It’s Your Baby: The Indian Parent’s Guide to the First Two Years 9789354893100, 9354893104

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Contents

Foreword Introduction 1. Parturition. The Birthday. Term Birth The Hospital Bag: A Checklist Inside the Delivery Room What a Newborn Looks Like What Is an APGAR Score? Your Baby’s First Check-Up before She Comes to You Tests for the Baby How to Hold a Newborn Baby A Few Points for Mothers Post-Delivery 2. The First Week Before the Baby Comes Home Feeding and Stool Sleep Frequently Asked Questions How to Hold the Newborn Baby while Burping How to Swaddle the Baby Genital Care

3. Transition: Settling at Home Bathing Routine Frequently Asked Questions Massage Dos and Don’ts 4. Sleep Newborn Sleep Patterns Types of Sleep Sleep Cycles Sleep Rhythms Helping Babies Get in Sync with the 24-Hour Day Tips: Helping Babies Sleep Sleep Hygiene: A Checklist Sleep Patterns According to Age Sleep Regression Frequently Asked Questions Mistakes Parents Make with Infant Sleep Routines Sleep Experts Further Reading Frequently Asked Questions Sudden Infant Death Syndrome (SIDS) 5. Breastfeeding Common Breastfeeding Terms Advantages of Breastfeeding How to Encourage Breastfeeding

Reasons Why Mothers Face Difficulty Exclusively Breastfeeding When to Top Up Medical Considerations with Breastfeeding Tips: Making Breastfeeding Easier Best Feeding Positions Latching Feeding Pattern: The First Week Changes in the Breasts Tips: Beating Yeast Infection Engorgement Mastitis Frequently Asked Questions Tips: Managing GER Babies Breastfeeding: The First Year Feeding Premature Babies Feeding Twins Formula Instead of Breast Milk Sterilisation 6. Weaning: Starting Solids Frequently Asked Questions 7 . Potty, Spit-Up, GERD and Other Problems Frequently Asked Questions Posseting, Regurgitations (GER) GERD

Colic Acid Reflux Vomiting Preparing Oral Rehydrating Solution (ORS) at Home Burping Hiccups Gas Urine and UTIs Vesicoureteral Reflux (VUR) 8. Vaccinations Herd Immunity Vaccines: Myths Debunked Frequently Asked Questions IAP Schedule for Vaccination Immunisation Chart 9. Growth and Development Weight Length Head Circumference Growth Monitoring Centile Charts Development Motor Skills Language

Social Emotional Cognitive/Intellectual Developmental Milestones: The First 2 Months Frequently Asked Questions Developmental Milestones: 4 to 6 Months Frequently Asked Questions Developmental Milestones: 6 to 9 Months Developmental Milestones: 9 to 12 Months Frequently Asked Questions Developmental Milestones: Birth to 2 Years Babies and Social Media Temperament and Behaviour Frequently Asked Questions Pacifier Dos and Don’ts Tips: Coping with a Crying Child Discipline Frequently Asked Questions Travelling with Your Baby Travelling in the Time of Covid-19 10 . Common Childhood Illnesses and Infections Common Cold Influenza CovidBronchiolitis (RSV or Respiratory Syncytial Virus) Croup or Laryngotracheobronchitis

Hand, Foot and Mouth Disease (HFMD) Herpes Stomatitis Viral Gastroenteritis Viral Exanthems Mosquito-Borne Illnesses Bacterial Infections Otitis Media Frequently Asked Questions Lung Infection or Pneumonia Skin Infections Conjunctivitis Gastroenteritis or Acute Food Poisoning Urinary Tract Infections (UTIs) Meningitis or Brain Infection Group B Strep (GBS) Strep Pneumoniae or Pneumococcal Meningitis Frequently Asked Questions Fungal Infections Worm Infestations 11 . Common Childhood Disorders and Diseases Asthma or The Wheezy Child Frequently Asked Questions Common Orthopaedic Problems Squints or Strabismus

Labial Adhesions Burns Falls Electric Shock Injuries in Children Stomach Ache Fever Medication Febrile Convulsions Red Flags Breathing Problems and the Common Cold Allergic Reactions Choking Vomiting Diarrhoea and Dehydration Bruises and Bleeding: What to Do and When to Panic Epistaxis or Nosebleeds Vomiting Blood Blood in the Potty Poisonings First-Aid Kit Frequently Asked Questions 12. Keeping Your Baby Safe Toxins Endocrine Disruptors Air Pollution

Frequently Asked Questions Cow’s Milk and Lactose Intolerance Ways to Reduce Pollutants in Your Child’s Environment Calling Your Doctor 13. Preterm Birth Possible Causes of Preterm Labour How Your Preterm Baby Looks NICU Equipment in the NICU Procedures in the NICU Problems of Preterm Babies Medical Solutions Nutrition for Preterm Babies Feeding Your Baby Preparing for Home Vaccinations Best Sleeping Position 14. Autism Spectrum Disorder (ASD) Social Skills Communication Development Causes Vaccines and ASD When to See a Doctor

Recipes 5–6 months 7–9 months 10–12 months Index Acknowledgements About the Book About the Author Copyright

Foreword

Dr Saroja Balan, a very senior neonatologist with more than thirty years of experience, works in one of the state-of-the-art tertiary care hospitals in New Delhi. Her book is specially written for and dedicated to all parents and grandparents for the care of the baby from birth till the age of two years. The first two years of an infant’s life are very crucial for optimal growth, development, and the baby’s vulnerability to various illnesses. This book highlights all aspects of babycare, including common illnesses. It also addresses domiciliary care and the danger signs that require you to contact your pediatrician in time. Pregnancy and childbirth are a physiological process, but proper advice and counselling are needed for an uneventful delivery. There are always apprehensions in the minds of expectant mothers regarding the dos and don’ts of care and precautions to be taken. This book perfectly describes the step-by-step care for those preparing themselves for both vaginal as well as elective caesarian deliveries. The birth of a baby is one of the most memorable events for the family. All parents and their families require guidance for the smooth transition of processes – from childbirth and the delivery room to immediate postnatal care of both mother and the baby. The initial chapters deal at length with this, and beautifully illustrate the care of both mother and child. There are many physiological changes that occur in the baby that may be very worrying for the parents and caregivers, but only need counselling and no intervention. The author has critically discussed all the physiological changes that are not harmful. Care of the umbilical cord and the application of several substances on the navel are

practised in our community. Dr Balan has emphasized the need of applying only the recommended agents and not harmful substances. The baby’s first feed is crucial, and the importance of colostrum and, later on, breastfeeding on demand, the duration of each feed and the number of feeds, including night-time feeding, all find significant place in this book. The illustrations for breastfeeding technique, including ideal positions and latching, make it easier for new mothers to learn. The importance of breastfeeding, the timely introduction of solid/semisolid food, the need for formula-feeding and the reasons why bottles should be avoided, are very well elucidated. Sleep is a critical aspect of everyone’s life, and that includes both the mother and the baby. Every pediatrician is flooded with innumerable questions on sleep and sleep patterns. How to tackle what often becomes a big problem for new parents has been explained in depth. It is fascinating to watch one’s baby growing, both physically and mentally. The chapter on growth and development has detailed illustrations on how physical and other developmental milestones are achieved and when to suspect that the baby needs help and attention from a pediatric specialist. Most parents worry about their babies’ bowel habits; the author has very ably discussed these vital aspects as well. The first bath and subsequent bathing routine; the dos and don’ts of oil-massaging the baby are elaborately described in the book. In India, we have many traditional practices and follow a variety of rituals for the care of both baby and mother. While some of these may be useful, others are definitely unnecessary, even harmful. Dr Balan mentions in detail about the traditional practices that are unsafe and should be avoided, and those that may be followed. Every baby requires preventive measures to fight against infections, since their immunity is low. There is comprehensive discussion on how to take care of genitals after urination and defecation as well as the use of diapers and need for proper handwashing for the caregivers. One of the best methods of prevention of infectious diseases is timely vaccination. Dr Balan provides an excellent account of different vaccines, their relevance and uses. There is a whole chapter on common infections e.g., upper and lower respiratory infections, diarrhoea, skin infections and, most importantly, Covid19. Apart from infections, other non-communicable disorders like allergic conditions, bellyaches, burns, falls and injuries, and common orthopaedic

problems, among others, also find important place in the book. Preterm births may require special attention and some very preterm babies require critical care. Dr Balan does an outstanding job of explaining the parent’s role in the care of preterm babies. Given the increasing number of disabilities that babies are born with these days, it is important to be aware of autistic spectrum disorder (ASD) so that it can be diagnosed early and addressed. There is a much-needed chapter on the subject in this book. The most invaluable part of the book is the frequently asked questions (FAQs) in each chapter. The author has addressed all the queries that new parents and caregivers have, simply and clearly. I congratulate Dr Saroja Balan for writing this excellent book, which includes the latest scientific knowledge and information and cites important references for every chapter. It’s Your Baby will be an extremely useful and important guide, and should find a place in every household. Dr Ashok K. Dutta Former Director–Professor and Head of the Department of Pediatrics, Lady Hardinge Medical College, New Delhi President, National Neonatology Forum of India 2001–2002

Introduction

Being a parent is both terrifying and exciting – this is parenthood in a nutshell. You’ll soon find that your time is no longer your own and you are now responsible for this creature, 24 hours a day, 7 days a week, with no time off for good behaviour. Now if that thought does not frighten you and have you running for the hills, then you are made of sterner stuff than most people I know. Having been there, I know what this feels like and I hope to guide you through the next 2 years of your baby’s life with detailed and up-to-date information backed by science. You may have many questions, ranging from why is my baby’s potty green in colour to why is my baby crying unconsolably, and I am hoping this book will answer most of them. Take a look at the parenting section of any bookstore and you’ll notice two things – lots of prettily coloured, voluminous books, and a cluster of confused and increasingly overwhelmed parents. The sheer number of books and movies, and additional support that new parents are offered, can have the opposite effect: Rather than equip parents, they inundate them with ‘helpful advice’ that tends to forgo simplicity and conciseness at the expense of ease of access to first-time parents. For instance, if you were to have a child-related emergency in the middle of the night – or at any point – when you have only yourself to rely on, leafing through pages and pages of repetitive and hard-to-locate information is of little use. I have been practising paediatrics for nearly 30 years, and after each outpatient clinic I realise that I’ve been answering the same questions day in and day out. There are times when I’ve felt that I should just make a small pamphlet regarding common ailments and dosages of medicines like paracetamol – just so

that patients are able to access this information regardless of whether they come to see me. It wasn’t until the mother of one of my patients approached me, saying that I should write a book that would make life easier for new parents, did I really consider it. I’ll admit, I’ve never thought of writing as my strength. I’m usually quite terse and blunt, which often scares a lot of my patients’ parents away (usually, though, this helps get straight to the point and allays their fears), and that is why the prospect of writing a parenting guide was quite daunting. Could I promise to be exhaustive and understandable at the same time? My excuses were many and varied – until I realised that this book, were I to write it, would be exactly what my patients needed. When a baby is brought into the room for an examination right after birth, most doctors, after years of practice, are quite adept at assessing whether the baby requires careful examination or not, and can accordingly reassure the worried parents. Health visitors – trained staff equipped to answer most questions that new parents have – are incredibly helpful in these situations. They attend to the parenting emergencies and direct parents with medical questions to paediatricians. Unfortunately, there aren’t any health visitors in India and paediatricians, such as myself, have garnered years of experience attending to these queries, enabling us to address the dual concerns of new parents. My hope is that most parents, after reading this book, will not have to wake up their paediatrician at 1 a.m. to ask whether green potty is normal for a two-month-old and if anything should be done about it. I could write a whole book on midnight calls that have kept me awake wondering if I have chosen the right speciality. Although, I must admit, it all feels worth it when you see children recovering quickly or even forgiving you quite easily after a painful vaccination. I have, since, found myself looking forward to writing this book because it really feels like a step in the right direction: To set up a community that helps new parents navigate this tricky terrain. Most of parenting is a learning on the job, and this book strives to be the best support to accompany you on your journey. The main goal of this book is to help you figure out when your child is sick and needs a doctor’s visit, so that you can handle the smaller illnesses on your own. I believe that most childhood illnesses need only symptomatic treatment, and less medicine is the way to go (lest these babies turn into pill-

popping adults). When I became a mother for the first time, despite having a degree in paediatrics, simple things like how much to feed, how to bathe, and how to clean the baby, were things that I had to learn on my own since they weren’t mentioned in any of my textbooks. While parents in India usually have a family support system to help them raise a child, this trend is changing, given the increasing number of nuclear families. And though parents these days have access to more information, there is a problem in discerning the quality of the information that they are receiving. Very often, the primary source of information for parents is the internet. While this is a helpful resource, it may also be a source of confusion or panic for new parents. Take, for example, the hapless mother who called me at midnight about green potty. She may have googled and found out ten different reasons for it, which would have frightened her. The information age can leave parents with more questions than answers and, in my practice as well as in this book, I try to answer questions that new parents have. Raising a child is a huge responsibility and it can drive even the best of us up the wall, or reduce us to an anxious mess. But in time you will hit your stride. This book does not claim to replace your doctor, but is meant to be a guide to help you navigate the first two years of your baby’s life – and, in turn, yours. The initial chapters are arranged in order of what to expect after the birth of your baby. Following that, it is arranged topic-wise – sleep, growth, development, and so on. Given that we are amid a pandemic, I have included a section on Covid-19. Currently, in some parts of the word, the vaccine is licensed to be used on children 2 to 18 years of age. India has licensed Covaxin to be used for children 2–18 years while Zydus Cadila will soon be available for children 12–18 years. At the end of the book, you will find recipes that should help you with your growing child. I have been handing out these recipes since I started my practice 30 years ago. Parents have found them useful over the years. I hope you do too.

1 Parturition. The Birthday. Term Birth

As the day that you are waiting for draws closer, I’m sure you feel nervous. Though your excitement knows no bounds, it is only natural that it is tempered by the fear of the unknown. You have taken classes, you have read books, but are you ready for the birth of your child? Are you really ready to be a parent? It’s no secret that many first-time parents find the delivery of their baby to be most daunting. Choosing between a vaginal birth and a caesarean section (Csection), managing post-op care and understanding postpartum depression can be quite overwhelming for a first-time parent. That’s where I come in: to filter and refine the barrage of information that will be thrown your way. I shall try to break down the entire first two years of your baby’s life into individual, manageable stages. For example, what happens after birth, how to manage breastfeeding, your baby’s development, vaccination, and so on. Think of it as a set of ‘parenting training wheels’ that come off in time for your child’s second birthday. By which point, you will be more than equipped to take on any parenting challenge that comes your way. Through the next few pages, I will try my best to simplify any and all ambiguous information that is available regarding childcare, and address all the common concerns.

The Hospital Bag: A Checklist

Around 36 weeks is a good time for you to start packing your bag, as some mothers go into labour well before the due date and you don’t want to be scrambling around then. Even if you are having an elective C-section and have chosen a date, you could still go into labour before the date. So, it’s a good idea to have your bag ready. I am going to suggest some essential items for both you and your newborn baby.

FOR THE MOTHER

All your outpatient papers, including all the antenatal scans and blood reports. Carry your insurance papers that the hospital will need. If you have a birth plan, make sure that goes into the bag. A notepad and pen are a good idea so that you can write down all the questions you may have for the relevant doctors when they come on the rounds. Toiletries like toothbrush and paste, your favourite soap and shampoo, things like lip balm and deodorant, and anything else that might make you feel better. Though hospitals may provide all this, you may be happier using your own. Your night gown and some loose-fitting clothes so that you are comfortable before and after delivery. Make sure you have some comfortable slippers and a robe, as you may want to walk around when you are in labour. You may need a few sets of clothes, as your clothes may get stained during labour and even after delivery. Your glasses are a better idea than carrying contact lenses, but if you prefer your contacts, then be sure to carry the case and solution – you will want to be able to see your baby clearly. Your phone (a very important gadget!). Also, the phone charger and even a multi-pin plug. To try and make the room as comfortable as possible, you can carry your own pillow and blanket or comforter; any photos that you would like close to your bed and some music that you enjoy.

During labour – which may take a few hours if you are induced – you may want to read or watch a movie. So, take what you’d like. You will need to keep yourself hydrated during labour. If there is something special that you like to drink – like coconut water or lime juice – carry it with you. However, if you have a Csection, you may not be allowed to eat or drink for a few hours according to the hospital policy. Especially with food – some hospitals may not allow you to eat while in labour, so please check with the relevant person before you grab a snack. After the delivery, you will want loose, comfortable clothes, especially around your C-section wound. You may be given an abdominal binder to wear for a few days after the delivery. Make sure you are carrying enough underwear and feeding bras if you’re going to use them.

FOR THE FATHER

Dads-to-be should also carry comfortable clothes, shoes, books, snacks and – the most important – a cell phone to take pictures. Carry your wallet with both credit/debit cards and cash. Carry your insurance papers or card.

FOR THE BABY For the new arrival, it is best to pack a separate bag.

A car seat is a good idea. Make sure you have done adequate research and learnt how to use it. You will need a rear-facing car seat for the newborn. Carry a few sets of baby clothes and a going-home outfit. Depending on the weather, use caps and socks. Carry

mittens, as most term babies have long nails and tend to scratch themselves. Take a baby blanket that you can use when you bring the baby home. Most hospitals these days provide diapers. But you may want to carry some, depending on where you are having the baby. This is by no means a comprehensive list and you can add or subtract, as the case may be. Now go ahead and pack your bag if you are nearly 36 weeks!

Inside the Delivery Room The end of the third trimester of pregnancy is typically full of both excitement and anxiety as mothers await their baby’s arrival and the baby inside is trying to make its way out. This is what you have been looking forward to over these past months. At the same time, it can also be physically uncomfortable and emotionally draining. Pregnant mothers might be experiencing swollen ankles and increased pressure in their lower abdomen, and wondering when they will go into labour. A full-term pregnancy is 40 weeks. At 37 weeks, labour induction might seem tempting – like a gift from the Gods – but we recommend that you wait till your baby is full term. The last few weeks are important as it is during this time that the mother’s body makes final preparations for the arrival of the baby. The baby also does most of its growing, especially the lungs, in the last few weeks. The risk of neonatal complications is the least if babies are delivered between 39 and 41 weeks. However, no two pregnancies are similar, and one might deliver a 37-week baby who is absolutely healthy, with no complications. Some women choose to go through labour without any pain-relief medication and instead rely on relaxation techniques to alleviate the pain. For most mothers, vaginal delivery is about treating labour as a natural event. This can be done even in a hospital setting with minimal monitoring. Most hospitals now permit your partner/husband into the delivery room, so that both of you can share that first moment. If they would like to cut the umbilical cord, your

obstetrician might allow them to do so, and give them a pair of scissors at the right time. Some of you may have an elective C-section because you may not be able to have a vaginal delivery due to many reasons, one of them being a breech presentation where the baby comes down bottom first, while others may end up with an emergency C-section after going through labour, due to certain complications. You might have heard about delayed cord clamping. There is a lot of literature advising that doctors delay cord clamping for up to a minute after the delivery of the baby. This is done to ensure more blood to the newborn from the placenta, so that your baby gets more iron, preventing anaemia in the coming months. Anaemia is a condition where you have low haemoglobin (iron is an important component in the formation of this haemoglobin). When you delay the cutting of the cord by a minute, the baby gets extra blood through the umbilical cord. Following delivery, over the course of next 4 to 6 weeks, the haemoglobin steadily falls and can even come down to as low as 8 gm/dl. Breast milk is not a great source of iron for the baby, so most paediatricians give iron supplements to exclusively breastfed babies because it takes longer to correct the anaemia if babies are iron deficient. So delayed cord clamping helps. Occasionally, due to this delay in cord clamping, the baby might receive more than the required blood, leading to polycythaemia, ultimately resulting in prolonged or early jaundice (see p. 16). The jaundice may be exaggerated because of polycythaemia. In case there is any problem with the baby, the obstetrician may decide to clamp the cord earlier, and hand the baby over to the neonatologist. Some people decide to do cord-blood banking. This must be planned with the obstetrician and the cord-blood bank before delivery. In this case, the umbilical cord may be cut earlier, and the obstetrician will insert a needle into a large vein in the umbilical cord from the mother’s side. The blood is collected in a special bag – this must be done quickly, before the placenta separates and the cord blood stops flowing. The blood which is collected is around 80–120 ml. Usually, this takes only a couple of minutes.

What a Newborn Looks Like

You are probably imagining a pink, gurgling, beautiful baby. In reality, many newborns are tiny, wet, odd-looking creatures when they first arrive. Their heads may be pointy and misshapen, especially if you have had a vaginal delivery. This is because the head moulds to pass through the birth canal. This is only temporary and will right itself in a few days. The baby may also look scrunched up since the legs and arms were kept bent in the womb. This is all perfectly normal, and the limbs will straighten over the coming weeks. You may notice that your baby’s fingers and toes are thin and may have long nails. The skin appears quite red and blotchy, and sometimes even purple. Some babies are born with a white coating, called vernix caseosa, which protects the tender skin while the baby is in the womb. This is usually washed off after the first bath. Some babies, especially those born prematurely, have a soft furry appearance because they are covered by fine hair called lanugo. This hair usually falls off in a few weeks. Rashes and blotchy skin are normal in the first few days. The baby’s skin colour and tone also change a bit in the coming weeks and months, and take on the natural complexion that the baby inherits from his parents. Right after birth, an APGAR score evaluates your baby’s health.

What Is an APGAR Score? An APGAR score determines which babies need extra help after their birth. The score is on a scale of 0 to 10, and the acronym stands for the following: A: Appearance or colour P: Pulse/heart rate G: Grimace (reaction to stimulation) A: Activity (tone) R: Respiration (breathing) A score between 7 and 10 is considered normal. The evaluation is done at 1 minute after birth and again at 5 minutes. The lower the score, the more trouble the baby had during delivery, and some of them may need observation in the nursery. It’s not that if your baby doesn’t score a perfect 10 he’s not going to graduate with honours from college. So, don’t hassle your paediatrician and

yourself worrying about it. After your baby is born, she will need a full examination from head to toe by your neonatologist. This will also include a few procedures like clearing the nasal passages, checking her height and weight, and taking the blood-pressure measurement. This will usually be done in the nursery before the baby comes to you. Let’s look at what this entails:

Your Baby’s First Check-Up before She Comes to You Head Some babies have an elongated swelling or bump on their head. This is because the head is moulded to pass through the vaginal canal. The condition is called caput succedaneum, is harmless and affects only the scalp. It settles in 24–48 hours from birth. Cephalohaematoma, on the other hand, is a condition caused by the collection of blood between the skull bones and the skin above it. It is caused during the delivery process and usually resolves in 6–8 weeks. This is one of the reasons for jaundice in a newborn baby. There are two soft spots on the newborn’s head. The anterior fontanelle is on top of the head, in the middle of the skull. It usually takes 9–18 months to close and remains open until then so that the brain can grow. The posterior fontanelle is on the back of the baby’s head. It is smaller and closes around 6–8 weeks from birth.

Eyes Your baby’s eyes are checked with an ophthalmoscope for a red reflex to rule out cataracts and tumours in the eye. Babies can also get haemorrhages in the eye because of the trauma of the delivery. They go away in a few weeks and can be left well alone to heal on their own. Some babies are born with a partially blocked tear duct, which can lead to excessive tearing. This only needs cleaning and massaging of the nasolacrimal

duct which is situated in the corner of the eye. You may have to do this a few times a day, for a few weeks, to open the duct. Rarely, this condition can lead to conjunctivitis, which results in a yellow pus discharge for which your doctor may prescribe antibiotics.

Ears Some babies may have skin tags or pits in front of their ears. Sometimes, this can be an indication of kidney problems. So, prior to discharge, your doctor may decide to get an ultrasound of the kidney or bladder. All babies usually get a hearing test before leaving the hospital or at least within the first month of life. If there is a problem, more complex tests like Brain Stem Evoked Response Audiometry (BERA) may be required.

Nose Most babies have nasal congestion during the first few weeks of their life as their nasal passages are narrow. They usually need only regular saline drops to clear it.

Mouth Babies are checked for cleft lip or palate, which is a defect in the lip or palate. Cleft lips are repaired usually between 3 and 6 months of age and palate repaired around 1 year of age. Babies with cleft lip can have difficulty in feeding. You’ll get help from the paediatrician or a breastfeeding advisor, so that you know what to do. Epstein’s pearls, white pimples in the roof of the mouth, need no treatment and disappear on their own.

Gums and teeth Some babies are born with teeth, called natal teeth. Sometimes, if they are loose, the dentist may decide to remove them. If they are very sharp and you find it difficult to breastfeed, they may require smoothening.

Throat Laryngomalacia or floppy larynx is heard occasionally in babies. This squeaky noise usually gets worse when the baby is agitated and settles on its own. It’s also the most common reason for noisy breathing in babies. In most cases, it resolves by the time she is a year old.

Chest The baby’s chest is checked with a stethoscope for breath sounds and babies are examined to see if there is any respiratory distress (fast-breathing and grunting). If they have problems with breathing, they are kept in the nursery for observation. Mild breathing problem is often seen in babies after a C-section. This is known as transient tachypnoea. It can lead to oxygen requirement or fast breathing. This usually settles within 24 hours, but the baby may have to stay in the intensive care unit (ICU) during that period.

Heart and circulation The baby is examined for any murmur: extra noises heard in the heart. They are usually present in cases of congenital heart disease. Some babies will need further evaluation by a paediatric cardiologist, a paediatrician specialized in treating children with heart disease. The pulses are carefully checked, especially the femoral pulses in the area where the thigh meets the abdomen. This is to rule out the condition of coarctation (congenital narrowing) of the aorta. At the time of being discharged, your baby will have her oxygen saturation checked. Some babies may have blue hands and feet, called acrocynosis. This is nothing to worry about, as it will settle in a few weeks as the baby’s circulation improves.

Abdomen The abdomen is checked to look for any enlargement of the liver or spleen. Some babies have a distended (bulging/swollen) abdomen due to an intestinal

problem, which can lead to yellow vomiting (bile). These babies will need further tests to diagnose the problem. Babies usually pass their first stool within the first 24 hours, called meconium. If this does not happen, they may need further evaluation. The umbilical cord is checked to see whether there are 3 blood vessels (2 arteries, 1 vein) in it. If there is only 1 artery, your doctor may ask for an ultrasound of the baby’s kidneys because it may be a sign of a kidney problem.

Genitals BOYS: The doctor will examine your baby boy to make sure both testes are in the scrotum. Undescended testes will need to be followed up on. In most cases, the testes will descend within 1 year of age. If not, you will be referred to a paediatric surgeon. Then, the doctor will check to see if the urethral opening is at the tip of the penis. If it is on the underside, it is called hypospadias; when it is on the top, it’s called epispadias. These may need surgery later on in life. In these cases, you may be counselled not to get your baby circumcised, as the foreskin will be needed later for corrective surgery. GIRLS: Some baby girls may have labial adhesions where the labia are joined, and there may be some white, mucous-like vaginal discharge. This is normal and can be cleaned when you give the baby a bath or after a diaper change. Occasionally, newborn babies have vaginal bleeding, called a pseudo period. This is caused by the presence of maternal hormones and settles in a few days. For persistent labial adhesions, your paediatrician may recommend an oestrogen cream that you will have to apply over the adhesions. This usually resolves with the cream but may return on discontinuing it. You can repeat the process, and this will eventually settle when the ovaries start making oestrogen, the female hormone. When baby girls are cleaned, you should wipe from front to back, so that the bacteria from the anal region doesn’t spread to the vagina and cause infections like urinary tract infections (UTIs). If the clitoris looks too large or the penis looks too small, your doctor may order some extra tests to determine the sex of the baby.

Enlarged breasts

Enlarged breasts Babies, both boys and girls, can develop mastitis or swollen breasts because of maternal hormones. It is temporary and will go back to normal in a few weeks. The breasts may even produce some milk called ‘witch’s milk’. This is also normal and soon goes away on its own. Never try to squeeze out any of the milky fluid from your baby’s breasts as it can damage the tissue or lead to infection.

Kidney and bladder Most babies pass urine in the first 24 hours. If this is not the case, then they need to be investigated.

Spine and nervous system The baby is turned over and the spine is inspected. Abnormalities over the skin or over the spine may be a clue to inner spinal problems like spina bifida. Reflexes like rooting (turning the head when a cheek is rubbed), sucking, palmar grasp (closing fingers on objects placed in the palm) and moro (startling of the body when the head is dropped back) are routine reflexes that are checked in the first examination.

Arms and legs Babies are examined to make sure that their arms and legs move equally. Their hips are checked to rule out congenital dysplasia, a condition where the ‘ball and socket’ joint of the hip has not formed properly. Some babies may be born with extra fingers (polydactyly), or in certain cases, the fingers may be fused (syndactyly). Club foot is a deformity of the feet for which you will be referred to an orthopaedic surgeon who will initially do serial casting and explain what further treatment will be needed.

Skin

Congenital nevus or moles or café-au-lait spots are light brown permanent markings on the skin. Port wine stains are red or purple marks. They are also permanent, and they can be very large. If they are present on the face, it can be associated with congenital glaucoma and also problems in the brain. These babies will then need a consultation with an ophthalmologist, and parents may be advised to do brain scans to rule out problems in the brain. Strawberry hemangioma are red marks and may be present at birth or appear a few days later. They grow and become raised over the first few months, after which they shrink and disappear by the time the child is 10 years of age. Nevus flammeus, otherwise called stork marks, are usually seen at the back of the neck, on the eyelids and the forehead. They are red or purple and usually fade within a few months of life. Mongolian blue spots are blue marks on the back or the buttocks and are usually seen in Asian babies. They do not fade and instead merge with the surrounding skin, thus becoming not so visible. There is no exact time frame for fading. Erythema toxicum are tiny bumps on the skin seen in the first few days of your baby’s life. They may look like pimples and may come and go. They require no treatment. Other rashes like milia and milaria are all newborn rashes and of no consequence. Neonatal acne usually starts in the third or fourth week due to hormonal changes and usually needs no treatment as it settles in 2–3 months.

After the baby is examined and brought to you, she may be put to your breast. You may find your baby quite alert with eyes open and reacting to sound. After the first couple of hours, you may find she sleeps a lot for the next 24 hours. It is important that you wake the baby up to feed at least every 2 to 3 hours.

Tests for the Baby Hearing screen test Your baby may have a few tests prior to discharge. One of them is a hearing screen. Congenital hearing loss occurs in 3 out of 1,000 babies born. Diagnosing this early is important as it can make a difference to the development of speech and language. If the baby doesn’t pass this test, it may be repeated a few days later. If the baby fails the second test as well, a more complicated test, called Brainstem Evoked Response Audiometry (BERA), is conducted.

Newborn screening test Newborn screening is done to detect inborn errors of metabolism. These are rare and often lead to fatal diseases caused by the inability of the body to break down or metabolise proteins, fat and carbohydrates completely. While this process is achieved through enzymes found in various cells of the body, if these products are not broken down, they accumulate in the body and result in disastrous effects on the brain and the heart, and most of them can even cause death. The test is usually done in the first week. There are only a few specialised labs in India that perform them. The test is done by taking a blood sample on a filter paper after the baby has been on feeds for a few days. One of the compulsory tests is thyroid screening to check if there is a congenital deficiency of the thyroid hormone which can lead to brain damage. If picked up early and replacement thyroid hormone given, you can avert this disaster. The metabolic screen comes in packages and your doctor will discuss with you as to which tests are to be performed on your baby. The costs vary according to the package. Though these metabolic diseases are very rare, early detection is important although not all of them have a cure.

Blood group test

In some hospitals, the blood group is ascertained from the cord sample. Other hospitals may send a sample to determine the blood group when they take out blood for the metabolic screen.

Bilirubin test (Checking for jaundice) Most newborn babies are jaundiced. This happens because bilirubin, which is produced from the breakdown of blood (and then comes out in the potty), isn’t being eliminated effectively. The bilirubin starts to colour the skin, giving it a yellow tint. If the baby has a darker skin tone, the yellow tint can be seen on the palms, feet and in the whites of the eyes. Physiological jaundice, or normal jaundice, usually sets in by 48 hours, can increase steadily for 5 days and comes down slowly over the next week. We can speed up the elimination process by getting the baby to have more feeds so that he does more potty and passes more urine. This will get the bilirubin down. In certain situations, the jaundice sets in early, that is, in the first 24 hours of life, persists beyond 5 days or its level is above the bilirubin range. Depending on the baby’s weight and hours of age, your doctor will use charts to decide whether your baby needs phototherapy. If your baby’s bilirubin range is in the phototherapy range, your baby will be placed under a special light for phototherapy. The special blue light helps to break down the bilirubin. If your paediatrician finds that the baby’s bilirubin level is higher than acceptable, she will check regularly, to prevent kernicterus, a cause of brain damage, where there is discolouration of the brain due to bilirubin. High levels of bilirubin may be because of less breastfeeding in the first few days, if mother’s milk is not flowing properly and the baby is not passing enough stool and urine. It may also be due to cephalhaematoma. Lastly, it may be because of blood group incompatibility. If the mother’s blood group is O and the baby’s is A or B, it can lead to ABO incompatibility. This leads to the destruction of the baby’s RBCs, thereby causing earlier and more severe jaundice. Depending on your baby’s bilirubin level, she may be placed under a special blue light for phototherapy. This helps break down the bilirubin. Sometimes extra fluid is given in the form of intravenous fluid or supplemented with milk with a spoon, to hydrate the baby. This also helps to

bring down the jaundice. Now that you know all the procedures that are done in the hospital and your breastfeeding is on track, you will be looking forward to taking your baby home. You will probably want to be in familiar surroundings. Healthy women and babies may be discharged within 24 hours and, if you have had a C-section, in 48 to 72 hours if there are no complications.

HOW TO HOLD A NEWBORN BABY

A Few Pointers for Mothers Post-Delivery If you have excessive bleeding or pass large clots or have a foulsmelling vaginal discharge, then you need to speak to your obstetrician. If you develop a fever or have pain or redness around your stitches you will have to consult your doctor. Headaches may be a result of high blood pressure or postpartum preeclampsia. Having a shower is not a problem, but swimming is not recommended. There is a chance of introducing infection. Ideally, swim only after 6 weeks of delivery. Tampons should not be used before 6 weeks. You really would not want to shove that thing inside as the raw area in the uterus where the placenta was attached may not have fully healed and you don’t want to introduce infection. Try not to apply too much pressure while you poop as it may strain and damage the stitches, resulting in bleeding. Please try not to hold your pee for too long as then it will hurt to pee. Try not to go on a diet or an exercise regime immediately after delivery. Don’t expect to squeeze into your pre-pregnancy clothes immediately. You need healthy food and calories to heal and make enough milk for your baby. Strenuous cardio immediately after delivery may lead to excessive bleeding. Try to stay away from that bottle of wine this early on after delivery, and from fish like mackerel, which has high mercury content. Lifting heavy objects even after a vaginal birth is an absolute no-no, as is driving a car for at least 6 weeks. Finally, don’t allow yourself to be steamrolled. All friends and family will have a hundred suggestions for you but it is up to you to make the choices, as you are the mum.

2 The First Week

Now that the baby is delivered, it is time to learn about feeding the newborn and other aspects of baby care that will help new parents transition from hospital to home seamlessly. Most first-time mums spend so much time obsessing about the actual process of childbirth that any thought of the difficulties they might face in the recovery period is not on their radar at all. The body is in shock. There is so much discomfort following the delivery – be it vaginal or caesarean. In the case of vaginal delivery, the episiotomy (a cut made to make way for the baby) usually heals quickly. After a C-section, it is advised to take pain medication just enough for you to move around as much as possible, which helps recover faster. A Csection wound takes 4–6 weeks to heal completely. One needs to keep an eye out for infection – if it turns red or leaks or smells, you need to speak to your doctor.

Before the Baby Comes Home Your baby is going to grow so fast, it’s a good idea to babyproof your home before the arrival of your little one. Make sure your water filter is serviced and that other appliances, such as air conditioners, geysers and heaters, are in working order.

If you have an older child or children, make sure they do not feel left out. Make sure you get adequate sleep and ‘me time’, as it gets hectic after the arrival of the baby. Visitors should be restricted, especially now with Covid doing the rounds. Family can see the baby on video calls and the few who come should be double-masked and asked to keep a distance of 6 feet. The immediate family must be encouraged to wash hands frequently if they are picking up the baby.

Coming back to a home prepared well for the baby’s arrival involves planning weeks before the due date for essentials such as diapers and bed sheets, and even getting a cot ready. Although many parents prefer their babies co-sleep (sleep in the same bed with them), it is a good idea to put the baby’s cot in your room or use a bassinet so that your baby is next to you, yet out of harm’s way. When you are getting the cot ready, make sure you don’t use pillows, blankets or bumpers because of the risk of sudden infant death syndrome (SIDS) (see p. 69). If breastfeeding has been going very well, you may not need a breast pump. But if you are too tired, then milk can be pumped and a secondary caregiver (such as the father, your partner or relative) can help with the feeding. Some mothers find it easier to use a nursing pillow to get the right position to feed the baby (more on this in Chapter 5, Breastfeeding). A lot of families don’t want to buy stuff before the birth of the child as they consider it bad luck. It’s quite all right to use clothing that has been used before, as long as it is washed properly. Even cots, strollers and breast pumps can be passed on and used again provided they are in good working order and their disposable parts are replaced. It is important that you get your house cleaned and organised so that when you come back home with your baby, you know exactly where all the stuff you need is placed. It’s a good idea to keep a separate space in your cupboard for your baby’s clothes and toiletries. If it’s only the two of you and the baby in the

house, you could freeze some food so that you don’t have to worry about cooking when you come home. If friends ask how they can help, you can request them to cook some meals for you.

Feeding and Stool If you are breastfeeding, take it one step at a time. Your goal right now is to get your baby to latch on correctly – lips out, chin close to the breast – and you should see that the jaw and ears move slightly in a rhythmic motion as the baby sucks (see p. 83–84). You may feel a little tingling or discomfort when your baby first latches on, but it should not be painful. In the first few days, this may produce uterine cramping which is quite normal. Keep in mind that lactation can happen anytime from 36 to 72 hours after birth and can even take up to 5 days sometimes. During the first week of your baby’s life, it’s important that you keep a track of how many feeds your baby takes and how long he feeds. Keeping an account of how many wet diapers and number of potties your baby has will also tell you how well your baby is feeding. The potties are initially dark, black, and gradually turn to green and then yellow. A typical breastfed stool is watery yellow, explosive, grainy and mild smelling. Your baby could do 8–10 such potties in a day. Babies pass urine infrequently during the first few days and, as your milk output increases, the number of pees will also increase. So, by the end of the week, your baby will be passing urine about 8–10 times in a day.

Sleep Babies sleep anything from 18 to 20 hours a day, but never more than 3 to 4 hours at a stretch. The mattresses used for babies should be firm and not soft. Ideally, heavy blankets and loose bedding should not be used. This is because at this age, babies are unable to lift their head to prevent suffocation due to soft bedding. Ideally, no pillows should be used in the first year, especially rai (mustard seeds) or thermocol-filled pillows. Horseshoe-shaped pillows are also

best avoided – some say they help to make a baby’s head round, but that is not the case. In the first few weeks, you can rock and pat the baby to sleep. Some babies like to be swaddled (see p. 30). Always put them to sleep on their back – and not stomach – to reduce the risk of suffocation. You can change the position of the baby’s head from time to time, to prevent flattening.

Frequently Asked Questions

QWhen will my baby have her first feed? You can start feeding right away provided your baby is doing well and doesn’t need to go to the nursery for observation due to a problem that may have occurred around the time of delivery. If you have had a caesarean, the baby may be brought to you to feed in the recovery room, or when you return to your room. Babies are usually alert for the first hour after birth and that is a good time to try your first feed. However, some babies delivered by C-section may not be ready to feed right away, as it may take time to clear the lung fluid.

QCan I put my baby on a feeding schedule early? Usually, babies feed anything from 8–10 times in 24 hours. The first few weeks, they don’t have any clear pattern: they may feed 1–2 hourly (every 1– 2 hours) initially and then sleep for 3–4 hours at a stretch. Feeding should be on demand. So, to get rest, the mother needs to sleep when the baby is sleeping. As they get older, babies will feed less often, and you may have a predictable schedule then.

QWhy does my baby have hiccups so often? Hiccups are normal at this age; it is because the nervous system is very

immature and the diaphragm is stimulated. It doesn’t need any treatment and will settle on its own.

QHow often should I feed my baby? The first few days, babies don’t have a routine and they tend to cluster feed. They may feed every hour and go to sleep for 2–3 hours. Initially, they may feed for short periods like 5–10 minutes. It is important to get a good latch. You may need help from a lactation consultant or nursing staff, otherwise breastfeeding could turn very painful as you may get sore nipples. You will be asked to track the feeds and the duration of feeds and the number of wet diapers and potties. This enables your doctors to see if your child is getting adequate feed. In the first couple of days, your baby may pee only once or twice a day. By the end of the week, the number of pees will significantly increase to around 8–10 times a day. Urine output directly relates to how much feed your baby gets, so it’s important that you keep an eye out for how much urine your baby passes.

QHow important is it to burp my baby? Burping helps to get rid of air that your baby might have swallowed during feeding. Not being able to burp properly can make your baby cranky and cause him to spit up. Repeated gentle taps to the baby’s back should do the trick and you can try different positions. Sit upright and hold your baby to your chest. The baby’s chin should be resting on your shoulder. Support the baby with one hand and, with the other, gently pat his back. Another way is to hold your baby sitting up on your lap or knee, support your baby’s chest and head with one hand, cradling your baby’s chin in your palm. (Make sure you are holding the chin and not the throat.) Use the other hand to rub the back.

HOW TO HOLD A NEWBORN BABY WHILE BURPING But if the baby does not burp, there is nothing to worry about – the air is bound to get out of the gastrointestinal tract either through the top or bottom end. So don’t bother spending hours trying to burp him.

QWhy does my baby have blood in the diaper? Some baby girls may have a ‘pseudo period’ due to the mother’s hormones. It is usually of no consequence and settles in a few days. Sometimes you may get an orange–pink stain in the diaper. These are uric acid crystals, and it just means that your baby needs to have more feeds.

QWhy is my baby losing weight? At birth, babies have more fluid and they lose this in the first few days. So, up to 10% weight loss is acceptable. If the baby’s feeding well, she will put it all back pretty quickly.

QHow do I clean the umbilical cord? The umbilical cord needs to be cleaned with alcohol or spirit as it helps to dry it quickly. It usually falls off after 5–21 days after birth. Antibiotic ointment needs to be applied only if there is an infection in the cord. Always ensure that the diaper is folded down and the cord is above the diaper and is kept dry.

QWhy are my baby’s eyes always sticky? Some babies have constant tearing or pus discharge from the eye. These may be due to a blocked tear duct. More than 99% of blocked tear ducts open up on their own and massaging the corner of the eye where the duct is located helps to open it up. Most discharges don’t need an antibiotic and just need to be cleaned with warm water and cotton wool. If there is a persistent discharge, then your doctor may prescribe antibiotic eye drops. Kajal or surma application is best avoided as it can lead to injury or infection of the eye.

QWhy does my baby have a stuffy nose? Most babies will have a mild stuffy nose that usually settles over the first few months. Nasal congestion can produce fast breathing and if you are worried, get the baby examined by a doctor. They could have a thick nasal discharge and have noisy breathing. Sometimes the stuffy nose interferes with feeding and it can be relieved by putting saline nose drops. Nasal congestion may be due to allergies like dust or smoke or even dry air. You can use a humidifier for short periods or sit in a steamy bathroom for some time. Avoid smoking in the house and remove pet dander by frequently vacuuming the house or using a wet mop. I don’t recommend any vapour rubs (menthol, eucalyptus or camphor) as these are proven to be dangerous for children under 2 years. Your paediatrician will be able to recommend some saline drops. Propping up the baby at an incline is no longer recommended nowadays because of the increase of SIDS.

QCan I use diapers for my baby? Cotton diapers can be used, and they should only be washed with a simple detergent or soap. Disposable diapers are convenient but if they are not changed frequently, there is the tendency to develop diaper rashes as they tend to trap humidity. Rashes can be prevented by keeping the area clean and dry and giving the baby some diaper-free time. Nappy rash creams or creams with zinc oxide can be used to prevent diaper rashes. If your baby gets a fungal diaper rash, then you will need to use an anti-fungal cream.

QHow often should I bathe my baby? Babies can have a bath every day and you really don’t need to use soaps. Creams and powders are not routinely required either. Talcum powder is best avoided as inhaling it can lead to pneumonia and breathing difficulties. (You

will find a detailed account of bathing in the next chapter.)

QDoes my baby need a massage? Oil massage is a social custom in many families in India, though medically it is not necessary. It’s a common belief that massage helps the child’s bones and muscles develop better. Sadly, this isn’t the case, as muscles and bones develop with active exercise, while with massage, it is passive. (More details on massage in the next chapter.)

QWhat should be the ideal temperature in the baby’s room? Temperatures should be kept around 24°C–25°C. The room should be kept clean. It’s best to avoid carpets that collect dust and there should be no soft toys on the bed where your baby sleeps. Babies should preferably be sleeping in their own cot but can be in your room. The cot should have side rails that you can lower down or raise to keep your baby secure. The mattress should be firm. You can swaddle the baby but don’t use pillows, cushions, bolsters and blankets which may inadvertently cover the baby’s face and pose a suffocation risk.

QWhat vaccines will my baby get before being discharged? Currently, the Indian Academy of Paediatricians (IAP) proposes that all babies get the first dose of hepatitis B, Bacille Calmette-Guérin (BCG) and oral polio prior to discharge.

QWhat is the correct way to swaddle my baby? 1. Take a swaddle blanket.

2. Fold it in half to form a triangle. 3. Place baby in the centre with her shoulders level with the straight edge. 4. Wrap one side of the blanket over baby’s arm and chest, tucking the corner end under the baby. 5. Bring the bottom corner of the blanket up, tucking it under the baby’s chin. Keep the hips loose. 6. Bring the remaining side of the blanket across the baby’s body, tucking it gently underneath her. 7. The swaddle stays in place with the weight of the baby.

