It’s Tummy Time! Taming tummy time torture

My oldest child hated tummy time. Miserable, she would flail on the floor and wail like a marooned walrus. Although she eventually learned to tolerate it for periods of time, she disliked time on her belly so much, she skipped the developmental milestone of flipping over from her back to her belly and went straight to sitting upright.

Babies spend a lot of time on their backs when they are young. In accordance with guidelines to prevent Sudden Infant Death Syndrome, babies are put to bed on their backs. But continual pressure on the back of an infant’s head when the baby is also awake leads to head flattening. Thus, current recommendations are to give your baby time on his belly when he is awake. But for some, tummy time is torture time. For those infants, Physical Therapist Deborah Stack gives us ideas on how to make tummy time tolerable.

Dr. Lai with Dr. Kardos

Physical therapists are sometimes enlisted to treat or prevent plagiocephaly (head flattening). Physical therapy for plagiocephaly is a combination of parent teaching, assessment of nursing positions, carseat and feeding seats, handling techniques for promotion of typical movement patterns, and facilitation of motor development. Much teaching revolves around different ways to incorporate tummy time into your family schedule. Remember…it is critical to keep weight off the flattened area for as many hours a day as possible. If needed, babies do best if referred to physical therapy by their doctors at two to four months of age. In fact, a 2008 research study¹ showed a significant improvement in plagiocephaly for children referred to physical therapy versus children whose parents were provided with an instructional pamphlet.

How can you get started? Try these ways to do “tummy time” with your baby.

1. Belly to belly with your baby

Recline back comfortably in a chair with your child on your chest. Try to help your baby keep his forearms supported on your chest. Talk to your baby to encourage him to lift his head to look at your face.

2. Eye level play with your baby

Place your baby on a bed, couch, or other raised large area with her head near the edge of the surface. Get down so you can look your baby in the face and talk, sing, or make funny faces or sounds. Keep one hand on your baby’s buttocks so she does not roll or fall. Siblings love to be the entertainment!

3. Lap play

Place your baby across you lap with his chest on one leg and his thighs on the other. You can raise the leg nearer the baby’s head a bit to make it easier.

4. Airplane carry

Carry your baby face down as you walk. If your child is small enough, place your forearm under her belly with your hand supporting the upper chest. Younger infants will need their heads and chest supported, but as your baby gains strength in the neck and trunk muscles, less support is needed. Most babies really like this!

Progress tummy time as tolerated. Many babies can initially only handle 20 or 30 seconds at a time without becoming distressed. Within a few weeks, many children will be able to be on their tummies for 15 minutes or more.

Remember, babies should be placed on their backs to sleep, but while your infant is asleep, you can still tiptoe in and rotate your baby’s head gently away from the flat side.

Deborah Stack, PT, DPT, PCS

Dr. Stack has been a physical therapist for over 15 years and heads The Pediatric Therapy Center of Bucks County in Pennsylvania www.buckscountypeds.com. She holds both masters and doctoral degrees in physical therapy from Thomas Jefferson University.

Source cited:1 van Vlimmeren LA, van der Graaf Y, Boere-Boonekamp MM, et al. Effect of pediatric physical therapy on deformational plagiocephaly in children with positional preference: a randomized controlled trial. Arch Pediatr Adolesc Med. 2008;162:712-718..

Why is my baby’s head flat? Positional plagiocephaly

Squeezed through the birth canal, many babies are born with pointy, cone-shaped heads. Others, delivered by caesarian section, start off life with round heads. No baby begins with a flat head. But as parents put babies on their backs to sleep in accordance with Sudden Infant Death Syndrome prevention guidelines, babies are developing flat heads.

Called positional plagiocephaly, a young infant’s head flattens when prolonged pressure is placed on one spot. Tricks to prevent positional plagiocephaly all encourage equal pressure over the entire head. Because babies’ heads are malleable, parents can easily prevent and treat the flatness. In fact, the flat shape begins to correct itself after six months of age, when babies spend less time lying down and more time sitting and crawling. Additionally, increased hair growth hides some of the flatness.

