Cottage cheese like curds coat the inside of your baby’s tongue and inner cheeks. What is this white stuff that won’t wipe off? Not breast milk, not formula, it’s thrush.

Thrush, fancy medical name Oral Candidiasis, is caused by an overgrowth of yeast, called Candida. Although not painful, it may cause discomfort akin to having a film of cotton coating the inside of the mouth. 

We all have Candida on our bodies. Usually we have enough bacteria on our bodies to suppress the growth of Candida, but in cases when there is less than usual bacteria such as in young babies or for kids who are on antibiotics, Candida can emerge. For older kids on inhaled steroids for asthma, failure  to rinse out the mouth after medication use also promotes an environment conducive to thrush. 

To treat thrush, we usually prescribe Nystatin, an anti-fungal/anti-yeast medication, which works topically. Parents apply the medicine to the inside of the baby’s mouth after feedings four times per day. Use Nystatin until thrush is no longer visible for 48 hours. A course takes one to two weeks to complete. An oral medication called fluconazole (brand name Diflucan) may also be prescribed. 

Watch out. Thrush may be thriving on mom’s breasts or on pacifiers or bottle nipples. Mothers can apply the same medicine to their breasts after breast feeding. Scrub pacifiers, bottle nipples, and any other object that goes in to a baby’s mouth extra well with hot water and soap or use the dishwasher.

Thrush that persists despite proper treatment can signal an immune system problem.  So if your child’s thrush is not resolving in the expected time, let your child’s health care provider know.

A newborn’s tongue may always look slightly white. This “coated tongue” in young babies could be residual breast milk or formula and does not need treatment. If you are not sure, bring him in to see his health care provider for proper diagnosis.

Julie Kardos, MD with Naline Lai, MD
©2011 Two Peds in a Pod®

I often pass a parent on her way out of my office carrying an infant in an infant car seat. As I stop to elicit a goodbye smile from the baby, I check to see that the car seat straps are buckled properly. I say to the parent, please make sure that the cross strap is across his chest, not down at his lap. And please tighten the shoulder straps; I should not be able to pinch the strap above his shoulders. These are too loose.

Car seats save many lives every year. After immunizations, they are the most effective way to prevent death in children, but car seats need to be used properly. Many families travel this time of year and that means it’s time to update your car seat safety knowledge.

Until recently, experts recommended that babies in car seats need to weigh at least 20 pounds AND be at least one year old until they could face forward. Newer recommendations say babies should stay rear facing in a car seat until two years old, or until they no longer fit facing backward. The reason for this change is that in a crash, children suffer fewer injuries when they face backward. Different car seat brands have different weight and height specifications so be sure to read the literature that comes with your car seat. If the seat fits well, the middle of the back seat is the best spot to install a car seat. Rear facing infant seats are the most difficult to install correctly. Luckily, many police stations and gas stations offer programs to check if car seats are installed properly. Check with your local police.

Children should remain in car seats as long as they correctly fit. For some kids this is age four years and for smaller kids this may be five or even six years. If your child is particularly tall or obese he may require a high-backed booster soon after age three. My friend had a tall child that unfortunately ended up in a car accident recently. Again, read the literature that comes with your car seat for the height and weight limit; this is more important than the age of your child. The more restraints, the safer the seat. Five point harnesses are safer than three point. After five years a car seat should be replaced. Usually the third born ends up with a new seat. Because of the risk of hairline cracks, also replace a car seat if it was in an accident.

When your child outgrows the car seat, he graduates to a booster. Again, remember the more restraints, the safer the seat. A high backed booster is preferable until your child outgrows it. Keep your child in his booster seat until he is tall enough for the chest strap of a car’s seatbelt to lie diagonally across his chest without hitting his neck and for the lap strap to lie straight across the bony parts of his hips, not his stomach. To provide neck support and minimize whip lash, his ears should not jut up past the top of the back of the booster or car headrest. Keep children 12 years old and younger in the back seat. The force of an air bag can harm a young child. 

Parents can call 1-800-CARBELT to access the American Academy of Pediatrics car safety seat hot line for their more specific car seat questions.

To ingrain good car safety habits in your children, remember to be a role model and buckle up yourself 100 percent of the time, even if you are driving only next door. Your children are watching you.

