months 4. Water and juice should be avoided at this age group along with day real 2-4 solid foods. It is much too early for any of these. tbsp. Start simple 5. Read the section on “Spoiling” in this handbook. finger foods 6. See the sleep requirement chart in this handbook.6-9 Usually 6 Ranges Twice per Twice per (eg Puffs) 7. If your baby is exclusively breast fed, start giving Vitamin D 400Months feedings from 24- day day fruit, IU once daily (Tri-vi-sol, D-vi-sol). per day 30 oz veggie or9-12 Usually 4 24 oz/day Three Three times Advance fin-Months feedings times per per day day per day ger foods (ie Cheerios, 54 21

1 MONTH VISIT Hot dogs and grapes are the leading cause of choking in infants and should be avoided. Even after one year of age, we recommend cuttingDate:_______________ Age:__________________ these into several small pieces. Until around age 4, children should never receive whole or circle shaped pieces.Present Diet______________________________________________ In the past, the recommendation was to avoid peanuts and other nutsQuestions you would like to ask: during the first year of life. However, current research actually supports giving peanuts and other nuts (in the form of a creamy butter) in small1.______________________________________________________ amounts starting at 4-6 months of age to decrease the risk of developing allergies. Please talk to your pediatrician before starting2.______________________________________________________ foods containing nuts.3.______________________________________________________ ConclusionAdvice for this visit: If all goes well, your baby at the age of one or shortly thereafter will be 1. Your baby learns with you as his/her teacher. Please review the sitting with you and the family eating breakfast, lunch and dinner. He “Development” section of this book for what is age appropriate. will have progressed a long way by this time, but you should still be 2. Water and juice should continue to be avoided at this age along prepared to have problems. At times your baby will show absolutely no with solid foods. Again, it is much too early for these. interest in food. This is absolutely NORMAL. Do not force that child to 3. Reread “Spoiling” in this handbook. eat. Do not engage in a debate- you will lose. Do not substitute junk 4. Read the section on “Tummy Time” in this handbook. food. Simply offer the child a balanced diet and offer nutritious snacks such as fruits and vegetables. Do not pressure the child to eat. Introducing new foods, going from liquids to solid foods, and introducing the use of a cup—these are milestones. They are also learning experiences, and like all such experiences, there will be successes and failures. You don’t need rigid guidelines. Try to follow the suggestions above with a healthy and happy attitude. You’ll get to love it, and so will your baby.22 53

Finger Foods/Drinking From a Cup 2 MONTH VISIT Date:_______________ Age:__________________As time goes on, you are introducing your child to a great variety of Present Diet______________________________________________food. About the sixth to eighth month the baby should be given finger Questions you would like to ask:foods. For example, teething biscuits, large piece of fruit or vegetable 1.______________________________________________________like a banana or a cooked carrot that the baby can pick up and chew on 2.______________________________________________________(but not swallow). 3.______________________________________________________ Advice for this visit:It is most important that you be on guard against choking during thisperiod. Avoid using hot dogs or meat sticks and other items which are 1. Your baby learns with you as his/her teacher. Please review thedifficult to chew. This would be a good time for you to review the “Development” section of this book for what is age appropriate.section under accidents dealing with choking. 2. Your baby is scheduled to receive immunizations at this visit.As the baby reaches the age of nine or ten months, great proficiency is You can read about these in the section “Immunizations” asdeveloped in picking up little items with the finger and thumb. When you well as see the schedule.notice this, other finger foods should be added such as Cheerios,macaroni, small pieces of cooked vegetables, and other items like 3. There is no reason to introduce solid foods until your baby isthese. Your child should do very well with such items and it gives the showing signs of wanting to eat from a spoon. This is unlikelybaby the added advantage of decide alone when it is time to stop at this age and will be discussed in detail at the 4 month visit.eating. Until then, continue breast milk and/or formula exclusively.At about six to eight month’s old water may be introduced. Babies do 4. Safety: do not leave the baby unattended on any surface. Do notnot need any water at this age, but it is good to give in small amounts to drink hot liquids while holding the baby.introduce it to the diet. You may want to give the water in a cup to givethe baby practice using a cup. The rule here is to observe the child’s 5. Please read the section of this handbook entitled “Nasalreadiness. If at first the baby shows no desire for a cup, simply defer its Congestion.”use and wait a few weeks to introduce again. Do not force it. The childwill let you know when the right time has come. 23Food to Avoid Until Age OneHoney has been reported to have caused botulism in babies less thanone year. We recommend avoiding it.Egg whites are highly allergic for some babies and can producerashes, snotty noses, and belly aches. Egg yolks are fine, but the whiteshould be avoided.Chocolate is associated with rashes, vomiting, and diarrhea in somebabies. 52

