on stomach, lift head up 45 degreesThis month, baby’s finally starting to discover that there’s more to life than eating, sleeping, and crying. Not to say that babies this age don’t do plenty of all of these (colicky infants generally keep up the late afternoon and early evening crying bouts until the end of the month)—just that they’ve expanded their horizons to interests beyond. Like their own hands—as far as two- and three-month-olds are concerned, the most fascinating toys ever invented. Like staying awake for longer stretches of play during the day (and hopefully, staying asleep for longer stretches at night). Like keeping mommy and daddy entertained with adorable live shows of smiles, gurgles, squeals, and coos that make parenting well worth the price of admission.
All babies reach milestones on their own developmental time line. If your baby seems not to have reached one or more of these milestones, rest assured, he or she probably will very soon. Your baby’s rate of development is normal for your baby. Keep in mind, too, that skills babies perform from the tummy position can be mastered only if there’s an opportunity to practice. So make sure your baby spends supervised playtime on his or her belly. If you have concerns about your baby’s development, check with the doctor. Premature infants generally reach milestones later than others of the same birth age, often achieving them closer to their adjusted age (the age they would be if they had been born at term), and sometimes later.
By three months, your baby … should be able to:
on stomach, lift head up 45 degrees
… will probably be able to:
laugh out loud
on stomach, lift head up 90 degrees
Many, but not all, three-month-olds can lift their heads to a 90-degree angle.
squeal in delight
bring both hands together
smile spontaneously
follow an object held about 6 inches above baby’s face and moved 180 degrees—from one side to the other, with baby watching all the way
… may possibly be able to:
hold head steady when upright
on stomach, raise chest, supported by arms
roll over (one way)
grasp a rattle held to backs or tips of fingers
pay attention to an object as small as a raisin (but make sure such objects are kept out of baby’s reach)
… may even be able to:
bear some weight on legs when held upright
reach for an object
keep head level with body when pulled to sitting
turn in the direction of a voice, particularly mommy’s
say “ah-goo” or similar vowel-consonant combination
razz (make a wet razzing sound)
Most doctors do not schedule regular well-baby checkups this month. Do call the doctor if there are any concerns that can’t wait until next month’s visit.
It’s a responsibility that can’t be found in any job description, yet more and more employed mothers are electing to take it on. It cuts into coffee breaks and lunch hours, makes a busy day even busier, and takes plenty of planning and even more dedication. And yet most women who pump on the job so they can keep nursing after they return to work wouldn’t have it any other way. For them, the benefits of continued Breastfeeding—from the physical (better health for baby) to the emotional (builtin close contact with baby before and after work; a strong link with baby while they’re on the job)—are well worth the extra effort. Besides, many find that once they get the hang of it, being a Breastfeeding employed mother isn’t such hard work after all.
As with everything else that’s related to going back to work when you have a young infant, plenty of forethought is necessary. To make nursing and employment work, keep the following in mind:
Wait with the bottle … Don’t start giving bottles until your milk supply is well established. Starting too soon can lead to nipple confusion (see page 91) and an inadequate milk supply. Wait to introduce the bottle until you’ve worked out any nursing kinks and feel confident about your milk supply. For most women, that’s somewhere around four to six weeks—though some find things going smoothly a bit sooner or later.
… but don’t wait too long. Though you won’t want to bring on the bottle much before four to five weeks, don’t wait much longer either—even if you won’t be heading back to work for a while. Typically, the older and smarter babies get, the less open they are to trying the bottle. Once you’ve made the introduction, get baby used to taking at least one bottle feeding a day—preferably during what will soon be your working hours.
Get an early start. Your first day back on the job will be stressful enough without adding the strain of figuring out how to use a breast pump. So begin pumping a few weeks before you’re due back on the job. That way, not only will you be a more confident pumper but also you’ll have started collecting a stash of frozen milk by the time you start collecting paychecks.
Do a couple of trial runs. With child care in place, rehearse your workday game plan, doing everything as you would if you were really going to work (including expressing milk away from home), but leave the house for just a couple of hours the first time, longer the next. Noting what problems arise now gives you time to figure out how they can be handled.
Start off slow. If you’re going back to a full-time job, you might try returning on a Thursday or Friday to give yourself a chance to get started, see how things go, and evaluate the situation over the weekend. Beginning with a short week will also be a little less overwhelming than starting out with five days ahead of you.
Work part-time. If you can swing a part-time schedule, at least at first, you’ll be able to spend more time strengthening breastfeeding links. Working four or five half-days is more practical than two or three full ones for several reasons. With half-days, you may not have to miss any feedings—and certainly no more than one a day. You’ll have little trouble with leakage (your silk blouses will thank you), and probably won’t have to do any on-the-job pumping (which means you’ll actually get to drink coffee on your coffee break). Best of all, you’ll spend most of each day with your baby. Working nights is another option that interferes very little with breastfeeding, especially once baby is sleeping through the night, but it can seriously interfere with two other very important commodities: rest and romance.
Once back on the job, finding the time and the place to pump can be a big challenge for nursing moms. Luckily, pumping is fast becoming a part of business as usual; in some workplaces, it’s even encouraged (see box, opposite page). Many women successfully combine nursing, pumping, and working. Keeping these tips in mind can help you succeed, too.
Dress for pumping success. Wear clothes that are convenient for pumping. Be sure your top can be lifted or opened easily from the front for pumping at work, and that it won’t be stretched out of shape or badly wrinkled by being pulled up. (See page 85). Whatever you wear, line your nursing bra with breast pads to protect your clothing, and carry an extra supply of pads in your bag as replacements for wet ones.
Look for privacy. Pumping at work will be infinitely easier if you have access to a private space, such as your own office with a door you can close, an unused office or conference room, or a discreet (and clean) corner in the bathroom lounge.
Be consistent. Schedule permitting, try to pump at the same times every day—as close as possible to the times you would be feeding your baby if you were home. That way your breasts will come to anticipate pumping (as they would anticipate nursing) and fill up with milk like clockwork.
Plan for storage. Store freshly pumped milk in the office refrigerator, well marked with your name (so that co-workers won’t mistake it for coffee creamer). Or bring a cooler from home with ice packs, or use the attached cooler that comes with many portable pumps. See page 162 for more on storing breast milk.
Use promptly. When you get home, refrigerate the pumped milk, and have the care provider feed it to your baby the next day. This way you should always have a full day’s supply available in the fridge.
Schedule in breastfeeding, too. Breastfeeding on schedule will help keep your milk supply up—as well as give you and baby that special time together. Breastfeed before going to work in the morning and as soon as you come home in the afternoon or evening. Ask the care provider not to feed the baby during the last hour of the workday, or to feed baby just enough to take the edge off any hunger.
Take a vacation from bottles on weekends. To keep your milk supply abundant, use weekends and holidays as time for exclusive nursing. Try to go bottle-free as much as possible then, or any other day you’re home.
Schedule smart. Arrange your schedule to maximize the number of nursings. Squeeze in two feedings before you go to work, if possible, and two or three (or more) in the evening. If you work near home and can either return during lunchtime for nursing or have the sitter meet you somewhere for a drive-by nursing session with baby (even at your office, if you can arrange it), consider doing this. If your baby is in day care, nurse when you arrive there, or in your car before you go in, if that works better. Also try nursing your baby at pickup time, instead of waiting until you get home.
The days of sneaking breast pumps down the hall to the ladies’ room and hiding milk stashes where they won’t be poured accidentally into someone else’s coffee are gone—at least at some enlightened workplaces. As companies begin to realize that policies which make working parents happier usually make them more productive on the job, more and more corporate lactation programs have begun springing up across the country. Companies with these programs make lactation rooms available for their employees, complete with pumps, refrigerators, and access to a lactation consultant. These programs benefit not only the mother (because of decreased stress) and baby (because of the health benefits of breast milk) but also the company; if the baby gets sick less often, the mother is absent from work less often—resulting in a more productive worker.
Even if your company does not have such a program, there are ways to make your place of work a more nursing-friendly environment. Get together with other breastfeeding mothers in the office (if possible) and lobby for periodic break time, a room for privacy, and other such pumping necessities on the job. Keep track of the amount of time other employees take breaks (for coffee, lunch or smoking) so that if your boss says there’s no time in the day to spend on pumping, you’re armed with an answer. Alert your employer to the many resources for corporate lactation programs, such as the one from the La Leche League. Point out that the AAP recommends not only that babies be breastfed for at least the first year, but also that employers provide a place for moms to nurse and pump. Also, check your local and state laws; there has been legislation passed in some areas protecting a woman’s right to pump milk for her baby at work.
Stick close to home. If your job entails travel, try to avoid trips that take you away from home for more than a day until your baby is weaned; if you must travel, try to express and freeze in advance enough milk for the duration of your trip, or get your baby accustomed to formula before you plan to go. For your own comfort and to keep up your milk supply, take along a breast pump (or rent one where you’ll be) and express milk every three or four hours. When you get home, you may find your milk supply somewhat diminished, but more-frequent-than-usual nursings, along with extra-special attention to diet and rest, should replenish it.
Work from home when you can. Try taking home any work that can be done out of the office (with your employer’s blessing). This will give you more flexibility and allow you to be home more of your baby’s waking hours. Though you will probably have to relegate most of baby’s care to a sitter when you’re working in your home, you should be able to nurse as needed.
Keep your priorities straight. You won’t be able to do everything and do everything well. Keep your baby and your relationship with your spouse (and any other children you have) at the top of the list. Your job—especially if it means a lot to you, either financially, emotionally, or professionally—will probably also have to make the top of the list, but be relentless about cutting corners everywhere else.
Stay flexible. A (relatively) calm and happy mother is more valuable to your baby’s well-being than a diet made up exclusively of breast milk. Though it’s entirely possible you’ll be able to continue providing all of your baby’s milk (as many women do), it’s also possible that you won’t. Sometimes the physical and emotional stresses of holding a job and nursing curtail a woman’s milk supply. If your baby isn’t thriving on breast milk alone, try nursing more frequently when you’re at home and, if it’s feasible, returning home during your lunch break to breastfeed and help rebuild your milk supply. If this doesn’t work and you find you can’t keep up with working and pumping, it might be best to supplement with formula.
“My mother tells me I have to get my baby on a schedule right away. My sister says to throw away the clock and just meet his needs. What’s the right thing to do?”
The right thing to do—as it is when it comes to so many aspects of parenting—is what’s right for you and your baby. Though advocates on both sides of this issue would argue otherwise, there are no absolutes that definitively answer the question of whether or not to put babies who are no longer newborns on schedules. That’s because every baby, like every parent, is an individual. What works for one parent and baby may not work well for another parent and baby, and may not even work well for two different babies in the same family. There are pros and cons to both philosophies of parenting, and many parents, rather than dogmatically following one method or the other, find a middle ground that’s comfortable for them.
By three months, some babies will have established a pretty regular daily rhythm, even without prodding from the parents. Typically, it’s something like this: He wakes about the same time each morning, feeds, perhaps stays awake for a short period, takes a nap, wakes again for lunch, follows with another nap, feeds, then perhaps has a fairly long period of wakefulness late in the afternoon, capped off by a meal and a nap in the early evening. If this nap tends to run past the parents’ bedtimes, they may wake him for a feeding before they go to bed, maybe about 11 P.M. (or as late as they can keep their eyes open). At this point he may go back to sleep again until early morning, since babies this age can often sleep six hours at a stretch, and sometimes more.
Other babies have a more idiosyncratic, yet still somewhat consistent, schedule. One, for example, may wake up at 6 A.M., feed, and go back to sleep for an hour or two. Once awake, he may be content to play for a while before nursing, but once he starts nursing, he wants to do so nonstop for the next three hours. After a twenty-minute nap, however, he wakes up ready to play all afternoon with just one nursing period and another five-minute nap. He nurses again at about 6 and by 7 is sound asleep, and he stays that way until mom wakes him for a nightcap before she goes to bed. His isn’t the traditional four-hour schedule, but there is still a consistent pattern of sleep–wake–eat to his day.
Parents of such “regular” babies have an easy time creating a regular routine; even the nontraditional yet consistent routine is still one a parent can plan the day around, if not set his or her watch to. And because the baby’s schedule is baby-led, not imposed, parents of these babies needn’t feel as if they’re being too rigid or not being responsive enough.
