There’s nothing quite as pathetic, vulnerable, and helpless-looking as a sick baby. With the exception of a sick baby’s parents.
An infant’s illness, even a mild one, usually hits mommy and daddy harder than it does baby, especially when it’s a first illness in a first child. There’s the anxiety when the initial symptoms appear, the alarm when they seem to worsen or others develop, the indecision over whether or not to call the doctor and when (children almost invariably get sick in the middle of the night or on weekends, outside of usual office hours), the pacing while waiting for the doctor’s callback (interminable, even if it’s only fifteen minutes), the ordeal of administering medicine, and the worry, worry, worry.
Believe it or not, things do get better. With experience, parents learn to handle a feverish infant or a vomiting baby with less panic and more self-assurance. To reach that point more quickly, it will help to learn how to evaluate symptoms, how to take and interpret a baby’s temperature, what to feed a sick child, what the most common childhood illnesses are, and how to recognize and handle a real emergency.
Most pediatricians want to hear from you if you think your baby is really sick—no matter what the time of day or night. But before you dial that probably already familiar number, be sure you’re armed with a written list of all the information your baby’s doctor might need to know in order to accurately assess the situation.
Start with symptoms. In most simple illnesses, only two or three symptoms will be present—in some cases, maybe just one—but running down the list that follows will ensure you haven’t missed anything. Be prepared to tell the doctor when symptoms first appeared; what, if anything, triggered them; what exacerbates or alleviates them (keeping baby upright reduces the coughing, for example, or eating increases vomiting); and which home remedies or over-the-counter medications you’ve tried treating them with. It will also be helpful to let the doctor know if your baby has been exposed to a cousin with chicken pox, a sibling with diarrhea, or anyone else with a communicable illness, if he or she has recently been injured, as in a fall, or has been recently sick. And don’t assume baby’s chart is in the doctor’s hand. Mention baby’s age, any chronic medical problems, and any medications he or she is taking.
Sometimes you can’t put your finger on any specific symptom, but your baby just doesn’t seem “right” to you. Put a call in to the doctor. Most likely you’ll be reassured, but it’s also possible that your parent’s intuition will have picked up something subtle that needs attention.
Have handy the name and phone number of an open pharmacy in case the doctor needs to phone in a prescription, and a pad and pen for jotting down any instructions you receive.
Temperature. The old lips-on-the-forehead technique for checking for fever is notoriously unreliable (though more reliable than a hand), especially if you’ve had a cold or hot drink recently or if you’ve just come in from the heat or the cold. While you might consider screening for fever this way (particularly if you’re not near a thermometer; keeping in mind the method is more likely to be accurate in the absence of fever than in its presence), don’t rely on it for accurate readings. Instead, turn to a thermometer if you suspect a fever in your baby (see page 566). Remember that in addition to illness, readings can be affected by such factors as room or air temperature (a baby’s temperature is likely to be higher after spending the morning in an overheated apartment than after coming in from the snow); level of activity (exercise, energetic play, and vigorous crying can all raise temperature); and time of day (temperatures tend to be higher later in the day). If baby’s forehead is cool, assume there’s no significant fever.
Heart rate. In some cases, knowing what your baby’s heart rate is may be useful to the doctor. If your baby seems very lethargic or has a fever, take the upper arm (or brachial) pulse (see illustration, page 534). The normal range in infants is much higher than it is for older children and adults, between 120 and 140 beats per minute when baby is awake (though the rate can go as low as 70 beats per minute when baby is asleep, and higher than 170 when he or she is crying).
Respiration. If your baby has difficulty breathing, is coughing, or seems to be breathing rapidly or irregularly, check respirations by counting how many times in a minute his or her chest rises and falls. Breathing is more rapid during activity (including crying) than during sleep, and may be speeded up or slowed down by illness. Newborns normally take about 40 to 60 breaths per minute; one-year-olds only 25 to 35. If your baby’s chest doesn’t seem to rise and fall with each breath, or if breathing appears labored or raspy (unrelated to a stuffy nose), report that information to the doctor, too.
Respiratory symptoms. Is your baby’s nose runny? Stuffy? Is the discharge watery or thick? Clear, white, yellow, or green? Is there a cough? Does it seem dry, hacking, heavy, crowing? Does the cough bring up any mucus? (Sometimes mucus will be brought up with a forceful cough.) Is baby wheezing (a whistling sound, mostly on breathing out)? Does he or she have stridor (a grunting sound from below the voice box)?
Behavior. Is there any change from the norm in your baby’s behavior? Would you describe your child as tired and lethargic, cranky and irritable, inconsolable or unresponsive? Or is baby his or her usual jolly self? Can you elicit a smile (if baby has started smiling already)?
Practice taking the brachial pulse when your baby is healthy and calm.
Sleeping. Is baby unusually drowsy or sleeping much more than usual? Or is he or she having trouble sleeping?
Crying. Is baby crying more than usual? Does the cry have a different sound or intensity—is it high-pitched, for instance?
Appetite. Is baby eating as usual? Refusing the breast or bottle and/or turning down solids? Or eating normally?
Skin. Does baby’s skin appear different in any way? Is it red and flushed? White and pale? Bluish or gray? Is it moist and warm (sweaty) or moist and cool (clammy)? Or unusually dry? Are lips, nostrils, or cheeks excessively dry or cracking? Are there spots or lesions anywhere on baby’s skin—under the arms, behind the ears, on limbs or trunk, or elsewhere? How would you describe their color, shape, size, texture? Does baby seem to be trying to scratch them?
Mouth. Is there swelling on the gums where teeth might be trying to break through? Any red or white spots or patches visible on the gums, inside the cheeks, or on the palate or tongue?
Throat. Is the arch framing the throat reddened? Are there white or red spots or patches?
Fontanel. Is the soft spot on top of your baby’s head sunken or bulging?
Eyes. Do baby’s eyes look different than usual? Are they glassy, vacant, sunken, dull, watery, or reddened? Do they have dark circles under them, or seem partially closed? If there is a discharge, how would you describe the color, consistency, and quantity?
Ears. Is baby pulling or poking at one or both ears? Is there a discharge from either ear?
Digestive system. Has baby been vomiting? How often? Is there a lot of material being vomited, or are baby’s heaves mostly dry? How would you describe the vomitus (like curdled milk, mucus-streaked, pinkish, bloody?) Is the vomiting forcible? Does it seem to project a long distance? Does anything seem to trigger the vomiting—eating, for example? Has there been any change in baby’s bowel movements? Is there diarrhea, with loose, watery mucus, or bloody stools? Are movements more frequent, sudden, and forceful? Or does baby seem constipated? Is there an increase or decrease in saliva? Or any apparent difficulty swallowing?
Urinary system. Are baby’s diapers less wet than usual? Or do they seem wetter? Is there any noticeable change in odor or color (dark yellow, for example, or pink)?
Abdomen. Does your baby’s tummy seem different in any way—flatter, rounder, more bulging? When you press it gently, or when you bend either knee to the abdomen, does baby seem to be in pain? Where does the pain seem to be—right side or left, upper or lower abdomen?
Motor symptoms. Has your baby had, or is he or she having, chills, trembling, stiffness, or convulsions? Does the neck seem to be stiff or difficult to move; can the chin be bent to the chest? Does there seem to be any difficulty in moving any other part of the body?
Babies have a lot to learn, but when it comes to their own bodies, they can often teach their parents a thing or two. You can trust your baby to tell you how much rest he or she needs during an illness, not in words, naturally, but in actions. A very sick infant will give up the usual daily pursuits in favor of needed rest, whereas one who is just mildly ill or on the way to recovery will be active and playful. In either case, there’s no need to impose restrictions of your own. Just follow baby’s lead. (If anyone needs a rest when a baby’s sick, it’s the parent.)
Loss of appetite often accompanies illness. Sometimes, as in the case of digestive upsets, that’s good, since an eating slowdown gives the stomach and intestines a break while they recover. Sometimes, as when there’s a fever, it’s not so good, since decreased appetite means baby’s not getting the additional calories needed to fuel the fever that fights the infection.
For most minor illnesses that don’t affect the digestive system, no special diet is necessary (except as noted under specific illnesses). But several general rules apply when feeding any sick baby:
Stress fluids. If your baby has a fever, a respiratory infection (such as a cold, influenza, or bronchitis), or a gastrointestinal illness with diarrhea, fluids—which help prevent dehydration—should take precedence over solids. Babies on breast milk or formula alone should suckle as often as they like, unless the doctor recommends otherwise. Older babies can also be given clear fluids and foods with high water content (juices, juicy fruits, soups, gels, and frozen-juice desserts, if they’ve been introduced). Offer fluids frequently throughout the day, even if baby takes no more than a sip at a time. Rehydration fluids may be recommended by the doctor if there has been a lot of diarrhea or vomiting and/or if baby seems to be dehydrated.
Play favorites. When you’re sick, certain foods appeal, others don’t. Be especially respectful of your baby’s tastes when his or her appetite has been rendered tender by illness. If that means nothing but breast milk or formula and bananas for four days, that’s okay.
Don’t force. Even if your baby hasn’t taken a bite in twenty-four hours, don’t force. Babies tend to take what they need when they need it. Once your baby recovers from the illness, his or her appetite is sure to recover, too. In fact, babies usually make up for missed meals big-time after they’ve been sick, eating ravenously and quickly regaining lost ounces. Do let the doctor know about this loss of appetite, however.
Few babies manage to get through their first year without coming down with an illness or condition that requires medication. Whether that medication is prescribed or recommended by your baby’s doctor, you’ll need to know a lot more than which drug store to pick it up at. To make sure your baby gets the right treatment, you’ll have to ask the right questions.
Either the doctor or the pharmacist (or the drug insert that the pharmacy supplies with the medication) will be able to answer the following questions. Since you’ll be likely taking the information in while holding a crying baby (and/or at 3 A.M., in a sleep-deprived haze), don’t rely on your memory. Jot the responses down so you’ll be able to refer to them later.
What is the generic name of the drug? The brand name, if any?
What is it supposed to do?
What is the appropriate dose for your baby? (Be ready with your baby’s approximate weight so that, if necessary, the doctor can calculate the dose accordingly.)
How often should the medication be given; should baby be awakened in the middle of the night for it?
Should it be taken before, with, or after meals?
Should it be washed down only with certain liquids and not with others?
What common side effects may be expected?
What possible adverse reactions could occur? Which should be reported to the doctor? (Remind the doctor of any previous reactions.)
If your child has a chronic medical condition, might the drug have an undesirable effect on it? (Be sure to remind the prescribing doctor of the condition, since he or she may not have your baby’s chart in hand.)