4 MONTH VISIT Here are some tips:Date:_______________ Age:__________________  Be sure your child is hungry. Offer the baby solid food beforePresent Diet______________________________________________Questions you would like to ask: offering the breast or bottle.1.______________________________________________________  Do not try to determine yourself the amount your baby is to eat. Let2.______________________________________________________3.______________________________________________________ the baby do that. When he/she has had enough, you will know.Advice for this visit: Babies refuse food when they are full. 1. Your baby learns with you as his/her teacher. Please review the This teaching process should have several purposes: “Development” section of this book for what is age appropriate.  To teach baby the tastes and textures of foods  To teach children eventually to eat using a spoon and sitting erect. 2. Your baby may be showing signs of wanting to learn how to eat from a spoon. Please read the section “Teaching Your Child to A high chair or burp-chair is recommended Eat” as well as the section “Oral Hygiene.” As you begin this transition to solid foods, keep in mind that the more 3. Today is another immunization visit- see the Immunization pleasurable you can make it for the baby, the more likely will be your Schedule, and review this section in the handbook. success. Take time during the feeding to play with the baby. Since you only have a few foods to offer initially, it is recommended that solid food 24 be given only once or twice daily. As the number of foods available increases, also increase the number of feedings. The ultimate goal is to have your baby eat three meals a day with you and the family. New Foods Once your baby has learned the fundamentals, new foods may be introduced slowly. Our recommendation is try one vegetable, fruit or meat at a time for 3-4 days. Once you know the child does well with that food, you may introduce another food. Overall, a variety is best because it gives the child different tastes. Do not pass along your own likes and dislikes to the baby. Make everything seem desirable, but be sure it is easily digestible. Note that as the baby’s solid food intake increases, the milk intake decreases. Keep in mind that this transition takes several months. Store bought baby foods may be used, but are not necessary. Any food you can grind up, mash, or puree is satisfactory. If making baby food, do not add salt or spices to the food. 51

Obviously, there are both social and developmental reasons that 6 MONTH VISITrequire the gradual introduction of solid food. Your child was not Date:_______________ Age:__________________intended to feed on liquids alone throughout life. The change, therefore, Present Diet______________________________________________must be made. But when? The answer is you teach your baby to eat Questions you would like to ask:solid food when the baby is ready for it. These are the following signs 1.______________________________________________________your baby is ready: 2.______________________________________________________ The baby begins to chew on things and ceases to suck on them. 3.______________________________________________________ Advice for this visit: Chewing is essential for eating solid food. Your child must be hungry. No baby will eat effectively if not hungry. 1. Your baby learns with you as his/her teacher. Please review the Saliva production increases. This is necessary to digest solid food. “Development” section of this book for what is age appropriate. Your baby begins to show interest in solid food. The child begins to 2. As your baby becomes more mobile, accidents represent the watch you and others as you eat. single greatest risk to his/her health. Please read the section in Your baby can keep his/her head steady while sitting up. this handbook on “Accidents.” Your baby will keep a spoon in the mouth if one is placed there 3. Please read the section in this handbook on “Separation instead of trying to thrust it out with the tongue. Anxiety.”These signs indicate that your child is ready and these signs will usually 4. Review the Immunization Schedule and section in the handbook.appear between 4-6 months of age. Remember that you are about to 5. Review the sleep requirement chart in this handbook.teach your child a new activity. The teaching-learning process of eating 6. If applicable, read the section on “Daycare.”is like any other area. It will have its ups and down, successes andfailures. On your part it will require patience and time. Keep in mind that 25the transition from breast milk or formula to food begins very slowlybetween 4-6 months old, and that it will require your attention for theremainder of the first year.Remember too, that this process will be greatly helped if feedingbecomes a truly happy event in your family’s life. If you approach thetask with this attitude, and do not attempt to force your child to eat, thenit can be a very happy and satisfying experience.The BeginningsWhen you note the readiness signs above, begin to offer baby verydigestible foods. Baby oatmeal, apple sauce, and mashed soft sweetpotatoes or avocados are good for starters because they are easilydigested and very well tolerated. 50