HOW TO SWADDLE THE BABY

Genital Care GIRLS: During a bath, or after every diaper change, the baby needs to be cleaned with warm water. Always clean from the front to the back. This

is to ensure that potty doesn’t enter the vagina and become a cause for urinary tract infections. Vaginal discharges are common at this age and are due to maternal hormones. They just need to be cleaned. Occasionally, the discharge may be blood-stained. This usually settles in 3–5 days. BOYS: Most boys have a tight foreskin and you don’t need to push this back forcefully, which is painful and unnecessary. It usually retracts on its own over the next 2–3 years. Circumcision is a part of religious rituals in certain communities in the world. There is no medical reason for routine circumcision, though studies have shown that penile cancer is less common in boys who have been circumcised. If the baby gets recurrent UTIs, some urologists may advise circumcision. The only real indication for circumcision is a condition called Balanitis Xerotica Obliterans where the foreskin gets stuck to the glans because of repeated infections and scar tissue develops so that the foreskin does not retract. These babies then need circumcision.

References Agarwal, R. & Deorari, A. K. (2002). ‘Unconjugated Hyperbilirubinemia in Newborns: Current Perspective.’ Indian Pediatrics, 39(1), 30–42. Bhutani, V. K., Johnson, L. & Sivieri, E. M. (1999). ‘Predictive Ability of a Predischarge Hour-Specific Serum Bilirubin for Subsequent Significant Hyperbilirubinemia in Healthy Term and Near-Term Newborns.’ Pediatrics, 103(1), 6–14. https://doi.org/10.1542/peds.103.1.6 Cloherty, J. P., Eichenwald, E. C., Hansen, A. R. & Stark, A. R. (2012). Manual of Neonatal Care. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Consolini, D. (2019). ‘Physical Examination of the Newborn: Children’s Health Issues. Retrieved 11 June 2020, from https://www.msdmanuals.com/home/children-s-health-issues/care-ofnewborns-and-infants/physical-examination-of-the-newborn Geme, J. W., Blum N. J., Shah S. S., Tasker R. C., Wilson K. M., Kliegman R. M. & Behrman R. E., editors. (2019). Nelson Textbook of Pediatrics, 21th ed. (pp. 532–38). Philadelphia, PA, USA: Elsevier.

Warren, J. B. & Phillipi, C. A. (2011). ‘Care of the Well Newborn.’ Pediatrics in Review, 33(1), 4–18. doi:10.1542/pir.33-1-4 WHO. (2011, 14 December). ‘Newborn Care at Birth.’ Retrieved 11 June 2020, from https://www.who.int/maternal_child_adolescent/topics/newborn/care_at_birth/en/

3 Transition: Settling at Home

Now that you have had your delivery and spent a couple of days in hospital adjusting to your newborn, it’s time to go home! Parenthood may seem daunting, and you may have many questions regarding feeding, changing and keeping your baby clean. In this chapter, we will talk about bathing and cleaning a baby and other matters of hygiene. We will also spend some time on massage. Over the years, I have come to realise that most new parents will struggle at first to juggle all the different responsibilities that bringing a baby into the home involve. If you are a very organised person, you may have everything ready. However, a lot of you may be working till the last moment and, understandably, would not have had the time to put things together. Some of us may not have the luxury of having a nursery for our baby or we may choose to keep the baby in our room to co-sleep. So, to help you out, I have put a few points together.

Make sure you have everything within easy reach – diapers, wipes, waste basket, burp cloths, sheets. The last thing you want is the baby rolling off when you turn to look for something clean. Avoid clutter. You don’t want to bang into a chair or a table corner, or slip on a toy or play mat, when you are trying to rock your baby at night. Make sure that the lighting in your room or nursery can mimic nighttime, to fake the dark so that your baby can nap in the daytime.

If you have a crib, ditch the bumpers and the blankets. Get fitted sheets so that it does not come loose when the baby is moving around in the bed. The mattress should be firm, as memory foam mattresses leave indentations, which can lead to suffocation. An alternative to a mattress is a sleep sack. You don’t have to spend a ton of money on nursery décor. Babies don’t care and may be happier in a bassinet close to you. Make sure you have enough diapers and baby clothes which include undershirts and onesies, one-piece stretchy sleepers, ideally with a zip, a few pairs of pants, socks, mittens. Get a mild detergent to wash baby’s clothes. You will need baby sheets, cotton blankets. Ideally, all the sheets should be made of breathable fabric, such as cotton. For bath, it may be easier to use a tub and in the initial days you may not need soap. Later, when you are buying products for the baby, use those which don’t have a fragrance – these are hypoallergenic.

Now that you are home, the next hurdle mothers face is bathing and establishing a routine.

Bathing Routine Choose a time for your baby’s bath when he is awake and not hungry. Make sure there are no interruptions during bath time so you can focus on bathing your baby. You can give the baby a bath in a plastic tub or even in the bathroom sink. Basically, you can bathe the baby in any room as long as it is warm, safe and clean. Get everything ready – baby towel, cotton balls, warm water for washing and rinsing, fresh clothes and a clean nappy. Ideally, soap is not necessary, as it can be quite drying. If you want, use a non-soap cleanser.

Fill a small tub with warm water (37°C–38°C) and cleanser, if you are using one, and another tub with plain warm water. The water should feel warm, not hot. If you don’t have a thermometer use your wrist or elbow to check the water temperature. Before removing the clothes, you can clean the baby’s eyes with cotton wool dipped in warm water (from inner eye to outer). Make sure you use new pieces of cotton wool for each eye. Undress the baby and wrap her in a towel. Wash the hair first. You can hold the baby in the crook of your arm, between the elbow and your body, while washing. Then dry the hair thoroughly and move on to wash the body. Wash the genitals last. If your baby has done potty, make sure you remove the diaper and clean the area properly before putting the baby in the tub. Gently clean the baby using the cleanser water and then use the clean warm water to rinse the baby. Dry the baby with a clean towel, then you can put on a diaper and dress the baby. If your baby’s skin is dry you may want to use a lotion. Children can drown in a few seconds in very shallow water, so keep the water level low and never leave your baby alone in the bath. It’s normal for some newborns to find bath time distressing at first. But most babies quickly learn to like it. Powders should be avoided unless they are recommended by your doctor. Shaking powder into the air releases dust and talc that are harmful to the lungs if inhaled.

Frequently Asked Questions

QWhen will my baby have her first bath? Most hospitals will either sponge the baby or not bathe the baby in the first 24 hours as the baby needs to learn to maintain her body temperature. Most

babies are covered with vernix (the sticky whitish-creamy layer that babies are born with) which helps to protect the baby’s skin. The World Health Organisation (WHO) recommends waiting for at least 6 hours before bathing the baby. Once you reach home, you can bathe your baby every day or as frequently as you would like, maybe once in two days, as babies don’t get very dirty. The decision is yours; it depends on what you are comfortable with. You should, however, keep your baby’s genitals clean between baths by using warm water and cotton wool.

QDo I clean my baby’s mouth? Sometimes, a baby’s mouth and tongue may be coated white. This may be milk residue which really doesn’t need to be cleaned. If you really want to clean your baby’s mouth, wrap a clean muslin cloth on your finger and clean the tongue gently. There is a chance you may injure your baby if you do it too roughly. Sometimes the white residue in the baby’s mouth is a fungal infection called oral thrush that will need to be treated with an antifungal lotion for which you will need to speak to your paediatrician. While milk wipes off and appears only on the tongue, thrush does not wipe off and can appear on the inner cheek and gums as well. If you are using feeding bottles, it is best you replace, them and be more vigilant about sterilisation. The mother’s breast may also have the infection, so she would need treatment too.

QHow should I clean my baby’s navel? You can clean the cord with an alcohol swab or cotton ball. Use the swab against the base of the belly button to remove the sticky stuff as the cord separates. You will need to keep an eye out for any redness or foul-smelling

discharge from the umbilical cord. This may be a sign of an infection (omphalitis) and you should get in touch with your doctor. Your doctor may prescribe an antibiotic cream or, in some cases, your baby may need an oral antibiotic.

QWhat products should I use for my baby? Babies have sensitive skin, so it’s best to use products made especially for babies. Ideally, whichever products you use on the baby should be free of perfume and chemicals. It’s best not to use products that smell good. If you want to apply lotion to the baby, you may do so after bathing him. Regarding soaps, cleansers and shampoo, anything mild is fine. Hair can be washed every day and if you want to skip the soap for bathing, plain water is also fine. In winter, it is better to bathe the baby after warming the bathroom.

QMy baby has excessively dry skin. Is it eczema? Some babies have dry scaly patches on their skin. The key to looking after the skin is to use a good moisturising soap and a good moisturising cream. Avoid oil massages for now. The key to treating eczema is to massage lotions or creams into the damp skin. Do not use very hot water as it ends up drying the skin. If the problem persists you may approach your doctor, who will prescribe a mild steroid cream.

QMy baby has acne. What do I do? Acne develops due to hormones, which may also come from breast milk. Usually, it doesn’t need treatment and should disappear by the time the child is 3 months of age. No creams or medicines need to be applied. Don’t try home remedies – raw milk, herbal pastes, rubbing placenta on the baby – as they can further aggravate the skin. Babies often have downy fine hair, particularly on the back, forehead and limbs. This is because of maternal

hormones acting on the baby and this hair gradually disappears over 6 months.

Q Can I use baby wipes and diapers? Hospitals tend to use gauze soaked in water to clean the diaper area; you can use wipes if you want to, though some wipes contain preservatives, which can irritate the baby’s skin. It’s best to use warm water from the tap to clean your baby’s bottom. Following which you should wipe it dry with a soft towel. Diapers can be used as long as they’re changed frequently. It may be trial and error before you decide which diaper best suits your baby. If it doesn’t fit properly, the pee will leak and stain your unsuspecting lap. Diaper/nappy rash creams are advisable since they act as a barrier between the contents of the diaper and baby’s skin. They are helpful in preventing nappy rash. Diaper rashes can be caused either by prolonged exposure to a wet diaper or it may be because of a fungal infection. With the former, it is common sense that you need to change the diaper more frequently instead of leaving it on for hours on end. Between diaper changes, it is advisable to give some diaper-free time to the baby. Using petroleum jelly or zinc oxide paste with every diaper change will prevent diaper rash. If it is a fungal rash, you will need to use an anti-fungal ointment along with the diaper rash cream. If it still does not settle, you may need to speak to a paediatrician.

QWhen can I cut my baby’s nails? For the first 2–3 weeks the nail is stuck to the nail bed, so trying to clip the nail at this time may injure the finger. It is advisable to file the nails or use mittens on the baby’s hands to prevent her from scratching the face. After 6 weeks or so, you can use baby scissors or a baby nail cutter to clip the corner of the nail and then carefully peel off the excess bit. It is best not to bite your baby’s nail off as you can introduce infection and also leave the nail

ragged.

QHow should I wash my baby’s clothes? Only babies who have sensitive skin need to have their clothes washed with a mild detergent which is perfume-free; otherwise, it may be washed with the rest of the family’s clothes. There is no need to wash your baby’s clothes with Dettol. Babies need to develop their own healthy bacteria called microbiome (this is each one’s unique community of bacteria on various surfaces of your body, keeping you healthy).

QCan I use a mosquito repellent? Mosquitos are known to cause dengue and malaria. As most mosquito repellents contain N,N-diethyl-meta-toluamide (DEET), it is recommended only for children over 2 months of age. Picaridin is the only mosquito repellent which can be used for babies 0 to 3 years. DEET can be applied once or twice a day; you may need to apply picaridin 3–4 times a day. So, when you buy a mosquito repellent, please check the label to see which active ingredient it contains.

QWhat is cradle cap? Will it go away? Seborrhea or cradle cap, red, scaly or crusty yellow patches on the scalp, is quite common in babies. Sometimes, your baby can get it on the eyebrows, in the neck folds and the diaper, behind the ears as well. It usually appears at around 2 weeks of age and disappears when the baby is a year old. The exact cause is not clear but may be due to excessive oil or sebum production by the oil glands in the skin and a type of infection caused by the yeast malassezia. Most cases need just a mild anti-dandruff shampoo and brushing with a soft brush to dislodge the crusts.

Some cases may need a mild steroid or an antifungal cream prescribed by your doctor. Don’t try to peel or scrape it off. It usually settles on its own.

QBaby massage – is it necessary? Baby massage is a lovely way to enjoy time with your baby and it can also help bond. Massage is something that Indian babies have been used to for decades. Most grandmothers believe that massage is important to develop muscle and bone. Though massage has many benefits, it does not help to do this. Before babies are able to understand language, we often communicate and comfort them through touch. Baby massage is a gentle rhythmic stroking of your baby’s body with your hands, and you may gently manipulate your baby’s wrist, ankles and fingers. While you are doing this you can talk, sing or hum to your baby as this creates a sense of calm, reassurance and love. Massage as therapy was introduced nearly 30 years ago in neonatal units in the UK to support the development of premature babies. A study in 2004 found that babies who received massage as therapy in the neonatal units not only spent less time in hospital, but also fared better in developmental assessments and had slightly fewer postnatal complications. Most of us paediatricians recommend massage after 1 month when the cord has healed and there is no risk of an infection of the umbilical cord. The skin is also less porous and less sensitive after a month.

Massage Dos and Don’ts Choose a time when the baby is content and alert, not tired or hungry. She should be interested in the surroundings. In this state, the baby is more likely to interact with you.

You can massage before the baby’s bath or before bedtime. A gentle massage, even a dry one, is a good way to get her ready for sleep. Sit on the floor or bed with your baby in front of you lying on a towel. You should be comfortable and the room should be warm. To know if your baby is interested in massage, you can begin by ‘asking permission’. You do this by rubbing some oil between your hands near your baby’s ear. This may sound strange, but your baby will soon start recognising this cue. Although you can massage without oil, using oil may help you glide easily, even though there is no other added advantage of using oil. Do this before the bath so that residual oil can be washed off using a soap or a cleanser. Note that if you baby has sensitive skin, oil may aggravate it. Start by gently holding one leg in your palm. Then hold the ankle with one hand and hold the thigh of the same leg with your other hand. Now, slowly glide the hand down the leg to the ankle. Repeat with the other leg. Move over to different parts of the body and massage the chest and abdomen. Turn the baby over and do the back. If you’re massaging the head, use gentle strokes. Be very careful, taking care not to put any pressure on the soft spots (fontanelles). Be gentle and look out for your baby’s cues. Stop if your baby looks uncomfortable or cries. There are many oils available: Cold-pressed oils can be used; they have fewer impurities. Mineral oils or petroleum-based ointments can be used for children with eczema. Mustard oil can have a toxic effect on the skin barrier and can cause irritation to the skin. Olive oil is not recommended because of a high oleic acid content. This can dry out some of the baby’s skin layers. Though coconut oil and many other different oils are used, none other than coconut oil have been studied in a research setting. So it may be useful to try different oils before you decide which one suits your baby best.

If your baby does not enjoy massage right away, don’t get worried. It’s a new experience and it may take some time getting used to.

References Kilpatrick, S. J., Papile, L., Macones, G. A. & Watterberg, K. L. (2017). Guidelines for Perinatal Care. Elk Grove Village, Chicago: American Academy of Pediatrics. Kulkarni, A., Kaushik, J. S., Gupta, P., Sharma, H. & Agrawal, R. K. (2010). ‘Massage and Touch Therapy in Neonates: The Current Evidence.’ Indian Pediatrics, 47(9), 771–76. doi:10.1007/s13312-010-0114-2 Navsaria, D. (2020, 3 March). ‘Bathing Your Baby.’ Retrieved 11 June 2020, from https://www.healthychildren.org/English/ages-stages/baby/bathingskin-care/Pages/Bathing-Your-Newborn.aspx Sarkar, R., Basu, S., Agrawal, R. K. & Gupta, P. (2010). ‘Skin Care for the Newborn.’ Retrieved 11 June 2020, from https://www.indianpediatrics.net/july2010/july-593-598.htm UPMC Magee Women’s Hospital, 4 May 2017. ‘Step by Step: How to Bathe Your Newborn Baby.’ Retrieved 29 June 2020, from https://share.upmc.com/2017/05/how-to-bathe-newborn/

4 Sleep

Once you have got over the excitement of the birth of your baby, it is sleep that most parents struggle with. As the novelty of new parenthood wears off, the exhaustion sets in, and one would give anything for a good night’s sleep. In fact, getting babies to sleep is what troubles most of my patients’ parents. In most households, I have observed, there is no routine, and babies tend to get overstimulated through the day. Parents don’t have a fixed time for sleep. In many cases, fathers come home late from work and babies are kept awake to see them. If children don’t have a sleep routine, it is difficult to get them to sleep through the night.

Newborn Sleep Patterns Newborns never sleep for too long at a stretch – they sleep anywhere from 30 minutes to 4 hours, and they can sleep randomly, day or night. Hunger and other bodily functions wake them up.

Types of Sleep The basic types of sleep are rapid eye movement (REM) and non-REM (NREM). REM is characterised by rapid eye movements, more dreaming and more body movements. You usually breathe faster in this sleep and your pulse rate is higher. Non-REM happens first and includes 3 stages, the last 2 of which

are when you sleep soundly and it’s hard to wake up. Adults spend only 30% of their sleep in REM, whereas 60% to 80% of a newborn’s sleep is in REM. Therefore, babies are quite active even when they are sleeping. They stretch, flutter their eyelids, move around, grunt and make noises, and their breathing can be rapid and irregular while they sleep. If you find your baby moving around in his sleep, it does not mean that he needs to be fed. Since sleep is light, they wake easily.

Sleep Cycles Your night’s sleep consists of many sleep cycles. Adults tend to have mainly NREM sleep in the early part of their night and REM cycles in the latter part. Babies, on the other hand, tend to mix it up. Their sleep cycle usually goes from light to deep sleep and again to light sleep before moving on to the next cycle. The average adult cycle lasts around 90 minutes while that of a baby is around 60 minutes. At the end of each cycle, while adults are partially awake, babies whimper or move around before going back to sleep. In the first few days, an average newborn sleeps anything from 16 to 20 hours a day.

Sleep Rhythms Adult sleep is governed by circadian rhythms. The body recognises a 24-hour cycle and is influenced by sunlight. For instance, if you are out in the day, you are helping your body calibrate its internal clock. Even if you are sleep-deprived, the morning light helps to stay more alert in the day. So the next time you are up all night, just sit in the balcony or garden in direct sunlight for half an hour. Fortunately, this helps with jet lag as well. Conversely, the absence of light at night helps your body wind down. When it gets dark, your body produces melatonin which helps you relax and fall asleep. While in the womb, babies usually follow the mother’s circadian rhythm, as melatonin produced in the mother can cross the placenta and affect the foetus’s internal clock. After they are born, newborns need to develop their own circadian rhythm. Unfortunately, this takes time and it is further complicated by

the fact that they need to wake up frequently to feed. Most babies take at least 12 weeks to show day–night rhythms in the production of melatonin. To complicate matters, circadian rhythm of the hormone cortisol, which helps regulate alertness, may take longer to be produced in adequate quantities. It might take as long as 4 to 5 months before your baby will sleep for more than 5 hours at a stretch. In the first 2 weeks, you may notice that your baby has a long sleep during the day, maybe after a bath. This means he might be up more during the night cluster feeding. So discourage this long sleep in the day and wake him up after 3 hours. In a similar vein, don’t let him sleep for more than 4 hours in the night for the first 2 or 3 weeks. Since the mother’s body needs stimulation to produce milk, once your baby starts gaining weight adequately, he can sleep for as long as he wants at night. If the baby sleeps for even 6 hours, be happy – and don’t tell your friends! Catch up on your sleep when your baby is sleeping – uninterrupted 6 hours is a good night’s sleep for a mother. Don’t expect babies to sleep 8 to 10 hours at night. And if you are sleep-deprived, get the extended family to come and give you a hand when they can feed your expressed breast milk while you catch up on some zzz.

Helping Babies Get in Sync with the 24-Hour Day Involve babies in daily activities. When parents engage the newborn in their day-to-day activities – eating meals, taking naps, talking with each other – the baby may adapt more rapidly to the 24-hour day. Reduce night-time stimulation. If the baby wakes up at night, keep activity to a minimum. Make as little noise as possible and don’t move around too much. Don’t switch on the main light, reduce the hustlebustle and give a quick business-like feed. Resist the temptation of playing with the baby then. You want the baby to understand that nighttime is for sleeping. I know, it might be difficult in case of extended families as, sometimes, cooking begins only at 10 p.m.! Expose your baby to natural lighting patterns. For example, one

study demonstrated that newborns slept longer at night if their parents observed a policy of turning off the lights at 9 p.m. Another study showed that if newborns were exposed to more afternoon sunlight, they slept longer and better at night. So babies who were taken out in the daylight hours and got more natural light tended to develop circadian rhythms faster. Try infant massage. Studies have shown that babies who were massaged with lotion or oil slept better and longer than infants who were not massaged. Though more research needs to be done, it is worth a try.

Babies also have differences in how alert they are during the times that they are awake. When a newborn awakens at the end of a sleep cycle, there is typically a quiet alert phase. Here, the baby is quiet and still and is usually taking in the environment. She may look and stare at objects and respond to sounds and motion. This then progresses to an active, alert stage where she is more alert to sounds and starts to move actively. This is followed by the crying stage. Here the baby can be easily overstimulated and you will need to find ways to calm her. Swaddling in a blanket may help calm a crying baby. It is usually best to feed babies before they get to this crying stage as at that time they will not feed. In newborns, crying is a late phase.

Tips: Helping Babies Sleep Not all babies know how to fall asleep. Remember that the sleep cycle consists of light to heavy and back to light sleep before the next cycle begins. At the end of each cycle, we check our environment and adjust our bodies before going back to sleep. By 3 to 4 months, your infant begins to be aware of his environment.

It is important that babies don’t breastfeed till they are fully asleep or get rocked till they are fully asleep. This will then become a habit and

babies will expect to be breastfed or rocked to go to sleep every time. Imagine having to do this to a 9-kilo 6-month-old baby! Most experts recommend allowing your baby to become sleepy in your arms, and to then place your baby in the bed or crib while he’s still awake. This way, the baby learns how to go to sleep on his own. Playing soft, soothing music is a good way to establish a bedtime routine. If he falls asleep in your arms or on your shoulder at the end of each sleep cycle, he will look for that familiar shoulder. Or, if he goes to sleep with a pacifier, he will look for it in between sleep cycles. You need to put the baby in bed when he is sleepy so that he can learn to go to sleep on his own. It’s important that you establish a bedtime and nap-time routine and stick with it. You should ensure that the place also remains the same for both nap time and bedtime. Occasionally, your baby may fall asleep in a car seat or a baby bouncer, but don’t make a habit of it. Try and set a time for naps and night sleep, and stick with it even when you are travelling or have guests at home – this holds true for a toddler too. Try and have a sleep ritual for bedtime – bathe, feed, sing, read a book, say a prayer, whatever suits you and your baby. Make sure you do this before your baby is too tired. It is a good idea to put babies to bed early; an overtired baby does not sleep for long. If your baby’s sleep routine has been upset because of travel or illness, then it is important to get back to it as soon as possible.

Sleep Hygiene: A Checklist Keep the room quiet and dark – you can use blinds or heavy curtains. Stick to the same bedtime and wake time. Put the baby to sleep drowsy but awake, so that she learns to

fall asleep by herself. Make sure the room is cool and clean – the bedsheets should always be clean. If your baby is overstimulated or overtired and needs relaxing, you can give her a massage and bath before bed. Switching on an air purifier in the bedroom at night is a good idea, as pollutants might have come in from other parts of the house, like the kitchen, during the day. You can play soothing music or sing to your baby. When checking up on your baby, make it short and sweet so that she is not overstimulated. If you are a smoker, this is the time to give it up. Smoking outside is also a compromise, as the smoke lingers on the skin and clothes and can be transferred to the baby.

Sleep Patterns According to Age 0 to 6 weeks Babies up to 6 weeks of age are typically unable to stay up for more than 30 minutes. So, essentially, they are awake to feed, get a diaper change and probably get a new outfit and nap again. You will feel that all you are doing is feeding and changing diapers, and then it’s nap time again. This is the most exhausting phase for new mums, so it’s important that you eat well and nap when the baby is sleeping. SLEEP ROUTINE: 0–6 WEEKS Wake up: 7a.m. Total sleep time: 15 to 18 hours Naps: 3 to 5 a day; 15 minutes to 3 hours per nap

Awake time between naps: 30 minutes to 1 hour Longest stretch of night-time sleep: 2 to 4 hours Bedtime: Between 9 p.m. and 11 p.m. During this time, babies need to be fed on demand as their stomachs are small. They need to sleep in a safe environment. If they are sleeping in a crib, there should not be any loose items or stuffed toys. And remember, it’s always ‘back’ to sleep!

2 to 3 months A sleep pattern will begin to emerge. The baby may be awake for longer now and you may be beginning to know her nap times. Even now, she will be awake for a maximum of about an hour and a half, if not overstimulated. You can start training your baby to fall asleep on her own after her feed and not allow her to fall asleep on the breast. You will still be feeding on demand but may find your baby giving a gap of 2 to 3 hours between feeds. You can start setting a nighttime ritual, like a warm bath or singing to her to calm her prior to sleep.

4 to 6 months Your baby will now begin to have a sleep pattern. Some babies may come down to only 2 naps a day, while others will start fighting sleep. Some babies may start showing signs of sleep regression due to changes in the sleep cycle, while others may be sleeping 6 hours through the night. Just when you thought that your baby only wakes up once at night and you were just about getting your life back in order, your baby starts waking up 10 times at night, cranky and irritable, or waking up early from naps or fighting sleep.

Sleep Regression During sleep regression, your baby will go from sleeping soundly to waking up frequently during the night. It will be harder for her to settle down to go to sleep; she will wake up early from naps or fight sleep. Parents are taken by

surprise as it seems to come out of the blue. Sleep regression happens around 4 months, 9 months and again around 18 months. During regression, the baby feeds more, is more clingy than usual, and wants to be held more. These periods tend to coincide with developmental milestones like turning or learning to crawl. These may be the reasons for disturbed sleep. You may not always notice these changes, especially in a 4month-old, where it may be because her sleep cycle is changing. As soon as babies get accustomed to these changes, they settle down. Although it can take 3 to 6 weeks to settle, it is important to keep bad habits that may form during this regression phase from lingering. You may have started rocking or feeding your baby to sleep, which you had stopped doing. Yes, I understand that at the end of the day you and your baby need sleep and rest, but take care that these methods don’t become habits.

Tips: Surviving Sleep Regression Be flexible with the nap and bedtime routine you may have set up. Try to stick to your routine even if the timing is slightly off, so that when your baby eventually settles down post regression, she can go back to her usual routine. Try adding massage, bath, singing or soothing music to your bedtime routine. The room should be dark and the temperature comfortable. You can pick up your baby and rock him but put him back in his bed as soon as possible. Adjust your sleep schedule to accommodate adequate sleep for both mother and baby – try an earlier bedtime and changing your morning routine. Feed your baby more if he is asking for it; the growth spurts that are seen during these periods may increase his appetite. Ask for help from friends and family so that you can get some rest. Take shifts with your partner so that both of you are not tired. Speak to your mother or friends who have gone through this and can offer moral support.

SLEEP ROUTINE: 4–6 MONTHS

SLEEP ROUTINE: 4–6 MONTHS Wake up: 7 a.m. to 8 a.m. Total sleep time: 12 to 15 hours Naps: 3 a day; 1 to 3 hours per nap Awake time between naps: 2 to 3 hours Longest stretch of night-time sleep: 4 to 8 hours Bedtime: 8.30 p.m. to 9.30 p.m. Your baby will probably feed 5 to 7 times in a day now. Most babies will still have 1 feed at night. Now is the time to start breaking sleep associations. Sleep association is anything that helps your baby fall asleep. Some sleep associations like swaddling or white noise are okay but rocking or nursing to sleep should be discouraged as these are not sustainable. Babies need to learn to self-soothe at some point and slowly breaking negative sleep associations like rocking is the first step. Once they no longer rely on outside help to fall asleep, they will learn to go to sleep independently.

White Noise White noise is random noise that has a flat spectral density, that is, noise that has the same amplitude. Since it includes all audible frequencies, white noise is used to mask other sounds. There have been studies which suggested that babies fall asleep quicker under the influence of white noise. However, this should not be used 24 hours a day. Use it to soothe a crying baby or during naps or night-time sleep.

6 to 10 months Each baby is unique. Your baby might only sleep 4 hours at a stretch while your friend’s baby may be sleeping through the night. SLEEP ROUTINE: 6–10 MONTHS

Wake up: 7 a.m. Total sleep time: 11 to 14 hours Naps: 2 to 3 a day; 1 hour to 3 hours per nap Awake time between naps: 2 to 3 hours Longest stretch of night-time sleep: 5 to 10 hours Bedtime: 8 p.m. to 9.30 p.m. You would have started weaning around 6 months, and your baby may still be on 5 to 6 feeds of either breast milk or formula. Some babies will still be feeding once at night. Now is the time to try and reduce the night feed.

10 to 12 months The sleeping patterns of babies at this age start to resemble adult sleeping patterns. Your baby is probably having a couple of naps a day and, hopefully, sleeping through the night. She should be spending more time getting about exploring her surroundings than sleeping. Sleep regression can happen again around this time. SLEEP ROUTINE: 10–12 MONTHS Wake up: 6 a.m. to 7.30 a.m. Total sleep time: 11 to 14 hours Naps: 1 to 2 a day; 1 to 2 hours per nap Awake time between naps: 2.5 to 3.5 hours Longest stretch of night-time sleep: 7 to 12 hours Bedtime: 8 p.m. to 9 p.m.

Frequently Asked Questions

Q Is it ok to swaddle my baby to sleep? How long can I carry on this practice? Of course you can swaddle the baby to sleep. When you wrap the baby, the arms can be snug inside but the legs should be loosely inside so that the baby can move his legs. Swaddling works for babies up to about 8 weeks. After that ditch the swaddle, as babies need to move around. If they continue to be swaddled, they can develop a flat head or plagiocephaly due to lying on their back without turning. Also, the blanket becomes a risk for SIDS, since the baby likes to move around now.

Q My baby has started rolling over even if I put him to sleep on his back. What do I do? That’s perfectly fine, let him sleep. Rolling over usually happens after the age of 4 months. Once they have figured out rolling, they are able to lift their head and clear their nose. SIDS incidence is much lower at this age. Parents are worried that putting babies to sleep on their back may lead to choking when they vomit. Doctors usually advice that babies who reflux (called gastroesophageal reflux or GER) be placed to sleep at a 30° angle or have naps in a baby bouncer.

Q I can’t decide where my baby should sleep – my bed or her own? The American Academy of Paediatrics (AAP) endorses room-sharing but not bed-sharing, promoting safe sleeping and breastfeeding. Historically, AAP has strongly discouraged bed-sharing with infants younger than 1 year since this practice puts babies at the risk of suffocation, strangulation and parent roll-over. They acknowledge that a vast number of parents fall asleep when feeding the infant and it is less hazardous to fall asleep on a sofa or chair. Co-sleeping is when the parents and baby are in the same bed. Convenience

is a big advantage here. As soon as the baby stirs, the mother knows and is able to feed right away; the baby falls back to sleep and so does the mother. Babies who sleep alongside their mothers tend to feed more than babies who sleep alone. Hence, both get less sleep. The disadvantages of sleeping in the same bed are SIDS and sudden unexplained infant death (SUID): it is used to describe the sudden and unexpected death of an infant less than a year old in which the cause is not obvious before investigation. These deaths happen during sleep or in the baby’s sleep area. Sleeping in their own bed or crib makes for a safe sleep environment and better quality of sleep for both, baby and parents.

QHow do I help my 4-month-old fall asleep? By now, your aim should be for the baby to fall asleep on his own without the need for rocking or feeding. If you are feeding before putting him to bed and he falls asleep on the breast, gently wake him up before placing him on his bed. I know it sounds cruel, but he needs to be aware that he is going to bed. You are indirectly giving him charge of going to sleep and it is a healthy habit to inculcate as soon as possible. You can try leaving him in bed to fall asleep on his own but if he starts protesting by crying, then you may need to go back and either pat or sing him to sleep while he’s still lying on his bed. The idea is that he has to learn to soothe himself to sleep. Try and stay there for as little time as possible. Rocking the baby to sleep should be the last resort.

QWhat is dream feeding and how does it work? When a baby is less than 2 months old, he needs to feed frequently, which means waking up a few times at night to feed. Usually, by 4 to 5 months, babies can go up to 6 hours without a feed, and they make up for it in the day. 6-month-olds can go even 8 to 10 hours without feeding. Some mothers, however, try to feed the baby when they are asleep so that they can postpone the waking up. I am not a great proponent of dream feeding as it sets up a

pattern of feeding kids before they are hungry and does not guarantee that the baby will sleep through the rest of the night. Secondly, once your baby gets her teeth, dream feeding can be the cause of dental caries. The idea is to set up healthy sleeping habits as soon as possible rather than go through the difficulties of sleep training an older child.

Mistakes Parents Make with Infant Sleep Routines Quietly sneaking baby into bed. Dr Ferber explains this in his sleep training technique (see p. 62). You rock your baby to sleep and then stealthily place her on the bed. Imagine you fall asleep in your rocking chair and your spouse picks you up and carries you to bed. Now when you wake up, you are disoriented and wonder how you got there. It’s the same with your baby – when she wakes up, she will be looking for you to put her back to sleep. You breastfeed him to sleep. It’s the same – when he wakes up, he will be looking to feed again to go to sleep. The same goes with the pacifier. Again, Dr Ferber explains it very well – you go to sleep with your head on the pillow and halfway through your husband steals your pillow. You wake up annoyed and confused as to what has happened to your pillow. Feeding the baby at night, beyond 6 months. If you, for example, eat at 3 a.m., your body will get used to it and look for food at this time. Stop this habit and your body will get used to not eating at that time. Same goes for your baby. If you continue to feed at night after 6 months, your baby will keep demanding that night feed. If you have not set a schedule, set one by the time the baby is 6 months old. Babies are creatures of habit. So, it is important to create a routine as far as nap and bedtime are concerned. Don’t change the bedtime if you are late from work or you are busy in the kitchen as you have guests for dinner. This upsets the schedule and is a recipe for disaster. Not having an early bedtime. Sleeping late does not ensure that the

baby will fall asleep faster and sleep through the night. Missed naps and late to bed will ensure that your baby wakes up early. Bringing the baby to your bed frequently at night. I know when you are sleep-deprived and your baby is fussing and is not ready to settle in her bed, it seems reasonable at 2 in the morning to bring her to your bed. She will start to expect this and continue to cry till she is brought to your bed. Make a plan with your partner to take turns at putting the baby to sleep and try to stick with it. Not letting your baby self-soothe. Thumb-sucking is acceptable as a means to self-soothe. Self-soothing is a learned behaviour and babies can learn it by 6 months of age. Babies stir at night before they turn and go back to sleep. In between 2 sleep cycles, they stir and readjust themselves before they go to sleep. You should resist the temptation to pick up the baby and allow them to go back to sleep.

A recent Canadian study showed that many sleep disorders of babies were actually brought on by excessive parental interventions in the hope of comforting the baby, such as:

putting the baby in the bed after she has fallen asleep hanging around in the room till the baby has fallen to sleep taking the baby out of the bed to comfort her

Sleep Experts There have been many books written by experts, a few of them doctors and a whole slew of sleep consultants. I will give you a short summary of three methods by three doctors who all run sleep labs and have conducted many years of research in sleep disorders.

Richard Ferber theory

Richard Ferber theory Dr Ferber is the director of the Sleep Lab, Boston Children’s Hospital, Harvard. According to him, what parents perceive as abnormal awakenings at night is actually normal and what they do to treat these abnormal awakenings is abnormal. In the first 4 months, it is normal to wake up a couple of times to feed. It is during these times that you need to start your sleep routines, so that by the time your child is 6 months, she is sleeping 6 hours at a stretch. If this is not the case at 6 months, then you need to start training her. Sleep training can make your little one sleep for 6 hours at a stretch by various methods listed here, but it is important to stick with the method you choose to go with. Babies under 4 months are not neurologically developed to self-soothe and go to sleep, so you cannot use this technique for babies this age.

Ferber method Otherwise called graduated extinction, this is a specific method of extinction sleep training (minimal parental interference to teach babies to self-soothe and go to sleep) or the ‘cry-it-out’ method. It really works, and that too quickly, in 3 to 5 days. The main disadvantage is, obviously, the crying. For most parents, including me, allowing your baby to cry for even a few seconds seems cruel. There is evidence from an evolutionary standpoint that we are wired to respond to our children crying. In most child-rearing ventures, it is important to be consistent. This method should only take a few days, not many weeks. After following your usual sleep routine for your baby, place your sleepy infant in his bed when he is still awake. You then leave the room. Check in on your child over increasing time intervals. If he starts crying, wait for a specific amount of time. If you give in and pick up, rock or feed the baby, it will prolong the process. Dr Ferber suggests 3 minutes the first night before you go in. Comforting the little one should only include patting his back or talking to him in a soothing voice. But it should not include picking up the baby, rocking, feeding or turning on the light. You should be out of the room in 2 minutes. After leaving the room, the next time you wait out for 5 minutes to allow the baby to cry before you intervene. Dr Ferber calls this progressive waiting. You may need to go back in a couple of times, extending the waiting period to 10

minutes till he falls asleep by himself without you being in the room. If your baby wakes up in the middle of the night, you may need to repeat this again. The second day you will wait 5 minutes to go in initially, then 10 and subsequently 12 minutes. On the third day, begin with 10 minutes, then 12 and then 15 minutes. The idea is with each passing day, by increasing the waiting-out time, your baby will learn to fall asleep on his own without the parents’ help. The second and third night will be the toughest for parents and this is called extinction burst – it is around this time that most parents give up. Don’t give up just then because it gets steadily better after this, and your baby should be sleeping on his own soon.

Dr Marc Weissbluth’s method The second method is also by a paediatrician. Dr Marc Weissbluth is the founder of the Sleep Disorder Programme at the Children’s Memorial Hospital, Chicago. His method also uses the process of extinction. He advises you to leave the baby in the bassinet or crib without going back, unless you feel the baby needs to be fed or changed or there is a medical emergency. Unlike the previous Ferber method, he encourages no interventions. It is meant to instil healthy sleeping habits in your infants around the time that you think your baby is old enough to sleep through the night (around 6 months of age). You need to put the baby down for the night in her own bed as soon as she starts to show signs of sleepiness. The next part is the difficult part – leave the room and don’t go running back even if she is crying. In this method, the baby will eventually cry herself to sleep, and I am sure most mothers will do too. Consistency is the key, and they say that with this method your baby should be in a sleep routine in 4 days’ time. This method is not for every baby and mother.

Dr Jodi Mindell method The third method is by Dr Jodi Mindell, the director of the Sleep Disorder Centre at Children’s Hospital, Philadelphia. According to her, a quarter to a third of all parents of babies younger than 3 years of age report that their kid suffers

from some sort of a sleep problem. She believes that as most of these are new parents, they are wrong in assuming there is a lurking problem. This is not to say that baby sleep problems don’t exist. It just means that baby sleep patterns are crazy and if your baby wakes up a couple of times at night, it is perfectly normal.

Establish good sleep routines and be consistent: Even if your baby has sleep problems, establishing a routine will go a long way in sorting it out. Enforcing an early bedtime every night: Babies who go to bed late will not only take longer to fall asleep but will also wake up frequently at night. If your baby is overtired, there are more chances that she will wake up more often. Keep things consistent: Consistency is important and your windingdown routine should stay the same. Also, research shows that the more involved the father is with childcare, especially the night-time routine, the better a child will sleep. Letting your baby self-soothe: Resist the temptation of jumping out of bed every time you hear her wake up. Do not rock and sing or feed your little one to put her back to sleep. Often, babies can fall asleep on their own, given a few minutes of silence.

This method is not as rigid about crying as the other two, but the bottom line is essentially the same.

Further Reading The No-Cry Sleep Solution: Gentle Ways to Help Your Baby Sleep through the Night by Elizabeth Pantley If the cry-it-out method is not for you, then you may be able to read this book and get some tips. Pantley says breaking bad habits (like co-sleeping, feeding or rocking to sleep) by letting the baby cry is insensitive and cruel. She helps parents understand common sleep obstacles and gives step-by-step advice on how to teach their baby to fall asleep without breastfeeding

or bottle feeding or pacifier. The main problem with this method is that it takes many weeks, but she believes the gentle and gradual no-cry method meets a baby’s needs. The Happiest Baby on the Block: The New Way to Calm Crying and Help Your Baby Sleep Longer by Harvey Karp Dr Karp believes there is a fourth trimester of pregnancy, but here the baby is outside. He feels that your beautiful nursery does not offer any comfort for your baby. ‘Creating an environment that makes your baby feel like he is still inside the womb is the key.’ You can accomplish this by techniques called the 5 Ss: swaddle, side–stomach, shush, suck and swing. The New Contented Little Baby Book: The Secret to Calm and Confident Parenting by Gina Ford This book is based on Gina Ford’s personal experience of caring for over 300 babies. It is all about establishing routines. According to her, babies are more content when they have a routine, especially with feeding and sleeping. This book has detailed information on how to get your baby to sleep through the night as soon as he is ready. The Sleepeasy Solution: The Exhausted Parent’s Guide to Getting Your Child to Sleep – from Birth to Age 5 by Jennifer Waldburger and Jill Spivack The authors are psychotherapists and sleep specialists Jennifer and Jill, the duo all of Hollywood calls on to sort out the sleep problems of their little ones. According to their method, the key is addressing the emotional needs of the child and the parent. They create a customised sleep planner to ensure consistency with both parents as well as extended caregivers. Secrets of the Baby Whisperer: How to Calm, Connect and Communicate with Your Baby by Tracy Hogg with Melinda Blau In this book, the authors promote that parents should build a flexible routine for babies from a very young age, of eating followed by activity followed by sleep. The routine must be based on the needs of the baby and not a schedule dictated by parents. The authors’ attitude towards sleeping is that the child should be taught to sleep in her own bed and should learn to calm herself with less and less assistance from parents. They encourage parents to learn to recognise the child’s cries and respond to them appropriately. It is a sensible compromise between Richard Ferber’s method and co-sleeping in parents’ bed.

Frequently Asked Questions

QWhen will my baby develop a schedule for napping? Usually, by 4 months most babies develop a schedule for napping. Around 2

months of age, your baby will start showing some semblance of a schedule as far as feeding and sleeping are concerned. You need to allow your baby to take the lead, and then you develop a schedule around it. As we discussed earlier, put your baby down in the crib awake when you think he is showing signs of feeling sleepy. If you have followed all the advice in the previous pages, by the time your baby is 6 months old, you should have a schedule. If your baby has not napped after being 1 hour in the bed, please conclude that is the end of that nap for that day. Naptime can be anything from 30 minutes to 3 hours; the younger the baby, the longer the nap time. By a year, they will have a short nap mid-morning and a longer afternoon nap.

Q My baby has a late afternoon nap and then has trouble sleeping at night. It’s best not to let your baby sleep later than 5 p.m. in the evening. Otherwise, your baby won’t be tired enough to go to sleep at a reasonable hour at night. Your baby should go to sleep in the afternoon latest by 2 p.m. so that he can be up by 5 p.m. Even if he takes a long time falling asleep, you still need to wake him up by 5 p.m.

Q My baby has GER. Will this delay his sleeping through the night? Yes, unfortunately babies with GER take longer to sleep through the night. The symptoms of heartburn get exaggerated when lying down flat and hence it is worse at night. Your baby may be on medication for these symptoms, so make sure the dosage is adjusted as he gets heavier. Crying usually increases GER symptoms, so you cannot let them cry for too long when you are trying to sleep train them. Further, research shows that children who are tired and cranky due to lack of sleep are less interested in learning and acquiring new knowledge. So it’s important that both children

and parents get a good night’s sleep. Usually, by 6 months, the symptoms start to abate.

Sudden Infant Death Syndrome (SIDS) New parents do everything they can to keep their baby healthy and safe. But sometimes, for no apparent reason, a baby who seems perfectly healthy passes away. In a baby less than a year, doctors refer to it as SIDS. Since it usually happens when the baby is asleep, it is also known as cot death.

What causes SIDS? Doctors are not sure, but sometimes it may be because of genetics. Other babies may be born with a problem in the part of the brain that controls breathing, heart rate, blood pressure, temperature and waking from sleep. Factors that raise the risk incidence of SIDS are:

Brain defects Age below 6 months Prematurity Poor sleep position Second-hand smoke Upper respiratory infection

Who does it affect? AGE: The age group that is commonly affected is 1 to 4 months, although it can affect any baby under 1 year. SEX: It’s more likely to affect boys. RACE: It is seen more often in African Americans and Alaskan natives. There is really no reason found for this predilection. BIRTH WEIGHT: Preterm and small-for-date babies are more

susceptible. FAMILY HISTORY: More likely to happen if a sibling, or firstdegree relative, has passed away due to SIDS. MATERNAL HEALTH: The younger the mother, the higher the risk – especially if she has not received good antenatal care. Other risk factors are if she was a smoker during pregnancy, or if she consumed excessive alcohol.

Prevention strategies Put your baby on his back to sleep. Only once the baby can roll on his tummy is it safe for him to sleep on his tummy. Until then, remember the phrase ‘back to sleep’. Choose a firm flat mattress for the cot. Use tight-fitting sheets for the mattress. Keep stuffed toys, blankets, bolsters and pillows out of the bed till at least 1 year of age. You can swaddle him to keep him warm but not after he learns to roll. Sleep in the same room but not in the same bed. Sharing the room with the baby significantly reduces the chances of SIDS, but not if the baby is sleeping in your bed. Vaccination and breastfeeding also reduce the risk. Keep the baby cool while he is asleep. Don’t overdress the baby when you put him to bed. The room should be cool and comfortable. If you want to use a sleep sack, it should leave his face uncovered. Don’t smoke or drink or use drugs.

References American Academy of Pediatrics. (2020, 10 February). ‘How to Keep Your Sleeping Baby Safe: AAP Policy Explained.’ Retrieved 15 June 2020, from https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-

Parents-Guide-to-Safe-Sleep.aspx Boston Children’s Hospital (n.d.). ‘Sudden Infant Death Syndrome (SIDS) Symptoms & Causes: Boston Children’s Hospital.’ Retrieved 15 June 2020, from http://www.childrenshospital.org/conditions-andtreatments/conditions/s/sudden-infant-death-syndrome-sids/symptoms-andcauses Ferber, R. (2013). Solve Your Child’s Sleep Problems: The World’s Bestselling Guide to Helping Your Child Sleep through the Night. London: Vermilion. Mindell, J. A. (2010). Sleeping Through the Night: How Infants, Toddlers, and Parents Can Get a Good Night’s Sleep (Revised Edition). New York: William Morrow Paperbacks. Moturi, S. & Avis, K. (2010). ‘Assessment and Treatment of Common Pediatric Sleep Disorders.’ Psychiatry, 7(6), 24–37. Weissbluth, M. (2015). Healthy Sleep Habits, Happy Child: A Step-by-Step Program for a Good Night’s Sleep. New York: Ballantine Books.