If your child is taking any other medication, could there be any adverse interaction?
How soon can you expect to see an improvement?
When should you contact the doctor if there is no improvement?
When can the medication be discontinued?
Medicines are meant to cure or relieve symptoms, but when used improperly, they can do more harm than good. Always observe these rules when giving medication:
Don’t give a baby under three months of age any medication (not even an over-the-counter one) not prescribed for him or her by a doctor.
Don’t use a drug if its expiration date has passed, or if it has changed in texture, color, or odor. Wrap expired medicines securely and place them in the trash.
Measure medications meticulously according to the directions the baby’s doctor has given you, or according to label directions on over-the-counter products.1 Use a calibrated spoon, dropper, plastic oral syringe, or special cup (all are usually available from your pharmacy) to get precise measurements; kitchen spoons are variable, so you’re better off not using them.
Keep a record of the time each dose is given so you will always know when you gave the last dose. This will minimize the risk of missing a dose or doubling up accidentally. (Since infants tend to keep drugs in their systems longer than older children or adults, the medication in their systems can quickly build up to an overdose level.) But don’t worry about being a little late with a dose; get back on schedule with the next dose.
Check the bottle label for care and storage directions, and follow them. Some medicines need to be stored in the refrigerator or at cool temperatures, and some must be shaken before use.
If directions on the label conflict with the doctor’s instructions and/or those received from the pharmacist, call the pharmacist or doctor to resolve the conflict before giving the medication.
Always read the label before giving a medication, even when you’re sure you have the right bottle. If it’s dark in the room, check the label in the light first.
Don’t give medicines prescribed for someone else (even a sibling) to your baby without the doctor’s approval. Don’t use even a medicine previously prescribed for your baby without the doctor’s okay.
Don’t administer medication to a baby who is lying down; this could cause choking. Instead, elevate your infant’s head slightly, or sit your older baby up.
Don’t put medicine in a bottle of juice or formula unless your doctor recommends it. Your child may not consume the whole bottle and won’t get the entire medication dose. Also, some medications become less effective when mixed with the acid in juices.
Always give antibiotics for the prescribed length of time, unless the doctor advises otherwise, even if your baby seems completely recovered.
If your baby is having an adverse reaction to a medication, stop it temporarily and check with the doctor right away.
Don’t continue giving a medicine beyond the time specified by the doctor; don’t start giving one again after discontinuing it without checking with the doctor first.
Record any medication you give your baby, the illness it was given for, the length of time it was taken, and any side or adverse effects in your baby’s health history for future reference (see page 557).
Learning how to give medication correctly is only the first step for parents, and usually the easiest. Actually giving it is another story. As far as many children are concerned, the cure is almost always worse than the illness, and without their cooperation, getting the medicine down can be a dreaded ordeal. And even when medicine does go down, it often comes right back up—all over baby, parent, furniture, and floor.
If you’re lucky, your baby will be one of those few who delight in the medicine-giving ritual and even in the strange, syrupy taste of vitamins, antibiotics, or pain relievers—and who opens up like a little sparrow at the first sight of a medicine dropper. If you’re not so lucky (and, unfortunately, the odds are against you here), you’ll have an infant who clamps down tight when presented with a dose of anything. There is probably nothing that will make administering medicine to such a baby a pleasure, but these tips will help get more medicine down with less trouble:
Unless you’re instructed to give the medication with or after meals, plan on serving it up just before feeding. First because baby is more likely to accept it when hungry, and second because if baby does vomit it right back up, less food will be lost.
Chill the medication if this won’t affect its potency (ask your pharmacist); the taste may be less pronounced when it’s cold.
Ask the pharmacy if they can mask the bad taste of a medication with a flavoring, such as FlavorX. (Keep in mind that any medication should be kept safely out of baby’s reach, but especially one that baby loves the taste of.)
Ask the pharmacist for a medicine spoon or plastic syringe, which will allow you to squirt the medicine deep into baby’s mouth; but don’t squirt more than a baby can swallow at one time. If your baby rejects medication from a dropper, spoon, or syringe and likes a nipple instead, try putting the dose in a bottle nipple or medicine pacifier so baby can suck it out. Follow this with water from the same nipple so any medication remaining in the nipple can be rinsed out in the baby’s mouth.
Aim a spoon toward the back of the mouth, a dropper or syringe between molars or rear gum and cheek, since the taste buds are concentrated front and center on the tongue (and the trick here is to avoid them as much as possible). But avoid letting the dropper or spoon touch the back of the tongue, where it could set off a gagging reflex.
As a last resort, mix the medication with a small amount (1 or 2 teaspoons) of strained fruit or fruit juice, but only if the doctor or pharmacist hasn’t ruled out such a mix. Don’t dilute the medicine in too large a quantity of food or juice because then your baby may not finish it all. Unless your baby is generally tentative about new foods, use an unfamiliar fruit or juice for mixing, since the medicine may impart an unpleasant taste to a familiar one, causing baby to reject it in the future.
Use a medicine spoon or dropper to ease medications into baby’s mouth.
Acetaminophen that comes in “sprinkle caps,” is tasteless, and can be emptied into a spoonful of juice or fruit can make giving this medicine much easier.
Enlist help when you can. Holding a wriggly, uncooperative baby while trying to bring a spoon filled to the brim with medicine to an unwilling mouth would be a challenge even for an octopus parent, and can sometimes be next to impossible for the two-armed variety. If your spouse (or another assistant) isn’t around to hold baby, try using an infant seat or a high chair as your extra pair of hands; but be sure to strap your baby in before you begin.
If you have to go it alone with no seat to hold baby, try this procedure with a young medicine resister: First, premeasure the medicine and have it ready to use on a table within reach in a dropper, syringe, medicine cup, or medicine spoon (which shouldn’t be filled to the brim). Sit in a straight chair and position baby on your lap, facing forward. Put your left arm across baby’s body, holding his or her arms securely. Take hold of his or her jaw with your left hand, your thumb on one cheek, your index finger on the other. Tilt baby’s head backward slightly and depress cheeks gently to open the mouth. With your right hand (reverse hands if you’re left-handed), administer the medicine. Keep baby’s cheeks slightly depressed until the medicine is swallowed. Speed is essential to the success of this maneuver; should it take longer than a few seconds, your baby will begin to fight being held down.
Keeping baby’s head steady when using eye drops will help ensure that at least some of the medicine will hit its mark.
Gently blow on your baby’s face when giving the medicine. It will trigger the swallowing reflex in young babies.
If any liquid leaks out of your baby’s mouth, use your finger to push it back in. Your baby will likely suck the rest off your finger.
If every dose is a battle, ask the doctor if it’s possible to prescribe a higher concentration of the medicine or a different medication that requires fewer doses per day.
Approach your baby confidently with medicine—even if past experience has taught you to expect the worst. If baby knows you’re anticipating a battle, you’re sure to get one. You may get one anyway, of course, but a confident approach could swing the odds in your favor.
Infants in their first year of life are generally healthy, and most of the illnesses to which they are susceptible are onetime affairs (see the chart starting on page 760 for details on these). But there are some illnesses that are so common, or that tend to recur so frequently in some babies, that parents need to know as much as possible about them. They include allergies, the common cold, constipation, ear infections, and gastrointestinal illnesses with diarrhea and vomiting.
Symptoms: Depend on the organ or system inflamed by the hypersensitivity. The following are common body systems affected, and the related symptoms and conditions:
The upper respiratory tract: runny nose (allergic rhinitis), sinusitis (though not in infants), earache (otitis media), sore throat (as much the result of mouth breathing of dry air as from allergy), postnasal discharge (a dripping of mucus at the back of the nose into the throat that can trigger a chronic cough), spasmodic croup. When swelling occurs in the throat, breathing can be hampered.
The lower respiratory tract: allergic bronchitis, asthma.
The digestive tract: watery, sometimes bloody diarrhea; vomiting; gassiness.
The skin: atopic dermatitis, including such itchy rashes as eczema (see page 324), hives (blotchy, itchy, raised red rash), and facial edema (swelling of the face, particularly around eyes and mouth, which is not as itchy as hives).
The eyes: itching, redness, watering, and other signs of allergic conjunctivitis.
Season: Any time of year for most allergies; spring, summer, or fall for those related to pollens.
Cause: The release of histamine and other substances by the immune system in response to exposure to an allergen in babies who are hypersensitive to the allergen or a similar one (the sensitization occurs at an earlier exposure). The tendency toward allergy runs in families. The way allergy is manifested is often different in different members of the family—one has hay fever, another asthma, and a third breaks out in hives upon eating strawberries.
Method of transmission: Inhalation (of pollen or animal dander, for example), ingestion (of milk or egg whites), injection (penicillin shot or insect sting), or contact (laundry soaps, paint) with the allergen.
Duration: Variable. The duration of a single allergic episode may vary from a few minutes to several hours or several days. Some allergies, such as an allergy to cow’s milk, are outgrown; others change, as children get older, from one kind of allergy to another. Many allergic people have allergies of one kind or another all their lives.
HAVING A PET IS NOTHING TO SNEEZE AT
To minimize the risk of developing an allergy to pets, parents and doctors have long believed that babies born to a family with a history of allergies should keep their distance from pets—which meant that these children grew up with Spot in their books, but not in their homes. However, a growing body of evidence now suggests that having pets in the home may actually protect children from pet allergies. Researchers have found that babies who live with cats or dogs from the first year of their life are less likely to show a pet allergy by the age of seven. And two or more pets in the home appear to protect even better than one.
Since researchers don’t yet know why having a pet seems to protect children from developing allergies, it’s not likely that doctors are going to issue a general “buy a pet” recommendation to families with allergy histories any time soon. And keep in mind, too, that although having a pet or two might prevent young children from developing allergies, flying fur can definitely bring on sneezes and wheezes in any family member who already has an allergy—in which case you will need to keep Fido in the doghouse.
Treatment: The most successful treatment for allergy, though also often the most difficult, is to remove the offending allergen from the sufferer’s life. Here are some ways in which you can remove allergens from your child’s environment, whether your child is definitely allergic (difficult to determine since skin tests are not very accurate in children under eighteen months) or only possibly so:
Food allergens (see Dietary changes, page 543).
Pollens. Pollen allergy is rare in infants, but if you and the doctor suspect pollen allergy (the clue is the persistence of symptoms as long as pollen is in the air, and their disappearance when it is gone), keep your child indoors most of the time when the pollen count is high or when it is particularly windy during pollen season (spring, late summer, or fall, depending on the type of pollen), give daily baths and shampoos (to remove pollen), and use an air-conditioner in warm weather rather than opening the windows and admitting the pollen. If you have a pet, the animal can also pick up pollen when outdoors, so you should bathe him or her frequently, too.