9 MONTH VISIT years old, the first time they receive the flu vaccine they must get aDate:_______________ Age:__________________ booster shot at least one month later. After that, it is yearly.Present Diet______________________________________________Questions you would like to ask: OFFICE SCREENING TESTS1.______________________________________________________ Blood Count and Lead Level2.______________________________________________________3.______________________________________________________ At your child’s 9-12 month well visit, we recommend checking yourAdvice for this visit: child’s lead level and hemoglobin (blood count). This is a blood test. A prescription will be given to you to have your child’s blood drawn at an 1. Your baby learns with you as his/her teacher. Please review the outside lab. The results will come to our office and you will be notified “Development” section of this book for what is age appropriate. of the results usually within 72 hours. 2. A routine hemoglobin and lead test may be done today. You can Vision and Hearing Screens read about this in the section entitled “Office Screening.” Before your child begins kindergarten, routine vision and hearing tests 3. Reread the section of this handbook entitled “Accidents.” will be performed in our office. Should these tests indicate any reason Remember accidents are the greatest risk to your child’s health. for concern, an appropriate referral to an eye or hearing specialist will be made. 4. Your baby may be showing a strong desire to feed him/herself. Reread the section on “Teaching Your Child to Eat” and focus TEACHING YOUR CHILD TO EAT on the “Finger Foods” section. Introduction 5. Begin introducing your baby to a cup. Read the section on “The Teeth and The Bottle.” Feeding your baby takes a major portion of your time. It should. It just happens to be one of the most important activities in your baby’s life. 6. A playpen is a safety island at this age. Please avoid walkers. Since it does take so much of your time and is important, it should be a Immobile exersaucers are safe. time of great joy and happiness in the life of both you and your child. That is not always easy to accomplish. Everyone will be most anxious 7. Please read the section on “Feet, Legs and Shoes.” to give you advice on the subject, particularly on the most appropriate time to introduce solid foods. Here are some basic facts: 26  Feeding with breast milk or fortified formula alone provides sufficient nutrition up to 6 months of age  Solid food does not make your child sleep better  Solid food does not fill your child more than breast or formula feeding 49

SECTION SIX: PARENTAL ADVICE 12 MONTH VISIT Date:_______________ Age:__________________ IMMUNIZATIONS Present Diet______________________________________________ Questions you would like to ask:Immunity is a condition of being able to resist a particular disease. This 1.______________________________________________________immunity is acquired in two ways. The first way, one becomes immune 2.______________________________________________________to certain diseases and viruses by being exposed to them, such as 3.______________________________________________________viruses that cause the common cold. As a child grows and develops, Advice for this visit:the building up of resistance is a normal consequence. The second wayis through vaccines. Some of these diseases can be prevented by 1. Your baby learns with you as his/her teacher. Please review thevaccines that have been developed over the years. These vaccines are “Development” section of this book for what is age appropriate.reliable and your child should receive them at the recommended time. 2. Review the immunization schedule for shots to be given at thisPrior to the time your child receives these immunizations, a handout will visit.be given to you describing the protection given by each vaccine anddescribing any possible reactions in greater detail. 3. It may be difficult for you to leave your child or you may notice that he/she has begun to waken at night. Please reread theFor more information regarding the importance and safety of vaccines, section on “Separation Anxiety.”we recommend reading www.cdc.gov/vaccines/spec-grps/parents.htmor speak with your physician for additional information. 4. Your baby may become very picky during mealtime. Reread the conclusion to the section on “Teaching Your Child to Eat.”Immunization Schedule 5. Read the section in this handbook on “Temper Tantrums.”Age Immunizations 6. Review the section on sleep times.Birth Hep B #12 Months Hep B #2, Pentacel*#1, Prevnar #1, Rotateq #1 274 Months Pentacel #2, Prevnar #2, Rotateq #26 Months Hep B #3, Pentacel #3, Prevnar #3, Rotateq #312 Months MMR #1, Varivax #1, Hep A #1, Prevnar #415 Months DTaP #4, Hib #418 Months Hep A#24 –6 Years MMR #2, Varivax #2, DTaP #5, Polio #411 Years Tdap, Menactra #1, HPV #1,2,316 Years Menactra #2 *Pentacel = DTaP, Hib, PolioFlu vaccine is given yearly starting at 6 months of age. For children <8 48