5 Breastfeeding

By the time your baby is born, you would have some idea about how you’re going to feed her. You will receive lots of advice from family, friends and wellwishers about what and how to feed the baby. The final decision, however, must be made by you – the primary caregiver. Medical bodies, such as the Indian Academy of Paediatrics (IAP), the WHO and the American Academy of Paediatrics (AAP), strongly recommend exclusively breastfeeding for 6 months. After that, they say, one can continue breastfeeding for up to a year at least, along with giving solid foods such as fruits, vegetables, grains and protein sources that should be started at 6 months of age. Over the next few pages, I will describe both the advantages and disadvantages of breastfeeds and formula feeds. Like every other medical body, I will try and convince you that breastmilk is the perfect food for your baby. Although formula companies have attempted to mimic breastmilk in terms of nutrients, their product falls short in comparison to the real thing. Before we move ahead, let’s look at some of the commonly used terms in relation to breastfeeding.

Common Breastfeeding Terms Colostrum This is the first milk that the breasts produce. It is thin and watery; some mothers

may produce it even before the baby is born. It is rich in the mother’s antibodies and has fewer calories than mature milk because of its reduced fat content.

Foremilk This is the milk that comes out first when the baby starts feeding. It contains less fat. Babies who tend to have short feeds or snack end up getting mainly this foremilk. Hence, they feed frequently and may even be fussy because they’re hungry.

Hindmilk This is the milk that comes out during the latter part of the feeding. It tends to contain more fat and babies who feed only from one breast and drain the breast completely tend to get more of this milk, and hence, are more satisfied.

Engorgement This happens in the first few days when you start producing the mature milk – the breasts feel hard, sore, lumpy and full.

Plugged/blocked ducts This happens when there is blockage in one of the milk ducts, creating a very hard, tender area. It has a risk of getting infected.

Inverted nipples It refers to an indentation at the centre of the nipple due to which babies find it difficult to latch (see p. 83–84). You can try and pull out an inverted nipple using a syringe – nursing staff at the hospital or midwives who conduct the delivery can show you how. Once the nipple is pulled out, direct feeds can be attempted.

Flat nipples

Flat nipples Here the nipples don’t stand out or protrude from the surrounding breast tissue – this also makes it difficult for the baby to latch.

Nipple shields These can be used either with flat or inverted nipples, or in cases of cracked nipples. Prolonged use can lead to a diminishing of milk production.

Advantages of Breastfeeding Breast milk has the ideal ingredients for your baby’s growth. It contains the mother’s antibodies, which will in turn protect the baby from various infections the mother has been exposed to. It has been observed that breastfed babies develop immunity from recurrent colds and tummy upsets. One of the main benefits of exclusive breastfeeding up to 6 months is protection against gastrointestinal infections. The risk of mortality due to diarrhoea and other infections is higher in infants who are breastfed partially or not at all. Breast milk is also an important source of energy and nutrition. Babies are very rarely allergic to breast milk. Instead, it reduces food allergies later in life. Breast milk has 5 antibodies, (immunoglobulins A, D, G, M and E). Each serves its own function to help the body stay healthy and avoid allergies. Though more research is needed, evidence suggests that passing these antibodies through breast milk may help reduce or prevent a few types of allergies while it may have no effect on others. Breast milk builds the baby biome as it contains good germs like bifido bacteria and nutrients like oligosaccharides. These oligosaccharides encourage microbes to grow, which, in turn, helps build immunity. Exclusively breastfed babies have reduced risk of asthma, diabetes and various other diseases that occur later in life.

Breastfeeding makes it easier for mothers to lose their pregnancy weight. It also reduces the risk of breast, ovarian and endometrial cancer. Occurrences of other diseases like diabetes, heart disease and blood pressure are seen to be lower in mothers who have breastfed babies for up to a year. Breastfed babies are likely to gain the right amount of weight as they grow and are unlikely to become overweight children. In comparison to formula, breast milk has lesser calories, and the proportion of fat is different. Above all, it is free, always at the right temperature and readily available!

How to Encourage Breastfeeding Hospitals should encourage rooming with your baby as soon as the baby is born or checked over. For the first 1 or 2 days of the baby’s birth, nursing staff or lactation consultants should evaluate whether the baby is latching on and that the breastfeeding position is right. Water, formula or sugar water should not be offered to babies unless prescribed by the doctor. Pacifiers should not be used until the baby is breastfeeding well. Since the two kinds of sucking are different, she may not learn how to breastfeed well. After being discharged from the hospital, babies should be seen by a paediatrician for the first 2 weeks to assess breastfeeding.

Reasons Why Mothers Face Difficulty Exclusively Breastfeeding

It is painful. Breastfeeding, in most cases, is not as easy as it is made out to be. Both the mother and the baby are learning. It requires a lot of patience and effort from many sources. First is the technique of getting the baby to latch properly. Then, there may be engorgement (full breasts) when the milk actually starts to come, and this can be very painful; you may also end up with sore nipples. You may need professional help in the form of a lactation consultant, who can sit with you and help your baby latch and feed well. It is tiring and there is no support. Since the mother is the only one who can breastfeed feed the baby, there are times when she never gets to sleep more than a couple of hours at a time. Here, the best thing to do is sleep when the baby is sleeping. If the mother is exhausted, she can always pump breast milk and get somebody to feed the baby with a spoon while she rests. This is a good time to get the extended family, and the husband- partner, to feed the baby while she catches up on her sleep. “There isn’t enough milk.” This is not a very common phenomenon, but it seems to be a common complaint from most mothers. It is very rare that the body does not make enough milk for the baby. But in such rare cases, with a lot of effort, patience, and sometimes medication, breastfeeding can be successful. Stay motivated and ignore people around telling you that your baby is always hungry and that you are not producing enough milk. If the baby has adequate wet diapers and the weight loss since birth is less than 10%, then you are absolutely on the right track. There may be a case of breast surgery, or if your age is over 35, or you’ve had hormonal issues when you may not have enough milk. One can try and increase milk supply by nursing often and trying to pump between sessions, or your doctor may prescribe medication to increase the supply. Breast milk production is about supply and demand – most women find that breastfeeding at least 8 times in a day promotes a good supply. The first milk that is produced – colostrum – is all the milk that a full-term baby needs. The mature milk – which is rich in fat – comes by the 4th or the 5th day, which will then keep your baby

more satisfied. The first 48 hours or so, you may find the baby falling asleep at your breast, because they’re exhausted from the birth process and not interested in feeding. This behaviour will change after 48 hours. It is common for babies to lose 5%–10% of their birthweight in the first week – so, if that is the case and the baby loses weight, it is not because the mother is not making enough milk. Using a breast pump gives additional stimulation to increase milk production. Every drop, every millilitre of breast milk, counts. So even if you can’t exclusively breastfeed, your baby will benefit from whatever little milk she gets. Sometimes, despite the best efforts, breast milk supply may be insufficient to satisfy your baby. In such cases, a top-up formula may be required.

When to Top Up After a very long feed, if the baby still shows signs of hunger, it usually means that you may need to give her a top-up feed. The other situation is when even after a long feed, the baby appears satisfied but gets hungry within an hour. You can try breastfeeding again but, in some cases, you may need to give a top-up. Some mothers are very motivated and don’t want to offer formula. But if your baby is losing weight and not passing adequate urine, then it’s a case for doing so. I have had instances when babies have lost huge amounts of weight because of exclusively breastfeeding and needed to come to the hospital because they were showing signs of severe dehydration. If in doubt, take the baby to see your paediatrician to chart her weight. If you want to exclusively breastfeed and are not sure if your baby is getting enough or if

you feel your baby is not passing enough urine, please get your baby’s weight checked every 2 or 3 days till there is a steady upward trend in your baby’s weight. In the initial days, the baby may need an occasional top-up formula, but over the coming few weeks, you may be able to get back to exclusive breastfeeding. Formula is best offered with a cup and spoon and it is best to avoid the bottle in the first few weeks. The idea is to give the least amount of formula milk to satisfy the baby, so that she can breastfeed frequently alongside the formula top-ups. It is usually during late evening that babies are constantly hungry. So offer top-up only in the evening. Some babies, however, may need a top-up after every feed. Over the next few weeks, you can slowly reduce the quantity of top-up formula and the number of times you give it. This may help increase your breast-milk output. Returning to work. When you have no other option but to return to work, it is difficult to find the time to pump. You can try to pump once before you leave for work and then once again at work, and then you can directly breastfeed the baby once you are back home. The rest of the time, the baby can be given formula. This way your baby can get at least some breast milk. The baby has issues that make it hard to breastfeed, like if your baby was born premature or if he has severe GER.

Medical Considerations with Breastfeeding In a few situations, breast milk could cause more harm to the baby. You should not breastfeed in the following cases:

You are HIV-positive (as the virus can pass through breast milk to the baby). You have an active, open case of tuberculosis of the lungs that has not been treated. You are receiving chemotherapy for cancer. You are using illegal drugs like cocaine or marijuana. Your baby has a rare condition called galactosaemia and cannot tolerate sugar galactose that is present in breast milk. You are taking prescription medications for conditions such as arthritis.

Tips: Making Breastfeeding Easier Ensure that your baby has latched on to the areola (the pink or brown part around the nipple base) and not the tip of the nipple, which is the main reason for cracked and sore nipples. If it continues to hurt, de-latch and get the baby to latch back on again. If the position you are using is not working, try another one. There are different ways of breastfeeding, such as the cradle hold, the football hold or the cross-cradle hold, lying on your side or laid-back breastfeeding after a C-section (see p. 82–83). If there is difficulty latching on, get your partner or your mother to gently hold open the baby’s mouth and manoeuvre the breast into it. If your breasts are sore, you can ask for a nipple shield as a temporary measure. You can use ointments containing lanolin to soothe the breast. To stimulate good milk production in the first month, it is ideal to feed from both breasts at each feed. Once you feel that your milk output is good, you can allow your baby to empty one breast. Last but not the least, despite the rough first 2 weeks, it is important to stick it out for your baby’s sake. Take the help of the lactation consultants or the nursing staff at your hospital if you have problems breastfeeding.

Best Feeding Positions The best position is the one in which both the baby and the mother are comfortable. Here are a few of the common ones: 1. Cradle position (most commonly used position). 2. Cross-cradle position (can be used for smaller babies, where you need to support the head better; some mothers prefer to use this for babies who struggle to latch). 3. Football position or clutch (I have often found that when babies have difficulty in latching on to a particular breast, they finally take to it with the football hold. Once he is a little older, you can move him on to the cradle position). 4. Reclining/side-lying down position (it is a convenient way to feed in the night; importantly, ensure you don’t fall asleep, else there is a chance of rolling over the baby).

Latching 1. Prior to feeding, make sure your hands are clean. 2. Hold your breast with the thumb above and your fingers below the breast and touch the nipple to the baby’s lips or cheek.

3. The baby will usually turn to grab hold of the breast – this is called the rooting reflex. 4. When the baby opens the mouth wide, put the nipple deep into her mouth, so at least an inch of the breast – the whole nipple and as much of the areola – is inside. If the latch is correct, breastfeeding should not be painful. 5. You should be able to hear the baby gulp and swallow, and your breast should feel empty at the end of the feed. You should not be left with sore or cracked nipples. 6. If you have an incorrect latch, you will not hear the normal gulping sounds and the breast will pain. In such a case, de-latch and try all over again. For a breastfeeding video tutorial, the Stanford Children’s Hospital breastfeeding education site is extremely helpful (www.firstdroplets.com). It is important to get the correct latch because if the baby doesn’t empty the breast properly, it can lead to engorgement and sometimes an infection called mastitis. Incomplete emptying of the breast means the baby gets less milk and she is constantly feeding.

Feeding Pattern: The First Week 0–24 Hours Usually, immediately after birth, the baby is awake. So we try and get the baby to feed within the first hour. You can either do it in the delivery room right away or within the first hour of his birth. If you have had a C-section, you may be allowed to put the baby to your breast only if you have had a spinal anaesthesia. If you are under the effects of general anaesthesia, then most units will give the baby a formula feed with a cup and spoon and then send the baby to you when you are awake.

Head tilted back slightly.

Bring baby in quickly, pushing gently on his shoulders.

LATCHING

24–36 hours Over the next 24–36 hours, babies tend to sleep a lot. This is because labour and delivery are tiring for the baby. The maximum that one can allow the baby to sleep is 4 hours at a stretch. During this time, as the baby is sleepy, one may find it difficult to figure out a pattern for feedings, so it may be short and disorganised. Try and feed the baby every 2–3 hours.

24–36 hours till 3 days The baby will suddenly be more awake now and feed a lot. She may feed 8–12 times in a day. Sometimes, babies feed frequently – every 1 or 2 hours – and sleep for 3–4 hours at a stretch. Each feed may last 30–45 minutes. At this time, it is normal for babies to demand feeds more often, and this is what helps in the production of milk, leading to the let-down reflex (see p. 87).

Between 3 and 7 days Mothers will feel like their breasts are heavier before the feed and empty after the feed. When the baby has a good feed, you can hear at least 6–8 gulps when she feeds. Babies are more settled during this phase. They could have 8–12

feeds in 24 hours and the gaps between feeds could be anything between 1 hour and 3 hours. Sometimes, babies tend to feed several times in a few hours – this is called cluster feeding. After this, they can sleep for 4–5 hours – this is also normal. By the end of the week, you should be able to get into a schedule of feeds every 2.5 to 3 hours.

Changes in the Breasts The breast can go through numerous changes during preganancy and while breastfeeding. So let’s put it all down in order.

Pregnancy Towards the end of your pregnancy, there may be some secretion called colostrum. This does not happen to every pregnant woman but if it does happen, it’s nothing to feel alarmed about. If you are feeling uncomfortable, you can express and remove some of it.

Postpartum (Post-delivery) Milk doesn’t set in till the first 2–5 days. Most mothers will experience a feeling of heaviness, called the let-down reflex. The heaviness is there before feeding, and once the baby has had a good feed, the breast will feel empty. Sometimes, when the mother is feeding on one side, there may be milk leaking out or dripping from the other breast. These changes usually then settle down over the next few weeks: the breast may not feel as full and one may not have any leaking, but that doesn’t mean there is less milk production. Some mothers usually feel sore, or a pulling sensation, when the baby starts to feed. However, this should settle in a few days. If the nipples have a burning sensation every time you feed, it may be because of a yeast infection. Yeast is a fungal infection that usually grows in dark, warm, moist places. It looks like a curdy deposit on the baby’s mouth

or tongue. You may feel burning and itching on your nipple and pain when you’re feeding. Get the baby checked by a paediatrician, who may prescribe an anti-fungal lotion to be applied on the baby’s mouth and a cream for your breast. Remember to wipe off the cream from the breast before feeding.

Tips: Beating Yeast Infection Wash hands thoroughly with hot, soapy water and dry them properly before feeding the baby and changing his diaper. Wash yours and your baby’s clothes in the hottest water possible. Iron your baby’s clothes before use. If using a pacifier or a nipple shield, sterilise it properly before each use. While being treated for the infection, don’t freeze and store your breast milk. Decrease consumption of sugar and increase intake of vegetables and garlic. Garlic is known to help fight these infections.

Engorgement Most mothers will feel some mild engorgement between the third and the fifth day. This soon settles when milk comes in and the let-down reflex becomes active. Once the baby starts feeding better and more frequently, the feeling of engorgement usually settles. Abnormal engorgement is when it remains severely painful and doesn’t settle even after feeding the baby. It can be associated with fever and redness on the overlying skin. REASONS

Incorrect latch: Due to improper latching, the breasts are not emptied

with each feed; hence, milk accumulates. Excess milk production: Some women just produce more milk than the baby can handle. With proper positioning, and as the baby’s appetite increases, this settles down. Blocked duct: In this case, the engorgement is more localised, and one area of the breast is hard and painful. Too many top-ups: Offering the baby more top-up feeds and not allowing the baby to breastfeed completely also results in engorgement.

TREATMENT It is better to tackle this early in the following ways:

Making sure the latch is proper because if the breast is not emptied it will just compound the problem. Take help from the nursing staff or a lactation consultant before leaving the hospital. Your baby’s paediatrician is not going to be able to help you with this on the phone. The mother can always express, whether manually or with a pump, to soften the breast so that the baby is able to latch more comfortably. If she feels that the breast is engorged even after feeding, she can express it then. Take a hot shower or apply a hot towel to improve the flow of milk. Cold compress or an ice pack may be used to reduce swelling. Analgesics like paracetamol or brufen can be taken to deal with the pain, after consultation with your doctor. It is important to continuously feed and express to treat engorgement – you cannot afford to lose heart as breast milk is extremely beneficial for the baby and engorgement will settle with time.

Engorgement can also happen when the baby is weaned and each breastfeed is replaced with solid food. However, as it happens gradually, most mothers do not experience uncomfortable engorgement. Occasionally, though, it can be

severe and painful. You can take analgesics and may need to express small amounts in order to relieve the pain, but don’t empty the breast as it will fill up again.

Mastitis (Breast infection) Although it is quite rare, mastitis is an extremely distressing and painful condition.

Sore nipples and breast engorgement are precursors to mastitis. When nipples are sore, bacteria can enter the breast and stagnant milk is an ideal medium for bacteria to multiply. It can be a localised infection associated with a blocked duct, where there will be tenderness in one area of the breast and redness of the overlying skin. The mother may also have flu-like symptoms. When it is associated with engorgement, the whole breast may be involved and as a result become hard and painful. The whole skin over the breast may be red and the mother may be systemically unwell with fever. Mild infections are treated with antibiotics and analgesics and you can continue to breastfeed, as keeping the milk flowing will prevent the spread of infection. In severe cases, if there is formation of an abscess, it will need to be drained (the mother may be asked to do an ultrasound for the diagnosis of an abscess). She may be asked to temporarily stop breastfeeding and pump to remove the milk. Once the abscess has healed, breastfeeding may be resumed.

Frequently Asked Questions

QHow long should each breastfeeding session last?

This can vary a lot and is different for each mother and baby. Some babies feed for nearly half an hour on each side while others are satisfied with just 10 minutes on each side. Usually, by the end of the first week, babies will be feeding 15–20 minutes and in the initial phase, both breasts should be offered. This encourages maximum production of milk. Once lactation has established, you can allow the baby to feed for 20–25 minutes on one breast. This allows the baby to get more of the hindmilk which is rich in healthy fats and keeps the baby more satisfied. At the end of the feed, if the baby still looks hungry, you can offer the second breast. Remember to start with the opposite breast for the next feed. Some mothers have told me they use methods like putting a rubber band on the hand to remind them which breast they fed from last – this really helps when you are sleep-deprived.

QFor how long should I feed my baby at night? For the first 6–8 weeks, you will be feeding your baby 3 hourly at night (once every 3 hours). After this, you can slowly discourage the baby from taking the middle-of-the-night feed around 2 a.m. to 3 a.m. If you are lucky, you may find that by the time your baby is 3 months of age, he may go 6 hours without a feed and allow you to sleep for 6 hours.

QHow do I know that my baby is getting enough milk? The baby will latch well and feed vigorously around 8 times a day. You’ll feel fullness before the feed and the breast will feel empty at the end of the feed. There will be no nipple soreness or engorgement. The baby will be satisfied for at least 2 hours and sometimes go 3–4 hours before asking for a feed. If the baby is feeding well, the stools will turn from dark green to yellow,

watery stools. She could have 6–8 stools per day. If feeding is inadequate, the stools remain green even at the end of the week. The baby may only pass 1 or 2 stools. By the end of the week, your baby will be passing urine at least 8–10 times in a day. If a baby isn’t feeding well, then the urine frequency is less, and it is more yellow in colour. Most babies lose about 5%–7% of their body weight in the first week. Any weight loss more than 10% is indicative of inadequate feed. Most babies should recover the weight loss and regain their birth weight by 10 days of life.

QWill using a breast pump help me with breastfeeding? Your baby is the best breast pump. So, you really don’t need any other breast pumps. Occasionally, when you have engorgement, then you can use the pump to relieve the engorgement. When you have started work, then you can use the pump to express and store the milk.

QHow do I store the milk? Wash your hands with soap and water before expressing milk. Make sure you sterilize your breast pump. Use cooler bags or sterile containers to store the milk. These containers should have the date and time of collection so that you know how soon you can use it. The containers should be either glass or polypropylene/polyethylene bags. The containers should be washed in hot, soapy water and rinsed and finally air dried. When using glass containers, make sure they are freezer-safe ones. Human milk should not be stored in hospital plastic specimen containers, such as those used for urine tests and other body fluids.

Freshly expressed breast milk can be stored safely at room temperature, which is between 10°C and 29°C, for up to 6 hours. If at 27°C–32°C, then up to 4 hours is safe, but it is best to chill or refrigerate as soon as possible if you’re not sure whether the milk will be used within 4 hours. In India, especially in the summer months, it is better to refrigerate milk as soon as it is pumped. If breast milk has less bacteria, then even up to 72 hours in the refrigerator is safe. However, since it is impossible to check whether there is bacteria in the breast milk or not, it is best to use it within 24–48 hours. It should be stored at the back of the fridge where the temperature is more stable and not affected so much by the opening and closing of the fridge door. I normally recommend only 24 hours in the refrigerator. Frozen breast milk (−4°C to −20°C) can be consumed by the baby within 3 months. At −18°C, the milk is safe indefinitely from bacterial contamination but there could be changes in the quality of milk. For example, fat, protein and calories reduce after 90 days. Refrigerated and frozen breast milk may have a different odour than fresh milk because of the breakdown of triglycerides into fatty acids. It tends to separate as well but all you need to do is shake it gently to mix it up again. Never fill the container to the brim since the milk will expand when frozen. It’s recommended you fill a container to about â…” of its capacity. Don’t mix the freshly expressed warm milk with the already cool or frozen milk. To thaw frozen milk, first place the container in the refrigerator overnight, then warm it by sitting it in a bowl of warm water, or you can use a waterless milk warmer. Microwaving can cause the milk to heat unevenly. It also decreases the activity of immunological factors in milk and therefore reduces the healthy properties of milk.

Once frozen milk is thawed and brought to room temperature, it should be used within 2 hours. Currently, there is no recommendation regarding the refreezing of thawed breast milk. Location of Storage

Temperature

Maximum Recommended Storage Duration

Room temperature

16â°C–29â°C (60â°F–85â°F) 4 hours optimal 6–8 hours acceptable under very clean conditions

Refrigerator

~4â°C (39.2â°F)

4 days optimal 5–8 days under very clean conditions

Freezer

95% coverage of vaccination. In India, a standalone measles vaccine is no longer available. It is a combination vaccine along with mumps and rubella. The first dose is administered around 9 months of age, the second dose around 15 months of age and the third dose around 5 years of age. Mumps is a viral infection involving the salivary glands, especially the parotid. There will be swelling along the jawline and can affect other body parts like the testes, ovaries and the brain. It can produce long-term sequelae like sterility in men, and deafness and intellectual disability following meningitis. This is also spread by droplet infection. Also known as German measles, rubella produces very mild symptoms in children. But it can be fatal and devastating for unborn foetuses when the mother gets it, especially in the first trimester of her pregnancy. It can also lead to a miscarriage. Congenital rubella syndrome can cause deafness, cataracts, intellectual disability and heart defects in the baby. The MMR vaccine is a live attenuated vaccine and reactions, usually in the form of fever or a rash all over the body, can happen 1 to 4 weeks after the vaccination.

Rotavirus Globally, rotaviruses are the leading cause of severe dehydrating diarrhoeal illness in children less than 5 years of age. In low-income countries, 80% of this infection occurs in infants less than 1 year of age.

The vaccine, given as oral drops, has made a significant impact on both the number and severity of cases. There are many brands available, and some have a 2-dose schedule while other have a 3-dose schedule. Usually, they can be given along with the combination vaccine starting at 6 weeks. The does have to be complete before your baby turns 9 months. As it is a live attenuated vaccine, the most common side effect of the rotavirus vaccine is mild diarrhoea within the week after vaccination. A rare side effect is intussusception, which leads to a block in the intestine. Studies have shown that the risk is no greater in the vaccinated population as compared to the general population. Parents should be looking out for severe abdominal pain/colic or blood in the stool after the vaccine.

Hepatitis A This is a viral illness which affects the liver. It spreads through infected food and water. The illness is generally mild in children, but occasionally it is known to produce liver failure, needing liver transplantation. Adults, however, can get very sick with this illness. There are 2 types of hepatitis A (hep A) vaccine: the live attenuated and the inactivated. For the live attenuated vaccine, a single dose is recommended around the first birthday and the inactivated one is to be given as 2 doses, 6 months apart. The first is given just around 1 year of age, and the next at 18 months. There are usually very mild side effects like local pain or a mild fever.

Chickenpox (Varicella) This is a common childhood illness, and most of us have heard of or seen children with chickenpox. The infection is spread by droplets or from the liquid that comes out from the vesicles, the water-filled blisters that appear all over the body. The baby may have the typical viral symptoms of body ache and fever before she breaks out in a rash, which appears as crops (numerous vesicles together). The child may be contagious for 7 to 10 days when she is likely to spread the infection. These lesions heal and finally fall off and the illness can last up to 3 weeks. Complications due to chickenpox include pneumonia and encephalitis and

secondary bacterial infection of the lesion. The chickenpox or varicella vaccine has certainly reduced morbidity. If you do get the disease despite the vaccine, it is very mild. Since this is a live-attenuated vaccine, you may get a mild rash which resembles chickenpox 1 to 4 weeks after the vaccine. The risk of getting shingles or herpes zoster after the vaccine is far less than getting shingles after getting chickenpox. There is a 2-dose schedule for the vaccine. The first dose is usually given around 13 to 15 months of age and the second dose anywhere after 3 months of the first dose, or any time between 4 and 6 years of age. After the second dose, the protection is over 95%. If your child has missed the vaccine, it can be given to anyone over 1 year of age. The IAP recommends getting the second does in quickly, 3 to 6 months after the first, to reduce of the incidence of the infection in the community.

Typhoid This is a disease of the developing world and is associated with poor public health and low socio-economic indices. It is contracted from eating or drinking contaminated food or water. It is accompanied by high fever, and infects mainly the intestine, liver and spleen. Serious complications include intestinal perforations, haemorrhage and encephalopathy. These complications usually require hospitalised treatment. There is a vaccine against typhoid but the efficacy ranges from only 50% to 80%. Hence, you should heed the warning boil it, cook it, peel it or forget it when it comes to any food that you feed your child. This Peace Corps advice for less-developed countries (‘If you can’t peel it, cook it or boil it, forget it’) is the best prevention. It goes for typhoid as well as diarrhoea. The vaccine currently used and recommended by the IAP is the conjugate vaccine, given any time after 6 months of age. The curent recommendation is for a single shot only. Side effects related to this vaccine are mainly local pain and mild fever.

Influenza

Influenza, or the flu as it’s commonly known, is an infection of the respiratory tract, usually seen in the monsoon and again in the winter. The symptoms of the flu are usually high fever, chills, body ache and headache. Some children may have some gastrointestinal symptoms as well, like vomiting or loose potty. This is followed by a cold and a cough that is difficult to shake off, unlike a common cold. Secondary bacterial infection, like ear and sinus infections and pneumonia, may complicate the flu. The flu can be deadly in the two ends of the age spectrum – children under 2 years and adults over 65. The flu vaccine can be given to any child over 6 months of age. The Centers for Disease Control and Prevention (CDC) recommends that all children between 6 months and 18 years, pregnant women, health workers and people suffering from chronic illnesses like asthma, diabetes and heart disease get this vaccine during the flu season. Household members and caregivers of children between birth and 5 years should also be administered the vaccine. The H1N1 or swine flu virus is also included in the flu vaccine. Most of the current influenza vaccines contains both influenza A and B strains. There are both trivalent and quadrivalent vaccines and they are inactivated split virion formulations, meaning a part of the virus is used to make up the vaccine, which is supposed to stimulate a better response to the vaccine. The vaccine can be given any time after 6 months. Following vaccination, the antibody titres (concentration) peak 2 to 4 weeks post vaccination. When your child gets the flu vaccine for the first time, 2 shots are given 1 month apart after which they receive a yearly vaccine till at last 5 years of age. This applies for all children under 9 years of age. Anybody over this age needs only 1 injection. The side effects are like any other vaccine – pain and mild fever.

Meningococcal Disease This life-threatening disease is caused by the Neisseria Meningitidis bacteria. This disease involves an infection in the blood stream called septicaemia and a

brain infection called meningitis. The conjugate vaccine that is now available is very effective in protecting against the 4 strains of the bacteria. The meningitis B strain that produces most of the diseases seen in the developed world also has a vaccine, which is currently not available in India. The incidence of this particular illness is quite low in India but, that said, it tends to be seen as an epidemic. The vaccine that is available is a conjugate vaccine with 4 sero types. Since we don’t see many cases, it is not part of the routine vaccination schedule. The IAP recommends this vaccine in special situations, like when children have a problem with their immune system called immunodeficiency syndrome, or a condition called aslpenia where there is an absence of the spleen, which is an important organ useful for fighting infections. Health workers, especially in contact with a patient, can be given 1 dose of the vaccine as prophylaxis. This vaccine can also be given in special situations, like when your child goes to university, especially in the USA, where it is mandatory. The vaccine has been made available in the last few years. It falls under the category of optional vaccines and you will be able to discuss the need to take it with your paediatrician. It is licensed to be used any time after your baby is 9 months old, when 2 shots can be given 3 months apart. If you are giving it after 2 years, then only 1 injection is needed. There are 2 brands available and you can discuss them with your paediatrician. Side effects are mild and include soreness at the site of the vaccination.

Human Papilloma Virus (HPV) HPV infections can lead to cervical cancer. This virus has also been linked to oral and anal/rectal cancer. There are 3 vaccines available in our country. While one has 2 strains and another has 4, the third vaccine, launched in October 2021, has 9 strains to combat cervical cancer. Currently, these are only licensed to be used in young girls over 9 years of age. You could consult your paediatrician on the best one for your child.

There are 2 dosing schedules. Children under 15 years of age are given 2 shots, 6 months apart, and those over 15 years are given 3 shots at 0, 1 month and 6 months. Side effects include pain and fever, which are minimal. Some girls faint after the injection, so they should lie down when they get it and stay like that for at least 10 minutes.

Rabies This is a viral illness that attacks the nervous system. Once you develop the symptoms, it’s usually fatal. The anti-rabies vaccine given soon after a bite usually helps in prevention of this deadly disease. The virus enters the body through a cut in the skin or through the mouth or eyes. It has a predilection for the nervous system, from where it moves through the nerves to other parts of the body. The rabies virus is present in animal’s saliva and is transferred through biting or even scratching, as animals often lick their claws. A child gets rabies if bitten by a rabid dog or even scratched by one. If the child has a sore or a scratch that comes in contact with the saliva of an infected dog, he can get rabies. You can get rabies from cats as well. In India, monkey bites are also known to transmit the virus. Symptoms can start as early as 5 days or as late as 3 months after the bite. In the first stage of the illness, symptoms are nonspecific – they include fever, headache, vomiting and reduced appetite. It is in the second stage that they go on to develop the classic symptoms of rabies which include trouble swallowing, even their own saliva (hydrophobia). It soon progresses to confusion, paralysis, coma and death. The IAP recommends what is known as pre-exposure prophylaxis in children, especially in two high-risk groups: where there is a pet dog in the house and if there is a high risk of being bitten by stray dogs. It is a 3-dose regime, at 0, 7 and 28 days. Following this, if there is re-exposure, for instance, and the child is bitten again, then she needs 2 shots, on day 0 and 3. Post-exposure vaccination usually requires human rabies immune globulin and the rabies vaccine. The

first dose is given on the day of the bite and the following doses are given again on days 3, 7 and 14. This is usually combined with the monodonal antibody cocktail for post-exposure prophylaxis. The dose is calculated according to body weight; some of it is infiltrated around the wound and the rest given as an intramuscular injection. Side effects are minimal and include fever and pain at the site of the vaccination.

General Advice for Parents Make sure your pet is vaccinated. If you live on a farm, make sure your pets are in a fenced yard. Never leave a child alone with a pet, however docile the pet is. Teach your child never to separate fighting dogs, to stay away from strange/stray dogs, and to leave animals alone when they are eating.

Japanese Encephalitis This is a mosquito-borne disease and is the leading form of viral encephalitis in Asia in children below 15 years of age. The mortality is very high, and those who recover don’t always make a full recovery – they are left with permanent neuropsychiatric sequelae or long-term effects. This vaccine is not recommended for routine use but only for children living in endemic areas. It is mainly a disease of rural areas. Eastern parts of UP, Assam, Bihar, Tamil Nadu and Andhra Pradesh are most affected. There are 2 vaccines available, JEEV and Jenvac. It is given as a 2-dose schedule, 4 weeks apart. Side effects include only fever and local pain. The first dose can be given after the child completes 1 year.

Immunisation Chart

Optional: Influenza, rabies, pneumococcal (PPSV), Meningococcus Japanese Encephalitis If you decide to get your child vaccinated against influenza, the first dose is given after 6 months of age and the second dose 1 month later, following which it should continue to be given yearly. In the case of the meningococcal vaccine, the first dose can be administered when the baby is 9 months old and the second dose must be given 3 months later, when the baby completes a year. Alternatively, your doctor could decide to vaccinate your child at 2 years of age, wherein only a single dose is needed. The meningococcal vaccines are

mandatory for children going abroad to study. So, 1 dose is required for children over 16 years of age.

References AAP. (2020). ‘Immunization Schedule.’ Retrieved 15 June 2020, from https://www.aap.org/en-us/advocacy-and-policy/aap-healthinitiatives/immunizations/Pages/Immunization-Schedule.aspx Balasubramanian, S. et al. (2020). IAP Guidebook on Immunization 2018– 2019: By Advisory Committee on Third ed. New Delhi: Jaypee Brothers Medical Publishers. Balsekar, D. & Choudhary, M. (2015). 0 to 2 Baby and You: A Pediatrician’s Handbook for Practical Parenting (1st ed.). Vakils, Feffer & Simons Pvt. Ltd. Centers for Disease Control and Prevention. (2021, 9 July). Measles Cases and Outbreaks. Retrieved 15 June 2020, from https://www.cdc.gov/measles/cases-outbreaks.html Centre for Disease Control, C. (2016, 26 May). ‘Vaccines and Immunizations.’ Retrieved 15 June 2020, from https://www.cdc.gov/vaccines/index.html Eick, A. A. et al. (2011). ‘Maternal Influenza Vaccination and Effect on Influenza Virus Infection in Young Infants.’ Archives of Pediatrics & Adolescent Medicine, 165(2): 104. doi:10.1001/archpediatrics.2010.192 Kasi, S. G., Shivananda, S., Marathe, S., Chatterjee, K., Agarwalla, S., Dhir, S. K., Verma, S., Shah, A. K., Srirampur, S., Kalyani, S., Pemde, H. K., Balasubramanian, S., Parekh, B. J., Basavaraja, G. V., & Gupta, P. (2021). Indian Academy of Pediatrics (IAP) Advisory Committee on Vaccines and Immunization Practices (ACVIP): Recommended Immunization Schedule (2020-21) and Update on Immunization for Children Aged 0 Through 18 Years. Indian Pediatrics, 58 (1): 44–53. https://doi.org/10.1007/s13312021-2096-7 Kliegman, R. M. et al. (2020). Nelson Textbook of Pediatrics (pp. 532–38). Philadelphia, PA: Elsevier. Offit, P. A., Quarles, J., Gerber, M. A., Hackett, C. J., Marcuse, E. K., Kollman, T. R., Gellin, B. G., & Landry, S. (2002). Addressing parents’

concerns: Do multiple vaccines overwhelm or weaken the infant’s immune system? PEDIATRICS, 109 (1): 124–129. https://doi.org/10.1542/peds.109.1.124 Popik, B. (2015, 7 August). Barry Popik. The Big Apple. Retrieved 15 June 2020, from https://www.barrypopik.com/index.php/new_york_city/entry/boil_it_cook_it_peel_it_or_ Rastogi, A. (2018, 18 June). Mission Indradhanush: National Health Portal of India. Mission Indradhanush and National Health Portal of India. Retrieved 15 June 2020, https://www.nhp.gov.in/mission-indradhanush1_pg Riedel S. (2005). ‘Edward Jenner and the History of Smallpox and Vaccination.’ Proceedings (Baylor University. Medical Center), 18 (1): 21– 25. Retrieved 15 June 2020, https://doi.org/10.1080/08998280.2005.11928028 Wakefield, A.J., Murch, S.H., Anthony, A., Linnell, J., Casson, D.M., Malik, M., et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998; 351: 637–41.

9 Growth and Development

An important aspect of parenting is understanding how your baby will grow and develop over the next few years. As children advance through a sequence of stages in growth, they may face several challenges. Children not only vary in their physical appearance, they are also different in the way their mental capabilities develop. How children interact with others and the environment also keeps changing as they grow. No two children are alike, but they have similar growth and development patterns. Generally, these follow an order, and this is what is meant by developmental stages. Doctors use growth charts as a guide to check the baby’s growth. Three parameters are plotted: weight, length and head circumference. Most babies have standard growth as far as weight, length and head circumference are concerned. They usually follow a trajectory and if they veer off this, it alerts the paediatrician to look more closely at the baby’s growth. A child’s nutritional needs also vary. As an infant, the caloric requirement is more than that of a toddler. This increases again around adolescence.

Weight From birth to 3 months of age, babies usually gain around 25–30 g per day. Between 3 and 6 months, they gain around 15–20 g a day. From 6 to 9 months, they gain 10–15 g a day. From 9 months to a year of age, they gain around 5–10 g a day.

Most babies double their birth weight by 4–5 months and triple it by a year. The weight gain slows down from birth to a year as the baby becomes more active and burns more calories. Since they are more active, they lose interest in eating. So don’t fret if your 1-year-old eats less now than he did when he was 9 months old. As a parent, you only need to provide the food in a presentable way in bite-sized pieces and encourage them to eat. Never forcefeed.

Length Most growth, lengthwise, happens in the first year of a baby’s life. From birth to 6 months, babies gain around 2.5 cm per month. From 6 months to a year, they grow 1.25 cm per month.

Head Circumference On monthly visits, your doctor will be measuring your baby’s head (the head circumference) and will plot it on the head circumference charts. In the first month, the head grows by 2 cm. Over the next 4 months, it grows by 4 cm. From 4 months to a year, it grows an average of 6 cm.

Growth Monitoring All paediatric clinic visits are incomplete without the height, weight and head circumference measurements. Most parents are very apprehensive when the paediatrician places the baby on the weighing scale. Remember: These are just numbers, and you should not be unduly worried about them. Doctors plot these numbers on growth charts and, unless these are plotted, it is easy to miss growth irregularities. It is important to plot them at least at every second, if not every, visit: Weight for age Length for age

Circumference for age

Centile Charts Growth is plotted as a percentile. The same goes for height. If your baby is on the 15th centile for height, then 85 children will be taller and 15 children will be shorter for every 100 children surveyed. Each child will grow along a particular centile and this is dependent on how heavy the baby was when he was born, coupled with his genetic make-up. The trend is more important than an absolute value. Thus, if the baby falls off from the 75th centile at 3 months to 5th centile at 1 year, then that baby will need to be investigated for failure to thrive. There are other charts called body mass index (BMI) charts. These charts indicate how heavy the child is compared to other children of the same age and height. The value is calculated by the formula:

The value is then put down as a percentile. Percentile between 15th and 85th is considered in the normal range. Anything above the 85th is overweight and above 95th is obese, while below 15th is underweight.

Normal Growth A normally growing child will usually be around the 50th percentile (median) and will tend to grow slightly above or below the 50th centile. There may be periods where it appears to be accelerated and periods when the growth may plateau. If there is no major variation, and the baby is growing parallel to the growth chart, we do not need to worry. Major changes either upwards or downwards need to be investigated.

Weight Gain You may find that, over a couple of months, the weight gain has been slow. But

if the child is generally well, there is no cause for concern. However, if this pattern of slow weight gain continues, it would be prudent to discuss it with your doctor, who may then decide to investigate further. Sometimes, the weight gain may be too rapid and this may lead to obesity. Childhood obesity is now a major concern in the developed countries, leading to diabetes and hypertension in young adults. This trend is gradually catching up in certain classes of society in India and needs to be identified and prevented at an early age.

Height Gain Just like weight, height can also show slow growth alternating with rapid growth. But if the height velocity is reduced over 2 or more visits to the paediatrician, the doctor may decide to investigate your child for nutritional or hormonal abnormalities. Rapid height gain, again, is nothing to be worried about. This may be because of natural genetic constitution but, sometimes, it may also be because of hormonal or skeletal abnormalities. The WHO has developed growth charts from data collected in 6 countries and 5 continents. These are considered standard reference charts to monitor the growth of young children in many countries, including India. These charts show how kids are growing compared to other kids of the same age and gender. Growth charts also follow height and weight gain over time and your doctor will be able to see if your baby is growing appropriately. One set of charts is used till 24 months and a different set from 2 to 20 years. There are special charts for children with certain problems like Down syndrome or if born extremely premature. Percentiles are measurements that show where the child is when compared to other children. On the charts, they are shown as lines drawn in a curved pattern. Your paediatrician will plot your baby’s height and weight and head circumference on the charts. The higher the plotting is on the chart for height and weight, the bigger the child and vice versa. Being on the higher or lower centile does not mean that your baby is healthier or that he has a weight or height problem. There is no ideal number for

the chart – healthy children come in all shapes and sizes. A child who is on the 10th centile can be just as healthy as a baby on the 90th centile. Ideally, a child will follow the same growth pattern for weight and height, which means he will remain on a particular centile chart.

Development

By development, we mean the rate at which your baby develops certain skills like walking, talking and rolling over. Let’s find out how your child’s brain works and the rate at which your baby develops new skills. We know that competition starts early. But the first thing that parents need to know is to not compare their child to other children. Each baby develops at his or her own pace and though there is a fixed timeline for developing skills, it is a rather broad range. Let us define development: Development here is broken down into different aspects. It involves motor skills, large and small muscles, language, social skills and intelligence.

Motor Skills Motor skills comprise gross motor and fine motor skills. Gross motor skills refer to using large muscle groups to function, like legs, arms, chest, upper torso. The milestones parents should look for are rolling, sitting, crawling, climbing, walking and running. 3-month-olds should have achieved head control, 6-month-olds should have shoulder and trunk support and should be able to roll over, 9-month-olds should have knee control and be able to hold on and stand up, and at around 12 months, they should be able to stand alone. Fine motor skills involve using small muscle groups. These muscles are used for picking up objects, grabbing, feeding oneself, holding utensils. Oral motor development uses the mouth and tongue muscles for chewing, swallowing and talking.

Language This refers to the ability to communicate with others. For this, we need oromotor development and the ability to hear properly. Milestones for this are cooing, babbling, imitating words, and saying a few words. Under language development, there are:

Receptive Language Skills

Receptive Language Skills Babies understand language long before they start talking. They can follow words long before they can actually say them.

Expressive Language Skills When people talk about language delay, this is what they usually mean – that the child is not yet talking. If you are worried that your baby is not talking, it is important to rule out a hearing problem or an auditory processing disorder.

Social Emotional Social skills are a learned process for which parents are the most important role models. Social emotional development refers to the way the baby adapts to the world. She will smile in response to smiling, know her caregivers, reach out, laugh, imitate, play peekaboo, have stranger anxiety.

Cognitive/Intellectual This is how babies figure out the world. They absorb vast quantities of information, like sponges, on a daily basis. This is the ability to understand the cause–effect relationship between their actions and the environment. Milestones include the baby following people and objects in their field of vision, exploring toys, knowing how to get people’s attention and remembering frequent visitors. How your baby plays, learns to speak, acts and moves offers an insight into your baby’s development. There are checklists (given in the following pages) designed to identify developmental delays in babies. I have divided them in 2month slots and what the baby is supposed to have achieved by then. As I’ve said earlier, there is a range of period for the baby to achieve this.

2 months Gross and Fine Motor Skills

By the age of 2 months, your baby will be able to lift his head and chest from the bed when lying on his tummy.

Social and Emotional Development Gives the first smile, called social smile, along with eye contact. Expresses emotions like pleasure, anticipation and even discomfort. Begins to look at the parent and caregiver and maintain eye contact. Can briefly calm himself by bringing his hands to the mouth.

Language and Communication Turns to sounds and startles to loud sounds. Coos and makes gurgling noises.

Cognition Follows parent’s face. Follows colourful or large objects. Fusses for attention. Gets bored easily if activity is not changed.

Red Flags: When to get concerned and speak to your doctor Does not respond to voices or sounds. Does not follow your face. Does not smile. Cannot hold head up when placed on tummy.

Does not bring hands to the mouth.

4 months Gross and Fine Motor Skills Holds head steady, unsupported. Pushes down on legs when feet are on a hard surface. Able to grasp a toy and shake it. Brings hand to mouth easily. When on tummy, able to push up on elbows.

Social and Emotional Development Smiles spontaneously, especially at people. Plays with people and may cry when stopped. Copies movement and facial expression.

Language and Communication Babbles, babbles with expression, and mimics sounds. Cries in different ways to denote hunger, pain, or just being tired.

Cognition Able to express if she is happy or sad. Responds to affection. There is hand–eye coordination, able to reach out for things she can see.

Moves eyes side to side to see moving things. Recognises familiar people from across the room.

Red Flags: When to get concerned and speak to your doctor Does not smile at people. Does not vocalise. Head is not steady. Does not push when made to stand.

6 Months Gross and Fine Motor Skills Rolls over – both front to back and back to front. Sits with support and tripod sitting (supporting herself with her arms between her legs). Stands with support and is able to bounce. When on tummy, will end up going backward instead of moving forward. Grasps things with the palm (palmar grasp). Able to transfer objects from one hand to another.

palmar grasp

Social and Emotional Development Able to recognise familiar faces and knows if someone is a stranger (stranger anxiety). Likes play time, especially with parents. Looks into the mirror. Often happy, and responds to others’ emotions.