Pet dander. Sometimes pets themselves cause an allergy. If this is the case, or might be, try to keep your animal and your baby in different rooms, or keep the animal outside. (In severe cases, the only solution may be to find the pet another home.) Since horsehair can also trigger allergy, don’t buy a horsehair mattress for your baby’s crib.
Dust mites. These microscopic critters are no problem for most people, but for someone with a hypersensitivity to mites, it can mean misery. Limit your baby’s exposure, even if you just suspect this allergy, by keeping the rooms he or she lives in as dust-free as possible.
Dust often with a damp cloth or furniture spray when baby is not in the room; vacuum rugs and upholstered furniture and damp-mop floors often; avoid chenille bedspreads, carpeting, draperies, and other dust catchers where baby sleeps and plays; wash stuffed toys frequently; keep clothing in plastic garment bags; put filters over hot-air vents; install an air filter. You can also buy a vacuum or air cleaner with a high-efficiency particulate arresting (HEPA) filter to trap dust mites and other allergens. Any curtains, throw rugs, or other such items you do have should be washed at least twice a month, or packed away. Since dust mites survive on moisture from the air, keep humidity low.
Molds. Control moisture in your home by using a well-maintained dehumidifier, providing adequate ventilation, and by venting steam from your kitchen, laundry, and baths. Areas where molds are likely to grow (garbage cans, refrigerators, shower curtains, bathroom tiles, damp corners) should be cleaned meticulously with an anti-mold agent. Outdoors, be sure drainage around your home is good, that leaves and other plant debris are not allowed to pile up, and that, if possible, plenty of sun hits the yard and house to prevent damp areas from spawning mold. Keep baby’s sandbox covered in the rain.
Bee venom. Anyone allergic to bee venom should avoid outdoor areas known to have bee or wasp populations. If your baby has an allergy to bee venom, any caregiver should be equipped with and know how to use a beesting kit.
Miscellaneous allergens. Many other potential allergens and irritants can also be removed from your child’s world: wool blankets (cover them or use cotton or synthetic blankets); down or feather pillows (use foam or hypoallergenic polyester-filled ones when baby’s old enough to use one); tobacco smoke (allow no smoking in the house at all, or near baby in other locations); perfumes (use unscented wipes, sprays, and so on); soaps (use only hypoallergenic types); detergents (you may have to switch to an unscented detergent or use baby soap flakes for the laundry).
IS IT AN ALLERGY—OR JUST INTOLERANCE?
Sit down at a dinner party these days, and you might get the impression that the rate of food allergies has reached epidemic proportions. Between those who decline the soup (“dairy”) to those who beg off on the bread (“wheat”), more and more diners are passing on foods they believe they’re “allergic” to. But the fact is that true food allergies involving the immune system are relatively uncommon. Most food “allergies” are really sensitivities or intolerances to a food. Here’s the difference: Someone with an allergy to a food must avoid it completely (especially when the allergy causes severe reaction), even in minuscule amounts. Someone with an intolerance doesn’t have to be as vigilant about avoiding the offending food (since the reactions generally aren’t more than uncomfortable), and can sometimes eat small (or even moderate) quantities of it without feeling the effect. While a baby who is merely lactose intolerant (lacks the enzyme needed to digest milk sugar) may suffer from abdominal pain, gassiness, and possibly diarrhea when fed milk, a baby with a true milk allergy will also have blood and/or mucus in the stool. So if your baby experiences what seems to be “allergic” symptoms after eating certain foods, check with the doctor, who may be able to determine whether your baby is actually allergic or simply sensitive.
Since an allergy is a hypersensitive (or oversensitive) reaction of the immune system to a foreign substance, desensitizing (usually via gradually increased injected doses of the offending allergen) is sometimes successful in eliminating allergies—particularly to pollen, dust, and animal dander. Except in severe cases, however, desensitization is not usually started until a child is four years old. Antihistamines and steroids may be used to counteract the allergic response and bring down the swelling of mucous membranes in both infants and children.
Dietary changes: Elimination of possible dietary allergens, always using nutritionally equivalent substitutes (see The Daily Dozen on page 317). Remove a suspected food allergen (such as cow’s milk, wheat, egg whites, and citrus) from your baby’s diet under medical supervision; if symptoms disappear within a few weeks, you’ve probably discovered the culprit. You get further confirmation if the symptoms recur when the food is returned to the diet (but try this only at the doctor’s suggestion). Substitute (as needed) oat, rice, and barley flours for wheat; soy or hydrolysate formula2 for cow’s milk formula; egg yolks for whole eggs; and mangoes, cantaloupe, broccoli, cauliflower, and sweet red peppers for citrus.
Prevention: Breastfeeding for at least six months—preferably for a year or more—may help. This is especially important if there is a family history of allergy.
Later introduction of solids, not until at least six months, and then with caution (see page 316). Even later introduction of the most common offenders (cow’s milk, egg whites, wheat, chocolate, citrus, peanuts, nuts, shellfish). Careful observation for reactions when food is introduced.
Probiotics, or friendly bacteria, have been shown to prevent food allergies in children. Ask the pediatrician about them.
Complications: Asthma
Anaphylactic shock, which is rare, but can be fatal without treatment
When to call the doctor: Soon after you suspect an allergy. Call again whenever your child has new symptoms. Call immediately if there are any signs of asthma (wheezing), difficulty breathing, or signs of shock (disorientation, panting, rapid pulse rate, pale, cold, moist skin, drowsiness, or loss of consciousness).
Chance of recurrence: Some allergies disappear in adulthood never to return; others return under different guises.
Conditions with similar symptoms:
The common cold (see box, page 544)
Bronchitis (but a child who seems to have repeated bouts of this disease probably has asthma)
Gastrointestinal illnesses (similar to digestive tract symptoms)
Food sensitivities (similar to digestive tract symptoms); see box, page 542
Symptoms of colds and allergies are so similar, it’s hard to tell them apart. But with a little medical detective work, you’ll be able to uncover the cause of your baby’s congestion. If you answer yes to one or more of these questions, chances are, you’re dealing with an allergy:
Are the symptoms lasting more than ten to fourteen days? (Though this can also indicate that a cold has turned into a secondary infection; check with the doctor.)
Is your baby’s nose always stuffy or running?
Is the mucus that drains from your baby’s nose clear and thin (instead of yellow or green, and thick)?
Does your baby seem to be constantly rubbing, pulling, or pushing his or her nose?
Does your baby sneeze a lot?
Are your baby’s eyes watery and red? Does your baby rub them often (when he or she’s not tired)?
Does your baby have a rash?
The common cold is even more common among the very young. That’s because babies and small children haven’t yet had the chance to build up immunities against the many different cold viruses. So be prepared to have at least a few run-ins with a runny nose during the first couple of years, probably more if your child attends day care or has older siblings.
Symptoms: Runny nose (discharge is watery at first, then thicker and yellowish)
Sneezing
Nasal congestion
Sometimes: Dry cough, which may be worse when baby is lying down
Fever
Itchy throat
Mild fatigue
Loss of appetite
Season: All year round, but more common when older children are in school
Cause: More than 100 different viruses are known to cause colds.
Method of transmission: Usually spread from hand to hand.
Incubation period: One to four days.
Duration: Usually three to ten days, but in small children colds can linger longer.
Treatment: No known cure, but symptoms can be treated, as necessary:
Suctioning of mucus with a nasal aspirator (see illustration page 548). If mucus is hardened, before suctioning soften with over-the-counter saline nose drops. This may be necessary to help baby to feed as well as to sleep. (If baby resists being suctioned, you can use the saline drops alone to loosen the mucus so that it can drip out or be swallowed.)
Most people consider flu just one step up from a cold, at least for the young and healthy. A few feverish, bedridden days off from work or school, some chills, a lingering cough. Miserable and annoying, yes, but dangerous, no—unless you’re elderly or sick.
These days, the medical community is trying to change that perception, urging parents to line young children up for flu shots right alongside their grandparents and great-grandparents. While it’s true that serious illness and complications from the flu are highest in folks over the age of 65, rates of flu infection are actually highest among children. And for babies and toddlers, the flu bug can bite harder than parents might expect. In fact, children between six and twenty-three months who come down with the flu often need to be hospitalized.
Luckily, there is a vaccine available for babies over six months old that protects against the flu (see page 232). The vaccine is usually offered beginning in October (the flu season in the United States generally runs from November through April). Protection develops within two weeks and lasts up to a year. Babies need two flu shots—given at least one month apart—the first time they get vaccinated. Ask for a thimerosal-free vaccine if possible.
As yet, there is no vaccine for babies under six months old. Until scientists develop one, parents can protect their babies from exposure to the virus by getting flu shots themselves and by immunizing older siblings and other household members. Remember, too, that even if your family has been vaccinated, it’s important to wash hands thoroughly and often to prevent the spread of the many other common viruses that cause colds and flu-like illnesses.
For more on the flu, see page 768.
Humidification (see page 758) to help moisten the air, reduce congestion, and make breathing easier for baby.
Letting baby sleep with head elevated (by raising the head of the crib mattress with a couple of pillows or other supports under the mattress; never put any pillows in crib with baby) to ease breathing.
Decongestants, only if recommended by the doctor (they rarely are for infants), to try to make eating and sleeping easier; they are usually ineffective and can make some babies irritable.
Nose drops, if recommended by the physician, to ease congestion. But follow directions carefully because these drops can have side effects and an overdose can be harmful. Use for more than a few days can cause a rebound reaction and make baby feel worse.
Petroleum jelly (Vaseline) or similar ointment applied lightly to outside of, and under, nose to help prevent chapping and reddening of skin. But be careful to not let it get into the nostrils, where it could be inhaled or block breathing.
Cough medicine, but only to ease a dry cough that interferes with sleep, and only if it is prescribed by the doctor (many physicians question both the effectiveness and safety of giving cough suppressants to young children). Antibiotics will not help and should not be used unless there is secondary bacterial infection.
For a baby who’s having trouble breathing through a stuffy nose, saline drops (left) to soften the mucus and aspiration (right) to suction it out will bring welcome relief.
Dietary changes: Baby can continue a normal diet (though many have a loss of appetite), with the following exceptions:
Increased intake of fluids to help replace those lost through fever, mouth breathing, or runny nose. If baby is old enough, drinking from a cup may be more comfortable than trying to nurse or bottle feed with a stuffy nose.
If recommended by baby’s doctor, reduce intake of dairy products (but not of breast milk or formula), since it is possible they may thicken secretions.