15 MONTH VISIT ConclusionDate:_______________ Age:__________________ An important part of growth and development is motility, exploration and curiosity. These are good qualities and it is important that you do notPresent Diet______________________________________________ develop an unhealthy attitude about this normal process. However, you are responsible for making this exploration as safe as possible for yourQuestions you would like to ask: child. Take all of the obvious and necessary precautions and exercise responsible supervision. Also, try to relax and enjoy this wonderful1.______________________________________________________ period in your child’s life.2.______________________________________________________3.______________________________________________________Advice for this visit: 1. Your baby learns with you as his/her teacher. Please review the “Development” section of this book for what is age appropriate. 2. Review the immunization schedule. 3. Please read the section in this handbook on “Oral Hygiene.”28 47

therefore run the risk of choking. 18 MONTH VISIT Date:_______________ Age:__________________When a child begins to use fingers for eating, a point of important Present Diet______________________________________________development has been reached and should be welcomed. Prevention of Questions you would like to ask:choking is the key. Keep small items such as coins, marbles, buttons, 1.______________________________________________________and other similar items off the floor. Likewise, avoid giving your child 2.______________________________________________________foods which are difficult to chew. We recommend avoiding popcorn, 3.______________________________________________________candies, whole grapes, whole hot dogs, peanuts and food pieces Advice for this visit:larger than cheerio-size in the first few years of life. Grapes andhotdogs are acceptable to give if they have been cut into smaller pieces. 1. Your baby learns with you as his/her teacher. Please review the “Development” section of this book for what is age appropriate.Learn the Heimlich maneuver. This maneuver can be used to dislodge aforeign body that becomes stuck in the throat. It is performed by placing 2. Your child may be showing early signs of desiring to be toiletyour arms around the child or adult from behind, join your hands, and trained. Please read the section on “Toilet Training.”making 2-3 tugs around the ribcage. Another option for younger childrenand babies is to deliver 2-3 blows to the child’s back between the 3. Review the immunization schedule.shoulder blades. 4. Sleep hygiene at this time should include a regular bedtime, andIf your child swallows a button battery, seek emergency care immediate- a regular routine before bed. Night awakenings are common asly. It is a pediatric emergency and the child needs immediate care. are night fears at this age. Review the section on “Sleep” as necessary.Trauma 29Be alert for any serious falls, head or body injuries that can occur duringthe early years. Your baby will fall countless times during the earlyyears. It is necessary to protect the child against serious falls. Gatesshould be installed where needed, especially at the top and bottom ofstairs, as well as stairs to the basement or stairs to the outside.Many falls occur from the bed or changing table. Remember as early as1 month some babies can roll over! Never leave a baby, no matter howyoung, unattended on a bed, sofa, or changing table. Should your childreceive a severe bump or a bad fall, contact our office immediately.Watch for these symptoms: Loss of consciousness Strange behavior, disorientation, extreme lethargy or fussiness Repetitive vomiting Any pain in any part of the body 46