But many babies don’t fall smoothly into any schedule at all, even past three months. Their wake, eat, and sleep pattern is totally random from day to day. If your baby is one of these, you’ll have to decide whether you want to take the initiative by trying to make the parts of his life you do have some control over as organized as possible or whether you want to take a laissez-faire attitude toward scheduling. Here’s the rundown on what both approaches might have to offer:
Parenting on schedule. Regular routines give children predictability, stability, and security, according to proponents of parenting on schedule. Routines keep the day dependable and calm, providing the order and consistency many babies are naturally comforted by. Establishing a schedule doesn’t mean a baby’s needs won’t be met—they’re just met within the framework of a daily routine. And because parents have rights, too, a predictable schedule theoretically allows you and your spouse to make time for each other, away from baby (at home or out), something that relationships thrive on, and that is often unattainable when it’s anybody’s guess when baby will eat or sleep. Schedules become increasingly important to family stability and to a child’s well-being as time goes by. Many children seem to do perfectly well without a schedule in early infancy, when they’re extremely portable and can fall asleep or be fed anywhere. Later, they often begin to respond to irregular mealtimes and sleep times with regular crying and crankiness. And once school starts, children who don’t have regular bedtimes often have trouble rising on time or getting enough sleep to get productively through their days.
Scheduling a baby, however, can be taken to the extreme—and shouldn’t be. Very young infants (under the age of two to three months) shouldn’t be put on a schedule—they should eat and sleep on demand. Even later on, denying your hungry baby the breast or bottle because the clock says he shouldn’t be hungry yet is never a good idea (and, if baby’s breastfed, can lead to a diminished milk supply and even failure to thrive). Not picking up a crying baby because the schedule says it’s “mommy and daddy time” now can make a child feel helpless, abandoned, insecure, and unloved. In other words, a strict schedule can be as stifling as a too lax one can be disorienting.
If you decide on a schedule, how much structure you should build into it should depend on your baby’s natural eating and sleeping patterns, his inborn personality (some children naturally seem to need more structure, some less), and the needs of the rest of the family. A schedule shouldn’t be thought of as a rigid set of rules to be followed and appointments to be kept, but rather as a flexible timetable around which your and your baby’s day revolves.
Parenting on demand. Though much of our society is run on schedules—train schedules, work schedules, class schedules—there are those who function perfectly well without them. If baby thrives without a schedule (seems perfectly contented, active, and interested by day, and sleeps well at night) and his parents do, too (they don’t mind putting baby’s needs first, even when it means that other areas of their lives will take a backseat), then this system can work well. Proponents say that responding to your baby’s every need on demand allows you to better understand your baby and foster trust, the foundation of good parent-child communication. That nursing baby whenever he cries for food (even if he just finished eating), letting him sleep whenever he wants to (and letting him stay up when he wants to), and carrying (or wearing) baby as much as possible during the day (or when he demands it) allows him to feel secure and valued as a human being and also reduces fussing and crying. And because it builds in more time together, demand parenting can also help parents get to know their babies better and faster. Families who choose demand parenting feel that scheduling baby for the sake of convenience is a short-term gain far outweighed by the long-term loss.
There can be, however, certain potential pitfalls to raising children in an unstructured environment. Some babies crave schedules right from the start. They become cranky when feedings are late or overtired when naps and bedtimes are delayed. If your baby reacts unhappily to your unscheduled days and nights, it may be that she needs a little more structure, even if you don’t. And for some babies, the absence of structure in their lives early on can interfere with their developing, and then exercising, self-discipline later in life. Getting to school on time, completing homework, and getting papers in on schedule can be difficult for children who have never been exposed to any kind of structure previously. Of course, some children continue to thrive in schedule-free homes. And since every child is different, and some can end up being quite different from their parents, there’s the distinct possibility that a child raised without a schedule may turn out to be a Type A who creates his own to meet his needs (giving himself the bedtime his parents never did), and the child who’s raised by the clock may turn out to be the one for whom schedules never fit.
If you choose to parent on demand, make sure, too, that in keeping up with those of your baby, you don’t neglect the demands of your relationship with your spouse. Without a regular bedtime for their babies, parents often find they never spend any time alone. They enjoy their threesome so much in the evening, they sometimes forget the fun two can—and should—have.
Not only isn’t there any right or wrong answer when it comes to schedules, what’s right or wrong for you and your baby may change as the months pass. You may start out with a schedule, only to find it too confining. Or you may start out with demand parenting, only to find out your baby demands a schedule. Or, like so many other parents, you may ultimately find that middle ground the most comfortable place to be. No matter what your choice, remember that it’s no one else’s to make. Do what works for you and your baby, and don’t worry about what anybody else has to say about it.
“My baby always falls asleep nursing. Is this a bad habit that needs to be broken?”
It’s an idea that looks good on paper: Put a baby to bed when she’s awake, not already asleep, so that later, once she’s weaned, she’ll be able to get to sleep on her own—without the breast or a bottle. In practice, as any mother who’s tried to keep her baby from falling asleep while nursing or tried to rouse a baby who’s conked out while suckling knows, it’s an idea that’s not necessarily compatible with reality. There’s just very little you can do to keep a nursing baby awake if she wants to sleep. And if you could wake her up, would you really want to?
DUELING PARENTING PHILOSOPHIES
Walk into any bookstore, check out any newsstand, or surf any on-line parenting site, and you’ll be confronted with a multitude of books, magazines, articles, and advice on how to parent your child. You’ll be bombarded with dozens of parenting philosophies, each with its own set of doctrines—most of them conflicting—and each claiming to offer the best approach to raising children. Whether the philosophy covers how to feed your baby, how to get your baby to sleep through the night, where your baby should sleep, how your baby should be carried, when your baby should be weaned, or what kind of schedule your baby should be on, they are all based on the same premise: Every child has needs, and it’s the parents who are there to meet those needs.
The spectrum of advice and philosophies is broad, with many methods pitting their own points of view against others. But most parents follow advice that falls into one of two “mainstream” philosophies. “Attachment parenting” promotes nursing on demand, co-sleeping, and baby wearing (meeting baby’s needs by being in close physical contact with him or her as much as possible). “Parent-guided parenting” promotes creating a structured environment in which a baby’s needs are met in a familiar and routine fashion.
Some parents alternate between philosophies depending on the issue. Some sample a little from each before choosing one they feel they and their babies can live with. Some continue to vacillate between philosophies, never feeling sure enough about any one to settle on it. Many take a little from each or from several to create their own philosophy. Other parents embrace one philosophy with everything they’ve got, even denigrating those who have chosen to parent in another way.
What many philosophies—and their subscribers—fail to take into account, however, is that there are very few absolutes when it comes to the job of parenting. With the exception of safety and health issues (keeping your child in a car seat, making sure he or she receives regular medical care), there are many good ways to be a good parent. Most doctors will agree that as long as both parents agree on an approach and are consistent in it, any parenting style (or a combination of a few) can work out well for a family. As long as your baby is healthy, safe, and content, doing what feels best for your family is always a better idea than dogmatically following a set system—or being made to feel guilty by those who disagree with your style of parenting.
Teaching your baby to fall asleep without assistance from breast (or bottle) can more practically wait until baby is older—between six and nine months—and nursing less often. And if the habit hangs on, breaking it can certainly be accomplished fairly quickly after your baby has been weaned.
Whenever the opportunity presents itself, however, you might want to consider putting your baby down for a nap or at bedtime while she’s still awake—not so awake that sleep will be elusive, but in a state of drowsy readiness. A little rocking, nursing, or lullabying can usually bring a baby to this state (but try not to prolong the comforting action to the point of sound sleep).
“My friend’s baby has been sleeping through the night since he got home from the hospital, but mine is still waking up and eating as often as he did when he was first born.”
In young infants, the habit of feeding frequently at night is often a nutritionally necessary one. Though some babies no longer need night feedings by the third month (and sometimes sooner), most two- or three-month-old babies, particularly breastfed ones, still need to eat once or twice during the night.
But while your baby may still need some middle-of-the-night nourishment, he certainly doesn’t need to be chowing down three or four times per evening. Gradually reducing the number of late-show feedings baby’s getting won’t only help you get more rest now, it’s an important first step in preparing him to sleep food free through the night later on. Here’s how:
Increase the size of the bedtime feeding. Many sleepy babies nod off before they’ve totally filled their tanks for the night; restart yours if possible, with a burp or a jiggle or some other ploy, and continue feeding until you feel he’s had enough. Don’t be tempted to add solids to baby’s diet (or put cereal in your baby’s bottle) before he or she is developmentally ready in an effort to buy extra hours of sleep. Not only won’t it work, giving solids isn’t recommended until four to six months.
Wake baby for a feeding before you turn in. A late-evening meal may fill him up enough to last him through your own six or eight hours of shut-eye. Even if he’s too sleepy to take a full meal, he may take enough to hold him an hour or two longer than he would have gone without a snack. (Of course, if your baby begins waking more often once you’ve instituted this procedure, discontinue it. It could be that being awakened by you makes him more prone to waking himself.)
Make sure baby’s getting enough to eat all day long. If he isn’t, he may be using those night feedings to catch up on calories. If you think this might be the case, consider nursing more frequently during the day to stimulate milk production (also check the tips on page 165). If your baby’s on the bottle, increase the amount of formula you give at each feeding. Be aware, however, that for some babies feeding every couple of hours during the day sets up a pattern of eating every two hours, a pattern they continue around the clock. If your baby seems to have fallen into such a schedule, you might want to go for longer, less frequent feedings instead.
Wait a little longer between feedings. If he’s waking and demanding food every two hours (necessary for a newborn, but not usually for a thriving three- or four-month-old), try to stretch the time between feedings, adding half an hour each night or every other night. Instead of jumping to get him at the first whimper, give him a chance to try to fall asleep again by himself—he may surprise you. If he doesn’t, and fussing turns to crying, try to soothe him without feeding him—pat or rub him, sing a soft, monotonous lullaby, or turn on a musical crib toy. If the crying doesn’t stop after a reasonable time (for however long you feel comfortable letting him fuss), pick him up and try soothing him in your arms by rocking, swaying, cuddling, or singing. If you’re breastfeeding, the soothing tactics have a better chance of success if dad’s in charge; a breastfeeding infant who sees, hears, or smells his source of food is not easily distracted from eating. Keep the room dark, and avoid a lot of conversation or stimulation.
If baby doesn’t fall back to sleep and still demands feeding, feed him—but by now you’ve probably stretched the interval between feedings by at least half an hour from the previous plateau. The hope is that baby will reach a new plateau within the next few nights and sleep half an hour longer between feedings. Gradually try to extend the time between meals until baby is down to one nighttime feeding, which he may continue to need for another one to three months.
Cut down the amounts at the nighttime feedings you want to eliminate. Gradually reduce the number of minutes he spends nursing or the ounces in his bottle. Continue cutting back a little more each night or every other night.
Increase the amount offered at the night feeding you are most likely to continue (for now). If your baby is getting up at midnight, two, and four, for example, you may want to cut out the first and last of these feedings. This will be easier to do if you increase the amount your baby takes at the middle one, either from breast or bottle. A nip from the breast or a couple of ounces from the bottle is not likely to knock him out for long. See the tips for keeping a sleepy baby awake for feeding on page 122.
Don’t diaper your baby during the night unless it’s absolutely necessary—a quick sniff can usually tell you when it is. (Of course, the fewer midnight snacks you indulge him in, the less necessary nighttime diapering will become.) If your baby is between diaper sizes, using the next larger size will provide extra surface area for absorption; or use the special nighttime diapers.
Consider some distance. If you’re sharing a room or a bed with your baby (and don’t want to continue co-sleeping in the long term), now might be a good time to think about splitting up (see page 263). Your nearness may be the reason he’s waking so often and why you’re picking him up so often.
By four months, most babies don’t really need to be eating at all during the night. (From a strictly metabolic standpoint, babies can usually go through the night without a feeding once they’ve reached 11 pounds; whether they will or not is another matter entirely.) If the night-waking habit continues into the fifth or sixth month, you can begin to suspect that your baby is waking not because he needs to eat during the night, but because he’s become accustomed to eating during the night; a stomach that’s used to being filled at regular intervals around the clock will cry “empty” even when it’s full enough to last a lot longer. See page 350 for tips on getting an older baby to sleep through the night.
