Sports and Bowlegs

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Infants frequently have bowlegs and as they age into early childhood they develop knock knees. The development of bowlegs during late childhood is unusual and often is associated with load bearing sports participation. Although physical activity is healthy the participation in certain sports that stress the lower skeleton of children can lead to knee changes (bow legs/ genu varum) which can increase the tendency to develop osteoarthritis and overuse syndromes later in life. Certain sport activities appear to cause an imbalance in leg and hip muscles which can change the alignment of the leg bones. Recent finding suggest for boys sports that require intense and frequent running, sidestepping and crossover cutting exert stress on the knee and appear to lead to changes that predispose the athlete to future problems. Future studies will be needed to see if the same pattern is seen for girls.
The key intervention to prevent imbalance is to focus on preservation of neuromuscular balance. This is something all the best exercise gurus have been touting for years. By changing up your work-out regimen and building up all the core, leg and hip muscles it can be hoped that the knee symmetry will be maintained and the incidence of bowlegs in adulthood and future secondary associated problems would be reduced.
So how do you do this? Allow boys and girls to participate in and try out many types of sports and engage in different physical activities. Activities such as dance, yoga, gymnastics and martial arts focus on the entire proximal and distal skeletal and muscular systems. Try to work these activities into your child’s schedule. Too much of one sport may not be best for a developing child.

Medicine Taste and Swallowing

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Children often avoid taking medication due to the taste, aftertaste, smell or texture. Some medications are bitter or gritty and this is a problem for many children. As children age their number of taste buds decrease and their emotional preferences for foods and flavors change.
Most children prefer sweet tasting substances. The addition of sweeteners such as chocolate or strawberry syrup, maple syrup or sweetened drinks can help. Sucking on a lollipop before and after the medication can also be effective. Flavoring agents are also available from most pharmacies.
Check with your pharmacist to see if the tablet your child is prescribed can be crushed into a powder and mixed with a variety of foods or drinks. It is best to choose a masking agent that can be given in a small quantity to make sure your child takes all the medication. Using a small amount of pudding, ice cream, yogurt, jam or applesauce can be very effective.
If the tablet or capsule cannot be crushed or opened your only choice is to practice swallowing pills.  Consider beginning to practice pill swallowing by age 5 years. It is important you avoid fear that is generated by the gag reflex. Once your child realizes they swallow many foods every day that are much bigger than a pill they are willing to practice swallowing pills. It also helps if you have a built in reward system. Swallowing pills and capsules bypasses the issues with taste, texture and aftertaste.
A basic routine to use for pill swallowing is to have your child take several consecutive sips of a liquid they enjoy. Ask him after each sip to swish it in his mouth and then swallow it. After several sips, ask him to place half of a frozen M and M (use a pill splitter to cut) on the tip of his tongue. Allow him to take another larger sip and swish and swallow it. Voila! The pill has disappeared. Reinforce his success with another whole M and M to chew and swallow.