Julie Kardos, MD with Naline Lai, MD
©2010 Two Peds in a Pod?

Addendum: Please note that the official updated car restraint policy of the American Academy of Pediatrics as of March 2011 include the above recommendations of staying rearfacing until age two years and avoiding riding in the front seat until at least age thirteen years. In addition, more specific guidelines about boosters were added: children should stay in a booster seat until the car’s seat belt fits properly, at the minimum height of 4’9″ and between 8-12 years of age.

Graco was founded nearly 70 years ago, and Evenflo and Child Craft have been around even longer. In fact, most of the prominent baby supply manufacturers have been in the baby business for decades, so I am always appalled when their products are recalled. Haven’t they perfected the art of manufacturing safe baby products yet? Drop-down side cribs are the latest example in faulty designs. In the past year, manufacturers announced the recall of many drop side cribs. Ultimately, last week, the Consumer Product Safety Commission completely banned drop-down side cribs  because they have been implicated in the deaths of at least 32 infants since 2001. 

Recalls occur slowly. Here’s an example. My husband and I discovered some of the plastic pieces which held up the mattress support for our firstborn’s crib had cracked in half when we tried to set up the crib for our second born. Thinking we had used too much force to snap the pieces into place, we simply ordered more parts and put the crib together. Not until after my third child was born, five years after my first, did a recall on this crib go out. Other families experienced some of the pieces snapping while babies were in the cribs and the mattresses fell to the ground.

Through the years, I’ve noticed most recalls are only for a handful of reasons. Look at your children’s toys and equipment for these potential dangers before the recall occurs:

• Head entrapment – The most common story is that the baby slides through a leg hole of a stroller or baby carrier and his neck gets stuck. A baby also may strangle when his neck is wedged between parts of a piece of equipment. This problem occurred with drop-down side cribs. The recommended width between crib rails is 2 3/8 inches (the width of a soda can) because a child is more likely to trap his head in any larger of an opening.  Make sure there are no openings or potential openings larger than 2 3/8 inches.

• Choking – Any part that can be pulled off and fit into a toilet paper tube is a choking hazard.

• Restraint failure – Equipment is often recalled for inadequately restraining a baby, e.g. loose swing straps.

• Lead ingestion – Lead needs to be consumed to cause poisoning so anything your baby chews on, including railings, are suspect. Lead check kits are readily available; the one I use is leadcheck.com.

If your child is injured because of faulty equipment, even with an injury which seems inconsequential, remember to report the problem to the consumer product safety commission and to the manufacturers.  

Forget waiting for the recall. It could be years. Don’t buy something that makes you suspicious in the first place.

For more baby proofing hints, please see our post The In’s and Out’s of Baby proofing.

© 2010 Two Peds in a Pod℠

Today our dear friend, pediatrician, and mom, Wendy Lee shares insights and personal experience on how to tell your child he is adopted.

My husband and I had waited three long years for “the phone call” letting us know who would become our baby.  Only three short weeks prior to boarding a plane to China, we got the news we would not be bringing just one beautiful girl home from China, but TWO. Twins. We should have known right at that moment we would begin living a life of improvisation.

As with all parenting, there are endless numbers of issues to tackle.  One unique to families formed by adoption is how and when to tell your child he is adopted.  There are many differing opinions on how to do this right, but all agree children should be told.  It wasn’t so long ago that “the experts” deemed it to be psychologically damaging for a child to know about his adoption, and recommended not revealing this information.  Thankfully, things have evolved, and we are faced not with if, but how, to best share the news about adoption.

Just as with many aspects of child rearing, it is often best to take cues from your child.  If your child is younger, as were our girls (thirteen months old at the time we first met them), it is a good time to discuss adoption openly so it takes on a normalcy.  We read a full library of children’s books to them about adoption, and show the girls pictures and videos of our trip over and again.  We speak with them about our “Gotcha Day” (the day we got them and they got us).  And we celebrate this day each year with some of the families who traveled to China and got their daughters on the same day.  We talk about their birth parents in China and celebrate their heritage which, although similar to ours, is not exactly the same (I am Korean, and my husband is Cambodian). 