“Since a neighbor’s baby died of SIDS, I’m so nervous that I’ve been waking my baby up several times a night to make sure she’s okay. Would it be a good idea to ask the doctor about a monitoring machine?”
The fear that a baby might die suddenly in the middle of the night has plagued parents probably from the beginning of time—long before such deaths were given the medical name sudden infant death syndrome (SIDS). Ancient writings mention such deaths; the baby described in the Book of Kings as being “overlaid” by his mother was very likely a victim of crib death.
But unless your baby has experienced an actual life-threatening episode in which she stopped breathing and needed to be revived (in which case, see next page), the chances of her actually succumbing to SIDS are very, very small. And preoccupation with the fear that your child might end up being among those very few is more harmful than helpful—to both of you.
For most parents, no reassurance will totally obviate the need they feel to check their baby’s breathing occasionally at night. Many, in fact, don’t breathe easily themselves until their babies have passed the one-year mark, the age when infants seem to outgrow the risk of SIDS. And that’s okay as long as you don’t let worry pervade your life with baby.
Though investing in a monitor—an apparatus that can signal if your baby suddenly stops breathing—may seem like an ideal (if expensive) way of easing your fears, monitoring a normal baby can cause more problems than it solves. The false alarms that are common with monitors result more in worry than relief.
What can make you feel more secure—besides taking all the preventive steps listed above—is learning infant CPR, and being sure that baby-sitters, housekeepers, and anyone else who spends time alone with your baby also knows this lifesaving technique. That way, if your baby ever does stop breathing, for any reason, resuscitation can be attempted immediately (see page 593). If gnawing fears continue to plague you, look to your baby’s doctor for reassurance. If that doesn’t calm you down, talk to a therapist who is familiar with SIDS and can help to allay your fears. (Sometimes, postpartum depression can trigger this kind of overwhelming anxiety; see page 673.)
SIDS, or sudden infant death syndrome, is the sudden and unexpected death of an apparently healthy infant that is unexplained by the baby’s medical history, an autopsy, or the examination of the scene of death. Though SIDS is the major cause of infant death between the ages of two weeks and twelve months, the risk of the average baby dying of SIDS is very small—about 1 in 1,500. And thanks to preventive steps parents can take (see Preventing SIDS, next page), that risk is getting smaller still.
SIDS most often occurs in babies between two and four months, with the majority of deaths occurring before six months. Though it was once believed that victims were “perfectly healthy” babies stricken without reason, researchers are now convinced that SIDS babies only appear healthy and actually have some underlying defect that predisposes them to sudden death. One hypothesis is that the control in the brain that wakes us when breathing conditions are dangerous is underdeveloped in these babies. Another theory is that SIDS may be caused by an undetected defect in the heart or a faulty gene involved in managing breathing and heart rate.
There is a higher SIDS risk for babies of women who had poor prenatal care, who smoked during pregnancy (smoking preand postnatally increases the risk threefold), or were under age twenty (this may be as much because of the poor pre- or postnatal care or because of smoking as because of age). Premature or low birthweight babies are also at somewhat higher risk.
SIDS isn’t caused by vomiting, choking, or illnesses. It is also not caused by immunizations. Nor is SIDS contagious.
There are many environmental factors that increase the risk of SIDS, including tummy sleeping, sleeping on soft or loose bedding or with pillows or toys, exposure to tobacco smoke, and being overheated. The good news is that all of them can be avoided. In fact, there has been a 40 percent decrease in the number of SIDS deaths since the American Academy of Pediatrics and other organizations initiated the “Back to Sleep” campaign in 1994.
You can reduce the SIDS risk significantly for your baby with these measures:
Put baby to sleep on his or her back. Make sure all of baby’s providers, including baby-sitters, day-care workers, and grandparents are instructed to do this, too.
Use a firm mattress and tightly fitting sheets for baby’s crib. Remove all loose bedding, pillows, fluffy quilts, sheepskins, and soft toys from the crib. If you use a blanket, make sure it’s a thin one, tuck it in around the mattress, and make sure it reaches only baby’s chest level. Or, better yet, skip the blanket and put baby in a one-piece sleeper. (If baby sleeps with you, you’ll need to be sure your bed is safe; see page 265.)
Never allow your baby to get overheated. Don’t dress baby too warmly for bed—no hats or extra clothing or blankets—and don’t keep his or her room too warm. Your baby should not feel hot to the touch. Overheating increases the risk of apnea, which can lead to SIDS in some babies.
Don’t allow anyone to smoke in your home or near your baby.
Recent studies have reported a lowered risk of SIDS among breastfed babies (with an even lower risk among babies breastfed longer than four months) and suggested a lower SIDS incidence among infants who use a pacifier. More research needs to be done to confirm these findings.
Devices designed to maintain sleep position (such as wedges) or to reduce the risk of rebreathing air are not recommended, because many have not been sufficiently tested for their safety, and none has been shown to be effective at reducing the risk of SIDS.
“Yesterday afternoon I went in to check on my baby, who seemed to be taking a very long nap. He was lying in the crib absolutely still and blue. Frantic, I grabbed him and he started breathing again. Now his doctor wants to put him in the hospital for tests and I’m terrified.”
As frightening as the experience may have been for you, you’re actually lucky it occurred. Not only did your baby come through it fine, but he gave both you and the doctor warning that it might happen again—and a chance to make sure that it doesn’t. And that’s exactly why the doctor has suggested hospitalization and tests.
Your son experienced an “apparent life-threatening event,” but that doesn’t mean his life is in danger. While an episode of prolonged apnea (when breathing stops for more than twenty seconds) does put an infant at slightly increased risk for SIDS, there’s a 99 percent chance that the risk will never become a reality. As a precaution, and to try to determine what triggered the event, your baby will be evaluated in the hospital through a complete health history and physical exam, diagnostic testing, and possibly monitoring for further spells of prolonged apnea. (This kind of evaluation may also be performed on an infant who has no history of apnea but who has had two or more siblings who succumbed to SIDS, or one who died and others who suffered apparent life-threatening events.)
REPORTING BREATHING EMERGENCIES TO YOUR DOCTOR
Though very brief (under twenty seconds) periods of breathing lapse can be normal, longer periods—or short periods in which the baby turns pale or blue or limp and has a very slowed heart-beat—require medical attention. If you have to take steps to revive your baby, call the doctor or emergency squad immediately. If you can’t revive your baby by gentle shaking, try CPR (see page 593), and call or have someone else call 911. Try to note the following to report to the doctor:
Did the breathing lapse occur when baby was asleep or awake?
Was baby sleeping, feeding, crying, spitting, gagging, or coughing when the event occurred?
Did baby experience any color changes; was he or she pale, blue, or red in the face?
Did baby need resuscitation? How did you revive him or her, and how long did it take?
Were there any changes in baby’s crying (higher pitch, for example) before the breathing lapse?
Did baby seem limp or stiff, or was he or she moving normally?
Does your baby often have noisy breathing; does he or she snore?
If tests at a local hospital are inconclusive, the doctor may recommend referral to a major SIDS center. For information on the center nearest you or for more information on SIDS, call the National SIDS Alliance (800-221-7437) or the American SIDS Institute (800-232-SIDS).
Sometimes the evaluation uncovers a fairly simple cause for such an event—an infection, a seizure disorder, or an airway obstruction—that can be treated, eliminating the risk of future problems. If the cause is undetermined, or if heart or lung problems that put him at high risk for sudden death are discovered, the doctor may recommend putting your baby on a device that monitors breathing and/or heartbeat at home. The monitor is usually attached to the baby with electrodes or is embedded in his crib, playpen, or bassinet mattress. You, and anyone else who cares for your baby, will be trained in connecting the monitor as well as in responding to an emergency with CPR. The monitor won’t give your baby absolute protection against SIDS, but it will help your doctor learn more about his condition and help you feel you are doing something, rather than sitting helplessly. Keep in mind, however, that some research has questioned the effectiveness of monitors; apparently even healthy babies often experience periods of apnea or slowed heart rate that don’t increase their risk of SIDS. False alarms are also very common.
Don’t let the episode, the hospitalization, or any monitoring become the focus of your life. Doing so could turn your probably normal baby into a “patient,” even interfering with his growth and development. Seek help from your doctor or a qualified counselor if a monitor seems to add to family tension rather than reduce it.
Though criteria may vary from doctor to doctor and community to community, babies who’ve had no critical episodes since their first usually come off a monitor when they have been free of events requiring prolonged or vigorous stimulation or rescue for two months. More stringent requirements for going off the monitor are usually set for those who have had a second critical episode. Though babies are rarely removed from the monitor until they pass six months, when the peak period for SIDS is over, a total of 90 percent are off their monitors by the time they reach one year.
“My premature baby had occasional periods of apnea for the first few weeks of her life, but her doctor says that I shouldn’t worry, that she doesn’t need to be monitored.”
Breathing lapses are very common in premature babies; in fact, about 50 percent of those born before 32 weeks’ gestation experience them. But this “apnea of prematurity,” when it occurs before the baby’s original due date is totally unrelated to SIDS; it doesn’t increase the risk of SIDS or of apnea, itself, later. So unless your baby has serious apneic episodes after her original due date, there’s no cause for concern or follow-up.
Even in full-term babies, brief lapses in breathing without any blueness or limpness or need for resuscitation are not believed by most experts to be a predictor of SIDS risk; few babies with such apnea are lost to SIDS, and most babies who do die of SIDS weren’t observed to experience apnea previously.
“I’ve heard that immunizations can cause SIDS, and I’m really worried about having my baby immunized.”
Research has confirmed that there is no link between the DTP vaccine and SIDS—and, yet, like many theories that have been disproved, it stubbornly continues to circulate. But not only was DTP never a factor in SIDS, the vaccine is not even given anymore. Your baby will be receiving the newer, safer form of the vaccine, DTaP (see page 224), which has never been related to SIDS even in theory. So there’s absolutely no cause for concern.
If you’re still worried, talk to your baby’s doctor, who will doubtless make you more comfortable about going ahead with your baby’s immunizations.
See page 226 for plenty more reasons why you should have your baby immunized.
“Our ten-week-old has been sharing our room since birth. We don’t really want to continue sharing, so when should we move him to his own room?”
In the first month or two of life, when baby’s at the breast or bottle as much as he’s in bed, and nights are a blur of feedings, diaper changes, and rocking sessions interrupted only occasionally by brief snatches of sleep, having him within a weary arm’s reach makes sense. And some parents find room sharing even beyond then—and well into childhood—convenient, pleasurable, or both for all concerned (see next question). But if it’s not your plan to continue sharing a room with your baby indefinitely, it’s probably a good idea to make the break once he outgrows the physiological need for frequent feedings during the night (anywhere from about two to four months). After that, having your baby for a roommate raises a number of potential problems:
Less sleep for baby. Being in the same room with your baby all night, you’re tempted to pick him up every time he whimpers, possibly interrupting his sleep cycles. After all, babies make lots of noises while they sleep, and most of the time, they’ll fall right back asleep within minutes, without any prodding. If you pick up baby at the slightest whimper, you may be inadvertently waking him up and interrupting his sleep. In addition, during his lighter phases of sleep, your baby is likely to be wakened by your activity, even if you tiptoe around in soft slippers and climb silently into bed.
Less sleep for parents. The fact that you pick him up more often at night if he’s in your room means less sleep not only for him but for you, too. And even if you resist picking him up, you’re sure to lie awake waiting for the whimper to turn to a howl. You may also lose a few good nights’ sleep over his tossing and turning; babies are notoriously restless sleepers. Some parents, however, aren’t bothered by baby’s nocturnal movements and find that the benefits of being in a baby-free quiet room are offset by the drawbacks of feeling their way down a dark hallway every time they have to fetch a crying infant from his crib.
Less lovemaking. Sure, you know (or at least you hope) your baby is sleeping when you start to make love. But how uninhibited can you really be when you’ve got company (breathing loudly, tossing his head back and forth, moaning softly in his sleep) so close by? Of course, this problem can be avoided if you’re creative in your choice of lovemaking locales (pull-out sofa, anyone?).