24 MONTH (2 YEAR) VISIT It is difficult to guard against all of these occurrences, but precautionsDate:_______________ Age:__________________ can be taken. The easiest approach is to first set your water heater toPresent Diet______________________________________________ 120 degrees Fahrenheit or below. This will prevent most scaldingQuestions you would like to ask: events from the faucet. Next, get in the habit of using the back burners1.______________________________________________________ on the stove and turning the handles away from the front of the stove.2.______________________________________________________ Also, stress to older children to never take a drink or bowl out of the3.______________________________________________________ microwave.Advice for this visit: Should your child receive a scalding injury, place the area under COLD 1. Your baby learns with you as his/her teacher. Please review the water immediately for at least 10 minutes. This will reduce the severity “Development” section of this book for what is age appropriate. of the burn. Then call our office for further instruction. 2. Remember that discipline is not to be equated with punishment. It Electrical burns are also a possibility. Cover any open outlets and keep is teaching your child in a loving way the difference between exposed wires to a minimum. All electrical work should be checked right and wrong. frequently to ensure safety. 3. Reread the section of this handbook on “Toilet Training.” Your family should also be alert as to what to do should you have a fire. 4. Review the section of this handbook on “Accidents.” Obtain smoke and carbon monoxide detectors for each floor of your 5. Read the section on “Spoiling” in this handbook. home. Ideally obtain these for each room in your home. Have a fire 6. Continue a regular bedtime routine and review the section on extinguisher available in the kitchen. In addition, occasionally have practice fire drills to learn the most effective ways to evacuate the “Sleep.” house in case of a fire. Designate a safe meeting spot (ex tree in the 7. Limit TV and video/DVD/tablet/computer time to a total of 1-2 yard, neighbor’s front door) that kids will remember to go to once they have gotten out of the house. hours a day. Drowning 30 Drowning can occur in the most unusual ways and places. Drowning can occur in even less than 1 inch of water and in as little as 20 seconds. Babies and children should never be left unattended in or near water. Two other suggestions include to keep the toilet seat closed and place non-slip pads at the bottom of the bathtub. Have an extra level of awareness in the summer, as baby pools are common. Never leave a child unattended, even briefly, in the tub or in a pool. Choking By 9-10 months of age, children are able to finger feed themselves. They may also pick up other items which cannot be chewed, and 45

SECTION FIVE: ACCIDENTS 30 MONTH VISIT Date:_______________ Age:__________________Introduction Present Diet______________________________________________ Questions you would like to ask:After the newborn period, accidents (not illnesses) represent the most 1.______________________________________________________serious risk to your child’s health. Accidents can be serious and can 2.______________________________________________________have life-long consequences. However, they can often be prevented. 3.______________________________________________________Six types of accidents are reviewed below. Advice for this visit:Poisons 1. Your baby learns with you as his/her teacher. Please review the “Development” section of this book for what is age appropriate.Along with the joy that comes when baby begins to move about andtouch things, there is the concern that the child will reach something 2. Now is the time to look into scheduling your child’s first dentalthat could be a danger. There are many things in every home that are visit. Review the section on “Oral Hygiene.”poisonous substances. Here are suggestions to help minimize yourchild’s risk of poisoning: 3. At this age potty training can be in full swing. Reread the section check on all cleaners, disinfectants, insecticides and medicines and on this in the handbook. put them out of reach. Put as many items as possible under lock 4. Social interactions are increasingly important to your child. If your and key. child is not in daycare, have play-dates or other ways for him/ Keep in a handy place the phone number of the Poison Control her to interact with other children of a similar age. Center. It is 1-800-222-1222. 31Car AccidentsAfter the newborn period, car accidents are the leading cause of deathand serious injury among children. Drive safely and remember that theprecious cargo you have is best protected by a car seat. Alsoremember to use your seat belt as well. Pennsylvania State Lawrequires the use of a car seat. It is important that you take the time tolearn the proper way to install and use this equipment. Literature isavailable in our office to assist you in using your car seat correctly.BurnsBurns and scalding accidents are very common amongst youngsters.Very often we hear that an exploring child reaches up and pulls aboiling pot or a cup of coffee down, or turns the hot water on in the sinkor bath and is scalded. 44

3 YEAR VISIT Do’s and Don’ts of Diarrhea and DehydrationDate:_______________ Age:__________________ Do’s:  Use pedialyte for rehydration if milk is completely refused.Present Diet______________________________________________  Do resume foods early and return to full strength formula or milk asQuestions you would like to ask: soon as possible.  Do use a generous amount of diaper creams to avoid a bad diaper1.______________________________________________________ rash from diarrhea. Apply diaper cream at every diaper change.2.______________________________________________________ Don’ts:3.______________________________________________________  Don’t use juice, flat soda, Gatorade, Jello or broth to rehydrateAdvice for this visit: unless Pedialyte is refused. 1. Your child learns with you as his/her teacher. Please review the  Don’t give fatty foods, fried foods, or liquids high in simple sugars. “Development” section of this book for what is age appropriate.  Don’t use anti diarrhea medications in babies or children. It will only 2. If you have not already done so, you should make an appoint- ment for your child to see the dentist. prolong the illness. 3.Your child is much more likely to suffer from a serious accident than from a serious illness. Reread the section on “Accidents.” Remember that good parental supervision is the best protection against accidents. 4. Home environment includes: A- Affection R- Respect O- Order M- Merriment A- Affirmation32 43

