If Your Kid Eats This Book, Everything Will Still Be Okay

Copyright

This book is intended to supplement, not replace, the advice of a trained health professional. If you know or suspect that your child has a health problem, you should consult a health professional. The author and publisher specifically disclaim any liability, loss, or risk, personal or otherwise, that is incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this book.

Copyright © 2009 by Lara Zibners, MD

All rights reserved. Except as permitted under the U.S. Copyright Act of 1976, no part of this publication may be reproduced, distributed, or transmitted in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.

Wellness Central

Hachette Book Group

237 Park Avenue

New York, NY 10017

Visit our website at www.HachetteBookGroup.com.

Wellness Central is an imprint of Grand Central Publishing.

The Wellness Central name and logo are trademarks of Hachette Book Group, Inc.

First eBook Edition: June 2009

ISBN: 978-0-446-55217-2

acknowledgments

This little project could never have happened without the time, dedication, and, frankly, blind support of so many people in my past, present, and, hopefully, future.

To my high school AP Biology teacher, Mr. Steven Ruggiero, who listened to me lament the excruciating boredom of scientific writing and told me that he had faith that someday I would be the one to find a way to make it interesting, I hope I did.

To every teacher who taught me how to become a scientist, nurtured my writings, or just helped me believe in myself, thank you.

To my friends, colleagues, and mentors who taught me the art of medicine, I try to remember those lessons every day.

To the nurses and staff who gently corralled an occasionally arrogant young doctor and taught me to respect you, I remember that always.

To my parents and sisters, who have unquestionably supported and proudly suffered through years of my never-ending education and the complete self-absorption that naturally accompanies such pursuits, thank you for still liking me.

To my friends who have listened to me talk about "writing a book" and actually believed it would happen, thank you for your senseless enthusiasm.

To my agents, Jeff Kleinman and Erin Niumata, and all the fabulous folks at Folio Literary Management, thanks for taking a leap on a total unknown and in the process becoming such dear friends.

To the people at Hachette Book Group, especially my editor, Natalie Kaire, thank you for believing that a doctor can also write and for pouring so much energy into this venture.

To my medical advisory review panel, Drs. John Fortney, Adam Vella, Daniel Cohen, and James Naprawa, thank you for your brains, time, and love.

And a final thank-you to my husband, Gernot, because it was your idea and we all know it.

CHAPTER 1

ten fingers…
eleven toes?

A Guide to the Newborn's Body, Behaviors, and Symptoms

The balloons are in the driveway, the cigars passed to all the neighbors. Now you are sitting in the living room, staring at the basket in the corner, sizing up your tiny opponent. Rather than sitting there, looking shell shocked and petrified, go pick little Johnny up, bring him over to the couch, strip off his fuzzy bunting, and dig right in. Is he supposed to have that spot? Why is his head shaped that way? Can he see you? Let's start this book by getting to know the newborn and making sure that all those things that are guaranteed to freak you out at 2 a.m. have been dealt with so you can move on. Most of your concerns can be found in other parts of this book, but here we'll touch on those that are particularly common in newborns and particularly prone to causing panic.

Dropping the Baby

Let's just get this one out of the way. You've dropped the baby. Maybe you fell asleep and she rolled down your leg and onto the carpet. Maybe you turned your back "for just a second" and there she was, screaming on the floor. Stop, take a big breath. Don't panic. Most babies survive their first experience with gravity just fine. Here's what you do need to know. If the baby is screaming and mad, moving everything, and looking at you with evil in her eyes, carefully feel her head, her back, and her arms and legs, and if everything seems okay, pick her up and turn to "Falls," on page 262. Call your doctor to let her know what happened. Without any external evidence of injury and with a moving, screaming, and purple-mad baby, most likely everything is fine.