For some kids, more problems adjusting later. Having your baby in your room for an extended period may make it more difficult when you finally do move him to a room of his own. (Not all children have trouble adjusting later on; some just leave their parents’ room when they’re ready to sleep on their own and never look back.)
Of course, “a room of his own” isn’t possible in every household. If you live in a one-bedroom apartment or a small house with several children, there may be no option but for your baby to share. If that’s the case, consider a divider—either a screen, or a heavy drape hung from a ceiling track (the drape is also a good sound insulator). Or give your bedroom up to the baby and invest in a sleep sofa in the living room for you. Or partition off a corner of the living room for the baby and do your late-night TV watching or talking in the bedroom.
If your baby will have to share with another child, how well the sleeping arrangement will work out will depend on how well the two sleep. If either one or both are light sleepers with a tendency to awaken during the night, you may all be in for a difficult period of adjustment until each has learned to sleep through the other’s wakings. Again, a partition or drape may help muffle the sounds, while providing the older child with privacy.
“I’ve heard a lot about the benefits of children sharing a bed with their parents. And with all the night waking our daughter has been doing, it seems like such an arrangement would mean more sleep for everyone.”
For some families, co-sleeping, or sharing a “family bed,” is an unequivocal (and cuddly) joy. For others, it’s merely a convenience. For still others, it’s a nightmare. Proponents of co-sleeping cite several advantages to the family bed: It cultivates emotional bonds, makes it easy to nurse or comfort a child, and combats loneliness. Supporters also say it reduces the risks of SIDS, though there are no data to show whether SIDS is more likely to occur during co-sleeping or when baby sleeps alone. Those on the other side of the co-sleeping fence believe that having a baby learn to sleep on her own encourages independence; discourages the development of sleep disturbances; averts any danger of suffocation from the pillows and fluffy quilts often found on parental beds; and is more comfortable for the parents (not only because they sleep better, but because there’s no risk of rolling over into a pool of spit-up or the contents of a leaky diaper).
While there’s no shortage of theories and certainly no shortage of opinions on the issue, the decision of whether to have your baby join you in bed or sleep solo in her crib—like so many decisions you’ll make in your tenure as parents—is a very personal one. And it’s a choice best made when you’re wide awake (read: not at 2 A.M.), and with your eyes wide open to the following considerations:
Baby’s safety. In this country, where sleeping accommodations are usually pretty cushy, keeping baby safe in her parents’ bed takes extra precautions. A report by the Consumer Product Safety Commission linked the family bed (and the hazards that too often lie therein) to numerous infant deaths. Proponents of co-sleeping, however, find the study’s data flawed and point out that some babies die while sleeping alone in their cribs. And other researchers have found that there is an innate connection between a co-sleeping mother and child, possibly because of the hormone response activated when the mother is in close proximity to, or breastfeeding, her child. These researchers theorize that this response may make a mother who co-sleeps more keenly aware of her child’s breathing and temperature throughout the night, allowing her to respond quickly to any significant changes. Not surprisingly, the hormone response is also responsible for the lighter sleep that women who co-sleep experience.
If you choose to co-sleep, make sure your bed and bedding meet the same safety criteria looked for in a crib. A firm mattress (not a pillow top or waterbed) is a must, as are tight-fitting sheets. Avoid plush comforters; keep pillows out of baby’s creeping reach; check for entrapment dangers (headboard slats should be no farther apart than 2
inches; there should be no gaps between the mattress and the frame). Never put baby on a bed that’s next to a wall (she could slip between bed and wall and become entrapped) or leave her in a position where she could roll off the bed (this can happen at a very young age) or allow her to sleep with a parent who is intoxicated, is taking medication that induces deep sleep, or is just a very deep sleeper. Never let a toddler or preschooler sleep directly next to your baby. And never smoke, or allow anyone else to smoke, in the family bed, since this can increase the risk of SIDS (as well as fires). A great way to keep your child close and safe is to use a bedside sleeper that attaches to your bed (see page 51).
Family feelings. A baby should come between her parents only if both have agreed she belongs there. So make sure you’re both onboard with the family bed before you bring baby onboard your bed—and consider both your feelings and your spouse’s. Keep in mind, too, that if you co-sleep, you’ll need to make other arrangements for intimacy, or three could quickly become a crowd that compromises your “two’s company.”
Sleep—yours and baby’s. For some parents, not having to get out of bed for midnight feedings or to calm a crying baby is reason enough to co-sleep. For breastfeeding moms, being able to nurse without having to be fully awake is a real plus. The flip side: Though they may never have to leave their beds at night, the sleep co-sleepers do get may be more broken up and, although emotionally satisfying, less physiologically satisfying (parents and children who co-sleep tend to sleep less deeply and sleep less overall). Also, co-sleeping babies wake more often and may have trouble learning how to fall asleep on their own, a skill they’ll eventually need. Another possible side effect of frequent awakenings is an increase in nighttime breastfeeding—fine when an infant is young, not so fine when she has several teeth. Continuous night feedings—breast or bottle—can lead to dental decay.
The future. In making your decision about the family bed, consider how long (ideally) you’d like the arrangement to continue. Some argue that co-sleeping causes prolonged dependency; others argue the opposite—that co-sleeping promotes independence by giving a child strong feelings of security. Often, the longer it lasts, the tougher the transition to solo sleeping. Switching a six-month-old over to a crib shouldn’t take too much effort; moving a baby who’s approaching her first birthday may be a little more trying; weaning a toddler or preschooler from your bed may be even more challenging. Some children voluntarily leave around age two or three, many are ready to move on by the time they start school, but a few stay on for the long haul—even through early adolescence.
Whether or not you decide to share your bed with baby at night, you’ll still enjoy bringing her in for early morning feedings or cuddling sessions. As your child gets older, you can continue to make family togetherness (if not a family bed) a favorite ritual on weekend mornings—complete with pillow fights.
“I was planning to let my daughter use a pacifier only until she was three months old, but she seems so dependent on it, I’m not sure I can take it away now.”
Babies are creatures of comfort. The comfort they crave can come in a number of packages, including a mother’s breast, a father with a bottle full of breast milk or formula, a soothing lullaby, or a pacifier. And the more accustomed they become to a particular source of comfort, the more difficult it becomes for them to do without it. If you don’t want to run into the problems that may later be associated with pacifier use, now is an ideal time to make a break. For one thing, at this age your baby’s memory is short, so she’ll easily forget the pacifier when it disappears from her life. For another, she is more open to change than an older baby—more likely to accept an alternative route to pacification. A toddler not only won’t forget her pacifier, but will probably demand its return with a storm of will and temper. And, of course, a habit of three months is easier to break than one that has been building for a year or more.
To comfort your baby without a pacifier, try rocking, singing, a clean knuckle for sucking (or help her to find her own fingers), or some of the other techniques listed on page 192. Admittedly, all of these take more time and effort on your part than tucking a pacifier in her mouth, but they’ll be better for baby in the long run, especially if they are gradually eliminated in favor of letting baby learn to comfort herself (as she could with her own thumb, a “pacifier” that’s in her control. (See page 194 for the pros and cons of using a pacifier.)
If your baby doesn’t seem ready to let go of the pacifier, you can limit pacifier usage to just nap time or nighttime. This way, it won’t interfere with socializing and vocalizing during the day. But keep in mind that it may be a struggle to wean your child off of the sleep-time pacifier later on, too.
“I’m going back to work full-time at the end of the month, and I’d like to give up nursing my daughter. Will it be hard on her?”
A three-month-old is, in general, a pretty agreeable and adaptable sort. Even with a budding personality all her own, she’s still far from the opinionated (and sometimes tyrannical) toddler she’ll eventually turn into. So if you’re going to pick a time for weaning from the breast that’s going to be easiest for her, this may be it. Though she may thoroughly enjoy nursing, she probably won’t cling to it as stubbornly as a six-month-old who’s never had a bottle and is suddenly subjected to weaning. All in all, you’ll probably find that weaning at three months is less difficult for your baby than it is for you. (Before you make your final decision, though, read over the section on making breastfeeding and working work, page 251; you may find that combining the two occupations for at least another few months—and possibly for the entire first year—may not be as difficult as you think.)
Ideally, mothers who want to wean their babies early should begin giving supplementary bottles, using either expressed milk or formula, by around four to six weeks so the infants become adjusted to suckling on the bottle as well as on the breast. If you haven’t, your first step is to get baby acclimated to an artificial nipple; you may have to try several different styles to find one your baby likes. At this point it would be best to use formula, so that your present breast milk supply will begin to diminish. Be persistent, but don’t force the nipple. Try giving the bottle before the breast; if your baby rejects the bottle the first time, try again at the next feeding. Bottles may be more acceptable to baby if someone other than mom gives them. (See page 215 for more tips on introducing the bottle.)
Keep trying until she takes at least an ounce or two from the bottle. Once she does, substitute a meal of formula for a nursing at a midday feeding. A few days later, replace another daytime breastfeeding with formula. Making the switch gradually, one feeding at a time, will give your breasts a chance to adjust without uncomfortable engorgement. Eliminate the evening breastfeeding last, as this will give you and your baby a quiet and relaxing time together when you get home from work. If you like, you may—assuming your milk supply doesn’t dry up entirely, and assuming your baby is still interested—be able to continue this once-a-day feeding for a while (or twice a day, if you’d like to nurse first thing in the morning, too), postponing total weaning until a later date, or until your milk is gone.
“I’m breastfeeding and would like to give my baby a supplement, but formula’s so expensive. Can’t I give him cow’s milk instead?”
Cow’s milk is a great drink for little cows and older humans, but it just doesn’t have the right mix of nutrients for human babies. It contains more salt (much more) and protein than breast milk or commercial formula, and these excesses put a strain on young kidneys. It is also lacking in iron. The composition of cow’s milk varies from that of breast milk (and formula) in a variety of other ways, too. In addition, it causes mild intestinal bleeding in a small percentage of infants. Though the blood lost in the stool is generally not visible to the naked eye, the bleeding is significant because it can lead to anemia.
It’s no news that breastfeeding is best for babies—and that even a little breast milk goes a long way when it comes to giving your baby the healthiest start in life. Six weeks of nursing, after all, can offer substantial benefits. But what is news—big news—is the research showing that longer is better, and that those substantial benefits increase substantially when a baby is nursed longer than three months. Which is why the American Academy of Pediatrics recommends that breastfeeding continue, ideally, for at least the first year of life. According to the latest reports from researchers, the many benefits may include:
Fewer battles with the bulge. The longer a baby is breastfed, the less likely he or she is to join the rapidly growing ranks of overweight children and adolescents.
Even fewer tummy troubles. Everyone knows that breast milk is more digestible than formula. But research has shown that infants who are fed only breast milk for the first six months have a lower risk of developing gastrointestinal infections than infants who are supplemented with formula beginning at three or four months. Another digestive plus for older breastfed babies: Those who are nursed while solids are introduced (usually at five to six months) are less likely to develop celiac disease, a digestive disorder that interferes with the normal absorption of nutrients from food.
Even fewer ear troubles. Studies have found that babies who are exclusively breastfed for longer than four months suffer from half as many ear infections as their formula-fed peers.
Less to sneeze at. Babies nursed for six months are much less likely to have problems with allergies of all kinds.
Higher IQ for smaller babies. Many studies have pointed to a link between continued breastfeeding and higher IQ. But research has also suggested that breastfeeding exclusively for the first six months boosts the IQs of small full-term babies (those who weighed under 6 pounds at birth).
A lower SIDS risk. The longer babies are breastfed, the lower their risk of succumbing to SIDS.
Of course, though the benefits of continued breastfeeding are compelling, not every mother and baby will be able to keep nursing for as long as is recommended. So it’s important to keep in mind that while longer may be better, some breastfeeding is still definitely better than none.
So if you’re planning to supplement, use either expressed breast milk or a formula recommended by the doctor—until your baby is a year old.
“I’m concerned that my breastfed baby may be constipated. She always had six or eight bowel movements a day, and now she rarely has more than one, and sometimes even misses a day.”
Don’t be concerned—be grateful. This slowdown in production is not only normal, but will send you to the changing table less often. Definitely a change for the better.