Juice and Gatorade are typically not recommended as the sugar in 4 YEAR VISITthose drinks will make the diarrhea worse. Date:_______________ Age:__________________ Present Diet______________________________________________Resume food once there has been no vomiting for 4 hours or so. Questions you would like to ask:Simple foods are best. For young children, try bananas, applesauce, or 1.______________________________________________________yogurt. For older children, these foods plus salty snacks, such as 2.______________________________________________________Saltine crackers or Goldfish, can help fluid stay in the body. 3.______________________________________________________ Advice for this visit:If the stools are remaining loose over one week, it can sometimes behelpful to use a lactose free milk product for one week to help the 1. Your child learns with you as his/her teacher. Please review theintestines to heal. Such options include soy based formula and milk, or “Development” section of this book for what is age appropriate.lactose free formula and milk (such as Lactaid). As the conditionimproves you can return your child to the regular formula or milk 2. If you have not already done so, you should make anproduct. appointment for your child to see the dentist.When there is significant vomiting and diarrhea, watch for signs of 3. Safety issues remain a primary concern: bike safety, cardehydration. Urine output of at least one urination every 8 hours is restraints, water safety, and safety around dogs for example.usually a good sign of adequate hydration. Contact the officeimmediately if: 4. Home responsibilities can include simple chores like cleaning the your child does not urinate for 12 hours table and picking up toys. your child becomes extremely lethargic or has very dry lips and 33 mouth your child vomits repeatedly, more than 5-6 times in a row the vomit is a bright green or bright yellow color the vomit is bloody or has coffee grinds in it the child has refused all fluids for over 4 hours the stools are more than 10 in a day or if they contain bloodThese illnesses are usually self-limited in nature, but if despite theabove measures your child has become dehydrated, the problem canbecome quite serious. Contact our office immediately. Dehydration canbe easily treated once it is diagnosed, but it may requirehospitalization. Please do not hesitate to call the office if you havequestions. 42

5 YEAR VISIT Sore ThroatDate:_______________ Age:__________________Present Diet______________________________________________ There are two kinds of throat infections: primary and secondary. MostQuestions you would like to ask: children under 2 years of age will have secondary throat infections- that1.______________________________________________________ is, irritation on the back of the throat resulting from nasal mucous2.______________________________________________________ draining into the throat. Such infections usually respond well to the3.______________________________________________________ symptomatic treatment noted in the section “Nasal Congestion/Colds”.Advice for this visit: Primary infections most often occur in children after age two. When 1. Your child learns with you as his/her teacher. Please review the children this age complain of a sore throat associated with a fever or “Development” section of this book for what is age appropriate. swollen glands or rash for 48 hours, they should be seen for an ap- pointment. Children with these symptoms should be seen promptly and 2. Most children are cooperative enough to check their vision at this tested for strep throat. Proper treatment of strep infections can prevent age, and it will be attempted at the visit. You can read about this serious complications such as rheumatic fever. in the section entitled “Office Screening Tests.” The majority of sore throats are caused by viruses, and only require 3. You are likely considering starting your child in kindergarten. symptomatic relief. Pain relief with ibuprofen (in those over 6 months Please read the section in this handbook entitled “Starting old), offering drinks cooled with ice cubes, and popsicles can be helpful. School.” (see Appendix B for ibuprofen dosing) 4. Because of your child’s normal desire to develop greater Vomiting and Diarrhea independence, we would recommend teaching him/her your phone number, address, and traffic safety. Both vomiting and diarrhea are common childhood symptoms and usually result from a virus. The vomiting part of the illness typically lasts 5. See the immunization schedule. 1-3 days, with or without fever. The diarrhea can last 7-10 days. 6. Continue to limit TV/media time to less than 2 hours per day. Occasionally the viral infection can irritate the intestines to such a de- gree that the child’s stools may take up to 3 weeks to return to normal. 34 The treatment goals of vomiting and diarrhea are to prevent dehydration and provide calories in an easily digested form. If your child is vomiting, provide liquids in small amounts at frequent intervals. This can be done using a medicine dropper, syringe, or spoon every 5-10 minutes. Try to give your child at least half of what they would take on a normal day. For younger children, use Pedialyte initially. Once the child is tolerating that and the vomiting has subsided, you may try either breast milk, formula, or whole milk, depending on what the child normally takes. 41