Head Lice

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These are two words no parent wants to hear. Head lice infections are common and each year between 6 and 12 million US children between the ages of 3 and 11 years are infested with head lice. Household members of these preschool and school aged children are also at risk for infestation.
The biggest concern with head live is discomfort due to itching and secondary bacterial skin infections and further spread of the infestation to others. Lice do not transmit disease but the effects on the family in terms of days lost at school and parents being unable to go to work due to child care responsibilities are substantial.
Although hygiene and hair length are not the cause of head lice infection, an infestation often causes many families to be embarrassed and suffer social stress and isolation.
The rash that is seen with a head lice infestation is due to the body developing sensitivity to the saliva of the louse which is injected under the skin when it is feeding on the host. It may take up to several weeks for the sensitivity and subsequent itching to develop.
A louse is about the size of a sesame seed and has six legs. The louse can live for up to a month and lays up to 10 eggs per day. The eggs are attached to the base of a hair shaft. Eggs that are not at the base of the hair shaft are not viable. When the eggs hatch the casings (nits) are white and easier to see. Within 10 days after hatching a louse can begin to lay eggs and the cycle continues. Eggs cannot hatch at room temperature. Body heat is needed to incubate.
Lice will die if not on a host for 24 hours. They do not jump or fly. They crawl quickly and sometimes can be seen easier if you use a lubricant such as oil, hair conditioner or water to slow them down. They avoid light.
It is best only to treat children who have living lice. Over half of all children with nits do not have living lice. Prevention is difficult and depends on avoiding head to head contact. Children need to avoid the sharing of combs, brushes and hats. Prompt treatment of children with living lice is the best way to curtail an outbreak.
Various medications are available for treatment. Choice depends on patient age and medication availability as well as potential side effects. Lice have become resistant to certain medications and often another medication may need to be used if the first medication fails to eradicate the infestation.
Treatment includes OTC medication containing 1% permethrin (Nix). The hair should be shampooed with a non-conditioning shampoo and then towel dried. The medication is applied thoroughly to damp hair and left on for 10 minutes. It is then rinsed off with warm water and the process is repeated in 7-10 days if live lice are seen. Nix is the least toxic lice medication and rarely causes redness, itching or scalp swelling. Permethrin (Nix) does leave a residue on hair that kills newly hatched lice for several days. The use of hair conditioners and hair products with silicone based additives hinders this protection and should be avoided for several days.
Another commonly used medication is malathion (Ovide). It is available by prescription. It is applied to the hair and scalp while eyes are tightly shut. The hair should start dry and end thoroughly wet. Leave hair air dry and uncovered. Shampoo hair after 8-12 hours and use nit comb to remove lice and eggs. It appears to be more effective than Nix but has more side effects. It has not been studied in children under age 6 years and is not used in children under age 2 years. It is highly flammable and contains almost 80% isopropyl alcohol. Avoid high temperatures and open flames while the hair is wet.
Another medication is benzyl alcohol (Ulesfia). It is available by prescription. It is applied to hair to completely saturate scalp and hair. Short hair takes 4 ounces and long hair up to 24 to 48 ounces. Rinse off with water after 10 minutes and repeat in 9 days. It kills lice by suffocating them. It is approved for children over age 6 months and can cause eye and skin irritation. In children under 6 months it can cause severe metabolic disturbances due to skin absorption.
Spinosad (Natroba) was approved by the FDA in 2011. It is used in children 4 years  and  older. It is applied to dry scalp and hair to cover the entire area. Apply up to 120 ml depending on hair length and leave on for 10 minutes. It is then thoroughly rinsed off with warm water and repeated in 1 week if live lice are seen. It is derived from the fermentation of a soil bacterium and may be more effective than Nix. It can cause application site irritation due to benzyl alcohol in the product.
The most recent new product is ivermectin (Stromectol). It comes in a 0.5% lotion called SKLICETM) and is indicated for head lice treatment in patients 6 months and older. It is applied to dry hair to cover scalp and hair and left on for 10 minutes and then rinsed off with warm water. A nit comb is not necessary. The person who applies the medication should wash their hands thoroughly after application. Repeat treatment is not needed.
Lindane (Kwell) is no longer indicated for the treatment of head lice. It can cause serious neurotoxicity and seizures.
Occlusive agents like mayonnaise, margarine and various oils have been used with varying effects in an attempt to suffocate head lice. Head shaving is effective but is undesireable for cosmetic reasons. Frequent wet combing with a nit comb and shampoo or conditioner as a lubricant may also be effective.

When Would My Child See an ENT Surgeon?

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If your child has sleep disordered breathing or obstructive sleep apnea with a history of restless sleep, snoring, gasping and sleep pauses your child will be referred to an ENT for a tonsillectomy and adenoidectomy evaluation. A sleep study is usually not needed. Adenoid enlargement alone may be the cause of obstructive symptoms. Often a trial of nasal steroid spray is pursued if the tonsils are not enlarged. In cases of severe tonsillar enlargement do to infection that does not respond to antibiotics and systemic steroid treatment ENT referral may be needed. Another uncommon condition is a retropharyngeal or peritonsillar abscess that would require surgical drainage.