Language and Communication Responds to sounds by making sounds. Makes babbling noises like ‘aah’, ‘eh’, and will look around to parent for approval. Starts to respond to own name. Makes sounds to show joy or displeasure. Starts to say consonant sounds (eg., ‘b’, ‘m’, ‘d’).

Cognition Brings objects to mouth. Shows curiosity and tries to reach out for things.

Red Flags: When to get concerned and speak to your doctor Shows no affection for caregivers. Does not try to reach out for things that are within reach. Does not respond to sounds. Does not vocalise (even incoherent noises). Does not roll over. Seems very stiff with tight muscles. Not sitting. Appears like a rag doll, no head control. Does not make squealing sounds or laugh.

9 Months Gross and Fine Motor Skills Stands with support, able to pull herself up to a standing position. Can sit up while lying down. Sits without support. Has started crawling. Picks up with thumb and fore finger (pincer grasp).

PINCER GRASP

Social and Emotional Development Tends to be clingy with familiar people. Afraid of strangers. Has favourite toys.

Language and Communication Understands ‘no’. Makes different sounds (eg., mamama). Copies gestures and sounds. Points at objects.

Cognition

Drops things and watches them falling. Looks for objects that you have hidden. Plays peekaboo. Transfers toys from one hand to the other. Explores objects by tasting, throwing.

Red Flags: When to get concerned and speak to your doctor Not crawling. Is not sitting unsupported. Does not bear weight on legs with support. Does not babble. Does not play games involving back-and-forth play. Does not respond to own name. Does not seem to recognise familiar people. Does not look where you point. Does not transfer toys from one hand to another.

1 Year Gross and Fine Motor Skills Gets to a sitting position unsupported. Pulls up to a standing position and able to walk holding furniture (cruising). May stand alone. Mature pincer grasp, able to hold a crayon (most often in tight fist). Attempts to build a tower with 2 blocks.

Social and Emotional Development

Is shy with strangers. Cries when parents leave (separation anxiety). Comes when called. Has favourite toys and people. Shows fear in certain situations. Cooperates with dressing. Calls out to get attention. Plays by herself.

Language and Communication Follows verbal commands (e.g., will come when called). Uses gestures (e.g., for no and bye-bye). Says ‘mama’ and ‘dada’. Tries to imitate your words. Vocalises to music.

Cognition Explores things in different ways like shaking, banging and throwing. Finds hidden things easily. Looks at objects when named. Starts to use things correctly, like combing hair and drinking from a cup. Puts things in a container. Copies gestures. Points with index finger. Follows simple instructions (e.g., pick up a toy).

Red Flags: When to get concerned and speak to your doctor

Red Flags: When to get concerned and speak to your doctor Does not crawl. Cannot stand when supported. Does not search for things you hide. Does not say ‘mama’/‘dada’. Does not point. Does not learn gestures like waving. Doesn’t use previously learnt words, or loses social milestones.

Developmental Milestones: The First 2 Months Initially, babies appear to only sleep and eat and poop all day, but this is far from the truth. They are continuously processing information. Their immature nervous system is slowly developing, and these are what we call milestones.

Newborn Reflexes Babies are born with certain reflexes, like sucking and rooting, through which they quickly know how to feed from the breast. If you place things in their hand, they will grasp it – this is the grasping reflex. Moro reflex is when you gently drop their head back, they will flail their arms out and open their eyes. These are what the doctor will check when your baby is born. These reflexes disappear by 5 to 6 months of age.

Motor Skills Newborn babies have extremely poor head control. This slowly improves over the coming months. They should not show any hand preference and should move both sides equally.

Vision

Babies are not born with great vision, nor are they blind. They can only see clearly less than a foot in front of them. So it’s important that you bring your face close to your baby’s face when you are talking to him. Babies appreciate contrast. By the time they are 2 months old, they are able to see 2 ft in front of them. They will fix their gaze on an object, like your face, and follow it should you move it side to side.

Hearing Newborns can hear well; they have heard you when they were inside the womb and they recognise their parents’ voices.

Social By 2 months, they develop a social smile, especially when they can see your face.

Language Initially, they only cry to have their needs met, but by 2 months, they start cooing and occasionally laugh.

Frequently Asked Questions

Q How can I boost my baby’s development? Spend a lot of time with the baby. Give the baby interesting toys or just your face to follow. Sing to your baby, use rattles or music boxes and musical toys with soft, soothing music like lullabies. Research has shown that babies are soothed by classical music. It has a more complex musical structure. Babies as young as

3 months can pick out that structure and can recognise music that they have heard before. Listening to any kind of music helps build music-related pathways. It also has positive effects on one’s mood that makes learning easier. I leave it to you parents to decide what music you want to play. But to name a few: ‘Rock a bye, baby’, the Beatles song ‘Good Night’ that John Lennon wrote for his son, ‘Lakdi Ki Kathi’ are good ones to sing to your baby. Most nursery rhymes can be sung as a lullaby. Choose any lullaby you may remember from your childhood and don’t worry about not having a melodious voice – your baby will not be a harsh critic. Give your baby tummy time a few times a day – this will help develop her shoulder and tummy muscles and go a long way in steadying the head. Tummy time literally means giving your baby time on their stomach while they are awake and you are there with them. Babies don’t like it at first because it is hard work, but please persevere. It also prevents the back of the head from flattening. If the baby’s head is left in the same position for long periods of time, it creates a flat spot as skull bones move in a certain way. Tummy time can also help babies build strength needed for sitting up, crawling, rolling over and even walking. You can leave some interesting age-appropriate toys within easy reach. Never leave your baby unattended during tummy time. It’s never too early to start reading to your baby. Set aside a time every day so that you can carry on till they can read the books themselves.

QCan I use an infant carrier? Of course! Most carriers provide good support to the head. You can use it and have your hands free to do other things, like when you have to go grocery shopping.

QMy child is cross-eyed. Is this normal?

Babies at this age appear to squint when they are focusing. This is because they have weak eye muscles which strengthen with time. Squints can be diagnosed only after 6 to 9 months of age. But if an eye turns inwards while the other is outwards, then you need to speak to your doctor.

Q I am worried that my baby will develop bow legs if I make her stand up and bear weight. What should I do? You can make her stand up – with you supporting her, she will not become bow-legged.

Q What are the milestones I should expect during this time? Head control should be pretty good by 3 months. If your baby has been doing good tummy time, she should be lifting her head well when she is on her tummy. Babies will not be rolling yet but will be able to bear weight on their legs. Your baby will try to reach out with her hands and, by 4 months, will be able to grasp at toys with a palmar grasp. She may reach out and pull your hair and earrings. So, watch out!

Q What stimulation can I provide for the baby during this period? Activity gyms are fun at this stage. Babies can remain engaged in them for some time so you can do your chores while keeping an eye on the baby. Tummy time continues to be important – it helps the baby roll over quickly. I cannot emphasise enough how important it is to read to your baby even at this age. Reading to him stimulates the baby’s brain. It is important that you read to the baby, so that he can hear your voice (as opposed to the TV or Alexa).

Developmental Milestones: 4 to 6 Months Gross Motor You will be able to make your baby sit, and she will support herself with her hands between her legs (tripod sitting).

Fine Motor Your baby’s grasp will improve. He’ll use his fingers more now, rather than just his thumbs. He will be able to transfer his toys from one hand to the other. He would have learned to start eating semi-solid food. He will be able to take the food from the front of his tongue to the back and swallow food.

Language Your baby will now start to make recognisable sounds, like ‘baba’ and ‘dada’. He will turn to your voice when you’re talking to him.

Social Your baby will be aware of her surroundings now. For instance, she will be familiar with her room.

Frequently Asked Questions

Q My baby is sitting up but did not really roll over. Should I be concerned? Because of SIDS, or sudden infant death syndrome, and the slogan ‘back to sleep’, a lot of children are spending less time on their tummies, so they may manage rolling over and sitting only by 6 months of age.

QHow do I help my baby’s development during this period? Gross motor: You can make your baby sit more during this period and give her more floor time so that she can practise the rolling. If you haven’t childproofed your house yet, make sure you spend some time now removing hidden dangers. Fine motor: As your baby is going to put everything in his mouth, give him large toys that he can explore; noisy toys are fun too. Just make sure that the volume of the toys is soft and the sound soothing. Loud, noisy toys can have a negative effect on his hearing (not to mention your sanity, as well). Language: Continue reading. You can also get waterproof books that you can read in the bath; textured books (touch and feel) are fun too. Social: Babies love spending time looking at the mirror. Encourage that! Babies like looking at faces. They like looking at their reflection and will try reaching out to touch the baby in the mirror.

Developmental Milestones: 6 to 9 Months Gross Motor During this period, the main milestone is moving around. This is the time when your baby is trying to figure out how to get to places. She may do this by rolling, crawling or cruising – which she will do with the help of furniture for support. Some babies skip crawling altogether; they may go from lying to sitting and then to standing using support.

Fine Motor The grasp gets finer, and he will be trying to perfect the pincer grasp using his thumb and forefinger. Dirt and dust on the floor that you cannot see will become very interesting for your baby. This grasp is what he will use when you offer him

finger foods at this stage.

Language Babies will be saying ‘dada’ and ‘mama’, but will not use it appropriately. She will understand you most of the time by now; her receptive language develops earlier than her expressive language. She will understand the word ‘no’.

Social/Cognition Around this time he will start appreciating object permanence (that things are still there even if you can’t see, hear or touch them). He will know when you have left the room and therein starts separation anxiety. Stranger Anxiety starts at this time. Your baby will follow you around and will want to be with you all the time. Don’t get too upset by this as this will also pass. He will start waving bye-bye and smiling at people from the safety of your arms.

Q When can I start using a walker? The AAP strongly discourages the use of walkers. Canada banned them over a decade ago. Using a walker, a baby can get around very quickly and end up banging into things. Injuries, including head injuries, are very common. There have been instances where babies have tumbled down stairs while using a walker. So, a walker is not a good idea. I actively discourage a walker, but find that parents have already got one even before the child has started rolling over!

Q What developmental stimulation can I provide during this period? Gross motor: As I said earlier, this whole period is about mobility. It’s important to provide a safe environment so that your baby can practise her skills without harm.

Fine Motor: The toys you get for your baby must be safe. They should not have small pieces that can come off (these are choking hazards) and should not have sharp edges. Babies love toys with sounds and light at this age. Objects from your kitchen, such as containers and wooden spoons, are useful to keep them amused. Language: If you have been reading to your baby right from the start, she will be eager for more now. Buy board books as she will put even books into her mouth. When you speak to her, use single words and short phrases – for example, if you think she wants water, just say ‘water?’ Social: This is the time to play peekaboo or hide a toy and wait for your baby to find it, because he has learnt/developed object permanence. He will also start to imitate your response to situations around this time.

Developmental Milestones: 9 to 12 Months Gross Motor Your baby will be able to stand with support or by holding your hand. He will be able to pull himself to a standing position, and it’s important to make sure the cot sides are up when he is sleeping. He may surprise you by standing up on his own, holding the railings, one day. Your baby may not be walking on his own by the time he is 1 year old. Most babies walk by 15 months of age.

Fine Motor Her pincer grasp has been perfected and she will be picking up stuff from the floor that you cannot see. She will be pointing quite well to try and make herself understood.

Oromotor He should be drinking from a cup now. Though most parents move to a sippy cup, there is no real reason why the baby should not be drinking from a real cup.

He can be taught to use a straw as well. Usually, by 1 year, babies should be drinking milk from a cup rather than from a bottle.

Social/Personality Around 1 year of age, babies get very good at non-verbal expression. They are able to point and grunt to express what they want. She may get frustrated when she is unable to express herself, which improves as her expressive language develops.

Anxiety Separation anxiety is seen around this time and also at around 18 months. So if you have to leave your baby behind and step out or are going to work, explain to him that you are going out and will be back shortly and give him a hug. Don’t just slip away.

Language Your baby will start calling you ‘mama’ and know the meaning. Little girls may have more of a vocabulary at this age. They could keep jabbering in a language that you don’t understand and even have a long conversation. They start to imitate your actions. If you are dusting, then you may find your little one alongside, giving you a hand. Your baby will want to be independent and now is the time to start discipline. He will want you to be around for consultation and reassurance. This is the time babies start developing an ego. You can boost his self-confidence by offering praise when he does something right.

Frequently Asked Questions

Q My 11-month-old son is not saying a single word. Should I worry? Girls nearly always talk earlier than boys and the reverse is true for motor

milestones, which are achieved earlier by boys. Girls are talkers, boys are walkers. When they are around a year old, they start imitating sounds and understand simple instructions. But if your 1-year-old is not showing any signs of non-verbal communication, then he needs to be assessed. You can talk to your child about what you are doing and where you are going. You can sing songs together other than play it on screen. Practise counting with your baby. Most children can acquire two languages simultaneously. So, if you want your child to know more than one language, it is best to start at an early age, before your baby even starts to learn the first language.

Q Ours is a multilingual household and the baby hears three different languages. Is this confusing for her? Will she end up speaking late? Experts suggests that the best way to maintain bilingualism is to compartmentalise the languages, separating how and with whom each language is used. A child who is developing language normally should be able to master many languages, regardless of the way she is exposed to them as long as the pattern of exposure is clear and consistent. For example, a child could use only Hindi with her mother and English with her father, or

Hindi at home and English outside the home. If you adhere to this routinely, the child will not get confused and speak the appropriate language in each case. Do what comes naturally: If a parent is comfortable with a language, use it. Contrary to popular myth, the more solid a base the child has in his first language, the easier it will be to pick up the second language. Evidence indicates that bilingualism does not cause language delay. The priority should be to preserve the home language, if at all possible.

QHow can I encourage development at this age? Gross Motor: You can have an area in your baby room, or outside, which is safe for your baby to roam around in without harming herself. You can get her toys that she can push around. Fine Motor: Stacking toys and shape-sorting toys help in development at this stage. Pat-a-cake is a good game to play with your baby now. Social: As your child loves to imitate you, while you are cooking, give him a couple of pots and pans to do pretend cooking. Babies will keep themselves amused like that; the same goes for when you are dusting – you will have a little helper. Your baby will be able to recognise body parts, so you can teach him to find his eyes, nose, mouth. Language: Books and more books. I cannot emphasise this enough. Use picture books and read at mealtimes and at bedtime. Reading will help in developing your baby’s vocabulary.

QWhen should I buy shoes for my baby? Ideally, babies should be allowed to go bare feet when at home, as they use their toes to grasp the floor. When they start walking outside, you can buy shoes. The shoes should fit well and not be too tight or too loose.

Babies and Social Media

Q I have been told that we can use media to teach our children things – at what age should I start this? For children less than 18 months of age, the AAP discourages any screen time, except video chatting. Parents of children 18 months to 2 years who want to introduce digital media should use high-quality programmes and watch them together, as this is how children learn. Despite this recommendation, 90% of American kids under 2 watch a significant amount of TV every day and many have TV sets in the bedrooms.

Why screen time is bad for your baby Watching TV or digital media hardly involves any physical activity. Your child is usually sitting in a chair in one place. When she starts school, she will be spending a lot of the day sitting in classrooms, anyway. As increasingly younger children are going to schools of various kinds, they end up leading a very sedentary lifestyle. So, children who watch too much TV are heavier and prone to childhood obesity. Other activities are forsaken for screen time. Children spend less time playing on their own, with their family or with other children. This is important for your child’s development – I know you cannot spend all day with your baby, but he should learn to play independently. Babies develop imagination and problem-solving skills when they are by themselves. One has to understand and comprehend what one is watching for it to be of any educational value. Educational programmes are of value when they are understood, and that happens to most children around 18 months to 2 years. This is more so if a parent is sitting with the child and explaining things to the baby. Most of these educational videos

have no research backup to say they are beneficial. So, using a tablet or smartphone when your child is eating for the sole purpose of distracting him is not such a good idea. Screen time reduces the talk time between a parent and the child, especially when the parent is doing a household chore with the baby by her side. A lot of what is on TV is inappropriate, especially violence; there is a lot of violence even in cartoons. Studies have shown that excessive TV watching leads to poor attention span, affects cognitive development and speech and can cause language delays. Most of the baby’s brain development happens in the initial 2 years of life. That is why it is important to explore the environment and experience many sights, sounds, tastes and textures. Interacting and playing with other children help them learn about the world around them. But in today’s world, it can be very tough to keep away babies and toddlers from TVs, tablets, smartphones and computers. Excessive screen times leads to excessive stimulation and, hence, sleep disturbances. As your child gets older, set a limit to screen time and adhere to it. Absolutely no screen at mealtimes. Most of the time, the child is unaware of what she is eating and does not realise when she is full. This can lead to obesity later on. Most of these online videos for children have good marketing tactics. They make you believe that they will make your baby brainier. However, spending time with your baby and talking to her has far more potential to make your baby smarter. Try not to watch your favourite TV show while your child is playing. Quite often, babies keep glancing at the TV. Resist going on your smartphones to check social media, WhatsApp and email while playing with the baby. Be a good role model for your child. Dr Dimitri Christakis, Director of Child Health, Behavior and Development at the Seattle Children’s Research Institute, University of Washington, Seattle, says, ‘toddlers need laps more than apps’. There are many great interactive apps that you can jointly engage in with your

baby, but apps cannot replace toys. Putting one block over the other cannot be learned on an iPad/tablet. Babies learn a lot through touch and feel, so encourage your baby to play with toys.

AGE-APPROPRIATE TOYS Birth to 6 months: Bright-coloured rattles, soft blocks, play mats and activity gyms and, not to forget, human faces. 6 months to 1 year: Safe toys that are harmless if children put them in their mouth, sorters, stacking cups, squeaky toys, push carts, 2- to 3-piece puzzles, music boxes.

Q How can I make my home safe for my crawling, walking baby? Childproof Your Home All electrical points within the baby’s reach to be covered. You can buy electric socket plug cover guards prior to the arrival of the little one. All wires (TV, telephones, chargers) to be moved beyond reach – some can even be tucked away behind furniture. Locks on cabinets that contain knives and other sharp utensils. Locks on cabinets that store cleaning substances and repellents. With sharp corners, one needs safety bumpers. You can either use foam sheets to cover sharp edges or stick readily available corner guard and edge protectors to avoid the baby from bumping into these and hurting himself. If you have a water dispenser at home, make sure the hot water is turned off. If you have a puja room, make sure the lamp and incense stand are high up. If you have dropped something on the floor, pick it up immediately. All medicines should be kept in a locked cabinet. Install a safety gate at the top and bottom of stairs and at the kitchen entrance.

If you live in a high-rise building, make sure the windows and balconies have safety grilles and that the furniture is placed away from the windows, as toddlers can climb easily on to the windowsill. Make sure your blinds don’t have long cords, as this is a strangulation hazard. Secure your TVs and bookcases so that they don’t topple over. There are brackets available especially for this. Your bathroom door should be kept shut as children love to explore. Remember, babies can drown even in a small amount of water. Change the settings of the hot water in the geyser to below 50°C, as toddlers have a fascination for knobs and are likely to play with the hotwater tap. I have seen many children being brought to the emergency with hot-water burns.

Temperament and Behaviour You are now ready to embark on a lifetime of disciplining your baby. For that we need to figure out the baby’s temperament. Temperament is your baby’s behavioural style which determines how she reacts to a situation and expresses emotions accordingly. The characteristics of a baby’s temperament emerge very early in life and they become more stable as the baby gets older.

QWhat are the characteristics of temperament? In the 1960s, some psychologists in New York started the largest study of temperament ever conducted. It ran for 3 decades and assessed 133 babies from the age of 3 months until adulthood. At the end of the study, they came up with 9 intensities of reaction (based on how intense the baby’s responses and emotions are): Sensitivity: How sensitive the baby is to flavours, textures and noises.

Adaptability: How the baby adapts to new situations. Quality of Mood: Whether the baby has a happy, positive disposition most of the time or an unpleasant, negative mood most of the time. Psychologists have analysed children into four groups: easy child, difficult child, slow-to-warm-up child and the rest.

Easy About 40% of children will fall into this category. These children have an easy temperament, meaning that they readily approach and easily adapt to new situations. They react mildly to things. They are regular in their sleeping, waking and eating routines and have a positive overall mood. Easy babies make their parents feel they are doing a great job.

Difficult The term ‘difficult’ has negative connotations as it overlooks valuable behavioural traits such as assertiveness, persistence and decisiveness. Other words such as ‘feisty’ and ‘spirited’ have been suggested because they sound positive. Approximately 10% of all children fall into this category. These children withdraw from, or are slow to adapt to, new situations. They have intense reactions and irregular routines. They tend to have long and frequent crying episodes. Parents of these ‘difficult’ children question their childcare abilities and wonder what they are doing wrong.

Slow-to-Warm About 5% to 15% of children are slow-to-warm in that they withdraw from or are slow to adapt to new things; they have low activity levels and show a lot of negative mood. They don’t like to be pushed into things and are frequently thought of as shy and sensitive.

The Rest

About 35% to 40% will have a combination of all the categories.

Frequently Asked Questions

Q I have an extremely active baby. Is he going to develop attention deficit disorder? A diagnosis of Attention Deficit Disorder (ADD) is based on the shortened attention span of a child when compared with others. Children under 1 don’t have the capacity to pay attention to anything for very long. This diagnosis can be made only in children older than 3 years.

Q Why is my baby crying so much? Babies cry because that is the only way they know how to communicate. The average baby cries for 1 to 4 hours. It is your job to figure out why your baby is crying. As you are spending most of your time with the baby, you will soon figure out the different reasons for why he may be crying.

Common Reasons Why Babies Cry Sleepiness or fatigue Wet or dirty diaper Hunger Overstimulation from noisy activity Pain or illness Fever Babies can also cry if they are too hot or too cold. And sometimes it may just be that all they want is a cuddle.

Soothing a Crying Baby

Swaddling: wrap your baby in a blanket so that she feels secure. Side or stomach position: hold your baby in such a way that she is on her side or stomach. But when going to sleep, she must be on her back. Shushing: create a ‘white noise’ that drowns out other noises like a fan, hair dryer or clothes drier. Sucking: let the baby suck on something like your finger. Give your baby a bath. Give your baby a massage. Take a walk with your baby in a stroller.

QCan I use a pacifier to soothe my baby? The decision to use a pacifier is yours. I will give you a few dos and don’ts and tell you how to help him break the habit if you decide to use one. Most babies have a strong sucking reflex. Some babies suck their thumbs or fingers even before they are born and are found to have sucking blisters at birth.

The Pros A pacifier may soothe a fussy baby. Some babies are happiest when sucking on something. A pacifier may help some babies fall asleep. If your baby has trouble going to sleep, the pacifier may do the trick. But the pacifier has no impact on a baby’s length of sleep or night-time awakenings. A pacifier offers temporary distraction. It may come in handy after vaccinations and blood tests. A pacifier may ease the discomfort during flights. Sucking on one helps to relieve ear pain on the flight.

The Cons

Early pacifier use may interfere with breastfeeding, as sucking on the breast is different from sucking on a bottle. There are studies that have shown that the use of a pacifier leads to less frequent breastfeeds or the stopping of breastfeeding after a few months. Your baby might become dependent on the pacifier. If your baby uses a pacifier to go to sleep, you may see frequent nighttime crying when the pacifier falls out. Pacifier use leads to tummy infection. In a country like India, where gastroenteritis forms a large chunk of childhood illness, the pacifier is a big source of infection. (Since the pacifier is likely to fall out of the baby’s mouth or hand and is picked up and used again without sterilising.) I have seen mothers put the pacifier in their own mouth before giving it back to the child, little realising that their mouth has an abundance of bacteria. Prolonged pacifier use can cause dental problems like misalignment of teeth.

Pacifier Dos and Don’ts If you choose to use a pacifier, keep the following in mind:

Wait until breastfeeding is well established. You don’t want to create nipple confusion. The AAP recommends you start using one when your baby is around 4 weeks of age. Don’t offer the pacifier as the first line of defence. A crying baby can be soothed by either being picked up or by rocking. Offer the pacifier after a feed or in between feeds. Choose a pacifier that is silicone and one piece. It should not be a choking hazard. Keep it clean. Under 6 months of age, your baby’s immune system is not well developed. Sterility is of utmost importance. Keep a few

pacifiers so that you can sterilise frequently. Don’t use sugar or honey on the pacifier.

Ideally, your baby should be off the pacifier by 6 months, as continuing it longer makes the baby prone to ear infections. This is what the AAP recommends. Though there is no hard and fast rule about when to ditch the ‘binky’, after 9 months, babies develop an emotional attachment to the pacifier and it gets harder to stop. After this age, be prepared for more protests – it gets even more difficult to get rid of it. These children develop lip-sucking and tongue-thrusting. This can alter the growth of the mouth and teeth, which makes future orthodontic work more difficult.

Q What is worse, thumb sucking or a pacifier? Nearly half of all children suck their thumbs, some starting even before they are born, leading to a sucking blister at birth. Ultrasound pictures of intrauterine life have shown foetuses sucking their thumbs. One way that infants explore the world is by putting everything in their mouths. Sucking the thumb is soothing for the child and many children continue this habit for comfort and security well into early school years. Most children give up the habit by 4 years of age. Thumb-sucking by itself is not a cause or symptom of physical or psychological problems. It is not known why some children suck their thumbs for longer. The literature regarding orality in the first year of life indicates no sex difference but suggests that, beginning with the second year, girls are more likely than boys to suck their thumbs. While thumb-sucking offers security to the child, it does not imply that the child is insecure. Most children have some sort of self-comforting ritual that may involve sucking the thumb, finger or pacifier, pulling or twisting hair, stroking or sucking a soft toy or blanket. These are all normal habits of infancy that children outgrow. These days, doctors find a few negative health effects of thumb- sucking,

even if prolonged, and parents are urged to let their child outgrow the habit on their own. Thumb-sucking may be more of a problem for the parent than the child. If the parent is unsettled by the behaviour, weaning a child from sucking her thumb before she is ready is usually difficult and may prolong the habit.

How to Stop the Thumb-Sucking Habit Sometimes, not paying attention to thumb-sucking is enough to stop the behaviour. If that does not work, you can try any of the following: POSITIVE REINFORCEMENT Praise your child or offer a reward, like an extra bedtime story or a trip to the park, when he is not sucking his thumb. Set attainable goals such as an hour before bedtime mark a star on a chart on the days he does not suck his thumb. IDENTIFY TRIGGERS If your child sucks her thumb in response to stress, then you need to identify the real problem and provide comfort in some way, such as a hug or reassuring words. You can give her a pillow or soft toy to squeeze. OFFER GENTLE REMINDERS If your child is sucking his thumb without thought, gently remind him to stop. Don’t scold or ridicule your child. I don’t think applying bitter substances like neem juice or castor oil works.

Tips: Coping with a Crying Child Break it up. Get family or friends to come and help out so that you can take a break and get some sleep. If you don’t have help, it’s good to step out for a while leaving the

baby in the crib for 5 to 10 minutes. Step out of the room or go to the balcony to calm down. Use white noise, like the vacuum cleaner, and put the baby in a sling and clean the house or step out for a walk. Get professional help if you cannot take it any more. This is not a sign of weakness.

Discipline As a parent, one of your jobs is to teach your child to behave. It takes time and patience, but you need to learn effective and healthy strategies. Discipline in its simplest form can start around 9 months of age. At this age, traditional methods like time out (see p. 215) do not work. Setting limits, reinforcing good behaviour and discouraging bad behaviour should start when your child is a baby. Because little children have limited language comprehension, memory and attention spans, the best strategies are more about damage control than about teaching discipline. Around 9 months of age, your baby is exploring her surroundings so, inevitably, everything goes into her mouth. She has figured out how to get a reaction from you, so when she pulls your hair and you shout, she will do it again. She constantly wants your attention, so she will be upset if you are working and don’t give her any. She wants independence and will want to feed herself even if she has not developed the skills and will end up feeding her face and make a mess. Welcome to parenthood! Your job is to help your toddler understand what good and bad behaviours mean for your family. You need to develop the following: Communicate with respect so as to nurture a relationship with your baby. Speak your baby’s language – with little children, use single words and short phrases that they understand. Don’t be a pushover. Set boundaries.

You are building a support system that will guide your child down the path of her life. Set reasonable limits and your rules should focus on behaviour that should be stopped immediately. The bottom line is you must be consistent. If you live in a joint family, then all family members should be on the same page. This might be a bit difficult at first, but eventually things should work out. It’s important for grandparents to know that parents have the last word and that their actions should be in sync with that of the parents. Easier said than done, but you have to try, as the very same grandparents will not appreciate a rude and badly behaved grandchild. There have to be a few house rules for behaviours that are absolutely unacceptable. These could include touching the stove, pulling on cords, fingers in electric sockets, turning on taps, especially hot water, exploring the kitchen or the bathroom, pulling hair, hitting and biting. The American Mental Health Association describes 4 styles of parenting:

Authoritative Parent The authoritative parent has clear expectations and consequences or responsiveness towards his or her child. The authoritative parent allows for flexibility and collaborative problem-solving with the child when dealing with behavioural challenges. This is the most effective form of parenting. These parents are affectionate and supportive, and encourage independence. Their children are happy and content, are more independent and achieve higher academic success. The children develop good self-esteem and interact with peers using competent social skills. They have better mental health, and are less prone to depression, anxiety, delinquency, alcohol and drug abuse.

Authoritarian Parent The authoritarian parent has high expectations from children with little responsiveness but shows little affection towards the child. The parent may say things like ‘you have to do this because I say so’ or ‘because I am the mummy, that’s why’. This is less effective parenting. These parents use a strict discipline style with little negotiation possible. Communication is usually one way, from

parent to child. Rules are not explained. Expectations are high and there is limited flexibility. So, high levels of parental control and low levels of responsiveness are the two characteristics of authoritarian parents. Their children usually have an unhappy disposition and are less independent. They always appear insecure and possess low self-esteem. They don’t perform well academically and have poor social skills. They exhibit behavioural problems and are prone to mental illnesses.

Permissive Parent The permissive parent shows lots of affection but provides little discipline. These parents let the children do what they want and offer limited guidance or direction. They are more like friends than parents. Communication is open but they let children decide for themselves rather than give direction. Parents in this category are warm and nurturing. Expectations are typically minimal or not set at all. Children of these parents cannot follow rules, have no self-control and possess egocentric tendencies. They invariably encounter problems in relationships and in their social interactions.

Uninvolved Parent Uninvolved parents give children a lot of freedom and generally stay out of their way. Some parents may make a conscious decision to parent in this way while others are less interested in parenting or unsure what to do. There is no particular discipline style. The children of such parents are more impulsive, cannot self-regulate emotion and encounter delinquency problems.

Disciplining Techniques Reward Good Behaviour Acknowledging good behaviour is the best way to encourage your child to continue it. Compliment him when he shows the good behaviour you have been seeking.

Natural Consequences When your child does something wrong, you let your child experience the consequences. Here you don’t need to lecture, for example. If your child throws her cookie, she does not get to eat the cookie. If she breaks a toy, she has no toy to play with. Natural consequences can work well when children don’t seem to hear your warnings about the potential outcomes of their behaviour. But you must make sure that any consequence they may experience is not harmful or dangerous.

Logical Consequences This is quite similar to the one preceding, but here you are describing to your child what the consequences are for his unacceptable behaviour. So, if your child throws out all the biscuits from the tin, then he will not get biscuits for a week.

Time Out Time outs work if you know exactly what the child did wrong or if you need a break from the child’s behaviour. You should have established a location ahead of time. It should be a quiet, boring place, not the bedroom where he can play, or the bathroom, which can be dangerous. It can only work for children older than 18 months who can understand the purpose behind it. Time outs work best for younger children for whom separation from the parent is seen as a real deprivation. Pick your battles! Saying ‘no’ 20 times a day loses its effectiveness. Categorise into major, minor and those too insignificant to bother with. Focus on the behaviour, not the child, and always let the child know that it’s the behaviour that is bad and not the child. Similarly, praise good behaviour. It provides encouragement. Always end your intervention with a positive comment. Remind your child that you love her. Don’t yell. It’s not the volume of your voice but the tone that gets your point across. Be a role model. If you want a well-behaved child, you have to be well-

behaved.

Frequently Asked Questions

QIs it okay to spank my child if he is uncontrollable? Absolutely not! I never recommend using physical force to discipline your child. Your child learns from you. If you are violent when you are angry, your child will be too. The AAP says spanking may make children more aggressive and violent, as it causes them to think that it’s all right to physically hurt someone you love.

Q How do I deal with my 1-year old’s temper tantrum? Temper tantrums are very common in children aged 1 to 3. You might see crying, screaming, stiffening limbs, an arched back, kicking, falling down or running away. Some children hold their breath, vomit or get aggressive. Tantrums are one of the ways that young children express and manage feelings and try to understand or change what’s going on around them. There are things you can do to make tantrums less likely: Reduce stress. Tired, hungry and overstimulated children are more likely to experience tantrums. Avoid triggers: If your child might have a tantrum while shopping because she is tired, you should plan ahead or change the environment. For example, go shopping after your baby has had a nap and been fed. Stay calm or at least pretend to stay calm. When you speak, keep your voice calm and even, and act deliberately. Acknowledge your child’s feelings. This can help prevent the behaviour getting more out of control and give your child a chance to reset her emotions. Wait out the tantrum. Stay close to the baby, but try not to reason with

him or distract him at this time. (It’s too late once the tantrum has started, anyway.) Be consistent. If you sometimes give in when he has a tantrum and sometimes you don’t, the problem could get worse. Don’t think that your child is doing it on purpose or is trying to upset you. Children don’t have tantrums deliberately – they are stuck in a bad habit or don’t have the skills right now to cope with the situation. Keep your sense of humour, but please don’t laugh at the tantrum. If you do, it might reward your child with attention or it might upset him even more if he thinks you are laughing at him. If other people give you dirty looks, just ignore them – it’s either that they don’t have children or that it’s been so long since they had a young child that they’ve forgotten what it’s like. Don’t judge yourself as a parent based on how many tantrums your child has. Instead, focus on how you are going to deal with it – parenting is all about learning as you go along.

Q How do I stop my baby from playing with his genitals? Many toddlers have a habit of playing with their genitals. It’s called masturbation. Barring any medical problem, it’s completely normal behaviour. This is seen in both boys and girls and is part of normal development. Keep your voice mild and neutral, as scolding could cause long-lasting shame. It is amazing how quickly babies find their body parts and discover that it feels good to touch them. They even get erections, which are also normal. Toddlers don’t have that filter in place that tells them it’s not appropriate to touch their penis anytime and anywhere when the urge strikes. When it first starts, it’s important to rule out medical conditions like fungal infections or

dermatitis and worm infestation. If you suspect one of these, speak to your doctor. If you find your son playing with his genitals all the time or you’d like him not to do it in public, don’t call too much attention to it. Ask him to do something else to distract him and to use his hand to do something else, like giving a high five. If your toddler is nearly 2, you can explain to him that it’s ok to touch his penis and that he should do it at home, in his room or in the bathroom. Now is the time to explain to him that no one looks at his penis except for his parents and doctor. If the weather is warm, it could be a case of diaper rash. Change diapers frequently, use a rash cream and give the baby some diaper-free time.

QHow do I deal with my baby’s stranger anxiety? It is a normal stage of development and usually begins around 6 to 8 months of age. It peaks around 1 year of age and then gradually settles over the next few months. Around the time that stranger anxiety begins, the baby realises that the relationship they have with the people they spend the most time with (parents or primary caregivers) is different from the relationship they have with strangers. As they realise this, babies seek out the familiar and express distress around the unfamiliar. While stranger anxiety is normal, the intensity and duration of the distress experienced by any baby, along with the way this is expressed, varies from baby to baby. Some strategies to help your baby overcome this:

First, it’s important to recognise that every baby is different. Each baby will warm to new people at a different pace. When you recognise that your child’s hesitancy to interact with new people is normal, you will develop the patience it takes to help them move through the big emotions associated with stranger anxiety. Take practical steps, introduce anyone new to your baby gradually and not suddenly. Use a gradual warm-up strategy even with those close to you. Suddenly your little one may become anxious with aunts, uncles, grandparents and other family members. It can be challenging when your baby appears distressed in front of a doting grandma whom she has not seen for some time. Encouraging a gradual warm-up period to allow for their comfort will make these interactions more positive. Support your baby as he experiences these big uncomfortable emotions. Pressurising your baby to go with or be held by a stranger before he is ready can often increase anxiety and make the next time he meets a stranger even more stressful. Stay calm and be positive when your baby is distressed about meeting a stranger. Try to maintain a positive and comforting tone as you comfort her verbally and physically. You can talk to her and hug and soothe her to be more comfortable with the situation. Offer advice to eager friends and family; recommend that they speak in a calm tone. They can be prompted to give your baby a familiar toy to help ease introductions. Ask them to give your little one plenty of time to get comfortable before picking up and cuddling your baby. Introduce your baby to new people from a young age. Take walks in the park. Place the baby facing outside in the carrier (once it’s safe to do so) to allow him to see new and unfamiliar faces. You can also allow others to hold your baby from a young age, as long as you are comfortable with it. Stranger anxiety is normal. With the right balance of warmth and comfort, it typically passes before the child’s second birthday.

QHow do I deal with separation anxiety in my 1-year-old? Separation anxiety varies widely between children. Some babies will cry hysterically when her mother leaves the room even for a short time while others seem to demonstrate anxiety at separations during infancy, toddlerhood and preschool.

Facts about Anxiety Infants: Separation anxiety develops after a child gains an understanding of object permanence. Once your infant realises that you are really gone, it may leave him unsettled. Some babies display object permanence and separation as early as 6 months while most develop it around 9 months of age. The leave-taking can be worse if your infant is tired, sleepy or hungry. Toddlers: Many toddlers skip the separation anxiety in infancy and develop it around 18 months.

Babies’ behaviours at separations are often loud, tearful and difficult to stop.

How to Survive This Create quick goodbye rituals. Blow many kisses, give a soft toy or blanket as you leave, keep the goodbyes short and sweet. If you linger, the transition will too. Use the same goodbye ritual at the same time every day. A routine can reduce the heartache and will allow your child to simultaneously build trust in her independence and in you. Stick to your promise. You will build trust and independence as your child becomes confident in his ability to be without you when you stick

to your promise to return. Use your child’s language when you are being specific. When you discuss your return, provide specifics that your child understands. So instead of saying you will return at 3 p.m., say I will be back when you wake up.

Q My child holds his breath when crying. It really scares me. How should I handle this? Most of us have heard stories of babies crying and holding their breath and going blue. These spells are terrifying for parents because sometimes babies hold their breath till they pass out. A typical spell lasts less than a minute before the child starts breathing again. These episodes are not intentional. They are an involuntary reflex – the baby has no control over them. They may be upsetting to watch but they are harmless and pose no serious health issue. This is usually seen in healthy children, between 6 months and 6 years. There may be a family history as well.

Types of Breath-holding Spells Cyanotic breath holding spell: Here, while crying, the baby holds her breath and turns blue in the face. They are usually triggered by something that upsets the baby, like an injection at the doctor’s visit or being disciplined at home. Parents can usually tell when it’s going to happen, as the face gradually turns blue and then to purple. Pallid breath-holding spell: These are less common and unpredictable, and usually happen after the child has gotten a fright or been startled. Here they turn pale or white.

In both varieties, babies can stop breathing and lose consciousness and, in extreme cases, have a seizure. This will not cause long-term problems, neither will it lead to epilepsy in the future. Most of the time you don’t need to do anything. If your child passes out, keep him lying down. Make sure he does not have anything in his mouth that could pose a choking hazard when he wakes up. Although these are harmless, talk to your doctor if you are worried, just to confirm that these are indeed breath-holding spells. Sometimes anaemia (iron-deficiency) might cause kids to have breath-holding spells. Treating this with iron supplementation may reduce their frequency and severity.

Preventing Future Spells A challenge most parents face greater than witnessing a spell is finding ways to discipline the child without triggering a spell. Try not to give in to tantrums and stubborn behaviour. Young children need limits and guidelines to help them stay safe and become emotionally well-adjusted. If you want to win the battle, you cannot afford to give in to your precious baby.

Q My child is biting me! Help! Biting is a common behaviour among toddlers. Children bite in order to cope with a challenge or fulfil a need – for example, your child may bite to express a strong feeling like frustration or to communicate a need for personal space if another child is too close to him. Or he may do it to satisfy a need for oral stimulation. There are many reasons why toddlers bite:

They lack language skills necessary for expressing important needs or strong feelings like anger, frustration, joy. Biting is a substitute for words she cannot say like ‘I am angry with you’.

They are overwhelmed by sound, light or activity level in this setting. They are experimenting to see what will happen. They are overtired and irritable. They are teething. They have a need for oral stimulation.

Strategies to Prevent Biting If you see your child is on the verge of biting:

Distract him with a book or toy; suggest going for a walk. The aim is to reduce the tension and shift your child’s attention. If you feel your child may be biting because of the need for oral stimulation, offer your baby something to bite and chew, like carrot sticks, crackers or a teether. Suggest ways to share, especially toys. Not wanting to share is one of the most common reasons to bite. When they do bite, resist the temptation to scream. Calm yourself and count to 10 and in a firm matter-of-fact voice, say ‘no biting’. Comment on how the other child is feeling. Shift your attention to the child who has been bitten. Often, when a child bites, adults pay a lot of attention to him. This is negative attention, but it is still very reinforcing, and the biting habit can continue instead of stopping. But when you shift the focus to the child that was bitten, you are clearly communicating that biting does not get you more attention. Learning a new behaviour takes time and it may take some time for your baby to get the message.

Harsh punishment is not going to stop the biting but can lead to the opposite – increased biting. Biting your child back is also not a useful response. There is no research to show that it reduces biting. However, it does teach your child that it’s ok to bite people when you are upset.

Travelling with Your Baby Most couples who did a lot of travelling prior to the arrival of the baby are worried that this part of their life is going to be put on hold for a few years. Their friends tell them to get all the travelling done before the arrival of the baby. I would strongly disagree, as I did most of my travel in Europe after my first child was born. Yes, it requires some planning. Most of the stress involved is in getting to the destination; once you are there, it will all fall into place till it is time to head back. Just a small outing to a park needs 15 minutes of putting things together, so, obviously, it is going to take time to put things together for a longer trip. But my advice is to chuck the list, as travelling with a baby means being flexible and going with the flow.

Try not to overpack – the tendency is to throw everything into the suitcase, including the kitchen sink. Try and take things that your baby absolutely cannot do without. Many holiday places are baby-friendly and may arrange cots and strollers if informed in advance. Try and take the flights around your baby’s nap time. I am not in favour of giving medication to babies for ease of travel, unless they have a medical problem and medicines are required to calm them down. I get frequent requests for a sleep medication, which I routinely decline. Sometimes these medications make the babies more irritable and your start to the holiday will be one with a wailing child. Carry some basic medicine like paracetamol and anti-vomiting medicines, especially if travelling outside the country. You may not be able to buy them without a prescription. Your paediatrician may give you a list. Try to reach the airport or train station well on time but not too early, or the baby could become fussy and overtired. Use a stroller and, if you are going to be moving around on rough terrain, make sure you have a sturdy one. When booking your seat, get the front row if your baby is small, so

that you can have a bassinet where you can place her from time to time. Prepare for the worst-case scenario so that you have enough extra baby clothes, diapers, bottles and formula if you are not breastfeeding. Sometimes, a homestay may be more comfortable than a hotel. You can also do luxury with the baby – a lot of 5-star hotels in India and abroad offer baby-friendly services. Safety standards vary from country to country, so please check the room, especially the railings, to see that the baby cannot slip through. Try to stick to your own time zone when you travel with your baby. If you are staying longer, then by all means follow the local time, and babies being more adaptable will usually settle in 3 days. If you are doing a car trip and your baby is small, use a rear-facing car seat. A car seat is a must, but make frequent stops to change his diaper and for the baby to move his legs. Carry a bag with a few favourite toys and a new one that your baby has not seen, so that it keeps her occupied for some time. Travel at off-peak times so that it is less crowded. If your baby likes music, carry some with you. If you’re flying, try and feed your baby during take-offs and landings. This helps to equalise pressure in the ears as cabin pressure changes. You can ask the flight attendant to let you know when they start the descent. Parents want medicines, like diphenhydramine, to make the baby go to sleep. This is usually not recommended in babies less than 6 months and for short flights. If you would like to use it for long-haul flights, speak to your paediatrician. A word of caution: As the whole situation is unfamiliar to babies, the drug may have the opposite effect – it may make the child irritable and cranky and spoil your travel. If your child is recovering from an upper respiratory tract infection, you can use a saline nasal spray to clear his nasal passages. I get asked quite often about taking newborns outside the house. There are no hard-and-fast medical rules about how long one should wait before taking a newborn out into the world or letting outsiders near the baby. In fact, if it is not too hot or cold, you should feel free to take

your baby outside whenever you feel like – both of you may benefit from some fresh air. But in public places like malls and movie theatres, your little one may be exposed to infections that others around may be carrying. A newborn’s immune system is still developing and may not be able to fight off infections. I would recommend waiting for a few months before taking babies to public places. Currently, with covid infections, it is better not to venture out too often and go out when the park is less crowded. Limit visitors to the house and if they insist, make sure they wear a mask and observe social distancing.

If you do take your baby out, make sure she has had at least the first couple of vaccines.

Avoid exposing your child to people with a cough and cold. Anybody touching the baby should have washed their hands. Make sure your baby is adequately clothed.

Travelling in the Time of Covid-19 The Covid-19 pandemic has led to many questions from parents about travelling safely with children. The more informed you are about travel protocols, the better you can plan your trip. The three basic Cs – closed spaces, crowds and close contact – are to be avoided. If social distancing is not possible, then wear a mask. The outdoors is your friend and road travel is the best way to travel as it allows for less contact with other travellers. You need to check and see the incidence of Covid in the area where you are going. If the cases are increasing, you may need to reconsider your destination. If you are not feeling too well or if someone in your household has been

exposed, you may want to reconsider your travel plans. In the absence of clear guidelines about travel during Covid times and since the medical fraternity is still not very clear about many aspects of the illness, it is up to individual families to decide if travel feels right and safe for them.