We gave ourselves a little pat on the back one day when we told our children one of our friends was going to have a baby, and they in turn asked which plane the parents were going to ride to get the baby.  They certainly thought adoption was a normal way to have a baby, but now we were faced with telling them other ways this could happen!  

As children grow, they enter new stages which may require improvisation.  A child’s age and temperament will guide you in your discussions regarding her birth and adoption.  Some children will never have any questions and will be satisfied with the here and now.  Others will have lifelong struggles to try and understand their history.  At certain stages, children will want nothing else but to fit in.  Being adopted, at that point, may set them apart from others and become something they will not want to advertise.  While “Gotcha Day” right now is another opportunity for our girls to have cupcakes, presents, and company, at some point it may be a day that reminds them of what they have lost and how they are different from their friends. They may choose not to celebrate this day any longer.  For some children, curiosity about their birth parents will be all-consuming and for others, it may just bring fleeting thoughts. 

Regardless of the age, stage or temperament of your child, my advice is to be truthful, open, supportive and positive. As your child grows, you will share more information. At some point, probably during his/her adolescence, your child should be given all the information that is known regarding his or her history, even if it may be difficult to share.   Discussions will move from simple explanations to potentially heart-wrenching, tear-ridden sessions where answers aren’t available.  I think whatever reaction your child will have to this part of her past, the longer she has to process it, and the longer you have to deal with your child’s emotions in this regard, the better it will be for all.

Wendy C. Lee, MD, FAAP
General Pediatrician

Presently full-time mama to two beautiful twin girls adopted from China

Anxiously awaiting a third child from Korea

© 2010 Two Peds in a Pod℠

Breastfeeding moms often ask us what medications they can take and not adversely effect the baby. The most complete database we have found is LactMed . Hope you won’t  have the need to refer to it too often.

A few days ago, I spoke with the faculty of a local early childhood education center about flu vaccine myths. See how you do on the true and false quiz I gave them:

I can tell when I am getting the flu and will leave work before I infect anyone.

False. According to the CDC (US Center for Disease Control), you are infectious the day before symptoms show up.

I never get the flu so it’s not necessary to get the vaccine. 

False. Saying I’ve never had the flu is like saying, “I’ve never a car accident so I won’t wear my seat belt.”

I hate shots. I hear I can get a flu vaccine in a different form.

True.  One flu vaccine, brand name Flu Mist, provides immunity when squirted in the nose. Non-pregnant, healthy people aged 2-49 years of age qualify for this type of vaccine.

I got the flu shot so I was healthy all year.

False. Perhaps it was the half-hour a day you added to your workout, or the surgical mask you wore to birthday parties, but your entirely healthy winter was not secondary just to the flu vaccine.  The United States flu vaccine protects against several strains of flu predicted to cause illness this winter. This year’s vaccine contain both seasonal and the 2009 H1N1 strains. Your body builds up a defense (immunity) only against the strains covered in the vaccine. Immunity will not be conferred to the thousands of other viruses which exist. On the other hand, the vaccine probably did protect you from some forms of the flu, and two fewer weeks of illness feels great.

My friend got the flu shot last year, therefore, she was sick all winter.

My condolences. True, your friend was sick. But the answer is False, because the illnesses were not caused by the flu vaccine.  Vaccines are not real germs, so you can’t “get” a disease from the vaccine. But to your body, vaccine proteins appear very similar to real germs and your immune system will respond by making protection against the fake vaccine germ. When the real germ comes along, pow, your body already has the protection to fend off the real disease. Please know, however, there is a chance that for a couple days after a vaccine, you will ache and have a mild fever. The reason? Your immune system is simply revving up. But no, the flu vaccine does not give you an illness.

I got the flu vaccine every year for the past decade. I will still need to get one this year.

True. Unfortunately, the flu strains change from year to year. Previous vaccines may not protect you against current germs.

I am a healthy adult and not at high risk for complications from the flu, so I will forgo the flu vaccine this year.

False. The flu vaccine is now recommended for everyone greater than 6 months of age. When supply is limited, targeted groups at risk for flu complications include all children aged 6 months–18 years, all persons aged ≥50 years, and persons with medical conditions that put them at risk for medical complications.   These persons, people living in their home, their close contacts, and their CARETAKERS are the focus of vaccination. 