Ten Little Fingers, Ten Little Toes

As soon as the nurse left the room, you unwrapped that blanket and checked to make sure he had ten fingers and ten toes, didn't you? What if you found eleven? It happens. No big deal. Extra fingers and toes tend to run in families, so check out Grandpa's feet next time you're at the beach. Some of these little digits are just small growths of skin and others have little bones. Either way, they come off pretty easily. Some physicians will tie them with a suture (after confirming the absence of any bone) until they literally just fall right off. Others prefer to have them removed by a surgeon. Just don't forget to warn him before he counts the toes of his own child someday.

Deep Breath In…

Newborns sputter. They gag. They turn red. They cough and sneeze. If you are worried about the way she is breathing, refer to Chapter 2, and if in doubt, call your doctor immediately. But you should know about this funky little newborn quirk called periodic breathing. They breathe really fast for a few seconds and then pause. It comes in little waves, especially when they are sleeping: normal breathing, really fast breathing, pause, normal breathing, really fast breathing, pause. These pauses are frightening, but last only a couple of seconds and then baby starts breathing again, all on her own. As long as the pauses are only a few seconds long, the baby never changes color, and begins breathing again with no help from you, this is normal. Completely normal. Babies have immature brains and the part that controls breathing will eventually mature and she will start breathing in a more regular pattern.

From Head to Toe

Now let us start at the top and work our way slowly down. It's how we were taught to do physician exams in medical school and it seems to work. This way I can try to systematically assure you that what you've found is normal, point out some things that you may not have noticed, and help to avoid a bleary-eyed 3 a.m. freak-out.

The Noggin

Take his hat off. Now look for the little scab where the fetal monitor was attached. If you see new blisters forming or the wound starts to look infected, give your doctor a call. Otherwise keep reading.

The Soft Spot. Have you ever wondered why a baby horse can stand up a few minutes after birth and within a few days is running around the farm like nothing happened while a human baby just lies there, day in and day out, staring at the ceiling, not even making rudimentary attempts to walk? It's because we're smarter than horses. And I don't mean because babies know that, by lying there, people will cater to them and they have to do essentially no work at all. I mean that our brains are bigger than the brains of most animals. Our heads are also larger in proportion to the rest of our bodies. So, in order for us to squeeze ourselves down the birth canal, we have to be born while we are still relatively small and immature. Hence, the helpless baby. Because our brains are going to continue to grow after we are born, the bones of our skull must be able to move and grow accordingly. Hence the "soft spot."

In medical terms, the "soft spot" is called the anterior fontanel. It is the meeting point of two bones of the skull, which will over time grow together, fusing into a solid skull. There are actually two fontanels at birth, but the one found on the front half of the tiptop of the head is the one you can most easily feel. Soft spots vary in size considerably and will most likely get bigger before closing up. Some babies have soft spots that are flat while others seem to bulge up a bit. In some newborns the bones may seem to overlap a bit and that is okay too. If you are at all worried that the soft spot is abnormal, call your doctor, but if your baby is behaving like a normal newborn, it's probably fine.

Don't worry about poking his brain out either. You can run a hairbrush over the soft spot and you won't hurt anything. There is a whole lot of nice thick skin and muscle and other good stuff protecting the contents of his skull.

He's a Conehead! There is a reason we put hats on little babies immediately after birth and it's not because they might catch cold. After spending several hours squeezing his way down the old birth canal, there is a good chance that his head will have "molded" and look rather misshapen for several days. A bit of swelling over parts of the scalp is also to be expected. This usually goes down over the first two to three days of life. Some babies actually develop some bleeding under the scalp (not on the brain!) during the birthing process that we call a cephalohematoma. That is a big word for "bruised scalp." Typically this occurs after a prolonged or difficult labor. Unless unusually large, these also pose no issues for the little peanut. The swelling may grow over the first couple of days and then take a few weeks to resolve. As the collection of blood dissolves, it may feel either hard like an eggshell or very soft and gushy. Both are normal. If you are concerned, just ask your pediatrician to take a look at the baby's head. And then put his hat back on.