Coughing 6 YEAR VISITMost coughing in children is caused by the mucous draining with an Date:_______________ Age:__________________upper respiratory viral infection. A cough is most indicative of nose andairway irritation. Coughing can serve a useful purpose- by keeping the Present Diet______________________________________________respiratory secretions from settling in the lungs, coughing can preventpneumonia. Questions you would like to ask:A child with a cough who otherwise appears well is no cause for alarm. 1.______________________________________________________On the other hand, if the cough is accompanied by noisy breathing, highfever, chest pain, or if the child looks ill to you, contact the pediatrician. 2.______________________________________________________Things you can do to help treat a cough: 3.______________________________________________________ bulb suction the nose for any mucous that may be contributing to Advice for this visit: the cough 1. Your child learns with you as his/her teacher. Please review the spray nasal saline into the nose every few hours as needed “Development” section of this book for what is age appropriate. use a cool mist humidifier next to the child’s bed 2. Your child will continue to need yearly well visits. Your child’s let the child spend time in the bathroom after the room as been filled growth, development, physical, social and mental well-being will be followed closely by us. with mist/steam from a hot shower 3. Review “Stranger Danger” with your child. over one year of age, offer warm honey water (warm water in sippy 4. Responsibilities can include cleaning his/her own room, setting and clearing the table, and other simple chores. This is a good cup plus 1-2 teaspoons honey) age to initiate an allowance. over 6 months of age, can give ibuprofen as needed (even in the absence of fever) to help decrease the inflammation that contributes to coughing. This may be most helpful before bedCough medication/suppressants/decongestants are only FDA approvedin children over 6 years of age, and even then are only mildly effective.You may try the above remedies in older children as well.Remember that most coughs last 7-12 days as part of a cold. If the childis not bothered by the cough, no treatment is necessary. If the coughworsens after a week or lingers over 2 weeks please call for anappointment.40 35

SECTION FOUR 3. Most local pharmacies have a nasal aspirator (bulb suction), and one was likely given to you at the hospitalIllnesses when your baby was born. Once the mucous is loosened by the vaporizer or the salt water nose drops, this aspirator can beOnce your baby has completed the newborn period there are two risks used to remove the mucous.to health that require concern. The first of these is illness. In this sectionthe subject of illness will be discussed. In the following sections the These suggested treatments of nasal congestion are intended tosecond risk to an infant’s health, accidents and injuries, will be relieve symptoms and therefore to make your child more comfortable.discussed. Use good judgment. If your child is generally happy, and is eating and sleeping well, these treatments are not needed. On the other hand, ifChildren do become ill. It is your pediatrician who stands ready to help your child is miserable, extremely fussy, having labored breathing andyou at such times. Here is some general information on childhood the symptoms are not eliminated by the suggestions here, then contactillnesses: our office immediately. in the first few years, the average child will have between 7-9 self Ear Infections limited viral illnesses, for which there is no curative treatment as the child grows older, the number of these illnesses decreases During the first few years of life, a child may have at least 2-3 ear once your child begins daycare, preschool, or school, the number of infections. Do not be alarmed. Ear infections are extremely common and usually follow upper respiratory tract infections. illnesses increases Some signs to look for include tugging the ear, fussiness, a feverWhat physicians do is determine whether or not your child’s illness is following symptoms of nasal congestion, and changes in sleep orserious or in the nature of an emergency. If so, the child needs eating patterns.evaluation and treatment. If not (which is most likely), we deal with thesymptoms to provide relief and allow the body time to heal. If your child develops an earache during the night, try these suggestions:In the following section we share information about childhood illnesses.  acetaminophen (if older than 2 months) or ibuprofen (if older than 6Of course, some things may occur that are not covered in this section.Should you have any questions, please call the office during regular months) as needed. (see appendix C for dosage)business hours. If an emergency occurs, call us immediately.  place a warm bottle wrapped in a towel against the infected earFever Older children will complain of ear pain on occasion. To be certain there is an ear infection, the ears must be examined. If you suspectOne of the symptoms which causes greatest parental concern is fever. your child has an ear infection, please call our office to arrange anA fever is simply a sign that your baby has an infection. The big appointment.problem is to determine what the infection is, and that cannot be de-termined by temperature alone. The height of the fever does not tell us If prescribed an antibiotic and symptoms have not improved in 48-72how serious the illness is. hours after starting medication, please call pediatrician for your child to be reevaluated. Additionally, the pediatrician may want to recheck the 36 ear after the course of antibiotics has been completed. 39