If your child accidentally swallows a small object and it is lodged in the windpipe he will need bronchoscopy to have it removed. General anesthesia is used in the operating room and a small endoscope with a camera is passed into your child’s windpipe and the object is removed. Small pieces to toys, peanuts or small objects like earrings are commonly aspirated. Coughing episodes are common and a foreign body should be considered whenever a previously healthy child has unexplained symptoms of airway obstruction that do not respond to routine asthma treatmentIf your child has a chronic middle ear fluid and is at risk for speech, learning or language problems he will be referred to ENT for tymanostomy (PE Tube) assessment. If your child is not at risk and has had no complications then he will be observed for 3 months before he is referred.
If your child has a suspected cholesteatoma he will be referred to an ENT. A cholesteatoma is a collection of cells that are in the upper anterior part of the eardrum. Although they are rare they are sometimes seen during ear examinations for children who have recurrent ear infections or hearing loss. They are congenital and can block the Eustachian tube opening causing Eustachian tube dysfunction and recurrent serous otitis media and otitis media and can cause other intracranial problems
If your child has a complication of otitis media called mastoiditis he will be referred to an ENT. Mastoiditis can cause brain infections and facial paralysis. Common symptoms include pain, swelling and redness behind the ear with protrusion of the ear.
If your child has a nasal fracture and a septal hematoma he will be referred to an ENT. Most nasal fractures do not require x-rays. If a septal hematoma is present then an ENT will need to evaluate your child for possible incision and drainage to prevent infection which is common several days after the injury.
If your child has orbital cellulitis he will be referred to an ENT. Orbital cellulitis is often a complication of sinusitis and can involve an infection around the eye or a more severe infection. Management is usually with intravenous antibiotics for younger patients with small infections and no complications. A pediatric ophthalmologist will also frequently be involved in the evaluation.
If your child has severe croup (Laryngotracheobronchitis) or stridor (an inspiratory sound due to airway structure collapse or impingement) an ENT referral may be needed. A fiber optic flexible laryngoscopy can be performed to evaluate for possible causes of stridor. All newborns with stridor will be referred to a pediatric otolaryngologist to evaluate for anatomic causes, such as vocal cord paralysis or subglottic stenosis. Older infants with stridor due to laryngomalacia are also frequently referred. In laryngomalacia, the supraglottic structures collapse into the airway during the inspiratory phase of respiration.
If your child has a rare newborn condition involving the ear, nose or throat regions such as a thyroglossal duct cyst, brachial cleft cyst, lymphatic malformation or dermoid cyst an ENT referral will be needed.
If your child has a neck abscess or enlarged lymph node that needs biopsy, drainage or excision an ENT referral may be needed.