Prevention: Careful hand washing for all the family, especially when someone has a cold, and particularly before handling baby or baby’s things. Coughs and sneezes should be covered.
Complications: Colds sometimes progress to ear infections or bronchitis. (In infants and young children, viral bronchitis is the natural extension of a cold into the larger breathing tubes of the lungs. It usually does not require separate treatment, and gets better by itself. If, however, a cough far outlasts a cold’s other symptoms, let the doctor know.) Less often, a cold can lead to pneumonia or sinusitis.
When to call the doctor: If this is a first cold; if your baby is under three months old and has a fever over 100.4°F
If the temperature goes up suddenly or a fever continues for more than two days
If a dry cough lasts more than two weeks, is interfering with baby’s sleep, causes choking or vomiting, becomes thick and productive (mucus is coughed up) or wheezy, or if breathing difficulties develop. A cough that lasts more than three weeks in an infant or six in an older baby may require consultation with a specialist.
The best way to prevent the spread of any kind of infection is frequent hand washing, after diaper changing, after toilet use or nose blowing, before food handling, and so on. Wash with soap and hot water for at least ten seconds.
Does it seem as if your baby has enrolled in the frequent cold program—catching every cold the older siblings come down with, or bringing one home from day care every other week? Don’t worry. Though they’ll try your patience and are rough on your baby’s nose, such frequent mild illnesses won’t do any harm—and can actually do some good.
The perks? Frequent colds (and ear infections and bouts with other bugs) boost your child’s immune system, making your child less susceptible to infection later in life. In fact, babies in day care (who catch illness more often than those at home) are much less susceptible to colds and other infections as they get older and enter school.
Frequent colds also appear to have absolutely no effect on your baby’s future development. Researchers have found that children who come down with multiple colds, ear infections, and diarrhea are no less prepared for preschool and have just as many social skills as their peers who were sick less often. (Plus, these children are already good at sharing—their germs, at least.)
If a thick, greenish yellow nasal discharge develops and lasts more than a day, or if the discharge is streaked with blood
If there is an unusual amount of crying (with or without tugging at the ears)
If there is a complete loss of appetite
If baby seems really out of sorts
Chance of recurrence: Since having a cold caused by one virus doesn’t make baby immune to a cold caused by another, babies, who haven’t had the chance to build up immunities to the more than 100 viruses that exist, can have one cold right after another.
If your baby or young child suddenly begins coughing uncontrollably and does not seem to have a cold or other illness, consider the possibility that an inhaled object could be the cause. See page 589 for emergency treatment.
Conditions with similar symptoms: Rubella and chicken pox begin with cold-like symptoms; check those diseases (see table starting on page 760) for additional symptoms
Respiratory allergies
Influenza
This problem is rare in breastfed babies (even if they move their bowels infrequently and their movements seem difficult to expel), because their movements are never hard. (In a breastfed newborn, infrequent movements—no matter how soft—can be a sign that baby isn’t getting enough to eat; see page 164.) Constipation can, however, plague formula-fed infants.
Symptoms: Infrequent bowel movements with stools that are hard (often small pellets) and hard to pass; infrequency alone, however, is not a sign of constipation and may be your baby’s normal pattern.
COMPLEMENTARY AND ALTERNATIVE MEDICINE
Most parents wouldn’t consider treating a baby’s symptoms with anything stronger than acetaminophen without first placing a phone call to the pediatrician. Some won’t even reach for the Infant Tylenol without the doctor’s okay. Yet many of the same parents wouldn’t hesitate to visit the local health food store to look for a holistic remedy for their baby’s cold, flu or constipation—or think twice about dosing baby with an herbal remedy without checking in with the doctor first.
They have plenty of company. According to some estimates, up to 40 percent of parents in the U.S. have joined the ranks of those choosing alternative therapies for their children. Whether it’s a dose of echinacea to nip a cold in the bud, a sniff of lavender to relieve stress, a bottle of chamomile to soothe a colicky baby, or a visit to the chiropractor to prevent recurrent ear infections, complementary and alternative medicine (CAM) has clearly found its way into the nursery.
But the question is—is the nursery any place for CAM? For years, alternative medicine—and those who practiced it—was considered the province of fringe practitioners. Today, it’s being integrated in one form or another into almost every area of traditional medicine, from cardiology to oncology. Unfortunately, however, the study of CAM in pediatric practice has lagged seriously behind. Virtually no CAM therapies have been tested on children, making determining which treatments are safe for the littlest patients and which aren’t an imprecise science—even for scientists. For parents, who have only anecdotal information to go on, the answers are even more elusive.
Some study is under way; much more needs to be done. In the meantime, here’s what you need to consider before taking a CAM approach to your child’s health. First, unlike over-the-counter and prescription medicines, herbal remedies are not rigorously regulated by the FDA. They haven’t been tested for effectiveness, safety, or proper dosing, even in adults. Second, “natural” doesn’t necessarily mean safe. Herbal remedies are not necessarily any safer than pharmaceutical preparations, and in some cases may be a lot less safe. In fact, some herbal remedies can actually cause serious side effects in children; others may interfere with traditional care a child is receiving—interacting badly with a prescribed medication, for instance. Third, while there are almost certainly CAM therapies that are beneficial, proceeding with any treatment—traditional or alternative—without consulting a knowledgeable physician is unwise and potentially unsafe. If you’re considering using a CAM therapy on your baby, always check with his or her doctor first.
Stool streaked with blood, if there are anal fissures (cracks in the anus caused by the passage of hard stool)
Gastric distress and abdominal pain
Irritability
Season: Any time
Cause: A sluggish digestive tract, illness, insufficient fiber in diet, not enough to drink, insufficient activity, or an anal fissure that makes defecation painful; rarely, a more serious medical condition.
Duration: May be chronic or occur just occasionally.
Treatment: Though constipation is not unusual in bottle-fed infants, symptoms should always be reported to the doctor, who can, when necessary, check for any abnormalities that might be causing it. Occasional constipation or mild chronic constipation is usually treated with dietary changes (see below); an increase in exercise may help (in infants, try moving the legs in a bicycle fashion when you see your baby having difficulty with a movement). Do not give laxatives, enemas, or any medication without the doctor’s instructions.
Dietary changes: Make these only after consultation with baby’s doctor:
If they’ve been introduced, give an ounce or two of prune or apple juice by bottle, cup, or spoon.
For a baby on solids, increase intake of fruits (other than banana) and vegetables.
In older babies, cut back on dairy products (but not breast milk or formula).
Prevention: When solids are added to baby’s diet, be sure to include mostly whole grains plus plenty of fruits and vegetables. Also be sure fluid intake is adequate and that baby has plenty of opportunity for physical activity.
Complications:
Fissures
Impacted stool (stool that is not passed naturally and may be painful to remove manually)
If it continues chronically through the toddler and preschool years, difficulty with toilet training can result.
When to call the doctor: If your baby seems to be constipated often or regularly; if the problem suddenly arises when it has not been noted before; or if there is blood in the stool.
Chance of recurrence: The problem can become a “habit” if it isn’t dealt with when it first occurs.
Conditions with similar symptoms:
Intestinal obstructions or abnormalities
This problem, too, is unusual in breastfed babies because there appear to be certain substances in breast milk that destroy many of the microorganisms that cause diarrhea.
Symptoms:
Liquidy, runny stools (not seedy like a breastfed baby’s stools)
Sometimes:
Increased frequency
Increased volume
Mucus in stool
Blood in stool
Vomiting
Cause: Very varied:
Gastrointestinal infection (viruses, most often rotavirus; also bacteria, parasites)
Sometimes, another infection
Teething (possibly)
Sensitivity to a food in the diet
Too much fruit or juice (particularly apple or pear)
Antibiotic medication (feeding yogurt with live cultures to a baby on antibiotics may prevent this type of diarrhea)
Method of transmission: Infectious cases can be transmitted via the feces-to-hand-to-mouth route. Also transmitted by contaminated foods.
Incubation period: Depends on the causative organism.
Duration: Usually anywhere from a few hours to several days, but some cases can become chronic if the cause is not discovered and corrected.
Treatment: Depends on the cause, but most common approaches are dietary (see below). Sometimes medication may be prescribed. Do not give antidiarrheal medication to an infant without the doctor’s approval—some can be harmful to young children. Protect baby’s bottom from irritation by changing diapers as soon as possible after they’re soiled and by spreading on a thick ointment after each change. If diaper rash develops, see page 269.
A very sick baby may need hospitalization to stabilize body fluids.
Dietary changes:
Continuing breast or formula feedings in most cases is best. Since a baby with diarrhea may develop a temporary lactose intolerance, a switch to a soy-based, lactose-free formula may be recommended if the diarrhea doesn’t improve on baby’s regular formula.
High fluid intake (at least 2 ounces an hour) to replace fluids lost through diarrhea. To augment breast milk or formula, a rehydration fluid (such as Pedialyte), available over the counter at any pharmacy, is sometimes recommended. Offer a few sips by spoon, cup, or bottle every two or three minutes, working up to 8 ounces between loose bowel movements. Do not give sweetened drinks (such as colas), undiluted fruit juices, athletic drinks, glucose water, or homemade salt-and-sugar mixtures.
Continuation of solids, if baby takes them regularly. The sooner a baby is fed, the less severe the diarrhea will be. Research shows that eating fat and fiber together bulks up stool. Good choices for solids include oatmeal and yogurt (which has the added bonus of “good” bacteria to aid in digestion). Small amounts of protein foods (such as chicken) are also appropriate. Steer clear of other fruits (besides bananas) and vegetables in the short term.
If there is vomiting, solid feeding is usually not resumed until vomiting has stopped. But do offer sips of clear fluids (diluted juices or oral rehydration fluid, if prescribed). Offering small amounts (no more than a tablespoon or two at a time, less for a very young infant) will greatly increase the chance that it will be held down. Once vomiting has stopped, foods can be added as above.
When stool begins to return to normal, usually after two or three days, the doctor will recommend that you begin to return your baby to a regular diet but continue limiting dairy products (other than breast milk and formula) for another day or two.
In diarrhea that lasts for two weeks or more in a bottle-fed infant, the doctor may recommend a change in formula.
Prevention: Diarrhea can’t always be prevented, but risks can be reduced:
Attention to sanitary preparation of foods (see page 328).
Careful hand washing by baby’s care providers after handling diapers and going to the bathroom.
The dilution of fruit juices taken by babies; limiting total intake to no more than 4 to 6 ounces a day; switching to white grape juice (see box, page 554).
Complications:
Diaper rash
Dehydration, if diarrhea is severe and left untreated
When to call the doctor: One or two loose stools is not a cause for concern. But the following indicate diarrhea that may need medical attention:
You suspect baby may have consumed spoiled food or formula.