It’s normal for many breastfed babies like yours to start having fewer bowel movements somewhere between one and three months of age. Some will even go several days between movements. That’s because as babies get bigger, they need more food, so their bodies digest more of what’s going in—resulting in fewer by-products. Others will continue their prodigious production rates as long as they are nursing. That’s normal, too.
Constipation is rarely a problem for breastfed babies, and infrequency isn’t a sign of it; hard, difficult-to-pass stools are (see page 179).
“I change my baby frequently, but she still gets diaper rash—and I have trouble getting rid of it.”
There’s a good reason why your baby (and up to 35 percent of her comrades-in-diapers) isn’t sitting on a pretty bottom. The diaper area is exposed to high moisture, little air, a variety of chemical irritants and infectious organisms in urine and feces, and often-times the rubbing of diapers and clothing, it’s an easy target for a wide variety of problems. Diaper rash can remain a problem as long as a baby is in diapers, but incidence usually peaks between seven and nine months, when a more varied diet is reflected in the more irritating nature of her stools, and then starts to diminish as baby skin toughens, becoming more resistant to the assaults.
Unfortunately, diaper rash tends to repeat in some babies—perhaps because of an inborn susceptibility, allergic tendencies, an abnormal stool pH (an imbalance between acidity and alkalinity), excessive ammonia in the urine, or simply because once skin becomes irritated, it is more susceptible to further irritation.
The exact mechanism responsible for diaper rash isn’t known, but it is believed that it probably begins when a baby’s delicate skin becomes irritated by chronic moisture. When the skin is further weakened by friction from a diaper or clothing, or by irritating substances in stool or urine, it is left open to attack by germs on the skin or in the urine or stool. Aggressive and frequent cleansing of the diaper area with detergents or soaps can increase the susceptibility of an infant’s skin, as can very tight diapers. The ammonia in urine, once thought to be the major culprit in diaper rash, doesn’t appear to be a primary cause, but can irritate already damaged skin. And the rashes do tend to start where urine concentrates in the diaper, toward the bottom with girls and the front with boys.
The term diaper rash itself describes a number of different skin conditions in the diaper area. Just what distinguishes one diaper rash from another is not widely agreed on in the medical community (maybe the subject just hasn’t aroused enough interest to stimulate serious study and clearer definitions), but they are often described this way:
Chafing dermatitis. This is the most common form of diaper rash and is seen as redness where friction is greatest, but not in a baby’s skin folds. It generally comes and goes, causing little discomfort if not complicated by a secondary infection.
Tidemark dermatitis. This is an irritation precipitated by friction from the edge of a diaper rubbing against the skin.
Perianal dermatitis. Redness around the anus usually is caused by the alkaline stools of a bottle-fed baby and is uncommon among breastfed infants until solids have been introduced.
Candidal dermatitis. Bright red and tender, this uncomfortable rash appears in the inguinal folds (the creases between the abdomen and the thighs), and spreads from that point. Diaper rashes that last more than seventy-two hours often become infected with Candida albicans, the same yeast infection responsible for thrush. This type of rash may also develop in a baby on antibiotics.
Atopic dermatitis. This diaper rash is itchy, and may turn up in other parts of the body first. It usually begins to spread to the diaper area between six and twelve months.
Seborrheic dermatitis. This deep red rash, often with yellowish scales, usually starts on the scalp as cradle cap, though it sometimes begins in the diaper region and spreads upward. Like most diaper rashes, it’s usually more bothersome to parents than to baby.
Impetigo. Caused by bacteria (streptococci or staphylococci), impetigo in the diaper area occurs in two different forms: bullous, with large, thin-walled blisters that burst and leave a thin yellow-brown crust, or nonbullous, with thick, yellow, crusted scabs and a lot of surrounding redness. It can cover thighs, buttocks, and lower abdomen, and spread to other parts of the body as well.
Intertrigo. This type of rash, which manifests itself as a poorly defined reddened area, occurs as a result of the rubbing of skin on skin. In infants it is usually found in the deep inguinal folds between the thighs and the lower abdomen, and often in the armpits. Intertrigo rash may sometimes ooze white to yellowish matter, and may burn when urine touches it, causing baby to cry.
The best cure for diaper rash is prevention—though it isn’t always possible. Keeping the diaper area dry and clean is one of the most important principles of prevention. See page 141 for diapering practices that will help you to do this. If preventive measures don’t work, the following may help eliminate your baby’s simple diaper rash, and will be helpful in warding off recurrences:
Less moisture. To reduce moisture on the skin, change the diaper often, even in the middle of the night if your baby’s awake and the diaper very full. Put any plans to try to get her to sleep through the night on hold until the diaper rash has cleared up. For persistent diaper rash, change baby as soon as you’re aware that she’s wet or had a bowel movement.
Once other fluids besides breast milk or formula are introduced, make sure that less superfluous liquid goes into baby, too (since what goes in must come out). Drinking bottle after bottle of juice leads to excessive urination and more diaper rash. Using a cup for juice can avoid overdosing.
More air. Keep baby’s bottom bare part of the time, placing her on a couple of folded cloth diapers or receiving blankets over a plastic or waterproof pad or sheet to protect the surface below. If the diaper rash is really persistent, you might let her sleep the same way, but be sure the room is warm enough so she won’t be chilly. If she’s in cloth diapers, use breathable diaper wraps, or leave the pants off altogether and put her on a waterproof pad. If she’s wearing disposables that have a plastic outer covering, poke a few holes in the outer cover. This will allow some air in, and it will also allow some moisture to seep out—which will encourage more frequent diaper changes.
Fewer irritants. You can’t limit the natural irritants such as urine and stool except by changing diapers frequently, but you can limit those that you apply to baby’s bottom. Soap can dry and irritate the skin, so use it only once daily. Dove, Cetaphil, and Johnson’s baby soap are among those generally recommended for babies (many so-called “gentle” soaps aren’t), or ask the doctor for a suggestion. For diaper changes when the infant has had a bowel movement, wash skin thoroughly (for about thirty seconds to one minute) with warm water and cotton balls instead of diaper wipes. Wipes may contain substances that irritate your baby’s skin (different babies are sensitive to different substances); those that contain alcohol are particularly drying. If the ones you’re using seem to cause a problem, switch—but don’t use wipes at all when your baby has a rash. A really messy movement may be best cleaned by a dip in the tub or sink; a sticky one can be gently removed with baby oil. Be careful to pat baby dry thoroughly after washing.
Different diapers. If your baby has a recurrent diaper rash, consider switching to another type of diaper (from cloth to disposables or vice versa, from one type of disposable to another) to see if the change makes a difference. If you home-launder diapers, rinse them with ½ cup of white vinegar or a special diaper rinse and, if necessary, boil them in a large pot for ten minutes.
Blocking tactics. Spreading a thick protective layer of ointment or cream (A&D, Desitin, zinc oxide, Balmex, or whatever your baby’s doctor recommends) on baby’s bottom after cleaning it at changing time will prevent urine from reaching it. Make sure, though, before you spread the ointment or cream on baby’s bottom, that her skin is completely dry. Otherwise, you’ll just be trapping the moisture in, leading to recurrent diaper rashes. If you buy these products in the largest sizes, you’ll save money and be more likely to use them liberally—which is best. But don’t use the ointment when you’re airing baby’s bottom.
A little baby cornstarch can absorb moisture, keeping baby drier, but don’t use a talc-based powder. And don’t use medications around the house that have been prescribed for other family members; some combination ointments (those that contain steroids and antibacterial or antifungal agents) are a major cause of allergic skin reactions, and you could sensitize your baby by using them. Besides, they may be too strong for baby’s skin.
If your baby’s diaper rash doesn’t clear up or improve in a day or two, or if blisters or pustules appear, call her doctor, who will try to uncover its cause and then treat it. For seborrheic dermatitis, a steroid cream may be necessary (but it should not be used long-term); for impetigo, antibiotics given by mouth; for intertrigo, careful cleansing plus a hydrocortisone cream and protective ointments; and for candida, the most common diaper infection, a good topical antifungal ointment or cream such as Zimycan. Ask how long it should take for the rash to clear, and then report back to the doctor if it isn’t better by then or if the treatment seems to make it worse. If the rash persists, the doctor may check for dietary or other factors that may be contributing to it. In rare cases, the expertise of a pediatric dermatologist may be needed to unravel the mystery of a baby’s diaper rash.
“I’m concerned about a red, raw area at the tip of my son’s penis.”
Chances are what you’re seeing looks a lot worse than it is, which is probably nothing more than a localized diaper rash. Such a rash is common and can sometimes cause swelling—sometimes enough to prevent a baby from urinating. Because spread to the urethra could eventually cause scarring, you should do everything you can to get rid of the rash as soon as possible. Follow the tips for treating diaper rash given above, adding warm soaks if your baby is having trouble urinating. If you use home-laundered diapers, switch to a diaper service or disposables until the problem has resolved. If the rash persists after two or three days of home treatment, and/or if baby’s having problem with urination, call the doctor.
“When my son tries to reach for something, he always misses, and his movements seem so spastic, I’m wondering if there’s something wrong with his nervous system.”
Though it has come a long way from the days when you felt little twitches in your uterus, your baby’s nervous system is still young and inexperienced, and it hasn’t worked out all its kinks. When your baby’s arm whips out in the direction of a toy but doesn’t land anywhere near its target, the lack of coordination is actually a normal stage in infant motor development. Soon he will gain more control, and the purposeful, clumsy batting will be replaced with skillful reaching movements. And once he gets to the stage when nothing within that cunning reach is safe again, you may look back fondly on a time when he looked, but wasn’t able to touch.
If you’d like some additional reassurance, talk with your baby’s doctor at his next checkup.
“My spouse loves to roughhouse with our twelve-week-old, and she loves it as well. But I’ve heard that shaking an infant too much, even in fun, can cause injury.”
Watching the glee in a young baby’s face as she’s tossed up in the air and caught by her adoring parent, it’s hard to imagine that such fun could end in tragedy. And yet it could. Certain types of roughhousing—whether they’re done in fun or in anger—can be extremely dangerous for children under two years of age.
There are several types of injuries that can result from throwing a baby in the air or shaking or vigorously bouncing her (as when jogging with her in a front or back baby carrier). One is a type of whiplash (such as a person can get when rear-ended in an auto accident). Because the baby’s head is heavy in proportion to the rest of her body and her neck muscles are not fully developed, support for the head is poor. When the baby is shaken roughly, the head whipping back and forth can cause the brain to rebound again and again against the skull. Bruising of the brain can cause swelling, bleeding, pressure, and possibly permanent neurological damage with mental or physical disability. Another possible injury is trauma to the delicate infant eye. If detachment or scarring of the retina or damage to the optic nerve occurs, lasting visual problems, even blindness, can result. The risk of damage is compounded if a baby is crying or being held upside down during the shaking, because both increase blood pressure in the head, making fragile blood vessels more likely to rupture. Such injuries are relatively rare, but the damage can be so severe that the risk is certainly not worth taking.
Some parents assume that shaking a baby is a safer way to discipline—or to let off their steam when they’re frustrated or angry—than spanking. That’s an extremely dangerous assumption to make. First of all, babies are too young to be disciplined effectively. Second of all, physical discipline of any kind (including spanking) is never appropriate (see page 451 for appropriate and effective ways of disciplining a toddler). But, most important of all, shaking a baby (whether in anger or fun) can cause serious injury or death. Never, ever shake a baby.
While the vast majority of these injuries occur when a baby is being shaken in anger, they can occasionally happen at play. So avoid roughhousing that vigorously shakes or jostles your baby’s unsupported head or neck. Also avoid jogging or other “bouncing” activities with a young infant in a baby carrier (do your running while pushing baby in a stroller, instead). That doesn’t mean no fun at all—it only dictates more gentle rough stuff. Many babies love “flying” as they are held securely midtrunk and glided smoothly through the air, participating in cuddlefests, and being chased when they are old enough to crawl. There are some babies, however, both male and female, who dislike any kind of rough handling, and they have the right to even more gentle treatment—even from exuberant family members.
Don’t spend time worrying about past roughhousing sessions. If your child hasn’t exhibited any symptoms of injury, she clearly hasn’t been harmed. If you have any concerns, consult your baby’s doctor.
“I was happy with my decision not to give our baby supplementary bottles until I realized it’s almost impossible to have a long evening out without him.”