Tonsillectomy

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A tonsillectomy is commonly performed to improve breathing and decrease sings of upper airway obstruction. Common signs include restless sleep, neck arching during sleep, snoring and difficulty swallowing chunky foods. It is also helpful for children who suffer from recurrent episodes of pharyngitis. The potential benefits of a tonsillectomy, usually in combination with an adenoidectomy, must be weighed against potential risks and the overall discomfort associated with having the procedure performed.
Children between the age of 3 and 6 years are at highest risk for tonsil and/or adenoid enlargement that is commonly called hypertrophy. Tonsil size generally decreases after age 8 years. This is why many children who snore prior to age 8 stop snoring by their teen years. If your child has upper airway symptoms with associated sleep apnea then the benefits of surgery clearly outweigh any risks. Snoring alone is not enough of an indication for the surgery. If the complaints listed above are present as well as other complaints including daytime sleepiness, academic difficulties, attention difficulty, enuresis or behavioral problems then surgery should be strongly considered. Children whose BMI is above the 95th% are considered severely overweight (obese). Their symptoms of nighttime upper airway obstruction are less often cured by adenotonsillectomy. Pre-operative sleep studies can often assist decision making on whether to perform surgery on these children.
In addition to the above upper airway obstruction indications children who have 7 episodes of severe recurrent sore throats in 1 year, 5 episodes in 2 consecutive years or 3 episodes in 3 consecutive years are candidates for surgery.
The greatest risk with surgery is the postoperative pain. Bleeding occurs in up to 5% of cases and the general anesthesia can cause transient post-operative disorientation, nausea and vomiting. A single dose of intraoperative dexamethasone has been shown to decrease postoperative nausea and vomiting.
The best way to prevent and manage any post-tonsillectomy problems is through good perioperative care. Make the doctor aware of any obstructive sleep issues or any accompanying medical problems including obesity, sickle cell disease, blood problems, heart problems, heart arrhythmias, craniofacial abnormalities or a family history of anesthesia problems.
After surgery a clot composed of fibrin, inflammatory cells and bacteria will coat the area where the tonsils were removed. This clot will come off after about 1 week and can be associated with delayed bleeding. The area will heal over 2-3 weeks.
Pain is usually intense on day 1 and decreases over the next week. There may be a period of increased pain on day 3 after surgery. This increase is associated with the intense healing and inflammation. The pain is usually gone by 2 weeks. Pain is worse if associated with anxiety. Age and prior experience with pain also affect the perception and severity of the pain. Ibuprofen is the present recommendation for pain management. Caution should be used with acetaminophen with codeine since some children over respond to the codeine and become over sedated. Rough foods and vigorous activity should be avoided after surgery. Your surgeon will give you instructions on returning to a regular diet and an active lifestyle.

Snoring

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Snoring is the sound of obstructive sleep apnea. It is a sound everyone is familiar with. Both children and adults snore. It is the sound produced by the forced flow of air through a reduced space and is caused by partial or complete airway closure. The term used to describe this is increased airway resistance. As everyone knows snoring varies throughout the night. It increases during dream sleep (REM) and causes sleep disruption not just for the person who cannot fall asleep due to the loud snoring (“Snoree”) but more importantly for the person who is snoring (“Snorer”). The results of this obstruction include an increased effort of breathing and secondary oxygen, carbon dioxide exchange abnormalities and subsequent physiologic changes.
Common risk factors for obstructive sleep apnea include adenoid and/or tonsil enlargement, obesity, craniofacial abnormalities, Down syndrome, neuromuscular disorders including cerebral palsy, and a family history of obstructive sleep apnea. The most common clinical signs include loud snoring, apnea and gasping sounds. Sleep is often restless with frequent moving, thrashing or awakening. Another common complaint is excessive sweating. For the younger child weight loss or poor weight gain are often seen. Due to the sleep disruption daytime sleepiness is common as is decreased cognitive performance at work or school and an increased incidence of bedwetting. Grades can decrease and frequent complaints include hyperactivity, distractibility and overall attention problems. Many of these children are diagnosed incorrectly as having an attention deficit disorder (ADHD).
The diagnosis is made by history and observation. A sleep study (Polysomnography) can be obtained to verify the diagnosis. In this study heart rate and breathing patterns are monitored in conjunction with the oxygen level in the blood.
Treatment depends on the cause. The most common cause is adenotonsillar enlargement. In this situation a tonsillectomy and adenoidectomy is required. If obesity is the issue then weight loss is needed and continuous positive airway pressure may be prescribed to alleviate symptoms while pursuing a weight management program. For neuromuscular and congenital causes intervention is specific to the cause. Chronic obstructive sleep apnea can lead to systemic and pulmonary hypertension which must be prevented.
If your child or teen snores seek help and advice. Snoring is never normal. If the snoring is associated with an acute illness patience may be the treatment of choice. If it is chronic then a thorough evaluation and subsequent intervention are required.

Generic Medication or Brand Name Medication – Is There a Difference?