Baby has had loose, watery stools for 24 hours.
Baby is vomiting (more than the usual spit-up) repeatedly, or has been vomiting for 24 hours.
There is blood in baby’s stools.
Baby is running a fever or seems ill.
Call immediately if baby shows signs of dehydration: significantly decreased urine output (diapers aren’t as wet as usual and/or urine is yellow); tearless and sunken eyes; a sunken fontanel (“soft spot”); dry skin; scanty saliva.
Chance of recurrence: Likely, if cause has not been eliminated, some babies are more prone to diarrhea.
Conditions with similar symptoms:
Food allergies
Food poisoning
Enzyme deficiencies
Babies and young children are more susceptible to earaches of all kinds, for a variety of reasons. Most outgrow the susceptibility.
Symptoms: In acute otitis media (AOM), infection of the middle ear, symptoms include:
Usually:
Ear pain, often worse at night (babies sometimes pull or rub or hold their ears but often give no indication of pain except for crying, and sometimes not even that; crying when sucking on breast or bottle may indicate ear pain that has radiated to the jaw)
Fever, which may be slight or very high
Fatigue and irritability
Runny nose and congestion (often, but not always)
Sometimes:
Nausea and/or vomiting
Loss of appetite
Occasionally:
No obvious symptoms at all
On examination, the eardrum appears pink (during the early stages of infection), and then red and bulging (later on). In many cases, AOM will get better without treatment (though the decision of whether to treat or to “wait and see” should be left to the doctor; see page 554 for more on treatment). Sometimes, however, if the infection is left untreated, pressure can burst the drum, releasing pus into the ear canal and relieving pressure. The eardrum heals eventually, but treatment helps to prevent further damage.
In serous otitis media (SOM), also known as otitis media with effusion, or fluid in the middle ear, symptoms include:
Usually:
Hearing loss (temporary but can become permanent if condition persists for many months untreated)
Sometimes:
Clicking or popping sounds on swallowing or sucking (as reported by older children)
A sick tummy got your baby down? It may be time for a change of juice. Researchers have found that children recover more quickly from diarrhea when they drink white grape juice than when they stick to those high chair standards, apple and pear. They’re also less likely to experience a recurrence on the white grape. Apparently, the sugar and carbohydrate composition of white grape juice is better for the digestive system (and a lot less challenging in the laundry department than its purple cousin). Apple and pear juices naturally contain sorbitol (an indigestible carbohydrate that can cause gas, bloating, and discomfort) and a higher amount of fructose than glucose, while white grape juice is sorbitol free, and has an even balance of fructose to glucose.
Before switching to white grape juice, though, discuss it with the doctor, who might recommend water or rehydration liquids instead. In some cases, too much of any type of juice can cause tummy troubles.
No symptoms at all, other than the fluid in the ear
Season: All year round, but much more common in winter.
Cause: Usually bacteria or viruses, but allergy can also cause middle ear inflammation. Babies and young children may be most susceptible because of the shape and size of their eustachian tubes; because they are more likely to get respiratory infections, which usually precede ear infections; because they have immature immune response; or because they are often fed while lying on their backs. The eustachian tubes, which drain fluids from the ears down the back of the nose and the throat and keep the middle ear ventilated with air, are shorter in a baby than in an adult, so germs can easily travel through them into the middle ear. And because the tubes are horizontal rather than vertical (as in adults), drainage is poor, especially in infants who spend a lot of time on their backs. The small diameter also makes the tubes more subject to blockage (by swelling from allergy or from an infection, such as a cold, by a malformation, or by enlarged adenoids). This blockage causes fluid buildup, which makes an excellent breeding place for infection-causing bacteria, causing serous otitis media.
Method of transmission: Not direct (you can’t “catch” an ear infection), but children in day care may be more vulnerable simply because they get more colds, which can lead to ear infections. There may be a family disposition to ear infections.
Incubation period: Often follows a cold or the flu.
Duration: Can be as short as a few days; can become chronic.
Treatment: Ear infections require consultation with a doctor; do not try to treat on your own. Treatment may include:
Antibiotics, when deemed necessary (sometimes they absolutely are necessary, sometimes they aren’t; see below). When antibiotics are prescribed, always give for the full time prescribed—usually five or ten days—to avoid reinfection, chronic infection, or antibiotic resistance. Decongestants are not usually helpful.
Watchful waiting in situations that do not require immediate antibiotic treatment. Research has shown that most uncomplicated cases of acute otitis media clear up within four to seven days without treatment. Ask your doctor whether antibiotics are absolutely necessary for your baby’s particular infection.
Ear drops, if doctor recommended.
Baby acetaminophen or ibuprofen for pain and/or fever.
Heat applied to the ear in the form of a heating pad set on low, a hot-water bag filled with warm water, or warm compresses (see page 758)—any of which can be used while you are trying to reach the doctor.
Myringotomy (minor surgery to drain fluid from the infected ear through a tiny incision in the eardrum) if the eardrum appears about to burst; incision will heal in about ten days, but may require special care until then. Another option is laser myringotomy, a newer treatment in which the doctor creates a tiny hole in the eardrum using a handheld laser, allowing the fluid in the ear to drain.
Insertion of a tiny tube to allow air into the middle ear, when fluid (serous otitis media; SOM) doesn’t respond to antibiotic therapy. This is done under general anesthesia and is a last resort for cases that don’t respond to other treatments. Usually a tube (which could be considered an “artificial eustachian tube”) is tried if fluid has remained in one ear for six months—or in both ears for four months—with no improvement. The tube falls out after six to eight months, sometimes sooner. Risks must be weighed against benefits before resorting to tubes, the long-term benefits of which are unclear.
Periodic ear exams until the ear (or ears) is back to normal, to be sure the condition has not become chronic.
Elimination or treatment of allergies related to repeated ear infections.
Dietary changes: Extra fluids for fever. If antibiotics are prescribed, whole milk yogurt with active cultures (if dairy products have been introduced) can help prevent stomach distress often caused by such medications.
Prevention: A sure way to prevent otitis media is not yet known. Recent research, however, suggests that the following may reduce the risk of ear infections in babies:
Overall good health through adequate nutrition and rest, and regular medical care
Breastfeeding for at least six months, preferably the entire first year
Flu shot, pneumococcal vaccine (see page 232)
A more upright feeding position, especially when a baby has a respiratory infection
Using angled bottles, instead of the traditional straight ones
A slightly elevated sleeping position when a baby has a cold (put a couple of pillows under the head of the mattress, not under baby’s head)
Having baby suck on a bottle or pacifier during takeoffs and especially landings, when most ear problems occur because of air pressure changes
Limiting the use of a pacifier during the day, and taking a pacifier out of your baby’s mouth once he or she is asleep
Low-dose prophylactic (given to prevent infection) antibiotics for children with frequent ear infections during the height of the otitis media season, or just when the child comes down with a cold, to prevent a secondary ear infection
Smoke-free living space (secondhand smoke can lead to more congestion, which can lead to SOM)
Home child care rather than group day-care situations, where children are more likely to come down with otitis media
Complications:
Among others:
Chronic otitis media with hearing loss
Mastoid infection (a rare condition in which the mastoid bone of the skull becomes infected)
Meningitis, pneumonia
When to call the doctor: Initially, as soon as you suspect your baby may have an earache. Again if symptoms do not seem to begin clearing within two days, or if baby seems worse. Even if no ear infection is suspected, call if baby suddenly doesn’t seem to be hearing as well as usual.
Chance of recurrence: Some babies never have an ear infection, others have one or two in infancy and then no repeats, and still others have them repeatedly on into toddlerhood and the preschool years.
Conditions with similar symptoms: A foreign object in the ear, swimmer’s ear, and referred pain from respiratory infection can mimic an earache. Teething sometimes causes referred pain to the ear.
There has been an apparent dramatic increase in the number of babies with GER recently—not because more babies are developing the condition but because more are being correctly diagnosed. Doctors believe that many babies who were labeled colicky in the past were actually suffering from GER. It’s a common condition in babies under a year of age, and even more common in premature babies.
Symptoms: GER is similar to heartburn (acid reflux) in adults. The acid in the stomach backs up into the esophagus or even up to the back of the throat, causing frequent spitting up or vomiting and irritation of the esophagus, indicated by unrelenting crying and discomfort. Symptoms include:
Sudden or inconsolable crying, severe pain, and arching during feeding
Excessive spitting up or vomiting
Extremely forceful vomiting
Vomiting hours after eating
Erratic feeding patterns such as refusing food or constant eating or drinking
Slow weight gain
Poor sleep habits
Gagging or choking
Frequent burping or hiccupping
Difficult or noisy swallowing
Excessive drooling
Sometimes:
Chronic coughing, recurrent croup
Frequent red or sore throat
Frequent ear infections
Respiratory problems including wheezing, labored breathing, asthma, bronchitis, pneumonia, and apnea
Season: Any time.
If there isn’t adequate space in your new arrival’s baby book, buy a notebook to use as a permanent health history. Record all your baby’s birth statistics, as well as information about each illness, medications given, immunizations, doctors, and so on. What follows is a sample of the kinds of things to include.
AT BIRTH
| Weight: | Length: | Head circumference: |
| Condition at birth: | ||
| Apgar score at one and five minutes: | ||
| Results of other tests: | ||
| Any problems or abnormalities: |
INFANT ILLNESSES
(for each illness record the following information)
| Date began: | Date recovered: | |
| Symptoms: | ||
| Doctor called: | ||
| Diagnosis: | ||
| Instructions: | ||
| Medications given: | How long: | |
| Side effects: |
IMMUNIZATIONS
| Type: | Received: | Reactions: |
Cause: GER is the return of stomach contents into the esophagus. Normally during swallowing, the esophagus propels food or liquid down to the stomach by a series of squeezes. Once food has entered the stomach, it is mixed with acid to start digestion. When this mixing occurs, the circular band of muscles at the lower end of the esophagus becomes tight, keeping the food from backing up. In premature and some term infants, the junction between the stomach and esophagus is underdeveloped and it sometimes relaxes when it should be tightening. This relaxation of the muscles allows the liquid and food to come back up. Reflux of the acidic stomach content irritates the lining of the esophagus and causes a form of heartburn.
Duration: GER usually begins between two and four weeks of age and can last until the child is one or two years old. Symptoms peak around four months and begin to subside around seven months when the baby begins to sit upright and take more solid foods.