If You Can Get His Eyes Open. At birth a baby's eyesight is good enough to see your face but gets a bit fuzzy when looking across the room at the TV. Color vision gradually appears by two to four months. In other words, if Dad is trying to convince the family that the brand-new 28-inch HD TV in your living room is for the baby, he should come up with a better story. If you are trying to see what color the baby's eyes are, try holding him upright. Newborns are loath to open up when lying down, wrapped up all cozy in a blanket.

Now that they are open, don't be alarmed if you see a large red area on the white part of the eyeball. This is called a subconjunctival, or scleral, hemorrhage, which is simply a broken blood vessel overlying the sclera, or white part, of the eye. Coughing vigorously, vomiting, or laughing hysterically are common causes of subconjunctival hemorrhages. Increased pressure in your face can make a little vessel burst. Having your face squashed along the walls of a birth canal can certainly do it. It will go away by itself within a couple of weeks. Don't fret.

Natal Teeth. Rarely, some babies are born with teeth. Even more rarely will a newborn have a tooth pop through the gum in the first few weeks after birth. These are usually rudimentary little teeth, not true teeth, and most will be removed shortly after birth. These teeth would fall out on their own but we pull them because most are very wobbly and not securely fastened to the gums. They also may cause some irritation to the tongue and lips. Just point them out to your physician if he failed to notice them in the nursery.

The Torso

The Wishbone. Do you know what the equivalent in humans is to the wishbone in a turkey? The clavicles. These are the bones at the top of the chest that help create the frame from which your arms hang. Sometimes during a more difficult delivery, one of these bones may break. If not noticed immediately after birth, you may later detect a small amount of swelling or feel a hard bump along one of the clavicles. These bones heal very well and this bump will eventually go away. This is a pretty common injury and does not in any way mean that the doctor was too aggressive during the birth.

The Waiter's Tip. In the same way that the clavicle can be broken during delivery, the bundle of nerves that start in the neck and run under the clavicle and into the armpit might also become injured during the birth process. Depending on which nerves are injured, a baby may have weakness of all or part of the arm. In many cases, a baby's arm will hang limply at his side when he's propped upward, with the hand facing backward as if waiting for a $20 tip after showing you to your seat. Absolutely any sign of weakness in the arm should be called to the attention of your doctor as some of these injuries may require further evaluation or repair.

The Breastbone. Some babies have a breastbone, or sternum, that caves inward (pectus excavatum), while others bow outward (pectus carinatum). Either way, newborns' chests are very soft and mobile and everything may seem quite exaggerated at this stage. Don't worry if you see ribs and bones, and everything seems to pull this way and that. At the very end of the sternum is a little bump, called the xiphoid process. This is just the tip of the sternum, but because babies and kids are still growing, it isn't fully attached yet to the main bone, making it seem more prominent and a lot of parents mistake it for a tumor or other abnormal growth. It's not.

Breast Bumps. Try to remember how incredibly hormonal moms feel when pregnant. And then remember that a little one was sitting inside this sea of hormones. So it's no wonder that babies can have estrogen and testosterone levels rivaling that of a teenager for a period of time after birth. Many babies will develop some swelling of the breasts or occasionally have some milky discharge from the nipples. This is a result of hormones and not true breast development. As the hormone levels fall to normal, there will be no more discharge and the breasts will return to normal baby size. Some babies will actually develop an infection in the breast, resulting in redness of the skin, more swelling on one side than the other, or a foul-appearing discharge. If any of these symptoms develop, call your pediatrician immediately.

Supernummary Nipples. Speaking of breast issues, some babies have extra nipples. These are called supernummary nipples but you may have heard them referred to as "witches' tits." During early embryonic development, we all have several rudimentary nipples that develop in a row on the front of the developing torso. Normally all but the uppermost disappear. You don't have to do anything about this, but if you are worried that he's going to get teased endlessly in the locker room, a plastic surgeon will be able to remove the extra little nubbin later.