To prevent positional plagiocephaly, place your baby prone (belly down) frequently WHILE AWAKE, starting in the newborn period. This tummy time decreases pressure on the back of the head. Some babies are not fond of tummy time and will cry until they are back on their backs. For those kids, in our next post, guest blogger physical therapist Deborah Stack will address ways to make the time tolerable.

Encourage your baby to look to both sides while lying down. Too much time turned to one side will cause flattening on that side. Alternate how you place the baby in crib so that sometimes she turns to the right and other times she turns to the left to face into the room and away from the wall. If your baby seems to prefer looking only to the right or only to the left, place toys or bright objects toward the non-preferred side. If bottle feeding, switch off which arm you use to feed your baby, so that the baby sometimes turns to the right and sometimes to the left . If breastfeeding, start and end on the side that the baby tends to avoid. These actions will help prevent neck muscles from becoming too tight on one side and thus allow your baby to turn easily to both sides.

Some babies wear helmets to correct their abnormal head flattening. Neurosurgeons, who are head and brain specialists, prescribe these helmets for babies who have extreme flattening. Fortunately, the majority of babies with positional plagiocephaly do not need to wear helmets.

You also may have heard of babies who need corrective surgery for an abnormal head shape. This condition, called craniosynostosis, is rare. Pediatricians monitor the size and shape of the head and check the soft spot on the top of the head at every check-up. A baby’s skull develops in pieces as a fetus, and these pieces eventually come together at predictable places called sutures. If the pieces come together too early or the soft spot closes too soon, corrective surgery must be performed.

So, avoid head flatness by rotating your baby’s position frequently (think rotisserie chicken!) and provide plenty of “tummy time” when awake. Start when the baby first comes home.

If you are worried about your baby’s head shape, just head on over to your baby’s pediatrician and bring up your concern. Trust us, your concern will not “fall flat.”

Julie Kardos, MD and Naline Lai, MD

Portable Parent: baby advice texted to your cell

“Calling” all moms and dads with cell phones! We discovered a new free service from the US National Healthy Mothers, Healthy Babies Coalition. The service text4baby texts health maintenance tidbits three times a week to your phone during pregnancy and during your baby’s first year of life.

Text BABY or BEBE (to receive messages in Spanish) to 511411, and you will receive three texts a week. This is an example text for expecting parents: “Your baby will be here soon, & it’s time to get a car seat. The hospital won’t let you leave by car or taxi without one.”

Since most cell carriers participate, even people in the United States without a text plan can get messages for free. If you have a text limit per month, text4baby won’t take away from that limit. Look at www.text4baby.org for more information.

Gotta <333 a service like this.

Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®

Infant CPR: Do you know what to do?

We asked Dr. Raymond Wu, the doctor behind the popular new infant iphone app babyCPR, to talk about how to perform CPR on babies under one years old. We even convinced him to time a discounted app price with the release of this post!

If you found your baby unconscious, would you know what to do? Could you pull it off correctly while in a panic? Every moment without Cardiopulmonary Resuscitation (CPR) increases your child’s possibility of brain damage and death. Learning CPR is just one of a number of safety precautions any parent should take.

Well-performed CPR can mean the difference between a good and bad outcome, which could be the difference between life or death. In this article, we’ll go over important aspects of CPR. After reading this article, you should have a good understanding of why CPR works and how to perform it effectively. CPR is different for when it comes to performing it on a baby. So you might have been trained in giving CPR to adults, but it won’t be the same for infants.

What is CPR?

CPR stands for Cardiopulmonary Resuscitation, or more simply, “heart-lung support.” The two main components include chest compressions and rescue breaths. When the heart stops beating, chest compressions are used to maintain some blood circulation. Since the body continues to use oxygen even when breathing has stopped, we help replenish oxygen by providing rescue breaths. The idea is to help pump oxygenated blood to the body’s organs — most importantly, the brain.

Infant CPR basics

The guidelines for infants (children less than 1 year old) are to provide 30 chest compressions and alternate with 2 rescue breaths.

For each chest compression, place the baby on a hard flat surface then place two fingers in the center of the child’s chest. Quickly press down 1.5 inches, or about 1/3 of the thickness of the baby’s chest. Then release until the chest recoils, which allows the heart to refill with blood for the next compression. Do this at a rate faster than 100 compressions per minute.