Treatment: Mild forms of GER are common, usually require no treatment, and subside on their own over a period of months. For more serious GER, treatment is aimed not at curing the illness but at making baby feel better until he or she outgrows it. Use the strategies for prevention (below) to help ease your baby’s discomfort. Medications that reduce stomach acid, that neutralize stomach acids, or that increase stomach motility are sometimes helpful but should be given only if the doctor prescribes or recommends one for your baby. If the condition is serious and other forms of treatment have failed, surgery may be performed to tighten the lower esophageal sphincter.
Dietary changes:
Avoid overfeeding. Offer smaller amounts of breast milk, formula, or solid food more frequently.
When the infant is old enough to eat solids, serve thicker, rather than thin, watered-down foods. Gravity holds down heavier foods more easily. Also, avoid acidic (once introduced) or fatty foods in large quantities.
Prevention: GER can’t always be prevented, but there are things you can do to reduce its severity:
Breastfeed for as long as possible. GER is usually much less severe in breastfed babies because breast milk is more easily and more quickly digested than formula and acts as a natural antacid. If you are breastfeeding, eliminate caffeine (a known contributor to reflux) from your diet.
Make feedings as calm and quiet as possible, avoiding interruptions.
Burp your baby frequently.
Prop your baby upright during feeding and for one to two hours after feedings. If possible, do this in a quiet place. If your baby falls asleep after a feeding, put him or her to bed flat, but at an incline. You can do this by placing a couple of pillows under the head of the mattress or using a slanted wedge pillow specially designed for babies with GER (Velcro straps keep baby from sliding down).3
Try offering a pacifier after feedings; sucking on a pacifier often eases reflux.
Avoid playing or jostling the baby immediately after feedings. Don’t give baths after feeding.
Don’t smoke around baby. Nicotine stimulates gastric acid production.
Complications:
Failure to thrive
Severe choking spells
Wheezing, aspiration pneumonia, and other lung problems
Apnea
When to call the doctor:
If GER is severe enough to interfere with weight gain or sleep.
If your baby seems to be in a lot of pain.
Chances of recurrence: The good news is that almost all babies with GER will outgrow it. And once they do, it usually doesn’t recur. Occasionally, reflux can continue into adulthood.
Conditions with similar symptoms:
Viral or bacterial infections
Asthma
Pyloric stenosis
Metabolic diseases
Hirshsprung’s disease
Urinary tract infections (UTIs) are bacterial infections of the urinary tract (kidneys, ureters, bladder, and urethra).
Symptoms: Symptoms of a UTI can be hard to recognize in a baby or young child, but they’re important to look for when a child is sick with a fever and urination appears painful. Symptoms include:
Unexplained fever in a baby
Crying, irritability, holding the genitals, or showing other signs of pain when urinating
Stomach or back pain (hard to detect in infants)
Foul-smelling urine
Cloudy urine
Bloody (brown, red, or pink) urine
More frequent than usual urination
Nausea, vomiting, or diarrhea with other urinary symptoms
Decreased appetite or lack of interest in eating
Irritability
Poor growth in an infant
Season: All year round
Cause: The urinary tract includes the kidneys, the bladder, the tubes that carry urine from the kidneys to the bladder (ureters), and the tube that carries urine from the bladder to outside of the body (urethra). Urinary tract infections occur when bacteria (or, more rarely, a virus or fungus) begin to grow in the urinary tract. UTIs are common in young children because the urethra is very short, providing bacteria with easy access to the bladder.
Method of diagnosis: The doctor will need to perform a urine culture on sterile urine to determine if the child does indeed have a UTI. To do this on a young baby, the doctor may place a plastic bag over the genitals to collect the urine. This method of collection isn’t very accurate because bacteria (from the rectum, from the environment) can contaminate the sample. A better way of collecting a urine sample for culture is by inserting a catheter up the urethra and retrieving urine directly from the bladder.
Method of transmission: The bacteria can come from the skin around the rectum and genitals and then travel up the urethra to the bladder. Some UTIs are caused by bacteria in the blood moving through the kidneys.
Duration: Depends on the type of infection and how severe it is.
Treatment: Most UTIs are effectively treated with antibiotics.
Dietary changes:
Increase fluid intake
Prevention: Some children are prone to UTIs because of their anatomy. Preventive measures include:
When changing a diaper, always wipe from front to back, even for boys.
Make sure your baby gets a lot of fluids to help flush unwanted bacteria out of the body.
Avoid bubble baths and perfumed soaps, which can irritate the genitals, especially in girls.
Some studies suggest that cranberry juice is effective against UTIs, but the studies have all been done on adults, not children; consult with your baby’s doctor.
Possibly, circumcision for boys. Some research shows that uncircumcised boys are slightly more prone to UTIs.
Complications: Untreated urinary infections can lead to kidney infections, which, if left untreated, can cause serious damage.
When to call the doctor: If your baby has a fever for a few days without any signs of a cold (such as runny nose), if urination seems to be painful, or if your baby is experiencing any of the symptoms listed above.
Chances of recurrence: Can recur at any time.
RSV is the leading cause of lower respiratory tract infections in infants and young children. Approximately two-thirds of infants are infected with RSV during their first year. For most babies, RSV infection causes no more than a minor illness. In certain high-risk babies, however, RSV may lead to something much more serious.
Symptoms: In most infants, the virus causes symptoms resembling those of the common cold, including:
Nasal congestion
Runny nose
Low-grade fever
Decreased appetite
Irritability
In some infants, it can sometimes cause lower respiratory (lung) symptoms (bronchiolitis):
Rapid breathing
Flaring of the nostrils
Rapid heart rate
Hacking cough
Grunting
Noticeable bluish color in the skin around the mouth (cyanosis)
Wheezing sound when breathing
Skin between the ribs is sucked in with each breath
Lethargy, sleepiness, dehydration
Season: Peaks between October and April.
Cause: RSV is such a common virus that nearly all adults and children are affected by it sooner or later. A normal cold virus or mild RSV infection affects just the nose and upper part of the lungs. But these symptoms can worsen rapidly in some babies, as the virus infects the lungs, inflaming the lower part of the lungs and the smallest inner branches of the airways, making it difficult to breathe (such an infection is called bronchiolitis). For most babies, the illness is mild. But babies at risk (such as premature babies whose lungs are underdeveloped and who have not yet received enough antibodies from their mothers to help them fight off RSV disease once they’ve been exposed to it) are more likely to get severe bronchiolitis and end up in the hospital. Those considered at higher risk include babies who:
Were born prematurely
Have pre-existing lung disease
Are not breastfed
Are exposed to tobacco smoke
Were one in a multiple birth (such as twins), since they’re more likely to be premature
Were born within 6 months of the RSV season (birthday in April or later)
Attend day care (because these babies are more likely to be exposed to RSV infection in the first place)
Have school-age siblings; again, because exposure is more likely
Method of transmission: RSV is highly contagious and is transmitted by direct hand contact from infected individuals. The infection can also be spread through the air, by coughing and sneezing. RSV can survive for four to seven hours on surfaces such as cribs and countertops.
Method of diagnosis: Diagnosis is generally made by nasal swab, with a chest X ray to confirm the diagnosis.
Incubation period: Four to six days from exposure.
Duration: Children with mild RSV bronchiolitis are treated at home and improve within three to five days, though they may remain contagious for up to a week.
Treatment: For those whose RSV has caused more severe bronchiolitis:
Oxygen administration if there is respiratory distress or blood oxygen levels are low. Rarely, infants may need to be briefly placed on a ventilator.
Albuterol, a medication that opens up the airways and is given through a nebulizer, may help. The nebulizer machine turns liquid medicine into a mist that is then inhaled.
Steroids have been found to decrease inflammation in the lungs and are sometimes used to treat severe RSV bronchiolitis.
Antibiotics are not effective because RSV is a virus, not a bacteria.
Dietary changes: As with the common cold, be sure your baby gets plenty of fluids.
Prevention:
Breastfeed, if possible.
Make hand washing a priority around the house.
Keep older siblings away from the baby as much as possible if they have a runny nose, cold, or fever.
Do not take a high-risk baby out to crowded areas such as shopping centers during RSV season.
Do not smoke around your baby.
Vaccination is available to prevent RSV (not as a treatment), but the vaccine, called Synagis, does not give long-term protection and must be administered monthly during RSV season to high-risk infants in the hospital. It is also extremely expensive.
Complications:
High-risk children who are infected with RSV disease often need to be hospitalized
Dehydration
Respiratory failure
When to call the doctor:
If your infant has any symptoms of bronchiolitis (see page 760).
If a fever persists for more than four to five days and/or remains elevated despite giving acetaminophen.
If your infant has changes in breathing pattern (rapid breathing, wheezing, or if the skin between the ribs is sucked in with each breath) or is difficult to console.
Chances of recurrence: Almost all children recover fully with no lasting effects. Reinfection throughout life is common, though lower respiratory tract symptoms are most common in infants and toddlers and most marked in the first infection. In older children, RSV is indistinguishable from the common cold.
Conditions with similar symptoms:
Common cold
Asthma (though less often in younger infants)
Pneumonia
Gastric reflux with aspiration of the stomach contents may also produce the symptoms of bronchiolitis, but cold-like symptoms do not precede respiratory distress in these cases.
Though you may remember your mother standing over you, thermometer in hand, concern in her voice, announcing, “You’ve got a fever, I’d better call the doctor,” fever hasn’t always been considered cause for alarm. The ancients welcomed an elevated temperature because they were convinced that it burned out bad “humors.” Hippocrates, too, speculated that fevers did more good than harm. In the Middle Ages, fever was actually induced on occasion to fight syphilis and certain other infections. And in fact, fever was believed so beneficial historically that it wasn’t even treated until about 100 years ago, when aspirin, with its fever-reducing capabilities, came on the scene. With the advent of aspirin, however, came a reformulating of medical opinion about fever. Throughout much of the twentieth century, even the slightest rise in temperature became a cause for worry, and a high fever for all-out panic.
Oddly enough, as it turns out, Hippocrates and the other ancients had a better notion of what fever is all about than did the modern medical community of a few generations ago. Research has confirmed that most fevers serve to heal, rather than harm—that they exist in a sense to burn out, if not the bad humors, at least the bad germs that invade and threaten the body. Instead of being a condition to be feared and fought, fever is now recognized to be an important part of the body’s immune response to infection. Fever is not a disease; rather, it is a sign of illness—and a sign of the body’s effort to overcome the illness.
A very high fever occasionally causes convulsions in infants and young children, usually at the very onset of the fever. Though febrile convulsions are frightening for parents, doctors now believe they are not dangerous. (See page 568 for safe handling of convulsions.) Studies have shown that children who have simple, brief febrile convulsions show no neurological or mental impairment later on. Babies who have once had convulsions with a fever have a 30 to 40 percent greater chance of a repeat episode, and medical treatment doesn’t affect that risk. Nor does treatment of a fever during the illness seem to reduce the incidence of seizures in these predisposed children, probably because the convulsions almost always occur just as the fever rises at the onset of an illness, before treatment can be given.