Most airlines have high efficiency particulate air filters (HEPA) which filter out infectious particles and viruses from the air. Airborne viral infection on a plane is only possible if you are sitting next to a person who is infected and unwell. As long as everybody is wearing a mask, the chances of getting the infection are low. All major airlines now require everybody above 2 years to wear a mask. Carry disinfectant wipes so you can wipe down all surfaces around you. Some parents want to take their newborn to large gatherings so that the extended family can drool over her. It scares me when I see little babies out in a mall or at weddings. The first 2 months of your baby’s life are important as the immune system is weak and you don’t want to expose her to germs. You can take your baby out when you go for a walk or sit out in the garden or porch. Just avoid crowded places.

References AAP. (2015, 21 November). ‘Effective Parenting.’ Retrieved 15 June 2020, from https://www.healthychildren.org/English/family-life/familydynamics/Pages/Effective-Parenting.aspx AAP (n.d.). ‘Parenting.’ Retrieved 15 June 2020, from https://www.aap.org/enus/advocacy-and-policy/aap-health-initiatives/practicingsafety/Pages/Parenting.aspx Brown, A. & Fields, D. (2020). Baby 411: Your Baby, Birth to Age 1 (9th ed.). Boulder, CO: Windsor Peak Press. Cohen, G. M. & Albertini, L. W. (2012). ‘Colic.’ Pediatrics in Review, 33(7), 332–33. doi:10.1542/pir.33-7-332 Frank, B. N. (2018, 11 December). CBS 60 Minutes ‘Extra’ Segment Reveals

Research Confirming That ‘Toddlers Need Laps More Than Apps.’ Activist Post. Retrieved 15 June 2020, from https://www.activistpost.com/2018/12/cbs-60-minutes-extra-segmentreveals-research-confirming-that-toddlers-need-laps-more-than-apps.html Goldman R. D. (2015). ‘Breath-Holding Spells in Infants.’ Canadian Family Physician, 61(2): 149–50. Guyer, A. E. et al. (2015). ‘Temperament and Parenting Styles in Early Childhood Differentially Influence Neural Response to Peer Evaluation in Adolescence.’ Journal of Abnormal Child Psychology, 43(5), 863–74. doi:10.1007/s10802-015-9973-2 Honzik, M. P. & McKee, J. P. (1962). ‘The Sex Difference in Thumb-Sucking.’ Journal of Pediatrics, 61(5): 726–32. Retrieved 15 June 2020, from https://doi.org/10.1016/s0022-3476(62)80345-x Thomas, A., Chess, S. & Birch, H. G. (1968). Temperament and Behavior Disorders in Children. New York: New York University Press. Thomas, A. et al. (1963). Behavioural Individuality in Early Childhood. New York: New York University Press. Victora, C. G. et al. (1997). ‘Pacifier Use and Short Breastfeeding Duration: Cause, Consequence, or Coincidence?’ Pediatrics, 99(3): 445–53. Retrieved 15 June 2020, from https://doi.org/10.1542/peds.99.3.445

10 Common Childhood Illnesses and Infections

In this chapter, I will give you an overview of some common childhood illnesses and the ways in which you can manage them at home, without having to speak to your paediatrician. We will divide these into bacterial and viral infections and also look at fungal and parasitic conditions that can cause itching in babies. Most illnesses in babies are viral illnesses that really don’t need treatment and get better on their own. Most parents and, unfortunately, some doctors too don’t realise this and feel the need to treat viral illnesses with antibiotics. Viruses are small germs, smaller than bacteria. They produce diseases by invading our cells and multiplying, finally leaving our body and infecting somebody else. The common cold is a viral illness, as is hand, foot and mouth disease. Some viruses, like the chickenpox, lie dormant. Once you have recovered, they lie in the nerve cells only to get reactivated in times of stress to produce herpes zoster. There are many species of viruses out there, and they live on surfaces for hours, which is why it is very important to wash hands frequently. Hand sanitisers with more than 60% alcohol content are most effective, but it is better to use them after changing diapers, or when you are out and about. The rest of the time, it is better to wash your hands with soap. If you have eczema or excessively dry skin, sanitisers will make it worse. Frequent use of sanitisers destroys our microbiome and leaves us prone to infections. So it’s better to use a moisturising soap. Let’s look at some common viral illnesses and what you need to know about

them.

Common Cold The common cold is spread by droplet infection when you sneeze and cough, and also from hand to hand. The virus that is responsible is rhinovirus. ‘Rhino’ in Latin means ‘nose’. There are many types of rhinoviruses. They usually enter the body through the nose and cause inflammation there. This is followed by fever, body ache and mucous from the nose. By the fourth day, you are at your worst, but it can take up to 2 weeks for the symptoms to clear. The mucous may turn green in colour, and even if it is not accompanied by fever, it is the same virus. The only treatment needed is paracetamol, for the body ache and fever. If your baby is miserable and saline nose drops don’t work, you can use a humidifier for short periods to loosen the mucous, as long as you don’t turn the room into a wet sauna. If you are using the humidifier, then it needs to be cleaned regularly, otherwise you will be spewing dust and germs into the room. You can place your baby at an incline by placing some rolled sheets or a pillow under the mattress. Sometimes, when you place your hand on the baby’s chest, you can feel a rattle or vibration. This is the air moving the mucous when your baby breathes. It is transmitted down to the chest wall and you can feel it. The baby is most contagious the day before she develops the symptoms and up to 3 days after when she has a fever. There is no magic potion to fix this condition and a parent or caretaker will have to take time off work to look after the child. Most colds settle with time and patience. Please don’t use antibiotics to treat a common cold. I’ve had instances when parents have used my prescription for an ear infection which needs an antibiotic to treat a cold. If you give antibiotics when it is not needed, you propagate antibiotic resistance in the community.

Influenza

Influenza or the flu is caused by a group of viruses that fall under the category of influenza A or B. Different strains of these viruses produce flu epidemics every year. The flu, though quite similar to the common cold, is far more severe and there is always a possibility of a secondary bacterial illness. (We’ll talk about bacteria later in the chapter.) It usually starts with high fever, body ache and chills, followed by a runny nose and cough. Some children may also have mild gastrointestinal symptoms like vomiting and loose potty. Your doctor will usually make a diagnosis from these symptoms after examining your baby. If a blood count is done, the white blood count may be low (4,000 or less, mainly lymphocytes) or in the normal range. Sometimes a nasal swab test may be asked for, to diagnose the flu. Swine flu or H1N1 is also a type of influenza. If diagnosed early, your baby may be prescribed an antiviral medicine. Otherwise, most flus need only paracetamol, fluids and plenty of rest to recover. The flu vaccine given every year for children over 6 months offers some protection.

Covid-19 Since 8 December 2019, an epidemic of coronavirus disease (Covid-19) has spread rapidly across the world. Studies since then have shown that it is likely to affect older men with comorbidities, and only a few infections were seen in children. It mainly happened in family clusters. One study from China found that out of 9 children affected and admitted in a hospital, 7 were female. Children of all ages can get affected with Covid, but all those who get infected don’t show any symptoms of illness. Scientists are still not sure why children react differently from adults. Some experts feel it may be due to other coronaviruses that spread through the community and produce common cold in children, and since children get frequent colds, their immune systems may be primed to provide them some protection again Covid-19. Another possibility is that children’s immune systems interact with the virus differently in comparison to adults’.

Newborns can get affected with Covid-19 during childbirth or after delivery, from a sick caregiver. If you develop Covid-19 prior to delivery or are waiting for the test results, you can feed the baby wearing a mask and make sure you wash your hands frequently. You can keep a 6-feet distance with your baby at other times. When these steps are taken, the chances of the baby getting Covid are very small. Research shows that only 2% to 5% of infants were infected from mothers who tested positive just prior to delivery. However, if the mother is severely ill with corona, she may need to be temporarily separated from the baby. Babies who test positive but are not symptomatic can be sent home with instructions that the caregivers frequently wash hands and wear a mask to protect themselves. They should be in frequent touch with the paediatrician through virtual consultations. Similarly, since infants less than 2 years cannot wear masks, they need specific protective measures. Adult caregivers should wash hands, wear masks, sterilise toys and clean tableware regularly.

Symptoms fever nasal congestion or runny nose sore throat shortness of breath or difficulty in breathing headache, muscle pain, fatigue nausea, vomiting, diarrhoea poor feeding loss of taste and/or smell conjunctivitis or pink eye If you suspect your baby may have Covid, call your paediatrician and keep the baby at home. If possible, keep the baby in a separate room. Your paediatrician will decide about doing a test for Covid. A nasopharyngeal swab is taken from the back of the nose, and it usually takes 24 hours to get the report.

Multisystem Inflammatory Syndrome in Children (MIS-C)

MIS-C is a serious condition in which some parts of the body, such as the heart, kidney, lungs, blood vessels, digestive system, brain, eyes and skin, get inflamed. The presence of Covid-19 antibodies in these children reveals a past Covid-19 infection, suggesting an immune-system reaction against Covid.

Signs and Symptoms high fever that lasts longer than 24 hours vomiting and diarrhoea pain in the stomach skin rash red eyes swollen, red tongue breathlessness fast heartbeat red and swollen hands feeling excessively tired headache and lightheadedness enlarged lymph glands Emergency warning signs that you need to take the baby to hospital or contact your doctor: drowsiness or inability to stay awake difficulty in breathing bluish discolouration of lips and face severe stomach ache

Tips: Preventing Covid-19 Most of you reading this book must be well aware of all the precautions one needs to take, but here they are again. The CDC and WHO recommend that you and your family:

Keep your hands clean. Wash your hands often with soap and water for at least 20 seconds. If you are unable to wash, use a hand sanitiser that contains at least 60% alcohol. Cover your mouth and nose with the inside of your elbow when you sneeze or cough, or use a tissue. After discarding the tissue, wash your hands. Avoid touching your face frequently. Have the children wash their hands after returning home. Teach them to wash with soap, especially between the fingers right up to the fingertips, including the thumbs and back of the hand. They can be taught to sing the ‘happy birthday’ song twice while washing their hands – that is around 20 seconds. Practise social distancing: Maintain a distance of 6 feet or 2 metres with anyone who is sick or has any symptoms. Go out only when needed and leave children at home, if possible. Avoid playdates during the pandemic. If other children are playing outside, try to keep a 6-feet distance. Clean and disinfect your home: Focus on everyday cleaning of surfaces that are frequently touched, such as tables, doorknobs, hardbacked chairs, switches, desks, handles, toilets and sinks. Clean areas that babies touch frequently, such as changing tables, bed frames and toys, among others. Use soap and water to clean toys that babies put in the mouth and make sure you rinse them well. Wash the baby’s bed linen and soft toys regularly. If your baby has Covid, caregivers must ensure they wash their hands well after changing diapers and handling toys. Wear a face mask: The CDC recommends face masks in public spaces, such as grocery stores, where it is difficult to maintain social distance. Children under 2 don’t need to wear a mask, and the same applies to children who have breathing problems or an illness that would prevent them from being able to remove the mask without help. Finally, don’t delay your doctor’s visits, especially with regard to

vaccines. Ensure they are done on time.

Bronchiolitis (RSV or Respiratory Syncytial Virus) This particular virus attacks the smallest branches of the respiratory tree called bronchioles. As these areas are swollen, they obstruct the airflow and cause wheezing. The smaller the baby, the more severe the illness is, as the breathing pipes are narrower in smaller babies.

Symptoms Fever and runny nose with fast breathing and wheezing. While some babies are quite comfortable even with the wheezing (happy wheezers), nearly 30% of babies who wheeze with RSV go on to develop childhood asthma. Diagnosis is usually made clinically, even though there is a test available to diagnose an RSV infection.

Treatment The treatment for RSV is symptomatic. So, your doctor will probably prescribe paracetamol for fever, and bronchodilators with a nebuliser or a spacer with a mask, if they are wheezing. Most of the time, babies need only nebulisation with 3% saline. Some hospitalised babies may need intravenous fluids and supplemental oxygen. These babies may remain contagious for up to 2 weeks. If babies are born extremely preterm with chronic lung disease, they are sometimes given an RSV antibody. This is given as weekly shots for 6 weeks in the RSV season; it is an imported medicine in India; hence, expensive and, sometimes, hard to come by.

Croup or Laryngotracheobronchitis This is a viral illness affecting the voice. The voice box gets swollen, making it more serious in smaller babies, as the airway gets narrowed, making breathing

difficult.

Symptoms It is usually bad for the first 3 nights. You may hear a high-pitched sound when the baby is breathing (stridor). You need to speak to your doctor when you hear this.

Treatment You can run a hot shower in the bathroom and sit there with your baby. The warm steam will help her breathe more easily. Oral steroids can help reduce the swelling in the voice box. Sometimes, racemic adrenaline is nebulised as a treatment to reduce the swelling – this is usually done in the hospital.

Hand, Foot and Mouth Disease (HFMD) This mild viral illness is brought on by a group of viruses called coxsackie.

Symptoms This usually starts with a mild fever which most parents are not aware of, reduced appetite, followed by a rash, as the name suggests, on the palms and feet. The rash may be initially flat or raised like pimples. Sometimes they may be around the knees and elbows and anus/genitalia. Babies develop ulcers in the mouth, especially on the palate, that can be quite painful. You may only realise this when the baby goes off food.

Treatment This is a very contagious illness and is spread through saliva, potty and fomites. Hence the common refrain of frequent hand-washing, as the virus can spread from the caregiver to the child, especially in day-care centres. As this virus affects the nail bed, your child may lose his nails a few weeks later – not to worry, they will grow back. As the nails fall several weeks later, both the parent

and doctor have often forgotten that the child had HFMD, so it comes as a surprise.

Herpes Stomatitis This is caused by the herpes simplex virus (HSV Type 1). Once you get a herpes simplex illness, the virus stays dormant in the body and produces cold sores around the mouth when you are down with any illness. Newborns can get herpes encephalitis which manifests soon after birth. They get this during the birth process. Most of the time, herpes encephalitis is from genital herpes or type 2 infection, but type 1 can also produce encephalitis.

Symptoms The viral prodrome (early symptom) is usually fever, body ache and numerous ulcers in the oral cavity. These are painful lesions and reduce oral intake, which leads to dehydration. Some children may need to get admitted to a hospital because of dehydration and need intravenous fluids.

Treatment Diagnosis is usually clinical and treatment is mainly symptomatic. If the diagnosis is made early – within 24 hours – then you can give the antiviral medication, Acyclovir. The infection is spread through saliva and contact of the lesion. So you can get the illness if somebody has a cold sore. It is very contagious and the infectivity period is usually the first week.

Viral Gastroenteritis The main viruses that produce gastroenteritis in infancy are rotavirus and norovirus.

Symptoms The symptoms are fever, nausea, vomiting and diarrhoea. The loose motions can be of a large volume and frequently lead to dehydration. These infections are very contagious and spread through infected stool and fomites.

Treatment The treatment is mainly oral rehydration. If that fails, the baby needs hospitalisation and intravenous fluids. Prevention is proper hand washing and hygiene.

Viral Exanthems This covers 3 viral illnesses, where a rash follows fever. These are parvovirus infection or slapped cheek, roseola and chickenpox.

Parvovirus or Slapped Cheek Another name for this viral illness is Fifth Disease or Erythema Infectiosum. It is caused by parvovirus 19.

Symptoms This produces a mild illness in young children with fever and body ache. As the fever subsides, a red rash develops on the arms, legs and face. The cheeks get very red, hence the name. Some older children may even develop joint pains. When pregnant women develop this illness, they sometimes remain asymptomatic, but it can affect the unborn foetus. This may lead to a miscarriage, or to a haemolytic anaemia and oedema or swelling of the foetus. It spreads primarily through saliva and respiratory droplets.

Treatment No treatment is required other than paracetamol.

Roseola or Sixth Disease This is probably one infection that the whole world has got at one point or another. It’s a herpes 6 virus, which is different from genital herpes. Once you have the infection, you continue to shed the virus. Babies under 6 months rarely get it as they have antibodies passed on from the mother.

Symptoms It usually starts with a fever over 102°F, with no other symptoms. As the fever is high with no symptoms, your doctor may order some blood tests and a urine examination to rule out a bacterial illness. In most cases, the fever breaks by the fourth or fifth day, and a rash breaks out all over the body, including the face. It may be quite subtle in some children, but in some cases can be quite dramatic.

Treatment It’s an easy diagnosis once a rash is out. The only treatment that is required is some paracetamol and keeping the baby hydrated.

Chickenpox This is another febrile illness characterised by a rash. The culprit is another herpes virus called varicella–zoster virus. Vaccines for chickenpox are now readily available. It can be given anytime after 1 year and a booster dose is given 3 months to up to 4 years after the first dose. After 2 doses, the chances of the illness are minimal and, if at all you get it, it is very mild. There is a chance of getting herpes zoster after chickenpox. It affects one area of your skin called dermatome. It is more painful than itchy. This can happen even after the vaccine, as the vaccine is a live one, though such cases are far less common.

Symptoms

The illness starts as a mild fever and body ache followed by a rash, which appears in the form of water-filled blisters or vesicles. They come in crops over 3 to 5 days. They are extremely itchy, then dry out, scab off and leave faint scars. The average number of lesions in the body is around 300 to 400. You can get a secondary strep skin infection on these vesicles for which, if extensive, your doctor may give the baby an antibiotic.

Treatment If chickenpox is diagnosed early, acyclovir can be given to shorten the course of the illness. Chickenpox is very contagious and the infection can spread 1 day before the lesions appear till all the lesions have crusted over and fallen off. These scabs are infectious as they contain the virus. The incubation period for chickenpox is as long as 21 days.

Mosquito-Borne Illnesses Dengue Dengue is characterised by fever, with debilitating generalised body ache and headache. An estimated 400 million dengue infections happen worldwide every year. Out of this, only 96 million show signs and symptoms of having the illness – the others are asymptomatic. Most of these cases occur in tropical countries such as India, South East Asia, Southern China, Taiwan, Caribbean Islands, Africa, Central and South America. This infection is transmitted by the bite of the aedes mosquito which has been infected by the virus. The mosquito is infected when it bites a person who has the virus in the blood.

Symptoms Dengue is characterised by a sudden onset of high fever, severe body ache,

pain behind the eyes along with joint and muscle pain, backache, fatigue, nausea and vomiting. A mild rash can appear 2 to 5 days after the onset of the fever. Sometimes, these symptoms are accompanied by bleeding from the nose or gums. Serious problems like dengue haemorrhagic fever may develop where damage to the lymph and blood vessels is accompanied by bleeding and hypotension. This can further progress to massive bleeding shock and even death. This is called dengue shock syndrome and tends to happen when children get a second or subsequent dengue infection or when they have a weakened immune system. Diagnosis can be made from a blood test – either the antigen test or antibody test.

Treatment Treatment is mainly supportive. Only paracetamol should be taken to bring down the fever. Aspirin and nonsteroidal anti-inflammatory agents like mefenamic acid or ibuprofen can increase the risk of bleeding. The main treatment is plenty of rest and fluids. But you must speak to your doctor.

Prevention Currently, there is no approved vaccine for dengue in India.

It’s important to use mosquito repellents indoors. Try and make sure your baby’s arms and legs are covered as much as possible. Try and get rid of places where mosquitoes can breed, like stagnant water bodies and old tyres, flowerpots that collect water. Change water in birdbaths and vases frequently, and keep the toilet lid closed.

Chikungunya This is another illness spread by the bite of an aedes mosquito.

Symptoms Symptoms usually begin 3 to 7 days after being bitten by the mosquito. The common symptoms are fever and joint pains, but you could also have headache, muscle pain and a rash. The joint pains can be quite severe and crippling and can last for months. Newborns tend to get the infection around the time of birth and it can be quite a serious illness as it can produce an encephalitis where it involves the brain. These children can then be left with residual neurological problems. With chikungunya, once you get the infection, the protection needed can be lifelong. The diagnosis can be suspected from the symptoms but can only be confirmed by a blood test.

Treatment Treatment is mainly supportive. The treatment here is only paracetamol until dengue is ruled out.

Malaria Malaria is transmitted through the bite of the female anopheles mosquito. These mosquitoes harbour the parasite called plasmodium, which causes malaria. After a mosquito bites you, the parasite is released into your blood stream. From there, they travel to the liver where they mature. Once they attain maturity, they re-enter the bloodstream and into the red blood cells (RBCs). Here they multiply and lead to the destruction of the blood cells. There are 4 types of malarial parasites that infect humans:

Plasmodium vivax

Plasmodium ovale Plasmodium malariae Plasmodium falciparum

The most severe form of malaria is caused by plasmodium falciparum. Death is higher in this form of malaria. Newborns can be affected from an infected mother (congenital malaria). Malaria can also be spread through organ transplant, blood transfusion and shared contaminated needles.

Symptoms Symptoms can develop from 10 days to 4 weeks after the bite. In some cases, it can lie dormant in the body for many months. The illness can manifest with the following symptoms: Shaking, chills, accompanied with fever Profuse sweating Headache Nausea, vomiting and diarrhoea Abdominal pain Fatigue, muscle pain Convulsions and even coma

Diagnosis A diagnosis is usually made after your doctor has assessed the history carefully. Your doctor will examine the baby to see if the spleen or liver is enlarged. Thereafter, some blood tests will be ordered to confirm if it is malaria and which type. These tests will also reveal if your baby is suffering from anaemia. Malaria also can have many life-threatening complications like brain swelling as seen in cerebral malaria caused by falciparum infection. Fluid can accumulate in the lungs, causing pulmonary oedema. Left untreated, or if not diagnosed on time, it can lead to multi-organ failure and even death. In severe infections, treatment is usually done in the

hospital. The drugs are given based on the type of malarial parasite causing the infection. Sometimes, more than 1 drug may be used, as these parasites develop drug resistance. In certain types of malaria, like vivax and ovale, the parasite can live in the body for a long time and produce frequent relapses. In such cases, a second medicine may be needed to prevent these relapses. The long-term outlook for drug-resistant malaria is poor. In these patients, recurrences and complications are frequent. There is no vaccine against malaria. You can use a mosquito net for your baby, but you have to make sure no mosquito gets into the net. Cover the baby’s skin with a mosquito repellent spray that has picardin or DEET. Ideally, babies under 2 months should not use insect repellent. It is better to wear full-sleeved clothes covering arms and legs to prevent the bites.

Bacterial Infections Bacteria are larger than viruses and, unlike viruses, can live on their own without a host cell. There are a lot of, what we call, healthy bacteria, which live on our skin and other parts of our body, like the intestine, mouth, nostrils and vagina. They do not produce disease. Some bacteria produce disease in certain children who have a problem with their immunity (immuno-compromised children, like those being treated for cancer, have a weakened immune system). Some bacteria may end up in the wrong place, producing an infection, like E-coli that produces a urinary tract infection but is otherwise a normal gut bacteria. They enter our body through openings and, under favourable conditions, multiply and produce an infection (in wounds or an ear infection or fluid in the eustachian tube in common colds, for instance). They then grow there and tend to hang around, which is why it is important to complete the course of an antibiotic, otherwise there is a chance of the infection coming right back.

Sinusitis This usually complicates a common cold or a flu-like illness. It may prolong a

runny nose and extend it to 10 to 14 days, accompanied by a green nasal discharge. There is usually a headache and excess irritability. The infection may also produce a night-time cough.

Diagnosis The diagnosis is usually made on clinical examination. Your doctor may decide to do an X-ray to look at the sinuses.

Treatment An antibiotic will be prescribed which you will have to give the baby for 7 days.

Otitis Media Middle-ear infections are a frequent complication in babies following a common cold. Your baby may seem fussy and appear to be in pain; some children tug at their ears. There may even be some ear discharge. Your doctor will examine the ear with a special light (otoscope) to confirm the diagnosis. The ear is made up of 3 parts, outer ear, middle ear and inner ear. Most babies and toddlers contract a middle-ear infection at some point, and most antibiotics prescribed for children are for ear infection. Most babies under 2 years would have had at least 1 ear infection. Unlike other childhood illnesses, middle-ear infections are usually caused by bacteria. The eustachian tube connects the middle ear to the nose and helps to equalise pressure in the ear. The eustachian tube in children tends to be more horizontal and hence doesn’t drain effectively. As children grow and the face lengthens, the tubes tend to angulate and drain more effectively. When your baby gets a cold, there is swelling of the lining of the eustachian tube; the fluid cannot drain and bacteria multiply here, turning the fluid into pus. Some children are more prone than others to get an ear infection. Firstly, you have to have a cold for the fluid in the ear canal to turn into pus. When a baby is in day care or a crèche, or if there are more children in a family, then the chances of getting upper respiratory infections are more (the

more exposure to other children, the more chances of infection). Constant use of the pacifier prevents adequate draining of the eustachian tube – the same way, when babies lie down and drink from the bottle, fluid from the back of the throat can come back up into the ear and cause ear infections. The normal eardrum appears translucent and behind this are the 3 small bones of the middle ear. In otitis media, the fluid turns into pus and the drum is red and bulging. There is a lot of pressure built up. This pus can either drain through the eustachian tube or it can drain after perforating the eardrum. The infection can only get better once the fluid has drained off. Usually, an antibiotic is prescribed along with saline nose drops to decongest the nose. Your doctor may even prescribe an analgesic or pain relief medicine such as brufen. Eardrops are usually not prescribed.

Frequently Asked Questions

Q My doctor says my baby’s eardrum has perforated. Will my child be able to hear after this infection is better? Sometimes, the drum has to perforate to let out all the pus and as soon as the infection settles, the drum heals. You have to make sure you finish the course of antibiotics and your doctor may want to check your baby again before the antibiotics are stopped.

Q Will my baby get an ear infection if water has gone inside his ear while bathing? No, this does not happen. In otitis media, the infection is on the other side of the drum. But it’s a good idea to wipe the ears with a towel after a bath. Resist the temptation to clean the ear canal with an ear bud.

Q Can ear infections develop suddenly? My baby only had a mild

cold yesterday and today my doctor says she has an ear infection. Yes, of course, this can happen. The eardrum can go from normal to red to pus discharge in a few hours.

Q Do I need to give antibiotics every time my baby gets an ear infection? Most of the time, otitis media is caused by bacteria; viruses rarely cause them. Sometimes, even bacterial ear infections clear up on their own without the need for an antibiotic. Babies less than 6 months usually need antibiotics since a complication like meningitis and mastoiditis, which involves the skull bones, can develop more easily in this age group.

Q Can we catch a flight even though my baby has been diagnosed with an ear infection and been put on antibiotics? Yes, you can travel. Your baby may experience some discomfort with takeoff and landing. You can feed the baby during these times because it will help in equalising the pressure in the ear.

QWhat is glue ear? Glue ear or secretory otitis media happens when thick fluid builds up in the middle ear behind the eardrum. The eustachian tube tends to be narrower in infants and can easily get clogged. These children are more prone to allergies. Children in day care are more prone as they are more exposed to germs. Other risk factors are poor air quality and exposure to cigarette smoke. They usually don’t present with earache but tend to have difficulty in hearing. This is because the liquid behind the drum obstructs the passage of sound waves. These children may sometimes present with speech delay.

The diagnosis is usually made by using an otoscope. Your doctor may give you some oral medicine along with decongestant nose drops to clear it. In most children, it clears up fairly quickly. When there is a chronic glue ear along with hearing loss in slightly older children, your child may be advised a surgery called adenoidectomy and little tubes called grommets are placed inside the ear. Grommets help in draining out the middle-ear fluid. They usually fall out on their own by 6 months and the drum heals.

Q Are there ways to try and prevent ear infections from happening? Try and feed your baby in an upright position, as when you feed her in the horizontal position milk can travel up the eustachian tube. This happens from the inside. Studies have shown that excessive use of the pacifier leads to ear infections. So ditch the pacifier if you are still using one when your baby is 6 months of age. Give up smoking, as cigarette smoke is linked to ear infections – smoke is an irritant and causes swelling of the eustachian tube. Get your baby vaccinated on time, especially in the case of the pneumococcal vaccine.

QMy child has a sore throat. Does she need an antibiotic? Sore throats are common in children and can be painful. However, a sore throat caused by a virus does not need antibiotics. Your doctor will be able to make the diagnosis by examining your baby, and all that he will need is pain relief. It usually takes a week to settle down. In some cases, it may be caused by a bacteria and is called strep throat. This diagnosis cannot be made by examining the throat; instead, a blood test and/or throat swab is required. If positive, your baby will be prescribed a

course of antibiotics which has to be completed even if he recovers in 2 days. Babies under 6 months rarely get strep throat unless they are in day care or have an older sibling who can transmit the infection. Scarlet Fever: This is also a strep infection. The baby can start off with a sore throat and then develop a pink rash, which starts on the chest and spreads to the rest of the body. Usually, antibiotics are given and the course needs to be completed so as to prevent complications like rheumatic fever.

Lung Infection or Pneumonia Bacterial pneumonia can complicate viral illnesses like chickenpox. Viruses can also produce inflammation in the lungs. Your child may have started with an upper respiratory tract symptom, which then got worse with high fever and cough. Or you may have a child who seemingly gets better but then relapses with high fever, fast breathing and cough. The treatment is usually antibiotics but sometimes your baby may need to go to the hospital for an intravenous drip in case he is dehydrated or needs extra oxygen.

Skin Infections Impetigo Impetigo is a common skin infection caused by both staphylococcal and streptococcal infections of the skin. These bacteria get into your body through a break in the skin from a scratch or an insect bite. It is contagious and may spread from the sores and clothes of an infected person who has been in contact with the bacteria. Sometimes children can carry the bacteria in the nose and it travels through the skin to produce infection, especially around the mouth. Insect bites, eczema, chickenpox, scabies and having an immunodeficiency make you more prone to getting the infection. It usually starts as a reddish sore, often around the nose or mouth, which quickly turns

into a blister, then bursts and oozes liquid and goes on to form a golden-yellow crust. They can be quite itchy at times. When they heal, they usually don’t lead to any scarring. It is usually diagnosed clinically and, in mild cases, only a topical antibiotic is needed. In more extensive infections, oral antibiotics may be necessary.

Cellulitis This is a deeper bacterial infection of the skin, involving the face, arms or legs. It can appear on normal skin but, usually, there is a history of some trauma that involves a break in the skin. Sometimes, it can follow a human or animal bite. It is usually caused by a staphylococcus aureus or a streptococcal infection. Sometimes a more serious infection may be caused by methicillin resistant staphylococcus aureus infection. The baby may have swelling of the skin, which is warm and tender. Sometimes there is bruising or blister formation, systemic symptoms like fever, chills and weakness. There may be swelling of the local lymph glands as well. Sometimes, cellulitis is an emergency, when large areas are involved or if the skin looks black or if it is around the eyes. The diagnosis is usually made from the history and an examination of the baby; your doctor may order some blood tests like complete blood count and blood culture. In more extensive cellulitis, your baby may need to go into hospital for intravenous antibiotics.

Conjunctivitis Conjunctivitis may be bacterial or viral. This involves the conjunctiva or the lining of the eye. In bacterial infections, the eye appears red and there is a yellowy green discharge, while in a viral illness, it’s usually a watery discharge. Antibiotic eye drops are prescribed for bacterial illnesses. No treatment is required for viral conjunctivitis as it settles on its own. It is very contagious and is spread through direct contact with the eye discharge.

Gastroenteritis or Acute Food Poisoning

Salmonella and shigella are the common bacterial tummy infections spread by faecal (potty) contamination of food and water. E-coli is another bacteria that produces a nasty gastrointestinal infection. The toxin produced by this bacteria can cause haemolytic uremic syndrome (HUS). In this illness, there is bloody diarrhoea and the toxin causes anaemia, low platelet count and kidney failure, and some children need dialysis. Children usually recover completely if treatment is instituted promptly but the disease can be fatal sometimes. The infection is spread from contaminated food, especially undercooked meats, hamburgers and unpasteurised milk. Children can get dehydrated and may need to be rushed to a hospital for intravenous fluids and monitoring. Usually, they need antibiotics as well.

Urinary Tract Infections (UTIs) Bacteria that migrate into the bladder from the perineal area (the skin around the anus and vagina) and/or the blood stream cause UTI. Sometimes it reaches the kidneys and produces a far more serious infection called pyelonephritis. These are more common in children who have a vesicoureteral reflux. These children tend to get repeated urinary tract infections and may need further testing like a DMSA scan, which is an isotope scan, and micturating cystourethrogram (MCUG), as required to evaluate the urinary system. The MCUG test helps in grading the extent of the reflux (see p. 133). There are 5 grades, from 1 to 5, where 1 is minimal and 5 is the worst. Your paediatrician may refer you to a paediatric urologist in the more severe cases. Sometimes, babies can get quite sick with these infections and need intravenous antibiotics in hospital, as children under 3 months can get bacterial sepsis and meningitis from this. Since this infection can come from the potty, it’s important to change your baby’s diapers quickly, and clean girls’ bottoms from front to back.

Meningitis or Brain Infection This involves inflammation of the meninges, the tissue that lines the brain.

Bacterial meningitis is life threatening, and sometimes survival may be associated with physical and mental disabilities.

Group B Strep (GBS) Group B strep is a normal flora found in the intestines, vagina and bladder in women. During delivery, as the baby passes through the vaginal canal, they can pick up this infection. Pregnant women are usually checked around 35 to 36 weeks for this bacteria. It seems to be more common in the developed world. If the mother is positive, the baby is screened at birth. If the baby shows signs of the infection, he may be started on IV antibiotics. If the bacteria enters the blood, there is a chance it could spread to the brain and produce meningitis. A lumbar puncture takes out spinal fluid to look for this infection. It is important to do this because, not only will it tell the doctor for how long the baby needs IV antibiotics, it also checks for complete recovery. Usually a mild sedative is given so that the baby does not feel any pain. Your doctor may not give you a green signal for full recovery even after finishing the course of antibiotics but would want to watch for developmental milestones in your baby.

Strep Pneumoniae or Pneumococcal Meningitis The pneumococcal vaccine is mainly to prevent the infections caused by S pneumoniae. This bacteria can cause pneumonia as well as meningitis. If babies with fever have meningitis, they may be irritable and may even have a convulsion. Pneumonia is accompanied by breathing difficulties, and some babies may need to be admitted to a hospital if they require oxygen.

Frequently Asked Questions

Q How does my doctor know that my baby has a bacterial infection? Usually, bacterial infection results in high fever lasting for more than 5 days

and your baby will be very sick; the fever will also tend to rise (sometimes more than 104°F). Your doctor will examine your baby looking for areas like the throat, ears, chest and abdomen to try and find out the possible causes. She may ask for a blood test, which may show a white cell count more than 15,000 and a higher-than-normal percentage of neutrophils. For a UTI, they may ask for a urine routine test and a urine culture. If your doctor suspects a brain infection, she may ask for fluid to be taken from the spine (lumbar puncture). From culturing the body fluids, they will be able to say which antibiotic will work for a particular bug. Sometimes, they may start an antibiotic, which through experience they know will work before the results of the culture report are out. Once they have the culture report, they match the sensitivities and see if your baby is on the right antibiotic, otherwise it is changed to the one that the bug is sensitive to.

Q What is drug resistance? I have heard my doctor talk about it. Drug resistance refers to the bacteria. It is the bacteria trying to find ways to survive the different antibiotics that try to disable it. What it essentially means is the bacteria will build up a tolerance for the antibiotics, thus rendering the antibiotics harmless to it. Frequent use of antibiotics aids the bacteria of environs to build up a tolerance for the same. Hence, it is important that we don’t overuse our antibiotics otherwise we will be left with no antibiotic worth its salt in our ammunition. Use an antibiotic appropriately. Don’t pop an antibiotic for a common cold, an upper respiratory tract infection or a sore throat, which are viral illnesses that don’t need an antibiotic. I have had parents call me to say that the nasal discharge has turned green – please prescribe an antibiotic. This is totally unnecessary and harmful for your child in the long run. Over-medication cannot build health; rather, it

weakens the body and your child’s immune system. Frequently, mothers will call to say I have a sore throat and my doctor has prescribed an antibiotic; I think my child has caught my infection and she also needs one. This is exactly the kind of trigger-happy antibiotic use that we need to curtail. Antibiotics are not to be doled out like sweets and should be used judiciously. Of course, you need antibiotics in some cases. Secondary bacterial infections, which complicate viral illnesses, need antibiotics (such as when the child starts to get worse because of a pneumonia, or an ear infection). Now let’s look at less serious, but nonetheless important, infections that make children itch.

Fungal Infections Fungi grow in damp places where there is less light and low levels of bacteria. Fungal infections are also seen in people whose immunity is poor. These fungi grow on the skin. Babies get fungal infections because they have less bacteria on their skin. Hence they are more prone to oral thrush and candida infection in the diaper area. Babies can also get a fungal diaper rash when given a course of antibiotics. Fungus can also produce a blood infection, but you seldom see this in healthy babies.

Ringworm Contrary to its name, this is not a worm but a fungal infection. These lesions are usually circular, with a raised border and the centre may have scales. The scraping from here can reveal the fungus. But not all need to have this done. The infection can spread through direct contact. The treatment involves using an antifungal ointment which you may need to use for 2 to 4 weeks.

Oral Thrush

Here, the baby develops curd-like white patches in her cheek, gums, tongue and palate. Below it lies a red base. Again, the treatment is anti-fungal and, if breastfeeding, the mother also needs to apply the same antifungal cream on her breasts. Bottles and nipples need to be properly sterilised.

Diaper Rash Candida or yeast infection can also produce a diaper rash. Here the rash looks red and raw, with satellite lesions. The treatment is an antifungal cream for 1 to 2 weeks. There are many creams in India which have a combination of steroid, antibacterial and anti-fungal elements. These should not be used for fungal infections.

Scabies This highly contagious infection is caused by a mite. The female mite burrows into the skin and lays many eggs. Once these eggs hatch, the larvae burrow into the skin and you can see the tracts made by them. The burrows are usually seen between fingers, elbows, groin, armpit and genital areas. In infants, you can see the burrows in the palms and soles and sometimes in the face as well. It is extremely itchy at this stage. Once you see the rash, it is easy to make a diagnosis; otherwise, you may need to take a scraping from the burrows and you may see the mites. Permithrin is the drug needed for this, and your doctor will explain how to use it. Clothes and bedding should be washed in hot water and hung out to dry in the hot sun.

Lice Head lice, as the name suggests, usually feed from our scalp. They travel from one scalp to another by crawling from one head to another. The adult louse is dark, and baby louse is light in colour. The adult louse lays the eggs on the shaft of the hair slightly away from the scalp. Seeing the nits on the hair shafts makes the diagnosis. The nits are the empty shells that remain after the nymphs have

hatched. It is a tedious task to remove the nits and it’s from here that the phrase ‘nit-picking’ derives. The treatment is the use of permithrin shampoo. You may need more than one application to get rid of lice. For very tiny babies, it may be better to shave off/remove the hair and treat all the caregivers.

Worm Infestations Worms are parasites that live in the intestine of babies and children and derive their nutrition from there. There are different types of worms that infect children, namely:

Tapeworm Tapeworms are called flat worms and look like ribbons. They attach themselves to the intestinal wall with the help of hooks and suckers and live off partially digested food. The main cause of tapeworm infestation is eating poorly cooked, infected meat and also contaminated raw food like salad, greens, and uncooked, contaminated vegetables. Although they don’t produce too many symptoms, they can cause serious life-threatening problems. The life cycle of a tapeworm has 3 stages – egg, larva and adult worm. The larva can get into the muscles of the host animal. The infection is picked up from eating the undercooked meat of the host animal. It is also possible to pick up the infection from a contaminated person. Because tapeworms are passed with bowel movements, a person who does not wash his hands thoroughly after using the toilet and then prepares food can contaminate the food.

Symptoms Symptoms can vary from nausea to diarrhoea, abdominal pain, loss of appetite and weight loss.

Rarely, the larva may migrate and damage different parts of the body like muscles, eyes, the heart and even the brain (neurocysticercosis). Seizures are the common effect when this happens. Your doctor may ask for stool tests or blood test, look for antibodies, to diagnose this infestation. In the case of a seizure, a magnetic resonance imaging (MRI) may be needed. Usually, oral medicines are given to treat the infestation. In the case of neurocysticercosis, anti-epileptic (medicine to control fit) treatments are needed. Prevention is by making sure you consume only well-cooked meat, wash produce and vegetables properly and follow regular handwashing.

Threadworms or Pinworms This is a very common infection in toddlers. These worms live in the intestine but travel to the anus to lay eggs. Infestations are spread between children and also through auto-infection, when children scratch their bottom. The worm’s egg ends up under their nail, the child puts their hand in their mouth, completing the cycle and reinfecting themselves. This infestation produces itchy bottom, especially at night, and sometimes the vagina itches too. Sticking a piece of scotch tape on the baby’s bottom and examining the sticky tape under the microscope will help you see the worm and eggs. Deworming medicine like albendazole or pyrantel is used for the treatment.

Round Worms Another name for this is ascaris lumbricoides. This is very common in Indian children and is usually spread from contaminated food and water. There may not be many symptoms, but if their numbers increase, round worms can lead to problems in the intestine. You can get the infection by ingesting the eggs, which may be in contaminated food or when children play with mud contaminated by human faeces. Once the eggs are ingested, they pass into the intestine where larvae are hatched. They traverse the intestinal lining and enter the blood stream, reaching

the lungs. Most of the growth then happens in the lungs and the adult worm travels to the throat and is swallowed back into the stomach. It looks like an earthworm. Most children may not have many symptoms, but may have a history of passing a worm in the stool. Sometimes they may be coughed up or come out through the nose. Other symptoms include abdominal pain, coughing, loss of appetite, wheezing and failure to thrive. Sometimes, when there are too many of them, they can obstruct the intestine and some children may even need surgery. Round worms can be treated with albendazole or pyrantel.

Hookworms Hookworms are another parasite present in our intestines and spread through the soil which contains hookworm eggs. When you walk barefoot, the worms can enter through the soles of your feet. These worms are present in many parts of the world but especially in warm, moist climes. They are usually seen in areas where there is poor sanitation or where human faeces are used as fertiliser. Most infected people don’t have many symptoms. The larvae enter through the skin and finally reach the intestine through the blood stream. Here they attach themselves to the intestinal wall and grow into adult worms. Sometimes you can get abdominal pain, loose stools, loss of appetite, blood loss and anaemia. The larvae, when they enter the skin, can cause an itchy skin rash called larva migrans. Treatment for this infection is also albendazole or pyrantel. By now, you should have most of your questions about common childhood illnesses answered. At any point, if you are not sure, or if you are worried about the illness, please contact your paediatrician, as she may want to see your baby before giving you any advice over the phone.

References Angelidou, A. et al. (2021). ‘Association of Maternal Perinatal SARS-CoV-2

infection with Neonatal Outcomes during the Covid-19 Pandemic in Massachusetts.’ JAMA Network Open, 4(4). Bakkeheim, E. et al. (2010). ‘Paracetamol in Early Infancy: The Risk of Childhood Allergy and Asthma.’ Acta Paediatrica, 100(1): 90–96. doi:10.1111/j.1651-2227.2010.01942.x Bharti, B., Bharti, S. & Khurana, S. (2017). ‘Worm Infestation: Diagnosis, Treatment and Prevention.’ Indian Journal of Pediatrics, 85(11): 1017–24. doi:10.1007/s12098-017-2505-z Diorio, C. et al. (2020). ‘Multisystem Inflammatory Syndrome in Children and Covid-19 Are Distinct Presentations of SARS-CoV-2.’ Journal of Clinical Investigation, 130(11), 5967–75. https://doi.org/10.1172/JCI140970 Gupta, A. K., Macleod, M. A., Foley, K. A., Gupta, G. & Friedlander, S. F. (2017). ‘Fungal Skin Infections.’ Pediatrics in Review, 38(1): 8–22. doi:10.1542/pir.2015-0140 Hoberman, A. et al. (2011). ‘Treatment of Acute Otitis Media in Children under 2 Years of Age.’ New England Journal of Medicine, 364(2): 105–15. doi:10.1056/nejmoa0912254 Geme, J. W., Blum N. J., Shah S. S., Tasker R. C., Wilson K. M., Kliegman, R. M. & Behrman R. E., editors. (2019). Nelson Textbook of Pediatrics, 21st ed. (pp. 532–38). Philadelphia, PA, USA: Elsevier. WebMD. (n.d.). ‘Children and Illness.’ Retrieved 15 June 2020, from https://www.webmd.com/children/features/children-illness Zimmermann, P. & Curtis, N. (2020). ‘Coronavirus Infections in Children Including Covid-19: An Overview of the Epidemiology. Clinical Features, Diagnosis, Treatment and Prevention Options in Children.’ The Pediatric Infectious Disease Journal, 39(5): 355–68.

11 Common Childhood Disorders and Diseases

We have addressed infections commonly seen in childhood and will now move on to other diseases or disorders that are common in this age group. The conditions that are going to be listed below are not caused by any infection. They may be a result of allergies like dust and pollution in the case of asthma, or orthopaedic problems that can develop as the child grows.

Asthma or The Wheezy Child Asthma is an allergic/immunological reaction that occurs in the baby’s lungs. It produces swelling of the lung lining, along with which there is constriction of the muscle lining the breathing tubes, and the third component is the mucous which obstructs the airway. The baby has difficulty pushing air in and out of these narrowed pipes. He ends up breathing faster and harder to get clean oxygenated air in and the stale or carbon-dioxide–laden air out. The trigger for this cascade of events may be brought on by viral illnesses, allergies, the weather, and even stress, which is more likely in older children. Asthma diagnosis is made from the history the parents give you, and what the doctor gleans from physical examination. If your baby wheezes every time he has a cold or flu, then your doctor may tell you that he has a tendency of asthma. Viral illnesses are the most common triggers for wheezing in children less than 1 year of age. Occasionally, the wheezing may be the result of your baby having choked on a raisin, a piece of a nut or even a toy.

An X-ray done at this time may indicate whether the wheezing is being caused by a foreign body or an infection. Asthma diagnosis cannot be made on the basis of tests; it’s your doctor putting a few things together and the response the child shows to the medications for asthma. Sometimes, the term reactive airway disease and asthma are used interchangeably, but they are not the same thing. The former is used when asthma is suspected and not confirmed. Reactive airway disease in children is a general term that does not indicate a specific diagnosis. It is usually used to describe a history of coughing and wheezing, and sometimes a shortness of breath, usually associated with an infection. These signs and symptoms may or may not be due to asthma. Although it’s possible for infants and toddlers to have asthma, tests to diagnose asthma are not very accurate before 5 years of age. The symptoms of reactive airway disease are quite similar: wheezing coughing shortness of breath excessive mucous in the bronchial tree swollen mucous membrane in the bronchial tube hypersensitive bronchial tubes Children who have GERD (see p. 123) can also have wheezing. These children lose their symptoms as the reflux gets better. The 2 main treatment strategies involve a bronchodilator and a steroid.