Taking a Temperature It is important to look at other symptoms to determine how ill the child is. How does your child look? If he/she is having periods of playfulnessDuring the first few years of life, a rectal temperature is the most and does not look terribly ill, then it is most unlikely that the fever isaccurate way to take a temperature. A temporal artery temperature is being caused by anything serious. Is the baby drinking/eating? Havingalso accurate. For children over age 3-4 years, on oral or temporal wet diapers? Any increased work of breathing? These are examples oftemperature is appropriate. Axillary (arm pit) temperatures are the least things that help determine how sick the baby is.accurate, but are better than no measurement at all. Due to safetyconcerns, mercury thermometers are not recommended. The primary reason for treating fever is to make the child more comfortable. If the fever goes down and your child “perks up”, that is aNasal Congestion and Colds reassuring sign that your child is not likely seriously ill. Acetaminophen (Tylenol) and ibuprofen (Motrin) are safe to use for fever.Children, especially in the first year of life, often develop rather Acetaminophen can be given once the baby is 2 months old, andsignificant nasal and upper airway congestion. This may be due to a ibuprofen may be given when the baby is at least 6 months old.common cold, dryness in the air (especially in winter), irritants andpollutants (especially if family members smoke) or to allergies. Should ***A complete listing with the proper dosage is included as Appendix Bcongestion develop, do all you can to keep your baby away from of this handbook***irritants and try to humidify the air that the baby breathes. Congestioncan be an issue in the first year of life because the air passages of the Do not use a cold water bath or rubbing alcohol to bring down the fever,infant are so small and because the average infant will have between 7 as it will cause chills and make the child more uncomfortable.-9 colds per year. Although fevers do not harm your child, the following are occasionsMedications are not very effective in relieving nasal congestion in when you should contact the pediatrician immediately:young children, and in fact can be dangerous. Over the counter cold  if your baby develops a temperature of 100.4F or above in the firstmedicines are not recommended in those younger than 6 years of age.However, you can try the following: two months of life. Newborns do show signs to tell if the infection is serious and therefore need immediate evaluation1. One of the most effective and safe ways to loosen mucous and  if your child, at any age, has a fever and appears lethargic or has clear the respiratory system is using a cool mist vaporizer/ persistent vomiting or diarrhea humidifier (do not use a steam vaporizer). Use only water in the  if your child acts extremely ill despite acetaminophen or ibuprofen vaporizer. Be sure to keep the vaporizer clean- use a disinfectant use to clean it periodically.  if the fever persists beyond 3 days2. You can buy or make a salt water solution to put in your baby’s Have confidence in your own ability to read your child’s signs of illness nose to help loosen the mucous. Commercially prepared solutions properly. You know your child better than anyone and can tell whether are called “nasal saline” or “salt water nose drops.” To make the he/she is extra fussy or lethargic. If you are ever in doubt, call us salt water solution, mix four ounces of sterile, warm water and ¼ promptly. teaspoon of salt. Allow the salt to dissolve and to cool to room temperature. When congestion occurs, place 2-3 drops of the so- 37 lution into your child’s nose. This may cause the child to cough or sneeze. Do not worry- it is not causing any harm to your child. 38