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“Are generic drugs just as safe and effective?” This question is raised by most parents since out of pocket costs are almost always higher for brand-name medications. In addition, most doctors are required by insurance carriers to substitute a generic product for a brand-name product. Most parents prefer a generic medication due to the added cost of a brand-name drug. Generally, this substitution is both safe and reasonable. There are a few situations, however, when generic substitutions can cause adverse health effects. A few medications have a narrow therapeutic index (NTI) and substitution of a generic drug for a brand-name drug can cause a change in the blood level of the drug which can cause a worsening of a medical condition or new medical problems. This can be seen in medication used to treat depression, anxiety, seizures and for medications used for blood thinning or contraception. Specific drugs in this category include levothyroxine, warfarin, phenytoin and digoxin.

Approved generic drugs have demonstrated therapeutic equivalence. The Food and Drug Administration’s (FDA) Orange Book provides the latest information on generic approvals. A drug is considered bioequivalent if testing shows the drug has bioavailability properties that fall within the 80% to 125% range of the brand-name medication.
This substitution can also occur without the doctor being notified. Many health insurance plans request and allow pharmacists to substitute generic medication. Issues raised by this substitution relate to quality standards and safety controls for drug manufacture. Simple issues including a change in pill shape or color also add to the confusion and increase the potential for errors in pill administration.
Here are some helpful tips:
·         Ask the doctor or prescriber if it is safe to use a generic medication.
·         Ask if there is a difference between the brand-name medication and the generic medication.
·         Ask if your doctor would be able to monitor the generic medications effectiveness and increase the dose if more of the generic medication is needed due to a lower bioavailability.
·         Ask the pharmacist if a generic medication was substituted for a brand-name medication.
·         If you are being treated for one of the above described conditions be cautious.
Overall, the use of generic medications is safe and effective. Always discuss medication changes or medical issues that could be related to a medication change with both your doctor and your pharmacist.

Well Child Care 2 Months

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Feeding
At this age, your baby needs only breast milk or infant formula to grow healthy and strong. At this age most babies take about 4 to 5 ounces of formula every 3 to 4 hours. Although not mandatory, some mothers who breast feed also give their babies pumped breast milk or commercial formula that is put in a bottle. Avoid giving a supplement if this hinders breast feeding. This can allow your baby to learn another way to drink milk and other people can enjoy feeding your baby. Always hold your baby during feeding time. Then your baby learns that you are there to meet his needs. This is an important and special time. It is not time to start cereal or baby foods yet. Cereal can be started at 4 to 6 months of age.   Don’t forget: breast fed babies need a daily Vitamin D supplement such as Tri Vi Sol drops.
Development
Babies start to lift their heads briefly. They reach for things with their hands. They enjoy smiling faces and sometimes smile in return. Cooing sounds are in response to people speaking gentle, soothing words.
Sleep
Many babies wake up every 3 to 4 hours, while others sleep for longer periods during the night. Every baby is different. Feeding your baby a lot just before bedtime doesn’t have much to do with how long your baby will sleep.  This is a good time to move your baby out of your room and put him in his own room if one is available.
When babies spend almost all of their time on their back they sometimes get flattening of one side of their head.  This happens when an infant’s head is always turned to the same direction (either the right or left).  The weight of the baby’s head will actually flatten one side of the head more than the other and the head will look lopsided.  (It is important to understand that this does not affect brain function, only the shape of the head.) To prevent this:
1.) Give your infant plenty of tummy time every day.  Remember, that in order to be on his tummy, you baby MUST be with an adult and awake.
2.) Place your child in such a way that he looks to his left some times and to the right other times.  For example, this can be accomplished by putting your baby’s head at the opposite end of the crib on alternate days.
Tips to get your baby to sleep through the night:
1.) Place your baby in the crib when he’s drowsy but still awake.  Babies who fall asleep more independently often learn to sleep through the night more quickly.
2.) Never put your baby in bed with a bottle.
Reading and Electronic Media
Your baby will enjoy just hearing your voice. You can read aloud your favorite novel while feeding or cuddling with the baby. Never prop your baby in front of a television.
Safety Tips
Never leave your child alone, except in a crib.
Choking and Suffocation
·         Use a crib with slats not more than 2 and 3/8 inches apart.
·         Place your baby in bed on his back.
·         Use a mattress that fits the crib snugly.
·         Keep plastic bags, balloons, and baby powder out of reach.
Fires and Burns
·         Never eat, drink, or carry anything hot near the baby or while you are holding the baby.
·         Turn your water heater down to 120°F (50°C).
·         Install smoke detectors and carbon monoxide detectors.
·         Keep a fire extinguisher in or near the kitchen.
Falls
·         Never step away when the baby is on a high place, such as on a changing table.
·         Keep the crib sides up.
Car Safety
·         Never leave a child alone in a car.
·         Use an approved infant car safety seat and follow the instructions for proper use. If you aren’t sure how to install the seat in your car, contact a local fire department.
·         Parents should always wear seat belts.
·         Babies must ride in the back seat of the car.
Smoking
·         Infants who live in a house where someone smokes have more respiratory infections. Their symptoms are also more severe and last longer than those of children who live in a smoke-free home.
·         If you smoke, set a quit date and stop. Set a good example for your child. If you cannot quit, do NOT smoke in the house or near children.
Immunizations
Vaccines are now combined to reduce the total number of shots for your baby.
Babies cannot receive influenza vaccinations (also called flu vaccinations) until 6 months of age.  If your baby cannot be protected against the flu, make sure all family members and close contacts get flu vaccinations.
Your baby may run a fever and be irritable for about 1 day after getting shots. Your baby may also have some soreness, redness, and swelling where the shots were given.