Bronchodilator A bronchodilator, like salbutamol, brings immediate relief when a child is wheezy. Paediatricians prescribe a nebuliser to deliver these medicines for smaller babies, and inhalers with spacer devices are useful for slightly older babies. These medicines bring about immediate relief, but their effect doesn’t last long, so you may be asked to use it a few times a day.

Steroid Medication

If your baby gets recurrent wheezy spells, a steroid medication given via a nebuliser or inhaler may be added to the salbutamol. The steroid works to reduce the inflammation, and hence the swelling in the airways. In some cases, if the child is very unwell, your paediatrician may even give oral steroids for 3 days. In this situation, the steroid is used as a preventer. Depending on how severe the asthma is, there is a step-wise pathway that your doctor may use to treat your baby. The third line of medication is an oral medicine that is given along with the steroid to prevent recurrent attacks. Since our knowledge of asthma is ever evolving, and we know that most of the problem is because of inflammation, steroids have become the front-line treatment along with the bronchodilator. So don’t be surprised if your doctor starts with a steroid inhaler, alongside the bronchodilator, for your wheezing child.

Frequently Asked Questions

QWill my child outgrow his asthma? There is more than a 50% chance that your baby may outgrow his asthma. This is especially true for babies who develop wheezing when they are less than 1 year. However, having a parent or sibling with asthma reduces this chance.

QWhat are long-term problems my baby can have? Since asthma involves the lungs which are important for oxygen transport, it is important to minimise the symptoms. Wheezing chronically is not a good thing. Doctors tend to treat asthma more aggressively now. Untreated asthma results in delay in puberty by approximately 1.3 years. Pubertal delay may explain the majority of apparent growth failure in asthmatics. The growth-suppressive effects of steroid are short lived and, on stopping the medication, it reverts to pretreatment levels.

Q Are eczema and asthma connected? Since both eczema and asthma are allergic in nature, a baby who has eczema or atopic dermatitis can go on to develop asthma or seasonal allergies. Other triggers for wheezing are air pollutants like cigarette smoke, allergies to dust mites, pet dander and pollen. Changes in the weather, like cold air, can also bring on an attack.

Eczema The basis of eczema is dry skin. It is also an allergic condition and usually presents as dry, red crusty patches on your baby’s skin. It can start within the first few months of birth. Most babies outgrow it. It can appear anywhere on the body but is usually seen on the cheeks and the joints of arms and legs. Cradle cap, or seborrheic dermatitis, appears quite similar to eczema but involves the scalp, eyebrows, eyelids and the area behind the ears. It usually clears up by 8 months of age and can be treated with an anti-fungal medication. Eczema, on the other hand, tends to run in families. There is a breakdown of the skin layer, you lose moisture and germs can enter. This is because the skin has less of a substance called ceramide.

Triggers Dry skin makes babies itchier. So, when the air is dry, as it is in winter, it tends to exaggerate the eczema. Irritants like woollen clothes, harsh detergents, fragrant soaps and perfumes. Heat and sweat can make the eczematous rash worse. Some dermatologists believe eliminating cow’s milk, peanuts, eggs,

soy and certain fruits like citrus fruits may help control eczema.

Treatment Moisturisers are the mainstay of the treatment. One with ceramides is the best option. Apply this on damp skin. Make sure the bath water is not too hot and use unscented soaps. Your baby’s clothes should be cotton, preferably the kind that is the most breathable. If your baby gets hot and sweaty, it can make the rash worse. We have to try and keep the baby from scratching, as it will make the rash worse. Cut and file nails, or put mitts on her hands so that she does not scratch herself. As far as medicine is concerned, mild potency steroids are prescribed to be applied locally, like 1% hydrocortisone. This will reduce both the inflammation and itching.

Sometimes, your baby may get a secondary bacterial infection on the eczema, for which she may need antibiotics. If there is a flare-up, your doctor may give the baby a sedating antihistamine to prevent the itching at night.

Common Orthopaedic Problems Intoeing/Pigeon Toes You may have noticed that your baby’s feet turn in when walking. This is called intoeing. Nothing needs to be done for this as it corrects itself as your baby grows older.

Bowlegs/Knock-Knees

When babies start walking, they walk with a wide-based gait and appear to have bowlegs. Usually, this straightens out with time, and some of them may appear knock-kneed later. This also usually corrects itself. But if your paediatrician suspects a vitamin D deficiency, which may be accompanied by swollen wrists and prominent forehead, he may run some tests to look for the calcium levels as well. If she suspects rickets, the doctor may ask for an X-ray of wrists or knees depending on which is swollen. Your baby may then need vitamin D and calcium until the blood levels normalise. The bones may take longer to remodel.

Flat Feet As the name suggests, there is an absence of the normal arch of the foot. In flexible flat feet, you can see an arch emerge when you ask the child to go on tiptoe. In the rigid variety, it stays the same. No treatment is really required, and the AAP feels orthotics or insoles are not required either. Flat feet don’t really cause problems at this age but later on in life, it can be a reason for foot pain.

Developmental Dysplasia of the Hip (DDH) In this situation, the femur (long bone of the leg) does not sit in its socket well, as it is shallow. This problem can start before the birth of the baby but, on occasion, it can happen as the baby grows. It can affect both sides or one hip. Here, the ball part of the joint, the head of the femur, does not sit in its socket – it can be completely or partially out of the socket. Sometimes, it can slide in and out of the socket. If this is not looked into, the hip joint will not grow well. It can lead to pain in the joint and arthritis in early adult life. DDH is more common in girls and in babies who have a breech presentation. If your doctor suspects this condition at birth, or if your baby is born breech, then an ultrasound of the hip is advised.

Signs and Symptoms of DDH

The baby’s hips making a popping or clicking sound can be heard or felt. The length of both legs is not equal. The creases on the thigh and buttocks do not line up. The hip or leg does not move equally. Later, when the baby starts walking, he or she will have a limp.

Some babies may have a hip laxity, where the hip feels very loose. The ligaments around the hips are stretchy, but this condition gets better spontaneously in 6 weeks.

Treatment Treatment depends on when the diagnosis is made. The goal is to keep the head of the femur in the socket and hold it in place so that the joint can develop properly. If this condition is picked up in the newborn period, then a Pavlik harness is used to keep the hip joint in place. The course of treatment may run anywhere between 6 and 12 weeks. The harness works very well and rarely is any further treatment necessary. If, in rare cases, the harness is not able to keep the ball of the hip joint in place, then the child will need either of these procedures:

closed reduction where your paediatric orthopaedic doctor manually pushes the ball back into the joint and the baby is in a plaster cast; or placing the ball surgically in the joint, and a cast is applied.

Both these procedures are done under general anaesthesia and a hip spica or cast is usually in place for 2 to 4 months. The baby will need to be seen by the orthopaedic surgeon until he reaches his full growth, which is usually until he is 16 to 18 years of age.

Squints or Strabismus Strabismus is when both eyes don’t line up, or when one or both eyes wander. They can be classified as: A. B. C. D.

Esotropia when it turns inwards. Exotropia when it turns outwards. Hypotropia when it turns downwards. Hypertropia when it turns upwards.

When the baby develops a squint, the eye that looks straight becomes more dominant. The acuity of that eye remains normal, and the pathway between the eye and the brain develops normally. The reverse is true with the abnormal eye. This eye does not focus well and hence the visual pathway that is the connection between the eye and the brain does not develop properly. Strabismus may be very obvious and present all the time for some children. In other children, it is only noticed when the child is tired or focuses very closely. If identified early, strabismus is very amenable to treatment. If not picked up

on time, the brain will ignore the visual images from the weaker eye. This is called amblyopia or lazy eye and will lead to double vision. The baby will also have difficulty in 3D vision or depth perception. If not treated on time, it can lead to permanent loss of vision in the lazy eye. Squints are usually diagnosed between 1 and 4 years. Usually the problem is noticed by family members. Younger children who are not talking yet may squint a lot or tilt their head often. Older children may complain of double vision. It is normal for a newborn baby’s eyes to wander occasionally in the first few months of their lives. Usually, the eyes straighten by 6 months of age. If after this the eye wanders up, down, in or out even occasionally, it is due to strabismus.

Treatment This entails getting the affected eye to focus more and develop the pathway between the eye and the brain. Sometimes, wearing glasses is enough to straighten the eye. Otherwise, a patch is worn over the good eye so that the baby is forced to use the lazy eye. This may be difficult to do, but slowly increasing the duration of patching usually works. The patch allows the weaker eye to do more of the ‘seeing’. Over time, the muscles and vision in the weaker eye get stronger. If you are unable to keep the patch on for the required time, your doctor may prescribe atropine drops. The drops blur the vision so that the weaker eye has more work to do. Over time, this strengthens the muscles. If none of the above treatments work, then surgery is the last option. Depending on the cause, either loosening or tightening of the eye muscle may be needed to stop the wandering of the eye. Regular eye exams are needed to detect/diagnose these problems early, and to institute the appropriate treatment. This helps in ensuring good vision and depth perception in the affected eye. Lastly, it’s important to keep social image in mind. Aligned eyes are important for a healthy self-image, both in children and in adults. Children are cruel and those with squints can be given nicknames when they join school, so

it’s important to identify and correct problems that have solutions.

Labial Adhesions This is a common problem seen in little girls. Ordinarily, the labia (lips of skin surrounding the entrance of the vagina) are separated. In rare cases, they grow together to block the opening partially or completely. This is called labial adhesions. It can happen early in life or later on due to inflammation in the area – the commonest reason for inflammation is diaper dermatitis. The oestrogen our body produces makes sure the labia and vagina stay lubricated. Once girls attain puberty, they start secreting oestrogen. Hence, this condition is usually seen in pre-pubertal girls. Your doctor will prescribe an oestrogen cream that you can apply on the labia. This will open up the adhesions and after that it’s important that you keep the area clean and lubricated with Vaseline. It only becomes a problem if the adhesions completely close the opening, including the urethra, and the child has difficulty passing urine. Rarely, this condition may need a surgical intervention.

Burns Scald burns from hot water and other liquids are the most common burns in childhood. They can range from mild to life threatening. Some can be managed at home while others need urgent medical care. If you think your child has a major burn, that is, when a large area of skin is involved, you need to make arrangements to take the baby to the emergency room.

Remove clothing from the burned area, except clothing stuck to the skin. Run cool water – not cold – on the burn. It may ease the pain somewhat. Cover the area with a bandage or soft cloth.

You can give some paracetamol to ease the pain. Please don’t apply butter or toothpaste on the burn – it may make it worse. Do not break any blisters.

Speak to your doctor. If you are not sure of the extent of the burn, it is important to take the child to the emergency ward of a hospital.

Problems that Warrant a Call or Visit to the Doctor Falls With all the crawling, exploring and trying to stand, it’s no surprise that falls are common in babies. Most of the time, it’s mild – bumps on the forehead or minor cuts and scrapes. Occasionally, the baby may be seriously injured. Some indications that it may be serious and you need to rush to an emergency is when:

you suspect there may be serious injury to the head, back, neck, hipbones or thigh the baby is unconscious the baby is having trouble breathing the baby has a convulsion

If your child does not have any of the above symptoms, you just need to comfort the baby and look for injuries. If there is a bump:

apply a cold pack give paracetamol watch your baby for any unusual symptoms for the next 24 hours

Red Flags The baby is unusually sleepy or is difficult to wake up Is easily irritable Vomits more than once Complains of increasing pain anywhere (some babies may be able to point or cry out when a particular area is touched or manipulated) Is not walking properly or is unsteady Not focussing her eyes normally

Prevention Never leave infants on a bed or any other furniture unattended Do not leave babies in a baby seat on top of a counter Do not use walkers and use gates if you have stairs at home Always strap children into a high chair, strollers and shopping carts

Electric Shock Injuries in Children When the human body comes into direct contact with a source of electricity, the current passes through the body, producing an electric shock. Depending on the voltage and length of contact, the shock can cause anything from a minor discomfort to serious injury, even death. Infants are prone to electric shock when they bite into wires or if they stick a metal object, like a fork, into sockets. The best way to prevent this is to cover all electrical outlets and make sure all wires are insulated and tucked away behind furniture. What you can do if such an incident happens is to first disconnect the power supply before touching the child. Never touch a live wire with your hands. To lift it off the baby, use a wooden stick or rolled-up newspaper. If you cannot remove the source of the power, use gloves or nonconductive material to lift the baby from the source. Once the power is off, check the baby’s pulse, breathing and colour. Start

cardiopulmonary resuscitation (CPR) if baby is not breathing or has no pulse.

Treatment Any child who has received an electric shock needs to be checked by her paediatrician. If there is a burn, it will need to be cleaned and dressed. Mouth burns can be nasty and will need to be closely monitored. They may even need surgery. The child may need to be hospitalised if there is any brain or heart damage.

Stomach Ache It is difficult to figure out if your baby is crying because of a stomach ache. There are signs you can watch out for. Your baby may have not been feeding well and may have been more irritable while feeding. He may have been drawing up his legs when crying. Sometimes, it could be a case of UTI or torsion testis, where the testis twists in the scrotum and the child is very uncomfortable. When you call your doctor, he will try to figure out whether this is an acute event that has just started, or something that has been persistent for the last few days, or chronic. Surgical emergencies are usually acute, like when the intestine may be blocked or kinked. The baby looks unwell and is inconsolable; her tummy appears very hard and bloated. The baby may have been vomiting, which would be yellow in colour. The stools may have had blood and the urine output might be negligible. If your baby is uncomfortable when passing urine, a UTI needs to be ruled out. All these signs are red flags and any one of them should prompt you to call the doctor. If there is more than one symptom, you absolutely cannot sit on it – it is an emergency that needs to be evaluated immediately. This is not a situation where you can wait to see if you will get an appointment to see the doctor.

Fever

The definition of fever is when there is elevation of body temperature. Our body temperature does not stay constant at 98.4°F. There is a variation throughout the day and it can go down to 97.5°F in the morning and rise to 100°F in the evening. When your child is ill with either a bacterial or viral illness, she can develop a fever. Fever will not harm your child. When your baby gets an infection, she feels feverish because the body is mounting an immune response to fight the infection. Fever helps to fight the infection in conjunction with the body’s white blood cells. You have to remember: the problem is not the fever but what is causing it. You may find that your baby had a fever at night, woke up in the morning and the fever was gone. But be prepared – it will be back around noon. This is because of the normal variation in the body’s temperature. Viral fevers usually last 3 to 4 days and the fever is higher in the evenings because of the normal diurnal variation of temperature. Fever in children less than 6 months, and especially less than 3 months, needs to be evaluated by a doctor as soon as possible. Older children can be at home, provided they seem well otherwise and are well-hydrated. But if there is persistent fever for more than 72 hours, they need to be examined. There are several ways of checking temperature:

Rectal Method Here, the thermometer is placed in the rectum or bum. It’s the first choice for babies below 1 year, and most accurate. Clean the thermometer with cool soapy water and rinse. Cover the silver tip with petroleum jelly, place the baby on the back with knees bent. Gently insert the thermometer about 2.5 cm or 1 inch. Hold it in place with your fingers for about a minute. Remove the thermometer, take the reading and thoroughly clean the instrument.

Oral Method This method is used for children over 5 years of age. Clean the thermometer with cool soapy water first, then place it under the tongue for 1 minute. Once it beeps, you can remove it and take the reading. Clean after use.

Armpit Method This method can be used for newborns as well as older children, but is not as accurate as the rectal method. Either a clean rectal or oral thermometer can be used. Make sure the thermometer is rightly placed in the middle of the armpit and the arm is snug against the body. Leave the thermometer in place till you hear the beep. Remove it and read the measurement. If you feel your baby is warm and your axillary (armpit) reading does not show a fever, you can use the rectal method.

Ear Thermometer This method is not very accurate and can sometimes give you very low readings. It all depends on how it’s done and is difficult to do with a squirming child. Use a clean probe each time. Gently tug at the ear lobe pulling it back – this straightens the ear canal. Gently insert the thermometer till the ear canal is fully sealed off. Squeeze and hold the button for 1 second. Remove and read the measurement.

Temporal Artery Method In this method, a strip thermometer, or an infrared scanner, is used to measure the temperature of the temporal artery that is in the forehead. This method is not very accurate when done at home, so I don’t recommend this method to patients. Normal temperature ranges Rectal

97.8°F–100.4°F

Oral

95.9°F–99.5°F

Axilla or armpit

97.5°F–99.5°F

Ear

96.4°F–100.4°F

Though I have given you the ranges, the temperature does not tell you how

serious the illness is. If your baby has a fever, remove extra layers of clothing (but don’t strip the baby completely as she will feel cold and start shivering). This will push up the body temperature. I am not a great proponent of sponging; you can do it when the temperature is really high, like 106°F, as an emergency measure. It is very unpleasant for the baby and, as far as I am concerned, it’s a waste of time.

Medication This is not always required to bring down the fever. In fact, the purpose of giving paracetamol is not to bring the fever down to normal but to reduce the aches and pains that are associated with the fever. Medication may bring the fever down; it does nothing to treat the underlying cause. Paracetamol is the drug of choice to be given in the case of fever. You can give it 4-hourly but try not to give more than 5 doses in 24 hours. If you think it’s required that often, it’s time to talk to your paediatrician. The other medicine you can give is ibuprofen or mefenamic acid. This should not be given to babies less than 6 months of age without speaking to your doctor. It should also not be given if your child is not drinking enough or appears to be dehydrated. This group of medicines is not recommended when you are suspecting dengue-like illness, as it can reduce platelet count and lead to bleeding. Ideally, try not to alternate paracetamol and ibuprofen, as it may lead to dosing errors. Aspirin should never be used for children to control fever as it can cause Reye’s syndrome which results in liver failure, especially if associated with viral illnesses like influenza or chickenpox. Please use the measure that comes with the bottle, otherwise you may end up giving the wrong dose.

Febrile Convulsions Febrile convulsions or seizures are caused by fever. They happen in 2% to 5% of children between 6 months and 5 years who get a fever.

The older your child is when they get the first febrile convulsion, the less likely they are to have more. Your baby may be more prone to them if there has been an immediate family member with febrile convulsions, like a parent, aunt, uncle or sibling.

QHow do I know if my baby is having a febrile convulsion? Very often, the seizure is the first sign that your baby has a fever. It can be very frightening when you see it the first time. Rest assured, these convulsions are not dangerous. Your child will have a fever more than a 100°F. The body may stiffen. Eyes may roll up, followed by jerky movements of both arms and legs. There may be a loss of consciousness for a short span. These convulsions may last up to 2 minutes.

What You Need To Do Stay calm though you may not feel like it. Place the child flat on the floor, making sure that there is nothing dangerous near him. Turn him to rest on his side. If the child has vomit on his mouth, wipe it away so that he doesn’t choke on it. Don’t try and insert anything into the child’s mouth; you can injure him by doing that. Allow the baby to wake up on his own. After that it’s important to get the baby checked to rule out any other problem.

30% of children can have repeated episodes of febrile convulsions. Unfortunately, giving fever medicine round the clock is not going to prevent your child from having them.

Red Flags For any fever in a baby under 3 months of age, you need to consult your paediatrician right away. Fever more than 102°F in babies between 3 and 6 months needs evaluation. Fever close to 104°F or above in babies over 6 months needs evaluation. Fever that has no obvious source of infection. Fever lasting more than 3 days. Febrile convulsion. Fever with lethargy and irritability. Fever with a petechial (tiny red) rash.

Breathing Problems and the Common Cold The Common Cold The common cold is caused by viruses that infect the nose, throat and sinuses. There are more than a hundred different cold viruses and they seem to affect children, as their immunity is just developing. Sometimes, it seems like your baby has just gotten out of one infection before she gets another. On an average, children under 2 years get 6 to 8 colds per year. A cold is spread through direct contact with a person suffering from a cold, like kissing, touching or holding hands. The virus, present in your nose, mouth, eyes and hands, is passed on to people you come in contact with. It can also spread through indirect contact, like touching a doorknob or tissue used by somebody with a cold, or even through toys. These are called fomites – germs can live on these surfaces for quite a long time. Some germs spread through the air when a person coughs or sneezes, and can reach across to enter another person’s nose or mouth. Cold symptoms are usually stuffy noses and sneezing, coughing, headache,

sore throat, loss of appetite and mild fever. When you have a cold, mucous is produced in the upper respiratory tract. This mucous, or snot, dribbles to the back of the throat and sets off a cough. Coughing helps to bring up the mucous, which is then swallowed. Don’t expect the baby to spit up the mucous. There is no need. Coughing is therefore a protective mechanism. Colds rarely produce laboured breathing, but you can get noisy breathing as air shifts the mucous up and down in the nasal passages. You need to speak to your paediatrician if your baby has trouble breathing, or is vomiting and not drinking or eating, and has a high fever (more than 100°F).

Croup or Laryngotracheobronchitis Croup or laryngotracheobronchitis, an infection which produces hoarseness, noisy breathing, and a bark-like cough, affects the voice box, producing swelling and narrowing of the airway. As the breathing pipes are smaller for babies, they seem to have more breathing difficulties – the younger the child, the more severe the symptoms.

Bronchiolitis Caused by RSV, this is a viral infection which affects the bronchioles or the smaller airways. There is swelling of the tubes and they have mucous which obstructs air flow, producing difficulties in breathing. Signs that your baby is having breathing difficulties:

The baby may be breathing faster than normal. She may be breathing fast, appears to be working hard to breathe, sucking in the rib cage and flaring nostrils as she breathes. Sometimes, a baby may make grunting noises as she breathes. Occasionally, her lips would appear blue.

All these signs warrant a visit to the emergency, or at least a call to the

doctor right away.

Croupy cough sounds like a bark and usually comes on at night. Sitting with your baby in a steamy bathroom for 10 to 15 minutes will help in reducing the swelling and make breathing easier. (Dry his hair and change your baby’s clothes after a steam session if they get damp. Or, cover his body with a towel to protect his clothing.) If the swelling gets worse, the bark also changes to a high-pitched squeaky noise called stridor. These children need to go to the emergency room to receive appropriate medication that may include steroids.

Nasal Congestion Newborn babies tend to have some nasal congestion for the first 4 to 6 weeks of their lives. This is not due to any infection. All that is needed is saline nose drops. I am not a great fan of the nasal aspirator/suction bulb, as I feel it causes more harm and, if used incorrectly, some babies may even stop breathing. Overthe-counter cough and cold syrups that you can pick up at the chemist without a prescription are not recommended for children under 4 years of age.

Cough Night-time cough is because of a post-nasal drip as mucous trickles to the back of the throat. It is usually worse at night as the child is lying down. Unfortunately, your paediatrician does not have any magic medicine that is going to make the cough disappear. Cough syrups that contain cough suppressants are usually not recommended for children under 5 years. You can use saline nose drops, and letting the baby sleep with the head elevated at a 30°-angle may help. But, at the same time, make sure the baby does not roll to the foot of the bed or into a position that may increase the breathing problems. If a cough persists beyond 3 weeks, then your baby needs to be checked for

causes other than a cold virus. This could also be due to the inhalation of a foreign body like a peanut or pea, or some part of toy that he may have inhaled that you were not aware of at the time. Tuberculosis can cause chronic cough and needs ruling out.

Allergic Reactions Most allergic reactions are caused by the release of a substance called histamines. The treatment of these reactions is using an anti-histamine. Histamines, once released, can hang around for many days. Since the antihistamine effect only lasts for a few hours, you will need to give the medicine for a few days. Allergic reactions can be caused by food allergens, insect bites, medicines, and sometimes even plants. Most of the time the symptoms are rashes.

Hives Here you have raised flat bumps like you see with mosquito bites. Or you see them as large red areas with raised edges/margins.

Erythema Multiforme These are multiple small red patches with raised borders.

Eczema The red patches are scaly and edges are rough.

Contact Dermatitis This, as the name suggests, produces a blistery rash on the areas which come in contact with the offending agent, maybe a plant. Sometimes you can get a serious reaction, which is associated with swelling of the airway and leads to difficulty in breathing, lip-swelling, and sweating. This is a medical emergency.

Choking An acute episode of choking can happen at any time and is a medical emergency.

If your child is coughing, gagging or crying, you should not do anything like putting your finger in her mouth, as the child is attempting to clear the airway on her own. If the child can’t breathe or can’t make sounds and is going blue, then the airway is blocked. You can place him face down on your forearm and push forcefully or thump between the shoulder blades. Repeat this 5 times. If there is no improvement, lay the baby on her back and give her 5 chest thrusts. Between each thrust, check if the blockage is clear. The area where you need to do the thrusts is 2 to 3 fingers below the internipple line in the middle. If the block is still not cleared, you may have to do CPR and take the baby to emergency right away. There are many infant CPR videos on YouTube that you can watch and learn from.

Vomiting Vomiting has many causes, but in babies it’s usually due to a viral illness (stomach flu/gastroenteritis). Here, the stomach contents are brought out forcefully. Initially, it may be the food and liquids that are there in the stomach. Once all that is out, the baby will have dry heaves where nothing comes out as the stomach is empty. You usually only get dehydrated if vomiting has been going on for a while, say around 18 hours. Usually, in most gastrointestinal illnesses, the vomiting settles in 12 hours. But if there is ongoing diarrhoea as well, then it can lead to dehydration. Very often a child with a common cold can vomit with all the coughing.

Vomiting can also accompany head injuries or brain infections. Unexplained vomiting needs to be evaluated. Do not attempt to feed your child immediately after vomiting because they will vomit again. Your baby will not get dehydrated from 1 vomit. Wait for about an hour and give her some liquid like ORS (see p. 130). If the baby is comfortable, offer sips with a spoon. If you allow the baby to drink the whole bottle, she may vomit again. So offer sips every 5 to 10 minutes for an hour. If nothing stays down, you need to speak to the doctor. If the baby keeps the sips down, then slowly increase the volume. If your baby has not vomited for 3 to 4 hours, then you can go back to breast- or bottlefeeding, as the case may be. If the baby is on solids, resume normal diet only after 24 hours of no vomit. Vomiting with the following features needs immediate attention:

When there are signs of dehydration like dry mouth, sunken eyes, reduced urine output, sunken fontanelle. Not keeping any clear liquids down. Greenish-yellow vomit, vomit has blood, or looks like coffee grounds. Repeated projectile vomiting in a 1 month old. Early-morning vomiting. Baby looks irritable and has fever. Vomiting accompanied by swelling, redness of the scrotum.

Diarrhoea and Dehydration Most of the time, diarrhoea or loose motions are caused by viral illness of the gastrointestinal tract. It may start with a few bouts of vomiting, moving on to loose stools 5 to 6 times a day and the whole illness is over in 4 to 5 days. Rotavirus infections can lead to vomiting and stools up to 25 times a day and your baby may need to go into hospital to be assessed for dehydration. Bacterial diarrhoeal illness may have mucous and blood in the stool. Bacterial diarrhoeal illnesses only account for less than 10% of diarrhoeal

illnesses in children. The common ones are shigella, salmonella, and certain strains of E. coli, clostridium difficile, and campylobacter. Giardia and amoebiasis are other common causes of diarrhoeal illness in our country. Other than the loose potty, babies may have fever, stomach cramps, tiredness, weight loss, loss of appetite and dehydration.

Signs of Dehydration There is less urine output as the body tries to conserve water. Your baby may show some degree of weight loss. Dry mouth. Sunken eyes. The soft spot or anterior fontanelle is depressed. Irritability. Skin appears cool to the touch. Lethargy (this is a little difficult to assess when your baby isn’t really showing much reaction).

Chronic Diarrhoea Chronic diarrhoea occurs when the diarrhoea has been going on for more than 2 weeks. Some children can develop a secondary lactose intolerance, and diarrhoea ensues because the ingested diary is not digested, especially milk. Fruit juice is another culprit for prolonged loose motions. Other causes of chronic diarrhoea are parasitic infections like giardiasis, inflammatory bowel disease or coeliac disease. Your doctor may ask you to get a stool test done to better guide the treatment. But at home you can try and prevent dehydration. In mild or moderate dehydration, you can start oral rehydration at home. You can give solution that can be reconstituted at home (see p. 130). Start with 5 to 10 ml every 5 to 10 minutes for the first hour and then slowly build it up. You should be breastfeeding during this time. You can start formula once you know your baby is not showing any signs of dehydration. Don’t give soda, fruit juices, tea or herbal concoctions. You can give buttermilk and rice water.

Once you see that your baby is passing good urine and is not showing any signs of dehydration, you can resume her normal diet. Sometimes, despite your best efforts, the number of stools are far more than the amount of liquid that is ingested. These children need to be evaluated for intravenous fluids. If diarrhoea lasts over a week, then replace the milk with lactose-free milk. Anti-diarrhoeal medicines like loperamide and kaopectate are not recommended for children. Probiotics or good gut bacteria can be given. It may shorten the course of illness. And good old curd is an excellent source of probiotics.

Bruises and Bleeding: What to Do and When to Panic Expect a few black-and-blue knees and scraped elbows for babies who have just started to walk. Hence, bruising in high-trauma areas like shins, knees, elbows and forehead is not worrisome. The tell-tale marks that appear when your little one bumps into things, or falls, are because some blood vessels under the skin surface break and the blood leaks out. Initially, it will appear red because blood is red in colour. It then turns blue to purple as the oxygen from the blood disappears. As it heals further, it changes to green and then yellow, before disappearing. As a parent, all that you need to do is ice the area and elevate the limb which allows for less pooling of blood in that area. You can childproof your home to some extent, such as by placing corner guards on tables, and installing a gate at the top of stairs. Sometimes, easy bruising may be because of low platelets. Platelets are important for clotting. Bruising along with petechiae is more worrisome. Petechiae are flat, tiny red dots that appear on the skin that do not blanch or turn pale on pressure. Petechiae can sometimes happen because of straining – for instance, with violent coughing or vomiting, you can see petechiae on the face.

Certain infections like meningococcal meningitis can also give rise to petechiae. Leukaemia and idiopathic thrombocytopaenic purpura (when blood doesn’t clot normally) can be a cause of low platelets. Your baby needs evaluation if there is fever with petechiae, bruising in unusual places like abdomen, both petechiae and bruising without fever, and uncontrollable bleeding. Just remember, bruising in active crawling children is normal. If they are not accompanied by petechiae or bruising in unusual places and your baby is not in excessive amounts of pain, then it is probably nothing to worry about.

Epistaxis or Nosebleeds When a child has blood pouring out of his nose, it can be quite alarming. Fortunately, nosebleeds in children are often not because of any serious ailment. The nosebleed can be anterior or posterior. The anterior nosebleed is more common, and happens due to the rupture of blood vessels inside the front part (anterior) of the nose. Posterior nose bleeds are rare in children, and occur because of injury to the back of the nose, or are related to injury to the face or nose.

Causes Dry air, whether it’s due to a dry climate or heated room, is the most common reason. This irritates and dehydrates the nasal mucosa. Picking at the nose. This injures blood vessels in the nose and leads to bleeding. Trauma or injury after a fall or injury to the nose. If bleeding does not stop after 10 minutes, the child needs evaluation. Cold, allergies or sinus infection can cause nasal congestion and irritation, and lead to bleeding from the nose. Bacterial infections like impetigo can cause red-crusted lesions just in front of the nostrils and bleeding.

Rarely, recurrent bleeding may be because of abnormal clotting factors or problems due to abnormal blood vessels.

Treatment Make the child sit up, leaning forward slightly, and gently pinch the soft part of the nose. Try and maintain this pressure for 10 minutes. You can also apply ice to the nasal bridge, which will reduce blood flow. If nosebleeds happen too frequently, then use saline nasal sprays a few times a day, or you can use an emollient like petroleum jelly just inside the nostril. Decongestant nose drops, recommended by your doctor, can also be used if your child has a cold. Ensure the child’s nails are trimmed so that he does not scratch or injure the nose.

Call your doctor If you feel the bleeding is because of something your child may have inserted into his nostril. If it is accompanied by bruising or petechiae in other parts of the body. If the bleeding does not stop after 10 minutes of continuous pressure on the nose.

Vomiting Blood Blood seen in the spit-up or vomit of the baby is enough to scare any mother. If your baby is otherwise well, has no fever, swollen tummy or lethargy, then you don’t need to be too alarmed; but it’s always wise to call your doctor. If the baby vomits red flecks right after birth, it may be maternal blood swallowed during the birthing process. There could be a case of blood swallowed during breastfeeding – check if your nipples are cracked or sore. You

can use some soothing ointment and recheck that the baby is latching properly. When the baby is learning to breastfeed, it’s important not to give up. Do not switch to feeding him with a bottle. Sometimes, babies vomit forcefully, which can lead to a minor tear in the baby’s oesophagus. You may get a small amount of blood in the vomit. Here, again, it should settle on its own and you must continue breastfeeding.

When to seek medical help If the blood continues in the spit-up and you are unable to see if there is any bleeding from the nipple, then it is definitely worth calling the paediatrician.

Causes Vitamin K deficiency can produce a condition called haemorrhagic disease of the newborn. That is why all babies are given Vitamin K at birth. At birth, a nasogastric tube is passed into the stomach to see if the nares are patent (nostrils and nasal areas are normal) and if the oesophagus has been formed properly. Sometimes, while passing the tube, there can be injury to the back part of the nose and blood may be swallowed. As blood irritates the stomach lining, it can induce vomiting and you may see a few flecks of blood. Some babies develop an allergy to cow’s-milk protein. This can lead to vomiting of blood or even blood in the stool.

Your doctor will ask you some pertinent questions to try and figure out why there is blood and the appropriate treatment will be instituted according to the cause.

Blood in the Potty Blood in your baby’s potty can be alarming and must be evaluated. The

diagnosis can be made from the colour of the blood. If it is bright red, it is from close to the anus. If it’s black and tarry, it’s likely from higher up, like the small intestine or even the stomach. In newborns or smaller babies, diaper rash is the most common reason for blood in the diaper and you can see the raw, sore bottom. Another reason for blood in this age group is cow’s-milk protein allergy. Even babies who are exclusively breastfed can develop this problem if the mother consumes milk and milk products and the cow’s-milk protein enters her breastmilk. In India, most lactating mothers are advised by obstetricians, as well as grandmothers, to drink close to a litre of milk to boost breastmilk production. If you eat a healthy diet, you don’t need more than a couple of glasses of milk and plenty of water to ensure adequate breast-milk production, at the same time meeting your own calcium needs. Even if you remove milk from your diet, there are other ways to get the nutrients you need to produce wholesome milk. You can consume other dairy products in your diet along with nuts and eggs. The vegan diet should contain plenty of green leafy vegetables, oats or rice or soya milk, tofu, sesame seeds, tahini paste and dried fruits like apricots, figs and prunes. It may take up to 6 weeks before the blood clears from the stool after the baby has cow’s-milk protein eliminated from the diet. Bacterial tummy infections like salmonella, which babies pick up from caregivers, can also be a reason for blood in the stool. These need to be evaluated with a stool test, and appropriate antibiotics are prescribed.

Foods to be avoided to prevent food poisoning or gastroenteritis Unpasteurised dairy products. Raw or undercooked meat and sea food. Unwashed fruits and vegetables. Undercooked eggs (sunny-side-up eggs, half-boiled eggs, eggs used in salad dressing, homemade ice cream and homemade mayonnaise) In older babies who have started on a semi-solid diet, constipation is the

most common reason for blood in the potty. When the child strains to pass this solid, rock-like potty, she may bleed because this rock produces a tear in the anal canal. This is not serious; you can apply some petroleum jelly, find out why she is constipated and treat it accordingly. A rare condition called intussusception happens when the bowel (intestine) telescopes and folds over on itself, and can lead to dark, red jelly-like stool. This needs immediate attention and is a surgical emergency.

Poisonings At Home Most poisoning happens when parents or caregivers are present but tied up with something else or distracted and not paying attention to the child. Very often, nobody is to be blamed as it takes only seconds for the baby to put the offending object in the mouth. The most dangerous potential poisons are medicines, cleaning products, pesticides, insect repellents, furniture polish, paints, perfumes, essential oils, gasoline, kerosene, nail varnish and batteries. You will also need to be more vigilant when there is a change in routine, like when you’re on holiday or when you have guests at home.

Store medicines, cleaning products and pesticides should be kept in their original packaging in locked cabinets. It is safest to store poisonous products out of the reach of children. Never refer to medicine as candy or any other appealing name. Never place poisonous products in food or drink containers. Keep toys and action books which contain small button cell batteries in a secure place.

Different types of poisoning need different methods of immediate treatment.

Swallowed poison: Remove the poisonous item. Have the baby spit out and wash the mouth but do not make your baby vomit. Making your children vomit forcefully may lead to aspiration (when the airways are obstructed) and the poison can go into the breathing pipe. Swallowed battery: If your child has swallowed a battery or the battery is stuck in the throat, then you need to rush to emergency as it will need to be taken out. The battery can leak and cause tissue damage. Skin contact: Remove the clothes and rinse the skin with lukewarm water for 15 minutes. Eye contact: Wash out the eyes and pour a steady stream of lukewarm water from the inner corner of the eye for 15 minutes. Inhalation: Take the child outside into fresh air; if the child has stopped breathing, perform CPR.

In case of an emergency, call the following numbers: NATIONAL POISONING CENTRE, AIIMS (24/7) Phone no.: 011-26589391, 011-26593677 Toll-free no.: 1800-116-117

Even if your child appears ok, it is important to have the baby checked. Some poisons may have a delayed reaction.

First-Aid Kit A first-aid kit is a must in every home where there is a baby, and it should be well-stocked. You could use a large box or storage container. Make sure all caregivers know where this is kept and always keep it in that specific place away from your child’s reach.

Keep a list of emergency phone numbers handy Alcohol swabs, sterile gauze pads and adhesive tape Plasters of different sizes Nail clipper Sharp pair of scissors Tweezers for removing splinters Hand sanitisers Elastic bandage Soap Antibacterial ointment (like mupirocin or fusidic acid) Ointment for burns like petroleum jelly Antiseptic solution to clean wounds Hydrocortisone cream 1% Paracetamol, ibuprofen Saline nose drops Antihistamine syrup (like cetirizine) ORS sachets Measuring spoon or dropper Disposable cold packs Calamine lotion Digital thermometer Petroleum jelly (like Vaseline) Flashlight and extra batteries

Medication There are some medicines you should keep handy at home or when travelling?

Paracetamol (Crocin/Calpol) In India, this is available in 3 forms: as drops with the strength of 100 mg in 1 ml as syrup 120 mg in 5 ml as double-strength syrup 240 mg in 5 ml

If you interchanged the formulations, it would be disastrous. There have been instances of paracetamol poisoning and liver failure because the wrong dosage was given. If you give 5 ml of the double-strength medicine in place of the 120 mg syrup, you will end up giving your baby double the recommended dose. Medicines for babies are given according to weight and not age. So it is important that you follow the recommended dose. It is better to stick to doublestrength dose only for heavier, older children and not for babies under 1 year, as it is very easy to overdose. Children under 4 weeks should not be given paracetamol for fever without talking to the paediatrician.

Ibuprofen This is a non-steroidal anti-inflammatory drug (NSAID). It is a useful medication for fever control. Ideally, you should not use ibuprofen for babies less than 6 months of age and, if you do, it should only be on your paediatrician’s recommendation. It should only be given when your baby is wellhydrated and passing adequate urine and should not be used when you are suspecting dengue as the cause of the fever. Ideally, paracetamol and ibuprofen should not be used together. Combinations like paracetamol and ibuprofen in the same syrup are not recommended. The minimum interval between 2 doses of ibuprofen is 6 hours.

Anti-Vomiting Domperidone and Ondansetron are 2 medicines used for vomiting in babies. Ondansetron is licensed to be used in babies over 1 month. In India, there are different strengths available as drops and syrup. So it is important that you follow the prescription and don’t let the chemist guide you about the medicine and dosage. Drops are always more concentrated than syrups. Remember to use the dropper or measuring cup that comes with the medicine. Alternatively, you could get a set of measuring spoons that you can use to give the medicine.

Antihistamines

Histamine is a chemical that is released as an allergic response, and causes nasal congestion. Antihistamines are mainly used for allergic reactions like urticaria. They are also found in cough and cold medicines. Antihistamines are sedating and work as cough suppressants, and help to dry up a runny nose. Ideally, they should be used only in children over 6 months and should not be used to for treatment of common cold, as there is no allergic element in a common cold.

Cough and Cold Cough and cold medicines are ideally not recommended for children under 4 years of age. There have been deaths in babies under 6 months of age who were given pseudo ephedrine for nasal congestion – the level of this compound is 10 times the recommended dose. A study in The Journal of Pediatrics looked at 100 children who took cough medicines to examine whether they slept better. The study found that neither the parent nor the child slept despite the medicines. Since these medicines do more harm than good, it is better to avoid them.

Frequently Asked Questions

Q My child has just thrown up the paracetamol that was given. Should I give it again? If your baby throws up within 15 minutes of giving the medicine, then you need to repeat it as there has not been enough time to absorb it.

Q I find it very difficult to administer the medicine. What do I do? It’s a good idea to give small amounts over a few minutes. You can mix it in a small amount of breastmilk or formula. In an older child, you can mix it in some chocolate syrup or strawberry jam as the last resort.

Q I have some leftover antibiotic from the previous prescription – can I use it? The leftover antibiotic cannot be used and should be discarded. Do not selfmedicate your child, especially with antibiotics.

QCan we give 2 medicines together? Yes, you can use paracetamol and an antibiotic together, if your baby has UTI, for example. But follow your doctor’s advice on how to do it.

QWhat can I give for teething? Can I use teething gels? Most paediatricians will recommend only paracetamol for teething pains. Most teething gels contain benzocaine, which can produce a life-threatening disorder called methaemoglobinaemia that reduces the oxygen-carrying capacity of the haemoglobin in the body. Teething is rarely the cause for diarrhoea or runny noses.

References Arora, M. (2018, 20 August). ‘Hip Dysplasia in Infants: Causes, Signs, Diagnosis & Treatment.’ Retrieved 16 June 2020, from https://parenting.firstcry.com/articles/hip-dysplasia-in-babies-signsdiagnosis-and-treatment/ Australian Parenting website. (2018, 22 June). ‘Febrile Convulsions.’ Retrieved 16 June 2020, from https://raisingchildren.net.au/guides/a-z-healthreference/febrile-convulsions Bailey, E. J. & Chang, A. (2008). ‘In Children with Prolonged Cough, Does Treatment with Antibiotics Have a Better Effect on Cough Resolution Than No Treatment?: Part A: Evidence-Based Answer and

Summary.’ Paediatrics & Child Health, 13(6): 512–13. Bergamini, M., Kantar, A., Cutrera, R. & Group, I. P. (2017). ‘Analysis of the Literature on Chronic Cough in Children.’ Open Respiratory Medicine Journal, 11(1): 1–9. doi:10.2174/1874306401711010001 De Leonibus, C. et al. (2016). ‘Influence of Inhaled Corticosteroids on Pubertal Growth and Final Height in Asthmatic Children.’ Pediatric Allergy and Immunology: Official Publication of the European Society of Pediatric Allergy and Immunology, 27(5): 499–506. Drescher, B. J. et al. (2013). ‘The Development of Chronic Cough in Children Following Presentation to a Tertiary Paediatric Emergency Department with Acute Respiratory Illness: Study Protocol for a Prospective Cohort Study.’ BMC Pediatrics, 13: 125. Global Initiative for Asthma. (2021). ‘Global Strategy for Asthma Management and Prevention. Retrieved 16 June 2021, from www.ginasthma.org Iapb.org. (2021). ‘What Is Squint in Children? Starbismus Causes & Treatment.’ Retrieved 5 September 2021, from https://www.iapb.org/wpcontent/uploads/ACTION_PLAN_WHA62-1-2009-2013.pdf Garone, S. (2020, 22 December). ‘How Much Milk Should a Toddler Drink? Nutrition and More.’ Healthline. Retrieved 16 June 2021 from https://www.healthline.com/health/childrens-health/how-much-milkshould-a-toddler-drink#recommended-amount. Geme, J. W., Blum N. J., Shah S. S., Tasker R. C., Wilson K. M., Kliegman R. M. & Behrman R. E., editors. (2019). Nelson Textbook of Pediatrics, 21st ed. (pp. 532–38). Philadelphia, PA, USA: Elsevier. Gwiszcz, J. A. (2016, 28 November). ‘Making the Switch to Cow’s Milk for 1year-olds.’ Children’s Hospital of Philadelphia website. Retrieved 16 June 2021 from https://www.chop.edu/news/making-switch-cow-s-milk-1-yearolds#:~:text=If%20your%20baby%20isn’t,milk%2Fformula%20to%20whole%20milk Sharathkumar, A. A. & Pipe, S. W. (2008). ‘Bleeding Disorders.’ Pediatrics in Review, 29(4): 121–30. doi:10.1542/pir.29-4-121 Singh, D., Arora, V. & Sobti, P. C. (2002). ‘Chronic/Recurrent Cough in Rural Children in Ludhiana, Punjab.’ Indian Pediatrics, 39(1): 23–29. Stein, R. T. (2008). ‘Early-Life Viral Bronchiolitis in the Causal Pathway of Childhood Asthma.’ American Journal of Respiratory and Critical Care

Medicine, 178(11): 1097–98. doi:10.1164/rccm.200808-1305ed Texas Children’s Hospital. (n.d.). ‘Labial Adhesions.’ Retrieved 16 June 2020, from https://www.texaschildrens.org/health/labial-adhesions

12 Keeping Your Baby Safe

Babies born in recent times are more exposed to toxins from different sources than any other generation in recent history. And, with technological advancement, these babies are going to live longer, exposing them further. These toxins can be present in the air or ingested through food and water. Babies are more prone to pollution because of certain features that are unique to them:

They breathe faster than adults, hence they shift more air. So they are exposed to more air pollutants like second-hand smoke, carbon monoxide and industrial chemicals. Given their body weight, their fluid intake is disproportionately higher than adults. So, if our water source is contaminated, they are more exposed to the chemicals. In the first year of their life, babies are constantly putting everything in their mouth. This exposes them to chemicals such as lead. Given their body weight, food consumption is disproportionately more than adults. Therefore, contaminated food affects them more. Their body surface area is larger than an adult. So, the skin absorbs more toxins as there is more surface for absorption. Unborn foetuses exposed to toxins can have problems with organ formation.