Belly Buttons. Belly buttons. Some people have "outies"; some have "innies." Some are filled with lint and others are decorated with metal studs. The medical term is the umbilicus. Most of us don't give them a lot of thought. But early on, at the very beginning, when Daddy is strong-armed into sawing through this life-giving yet surprisingly tough and rubbery appendage that stretches strangely from the middle of your baby, the "umbilical cord" becomes every parent's worry. Along with wiping away spit-up and changing diapers, caring for The Cord becomes part of caring for baby. And with every passing day, Mom and Dad can find new reasons to worry about their little one. A small amount of oozing blood is completely normal. A slightly goopy and gelatinous consistency to the base of the cord is also normal. You simply need to make sure that any cord care regimen your pediatrician has recommended, such as applying rubbing alcohol, actually involves the base of the cord that remains attached to the baby. Repeatedly wiping the already dried-out piece sticking two inches away from baby is an exercise in futility.

The following are absolutely not normal: Any foul-smelling or discolored drainage from the newborn's belly button warrants an urgent evaluation. Any redness spreading onto the belly is also an absolute urgency. (A small amount of pink tissue right at the center of the umbilicus is normal healing tissue, however.) Also, please let your doctor know if there is any persistent drainage of any type coming from the umbilicus after the cord has fallen off.

Sacral Dimple. Now, flip him over and look at his back. Pay special attention to the area just above his little baby bottom. A tuft of hair or little dimple should be pointed out to your doctor, but it's not an emergency. Abnormalities at the base of the spine are quite common and infrequently significant but can rarely signify an underlying problem with the lower spine. Your pediatrician may decide to evaluate this further with special X-ray studies, but not in the middle of the night.

In the Diaper

Urine Output: Dry Diapers. New parents are often advised to keep track of the "outputs" deposited in little Marge's diapers. While this is especially important for breastfed infants, when we are not sure of their actual intake during the first several days of life, some parents exhibit a tendency to become, how shall I say this, obsessed. Some parents actually go so far as to carry a small notebook filled with detailed information such as how many milliliters little Marge drank at 1:32 a.m. and how many grams of output were received at 2:08 a.m. If you are so sleep deprived that you are afraid you will forget who little Marge is, let alone what she ate and when she pooped, then please get yourself a notebook and follow suit. We can all laugh about it later when you've had some rest. Regardless, there is something that you should know. Today's commercial diapers are true wonders, the result of hours and hours of engineering and scientific diligence. I've even been told that they let "volunteer" toddlers in diapers filled with creamed corn loose on jungle gyms to monitor leakage. However, all this fantastic "superabsorbency" makes it virtually impossible to tell whether a newborn has wet his pants. Try tucking a small piece of tissue or some cotton balls onto the part of the diaper where your little one is most likely to aim a stream of urine (middle for girls, front for boys). This allows you to know with certainty whether or not Marge has successfully produced urine.

Bloody Diapers, Part 1: Did He Pee Blood?! It is very rare for a newborn to actually have blood in his pee. If it is a girl, a small amount of bleeding from the vagina is completely normal. What is even more common is finding a pinkish orange staining of the diaper, in the area hit by urine. The uric acid found in urine can react with the material in the diaper and form pink crystals. It is absolutely not blood, is normal, and is 100 percent harmless. You don't need to change her diet or give it another thought. If you still truly believe there is blood in the urine, give your doctor a call, especially if the baby seems more irritable, is lethargic, or has a fever.

Constipation/Diarrhea/Other Poop Issues. Many a family, complete with Grandma, Grandpa, Aunt, Uncle, cousins, and neighbors, comes to the ER to report that the baby has not produced stool in two days, ten days, two hours, or [insert time period]. If you are lucky, maybe by the time you've waited six hours to see me, Billy will have laid a little present in his diaper, giving us all a hearty chuckle and you a quick trip back out the front door. However, more likely is that you will receive the following speech from me. All babies are different. Usually the first several stools are that thick, green, slimy product referred to as meconium. You don't really want to know what that is. Rather, you should just be thankful that after the first several stools, most babies begin producing something that resembles, well, um, creamed corn. However, some babies, especially those that are formula fed, will produce stools that look like anything from canned vegetables to normal adult formed stool. The consistency and color are of less interest to us than you might think. And some babies poop five times a day; some poop once a week. That is also not so exciting to me.