Well Child Care 4 Months

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Feeding
Your baby should still be taking breast milk or infant formula. Most formula-fed babies now take about 6 to 7 ounces every 4 to 5 hours. If you give your baby breast milk, you might want to feed your baby an occasional bottle with pumped milk or commercial formula. Then your baby will learn another way to drink milk and other people can enjoy feeding your baby. Some babies are now ready to start cereal. A baby is ready for cereal when he is able to hold his head up enough to eat from a spoon. Use a spoon to feed your baby cereal, not a bottle or an infant feeder. Sitting up while eating helps your baby learn good eating habits. When you start cereal, start with rice cereal mixed with breast milk or formula so that it has a pea soup consistency.
Pureed fruits and vegetables can also be started between 4 and 6 months. Start a new food no more often than every 3 days to make sure your baby is not allergic to the new food.
Babies will respond gleefully when they see a bottle, but don’t give your baby a bottle just to quiet him when he really isn’t hungry. Babies who spend too much time with a bottle in their mouth start to use the bottle as a security object, which makes weaning more difficult. They are also more likely to have ear infections and tooth decay problems. Find another security object like a stuffed animal or a blanket.
Development
Babies are starting to roll over from stomach to back. In order to encourage this your baby will need lots of tummy time (when your baby is both awake and with an adult).  Tummy time also decreases the likelihood that the back of your baby’s head will become flattened.
Your baby’s voice may become louder. He may squeal when happy or cry when he wants food or to be held. In both cases, gentle, soothing voices are the best way to calm your baby. Babies at this age enjoy toys that make noise when shaken.
It is normal for babies to cry.
Sleep
Many babies are sleeping through the night by 4 months of age and will also nap 4 to 6 hours during the daytime. If your baby’s sleeping patterns are very different than this you may want to ask your doctor for ideas about ways to keep your baby alert and awake during the day and sound asleep at night. Remember to place your baby in bed on her back, NOT the side or tummy.
Reading and Electronic Media
As the baby gets older, read to her every day. Choose books that are durable (cloth or board books). Pick books with bright colors and large simple pictures. Never prop your baby in front of a television.
Teething
Your baby may begin teething.  A teething ring may be useful if you believe your baby is in pain.
Safety Tips
All parents, caregivers and babysitters should be certified in CPR every two years.  Your local hospital may have a class available.
Choking and Suffocation
·         Remove hanging mobiles or toys before the baby can reach them.
·         Keep cords, ropes, or strings away from your baby, especially near the crib. Ropes and strings around the baby’s neck can choke him.
·         Keep plastic bags and balloons out of reach.
·         Use only unbreakable toys without sharp edges or small parts that can come loose.
Fires and Burns
·         Never eat, drink, or carry anything hot near the baby or while you are holding the baby.
·         Turn down your water heater to 120°F (50°C).
·         Check your smoke and carbon monoxide detectors to make sure they work.
·         Check formula temperature carefully. Formula should be warm or cool to the touch.
Falls
·         Never leave the baby alone on a high place.
·         Keep crib and playpen sides up.
·         Do not put your baby in a walker.
Car Safety
·         Use an approved infant car seat correctly in the back seat.
·         Never leave your baby alone in a car.
·         Wear your safety belt.
Smoking
·         Children who live in a house where someone smokes have more respiratory infections. Their symptoms are also more severe and last longer than those of children who live in a smoke-free home.
·         If you smoke, set a quit date and stop. Set a good example for your child. If you cannot quit, do NOT smoke in the house or near children.
Immunizations
Babies cannot receive flu vaccinations (also called influenza) until 6 months of age.  If your baby cannot be protected against the flu, make sure all family members and close contacts get flu vaccines.Vaccines can be combined to reduce the total number of shots for your baby.
Your baby may run a fever and be irritable for about 1 day after the shots. Your baby may also have some soreness, redness, and swelling where the shots were given.
You may give acetaminophen drops in the appropriate dose to prevent the fever and irritability. For swelling or soreness, put a wet, warm washcloth on the area of the shots as often and as long as needed for comfort.
Call your child’s pediatrician if your child has a rash or any reaction other than fever and mild irritability or your child has a fever that lasts more than 36 hours.