Toxins Let’s look at some of these toxins that occur naturally, and those that are manmade.

Naturally occurring toxins: Lead Mercury Radon Formaldehyde Benzene Cadmium

Man-made toxins: Bisphenol A (BPA) Phthalates Pesticides

Many of these: cause cancer (benzene, radon and formaldehyde) act as endocrine disruptors (BPA, pesticides, phthalates) cause organ failure or developmental problems (lead, mercury or cadmium)

Lead Most people are aware of lead poisoning, a serious and, sometimes, fatal condition. The sources of lead are old lead pipes and lead-based paint found on

walls, toys and art supplies.

Cadmium toxicity Cadmium is a toxic non-essential transition metal that poses a health risk for humans as well as animals. It naturally occurs in the environment as a pollutant derived from industrial and agricultural sources. Industrially, it is best known for its use in electroplating and the production of nickel-cadmium batteries. You can be exposed to cadium mainly by consuming contaminated food and water and also through cigarette-smoking. Cadmium can accumulate in both animals and plants and has a very long half-life (take time to leave your baby) of 25 years. Occupational and environmental exposure to cadmium can lead to various cancers, involving the lungs, breasts and kidneys, and osteoporosis in adults.

Mercury This is a heavy metal that is present naturally in the environment (soil, minerals and fossil fuel). It exists in 3 forms: Elemental (thermometers, dental fillings) Inorganic (batteries, disinfectants) Organic (methyl mercury in fish, pesticides, fungicides, insecticides) Mercury can be introduced into the food supply in a variety of ways, most commonly as a by-product of pollution. Burning fossil fuel and mining (mercury is used to extract gold) can emit inorganic mercury vapour into the air. This mercury floats around and finally enters our water systems. In water, it is converted to its organic form, methyl mercury, by microorganisms. The greatest risk of mercury poisoning comes from the mercury that is in our diet. It can also come from the following: Livestock that has been fed fishmeal Plants grown in water contaminated with mercury

Foods stored in pottery with mercury-based paint. The older the piece, the more chances of it having both lead and cadmium. Mercury is used in paint as it’s a fungicide as well as an antibacterial. All paints have some mercury and unfortunately, here in India, they don’t have any body to regulate the level of toxins in our everyday household cleaners and paints. Duck eggs Pesticides Fish oil Mercury accumulates in the tissues of both humans and fish. Larger fish have more mercury as they eat more and live longer. Farmed fish has less mercury because they have a shorter life span. Cooking and cleaning fish does not help to get rid of mercury. High mercury levels in pregnant women can cause irreversible damage to the foetus. Mercury poisoning has been linked to problems in the nervous system and kidneys. The body can eliminate mercury with the help of fruits and vegetables and non-contaminated omega 3s, such as: Cruciferous vegetables like cauliflower, and others like garlic, onions, leeks, avocados and asparagus Fruits like watermelon Nuts like walnuts and cashews Coconut Seeds like flax and chia Wholegrains like oats and lentils

Endocrine Disruptors These include a wide range of substances that are natural or man-made that may interfere with body’s endocrine system and produce adverse developmental, neurological and immune effects. They mimic oestrogen and are found in many everyday products:

Plastic bottles and containers Food can liners Detergents Flame-retardants Toys Cosmetics Pesticides The most potentially dangerous ones are BPA, phthalates and pesticides. These endocrine disruptors pose the greatest risk during the prenatal and early postnatal life.

BPA BPA is used in the manufacture of polycarbonate plastics and epoxy resins that are used in food and drink packaging, water and baby bottles, bottle tops and water-supply pipes. Low-dose exposure can lead to obesity, aggressive behaviour, early onset of puberty, hormone-dependent cancers like breast and prostrate and low sperm count. This chemical leaches out of plastic into food and water when containers are stressed (from heating or using a dishwasher with hightemperature settings). The highest levels of these compounds are usually seen in infants. Canada has been the first country to declare BPA a toxic substance. You can reduce BPA exposure by:

Minimising the use of plastic containers that have ‘#7’ and ‘#3’ on the bottom Not heating food in plastic containers in the microwave Using glass or steel containers Using BPA-free baby bottles Eating less canned foods Using glass or porcelain to warm and serve food

Pthalates This is the second big group of endocrine disruptors and animal carcinogens. Phthalates are found in plastic cooking wrap, shampoos, diaper rash creams and even toys. These compounds are absorbed through both the skin and the intestine and is finally excreted through urine. So please always read labels when you buy plastic toys to ensure they are phthalate free – especially teethers. Don’t use plastic lids and wraps when warming food in the microwave.

Air Pollution Children face a special risk from air pollution because their lungs are growing, they are extremely active and they breathe in a great deal of air. Most of the lung growth happens after your baby is born and lung development carries on till adulthood. The air sacs or alveoli develop mainly after birth. This is where the air exchange happens and oxygen moves into the blood to be carried to the tissues. Since the immune system is still developing in young children, they are also more prone to frequent upper respiratory infections. Little children are also outdoors more often and hence inhale more polluted outdoor air. There are studies linking air pollution and preterm births. Studies have linked prolonged exposure to air pollutants to reduced lung growth which may never recover to its full capacity. Air pollution also leads to more episodes of chronic cough, common cold and conjunctival symptoms.

Frequently Asked Questions

Q I am worried about hormones in cow’s milk. Can I give my baby soya milk? Does it have oestrogen? Growth hormones are used to increase milk production in cows. This hormone is destroyed by pasteurisation. Also, the growth hormone is ‘species

specific’, meaning it will not have any effect on humans. The main concerns in dairy are pesticides which come from water, and antibiotics and growth hormones that are given to cows. Pesticides are found even in breastmilk, as most of our water is contaminated with pesticides. Even though organic milk may not have antibiotics, antibiotics are used for cows, and this is what produces antibiotic resistance. So it’s important to find alternatives to antibiotic use in cattle to prevent antibiotic resistance in the community. Farms where you get organic milk are supposed to discard the milk from cows that are on antibiotics for various reasons. Soya milk has a compound called isoflavones, which is like oestrogen. Soya milk is routinely used only for certain conditions like galactosaemia (when the body is unable to use a sugar called galactose). Or, for short periods, when you suspect lactose intolerance or cow’s milk protein intolerance, though currently there are other extensively hydrolysed cow’s milk formulas to treat cow’s milk-protein intolerance.

Cow’s Milk and Lactose Intolerance For the first 6 months, babies need breastmilk, or formula in case breastfeeding is not possible. Once you start adding solid foods to your baby’s diet, you should ideally continue breastfeeding or formula at least until your baby reaches 10–12 months. This is to ensure that your child gets properly nourished. After which, I personally do not recommend more than 300–350 ml of milk in a day. However, you can continue to breastfeed, if you so desire, till 2 years of age. After 1 year, your baby can have regular cow’s milk, but it should be full cream. Skimmed milk can be given to children after they reach 2 years of age. While it is important that your child is not calcium deficient, you should make sure that you do not overdo it with the milk. In addition, milk can be very filling and can reduce your child’s appetite, which can affect mealtimes. It can also interfere with iron absorption, leading to iron deficiency anaemia. In case there is a family history of allergies, or if the family is vegan, calcium can be found in green and leafy vegetables, fish, nut and nut butters, as well as plantbased oils and avocados. For protein requirements, legumes and tofu are ideal. Unfortunately, alternatives like rice milk lack protein and nutrients when compared to dairy but you can offer your child fortified soya milk. If soya milk is not your or your child’s cup of tea, then you can try almond milk. However, this can only be offered after your child is a year old. Almond milk has less calcium than cow’s milk but once it is fortified, it nearly equals the

calcium levels found in the latter.

QDoes rice contain arsenic? Arsenic is one of the most toxic elements. It is present in its organic form in plants and animals. This is the less toxic form. Inorganic arsenic, which is more toxic, is found in soil and rocks, or dissolved in water. Arsenic is present in small quantities in nearly all food and drink. High levels are found in contaminated water and mostly seen in South East Asia and South America. It is also present in its organic form in seafood like shrimp and other shellfish. The single biggest food source of arsenic is rice, especially in its inorganic or more toxic form. It is found in rice milk, rice bran and all rice-based products. Paddy needs a lot of water to be cultivated, and this arsenic also remains in the soil. Rice absorbs more arsenic from soil and water than other food crops. It even absorbs it from cooking water. The main sources of arsenic pollution are pesticides, wood preservatives, phosphate fertilisers, industrial waste, mining coal, burning and smelting. This arsenic drains into ground water and from there into wells and other water supplies used for irrigation and cooking. Toxic symptoms of arsenic take many years to develop. Long-term ingestion may increase the risk of cancer, heart disease, type 2 diabetes and even decreased intelligence. Young children are especially vulnerable to arsenic poisoning since they eat more, compared to their relative size, than adults do. As a result, they take in greater quantities of arsenic. In some parts of the world where rice is the main staple, it is more of a concern. An additional concern is brown-rice syrup, which is used to make infant formula. It is difficult to ascertain which rice has more arsenic as it involves getting it tested from a lab, which is not always feasible.

Things you can do to minimise the effect is to wash rice very well before cooking, use plenty of water for cooking, and throw out that water once the rice is cooked. Brown rice has more arsenic than white rice. Rice grown in the Himalayan regions, like Basmati, has been shown to have less arsenic. The most important thing is to give your baby a varied diet. This way your baby gets all the nutrients that she needs, and the diet is not dominated by one food group.

QWhat are genetically modified foods? Are they safe? As technology advances, seeds are modified to withstand drought, disease and many other factors, so that they are sturdy. This makes sure that people all over the world have enough food. There are many who are worried about long-term effects of these genetically modified organisms (GMOs). Though studies have not shown any direct link between this and any disease, infant formula companies claim that they are using non-genetically engineered ingredients in their products. If you are worried, you can look for products that say non-GMO.

QIs food colouring harmful for my baby? Food dyes or colours are added to food to enhance or maintain their appearance. The FDA allows 9 different food colours to be added in our food. The 4 colour additives that are commonly used are: Red #4 (Allura Red) Yellow #5 (Tartrazine) Yellow #6 (Sunset Yellow) Blue #1 (Brilliant Blue)

Natural colours come from food like beta-carotene from carrots, saffron and purple grapes. Synthetics colours are derived from chemicals, and they are of 2 types – dyes or lakes.

Dyes are usually water-soluble colouring agents which may be in the form of a liquid or a powder. Lakes are usually found in oils and fats and are not water-soluble.

These artificial colours have no nutritive value. Beverages, as they are consumed in large quantities, are one of the largest sources of food colour in our diet. Other foods that are sources of these additives are candy, ready-toeat cereals, popsicles, ice creams, cakes, desserts and boxed snacks. Even foods like white icing may have white colouring to make it look very white. Children that are sensitive to food colour exhibit symptoms like eczema and a recurring allergic cough. Which is why you should limit their intake of foods that contain synthetic dyes. Studies have not shown a direct link between ADD and artificial food colouring. But I think it’s not a bad idea to limit the intake of processed foods. Talking about chemicals, heterocyclic amines (HCAs) are produced when foods are cooked on high heat like frying or grilling. These chemicals are thought to cause cancer. Chicken produces more HCAs than other meats. So it’s prudent to limit this form of cooking to maybe once a week. Moderation is the name of the game. The other chemical is sodium nitrate. This is usually present in processed meats like sausages to prevent botulism. It also makes the food look better. These nitrites get converted to nitrosamines, which are known animal carcinogens.

Processed meats also have a larger salt and fat content compared to nonprocessed meats. Hence, their consumption should be in moderation.

Q It’s time to do pest control at home, but I have a small baby. How do I go about it? You have to be very careful if you want to do pest control in your house. Pesticides come in many forms: bug sprays, insect repellents, weed killers and rat poison. All these chemicals are toxic for your baby. They can be ingested or absorbed by the skin or inhaled. These pesticides have been linked to childhood cancers, like leukaemia, soft tissue, sarcomas, and even brain tumours. So, ideally, don’t do routine pest control; it’s better to get pest control services from companies that use child-friendly chemicals or natural alternatives. If you must do pest control, set traps, do the outside of the house before you do the inside. See if there’s any pest control company close to where you live that uses organic products. Prevention is what you need to practise. Pests need food and water and if you make your house unappealing, then they are unlikely to hang around.

Pick up all food spills and crumbs right away. Keep counters, tables, sinks and floors clean. Wash, clean and dry dishes as soon as the meal is done. Clean under kitchen appliances like refrigerators, ovens and gas stoves. Store food in containers with airtight lids or in a refrigerator. Keep trash in a covered bin with a tight lid. Fix leaks and keep surfaces dry. Try to keep your home clutter-free; piles of books and magazines can attract pests. Don’t leave pet food out overnight.

Q Is it ok if I smoke outside the house? This way my baby will not inhale the smoke. It is not ok! If you are smoking, whether inside or outside, the smoke settles in your clothes and hair and skin. And then, your baby automatically gets exposed to second-hand smoke and its effects. Air pollution has a direct link to asthma. It can trigger exacerbations.

Ways to Reduce Pollutants in Your Child’s Environment Don’t smoke. Don’t use barbeques indoors. Keep windows open for short periods to ventilate the rooms and do damp dusting. Limit cell-phone use, especially when talking to grandparents – use video-calling instead. (This limits the exposure to electromagnetic forces.) Days when air pollution is bad, it’s better to stay indoors. Do pest control only when it is necessary, as the pesticide residue tends to stay in upholstered furniture and stuffed toys. First thing in the morning, let the kitchen tap run for a minute before you use the water. Try and grow your own vegetables, if possible. Consume seasonal vegetables. Scrub and wash the vegetables well. Peel whatever vegetables and fruits you use. Include different food groups in the diet, e.g., fruits, vegetables, grains, protein and dairy. Reduce the amount of processed food in your baby’s diet. Limit canned foods.

Avoid plastic containers as much as possible, especially to heat food. Use glass or porcelain instead. Reduce the amount of tuna and shellfish your baby eats. Try walking to places more and use carpools. If more people do that, the air quality might improve. Try and use more organic cleaners.

Calling Your Doctor: You may be scared of calling your paediatrician in case she is busy – you don’t want to disturb her. But counselling parents on the phone is part of the job description of a paediatrician. Your doctor will always carry the phone, but it is important to know when to call. You should not call your doctor at 2 a.m. for a problem that has persisted for 3 days, or discuss a diaper rash in the wee hours of the morning. If your doctor answers your queries via text messages, then it is better to text her rather than calling during outpatient hours. Don’t expect your doctor to prescribe antibiotics on the phone and don’t ask permission to use an antibiotic prescribed in the previous visit. Don’t expect an answer immediately. You cannot expect your doctor to stop doing what she is doing to answer your call. Most doctors answer messages after they have finished their outpatient hours. Nowadays, doctors are doing video consultations as well. This can save you a trip to the clinic if it is a minor problem. Please have your questions ready, and a pen and paper handy to write down what is told. At the end of the phone call, don’t send a message asking the doctor to text the name of the medicine, as you did not hear properly.

References

References AAP. (2018, February). ‘Poison Prevention Tips from the American Academy of Pediatrics.’ Retrieved 16 June 2020, from https://www.aap.org/enus/about-the-aap/aap-press-room/news-features-and-safetytips/Pages/Poison-Prevention-Tips-from-the-American-Academy-ofPediatrics.aspx Lanphear, B. P., Vorhees, C. V. & Bellinger, D. C. (2005). ‘Protecting Children from Environmental Toxins.’ PLoS Medicine, 2(3): e61. Liu, Y., Xu, J., Chen, D., Sun, P. & Ma, X. (2019). ‘The Association between Air Pollution and Preterm Birth and Low Birth Weight in Guangdong, China.’ BMC Public Health, 19(1). Ritz, B., Wilhelm, M., Hoggatt, K. J. & Ghosh, J. K. (2007). ‘Ambient Air Pollution and Preterm Birth in the Environment and Pregnancy Outcomes Study at the University of California, Los Angeles.’ American Journal of Epidemiology, 166(9): 1045–52. WHO. (n.d.). ‘Children and Air Pollution.’ Retrieved 16 June 2020, from https://www.who.int/airpollution/news-and-events/how-air-pollution-isdestroying-our-health/children-and-air-pollution

13 Preterm Birth

Being a new parent is already tough, but when the baby is born early (a preterm birth), there are many more challenges. Preterm babies are those born between 24 weeks and 36 weeks of pregnancy. Delivery before 22 weeks is usually termed a miscarriage according to Indian law and a paediatrician will not be called to attend the birth. Between 22 and 24 weeks, the couple, in consultation with the paediatrician or neonatologist, will take a decision on the resuscitation of the baby. Preterm babies are further divided into: Late preterm (34 weeks to 36 weeks and 6 days) Moderate preterm (32 weeks to 34 weeks) Very preterm (28 weeks to 32 weeks) Extremely preterm (less than 28 weeks) According to Indian law, after the 24th week of pregnancy (the stage beyond which the baby is able to survive on its own), aborting a baby is illegal. If a baby is born after 24 weeks, the neonatologist will be called to attend the delivery and all efforts to help the baby survive that transitional period immediately after birth will be made. If the delivery is not imminent, the neonatologist will discuss all the possibilities that can happen after the baby is born. She will explain the different challenges the baby will face over the coming weeks. Most units will have a counselling session with the parents every day, explaining all the things

that have happened to the baby and those that are likely to happen over the next few days. Babies born between 37 and 38 weeks are simply called early-term babies. A neonate is the term used for babies from the period of birth up till 28 days after delivery. Neonates are further divided into: Early neonate (0–7 days) Late neonate (7–28 days) Special care given to this group of babies is provided by trained doctors (neonatologists) in a NICU. Babies weighing less than 2.5 kg are called low-birth-weight babies. Usually, premature births are the result of various issues that cause early labour. At other times, it may be because of problems that necessitates the early termination of the pregnancy. Sometimes, there is no obvious cause. To help reduce the incidence of preterm deliveries, specific care and attention is given to the mother during pregnancy, especially if there are risk factors. This period is called the prenatal period, to denote the period before the time of delivery.

Possible Causes of Preterm Labour Being pregnant with more than one baby: Increased use of in vitro fertilization (IVF) and other assisted reproductive techniques (ART) has made multiple births and twin pregnancies very common. So it is important that we identify such pregnancies and provide them with a higher level of care, especially as they need closer monitoring. In multiple births, as the weight of the 2 or 3 babies together is always more than a singleton, the uterus overdistends and leads to preterm labour. Bleeding or other problems in the uterus. Infection in the body or in the uterus.

Stress: This seems to be the reason for many problems lately. The exact mechanism is unknown but it is a well-known cause of preterm birth. Some types of stress can lead to high blood pressure which leads to preterm labour. Having had a preterm labour or birth before. Getting pregnant again within 1 year of delivering a baby. Age: Being younger than 16 and older than 36. Chronic health problems like heart disease or kidney disease. Smoking and addiction to drugs (like cocaine). Problems caused by pregnancy: Infections High blood pressure Diabetes Blood-clotting Placental problems

Nowadays, thanks to neonatal intensive care, more and more preterm babies are surviving. Babies born after 28 weeks and weighing more than 1 kg have as much as a 90% chance of survival in a good NICU. A small number of these babies may have long-term health and developmental problems. Babies born earlier than 28 weeks could have more complications than if they were born at term. If your baby has a relatively smooth course in the ICU before discharge, then the chances of her having any long-term problems is very small. But if your baby has complications during her stay in the NICU, then your paediatrician will keep a close watch on your baby’s development in the coming months.

How Your Preterm Baby Looks The earlier your baby arrives, the smaller your baby will be. The head will appear larger in relation to the body. She will have less fat. So her skin will look thinner and may appear

transparent. You might even be able to see her blood vessels through the skin. She will be covered with fine hair called lanugo, more on her back and shoulders. Her features will appear sharper and less round than a full-term baby. She might not have any vernix caseosa – the cheesy white material that covers term babies, mainly in the third trimester. This layer protects the newborn baby’s skin helping it to adapt to postnatal life. Your baby may not cry very loudly, or very much, depending on how early she has arrived and what problems she may have been born with. (We will discuss these in detail in this chapter.) As these babies have hardly any layer of fat, they have difficulty in maintaining normal body temperature. Hence, they may need an incubator or radiant warmer to keep them warm.

NICU This is where your baby will stay for a few days or even a few weeks. Most neonatal units will allow parents to visit and, as the baby becomes more stable, parents may be asked to participate in the care of the baby.

Equipment in the NICU Incubator The incubator is meant to mimic, as much as possible, the environmental conditions that your baby enjoyed while in the womb. The incubator provides your baby with the optimal growing environment – the right amount of warmth, humidity and oxygen so that she can grow. Babies less than 1 kg will usually be looked after in an incubator, as humidity is important to maintain the balance of sodium and potassium in the little body.

Hence, the baby’s treatment is conducted within the incubator so that he doesn’t have to come out and be exposed to the risk of infection. His temperature will be monitored constantly and the heating adjusted so that all the calories that are given to him will be used mainly for growth.

Infant Warmer In some neonatal units, infant warmers or open-care systems are used. They provide easy access to babies, hence may be used for looking after sicker babies who are not stable and who need procedures done to them. Bigger preterm babies who don’t need much humidity can also be managed under an infant warmer. The temperature of the infant warmer can be adjusted to optimise the condition of the baby in relation to the temperature of the room.

Ventilator Through major improvements in technology, ventilators minimise lung damage in preterm babies. Small puffs of oxygenated breath are provided by the ventilator to the baby, according to her needs. These machines are calibrated to support the baby’s breath and also provide a breath when there is no spontaneous breathing by the baby. As the baby’s lungs improve and mature, the support is slowly reduced – this process is called weaning. For some babies, it can happen in a couple of days, while the very small ones may take a few weeks.

Phototherapy Unit The phototherapy system shines a warm blue light over your baby that helps to break down bilirubin, which is then passed out harmlessly in the stool. Your baby may need a few days under the light. The more premature the baby, the longer they will spend under these lights. This has been discussed earlier in the chapter on jaundice in the newborn (see p. 17).

Infusion Pumps

The infusion pump is used to provide fluids, nutrients and medicines to your baby through an intravenous cannula placed in a vein. The cannula is a small tube placed in the baby’s vein through which dextrose and other fluids run into the body. These machines are calibrated to provide even very small doses without error. Some babies may need more than one pump at a time as they may need fluids and multiple medication like antibiotics and pain relief medicines at the same time.

Monitors As soon as your preterm baby arrives, she will be hooked on to one of these monitors with the help of wires or probes that help to monitor the heart rate, breathing rate and oxygen levels in the blood. These parameters are important – they help the nurses and doctors looking after your baby provide optimal care and indicate if things are going wrong.

X-rays and Ultrasound X-rays are done to monitor the progress of internal organs, especially the lungs, and help chart out the best treatment plan for your baby. Ultrasound imaging is a common bedside procedure done in the NICU. It can give doctors a clearer picture of internal organs like the brain, heart, lungs and liver. There is no radiation involved and it is painless. Serial ultrasound can be done to chart the course of the problem.

Procedures in the NICU Intravenous (IV) Lines Intravenous lines or cannulae are used to provide fluids and medication to the baby. These lines may be placed in the umbilicus, arm, leg and even the scalp. Once the line is inserted, it will not cause pain. Sometimes they are inserted into deeper veins in the neck or groin so that they last longer. These are called peripherally inserted central catheters (PICC) or central venous catheters.

Arterial Lines An arterial line is a cannula or plastic tube called a catheter line placed in one of the arteries – either in the umbilicus, arm or leg. This helps the staff monitor the blood pressure as well as take frequent blood samples. An infusion of normal saline with a small amount of heparin is run through it to prevent it from blocking.

Eye Tests All babies less than 1.5 kg of weight and below 32 weeks of age get regular eye tests. The first check-up happens 2 weeks after birth or when the baby reaches 32 weeks corrected age, whichever is sooner. (If your baby was born at 28 weeks and is now 4 weeks old, the corrected age is 32 weeks.) Drops will be put in the baby’s eyes to dilate the pupils for the examination. These examinations are done to rule out retinopathy of prematurity which is a potentially blinding disease seen in premature babies or babies who have experienced a particularly stormy neonatal period (see p. 345).

Newborn Hearing Test Newborn babies have their ears checked on discharge from the hospital or a few days after going home. These hearing tests aim to rule out congenital nerve deafness. A failed test does not necessarily mean your baby has a serious hearing problem, but close monitoring, follow-ups and advanced screening may be necessary.

Blood Transfusions When babies are ill, they need to have a lot of blood tests done. Sometimes they may lose blood around the time of delivery. Newborn babies, especially premature babies, are unable to make enough blood to replace these losses. So anaemia may develop and the baby may need a blood transfusion. This is done through a vein for 3–4 hours. Some sick preterm babies may need multiple transfusions over the course of their stay in the NICU.

Problems of Preterm Babies Respiratory and Lung Problems Many babies admitted to the NICU have some degree of breathing problems. It may range from needing extra oxygen in mild cases to needing ventilatory support. The ventilatory support may be either by continuous positive pressure ventilation (CPAP) or assisted ventilation.

Respiratory Distress Syndrome (RDS) This is the most common condition that affects premature babies. It is due to immature lungs which are deficient of a substance called surfactant. Surfactant is a substance that coats the small air sacs in the lung and allows them to open and close with minimum effort. It is produced in the developing lung from 20 weeks gestation onwards, but the greatest production happens 6 weeks before term. If there is a chance of preterm labour, then mothers are given a steroid injection to mature the lungs and increase the production of surfactant. Lack of surfactant will make breathing much harder. The signs are that the baby breathes much faster than normal for his age and with greater effort. There will be indrawing of the muscles of the ribcage (retractions) and you will hear a moan or grunt every time the baby breathes. This grunt is the body trying to keep the air sacs from fully collapsing with each breath. Respiratory distress will usually worsen over the first 72 hours and then slowly start to improve as the immature lung increases its production of surfactant. Nowadays, surfactant can be instilled in the lung immediately after birth through the endotracheal tube or breathing tube.

Medical Solutions Mechanical Ventilation A ventilator is a machine that can help premature babies breathe or even completely take over the process of breathing. For this, a plastic tube called the

endotracheal tube is passed via the mouth into the trachea. It is fixed in place with the help of tape and is connected to the ventilator. The nurse and doctor will adjust the settings depending on how much help the baby requires with the breathing. As the babies’ lungs improve, the settings of the ventilator are reduced till it is time to come off the machine. This process is called weaning. Depending on the baby, this process may take from a few hours to several days. Some babies who are very sick may not do very well on the conventional ventilator and will have to be shifted to a different form of ventilation called high frequency oscillatory ventilation (HFOV). The HFOV delivers very small breaths at a very high rate and it will seem like the chest wall is vibrating.

Continuous Positive Pressure Ventilation (CPAP) This machine continuously blows warmed moist air and oxygen into the baby’s lung under a slight positive pressure. The air and oxygen can be delivered by soft tubes placed in the nose called nasal prongs or by a mask fitted over the nose. The prong or mask is held in place by being tied to a cap on the baby’s head. In this form of ventilation, the baby is doing all the breathing himself, but the positive pressure delivered by the machine prevents his lungs from collapsing completely with every breath, therefore making breathing easier. You can use CPAP right from birth or as a transition from the ventilator to breathing on his own. It is not uncommon for babies to need CPAP off and on for a few weeks as the lungs grow and mature. In some units, they use a heated humidified high flow nasal cannula (HHHFNC). This delivers a high concentration of oxygen and some degree of positive pressure. Its ease of use and less trauma to the nose make it popular.

Nasal Oxygen Some babies need low levels of oxygen when they come off the ventilator or CPAP. This can be given by placing tiny tubes in the nostrils called nasal prongs. Some babies may need this extra oxygen for a long time and occasionally may be discharged needing oxygen.

Nitric Oxide

Nitric oxide is a gas that is naturally produced by the body and helps relax blood vessels. In some cases it is needed to help difficult ventilation by relaxing the blood vessels in the lung. The gas is put directly into the lungs via the breathing circuit of the ventilator.

Transient Tachypnoea of Newborn When babies are in the womb, their lungs are filled with fluid. During delivery, most of the fluid is pushed out of the lungs or reabsorbed into the blood stream so that the baby can start to breathe. If, for any reason, some of this fluid remains in the lung, the baby will have rapid breathing after birth. This results in transient tachypnoea of newborn (TTN). This is more commonly seen in term or near-term babies than in preterm babies. Treatment may involve giving supplemental oxygen or more assistance with breathing. It usually improves over the first few hours or days of life. Generally, the baby will not be fed or fed smaller volumes through a tube placed through the mouth or nose into the stomach, until her breathing has slowed to the normal range of 40 to 60 per minute.

Apnoea and Bradycardia All newborns tend to have an irregular breathing pattern with episodes of very quick breathing followed by a pause. Premature babies may also have an immature breathing centre and so might ‘forget to breathe’, which is called apnoea. Apnoea may also be accompanied by bradycardia where the heart rate slows down. These episodes can be quite frightening for parents but are seldom a real risk to your baby. An alarm sounds instantly as the problem occurs, and nursing staff helps at once by gently patting the baby’s back or rubbing the soles of his feet to remind him to breathe. Caffeine is a medicine given to babies to stimulate their breathing. It is usually given till 34 weeks’ gestation, but some babies may need to take it for longer. If they don’t respond to these methods, they may need more assistance with breathing like CPAP or ventilation.

Chronic Lung Disease

This is usually a lung condition that is seen in very premature babies who have been on mechanical ventilation or CPAP or even oxygen for RDS. Some babies experience spasms or tightening of their airways similar to that in asthma. It is often difficult to wean her from CPAP and oxygen and establish full feeds. Some of these babies are started on diuretics. As the baby grows, new, undamaged lung tissue will grow, improving her condition.

Pneumothorax This is otherwise called an air leak, because air leaks from damaged parts of the lung into the space surrounding the lung. The good lung then becomes compressed and breathing becomes harder. The baby will need extra oxygen or, if on the ventilator, the requirements will increase. Usually, a small tube is placed through the chest wall to remove the collected air so that the collapsed lung can re-expand. She will be given either a local anaesthetic or a painrelieving medicine before the procedure. Some newborns, generally larger babies, may have a spontaneous pneumothorax after birth. This will usually settle by giving extra oxygen, intravenous fluids and rest.

Persistent Pulmonary Hypertension of Newborn (PPHN) Term or post-term babies are most prone to PPHN. It happens when the newborn’s circulatory system does not adapt to breathing outside the womb. The pressure in the lungs remains very high and blood bypasses the lungs via a blood vessel called ductus arteriosus. When the blood bypasses the lungs, it does not get oxygenated. Causes may include a difficult birth process, even infection picked up prior to delivery, meconium aspiration syndrome or birth asphyxia. The treatment involves trying to lower the pressure in the lung. This can be achieved by adequate ventilation and high levels of oxygen, and sometimes nitric oxide.

Meconium Aspiration Syndrome Sometimes, when a baby experiences problems prior to delivery, she may pass

meconium in the womb. So when the baby gasps in the womb, she inhales this meconium-laden amniotic fluid. The inhaled meconium irritates her airways and makes it difficult for her to breathe. Mild cases may only need oxygen but severe cases will need ventilation.

Jaundice Newborns are constantly making new red blood cells and the old ones are being broken down. One of the waste products of this process is bilirubin. Bilirubin is processed by the liver into an easily disposable form and then eliminated from the body in the stool. Bilirubin is the end product of destruction of RBCs and further processed in the liver. Babies who are jaundiced become sleepy and difficult to feed. When your baby’s doctor tells you that she has jaundice, it means her skin has a yellow tint. This is not the same jaundice that adults get which is caught from eating contaminated food (hepatitis A) or caught from the blood of an infected person (hepatitis B and C) through transfusions, surgery or dental work. Some babies make bilirubin faster than they can get rid of it, causing the bilirubin to build up in the body and make the skin appear yellow. The yellow colour is most visible in daylight. Sunlight usually breaks down this excess bilirubin, but the baby has to be placed in direct sunlight with no clothes on. Given the fragile nature of these babies, technology steps in. Phototherapy is a process by which this bilirubin in the skin is broken down so that it can be excreted in the urine and stool. The phototherapy can be given by an overhead blue light or a bili blanket, a flat rectangular pad on which the baby is placed. This will not get hot and cause any discomfort to the baby. She will be given eye pads to protect her eyes from the light.

Sepsis Preterm babies are more prone to infection. This may be because:

Protective substances called immunoglobulins normally cross the placenta during the final weeks of pregnancy and babies that are born

early may not have had enough time to receive them. The normal responses to fight infection are poorly developed in preterm babies. The extra lines and tubes that are placed in them as part of treatment can pose the risk of infection.

It is important that the treating team is always on the lookout for early signs and symptoms of infection. If infection is suspected, then blood will be taken for some tests including a blood culture. A lumbar puncture, which involves taking fluid from the spinal canal to rule out meningitis, will also be done along with looking for infection in the urine. Antibiotics are given straightaway, as the test results may take up to 48 hours to come. The treating team’s aim is to prevent infection at all costs. Hand hygiene is the most important step to prevent infection in the NICU. You may be asked to frequently wash your hands and use hand sanitisers before and after touching your baby.

Low Blood Pressure When premature babies are sick, they frequently have problems maintaining their blood pressure. This is usually treated by giving extra fluids through an intravenous cannula or medication or even by giving blood.

Low Blood Sugar Blood sugar is one parameter that is frequently monitored in premature babies. It can be too high or too low. This is easily corrected by changing the concentration of sugar (dextrose) in the baby’s IV fluids. Blood sugar levels are usually checked from a heel prick sample. Variations in blood sugar may be an early sign of sepsis in a preterm baby.

Necrotising Enterocolitis (NEC) This is an inflammatory bowel disease affecting some newborns and premature

babies. The reason why some babies develop NEC is not fully understood but it usually happens when there is reduced blood supply to the premature baby’s bowel. This disease is staged from mild to severe. Treatment includes withholding feeds for up to 2 weeks or longer and giving intravenous fluids and antibiotics to help the intestine heal. Parenteral nutrition, a special drip which contains carbohydrates, protein and fat, is given till the baby can tolerate milk again. Although potentially a very serious complication, most infants given the right treatment will recover. A small number of infants who develop this problem will require surgery. Breast milk has been shown to reduce the incidence of this condition and for this reason we strongly encourage you to consider expressing breast milk for your baby. Probiotics have also been shown to reduce the risk of NEC, which is why most premature babies will be given probiotics.

Retinopathy of Prematurity (ROP) This is a condition where there is growth of abnormal vessel in the retina of the premature baby. Most babies don’t require any treatment but need regular monitoring. Moderate or severe ROP will need treatment. The ophthalmologist may inject a special substance into the eye or your baby may need laser therapy to destroy the abnormal blood vessels. Usually, this is done under sedation and some medicine for pain is also given. Even after the treatment, the baby will need regular check-ups. Long-term outcome depends on the severity of the condition with severe cases requiring spectacles (for short-sightedness). These babies need to be reviewed weekly or fortnightly till the retina matures, usually around 44 weeks post conceptual age.

Intraventricular Haemorrhage (IVH) This refers to bleeding into the natural spaces (ventricles) in the brain. Premature babies are more prone to this kind of bleeding as their blood vessels are very fragile. If the bleed is small, the baby may not show any signs or symptoms and it is only detected during routine ultrasound scans. These small bleeds are reabsorbed by the body just like a bruise. Larger bleeds may leave behind damaged tissue. An IVH may occur in as many as 60% of babies less

than 1 kg but they are usually small and don’t leave any residual effects. Larger ones could have both short- and long-term problems.

Patent Ductus Arteriosus In the womb, the blood circulating in the baby’s heart follows a certain route. This is referred to as foetal circulation, where it bypasses the lungs. This is because the lungs are filled with fluid and the baby doesn’t need to use her lungs as she gets her oxygen supply from her mother through the placenta. After delivery, once the connection to the placenta is cut, blood is redirected to the lungs as the baby needs to breathe in oxygen herself. The patent ductus arteriosus is a blood vessel that connects the pulmonary vein with the aorta. This structure which is useful in foetal life is supposed to spontaneously close after birth. If this remains open, the heart has to work harder and the baby develops breathing problems. She may need oxygen and sometimes ventilation too. A heart murmur may be heard, her pulse may be very easily felt but an ultrasound of the heart (echocardiogram or ECHO) is usually needed to confirm the diagnosis. Most of the time just reducing the amount of fluid given to the baby and a medication given to close the duct is all that is needed. Occasionally, a surgery may be needed to close the duct.

Seizures When a baby has abnormal movements of her arms, legs or eye, she may have had a seizure. There are many reasons why a baby may have a seizure: for example, infection, brain injury, metabolic or endocrine causes. Most babies will need medication to stop the seizure. An ultrasound of the brain will be done along with a test called electroencephalogram (EEG). Some babies may even need an MRI scan. Long-term outcome depends on the cause and severity of the seizure. She will be followed up long term to see how she grows and develops.

Neonatal Encephalopathy Sometimes during pregnancy, prior to or during birth, there may be a reduction

in the oxygen supply to the baby from the placenta. This can affect all of baby’s organs, but especially the brain, leading to brain injury (neonatal encephalopathy). There are different degrees of brain injury and the long-term outcome depends on the severity of injury. Recent evidence has shown that total body cooling can limit the degree of brain injury caused by neonatal encephalopathy. In this process, the body temperature which normally is 37°C (98.6°F) is cooled down to 33.5°C (92.3°F). The baby’s temperature is kept at this level for 72 hours and thereafter the baby is rewarmed to 37°C over the next 12 hours. The cooling is started as soon as possible and the baby is placed on a special mattress. While on treatment, he will be monitored closely and given pain relief. He will not be fed and will be given IV fluids instead. Sometimes, if there is a problem with his breathing, he may need to be ventilated. The period of cooling gives the brain a chance to recover from the injury. There are set guidelines which your doctor will follow to see which babies can be offered cooling as treatment.

Nutrition for Preterm Babies Premature and/or ill infants are often too weak to suck from the breast. These babies need special ways of feeding, such as tube feeding or intravenous fluids till they are ready to suck efficiently. All babies lose weight after birth and it can be up to 10% of their birth weight. Sometimes, babies who are not fed milk or are very sick may lose more weight or are slow to regain their birth weight, but this usually resolves with time. Thereafter, they start to gain weight steadily and gain about 150 gm a week for the first 3 months of their life, once they’re on full feed. Anything more than this is a bonus!

Intravenous Feeding The first issue for premature and/or ill infants is to regulate breathing and heart rate. At this time, digesting milk may be a problem and it may take a few days for the stomach to tolerate milk. Glucose and nutrients are given

intravenously through a cannula. As mentioned earlier, they may be placed in the umbilicus or belly button, or in a vein in the arm or leg. Sometimes it may need to be placed in the scalp (when we run out of veins in the arms and legs), for which a small area in the scalp is shaved off. Sometimes a PICC line may be inserted through a vein in the arm or leg. These can be left in place for a longer period of time. Some babies who cannot tolerate feed for various reasons, or babies who have had bowel surgery, may need to be given parenteral nutrition which comprises carbohydrates, protein and fat along with multivitamins and trace elements. This is provided intravenously.

Expressing Breast Milk If you had planned on breastfeeding your baby, you can do so even if your baby is premature. As premature babies cannot suck directly from the breast for various reasons, breast milk can be expressed or pumped with either a pump or by hand. This collection should be done in a sterile way. The nurse then feeds this to the baby with a tube placed right through the nose and into the stomach. Breast milk is the best milk for your baby because it meets her nutritional needs, is more easily digested, offers protection from infection and encourages growth and development of the gut. It is important that you start expressing as soon as possible after delivery, ideally within 6 hours. By expressing milk regularly, at least every 3 hours in the day and at least once at night (7 to 8 times a day), you will stimulate your milk supply in the same way as a baby sucking. This will help in establishing your breast milk supply and maintaining it till it is time for your baby to feed directly. You can express by hand or use a breast pump. It’s better if you express by hand in the beginning and at the end of each session. You need to wash your hands properly and also wash and sterilise parts of the pump after each session. It is important to label the milk with the date and time before you give it to the nurse in charge of your baby. Sometimes, if you have problems with the amount of milk that you express, you may be given a medicine to increase the output. It’s important that you maintain a sterile technique when expressing the milk which is then stored in the refrigerator. It cannot be stored for longer than 24 hours in the refrigerator. This milk is then carried to the

hospital in an ice bucket. If for any reason the mother is unable to express, there are breast milk banks that have milk donated by other mothers. This milk is heat-treated, tested and stored. Preterm babies need extra protein, minerals and vitamins over and above what is contained in breast milk. We can add these breast-milk fortifiers in the expressed breast milk to provide these extra additives. Probiotics are healthy bacteria that live in the gut. They help to keep the gut healthy and prevent the growth of harmful bacteria in the intestine. They are fragile, easily killed by antibiotics, and are replaced by harmful bacteria. As probiotics are less plentiful in the gut of premature babies as compared to older children and adults, they are given probiotics each day.

Tube Feeding Even after your baby can manage to digest milk, it may be some time before she can suck directly from the breast. The sucking reflex usually matures around 33 to 35 weeks’ gestation. In the meantime, he will be fed through a soft fine plastic tube passed through the nose or mouth into the stomach. A syringe is attached to the tube and milk is placed in the syringe. Gravity gradually pulls the milk into the stomach. At first only 1 to 2 ml of feed is given 2 hourly and the feed is built up slowly, as tolerated by the baby. Once the baby reaches 32 weeks, the cup or breastfeeding is attempted. Cup-feeding has been traditionally done by mothers using a paladai in Tamil Nadu and a jhinuk in Bengal. The nifty cup, made of silicone, now used in western units, is an adaptation of this. This cup feeding is a stop-gap method in the transition to breastfeeding. Once the baby is mature, around 33 to 34 weeks, he can be put directly to the breast and cup- and spoon-feeding can be reduced slowly. As they get older, it is very difficult to feed with a cup, as the baby gets very active. Babies also need the satisfaction of sucking, which is part of their development.

Feeding Your Baby As soon as your baby is well enough, you will be able to breastfeed her yourself.

The nursing staff will help you with this and most units will encourage breastfeeding. Initially she may feed every 2 hours and may get tired after a few minutes; you may then need to give the rest of the feed with the cup. The nurses will show you how to latch and recognize feeding cues. Sometimes it may take a little while to establish breastfeeding, so don’t give up – it’s worth all the trouble.

Preparing for Home There is no place like home. Your baby will be ready to come home when he is breastfeeding or cup-feeding, maintaining his temperature in a cot and gaining weight. He must also be free from apnoea and bradycardia and off the medicine caffeine. Some parents may choose to ‘room in’, where they stay in a room with the baby overnight. This will give the parents an opportunity to become familiar with the baby’s specific needs, knowing that the staff is close by in case you need help. Many parents are apprehensive at the thought of taking the baby home. Remember that the staff will not discharge your baby if they do not think the baby is ready for it. You should not worry as the hospital and doctor are only a phone call away.

Vaccinations Preterm babies need immunisations like all other babies to protect them from certain diseases that can cause serious illness or even death. Immunisation is a safe and effective way to protect your baby and works by causing the baby’s immune system to produce antibodies to fight diseases. For vaccination purposes, the actual age of the baby is used, not the corrected age. By this I mean, if your baby was born at 32 weeks and discharged at 34 weeks of age, the baby can be given the first set of vaccine 6 weeks after discharge when the baby will be 40 weeks post conceptual age. The corrected age is used when we are talking about developmental milestones in preterm babies. For vaccination, your doctor will try and sync your baby’s vaccine into the Indian vaccination schedule.

All the vaccines are similar to the vaccination schedule for term babies and have been discussed in the vaccination chapter (see p. 137).

Best Sleeping Position The best sleeping position for your baby is on her back. When in the ICU under a warmer, she may have been placed on her tummy to ease her breathing problems. Once she is in a cot, she should always be placed on her back. Even if she vomits, she will not choke when lying on her back. You can turn the baby’s head to one side. She should be placed on her back and her feet near the foot of her cot or basket. The covers should be tucked below her shoulders so that they don’t slip over her head. It is best not to share your bed with the baby, especially if you smoke or have consumed alcohol. You can feed on your bed but take her back to her cot to sleep. Caring for a preterm baby can be more demanding than caring for a fullterm baby. So you need to eat well and get enough rest. If you have other children, spend time with them as well. Get help from others.

References AAP. (2019, 31 October). ‘Caring for a Premature Baby: What Parents Need to Know.’ Retrieved 26 June 2020, from https://www.healthychildren.org/English/agesstages/baby/preemie/Pages/Caring-For-A-Premature-Baby.aspx Cloherty, J. P., Eichenwald, E. C. & Stark, A. R. (2008). Manual of Neonatal Care. Philadelphia: Lippincott Williams & Wilkins. Rennie, J. M. & Roberton, N. (2012). Rennie & Roberton’s Textbook of Neonatology (5th ed.). Edinburgh: Elsevier/Churchill Livingstone.

14 Autism Spectrum Disorder (ASD)

This group of disorders causes developmental issues due to problems in the brain. Children have problems in their social and communication skills and have repetitive and restrictive behaviours. Despite years of research, scientists have not been able to identify the exact cause. In fact, there are multiple causes of autism spectrum disorder (ASD) and genetics is one of them. Children with autism are at first glance no different from those without it. But they may interact, communicate and learn differently from other children. The learning, thinking and problem-solving can vary drastically among autistic children, with some falling in the genius category while others have severe learning difficulties. With regard to day-to-day tasks, some children need a lot of help while others do not. The disorder can manifest in different ways and includes a spectrum of behaviours. For example, a child may have normal intelligence but be socially awkward and have panic attacks if his omelette is not cut in the way he wants it. Or, at the severe end of the spectrum, the child may spend all day flapping his hands. Children at this end of the spectrum are diagnosed much earlier, but a child who is socially awkward and autistic, may miss getting diagnosed. ASD usually presents before 3 years of age and lasts the child’s lifetime. Some children show autistic symptoms before the first year of life while others improve with time. Some show symptoms after 2 years of age while some children may develop normally till 18 to 24 months, stop gaining new skills after that and may also start to lose skills that they have already learnt. Studies have shown that parents start noticing problems before the child’s first birthday and

nearly 80% notice symptoms before the second birthday. Language delay is one of the features due to which babies are diagnosed around 18 months to 2 years. Early clues are not smiling back at people, poor eye contact, not gesturing, not imitating, not responding to his name and not trying to connect and communicate with other people by 1 year of age. Other unusual behaviours that should prompt you to think about autism: children with autism do not like to cuddle and don’t like being touched. Bright lights and loud noises upset them. As they don’t feel comfortable with the outside world, they turn inwards and find comfort with repetitive behaviours like spinning, flapping and rocking. Some common symptoms to be on the lookout for: does not respond to name by the first birthday does not point to an object of interest (e.g., a car) by 15 months of age does not play pretend games by 18 months (feed a doll) delayed speech and language avoids eye contact, likes to play by herself repeats words and phrases (echolalia) gets upset by change in routine repetitive movements like spinning, flapping hands and rocking her body has obsessive interests has unusual reactions to the way things smell, sound, feel and taste

Social Skills Social problems are some of the most common symptoms of ASD. This goes far beyond being awkward or shy and causes immense difficulties in everyday life. These are: does not have shared interests has flat affect or inappropriate facial expressions does not interact and prefers to play alone resists physical contact no eye contact

does not understand personal space boundaries Typically, children are interested in people and the world around them. By the age of 1, most babies interact with others around them by looking into their eyes, copying words and actions, clapping and waving bye. They can also play peekaboo around this time. But children with ASD have difficulty in interacting with others. Some children with ASD have difficulty learning to share and play with other children. As they get older, they have difficulty showing their feelings and talking about them. They don’t like being touched and cuddled and indulge in self-stimulatory actions like flapping their hands.