Constipation means that the stools are hard, rocklike, and difficult to pass. A baby is not necessarily "constipated" when he doesn't create stool on the expected time schedule laid out for him by anxious caregivers. In addition, all babies turn red and grunt and draw their legs up when they poop. It is rare that a newborn is actually constipated, and requires nothing more than a little patience and understanding.

If your baby produces no stool in the first seventy-two hours of life or if he produces rare stools that are very thin and ribbonlike, please call your pediatrician. In addition, an infant whose stools are completely white needs to be evaluated.

Bloody Diapers, Part 2: Bloody Stools. A very common cause of bloody poop in a newborn is swallowed maternal blood. In other words, he inadvertently took a swig on the way out. These stools are usually dark and tarry because the blood has passed all the way through the gut and been digested. If the blood is truly from the birthing experience, it should pass within the first couple of days of life.

Blood appears in the stool after the first couple of days most commonly under the following two conditions. Case one is that Billy is actually constipated and has passed a large, hard stool that is streaked with blood. This is the result of the large, difficult-to-pass stool creating tiny tears on its way out. These little rips in the skin are of little concern other than as a sign that the poops should be softer. If this is a one-time event, no worries, but if the stools are consistently very hard and large, talk to your pediatrician about appropriate ways to encourage softer poops in a tiny baby. More commonly in a newborn, the stool is loose, with strings of blood and mucus mixed throughout. This is truly bloody stool and someone should definitely hear about it. Most often the blood is the result of a condition called allergic colitis. When a baby becomes sensitive to something in his diet, the most common offending agents being cow's milk and soy proteins, the gut can become raw and inflamed and begin to bleed. Breastfed babies are not immune to allergic colitis since what Mom eats can show up in the milk. You should call your pediatrician, who can advise you on appropriate dietary changes, either for Mom or babe. Be aware that there may still be some blood in the stools for up to a couple of weeks while his gut heals.

Any newborn that is passing large amounts of blood, or anything that looks like pure blood or strawberry jelly, should be seen by his doctor. A baby who seems very irritable or lethargic, has fever, or has a tense or hard and distended belly should also be seen urgently. But remember that serious causes of bloody stools are quite rare in otherwise healthy newborn babies.

King Arthur's Sword. Circumcisions: There are arguments for and against what has become the most common elective surgical procedure in this country and should be discussed with your pediatrician prior to little Fred's arrival. Should you decide to circumcise your little football player, here are a few things you should know. There are a couple of common methods of circumcision in newborns and each comes with its own set of postprocedural care instructions. Follow your doctor's advice. However, what many physicians forget to warn new parents about is that healing circumcision wounds can look gross. When a wound heals in a warm, moist environment (as on a penis), it can look very white and goopy. This is normal and shouldn't panic you.

Once the wound has healed, the circumcised penis needs to be gently yet thoroughly cleaned at every diaper change with the remaining foreskin gently retracted to allow visualization and cleansing of the entire glans, or tip of the penis. Otherwise a buildup of smegma, which is just dead skin cells and looks like cottage cheese, can occur in the space between the foreskin and the glans. The other reason for gently retracting the foreskin during a diaper change is to prevent the development of adhesions, or scar tissue, between the remaining foreskin and glans, which can eventually make the foreskin no longer retractable. If this happens, the penis can look uncircumcised or it might actually become sucked into all that chubbiness on top of his pelvic bone and get stuck, like a magical disappearing penis trick. These conditions can be remedied, but in severe cases may require surgical correction. So maintain vigilance!

If you've elected to leave his little manlihood alone, then a diaper change is much simpler. The uncircumcised