Nothing’s perfect, not even the decision to breastfeed exclusively. For all its many advantages, it can also be occasionally inconvenient—as when dinner and a movie last longer than the window between two feedings, making dates with your spouse or friends a logistical impossibility. And circumventing those logistics may be especially difficult now, with baby still feeding so often. If you’re willing to sacrifice sleep for a few hours out, you may be able to accomplish a late evening on the town by getting your baby down for the night by 8 or 9 P.M. before heading out (unless it’s his habit to awaken again before midnight). Or just stick to dinner or a movie for now.
Things will get a little easier once solids are introduced (usually around the sixth month) and when baby starts going for longer stretches at night without nursing. And once you’ve introduced the cup (around five or six months), your baby will even be able to have a drink if he’s thirsty without resorting to a bottle.
In the meantime, if you have a special event you’d like to attend that will keep you from home for more than a few hours in the early evening, try these tips:
Take baby and sitter along, if there’s an appropriate place for them to hang out while they’re waiting. That way baby can nap in a stroller or carriage while you enjoy the event, slipping out to nurse as needed.
If the event is out of town, take the family along. Either bring your own sitter or hire one where you will be staying. If the place where you’re staying is near enough to the event, you can pop in at feeding time.
Adjust baby’s bedtime, if possible. If your baby doesn’t usually go to bed until after nine, and you need to leave at seven, try to get him to cut down on his afternoon nap and put him to bed a couple of hours early. Be sure to give him a full nursing before you leave, and plan on feeding him again when you return home, if necessary.
Leave a bottle of expressed milk and hope for the best. If your baby wakes up and is really hungry, he may take the bottle. If he doesn’t take it, he may scream for a while, but will very likely fall back to sleep eventually—and you can always feed him when you get home. Carry a beeper or cell phone so the sitter can reach you; if the sitter feels baby is so upset that you need to return, you’ll need to be ready to do so.
“We’d love a night out alone, but we’re afraid of leaving our daughter with a sitter when she’s so young.”
Go to town—and soon. Assuming you’re going to want to spend some time alone together (or just alone) during the next sixteen or so years, getting your baby used to being cared for occasionally by a nonparent will be an important part of her development. And in this case, the earlier she starts making the adjustment, the better. Infants two and three months old may recognize their parents, but out of sight usually means out of mind. And as long as their needs are being met, young babies are generally happy with any attentive person. By the time babies reach nine months (much sooner in some babies), most begin experiencing what is called separation or stranger anxiety—not only are they unhappy being separated from mother or father, they’re also very wary of new people. So now’s the perfect time to bring a sitter into baby’s life—and a little adults-only fun into yours.
At first you’ll probably want to take only short outings, especially if you’re nursing and have to squeeze your dinner in between baby’s meals. What shouldn’t be short, however, is the time you spend choosing and preparing the sitter, to ensure your baby will be well cared for. The first night, have the sitter come at least half an hour early so you can fully acclimate him or her to the eccentricities of your child’s needs and habits and so baby and sitter can meet. (See the information on choosing child care, starting on the next page, including the Baby-Sitter Checklist, page 276).
“We almost always take our baby with us when we go out; we leave her with a sitter only when she’s asleep, and then only for a couple of hours. Friends say this will make her too dependent.”
Again, you’ll need to follow your instincts—not those of your friends. While there are some advantages to getting your baby adjusted to a sitter now (before stranger anxiety rears its unfriendly head), and to having more social outlets (realistically, not every place you’ll want to go or every event you’ll want to attend will welcome babies), a baby whose mommy or daddy is always around doesn’t necessarily become overly dependent. Often, in fact, the child who spends a majority of the time in early infancy with one or both parents turns out to be very secure and trusting. After all, she’s likely to have unswerving faith that she is loved, that any sitter her parents leave her with will take good care of her, and that when her parents go out, they will return when they say they will. (Of course, a child who’s left with a good sitter can also feel this way.)
So do what makes you most comfortable, not what will satisfy your friends. But as your baby gets older, you might consider at least occasionally leaving her with a sitter when she’s awake. If you always leave while she’s sleeping, and she ends up waking while you’re out, she may panic to find herself in the hands of a stranger.
Leaving your child with a sitter for the first time can be stressful enough without worrying about whether you’re leaving him or her with the right person in the right place. And finding child care that you’re confident about is no longer as easy—at least, not for most—as picking up the phone and enlisting grandma or the grandmotherly next-door neighbor. With extended family often extending beyond city and state limits, and many grandmothers (and grandmotherly types) working themselves, the parent who needs a sitter must usually depend on a stranger.
When a grandparent is the sitter, a parent’s biggest worry is whether her child will be plied with too many cookies. Turning your baby over to a stranger (or group of strangers) raises a great many more concerns. Will she be responsible and reliable? Attentive and responsive to your baby’s needs? Capable of providing your baby with the kind of play-learning stimulation that will help develop mind and body to their fullest potential? Will her childcare philosophies mesh comfortably with yours, and will she accept your ideas and respect your wishes? Will she be warm and loving enough to act as a parent substitute without presuming to take your place as a parent?
Separating from your baby—whether for a 9-to-5 job or a Saturday-night dinner and a show—will never be easy, especially not the first few times. But for you (and the other nearly 50 percent, of parents of babies under age one who regularly use child care), separating satisfied that you’ve left your baby in the best possible hands will help ease both your anxiety and your guilt.
Most experts agree that if a parent can’t be with his or her baby all of the time (because of work, school, or other commitments), the next best option is a parent substitute (a nanny, sitter, au pair) who cares for the child at home.
The advantages are many. Baby is in familiar surroundings, with his or her own crib, high chair, and toys; is not exposed to a lot of other babies’ germs; and doesn’t have to be transported to and fro. He or she also has the complete attention of the care provider, (assuming she hasn’t been assigned a multitude of other tasks), and there is a good chance for a strong relationship to develop between baby and sitter.
There are some disadvantages, however. If the care provider is sick, unable to come to work for other reasons, or suddenly quits, there is no automatic backup system. A strong attachment between sitter and an older baby can lead to a crisis if the sitter leaves suddenly, or if the parent develops more than a mild case of envy. For some parents, the loss of privacy if the care provider lives in is an added complication. And home care can be costly, probably more so if you choose a professionally trained nanny, probably less so if you choose a college student, an au pair, or someone with minimal experience.
Even the best-trained, most experienced baby-sitter needs instructions (after all, every baby and every family has different needs). Before you leave your baby with anyone, make certain that he or she is familiar with the following:
How your baby is most easily calmed (rocking, a special song, a favorite mobile, a ride in the baby carrier)
What your baby’s favorite toy is
That your baby should sleep faceup with no pillows or comforters
How your baby is best burped (over the shoulder, on the lap, after feeding, during feeding)
How to diaper and clean baby (do you use wipes or cotton balls? an ointment for diaper rash?) and where diapers and supplies are kept
Where extra clothing is kept in case those baby is wearing get soiled
How to give the bottle, if your baby is bottle fed or is to get a supplement of formula or expressed milk
What your baby can and can’t eat or drink (making it clear that no food, drink, or medicine should be given to your baby without your okay, or the doctor’s)
The setup of your kitchen, the baby’s room, and so on, and any other pertinent facts about your house or apartment (such as a burglar alarm that might go off, and where fire exits are located)
Any habits or characteristics of your baby that the sitter might not expect (spits up a lot, has a lot of bowel movements, cries when wet, falls asleep only with a light on or when being rocked)
The habits of any pets you may have that the sitter should be aware of, and rules concerning your baby and pets
Where the first aid kit (or individual items) is located
Baby safety rules (see page 208); you might want to photocopy rules and post them in an obvious place for the sitter
Where a flashlight is located (or candles)
Who is cleared by you to visit when you are not at home, and what your policy is on a sitter having visitors
What to do in case the fire alarm goes off or smoke or fire is observed, or if someone who hasn’t been cleared by you rings the doorbell
You should also leave the following for the sitter:
Important phone numbers (the baby’s doctor, your cell phone or pager number or place you can be reached, a neighbor who will be home, your parents, the hospital emergency room, the poison control center, the building superintendent, a plumber or handyman), and a pad and pen for taking messages
The address of the nearest hospital emergency room and the best way to get there
Cab fare in case of an unexpected emergency (such as the need to take the baby to the emergency room or the doctor’s office), and the number to call for a cab
A signed consent form authorizing medical care within specific limits, if you cannot be reached (this should be worked out in advance with baby’s doctor)
It’s helpful to combine all the information necessary for caring for your baby—for instance, phone numbers, safety and health tips—in a small loose-leaf binder, or use The What to Expect Baby-Sitter’s Handbook.
Finding the ideal care provider can be a time-consuming process, so allow as much as two months for the search. There are several trails you can take to track her down:
The baby’s doctor. Probably no one else you know sees as many babies—and their mothers and fathers—as your baby’s doctor. Ask him or her for nanny recommendations, check the office bulletin board for notices put up by care providers seeking employment (some pediatricians require that references be left at the reception desk when such notices are posted), or put up a notice of your own. Ask around the waiting room, too.
Other parents. Don’t pass one by—at the playground, at a baby exercise class, at cocktail parties and business meetings—without asking if they’ve heard of, or have employed, a good care provider.
Your local community center, library, house of worship, preschool. Here, too, the bulletin board can be an invaluable resource. So can your clergyperson, who may know of congregants who would be interested in caring for your child.
Teachers of nursery-age children. Preschool teachers often know of, or employ part-time in their programs, experienced childcare workers. They sometimes are available themselves evenings and weekends.
Nanny agencies and registries. Trained and licensed (and usually expensive) childcare workers and nannies are available through these services; selecting a care provider this way usually eliminates a lot of guesswork and legwork. (But always check references and background yourself, anyway.)
Want to make sure the baby-sitter you hire has all the information she needs to best care for your child? Hand her a copy of The What to Expect Baby-Sitter’s Handbook. Not only does it contain all those essential basics of baby and child care (from feeding to first aid), but it also has a fill-in section, so you can personalize the handbook for your child’s particular needs.
Baby-sitting services. Screened baby-sitters are available through these services, listed in your local classified phone book, for full-time, part-time, or occasional work.
A local hospital. Some hospitals offer baby-sitting referral services. Generally, all sitters referred have taken a babysitting course offered by the hospital, which includes baby CPR and other first-aid procedures. At other hospitals and nursing schools, nursing students may be available for baby-sitting jobs.
Local newspapers. Check daily papers and specialized parent papers for ads run by care providers seeking employment, and/or run an ad yourself.
College employment offices. Part-time or full-time, year-round or summer help may be found through local colleges.
Senior citizen organizations. Lively seniors can make terrific sitters—and surrogate grandparents at the same time. (Just make sure they’re trained in the “new” ways of baby care, such as putting baby to sleep on his or her back.)
Au pair or nanny organizations. These services can provide families with a live-in au pair, usually a young person from a foreign country who wants to visit or study in the United States for a year or so, or with a well-trained nanny.
You won’t want to spend endless days interviewing obviously unsatisfactory candidates, so sift them out either through résumés that have come in the mail or phone conversations. Before you begin talking to people, develop a detailed job description so you know just what you are looking for. Responsibilities may include such chores as marketing and laundry duties, but be wary of overloading the sitter with activities that will distract her attention from your baby. Also decide how many hours a week you’ll need her to work, whether the hours will have to be flexible, and whether and how much you’ll pay—both as basic salary and for overtime. In a preliminary phone interview, ask the person’s name, address, telephone number, age, education, experience (this may actually be less important than some other qualities, such as enthusiasm and natural ability), salary requirements and benefits (check beforehand to see what the going rate is in your area; two weeks’ paid vacation a year is a standard perk), and why she wants the job. Explain what the position will entail, and see if she is still interested. Set up a personal interview with those applicants who sound promising.
During interviews, look for clues in a candidate’s questions and comments (“Does the baby cry a lot?” might reflect impatience with normal infant behavior), as well as in her silence (the woman who never says anything about liking kids and never comments on yours may be telling you something) to learn what she’s like. To learn more, ask questions such as the following, phrasing them so that they require more than a yes or no answer (it doesn’t mean much when you get a “yes” to “Do you like babies?”):
Why do you want this job?
What was your last job, and why did you leave it?