To deliver rescue breaths, first attempt to open the infant’s airway by tilting their head and lifting his or her chin. After opening the airway, put your mouth over the infant’s mouth and nose, and make a good seal. For each breath, blow gently for about 1 second. A good breath will make the baby’s chest rise. Avoid blowing too hard since that can damage the baby’s small lungs.

If someone is with you, send them for help right away while you perform CPR. If you are alone with the baby, perform 2 minutes CPR before calling for help, then immediately resume CPR as soon as possible.

Infant CPR is NOT like adult CPR

Babies are not just tiny little adults. They have special needs and therefore require special care. You may have heard about hands-only CPR for adults. This does NOT apply to infants. Since they are so small, they have limited oxygen reserves in their body. You need to provide rescue breaths regularly to replenish these reserves.

Why the compression rate is now faster than 100 per minute

The previous American Heart Association (AHA) guidelines asked people to do compressions at exactly 100 per minute, but the newest 2010 guidelines now simply ask to go faster than 100 compressions a minute. Researchers found that with the previous guidelines, most people were going too slow and had overly long breaks between sets. The new guidelines encourage people to focus on improving blood circulation in the baby.

Tip: Following the beat of songs in your head like “Staying Alive” or “Mary Had a Little Lamb” can help you maintain the correct timing while you do chest compressions.

Practice makes perfect

If you learn CPR correctly and then practice correctly, you won’t lose any precious time when your baby needs saving. Practicing allows you to quickly recognize what to do and cements the skills. That way, you can remember what to do even when in a panic. Your baby’s life may depend on this.

For more information

I covered some basic aspects of infant CPR here but there are more details that are important to know, including what to do when your baby is choking. Traditional CPR classes are available in many areas and usually take about 3-4 hours. The American Red Cross provides many of these courses and The American Heart Association has a class locator on it’s website.

Looking for other ways to learn? A new method of learning CPR is iphone app BabyCPR (available on itunes). This app allows you to practice on a simulated baby.

Raymond Wu, MD

Dr. Wu completed medical school and internal medicine training at Northwestern University. He founded Transcension HealthCare to pursue his passion and vision for improving healthcare through the effective use of technology. He specializes in medical simulation technology and is a leader in developing computer-based medical simulators. Recently, he had the pleasure of becoming an uncle, and looks forward to creating software for his niece as she grows older

Newborn eyes: blocked tear ducts, crossed-eyes, vision, and eye color

This post was inspired by a newborn whose mom asked me about his eyes. “Here’s looking at you, kid!”

What is this goop in my baby’s eye?

Blocked tear ducts: About 25 percent of infants, by the second or third week of life, develop some slightly yellow or clear eye discharge from one or both eyes. The discharge looks worse when the infants first awaken. At this age, they start to produce some tears (although they do not “cry tears” until closer to three months old). But because newborn tear ducts, the drainage system for tears, are not completely open, tears either spill over, causing a watery discharge, or accumulate in the eyes during sleep and become slightly thicker “goop” that wipes away easily.

Babies with blocked tear ducts have normal appearing sclera (the whites of the eyes) and normal vision. Blocked tear ducts are not painful. Fortunately, the tear ducts open up spontaneously in most babies without intervention. This process, which is usually complete by three month of age, can take up to one year of age. An infection in the eye causes a baby’s eye to become painful, red on the inside, and sensitive to light. The discharge becomes pus-like and increases in amount. If you are not sure if your baby’s eye discharge is from an infection or a blocked duct, consult your pediatrician.

Why do my baby’s eyes cross?

Young infants’ eyes may cross as they gaze at an object. This crossing is a result of an immature nervous system. By three to four months of age, a baby’s eyes should always move in concert when she gazes or follows an object with her eyes. If your baby’s eyes cross after this age, alert your child’s pediatrician, who will likely refer your baby for an exam by an ophthalmologist who is comfortable examining babies. It is important to make sure the eyes are both seeing equally and adequately, as well as to make sure the eye muscles work properly. See our previous post on crossed-eyes.

What is normal vision for a newborn?

Babies are born nearsighted. They see clearly the distance to a face when being held. Some newborns will stick out their tongues in response to seeing their parents do the same. So, be sure to look at your infant when you are feeding or rocking her. Far vision develops gradually over months to years. A child’s vision is not 20/20 until about five-years old.