Communication Children with ASD have varying degrees of communication issues. About 40% of children with ASD do not talk at all. About 25% may say 10 to 15 words by 18 months but they could lose them as they get older. Some others have speech delay. Children with ASD may present with these communication issues: speech and language delay echolalia (repeat words) does not point, or does not respond to pointing talks in a flat robotic voice hardly uses any gestures no pretend play as she gets older, does not understand jokes and teasing Children with ASD use language inappropriately. If you ask a question, you will find them repeating it and not giving you an answer. For instance, if you ask ‘Do you want water?’, they will say, ‘Do you want water?’ instead of answering. Many normal children go through this phase as well, but it rarely extends beyond 3 years.

As children with ASD get older, they have a hard time using and understanding gestures and tone of voice. Facial expressions may not match what they are saying. Some children who have good language skills talk like little adults. Since they are not aware of personal boundaries, they may stand really close to you when talking. Unusual behaviour associated with ASD: lines up toys and other objects in a row obsesses with parts of an object like wheels of a toy car has obsessive interests can throw a huge tantrum over something trivial likes routine and is very organised flaps hands or spins around Repetitive movements are seen very often in these children. These are actions that are repeated over and over again. They can involve the whole body, like rocking, or a part of the body, like the flapping of arms. Children may turn a light on and off repeatedly or spin the wheels of a toy car. These are selfstimulatory activities called stimming. As they like routine, anything out of their routine – like a stop on the way back from school – can upset them and they can have a mega tantrum or ‘meltdown’. These children develop routines like looking into every window while walking down a street and if they are not allowed to do this, they become extremely upset. Other symptoms that may be present: hyperactivity and short attention span acting impulsively temper tantrums under-react or overreact to pain or loud noises unusual eating and sleeping habits Children with ASD limit themselves to eating only a few foods. They can

have resistant constipation and sometimes diarrhoea. They have odd sleeping habits like irregular sleeping and waking patterns. They may sleep much less than expected for their age or lie awake for more than an hour at night. They react inappropriately like laughing or crying at unusual times.

Development Children with ASD develop in different areas at a different rate. Their motor skills may be age appropriate but they may have speech delay. Others might be able to do complex word puzzles but have difficulty in social interactions. So it is important for the child to be fully assessed by a health professional trained in this before you label a child autistic. A diagnosis of ASD now includes several conditions that used to be diagnosed separately: autistic disorder, pervasive developmental disorder not otherwise specified (PDD-NOS) and Asperger’s syndrome.

Causes This is difficult to determine as there is no single cause. Given how complex the disorder is, in both the range of symptoms and severity, it is thought to be multifactorial. In the ’80s, it was not so frequently diagnosed, and the reason is not because it was not identified. It was most probably because there were fewer cases. In America, the statistics show that 1 in 59 8-year-olds have some form of autism. This is the situation worldwide. Autism is more common in boys than girls by 4 to 1, which may be because it’s more difficult to detect in girls. A large number of children with language and communication challenges, hyperactivity and social awkwardness, contribute to a large number of cases today.

Genetics Autism tends to run in families but the inheritance pattern is unknown. In twins, if one twin has been diagnosed with having autism, there is a 90% chance that

the other will be too. In a large multinational cohort study which involved 2 million individuals, 22,156 were diagnosed to have ASD. In this study, it was found that genetics played a part up to a tune of 80%. A fragile X syndrome is a known genetic cause of autism, where there is a defect in the X chromosome. Retts syndrome is another cause of autism, especially in girls, where they have repetitive behaviour involving the hands; there may be developmental regression caused by a defect in the MECP2 gene which is located in the X chromosome. Genetic mutations are also thought to be another cause.

Older Parents Recently, more couples in their 40s and 50s are having children. Mothers over 40 have a 30% increased risk of having a child with autism while for fathers over 40, the risk is 50%. The theory being that the older dad’s sperm may have more defective genetic material than that of a father in his 20s.

Abnormal Brain Growth Babies are born with an immature brain that grows rapidly in the first year of life. While the brain is growing, numerous synapses are being formed, which get pruned later on. This pruning is defective in children with autism spectrum disorder. This is probably the reason why children who turn out to have ASD have abnormal head growth in the first year of life.

Drugs Thalidomide, a drug used for morning sickness that is no longer used now, is known to increase the risk of ASD. Sodium valproate, which is used in the treatment of epilepsy, has also been implicated as a cause for autism.

Obesity Researchers from UC Davies found that women who were obese (BMI more than 30) at the start of their pregnancy were more likely to have children with

ASD.

Folic Acid Deficiency of folic acid prior to conception and pregnancy is known to cause spina bifida and other neural tube defects. Hence, prior to planning a pregnancy, women are advised to start taking folic acid. A Norwegian study has shown that women who took folic acid 4 to 8 weeks prior to getting pregnant had a 40% less chance of having a baby with ASD.

Environmental Toxins We are not sure if there is any particular toxin that may cause autism, but we know that, just after conception, the brain of the foetus, which is rapidly growing in the early part of pregnancy, is especially vulnerable. Studies have shown that there are numerous environmental toxins in the umbilical cord blood of the foetus; whether these could have an effect on the brain is not known. Certain viral infections like cytomegalovirus (CMV), toxoplasmosis and rubella are all known to affect the foetus, leading to severe mental retardation. There are studies underway to decipher if air pollution is also a cause. Vaccines like MMR have been implicated, but many studies have debunked the fact that vaccine exposure is not the cause of autism (see p. 148 FAQ). Babies born prematurely and low-birth-weight babies have a 25% more chance of developing an autism spectrum disorder.

Vaccines and ASD One of the greatest controversies is whether vaccines lead to ASD. Despite extensive research, there has been no study linking any vaccine to ASD and the original paper that started off the debate has been retracted because of poor study design and questionable research methods. Though ASD affects children of all ages and nationalities, there are certain risk factors:

your child’s sex: boys are up to 4 times more commonly affected than girls family history families who have one child with ASD are at an increased risk of having another child with ASD. Also, it is not uncommon for either a parent or a close child with ASD to have a problem with communication or social skills. other disorders: children with certain genetic disorders like Fragile X or Rett’s syndrome may develop autism-like symptoms extremely premature babies: babies born below 26 weeks gestations may have a greater risk for developing autism. low-birth-weight babies have a 25% more chance of developing an autism spectrum disorder.

Unfortunately, there are no preventive measures nor any treatment options. Early diagnosis and intervention are the key to improved behaviour and language development.

When to See a Doctor Babies develop at their own pace and don’t develop at the exact timelines set in many articles and books on parenting. But nearly always, children with ASD will show some aspects of delayed development before 2 years of age. So if you are concerned, especially if you notice any of the red flags mentioned above, speak to your doctor. Your doctor might decide to get a full developmental assessment to identify delay in speech, language or cognitive skills in your child.

References Brasic, James Robert. (2021, 3 May). ‘Autism Spectrum Disorder. Practice Essentials, Background, Pathophysiology.’ Retrieved 15 June 2021, from https://emedicine.medscape.com/article/912781-overview. CDC. (2020, 25 March). ‘What Is Autism Spectrum Disorder?’ Retrieved 14

March 2021, from https://www.cdc.gov/ncbddd/autism/facts.html Lord, C., Elsabbagh, M., Baird, G. & Veenstra-Vanderweele, J. (2018). ‘Autism Spectrum Disorder.’ Lancet, 392(10146): 508–20. Rossignol, D. A., Genuis, S. J. & Frye, R. E. (2014). ‘Environmental Toxicants and Autism Spectrum Disorders: A Systematic Review.’ Translational Psychiatry, 4(2): e360. Surén, P. et al. (2013). ‘Association between Maternal Use of Folic Acid Supplements and Risk of Autism Spectrum Disorders in Children.’ JAMA, 309(6): 570–77.

Recipes

I don’t encourage the use of salt and sugar till the baby is 9 months of age. After 9 months, minimal amount of salt may be added if desired. Instead of using sugar, use fruits to sweeten food preparations like porridge. You can give the baby egg, scrambled or boiled, from when she is 6 months of age. Do remember that the yolk must be fully cooked to avoid chances of allergy and salmonella infection. When it comes to milk and oil, go with whichever milk you drink at home and your cooking oil of choice.

5–6 months Moong Dal Khichdi Ingredients 1 tablespoon split yellow moong dal 1 tablespoon rice, washed ¼ teaspoon turmeric (haldi) powder ½ teaspoon ghee/butter

Method 1. 2. 3. 4.

Wash and soak the moong dal and rice together. Add the turmeric powder and pressure-cook for 3 whistles. Remove from pressure cooker and add the ghee. Mix well. Mash the khichdi.

Beetroot, Carrot and Potato Soup Ingredients ¼ cup beetroot, peeled and chopped ¼ cup potatoes, peeled and chopped ½ cup carrot, peeled and chopped

Method 1. Combine the beetroot and carrot in a pressure cooker with 1 cup of water and pressure-cook for 2 whistles. 2. Cool and mash into a smooth soup.

Apple and Carrot Soup with Potatoes Ingredients ¼ cup apple, peeled and chopped ¼ cup potato, peeled and chopped 1 tablespoon onion, chopped ¼ cup carrot, peeled and chopped

½ teaspoon oil

Method 1. 2. 3. 4.

Heat the oil in a pressure cooker and sauté the onion for 2 minutes. Add the apple, carrot and potato. Sauté for 2–3 minutes. Add 1 cup of water and pressure cook for 2–3 whistles. Cool, mash and feed your baby.

Dal and Vegetable Soup Ingredients 1 tablespoon split yellow moong dal

1 tablespoon barley ¼ cup potato, mashed 1 tablespoon cabbage, chopped

Method 1. Wash the dal and combine all ingredients in a pressure cooker with 1 cup of water. 2. Pressure cook for 2–3 whistles. 3. When cool, mash and feed the baby.

Mashed Vegetables with Dal Ingredients 2 tablespoons split yellow moong dal ¼ cup carrot, peeled and chopped ¼ cup potato, peeled and chopped 4 leaves of spinach (paalak) 2–3 French beans, stringed and finely chopped

Method 1. Pressure cook all the ingredients together with ½ cup of water for 3 whistles. 2. Mash the mixture and serve lukewarm.

Banana Smoothie Ingredients ½ cup banana, chopped 4 tablespoons fresh curd (yogurt) 4 tablespoons orange juice

Method 1. Combine all the ingredients and mash till smooth. Serve immediately.

Banana and Papaya Purée Ingredients 4 tablespoons banana 4 tablespoons papaya

Method Mash into a smooth purée.

Vegetable Khichdi Ingredients 1 tablespoon rice, washed 2 tablespoons split yellow moong dal 1 tablespoon bottle gourd (lauki), peeled and grated 1 tablespoon carrot, peeled and grated 1 clove (laung) 1 peppercorn (kali mirch) 1 pinch turmeric (haldi) powder 1 pinch asafoetida (heeng) ½ teaspoon ghee

Method 1. 2. 3. 4. 5. 6.

Wash the rice and moong dal together and keep aside. Heat the ghee in a pressure cooker and add the vegetables. Sauté gently. When the seeds crackle, add the heeng, clove and peppercorn. Add the bottle gourd and carrot and sauté for few seconds. Add the dal, rice, turmeric powder and 1½ cup of water and pressure-cook for 3 whistles. When it is done, remove the peppercorn and clove. Whisk to combine the rice and dal together. Serve lukewarm with fresh curd.

Chikoo Milkshake Ingredients ¾ cup chikoo, peeled and chopped ¾ cup milk

Method Mash with the back of the spoon and feed.

Phirnee Ingredients 1 cup milk 1½ teaspoon rice, washed 3 tablespoons fresh fruit purée (strawberry/peach/apricot/mango)

Method 1. Bring the milk to a boil in a non-stick pan and add the rice. 2. Mix well and simmer till the rice is cooked (7–8 minutes). 3. Cool and add the fruit purée. Serve at room temperature.

Banana–Apple Pudding Ingredients ½ cup banana, chopped and mashed ½ cup apple, peeled, chopped and mashed 1 Digestive biscuit, crushed ½ teaspoon ghee/1 teaspoon butter ½ cup milk

Method 1. Bring the milk to a boil and add the biscuit. Allow it to mix with the milk so that the milk thickens. Mix well so that the custard does not have any lumps. 2. Cool completely and add the fruits. Serve immediately.

Sabudana Kheer

Ingredients 2 tablespoons tapioca pearls/sago (sabudana), soaked at least for 1 hour ½ cup milk ½ teaspoon date (khajur) paste or jaggery (gur)

Method 1. 2. 3. 4.

Bring the milk to a boil. Add soaked sabudana and allow it to mix so that the milk thickens. Add date paste or jaggery. Serve lukewarm.

7–9 months Foods like rice, idli, dosa, sooji halwa cooked for the family at home can also be fed to the baby.

Dalia Porridge Ingredients 1 tablespoon oats (dalia) Dates (khajur) deseeded ¾ cup milk

Method 1. 2. 3. 4. 5.

Pressure-cook dalia and dates with ½ cup of water for 3 whistles. Mash the cooked dalia and dates with ½ cup of milk till it is smooth in texture. Transfer this into a pan and add ¼ cup of water and remaining ¼ cup of milk and mix well. Bring to boil, stirring continuously so that no lumps remain. Serve lukewarm.

Apple Porridge Ingredients 4 tablespoons quick-cooking rolled oats

½ cup milk ¼ cup apple, peeled and finely chopped 1 teaspoon butter

Method 1. Heat the butter in a pressure cooker and sauté the oats for 2 minutes. 2. Add ½ cup of water and pressure-cook for 2 whistles. 3. Add milk and apple pieces and cook for 5 minutes and mix well, using a whisk. Serve lukewarm.

Spinach–Pasta Purée Ingredients ½ cup spinach (paalak), chopped 1½ tablespoons wholewheat pasta 1 tablespoon cottage cheese (paneer), shredded

Method 1. 2. 3. 4. 5. 6.

Boil 2 cups of water in a pan and add the pasta. Allow it to cook completely. Drain out all the water and keep the pasta aside. Cook the spinach in about ½ cup of water and allow it to simmer for 2–3 minutes. Add the cooked pasta, paneer, and mix well. Bring it to a boil and cool slightly. Mash this mixture to a smooth purée. Serve lukewarm.

Coriander Curd Rice Ingredients 2 tablespoons rice, washed ¼ tablespoon cumin (jeera) seeds 1 pinch asafoetida (heeng) 3–4 tablespoons fresh curd (yogurt) 1 tablespoon coriander (dhania) leaves, chopped ½ tablespoon ghee or oil

Method 1. 2. 3. 4. 5.

Heat the ghee in a pan and add the jeera. When the seeds crackle, add the heeng and sauté for 2–3 minutes. Add about ¾ cup of water and cook till the rice is overdone and can be mashed easily. Cool the rice. Add the curd, dhania leaves and mash slightly to make a rough purée. Serve at room temperature.

Paalak–Paneer Rice Ingredients ¼ cup rice, washed ¼ cup spinach (paalak), chopped ¼ cup cottage cheese (paneer), chopped 1 pinch cumin (jeera) seeds ½ teaspoon ghee or oil

Method 1. 2. 3. 4.

Heat the ghee in a pan and add the jeera. When the seeds crackle, add the rice and sauté for 2–3 minutes. Add the paalak, paneer, and 1 cup of water and pressure-cook for 2–3 whistles. Mix well and serve lukewarm with fresh curd or dal.

Chicken-Stock Khichdi Ingredients 2 tablespoons rice, washed 2 tablespoons split yellow moong dal or 1 tablespoon split green dal 2 tablespoons chicken mince, cleaned and washed 1 small onion 1 tomato 1 clove (laung) 1 peppercorn (kali mirch) 1 pinch turmeric (haldi) powder 1 pinch asafoetida (heeng) ½ teaspoon ghee/ butter

Method 1. 2. 3. 4. 5. 6. 7.

Wash the rice and moong dal together and keep aside. Heat the ghee in a pressure cooker and add the jeera. When the seeds crackle, add the heeng, clove and peppercorn. Add the chicken mince and sauté for a few seconds. Add the dal, rice, haldi powder and 1½ cup of water and pressure cook for 3 whistles. When it is done, remove the clove and peppercorn. Whisk to combine the rice and dal together. Serve lukewarm.

Moong Dal Chilla Ingredients ½ cup split yellow moong dal 1 small onion, finely chopped 8–10 coriander (dhania) leaves, finely chopped A pinch of turmeric (haldi) powder Salt to taste

Method 1. 2. 3. 4. 5.

Soak moong dal for at least 1 hour before preparation. Grind the dal in water to make a batter the consistency of dosa batter. Add salt and haldi powder. Heat the tawa and put some oil to make it greasy. Pour the mixture on to the tawa and sprinkle some dhania leaves along with a little onion on one side of the chilla. 6. Cook both sides of the chilla. 7. Serve immediately.

Finger Chips Ingredients 1 or 2 potatoes 2 tablespoons oil

Method

1. Cut potatoes into fingers and boil for 5 minutes. 2. Fry in oil till it is light brown and serve lukewarm.

10–12 months Vegetable Parathas Ingredients ½ cup wholewheat flour (gehun ka atta) 1 tablespoon fenugreek (methi) leaves, finely chopped 3 tablespoon bottle gourd (lauki), grated, or any other vegetable that can be grated 1 tablespoon carrot, grated 1 tablespoon curd (yogurt) 1 pinch turmeric (haldi) powder 1 pinch cumin (jeera) powder Salt to taste 2 tablespoons ghee

Method 1. Combine all the ingredients and knead into dough using enough water. 2. Divide the dough into 6 equal portions and roll each portion into a 75 mm (3”) diameter circle. 3. Cook each paratha on a tawa, using a little ghee till both sides are lightly browned. Serve lukewarm with curd. 4. You can also knead dough using leftover vegetables and dal to make a variety of parathas.

Dalia and Vegetable Khichdi Ingredients 2 tablespoons oats (dalia), washed 2 tablespoons rice, washed ½ small capsicum, chopped 1 tomato, chopped 1 pinch turmeric (haldi) powder 1 pinch cumin (jeera) seeds 1 pinch asafoetida (heeng) ½ spinach (paalak), chopped

½ cauliflower florets, chopped Salt and pepper to taste ½ teaspoon ghee

Method 1. Heat the ghee in a pressure cooker and add the jeera seeds. 2. When they crackle, add heeng, haldi powder, dalia, rice and all the vegetables and sauté for 2–3 minutes. 3. Add 1½ cup of water, salt and pepper and pressure cook for 3–4 whistles till the dalia is cooked. 4. Mix well and serve lukewarm with curd or raita.

Soya and Vegetable Pulao Ingredients ¼ cup rice, washed ¼ cup soya granules ½ teaspoon cumin (jeera) seeds 1 pinch asafoetida (heeng) 1 small stick of cinnamon (dalchini) 1 green cardamom (elaichi) ¼ cup onions, chopped ¼ cup carrot, chopped ¼ cup green peas ¼ teaspoon turmeric (haldi) powder 1 teaspoon coriander (dhania) powder 1 teaspoon cumin (jeera) powder 1 teaspoon ghee Salt to taste

Method 1. Boil the soya granules in 1 cup of water till they are soft. Keep aside. 2. Heat the ghee in a pan and add jeera, dalchini and elaichi. When the jeera crackles, add the heeng and onions and sauté for 2–3 minutes. 3. Add the carrots, peas, rice and soya granules and sauté for another 2 minutes.

4. Add haldi powder and salt and mix well. 5. Add 1 cup of water and pressure-cook for 3 whistles. Mix well. 6. Serve lukewarm with curd or raita.

Dal and Vegetable Soup Ingredients 1 tablespoon split yellow moong dal 1 tablespoon cow peas/black-eyed peas (chawli/lobia), chopped ¼ cup tomato, chopped ½ cup cabbage, chopped

Method 1. Wash the dal and combine all the ingredients in a pressure cooker with 1 cup of water. 2. Pressure-cook for 2–3 whistles. 3. When cool, blend in a liquidiser. Serve lukewarm.

Vegetable Risotto Ingredients 1 tablespoon rice, washed 1 tablespoon carrot, grated 1 tablespoon broccoli, chopped 1 tablespoon French beans, chopped 2 tablespoons spring onions, chopped 1 tablespoon onion, chopped 1 clove garlic, grated 1 teaspoon butter 1½ tablespoons cheese, grated Salt to taste

Method 1. Heat the butter in a pan, add the onions and garlic and sauté for 2–3 minutes. 2. Add the rice with ¾ cup of water and allow it to cook till the rice is done.

3. Add the carrots, broccoli, spring onions and French beans and cook till the vegetables are soft. 4. Add the cheese and salt and mix well. 5. Mash it to the consistency your baby likes. Serve lukewarm.

Vegetable Idlis Ingredients ½ coconut, grated (for coconut milk) 2 cups warm water 2 tablespoons split black gram (urad dal) 1 cup parboiled rice ½ cup onion, finely chopped ½ carrot, grated ¼ cup cabbage, grated ½ teaspoon cumin (jeera) seeds 1 tablespoon grated coconut Salt to taste Oil for greasing

Method 1. Grind the coconut with 2 cups of warm water in a blender. Strain using a muslin cloth to extract the milk. Keep it aside. 2. Wash and soak the urad dal and parboiled rice together for at least 2 hours. 3. Drain and grind to a paste using the coconut milk. 4. Add the onion, carrot, cabbage, jeera, coconut and salt and mix well. Cover and allow to ferment in a warm place for 3–4 hours. 5. Pour into greased idli moulds and steam for 10–12 minutes. 6. Serve hot with sambar or any dal.

Index

abdominal binder abnormal bladder abnormal engorgement abscess acid reflux acrocynosis Acyclovir airborne infection air pollution allergic reaction allergies common food with milk American Academy of Paediatrics (AAP) anaemia analgesics anaphylactic reaction antacid antenatal scans antenatal ultrasound anterior fontanelle antibiotic ointment antibiotics antibodies anti-epileptic anti-fungal cream/ointment antihistamines anti-reflux medicines

anti-reflux medicines anti-vomiting medicine APGAR score apnoea Apple and Carrot Soup with Potatoes Apple Porridge areola arterial lines artificial sweeteners ascaris lumbricoides Asperger’s syndrome assisted reproductive techniques (ART) asthma atopic dermatitis Attention Deficit Disorder (ADD) authoritarian parent authoritative parent autism spectrum disorder (ASD) abnormal brain growth causes communication development drugs environmental toxins folic acid genetics obesity older parents social skills vaccines and autistic disorder baby-led weaning Bacille Calmette-Guérin (BCG) bacterial infections Balanitis Xerotica Obliterans

Balanitis Xerotica Obliterans Banana and Papaya Purée Banana–Apple Pudding Banana Smoothie bassinet Beetroot, Carrot and Potato Soup before baby’s arrival bassinet cot diapers nursing pillow bifido bacteria biliblanket bilirubin test (checking for jaundice) biome. See also microbiome birth plan Bisphenol A (BPA) blanket blocked tear duct blood group group test in the potty reports transfusions bloody diarrhoea booster doses bouncer bowlegs/knock-knees bradycardia brain growth BrainStem Evoked Response Audiometry (BERA) brain tumour breast engorgement breastfeeding advantages of

advantages of best feeding positions changes in breasts colostrum difficulty encouragement engorgement feeding pattern first year flat nipples foremilk formula instead of breast milk types of frequently asked questions hindmilk inverted nipples latching making it easier managing GER babies mastitis (breast infection) medical considerations with nipple shields nursing pillow plugged/blocked ducts to premature babies sterilisation to twins yeast infection breastmilk breast pump breast surgery breath-holding spells breathing problems bronchioles bronchiolitis (RSV or Respiratory Syncytial Virus)

bronchiolitis (RSV or Respiratory Syncytial Virus) bronchodilator brown-rice syrup burning sensation burns burp/burping cloths frequently try buttermilk cadmium toxicity caesarean section (C-section) caps and socks caput succedaneum carbon monoxide cardiopulmonary resuscitation (CPR) carotinemia car seat cataracts cellulitis cephalohaematoma checklist, hospital bag for the baby baby blanket baby clothes caps and socks car seat diapers mittens for the father books cash cell phone clothes credit/debit cards

credit/debit cards insurance papers shoes snacks wallet for the mother abdominal binder antenatal scans birth plan blanket blood reports clothes sets contact lenses deodorant drink feeding bras glasses insurance papers lip balm loose-fitting clothes multi-pin plug music night gown notepad and pen outpatient papers phone phone charger photos pillow robe slippers soap/shampoo toiletries toothbrush and paste underwear chickenpox (Varicella)

chickenpox (Varicella) Chicken-Stock Khichdi Chikoo Milkshake chikungunya childhood obesity choking chronic lung disease circadian rhythms circumcision cleft lip/palate clostridium botulinum club foot cluster feed coarctation coconut oil coeliac disease cold compress cold-pressed oils colic colic-aid drops colicky babies colostrum common childhood disorders and diseases allergic reactions asthma bleeding blood in the potty bowlegs/knock-knees breathing problems bronchiolitis bronchodilator bruises burns choking common cold

common orthopaedic problems contact dermatitis cough croup/laryngotracheobronchitis dehydration Developmental Dysplasia of the Hip (DDH) diarrhoea eczema electric shock injuries in children epistaxis/nosebleeds erythema multiforme falls febrile convulsions fever first-aid kit flat feet frequently asked questions hives intoeing/pigeon toes labial adhesions medication nasal congestion poisonings squints/strabismus steroid medication stomach ache vomiting vomiting blood wheezy child common childhood illnesses and infections bacterial infections bronchiolitis (RSV or Respiratory Syncytial Virus) common cold conjunctivitis coronavirus disease (Covid-19)

coronavirus disease (Covid-19) croup or laryngotracheo bronchitis frequently asked questions fungal infections gastroenteritis/acute food poisoning Group B Strep (GBS) hand, foot and mouth disease (HFMD) herpes stomatitis influenza lung infection/pneumonia meningitis or brain infection mosquito-borne illnesses Multisystem Inflammatory Syndrome in Children (MIS-C) otitis media preventing Covidskin infections strep pneumoniae/pneumococcal meningitis Urinary Tract Infections (UTIs) viral exanthems viral gastroenteritis worm infestations common cold. See also common childhood disorders and diseases common food allergens communication community health complementary solid foods congenital dysplasia congenital glaucoma congenital hearing loss congenital heart disease congenital nerve deafness congenital nevus conjunctivitis constipation contact dermatitis contact lenses

contact lenses contaminated water continuous positive pressure ventilation (CPAP) cord-blood banking Coriander Curd Rice coronavirus (Covid-19) coronavirus disease (Covid-19) cortisol co-sleeping cot cotton diapers cough cow’s milk formula cow’s milk protein cow’s milk protein allergy cow’s milk protein intolerance cradle cap cradle position cross-cradle position croup or laryngotracheobronchitis ‘cry-it-out’ method curd-like white patches Dal and Vegetable Soup Dalia and Vegetable Khichdi Dalia Porridge dehydrating diarrhoeal illness dehydration delayed cord clamping delivery room, inside dengue dental caries Developmental Dysplasia of the Hip (DDH) diapers blood in dermatitis

dermatitis orange–pink stain in rash creams rashes uric acid crystals in wet diarrhoea dimercapto succinic acid (DMSA) diphtheria Diphtheria, Tetanus and Pertussis (DTP/DTaP) diphtheria, tetanus and whole-cell pertussis (DTwP) disposable diapers docosahexaenoic acid (DHA) Domperidone downy fine hair drug resistance drugs drum heals dry scaly patches dual allergen exposure E-coli eczema electric shock injuries in children elemental formula elimination encourage rooming endocrine disruptors engorgement. See also abnormal engorgement environmental toxins epiglottitis episiotomy epispadias epistaxis/nosebleeds Epstein’s pearls

Epstein’s pearls errors of metabolism erythema multiforme erythema toxicum European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) excess milk production expressing breast milk extinction burst eye tests faecal (potty) contamination falls febrile convulsions feeding bottles feeding bras femoral pulses Ferber, R. Ferber method fever fighting infection fighting sleep Finger Chips first-aid kit first check-up of baby abdomen arms and legs chest ears enlarged breasts eyes genitals gums and teeth head heart and circulation kidney and bladder

kidney and bladder mouth nose skin spine and nervous system throat first feed first week of baby before baby’s arrival cluster feed episiotomy feeding and stool frequently asked questions genital care hiccups losing weight pseudo period sleep flat feet flat nipples flat worms floppy larynx flu flu-like symptoms folic acid fontanelles food allergens food allergies later in life food-borne infection food intolerance football position/clutch foremilk formula feeds formula potty foul-smelling urine Fragile X syndrome

Fragile X syndrome frequently asked questions frequent urination frozen breast milk fungal infections galactosaemia galactose gas gastroenteritis gastroenteritis/acute food poisoning gastroesophageal reflux (GER) gastrointestinal infections gastro-oesophageal reflux disease (GERD) gauze genetically modified organisms (GMOs) glasses glue ear glycerine suppository graduated extinction grasping reflex Group B Strep (GBS) growth and development 4 to 6 months 6 to 9 months 9 to 12 months abnormal brain of abnormal vessel age-appropriate toys authoritative parent babies and social media babies cry birth to 2 years brain centile charts charts

charts cognitive/intellectual crying child discipline disciplining techniques dos and don’ts failure first 2 months frequently asked questions head circumference height gain hormones language and communication length logical consequences monitoring natural consequences normal growth parameters percentile permissive parent rapid reduced lung slow social and emotional development stages in temperament and behaviour thumb-sucking habit time out travelling in the time of Covidtravelling with baby uninvolved parent weight gut-friendly bacteria H1N

H1N haemolytic uremic syndrome (HUS) haemophilus influenza haemophilus influenza B (Hib) haemorrhages hand, foot and mouth disease (HFMD) healthy bacteria hearing screen test heartburn heated humidified high flow nasal cannula (HHHFNC) hepatitis A hepatitis B (hep B) herd immunity herpes encephalitis herpes simplex virus (HSV Type 1) herpes stomatitis herpes zoster heterocyclic amines (HCAs) hiccups high efficiency particulate air filters (HEPA) hindmilk hives hookworms hormonal issues Human Papilloma Virus (HPV) humidifier hydrolysed cow’s milk formulas hydrolysed cow’s milk protein hydronephrosis hydroureter hypoallergenic formulas hypospadias ibuprofen ideal room temperature

ideal room temperature idiopathic thrombocytopaenic purpura immature gastrointestinal tract or digestive system immunisation chart immunity immuno-compromised children immunoglobulin E (IGE) levels impetigo Inactivated Polio Vaccine (IPV) inactivated vaccine incorrect latch incubator indentation Indian Academy of Paediatricians/Paediatrics (IAP) industrial chemicals infant mortality rate infant warmer influenza infusion pumps inguinal hernia inoculations insurance papers intellectual impairment Intensified Mission Indradhanush (IMI) intensive care unit (ICU) intoeing/pigeon toes intolerance intravenous drip intravenous feeding intravenous fluids intravenous (IV) lines intraventricular haemorrhage (IVH) intussusception inverted nipples in vitro fertilization (IVF) iron deficiency

iron deficiency iron-rich foods iron supplements isoflavones Japanese encephalitis jaundice Jenner, E. keeping safe, baby air pollution endocrine disruptors frequently asked questions toxins kernicterus kidney infections labial adhesions lactation lactose-free milk lactose intolerance lanugo laryngomalacia latch/latching lead less fat leukaemia lice lip balm liquid and solid nutrition perspective live attenuated vaccines localised infection logical consequences loose-fitting clothes loose potty loss of consciousness

loss of consciousness low blood pressure low blood sugar lower oesophageal sphincter (LES) lung infection/pneumonia magnetic resonance imaging (MRI) malaria malassezia man-made toxins Mashed Vegetables with Dal massage as therapy mastitis (breast infection) masturbation mature milk measles, mumps and rubella (MMR) mechanical ventilation meconium meconium aspiration syndrome meconium plug MECP2 gene medication melatonin meningitis/brain infection meningococcal disease mercury microbiome microwaving micturating cystourethrogram (MCUG) milaria mild detergent/perfume-free mild infections mild steroid mild steroid cream milia milk allergies

milk allergies milk residue Mindell, J. Mindell method mineral oils mittens mongolian blue spots monitors Moong Dal Chilla Moong Dal Khichdi moro reflex mosquito-borne illnesses mother’s antibodies mothers post-delivery Multisystem Inflammatory Syndrome in Children (MIS-C) music mustard oil nasal congestion nasal discharge nasal oxygen nasal swab test nasolacrimal duct nasopharyngeal swab natal teeth natural consequences naturally occurring toxins necrotising enterocolitis (NEC) neonatal acne neonatal encephalopathy neonate nervous system neurological problems nevus flammeus newborn, looks of newborn hearing test

newborn hearing test newborn screening test night gown nightly antibiotics night-time ritual nipple shields nitric oxide N,N-diethyl-meta-toluamide (DEET) no-cry sleep solution noisy breathing non-nutritive sucking non-REM (NREM) notepad and pen nursing pillow obesity obstetrician-gynaecologist (OB/GYN) obstruction of the intestine oestrogen oil massage older parents old lead pipes oligosaccharides olive oil omegaomphalitis Ondansetron ophthalmoscope oral medicines oral polio oral polio vaccine (OPV) oral rehydration oral rehydration solution (ORS) oral thrush otitis media outpatient papers

outpatient papers over-medication Paalak–Paneer Rice pacifier paediatric gastroenterologist paediatric nephrologist paediatric urologist palmar grasp paracetamol (Crocin/Calpol) parvovirus/slapped cheek patent ductus arteriosus peripherally inserted central catheters (PICC) permissive parent permithrin persistent pulmonary hypertension of newborn (PPHN) pertussis pervasive developmental disorder not otherwise specified (PDD-NOS) petroleum-based ointments petroleum jelly Phirnee phototherapy phototherapy unit picaridin pillow pincer grasp, plagiocephaly plugged/blocked ducts pneumococcal meningitis pneumococcal vaccine (PCV) pneumonia pneumothorax poisonings polio (OPV and IPV) polycythaemia polydactyly

polydactyly poor air quality port wine stains posterior fontanelle potty of baby blood in contamination formula frequency genitals wash loose meconium passes blood mixed with mucus rock-like training pregnancy weight prenatal period preterm birth baby looks causes of preterm labour feeding medical solutions NICU nutrition for preterm babies preparing for home problems of preterm babies sleeping position vaccinations preventive medicine probiotics problem-solving skills progressive waiting projectile vomit of baby Proton Pump Inhibitors (PPIs)

Proton Pump Inhibitors (PPIs) prune juice pseudo period pthalates Pulse Polio Programme pyloric stenosis pylorus rabies rapid eye movement (REM) rash creams rashes rast test raw organic ingredients recipes months Apple and Carrot Soup with Potatoes Banana and Papaya Purée Banana–Apple Pudding Banana Smoothie Beetroot, Carrot and Potato Soup Chikoo Milkshake Dal and Vegetable Soup Mashed Vegetables with Dal Moong Dal Khichdi Phirnee Sabudana Kheer Vegetable Khichdi months Apple Porridge Chicken-Stock Khichdi Coriander Curd Rice Dalia Porridge Finger Chips Moong Dal Chilla

Moong Dal Chilla Paalak–Paneer Rice Spinach–Pasta Purée months Dal and Vegetable Soup Dalia and Vegetable Khichdi Soya and Vegetable Pulao Vegetable Idlis Vegetable Parathas Vegetable Risotto reclining/side-lying down position rectal stimulation rectal thermometer reflux renal scarring respiratory and lung problems respiratory distress syndrome (RDS) respiratory syncytial virus (RSV) retinopathy of prematurity (ROP) Retts syndrome reward good behaviour rheumatic fever rice-based products rice bran rice milk ringworm rooting rooting reflex roseola/sixth disease rotavirus round worms Sabudana Kheer saline nose drops salmonella and shigella scabies scarlet fever

scarlet fever seborrhea secondary bacterial infections secondary strep skin infection second-hand smoke secretory otitis media. See also glue ear sedentary lifestyle seizures sensitive skin separation anxiety sepsis serious life-threatening problems shampoo shellfish shrimp side rails single-dose vial skin infections skin tags/pits skin testing sleep 24-hour day associations checklist for hygiene cycles experts frequently asked questions mistakes newborn sleep patterns patterns according to age regression rhythms routine Sudden Infant Death Syndrome (SIDS) tips training technique

training technique types of smallpox social skills sodium valproate soft towel sore nipples Soya and Vegetable Pulao soya-based formula specialised formulas spina bifida Spinach–Pasta Purée spit-up sponge squints/strabismus sterilisation steroid medication stimming stomach ache stool test stranger anxiety strawberry hemangioma strep pneumoniae/pneumococcal meningitis sudden infant death syndrome (SIDS) sudden unexplained infant death (SUID) sunlight swine flu syndactyly tapeworm tearing/pus discharge tests for baby bilirubin test (checking for jaundice) blood group test hearing screen test

newborn screening test tetanus texture aversion thalidomide threadworms/pinworms thumb-sucking habit thyroid screening tight foreskin toxins environmental man-made naturally occurring transient tachypnoea transient tachypnoea of newborn (TTN) transition, hospital to home bathing routine dos and don’ts frequently asked questions travelling in the time of Covidtravelling with baby tube feeding tuberculosis (TB) tummy ache tummy infections tumours typhoid ultrasound umbilical hernia uncontrollable bleeding undescended testes uninvolved parents Universal Immunisation Programme (UIP) untreated asthma upper respiratory tract symptom

upper respiratory tract symptom uric acid crystals urinary tract infections (UTIs) urine vaccinations advice for parents defined before discharged from hospital diseases, prevented by first set of herd immunity IAP schedule for immunisation chart importance of Japanese encephalitis mercury MMR myths serious adverse effects of side effects of smallpox vaginal birth vaginal bleeding vaginal discharges varicella–zoster virus Vegetable Idlis Vegetable Khichdi Vegetable Parathas Vegetable Risotto ventilator vernix vernix caseosa Vesicoureteral Reflux (VUR) viral exanthems viral gastroenteritis

viral gastroenteritis vomiting bile blood dehydration and due to gastroenteritis fever and on waking up warm water weaning baby-led common food allergens frequently asked questions guidelines liquid and solid nutrition perspective Weissbluth, M. Weissbluth’s method wet diapers wheezy child white noise whooping cough wipes World Health Organisation (WHO) worm infestations X-rays zinc oxide

Acknowledgements

Early in my career, I was not keen on starting an outpatient paediatric practice. The adrenaline rush of a busy neonatal intensive care unit (NICU) was enough to keep me going. So much so that outpatient practice paled in comparison. However, I soon realised that somebody had to follow up on the babies that left my NICU, and thus my career as a paediatrician was born. Without my patients and their wonderful parents, none of this would have been possible. I am also incredibly grateful to Diya, mother of one of my patients and now my publisher. She was the one who convinced me to write this book. Every time she brought her son to the clinic for his routine visit, she would chip away at my resistance. I even tried to tell her there were many books in the market and another such book would not help anyone. We soon realised there were, in fact, not so many books written by paediatricians in India, and so, finally, the idea took shape. Special thanks to my family and all my friends who encouraged me through this period. Those of you who took pains to proofread my book, to gauge how technical it is, I genuinely appreciate it. You have been integral to the whole process and I really value your input. Without all of you, writing this book would have been considerably harder and infinitely less enjoyable. And, finally, I would be remiss if I did not thank my three children. They grumbled that my spelling was atrocious and corrected all my typos (at the beginning when I was learning how to type). One of my twins, Nayantara, even illustrated the book for me, and for that I am incredibly grateful. Which is why, I would like to dedicate this book to my three children, Shreya, Nikhila and Nayantara – despite the fact that as you were growing up I only knew a fraction of what I now know, I can say that you have all exceeded my expectations and I am proud to be your mother.

About the Book Becoming a parent can be both terrifying and exciting. You will have a million questions, from how to prepare for the birth to how to feed your baby to what to expect in terms of growth and what vaccines the baby needs. It can all be overwhelming. ‘Helpful advice’ often ends up being confusing, and the internet can be a source of panic. During her thirty years of practice, paediatrician Dr Saroja Balan has met thousands of parents and found herself answering the same questions. While she firmly believes parenting is mostly learning on the job, she knows a little help goes a long way. Written specifically for Indian parents, It’s Your Baby is the best support to accompany you on your journey. It is meant to help you figure out when your child needs to see a doctor and when you can handle things on your own. Covering basics such as sleep, breastfeeding and common ailments, it also includes all you need to know about screen time, childhood obesity, pollution and parenting styles, helping you navigate the first two years of parenthood. Dr Balan’s reassuring, no-nonsense approach makes this the essential guide for a safe and healthy child – and a more confident you!

About the Author

Dr Saroja Balan is Senior Consultant Neonatologist at the Indraprastha Apollo Hospital, New Delhi, specialising in neonatal intensive care as well as paediatric outpatient practice. She graduated from Madras Medical College, trained in paediatrics and neonatology in the UK, and is a Fellow at the Royal College of Physicians, Glasgow. Dr Balan consults as a paediatrician at BabyCenter, the go-to online platform for new parents. She has contributed several articles to medical journals and publications.

Praise for It’s Your Baby

‘I started reading the book and just couldn’t stop. It is a complete book for today’s parents – it has everything they need to know – so they learn from an experienced paediatrician rather than internet blogs! Till date we do not have such a comprehensive book which is written keeping the urban Indian context in mind. Paediatricians beginning their practice will also benefit immensely, as it has all the FAQs of parents answered in a simple way.’ –Dr Arun Wadhwa, paediatrician ‘This is a must-read and a must-have for expectant parents, new parents, and for students and practitioners of paediatrics. What shines through cover to cover is Dr Saroja Balan’s formidable insight and empathy that have made her the go-to paediatrician, empowering generations of parents.’ – Raj Kamal Jha, Rain’s father ‘Dr Balan’s extensive clinical experience, her sound common sense and her candour have come to the rescue of many of us as we grappled with parenthood. With this work, she does what Dr Spock did for post-war America – bring robust advice to your bedside so grandparents far away can have a good night’s rest, while also sharing some delicious homemade recipes!’ – Gopal Sankaranarayanan, Anika, Ameya and Arjun’s father ‘Written in a conversational style, It’s Your Baby is an invaluable resource for new parents. Dr Saroja Balan held my hand and taught me how to care for my baby when I first became a mother. This book affords the same access to her expert, practical, no-nonsense advice on everyday questions and challenges that parenting throws up, specifically in the Indian context.’ – Shivani Sibal, Anina and Anisha’s mother ‘Dr Balan is the best! In this book, just as she does for her patients in her

practice, she reminds us that a healthy baby has happy, confident parents. Dr Balan anticipates and allays the most common concerns that new parents have, giving practical suggestions and steer, based on decades of experience. A mustread!’ – Devaki Nambiar, Kleio and Callie’s mum ‘Dr Balan’s precise diagnosis of every health issue which my children have faced, from childhood to teenage, makes me believe she has a special gift as a doctor. Our children’s bond with her has outlasted their childhood, which is rare and precious. This book captures Dr Balan’s wealth of experience and her precise narration of simple to complicated childhood ailments. I only wish she had written this book 18 years ago, when I was a freshly minted parent.’ – Manisha Natarajan, Riva and Siddharth’s mother ‘In an age of information excess, Dr Balan cuts through the noise to craft this one-stop guide – simple, filtered and authoritative.’ – Anjali and Pranab Dhal Samanta, Divena’s parents ‘Dr Balan is that rare doctor: the perfect combination of technical brilliance and parent-friendly pragmatism. We have been unbelievably lucky to have her guidance – and now everyone else can too, with this book!’ – Sapna Desai, epidemiologist ‘I must compliment Dr Saroja Balan for writing such a readable and information-filled book. The experience of so many years and the wisdom gained through years of treating babies and children is apparent when one reads the book. What to expect during delivery, possible problems in the newborn period, care of the newborn baby, vaccinations, normal growth and development as well as common and not-so-common problems are explained. If a parent has a question, the answer is there in the book. Every question is answered simply and with great clarity. There is a solution to every problem you might face as a new parent. There is no need to take advice from “Dr Google” any longer!’ – Dr Vidya Gupta, paediatric neonatologist

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First published in India by HarperCollins Publishers 2022 4th Floor, Tower A, Building No. 10, Phase II, DLF Cyber City, Gurugram, Haryana -122002 www.harpercollins.co.in 2 4 6 8 10 9 7 5 3 1 Copyright © Dr Saroja Balan 2022 P-ISBN: 978-93-5489-310-0 Epub Edition © Janauaray 2022 ISBN: 978-93-5489-202-8 The views and opinions expressed in this book are Dr Saroja Balan’s own in her personal capacity and do not reflect the views of any organisation or institution she is associated with. The facts are as reported by her and the publishers are not in any way liable for the same. The views and opinions expressed in the Foreword by Dr Ashok Dutta are his own in his personal capacity and do not reflect the views of any organisation or institution he is associated with. Dr Saroja Balan asserts the moral right to be identified as the author of this work. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publishers. Cover design: Devangana Dash Cover image: Getty Images