What do you think a baby my child’s age needs most?
How do you see yourself spending the day with a baby this age?
How do you see your role in my baby’s life?
How do you feel about breastfeeding? (This is important, of course, only if you are breastfeeding and intend to continue—which will require her support.)
When my baby starts getting more active and getting into mischief, how will you handle it? How do you discipline young children?
How will you get to work on a daily basis? In bad weather?
Do you have a driver’s license and a good driving record? (If driving will be necessary on the job.) Do you have a car? (If that will be necessary in your case.)
How long do you envision staying with this job? (A long stay can never be guaranteed, but the sitter who leaves as soon as your baby becomes adjusted to her can create a multitude of problems for your entire family.)
Do you have children of your own? Will their needs interfere with your work? Will you be able to come to work, for instance, when they’re home sick or off from school? Allowing a caregiver to bring her children along has some benefits and some drawbacks. On the one hand, it gives your child the chance to be exposed to the companionship of other children on a daily basis. On the other hand, it gives your child more of a chance to be exposed to all of these extra germs on a daily basis; and having other children to care for may also affect the quality and quantity of attention the caregiver can give your own baby. It may also result in greater wear and tear on your home.
Will you cook, shop, or do housework? (Having some of these chores taken care of by someone else will give you more time to spend with your baby when you’re at home. But if the care provider spends a lot of time with these chores, your baby may not get the attention and stimulation he or she needs.)
Are you in good health? Ask for evidence of a complete physical exam and a recent negative TB test, as well as about smoking habits (she should be a nonsmoker), alcohol and drug use. This last information will probably not be forthcoming from a drug or alcohol abuser, but be alert for clues, such as restlessness, talkativeness, nervousness, agitation, dilated pupils, poor appetite (stimulants, such as amphetamines or cocaine); slurred speech, staggering, disorientation, poor concentration, and other signs of drunkenness with or without the odor of alcohol (alcohol, barbiturates, and other “downers”); pinpoint pupils and craving for sweets (early heroin addiction); euphoria, relaxed inhibitions, increased appetite, loss of memory, possibly dilated pupils and bloodshot eyes (marijuana). A sitter who is trying not to use drugs or alcohol at work may exhibit signs of withdrawal from the abused substance, such as watery, runny eyes, yawning, irritability, anxiety, tremors, chills, and sweating.
Of course, many of these symptoms can be signs of illness (mental or physical) rather than drug abuse. In either case, should they show up in a childcare worker, they should concern you. You will also want to avoid someone with a medical condition that could interfere with regular attendance at work.
Have you recently had, or are you willing to take, CPR and baby first-aid training?
Though you’ll be asking the questions, the job applicant shouldn’t be the only one answering them. Ask these questions of yourself, based on your observations of each candidate, and answer them honestly:
Did the candidate arrive for the interview well groomed and neatly dressed? Though you may not require a freshly starched nanny’s uniform on the job, soiled clothes, unwashed hair, and dirty fingernails are all bad signs.
Does she seem to have a sense of orderliness that’s compatible with your own? If she has to rummage through her handbag for five minutes for her references and you’re a stickler for organization, you’ll probably clash. On the other hand, if she seems compulsively neat and you’re compulsively messy, you probably won’t get along either.
Does she seem reliable? If she’s late for the interview, watch out. She may be late every time she’s due to work. Check this out with previous employers.
IS HE MANNY ENOUGH FOR THE JOB?
If it’s true what they say (and it is!) that there’s nothing that a mother can do that a father can’t do equally well if not better (besides breastfeed, that is), then it’s also true that there’s nothing that a female nanny can do that a male nanny can’t do equally well if not better. Which is why more and more men are signing up to provide child care—and why more and more parents are hiring them as nannies. In fact, this newer breed of childcare providers have even had a name coined in their honor: manny. Though still a minority in the childcare business, the ranks of mannies are growing fast. Who says a good manny is hard to find?
Is she physically capable of handling the job? A frail older woman may not be able to carry your baby around all day now, or chase your toddler later.
Does she seem good with children? The interview isn’t complete until the applicant spends some time with your baby so that you can observe the interaction, or lack thereof. Does she seem patient, kind, interested, really attentive and sensitive to your baby’s needs? Find out more about her aptitude for child care from previous employers.
Does she seem intelligent? You’ll want someone who can teach and entertain your child the way you would yourself, and who will show good judgment in difficult situations.
Does she speak English? How well? Obviously, you’ll want someone who can communicate with your baby and with you (especially if you speak only English), but there are some benefits to a sitter who has a working understanding of English but isn’t a fluent speaker—she might be able to teach your baby a second language at a time when baby is ripe for learning one (see page 222).
Are you comfortable with her? Almost as important as the rapport the candidate has with your baby is the rapport she has with you. For your baby’s sake, there needs to be constant, open, comfortable communication between a chosen caregiver and you; be certain this will be not only possible, but easy.
If the first series of interviews doesn’t turn up any candidates you feel good about, don’t settle—try again. If it does, the next step in narrowing down your selection is to check references. Don’t take the word of a candidate’s friends or family on her abilities and reliability; insist on the names of previous employers, if any, or if she doesn’t have much work experience, those of teachers, clergy, or other more objective judges of character. You might also consider hiring an employee-screening firm to do a thorough background check (some, but not all, agencies do thorough prescreens). The prospective employee’s permission is needed to do this.
You’d probably be very unhappy if you were left alone to spend the day with a perfect stranger. You can expect your baby, who will experience the added stress of missing mommy and daddy (less so in the early months, more so in the second half of the first year), to be unhappy at first, too. To minimize the misery, introduce baby and sitter in advance. If it’s a sitter-for-the-evening, have her come at least half an hour early the first time (an hour if your baby is more than five months old), so that your baby will have some time to adjust. Make the introduction gradually, starting baby off in your arms, moving him or her next to an infant seat or swing so the sitter can approach on neutral territory, then, finally, as baby becomes more comfortable with the newcomer, into the sitter’s arms. Then, once the initial adjustment has been made, stay away for just an hour or two. The next time, have the sitter arrive half an hour ahead of your departure once again, and stay out a little longer. By the third time, a fifteen-minute period with you still at home should suffice, and after that sitter and charge should be bosom buddies. (If they aren’t, consider whether you’ve chosen the right sitter.)
The daily sitter needs an even greater introduction period. She should spend at least a full paid day with you and the baby, becoming familiar not only with your baby but also with your home, your childcare style, and your household routines. That will give you a chance to make suggestions, and her a chance to ask questions. It will also give you a chance to see the sitter in action—and a chance to change your mind about her if you don’t like what you see. (Don’t judge the sitter on baby’s reaction but rather on how the sitter responds to it. No matter how good a sitter is, children—even very young children—often protest being with one as long as a parent is around.)
Your baby will probably adjust to a new care provider most easily when he or she is under six months old, and will take much longer once stranger anxiety appears on the scene (usually sometime between six and nine months; see page 429).
Always hire a childcare provider on a trial basis so that you can evaluate her performance before deciding whether you want to keep her on for the long term. It’s fairer to her and to you if you make clear in advance that the first two weeks or month on the job (or any specified period) will be a trial period. During this time, observe your baby. Does he or she seem happy, clean, alert when you come home? Or more tired than usual, and more cranky? Does it seem a diaper change has been made fairly recently? Important, too, is the care provider’s frame of mind at day’s end. Is she relaxed and comfortable? Or tense and irritable, obviously happy to be relieved of her charge? Is she eager to tell you about her day with the baby, reporting the infant’s latest achievements, as well as any problems she’s noted, or does she routinely tell you only how long the baby slept and how many ounces of the bottle were emptied—or, worse, how long the baby cried? Does she keep in mind that this is still your baby, and accept the idea that you make the major decisions about her care? Or does she seem to feel that she’s in charge now?
THE BUSINESS OF HIRING A NANNY
Hiring a nanny comes with its share of paperwork. By law, you are required to apply for federal and state household employment tax ID numbers, and pay half of your nanny’s Social Security and Medicare payments, as well as her unemployment taxes. A lot of trouble, true, but there are perks for the law-abiding (besides avoiding hassles with the IRS for noncompliance). If your company offers a flexible spending account, you may be able to get a tax break on the money you use to pay for child care.
If you’re not happy with the new caregiver (or if she’s clearly not happy with the job), start a new search. If your evaluation leaves you uncertain, you might try arriving home early and unannounced to get a look at what’s really happening in your absence. Or you could ask friends or neighbors who might see the sitter in the park, at the supermarket, or walking down the street how she seems to be doing. If a neighbor reports your usually happy baby is doing a lot of crying while you’re away, that should be a red flag. Another option: considering video surveillance with a “nanny cam” (see box, opposite page).
Do you ever wonder what really goes on when you’re not at home? Does the sitter spend all day providing your baby with loving, nurturing care, or talking on the phone and watching soaps? Does she coo, cuddle, and dote on your infant, or leave him or her strapped in an infant seat or crying in the crib? Does she follow your instructions to the letter, or throw them out the window the moment you’re out the door? Is she the Mary Pop-pins you hoped you hired, or the baby-sitter nightmares are made of—or more likely somewhere in between?
To make sure the sitter they’ve chosen is close to everything they thought she is, or to determine if she’s far from it (especially if some red flags have been raised), more and more parents are turning to so-called “nanny cams”—hidden video surveillance to watch those who are watching their children. If you’re considering installing such a system, consider the following first:
The equipment. You can either buy or rent cameras, or hire a service that will set up an elaborate surveillance system throughout your home. The least expensive option—a single camera hidden in a room your baby and the sitter are likely to spend the most time in—can provide you with a glimpse of what goes on while you’re away, but not a full picture (abuse or neglect might be occurring in a different room, for instance). A wireless camera hidden inside of a stuffed animal is more expensive but is also more inconspicuous, and since it can be moved from room to room, you’ll be able to view different rooms on different days. A system that monitors the entire home will obviously offer the clearest picture of your baby’s care but is much more expensive.
Keep in mind, too, that how well the surveillance works will depend on how well you survey it. You’ll need to be committed to taping at least several days a week (daily would be best) and watching the tapes regularly, otherwise you might not catch abuse or neglect until days after it occurs.
Your rights—and your nanny’s. Laws regarding covert videotaping vary from state to state, though in most cases it’s considered legal to videotape a sitter at work in your own home without her knowledge. Your equipment supplier should be able to inform you about the legal considerations in your state. The ethical issues are another matter—and very much open for debate. Some parents feel that nanny cams are an invasion of the sitter’s privacy; others feel that it’s the best investment they can make for the safety of their child.
Your motivation. If you’re just eager for some peace of mind, a nanny cam might just buy it. On the other hand, if you’re already feeling uncomfortable enough about the childcare provider you’ve hired that you’re compelled to spy on her with a nanny cam, perhaps that person shouldn’t be in your home at all. In that case, you might be wiser to trust your instincts, save your money, and find your baby a sitter you have confidence in.
If you do decide to install a nanny cam, don’t use it as a way of screening prospective childcare providers. Any baby-sitter should be thoroughly prescreened before she’s left home alone with your baby.
If everything and everyone seems to be fine except you (you’re anxious every time you leave your baby, you’re miserable while you’re away, you keep looking for fault in a sitter who’s doing a good job), it’s possible that it’s the arrangement, not the sitter, that isn’t working out. Rather than subjecting your baby to a series of sitters (if, from your point of view, the right full-time sitter seems not to have been born yet), perhaps you should reconsider your decision to go back to work.
A good day-care program can offer some significant advantages. In the best of them, trained personnel provide a well-organized program specifically geared to a baby’s development and growth, as well as opportunities for play and learning with other babies and children. Because such facilities are not dependent on one person, as in-home care is, there is generally no crisis if a teacher is sick or leaves, though the baby may have to adjust to a new one. And in communities where day-care services are licensed, there may be safety, health, and in some cases even educational monitoring of the program. It is also usually more affordable than in-home care, making it not only the best option but also the only option for many parents.