When will my baby’s eyes change color?

The color of a baby’s eyes generally becomes established during the first year. Some stay the same color from birth. My own children were all born with either blue or grey eyes but now all are brown, much to the delight of their blue-eyed grandmother. My oldest was nine months before his eyes turned brown. Some of my patients did not develop their permanent eye color until two years.

Here a few more eye facts: The part of the eye with color is called the iris. The hole in the center of the iris is called the pupil. Pupils should always look black. In a photograph they can look red from a flash. However, if you ever see white, yellow, or grey reflected in the pupils, alert your baby’s doctor.

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

What you need to know about Whooping Cough

Pertussis is “whooping cough,” also known as the “100 day cough.” In children and adults, the disease starts out looking like a garden-variety cold, complete with runny nose, runny eyes, and mild cough. Sometimes fever is present, sometimes not. However, after a few days, coughing spasms emerge – severe, persistent coughing spasms that go on and on and on. In between coughing fits, children may appear okay.

There is no treatment except to “ride it out” and the cough can last up to three months. Doctors prescribe antibiotics to a child with pertussis because antibiotics can decrease how much a person with whooping cough will spread it to others. Close contacts of kids with pertussis may also receive antibiotics to reduce their chance of getting pertussis.

Whooping cough gets its name from the “whoop” noise kids make after a coughing fit. The fits leave them so breathless that it’s difficult to take a breath in again after the coughing spell. To hear the “whoop” with coughing fit, visit www.whoopingcough.net.

Teens and adults with whooping cough don’t tend to make the whoop sound because their airways are bigger, but the coughing spasms can leave them feeling like they might throw up or pass out. Some in fact do end a coughing fit with vomiting or fainting.

Babies don’t make the whoop either. Instead, babies with pertussis simply cannot catch their breath and stop breathing. That is why babies are the ones who tend to die from this illness. Dr. Lai and I both have watched over hospitalized infants blue from pertussis.

Thankfully, we have a vaccine that is effective at preventing pertussis. The “P” in pertussis is the “P” in the DtaP vaccine that children receive as babies, usually at two, four, and six months of age. The DtaP vaccine is then next given after the first birthday, another between ages four and six years old, and another at age eleven years. Teens who have not received the pertussis vaccine since they were in preschool, and adults who care for infants also should also get the vaccine. For more specific up-to-date recommendations: www.vaccineinformation.org/pertuss/.

As we enter the season for catching snowflakes and coughs, we hope none of your children catch whooping cough.

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

revised Nov 16, 2011 to reflect the indications for antibiotic prophylaxis

Should I vaccinate my child?

Yes, yes, yes.

However, in the face of overwhelming evidence of safety and benefits of vaccines, we pediatricians despair when we see parents playing Russian roulette with their babies by not vaccinating or by delaying vaccinations. We hope fervently that these unprotected children do not contract a preventable debilitating or fatal disease that we all could have prevented through immunizations.

Should you vaccinate your child?

YES!

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

Visit these posts for more information about vaccines: Evaluating Vaccine Sites on the Internet, and Closure: there is no link between the MMR vaccine and autism

Hear ye, hear ye: how can I tell if my child hears?

I just watched “The Miracle Worker” with my oldest son. This classic 1962 movie depicts Helen Keller, who was deaf and blind, struggling to understand language, with the help and supreme patience of her determined teacher Annie Sullivan.

As I watched the movie, I was reminded about how children depend on their senses to learn about the world. Starting today, Two Peds in a Pod will bring you periodic posts about the early development of senses. We start with hearing.

Unlike eyesight, which is limited at birth, babies are usually born with normal hearing. Before leaving the hospital after birth, or by two weeks of age, your newborn should receive a hearing test. Then, at every well child check, your child’s health care provider will ask you questions to confirm your child’s hearing remains the same.

Even though they are unable to localize where sound is coming from, newborns will startle to new or sudden sounds and their eyes will open wider in response to the sound of your voice. All babies babble, even deaf ones, but language progression will stop in children who cannot hear. By six months, kids usually babble one syllable at a time. By nine months, children will produce syllables that sound like whichever language they hear the most. At this point they should also respond to their name. Babies who fail to meet these milestones may do so because they cannot hear.