Here’s how scientists now believe fever plays its role. In response to invaders such as viruses, bacteria, and fungi, white blood cells in the body produce a hormone called interleukin, which travels to the brain to instruct the hypothalamus to turn up the body thermostat. At higher body temperatures, the rest of the immune system is better able to fight infection. Viruses and bacteria grow best in cooler temperatures, so a fever actually makes the body less hospitable to infection. Fever may also lower iron levels while increasing the invaders’ need for that mineral—in effect starving them. And when it’s a virus that has launched the attack, fever helps enhance the production of interferon and other antiviral substances in the body.
When a person’s body temperature suddenly rises a couple of degrees above normal (98.6°F taken orally), he or she often feels, paradoxically, chilled. The chilling serves to encourage a further rise in temperature in several ways. The involuntary shivering that usually occurs signals the body to turn its thermostat up still another notch and prompts the fever sufferer to take other measures that raise the body temperature: drink hot drinks, throw on another blanket, put on a sweater. At the same time, outlying blood vessels constrict to reduce heat loss, and body tissues—such as stored fat—are broken down to produce heat (which is why it is important to take in extra calories during a fever).
An estimated 80 to 90 percent of all fevers in babies are related to self-limiting viral infections (they get better without treatment). Most doctors today don’t recommend trying to reduce such fever in babies over six months unless it is 102°F (rectally) or more, and some wait for significantly higher temperatures before they advise parents to break out the medicine dropper as long as baby doesn’t seem to be in discomfort. (For guidelines on when to call the doctor with fever, see page 567.) They may, however, suggest the use of baby acetaminophen or ibuprofen even with lower temperatures to relieve aches and pains, make a baby more comfortable, improve sleep, and sometimes, to make a nervous parent feel better. But while the fever may not need treatment, the illness that’s triggering the fever may. For instance, illness caused by bacteria usually needs to be treated with antibiotics, which will wipe out the infection (thereby indirectly lowering temperature). Depending on the illness, the antibiotic selected, the child’s level of comfort, and the height of the fever, antibiotics and fever reducers may or may not be prescribed simultaneously.
Unlike most other infection-related fever, fever related to shock from a generalized bacterial invasion of the body, as in septicemia (blood poisoning), requires immediate medical treatment to lower the body temperature. So does fever related to heatstroke.
Normally, body temperature is at its lowest (as low as 96.5°F taken orally) in the middle of the night (between 2 A.M. and 4 A.M.), is still relatively low (as low as 97°F) on getting up in the morning, then slowly rises over the day until it peaks (at about 99°F) between 6 and 10 in the evening. It tends to be slightly higher in hot weather, lower in cold, and higher during exercise than at rest. It’s more volatile and subject to greater variation in babies and young children than in adults.
Fevers behave differently in different illnesses. In some, a fever may remain persistently elevated until a baby is well; in others it will be consistently lower in the morning and higher in the evening, spike (shoot up) periodically, or come and go with no obvious pattern. The pattern sometimes helps the doctor to make a diagnosis.
When fever is part of the body’s response to infection, temperatures above 105°F are rare and those beyond 106°F unheard of. But when fever is the result of the failure of the body’s heat-regulation mechanism, as in heatstroke, temperatures can soar as high as 114°F. Such temperatures can occur when the environment is very hot and the body can’t cool itself effectively. This can occur either through an internal abnormality or, more commonly, through overheating caused by an external heat source, such as a sauna or a hot tub, for example, or the inside of a parked car in warm weather (air temperatures inside the car can quickly shoot up to 113°F even with the windows open 2 inches and the temperature outside a moderate 85°F). Overheating can also result from strenuous physical activity in hot or humid weather, or from being overdressed in warm weather. Infants and the elderly are most susceptible to heat illnesses because their temperature-regulation mechanisms are less dependable. Fever due to the failure of heat regulation is an illness in itself, and not only is it apparently not beneficial, it is dangerous and requires immediate treatment. Extremely high temperatures (over 106°F), whatever their cause, require immediate treatment to prevent damage to the brain and other organs. It’s believed that when a fever is that high it ceases to be beneficial, and its positive effects on the immune response may be reversed.
Most doctors prefer a more accurate indicator of a baby’s condition than a parent’s kiss (though the kiss will still be welcomed by a baby who’s not feeling well). Enter the thermometer.
Taking the temperature during the course of an illness can help answer such questions as “Has the treatment effectively lowered the temperature?” or “Has the fever risen, meaning a turn for the worse?” But keep in mind that while temperature readings can be useful, they needn’t be taken every hour on the hour. In most cases, once in the morning and once in the evening is adequate. Take it in between only if baby suddenly seems sicker. If baby seems better, and your lips testify that the fever has broken, you don’t really need a second opinion from the thermometer.
FEVER DOESN’T TELL THE WHOLE STORY
Fever isn’t the only indication of illness—and on its own can be an unreliable measure of how sick a baby really is. A baby who’s running a moderately high fever but is cheerful and active is likely to be less sick than a baby who’s running a low-grade fever (or no fever at all) but is clearly out of sorts and lethargic. After taking a baby’s temperature, also take a look at other measures of well-being, including how a baby looks, is behaving, and is eating.
Temperatures are most often taken through the mouth, the rectum, the armpit (axilla), or the ear. Since putting a thermometer in a baby’s mouth is dangerous (most doctors do not recommend taking oral temperatures until a child is four or five), you’ll go one of the other routes for now.
Before you start. Try to keep your baby calm for half an hour before temperature taking, since crying or screaming could turn a slightly elevated temperature into a high one. (Though it’s necessary to withhold hot or cold drinks or foods before taking an oral temperature, as they too could affect temperature readings, this precaution isn’t necessary when taking rectal, axillary, or tympanic temperatures.)
Choosing a thermometer. The AAP recommends that parents no longer use glass mercury thermometers because of the dangers of mercury exposure. Instead, choose from the following:
Digital thermometers. These are safe, easy to use, readily available, and relatively inexpensive. They can be used to take a rectal, oral, or axillary (armpit) reading (but don’t use the same thermometer for oral and rectal). With a digital thermometer, you’ll have your reading in about 20 to 60 seconds—a real advantage when you’re dealing with a squirming infant. Look for a thermometer that has a flexible tip for extra comfort. If you want, you can use disposable covers available in drugstores, but they are not necessary.
Pacifier thermometers. Shaped like a pacifier, and designed to give an oral reading in a baby too young to use an oral thermometer, these usually read between 0.2°F and 0.5°F lower than rectal thermometers. And since they require an average of three minutes to get a reading, they are difficult to use with an uncooperative baby and therefore are not very reliable.
Tympanic thermometers. These thermometers, which measure the temperature in the ear, are fairly expensive. And even though they provide a reading in just seconds, they can be difficult to position (though some have feedback guides to make sure it’s placed properly). In general, a reading from the ear is less reliable than an axillary (armpit) one, and neither is as accurate as a rectal reading—still considered the gold standard. Ear readings may be even less accurate in young infants, who have very narrow ear canals; most experts agree that you should hold off using an ear thermometer until your baby is at least three months old, preferably over a year. Wax in the ear can also interfere with the temperature reading, no matter what a child’s age. If you do have a tympanic thermometer, ask the doctor for a demonstration on proper use.
The rectal method.
Temporal artery thermometers. These measure temperature with a transducer that rolls across the forehead, and have been shown in studies to be very accurate (though still not as accurate as a rectal). They’re easy to use and are becoming more widely available, though they’re expensive.
Taking the temperature.
Rectal: Prepare the thermometer by lubricating the sensor tip with Vaseline and bare baby’s bottom, speaking reassuringly as you do. Then turn baby onto his or her tummy on your lap (which allows the legs to hang down, making insertion easier) or on a bed or changing table (where a small pillow or folded towel under the hips will raise the baby’s bottom slightly for easier insertion). To distract baby, try singing a couple of favorite songs, or putting a favorite book or toy in baby’s line of vision. Spread the buttocks with one hand, exposing the anus (the rectal opening). With the other, slip about an inch of the tip of the thermometer into the rectum, being careful not to force it. Hold the thermometer in place until it beeps, using your other fingers to press the buttocks together to keep the thermometer from sliding out and to keep baby from wriggling. Remove the thermometer immediately, however, if baby begins to show very active resistance.
Axillary, or underarm: An axillary reading is useful when a baby has diarrhea or won’t lie still for a rectal or if only an oral thermometer (which should never be used rectally) is available. You can use a digital rectal or oral thermometer for an underarm reading. Remove baby’s shirt so it won’t come between the thermometer and baby’s skin, and be sure the armpit is dry. Place the tip of the thermometer well up into the armpit and hold the arm snugly over it, gently pressing the elbow against baby’s side. Distract baby as needed.
Tympanic: Use one that uses feedback to guide you to the proper position or ask the doctor for a demonstration.
Reading the thermometer. A rectal temperature is the most accurate since it picks up temperatures from the body’s core. Temperatures obtained rectally, as they are most frequently in infants, are usually one-half to a full degree higher than those determined orally; axillary readings are about one degree lower than an oral temperature. The norm for an oral reading is 98.6°F; the norm rectally is 99.6°; and 97.6° is normal for an axillary reading. A fever of 102.2° taken rectally is roughly equivalent to 101.2° taken orally and 100.2° by an armpit reading.
The underarm method.
Storing the thermometer. After use, wash the thermometer with cold soapy water, rinse, and swab the sensor tip with alcohol. Be careful not to wet the digital display, on/off button, or battery cover.
Behavior is a better gauge of how sick an infant is than body temperature. A baby can be seriously ill, with pneumonia or meningitis for example, and have no fever at all, or have a high fever with a mild cold.
Under the following circumstances a baby with a fever requires immediate medical attention (call the doctor even in the middle of the night, or go to the emergency room if the doctor can’t be reached):
The baby is under two months old with a fever of over 100.2°F rectally.
A baby over two months has a fever over 105°F rectally.
The baby has a convulsion for the first time (the body stiffens, eyes roll, limbs flail).
The baby is crying inconsolably (and it clearly isn’t colic), cries as if in pain when touched or moved, or is whimpering, nonresponsive, or limp.
The baby has purple spots anywhere on the skin.
The baby is having difficulty breathing once you’ve cleared the nasal passages.
The baby’s neck seems stiff; baby resists having the head pulled forward toward the chest.