Even if I get the flu, I’ll just wash my hands a lot to keep the germ from spreading. I have to come back to work because I don’t have much time off.

False, According to the American Academy of Pediatrics Report of the Committee on Infectious Diseases, the influenza virus can spread from an infected person for about a week after infection.

Yes, kids get sick from others kids, but as a parent who comes in contact with two children, an early childhood educator who comes in contact with ten children, an elementary school teacher who comes in contact with twenty children or a high school teacher who comes into contact with one-hundred children daily, you may end up the one who seeds your community with a potentially deadly illness.  Right now, flu vaccine clinics are as plentiful as Starbucks. Hit that CVS or Walgreens on the way home, wander into your doctor’s or grab a shot while you get groceries.  By protecting yourself from the flu, you protect the children you care for.

Naline Lai, MD with Julie Kardos, MD

© 2010 Two Peds in a Pod℠

Picture this: you are going back to work after a too-short maternity leave. Briefcase? Check. Lunch? Check. Breast pump? Check. Photo of your baby to put on your pump for inspiration? Check.

Many moms ask how to continue breastfeeding when they return to work. Because babies should receive breast milk or formula for at least their first year, here is how you can incorporate breastfeeding into your work routine:

Offer bottles by four weeks of age. Bottles can contain breast milk or formula, but you need to give your baby practice taking milk from a bottle by four weeks old. If you wait much longer, your baby will likely refuse the bottle. Have someone other than yourself give at least one bottle per day or every other day. In this way, your baby learns to accept nutrition from someone else.

Store breast milk using the simple and conservative “rule of twos.”  Leave breast milk in a bottle at room temperature for no more than two hours, store breast milk in the refrigerator for no more than two days, and store in the freezer for no more than two months. If your baby has already sucked out of a breast milk bottle, that milk is only good for up to two hours. Remember to write the date on your milk storage bags and use the oldest ones first.

Now select from the following breast feeding menu, understanding that you might start with option 2 or 3 and then change to option 4. The best option is the one that works best for you and your baby.

Option 1: Continue to breast feed at work. This option works for moms who work from home, moms who have child care in their work setting, and moms close enough to dash home to breast feed during the day or who have caregivers willing to drive babies over to work for feedings.

Advantage: no pumping, no buying formula, no bottle washing. Disadvantage: may require some creative scheduling.

Option 2: Breast feed when home and pump and store breast milk at work. Have child care givers offer stored breast milk in bottles. This method allows moms to provide exclusively breast milk to their babies. Start pumping after the first morning feeding (or any other feeding that you feel you produce a bit more than your baby needs for that particular feeding) beginning when your baby is around four weeks old. Also pump if your baby happens to sleep through a feeding. Store this milk in two or three ounce amounts in your freezer. You can obtain breast milk freezer bags from lactation consultants and baby stores, or you can store milk in zip lock bags.  As you continue to pump after the same feeding each day, your body will produce more milk at that feeding.

Once you have some breast milk stored and you are a few days out from returning to work, try pumping during the feedings you will miss while at work. Have someone else feed your baby breast milk bottles for these feedings. Finally, when you return to work, continue to pump at the same schedule and leave the stored breast milk for your child’s caregivers. Consider leaving some formula in case caregivers run out of breast milk. Remind them never to microwave the milk (this kills the antibodies in breast milk as well as creates a potential burn hazard) but rather to thaw the milk by placing in a hot water bath.

This method becomes easier as babies get older. Once babies start solid foods, they breast feed fewer times per day. Somewhere between six to nine months, your baby eats three solid food meals per day and breastfeeds four or five times per 24 hours. Thus, the number of times you need to pump decreases dramatically.

Advantage to this option: breast milk with its germ-fighting antibodies given through the first year and no expense of formula. Disadvantage: having to pump at work.

Option 3: Breast feed before and after work and give your baby formula while you are at work.  If you do not pump while at work, your body will not produce milk at these times. If you work full time, then on weekends you might find it easiest on your body to continue your “work time” feeding schedule. If you choose this method, wean your baby from daytime breast feeding over that last week or so before returning to work. Suddenly going a long time without draining your breasts can lead to engorgement, subsequent plugged ducts, and mastitis.