For older kids, hearing screening may be conducted in schools or the pediatrician’s office. The American Academy of Pediatrics recommends formal hearing screens starting at four years old. These screening tests can detect subtle hearing loss that parents did not notice. Kids who fail the screen should have a more comprehensive hearing evaluation by an audiologist. Many kinds of hearing loss are either reversible or manageable. The earlier the diagnosis the better.

Sometimes speech, behavior, or attention problems are secondary to hearing difficulties. School aged children may mispronounce words because they cannot hear sounds clearly. These children commonly do not distinguish well between the “s,” “ch,” and “sh” sounds (please click here to review language development). Symptoms attributed to Attention Deficit Hyperactivity Disorder such as difficulty focusing or inattentiveness may actually result from hearing loss. Some kids who “just don’t listen” to adults simply can’t hear well enough to follow directions.

As your child’s hearing loss progresses, you may notice your child’s language regresses, or that your child turns the volume up on the TV. Your child may accuse you of mumbling or ask you to often repeat questions. Although a common myth, a child who talks loudly is not necessarily deaf. After all, a child does not need to raise his own voice in order to understand himself.

Finally, I should mention signs of “selective hearing loss.” Many parents describe this form of “hearing loss” to me in the office. In these cases, a child does not hear her mom say “Clean your room,” yet hears her mom whisper “Let’s go out for ice cream.”

We address the topic of listening, as opposed to hearing, in our next post.

It’s a gas! your young infant’s burps and farts

Gas is another topic most people don’t think much about until they have a newborn. Then suddenly gas becomes a huge source of parental distress, even though parents are not the ones with the gas. It’s the poor newborn baby who suffers, and as all parents know, our children’s suffering becomes OUR suffering.

So what to do?

First, I reassure you that ALL young babies are gassy. Yes, all. But some newborns are not merely fussy because of their gas. Some become fussy, ball up, grunt, turn red, wake up from a sound sleep, and scream because of their gas. In other words, some babies really CARE about their gas.

Remember, newborns spend nine months as a fetus developing in fluid, and have no experience with air until they take their first breath. Then they cry and swallow some air. Then they feed and swallow some air. Then they cry and swallow some more air. Eventually, some of the air comes up as a burp. To summarize: Living in Air=Gas Production.

Gas expelled from below comes from a different source. As babies drink formula or breast milk, some liquid in the intestines remains undigested, and the normal gut bacteria “eat” the food. The bacteria produce gas as a byproduct of their eating. Thus: a fart is produced.

The gas wants to escape, but young babies are not very good at getting out the gas. Newborns produce thunderous burps and expulsions out the other end. I still remember my bleary-eyed husband and I sitting on the couch with our firstborn. On hearing a loud eruption, we looked at each other and asked simultaneously, “Was that YOU?” Then looked at our son and asked “Was that HIM?”

Gas is a part of life. If your infant is feeding well, gaining weight adequately, passing soft mushy stools that are green, yellow, or brown but NOT bloody, white, or black (for more about poop, see our post The Scoop on Poop), then the grunting, straining, turning red, and crying with gas is harmless and does not imply that your baby has a belly problem or a formula intolerance. However, it’s hard to see your infant uncomfortable.

Here’s what to do if your young baby is bothered by gas:

Start feedings before your infant cries a long time from hunger. When infants cry from hunger, they swallow air. When a frantically hungry baby starts to feed, they will gulp quickly and swallow more air than usual. If your infant is wide awake crying and it’s been at least one or two hours from the last feeding, try to quickly start another feeding.
Burp frequently. If you are breastfeeding, watch the clock, breastfeed for five minutes, change to the other breast. As you change positions, hold her upright in attempt to elicit a burp, then feed for five more minutes on the second breast. Then hold your baby upright and try for a slightly longer burping session, and go return her to the first breast for at least five minutes, then back to the second breast if she still appears hungry. Now if she falls asleep nursing, she has had more milk from both breasts and some opportunities to burp before falling asleep.
If you are bottle feeding, experiment with different nipples and bottle shapes (different ones work better for different babies) to see which one allows your infant to feed without gulping too quickly and without sputtering. Try to feed your baby as upright as possible.
Hold your infant upright for a few minutes after feedings to allow for extra burps. If a burp seems stuck, lay her back down on her back for a minute and then bring her upright and try again.
To help expel gas from below, lay her on her back and pedal her legs with your hands. Give her tummy time when awake. Unlike you, a baby can not change position easily and may need a little help moving the gas out of their system.
If your infant is AWAKE after a feeding, place her prone (on her belly) after a feeding. Babies can burp AND pass gas easier in this position. PUT HER ONTO HER BACK if she starts to fall asleep or if you are walking away from her because she might fall asleep before you return to her. Remember, all infants should SLEEP ON THEIR BACKS unless your infant has a specific medical condition that causes your pediatrician to advise a different sleep position.
Parents often ask if changing the breast feeding mother’s diet or trying formula changes will help decrease the baby’s discomfort from gas. There is not absolute correlation between a certain food in the maternal diet and the production of gas in a baby. However, a nursing mom may find a particular food “gas inducing.” Remember that a nursing mom needs nutrients from a variety of foods to make healthy breast milk so be careful how much you restrict. Try any formula change for a week at a time and if there is no effect on gas, just go back to the original formula.
Do gas drops help? For flatulence, if you find that the standard, FDA approved simethecone drops (e.g. Mylicon Drops) help, then you can use them as the label specifies. If they do not help, then stop using them.

The good news? The discomfort from gas will pass. Gas discomfort typically peaks at six weeks and improves immensely by three months. At that point, even the fussiest babies tend to mellow. The next time your child’s gas will cause you distress won’t be until he becomes a preschooler and tells “fart jokes” at the dinner table in front of Grandma. Now THAT is a gas.

Julie Kardos, MD with Naline Lai, MD

Parents of newborns: get your Zzzzzs back

Recently I’ve seen some very tired parents of newborns in my office.

Sleep deprivation, while common, leaves you prone to emotional distress and more susceptible to illness. Driving sleep deprived is as dangerous as driving drunk. Lack of sleep can even cause brain wave patterns similar to those seen in people with seizures.

Ask for help. If you live near family, take them up on offers to cook a meal or come hold the baby while you take a nap during the day. If you don’t have friends or family to provide free help, look for local teens trying to earn some community service hours or volunteer seniors from your local house of worship or YMCA. For a relatively small expense you could probably pay a money-starved teen to complete some household chores or to babysit in your home while you, the parents, grab some much needed sleep. Remember, too, that this is the time to get to know the baby as a family member, not to entertain others. If the people standing in your kitchen are not willing to do the dishes, then point them to the door.

For a larger expense but sanity-saving measure, pay someone to help out overnight a few times a week, or ask a kind relative to sleep over. My husband and I still credit our neighbor, who helped us out some nights after our twins were born, for saving our marriage (sleep deprivation does not enhance a spousal relationship). Even breastfeeding moms can make this work. The helper should wake mom to breastfeed, then take the baby away so the mom can go immediately back to sleep. Meanwhile the helper burps, changes, soothes, and settles the infant.

Even if you never took naps before, you will learn to extract super-human refreshment from a series of short naps throughout the day and night. Remember that the frequent awakenings are temporary because newborns only have newborn sleep patterns for as long as they are, well, newborns. Although this time FEELS like centuries while you are living it, in reality it lasts at most for about three months. After that, babies naturally lengthen time between feeds because their growth rate slows and thus they are able to stay asleep for longer periods of time. Sleep when the baby sleeps. Do not try to do anything “productive.”

Other tricks to fend off the effects of sleep deprivation, I learned as a pediatric resident. In those days I worked 36 hour shifts every fourth day for three years. I found seeing sunlight and smelling coffee helps ameliorate sleepiness. A shower FEELS like about two hours of sleep.

New parents need to force themselves to nap and put the rest of their household on hold. Hire a cleaning service if you can afford it, order take-out or eat breakfast cereal for dinner, and don’t worry about keeping up with laundry.

Sleep is an essential of life, just like food and water. If this post put you to sleep, then you are not getting enough. Sleep, that is. Hey, did you just see a sheep? Count it!