The onset of fever follows a period of exposure to an external heat source, such as the sun on a hot day or the closed interior of an auto in hot weather. Heatstroke is a possibility (see page 582), and immediate emergency medical attention is indicated.
A sudden increase in temperature occurs in a baby with a moderate fever who has been overdressed or bundled in blankets. This should be treated as heat illness.
The doctor has instructed you to call immediately should your baby run a fever.
You feel something’s very wrong, but you just don’t know what.
Under the following conditions a baby with fever needs medical attention as soon as practical:
The best time to ask the doctor what to do when your baby has a fever is before that first fever strikes—especially because it’s most likely to strike (call it another Murphy’s Law of Parenting) in the middle of the night. The two-month well-baby visit is a good time to set up or review that protocol. Find out, for instance, when to call the doctor, when to give medication, and what other methods of reducing a fever you should try.
Convulsions due to fever usually last only a minute or two. Should your baby have one, keep calm (remember, such convulsions are not dangerous) and take the following steps. Keep baby unrestrained in your arms or on a bed or another soft surface, lying on one side, with head lower than body if possible. Don’t try to feed or put anything into baby’s mouth, and remove anything (like a pacifier) that might be in it. Babies often lose consciousness during a seizure, but they usually revive quickly without help. When a seizure has ended, the baby often wants to sleep.
Once the seizure has stopped you should call the doctor. (Any seizure that lasts five minutes or more requires immediate emergency help—dial 911 or your local emergency number.) If you don’t reach help immediately and he or she is more than six months old (as most babies who have convulsions are), you can dose with acetaminophen or ibuprofen to try to lower the temperature while you’re waiting (but not while baby is convulsing). You can also give a sponge bath. But don’t put baby in the tub to try to reduce the fever, since another seizure could occur and water could be inhaled.
The fever is over 100.4°F rectally for babies two to six months or over 102.6°F for babies older than six months (or whatever temperature your baby’s doctor recommends you call at). Though such a temperature is not in itself an indicator of a baby’s being very sick (babies can run fevers of 104°F with minor illness), check with the doctor, just in case. Remember, younger babies need medical attention for any fever over 100.2°F.
The baby has a chronic illness, such as heart, kidney, or neurological disease, or sickle-cell or other chronic anemia.
The baby is having febrile convulsions and has had convulsions with a fever in the past.
The baby exhibits signs of dehydration: infrequent urination, dark yellow urine, scant saliva and tears, dry lips and skin, sunken eyes and fontanel.
The baby’s behavior seems uncharacteristic: he or she is excessively cranky; lethargic or excessively sleepy; unable to sleep; sensitive to light; crying more than usual; refusing to eat; pulling at ears.
A fever that has been low grade for a couple of days spikes suddenly; or a baby who has been sick with a cold for several days suddenly begins to run a fever (this may indicate a secondary infection, such as otitis media or pneumonia).
A fever isn’t brought down by fever-reducing medication.
A low-grade fever (under 102°F rectally) with mild cold or flu symptoms lasts for more than three days.
A fever lasts more than twenty-four hours when there are no other detectable signs of illness.
If your baby has a fever, take these measures as needed, unless the doctor has recommended a different course of action.
Keep baby cool. Contrary to popular belief, keeping a feverish baby warm with blankets, heavy clothing, or an overheated room is not a safe practice. These measures can actually lead to heatstroke by raising body temperature to dangerous levels. Dress your baby lightly to allow body heat to escape (no more than a diaper is needed in hot weather) and maintain room temperature at 68°F to 70°F (when necessary to keep the air cool, use an air conditioner or fan if you have one, but keep baby out of the path of the air flow).
Increase fluid intake. Because fever increases the loss of water through the skin, it’s important to be sure a feverish baby gets an adequate intake of fluids. Give young infants frequent feedings of breast milk or formula. For older babies, offer good sources of fluids often. These include (if they’re been introduced) diluted juices and juicy fruits (such as citrus and melons), water, clear soups, and gelatin desserts (see pages 752–753). Encourage frequent sipping but don’t force. If baby refuses to take any fluids for several hours during the day, inform the doctor.
Give fever-reducing medication, if necessary. The decision of whether (and when) to give a fever-reducing medication to your baby should be based on the doctor’s recommendations (which you’ve hopefully secured in advance). In general, most doctors are comfortable having parents give acetaminophen to infants over two months old when they have a high fever (over 100.4°F rectally for babies two to six months; over 102.6°F for babies older than six months) before they contact the doctor. If the fever goes down after giving the medicine and there are no other indications that baby needs immediate medical attention (see Evaluating a Fever, page 567), contact the doctor as soon as practical (in the morning if the fever began in the middle of the night, for instance). If the temperature does not go down, or if it goes up, or if baby seems very uncomfortable, call the doctor right away—even if it’s the middle of the night.
Sponging. Once a routine treatment for fever, sponging is now recommended only under certain circumstances, such as when fever-reducing medication isn’t working (the temperature isn’t down an hour after it is given); when trying to lower the body temperature of a baby under six months old without medication; or when trying to make a very feverish baby more comfortable.
Only tepid or lukewarm water (body temperature, neither warm nor cool to the touch) should be used for sponging. Using cool or cold water, or alcohol (once a popular fever-reducing rub), can raise rather than lower temperatures by inducing shivering, which prompts the confused body to turn up its thermostat. In addition, the alcohol fumes can be harmful if inhaled. Using hot water will also raise body temperatures and could, like overdressing, lead to heatstroke. You can sponge a feverish baby in the tub or out, but in either case the room should be comfortably warm and draft free. (If sponging seems to upset your baby, discontinue it.)
Sponging out of the tub. Have three washcloths in a tub or basin of tepid water ready before you begin. Spread a waterproof sheet or pad, or a plastic tablecloth, on the bed or on your lap; place a thick towel over it and place baby, faceup, on top of the towel. Undress baby and cover with a light receiving blanket or towel. Wring out one washcloth so it won’t drip, fold it, and place it on baby’s forehead (remoisten if it begins to dry at any point during the sponging). Take another cloth and begin lightly rubbing baby’s skin, exposing one area of the body at a time and keeping the rest lightly covered. Concentrate on the neck, face, stomach, inside of the elbows and knees, but also include the area under the arms and around the groin. The blood brought to the surface by rubbing will be cooled as the tepid water evaporates on the skin. When the rubbing cloth begins to dry out, switch it with the third cloth. Continue rubbing and sponging your baby, alternating cloths as needed, for at least twenty minutes to half an hour (it takes this long to lower body temperature). If at any time the water in the basin cools to below body temperature, add enough warm water to raise it again.
There are many kinds of pain relievers and fever reducers on the market, but only two should be considered for young children: acetaminophen (Tylenol, Tempra, Panadol, and generic store brands) and ibuprofen (Motrin, Advil, and generic store brands). Giving aspirin to children became taboo after children who took aspirin to treat the symptoms of viral infections such as the flu were found to have a greater risk of contracting Reye’s syndrome, a rare and potentially fatal disorder affecting the brain and liver. Because of this increased risk, the American Academy of Pediatrics advises against giving aspirin to children unless a doctor specifically prescribes its use.
Both acetaminophen and ibuprofen work as well as aspirin to relieve pain or fever (and also taste good to many children), though they work differently in the body and have different side effects. For many years, acetaminophen was the first choice for nonaspirin pain relief. Then over-the-counter ibuprofen liquids became available, and many pediatricians started to recommend them because they’re slightly more powerful and longer lasting (with dosing every 6 to 8 hours compared to every 4 to 6 hours with acetaminophen).
Acetaminophen for infants is available in liquid syrup, drops, sprinkle or suppository form (which can come in handy when a child with a stomach flu needs to take fever medication but is vomiting, or when a baby refuses medication by mouth). Ibuprofen is also available in liquid or drop form. Ibuprofen should be given only to children older than six months, and it should never be given to children who are dehydrated or vomiting continuously or who have abdominal pain.
There are few side effects to these medications when used properly—and that’s the critical part. Although acetaminophen is considered safe when used as recommended, taking it regularly for longer than a week at a time can be dangerous. A large overdose of acetaminophen (about 15 times the recommended dose) can cause fatal liver damage, which is probably why infant liquid acetaminophen comes in such tiny bottles (and why all medicines should be stored out of baby’s reach). The biggest drawback to ibuprofen is the potential for stomach irritation. To avoid this side effect, give your baby the medicine with a meal or drink.
The practice of alternating doses of acetaminophen and ibuprofen to treat fever in children had been recommended by some pediatricians, but most doctors now agree that doing so long-term isn’t beneficial and could be harmful. There have been some cases of kidney problems caused by long-term combination therapy with these two drugs.
If your child is over six months and has pain or fever, start with whichever of the two medications is in your medicine cabinet (if your baby is younger than six months, stick to acetaminophen). If that doesn’t do the job, try the other one, as long as you make sure to give correct doses, wait until it’s safe to give another dose of medication (at least 4 hours with acetaminophen, at least 6 hours with ibuprofen), and follow the recommended schedule according to the instructions on the label and advice from the doctor. And when you’re not using them, keep them (like all medications) safely locked away, out of the reach of babies and children.
Sponging in the tub. For many babies, baths are soothing and comforting, especially when they are sick. If yours is one of these, do the sponging in the tub. Again, the water should be body temperature, and you should sponge and rub for at least twenty minutes to half an hour to bring the temperature down. Do not put a baby who has had a febrile convulsion in a tub for sponging.
What not to do. As important as knowing what to do when your baby has a fever is knowing what not to do:
Do not force rest. A really sick baby will want to rest, in or out of the crib. If yours wants out, moderate activity is okay, but discourage strenuous activity as this could raise body temperature further, especially in a warm room.
Do not overdress or bundle a baby warmly.
Do not cover baby with a wet towel or wet sheet, since this could prevent heat from escaping through the skin.
Do not “starve a fever.” Fever raises the caloric requirement, and sick babies in fact need more calories, not fewer.
Do not give aspirin or acetaminophen when heatstroke is suspected. Instead, see page 582.
1. There is no recommended dosage for children under two years of age on labels of infant or children’s fever-reducing medication. That’s because the appropriate dosage is based on the weight of your baby, not on his or her age. Ask the doctor or pharmacist to tell you how to dose the medication properly.
2. About 40 percent of babies allergic to cow’s milk are also allergic to soy, so hydrolysate formula is usually a safer bet. Do not use so-called soy milks, since they do not provide adequate nutrition for infants.
3. Though changing an infant’s position during and after a feeding may work for some babies, there is some evidence suggesting that placing an infant upright may actually worsen reflux. Talk to your doctor to determine what is best for your baby.