The disadvantages for babies, however, can also be significant. First of all, not all programs are equally good. Even in a good one, care is less individualized than it is in a baby’s own home, there are more children per caregiver, and teacher turnover may be high. There is less flexibility in scheduling than in a more informal setting, and if the center follows a public school calendar, it may be closed on holidays when you’re working. The cost, though typically less expensive than good in-home care, is still usually fairly high, unless subsidized by government or private sources (as in corporate day care). Possibly the greatest disadvantage is the increased rate of infection among children in day-care situations. Since many employed parents don’t have another option when their children have colds and other minor ills, they often send them to the center anyway—which is why babies who attend them end up with more than their share of ear infections and other bugs.
Certainly, there are some excellent day-care facilities; the trick may be to find such a facility in your area that you can afford and that has space for your baby.
You can get the names of local day-care facilities (which may be nonprofit, cooperative, or for profit) through recommendations from friends whose parenting style is similar to yours by calling the state regulatory agency (the state health or education department should be able to refer you), or by asking at your local community center or house of worship. You can also ask your baby’s doctor for a suggestion or check the phone book or a local parenting newspaper for childcare referral services or day-care centers themselves. Once you have a few possibilities, you’ll need to start evaluating them.
Day-care centers range in quality from top-of-the-line to bottom-of-the-barrel, with most falling in the mediocre middle. If you’ll accept only the best for your baby, you’ll have to examine every aspect of each possibility. Look for:
Licensing. Most states license day-care facilities, checking them for sanitation and safety but not for the quality of care. Some states, however, don’t even have adequate fire and sanitation regulations. (Check with your local fire and health departments if you have any questions.) Still, a license does provide some safeguards.
A trained and experienced staff. The “head” teachers, at least, should have degrees in early childhood education; the entire staff should be experienced in caring for infants. Too often, because of the low pay, day-care workers are people who are in the job because they are qualified for nothing else; in that case, it’s likely they aren’t qualified for child care, either. The staff turnover should be low; if there are several new teachers each year, beware.
A healthy and safe staff. Ask if all childcare workers have had complete medical checkups, including a TB test, and thorough background checks.
A good teacher-to-baby ratio. There should be at least one staff person for every three infants. If there are fewer, a crying baby may have to wait until someone is free to meet his or her needs.
Moderate size. A huge day-care facility might be less well supervised and operated than a smaller one—though there are exceptions to this rule. Also, the more children, the more chance for the spread of illnesses. Whatever the size of the facility, there should be adequate space for each child. Crowded rooms are a sign of an inadequate program.
Separation of age groups. Infants under one year should not be mixed with toddlers and older children, for safety, health, attention, and development issues.
A loving atmosphere. The staff should seem to genuinely like children and caring for them. Children should look happy, alert, and clean. Be sure to visit the facility unannounced in the middle or toward the end of the day, when you will get a more accurate picture of what the center is like than you would first thing in the morning. (Be wary of any program that does not allow unannounced parent visits.)
A stimulating atmosphere. Even a two-month-old can benefit from a stimulating atmosphere, one where there is plenty of interaction—both verbal and physical—with caregivers, and where age-appropriate toys are available. As children become older and developmentally advanced, there should be plenty of appropriate toys to play with, as well as exposure to books, music, and the out-of-doors. The best programs include occasional “field trips”: three to six children along with one or two teachers go to the supermarket, the mall, or other places a baby might go with a stay-at-home parent.
Parent involvement. Are parents invited to participate in the program in some way; is there a parent board that makes policy?
A compatible philosophy. Are you comfortable with the day-care center’s philosophy—educationally, religiously, ideologically?
Adequate opportunities for rest. Most infants, in day care or at home, still take a lot of naps. There should be a quiet area for such napping in individual cribs, and children should be able to nap according to their own schedules—not the school’s.
Security. The doors to the facility should be kept locked during operating hours, and there should be other security measures in place (a parent or visitor sign-in sheet, someone monitoring the door, requesting ID when necessary). The center should also have a system in place for pickups that protects children (only those on a list pre-approved by you should be able to pick up your child).
Strict health and sanitation rules. In your own home, you needn’t be concerned about your baby putting everything in his or her mouth; in a day-care center, with a convergence of children, each with his or her own set of germs, you should be. Day-care centers can become a focus for the spread of many intestinal and upper respiratory illnesses. To minimize germ spreading and safeguard the health of the children, a well-run day-care center will have a medical consultant and a written policy that includes:
Caregivers must wash hands (with liquid soap) thoroughly after changing diapers or don a fresh pair of disposable gloves for each change. Hands should also be washed after helping children use the toilet, wiping runny noses or handling children with colds, and before feedings.
Diapering and food preparation areas must be entirely separate, and each should be cleaned after every use.
Diapers should be disposed of in a covered container, out of the reach of children.
Toys must be rinsed with a sanitizing solution between handling by different children, or a separate box of toys must be kept for each child.
YOUR CHILD AS A BAROMETER OF CHILD CARE
No matter which childcare alternative you choose for your baby, be alert to signs of discontent: sudden changes in personality or mood, clinginess, fretfulness that doesn’t seem attributable to teething, illness, or any other obvious cause. If your baby seems unhappy, check into your childcare situation; it may need a change.
Stuffed animals should not be shared and should be machine-washed frequently.
Teething rings, pacifiers, washcloths, towels, brushes, and combs should not be shared.
Feeding utensils must be washed in a dishwasher or, better still, must be disposable (infant bottles should be labeled with their owners’ names so they aren’t mixed up).
Food preparation for infants on solids must be carried out under sanitary conditions.
Immunizations must be up-to-date for all babies.
Children who are moderately to severely ill, particularly with diarrhea, vomiting, high fever, and certain types of rashes, must be kept at home (this isn’t always necessary with colds, since the cold is contagious before it is evident) or in a special infirmary section of the facility.
There should be a policy about dosing children who attend with medication.
When a baby has a contagious illness, all the parents of children in the center must be notified by the center; in cases of Hemophilus influenzae, immunization or medication may be given to prevent spread of the disease.2
Also check with the local health department to be sure there are no outstanding complaints or violations against the center.
Strict safety rules. Injuries, mostly minor, are not uncommon in day-care facilities. But the safer the facility, the safer your baby will be. The top hazards are climbers, slides, hand toys and blocks, other playground equipment, doors, and indoor floor surfaces. Even a crawling baby can get into trouble with these; all babies can get into trouble with small objects (that can be choked on or swallowed), sharp objects, poisonous materials, and so on. A childcare center should meet the safety requirements you maintain in your own home:
Infants should be put to sleep on their backs.
Cribs, changing tables, high chairs, play yards, and other furnishings should meet safety criteria.
Mattresses should be firm; no pillows, fluffy bedding, or toys should be used in cribs.
Open stairways should have safety gates on them; watch, too, for doors that can slam on little fingers or can open on little faces.
Windows above ground level shouldn’t be able to be opened more than 6 inches and/or should have window guards.
Special precautions should be taken to protect children from radiators and other heating devices, electrical outlets, cleaning materials, and medications (often teachers have to dispense these to children recovering from illnesses or those with chronic problems).
Floors should not be littered with toys that can trip a newly toddling twelve-month-old or caregiver carrying an infant.
Materials used by older children (paints, clay, toys with small or sharp parts) should be kept out of reach of babies.
Smoke detectors, clearly marked fire escape routes, fire extinguishers, and other fire safety precautions should be in evidence.
Staff should be trained in CPR and first aid, and a fully equipped first-aid kit should be readily available.
Careful attention to nutrition. All meals and snacks should be healthful, safe, and appropriate for the ages of the children being served. Parental instructions regarding formula (or breast milk), foods, and feeding schedules should be followed. Bottles should never be propped.
Many parents feel more comfortable leaving a baby in a family situation in a private home with just a few other children than in a more impersonal day-care center; and for those who can’t arrange for a sitter in their own homes, home day care is often the best choice.
There are many advantages to such care. Family day care can often provide a warm, homelike environment at a lower cost than other forms of care. Because there are fewer children than in a day-care center, there is less exposure to infection and more potential for stimulation and individualized care (though this potential is not always realized). Flexible scheduling—early drop-off or late pickup when that’s necessary—is often possible.
The disadvantages vary from situation to situation. Such day-care facilities are often unlicensed, giving little protection in the way of health and safety. The care provider may be untrained, lacking in professional childcare experience, and may have a child-rearing philosophy that differs from the parents’. If she or one of her children is ill, there may be no backup. And though the risk may be lower than in a larger day-care facility, there is always the possibility of germs spreading from child to child, especially if sanitation is lax. See the section on group day care, starting on page 283, for tips on what to look for and look out for when checking out home day care.
A common option in European countries for many years, day-care facilities in or adjacent to a parent’s place of work are much less common in the United States, though more and more companies have started to offer such services. It’s an option many parents would choose if they had it.
If you’re leaving a young infant in the care of someone else—whether a sitter, grandparent, friend, or day-care provider—be sure he or she is aware of the “back-to-sleep, tummy-to-play” policy of the American Academy of Pediatrics. All babies should nap on their backs (unless a medical condition dictates otherwise) on a safe surface and should spend some wakeful time on their tummies (but only under constant supervision).
The advantages are extremely attractive. Your child is near you in case of emergency; you can visit or even breastfeed during your lunch hour or coffee break; and since you commute with your child, you spend more time together. Such facilities are usually staffed by professionals and are very well equipped. Knowing your child is nearby and well cared for may allow you to give fuller attention to your work. The cost for such care, if any, is usually low.
There are some possible disadvantages. If your commute is a difficult one, it may be hard on your child to weather on a daily basis—and hard on you if there’s a lot of struggling on and off of buses or subways with diaper bags and strollers. Sometimes seeing you during the day, if that’s part of the program, makes each parting more difficult for your baby, especially during times of stress (and, later, separation anxiety). And visiting, in some cases, may take your mind from your work.
Corporate day care, of course, should meet all the educational, health, and safety standards of any childcare facility. If the one set up by your employer doesn’t, then speak to those responsible for the facility about what can be done to make the program better and safer. Rallying other parents around the cause may help, too.
Very occasionally, a parent is able to take her or his baby to work, even when no day care is provided. And, occasionally, the situation works. It works best before a baby is mobile and if colic is not a problem—and, of course, when the parent has the space for a portable crib and other baby paraphernalia near her or his work area and the support of both employer and co-workers. Ideally, you should also have a sitter on the spot, at least part of the time, or a lot of flexible time; otherwise, baby may actually end up getting less attention and stimulation than he or she might in another childcare situation. Keeping baby on the job usually works best, too, if the atmosphere in the workplace is relaxed; a high stress level can have a negative impact on baby. When it does work, this kind of situation can be perfect for the nursing mom, or for any parent who wants to stay on the job and keep baby close, too.
No parent likes to see his or her baby sick, but the working parent particularly dreads that first sign of fever or upset stomach. He or she knows that caring for a sick baby may present a great many problems, the central ones being who will take care of the baby, and where?
Ideally, either you or your spouse should be able to take time off from work when your child is ill, so that you can administer care yourself at home. After all, as anyone who’s ever been a sick child knows, there’s nothing quite the same as having your mommy or daddy around to hold your hot little hand, wipe your feverish brow, and administer specially prescribed doses of love and attention. Next best is having a trusted and familiar sitter or another family member you can call upon to stay with your baby at home. Some day-care centers have a sick-child infirmary, where a child is in familiar surroundings with familiar faces. There are also special sick-child day-care facilities, both in homes and in larger freestanding centers sprouting up to meet this need; but in these, of course, the child has to adjust to being cared for by strangers in a strange environment when he’s or she’s least able to handle change. Some corporations, in order to keep parents on the job, actually pay for sick-child care, such as space in a sick-child day-care center or for a sick-baby nurse to stay with the child at home (which will also require adjustment to an unfamiliar caregiver).
1. Babies who spend little time on their stomachs during playtime may reach this milestone later, and that’s not cause for concern (see page 210).
2. Cytomegalovirus (CMV) is easily transmitted among babies in child care because of the frequent contact of caregivers with virus-laden urine and saliva. Since there is a very remote risk of infecting an unborn baby if the mother is infected, take precautions. If you know you are not immune to CMV (most women are), and you are pregnant again or planning to become pregnant again soon, be particularly careful to wash your hands after diaper changes; don’t kiss your child on the lips or eat his or her leftovers. (If you are immune, you can’t “catch” CMV and don’t have to take special precautions. There is also no risk to the fetus—and no need for precautions—after the 24th week of pregnancy.)