Advantage: baby continues to receive breast milk. No need to pump at work. Disadvantage: you still have to wash bottles and have the added cost of formula.

Option 4:  Breast feed until you return to work, then formula feed. Wean over the last week you are home with your baby to avoid engorgement and leaking while at work. Your baby still benefits from even a few weeks of breast milk.

Advantage: No need to incorporate pumping into your work schedule.  Baby still gets adequate nutrition. Disadvantage: babies who are in childcare and exposed to many germs miss out on receiving extra antibodies in breast milk. However, weaning your baby off breast milk will not cause illness. Do what works for your family. Also, more expensive to buy formula and time-consuming to wash bottles.

Pumping should not take longer than 15 minutes if you’re pumping both breasts at the same time and can take as short as 7-10 minutes. Remember to wash your hands before pumping.

What kind of breast pump should you buy/rent? If you are in it for the long haul, we recommend the higher-end electric double pumps with adjustable suction. Ask the hospital nurses, your midwife, or your obstetrician for names of people who rent or sell pumps in your area.

Finally, remember that the calorie count and nutritional content of breast milk and formula are the same. So do NOT feel guilty if pumping does not pan out and you and end up giving some formula. Your baby is almost always going to be more efficient than a breast pump and some breasts just don’t produce milk well during pumping sessions. In contrast, some of my patients never got the hang of breast feeding and their moms pumped breast milk and bottle fed them for the entire first year. Dr. Lai and I have each had patients who refused to take a bottle at childcare but just waited patiently for their moms to arrive. These babies got what they needed by nursing throughout the night. The babies didn’t mind what time of day they ate. Just like many aspects of parenting, sometimes with breast feeding, you just have to “go with the flow.”

Julie Kardos, MD with Naline Lai, MD
2010 Two Peds in a Pod®

A concerned parent wrote to us:

Why do babies cry? This may seem like a silly question, but sometimes you really want to know why your infant is crying.

Remember, newborns cannot talk. They can’t even smile back at you until around six weeks of age.  Why do babies cry? In short, newborns cry to communicate.

Ah, but what is it, exactly, that they try to communicate? Babies cry when they…

      – Are tired.

      – Are hungry.

      – Feel too cold.

      – Feel too hot.

– Need to be changed –I never really believed this reason before I had my twins. My firstborn couldn’t have cared less if he was wet and could nap right through a really poopy diaper. Then I had my twins.  I was amazed that their crying stopped if I changed the tiniest bit of poop or a wet diaper. Go figure.

– Are bored. Perhaps she is tired of the Mozart you play and prefers some good hard rock music instead. Maybe she wants a car ride or a change of scenery. Try moving her to another room in the house.

– Feel pain. Search for a piece of hair wrapped around a finger or toe and make sure he isn’t out-growing the elastic wrist or ankle band on his clothing.

– Need to be swaddled. Remember a fetus spends the last trimester squished inside of her mom. Discovering her own randomly flailing arms and legs can be disconcerting to a newborn.

– Need to be UN-swaddled. Hey, some like the freedom to flail.

– Need to be rocked/moved. Dr. Lai’s firstborn spent hours tightly wrapped and held by her dad in a nearly upside down position nicknamed “upside-down-hotdog” while he paced all around the living room.

– Check to see if there is a burp stuck inside her belly. Lay her down for a minute and bring her up again to see if you can elicit a burp. 

– Does your baby seem gassy? Bicycle his legs while he is on his back. Position him over your shoulder so that his belly presses against you. You’d be gassy too if you couldn’t move very well. The gassy baby is a topic for an entire post- talk to your doctor for other ideas.

– Are sick. Watch for fever, inability to feed normally, labored breathing, diarrhea or vomiting. Check and see if anything is swollen or not moving. Listen to his cry. Is it thin, whimper-like (sick) or is it loud and strong (not sick)? Do not hesitate to check with your pediatrician. Fever in a baby younger than eight weeks old is considered 100.4 degrees F or higher measured rectally. A feverish newborn needs immediate medical attention.

What if you’re certain that the temperature in the room is moderate, you recently changed his diaper, and he ate less than an hour ago?

– Walk outside with your baby- this can be a magic “crying be gone” trick. Fresh air seems to improve a newborn’s mood.