Well Child Care 6 Months

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Feeding

Your baby should continue to have breast milk or infant formula until he is 1 year old.  Please continue your Vitamin D drops for those babies who are mostly breast fed.  Your baby may soon be ready for a cup although it will be messy at first. Try giving a cup sometimes to see if your baby likes it. Don’t put your baby to bed with a bottle. Your baby will see the bottle as a security object and this will make it hard to wean your child from the bottle. Leaving a bottle with your baby, especially at night, will lead to tooth decay and may cause ear infections.
Make cereal with formula or breast milk only. Use a spoon to feed your baby cereal, not a bottle or an infant feeder. Sitting up while eating helps your baby learn good eating habits.
If you haven’t started your baby on baby foods (other than cereal), you can start now. Start with pureed fruits and vegetables. Start one new food at a time for a few days to make sure your baby digests it well. If your family eats meat you may begin pureed meats at this time.  Do not give finger foods or foods that require chewing.

Development

At this age babies are usually rolling over and beginning to sit by themselves. Babies squeal, babble, laugh, and often cry very loudly. They may be afraid of people they do not know. If you feel overwhelmed, ask people you trust for help, or talk with your healthcare provider.
Sleep
6-month-olds may not want to be put in bed. A favorite blanket or stuffed animal may make bedtime easier. Do not put a bottle in the bed with your baby. Develop a bedtime routine like playing a game, singing a lullaby, turning the lights out, and giving a goodnight kiss. Make the routine the same every night. Be calm and consistent with your baby at bedtime.
When babies do not sleep through the night the problem is not typically something that occurs in the middle of the night.  The problem most often occurs when you are putting your baby to sleep.
In order for healthy babies to sleep through the night it is important for them to fall asleep in the same environment he or she will experience the rest of the night.  Sleep is divided into deeper and lighter stages.  It is normal to wake up enough to assess your surroundings.  It is not hard to imagine that a baby who wakes up in the middle of the night might become upset if he or she is no longer in mom’s arms.
So, it is important that your baby fall asleep independently.  At bed time put your child in his or her crib while awake enough to know where he is (not with eyes so heavy he or she can barely stay awake).  Dim the lights the way they will be the rest of the night.  Do not put your child to bed with a bottle, and mom and dad must not be in the room.  If your baby cries, allow it to go on for 5 – 10 minutes.  If your baby is still crying, go back into the room and calm your baby with the least amount of contact possible.  If you have to pick up your baby do not feed him back to sleep.  Once your baby stops crying put him or her back down, leave the room and allow another 5 – 10 minutes of crying before going back in.  Be prepared for quite a bit of crying the first few nights.  Most families get very good results in less than 2 weeks.  If you are not making any progress in 2 weeks please call your pediatrician. Infants require 14-15 hours per night. Never put a bottle in the bed with your baby.