– Offer a pacifier. Try many different shapes of pacifiers. Marinade a pacifier in breast milk or formula to increase the chance your baby will accept it.

– Pick her up, dance with her, or walk around the house with her. You can’t spoil a newborn.

– Try vacuuming. Weird, but it can work like a charm. Place her in a baby frontal backpack or in a sling while cleaning.

– Try another feeding, maybe she’s having a growth spurt.

-When all else fails, try putting her down in her crib in a darkened room. Crying can result from overstimulation. Wait a minute or two. She may self-settle and go to sleep. If not, go get her. The act of rescuing her may stop the wailing.

-If mommy or daddy is crying at this point, call your own mom or dad or call a close friend. Your baby knows your voice and maybe hearing you speak calmly to another adult will lull her into contentment.

– Call your child’s health care provider and review signs of illness.

– If you feel anger and resentment toward your crying baby, just put her down, walk outside and count to ten. It is impossible to think rationally when you are angry and you may hurt your child in order to stop your frustration. Seek counseling if these feelings continue.

Now for the light at the end of the newborn parenting tunnel: the peak age when babies cry is six weeks old. At that point, infants can cry for up to three hours per day. Babies with colic cry MORE than three hours per day. (Can you believe people actually studied this? I am amused that Dr. Lai won a prize in medical school for a paper on the history of colic). By three months of age crying time drops dramatically.

While most crying babies are healthy babies and just need to find the perfect upside-down-hot-dog position, an inability to soothe your baby can be a sign that she is sick. Never hesitate to call your baby’s health care provider if your baby is inconsolable, and don’t listen to the people who say, “Why do babies cry?…They just do.”

———

Thanks to our Facebook friends for other ideas for what the cartoon baby is saying:

“Stop looking at me like that and please loosen this blanket and don’t hold me up here like this and where is my hat my diaper is giving me a wedgie! JUST MAKE IT ALL STOP!”

“WHY CAN”T YOU LET ME GO BACK TO SLEEP, PEOPLE!”

———

Julie Kardos, MD with Naline Lai, MD

©2010 Two Peds in a Pod℠

Ok, so now you are in charge of caring for a newly circumcised penis. As a mom who’s never had a penis or as a dad who has no memory of his pre-circumcised days, you may have questions after you leave the hospital about how to care for this “wound.” 

Unlike most infants in the world, in the United States, most boys are circumcised. Parents choose to circumcise their sons for various reasons including medical and cultural beliefs. In this blog post I will not address any debates about circumcision. I will only address care of the recently circumcised penis.

It takes about one week for a circumcised penis to fully heal. This is not long in the scheme of things. While there are no absolute standards of circumcision care, most providers recommend putting a walnut size amount of either petroleum ointment or antibiotic ointment directly onto the head of the penis at every diaper change for the first 3 or 4 days. Some find it easier to dollop the ointment onto a gauze pad and then tuck the ointment covered pad into the diaper.

Be sure to clean any stool on the penis using mild soap and water. Some white, gray, or yellow material will accumulate on the head of the penis around the third or fourth day. This material, called granulation tissue, is a normal part of the healing process. (You may remember a similar healing process occured when you skinned your knee as a child). Go ahead and wash the goo with warm water, the secretions will disappear over the next few days.

Infection is rare, but does occur. Watch for an increase in swelling, an increase in redness, redness extending down the shaft of the penis, an increase in pain, pus discharge from the wound site, and fever of 100.4 F or higher. With any of these symptoms, take your child to be evaluated by your child’s health care provider.

Sometimes extra, or redundant, foreskin remains around the head of the penis. Over time, this extra tissue does retract back. Scar tissue rarely forms permanently because with each erection (yes, infants have erections) the head of the penis pulls away from the shaft. As the baby gets older, parents can gently pull back redundant skin with their hands when they give the baby a bath. If you are concerned about the appearance of your child’s penis, ask his health care provider to take a look.

One last tip: remember to point the penis DOWN when putting a new diaper on your son; otherwise he will urinate “up” through the diaper and all over his shirt. Trust me on this one.

Julie Kardos, MD and Naline Lai, MD
©2010 Two Peds in a Pod®