Reading and Electronic Media

Books help parent and child grow closer. One way to help your child learn to love reading is to show that you enjoy reading. Pick books with bright colors and large simple pictures. Reading the same books over and over will help your baby to recognize and name familiar objects. Do not prop a baby in front of a television.

Teething

Teeth come in almost constantly from 6 months to 2 years of age.  It may help to massage your baby’s swollen gums with your finger for 2 minutes. A teething ring may be useful.
Fluoride supplementation is important to make teeth stronger and prevent decay.  If the water in your community is fluoridated you will not require an additional supplement.  If there is no fluoride in the water your doctor will recommend a fluoride supplement for your baby.

Safety Tips

All parents, caregivers and babysitters should be certified in CPR every two years.  Your local hospital may have a class available.

Choking and Suffocation
·         Cords, ropes, or strings around the baby’s neck can choke him. Keep cords away from the crib.
·         Keep all small, hard objects out of reach.
·         Use only unbreakable toys without sharp edges or small parts that can come loose.
·         Avoid foods on which a child might choke (such as candy, hot dogs, peanuts, popcorn).
Fires and Burns
·         Check your smoke detector to make sure it is working.
·         Keep a fire extinguisher in or near the kitchen.
·         Check food temperatures carefully, especially if a microwave is used.
·         Keep hot foods and liquids out of reach.
·         Put plastic covers on unused electrical outlets.
·         Throw away cracked or frayed old electrical cords.
·         Turn the water heater down to 120°F (50°C).
Falls
·         Keep crib and playpen sides up.
·         Do not use walkers.
·         Install safety gates to guard stairways.
·         Lock doors to dangerous areas like the basement or garage.
·         Check drawers, tall furniture, and lamps to make sure they can’t fall over easily.
Poisoning
·         Keep all medicines, vitamins, cleaning fluids, and other chemicals locked away. Dispose of them safely.
·         Put safety latches on cabinets.
·         Keep the POISON CONTROL number (1-800-222-1222) on all phones.
Smoking
·         Children who live in a house where someone smokes have more respiratory infections. Their symptoms are also more severe and last longer than those of children who live in a smoke-free home.
·         If you smoke, set a quit date and stop. Ask your healthcare provider for help in quitting. If you cannot quit, do NOT smoke in the house or near children.

Immunizations

Flu (also called influenza) vaccines are given every year starting in late September.  Your baby will require a flu vaccine every year because each flu season is caused by a different set of viruses.  If flu season has not started please mark your calendar and call our office in late September.
Vaccines can be combined to reduce the total number of shots for your baby.
Your baby may run a fever and be irritable for about 1 day after the shots. Your baby may also have some soreness, redness, and swelling in the area where the shots were given.
You may give acetaminophen drops in the appropriate dose to prevent fever and irritability. For swelling or soreness, put a wet, warm washcloth on the area of the shots as often and as long as needed to provide comfort.
Call your child’s healthcare provider if:
·         Your child has a rash or any reaction to the shots other than fever and mild irritability.
·         Your child has a fever that lasts more than 36 hours.